Withdrawal Design Research Articles

A Personal Narrative Intervention for Adults With Autism and Intellectual Disability.

Due to the unique social cognitive profiles of individuals with autism spectrum disorder (ASD) with and without intellectual disability (ID) sharing coherent and complex personal narratives can be challenging. To address these challenges research has focused on teaching macrostructure components using visual supports and repeated opportunities to practice. Despite success by young children with ASD and ID, the application of this instruction for adults with ASD with and without ID is still largely unknown. An ABAB single case withdrawal design was used to determine the effects of a personal narrative intervention to teach macrostructure within participant-generated personal narratives. Results indicate all participants demonstrated more coherent and complex personal narratives with the intervention. The results and implications for practice are discussed.

Using Continuous Glucose Monitoring to Detect and Intervene on Dietary Restriction in Individuals With Binge Eating: The SenseSupport Withdrawal Design Study.

Dietary restraint is a key factor for maintaining engagement in binge eating among individuals with binge eating disorder (BED) and bulimia nervosa (BN). Reducing dietary restraint is a mechanism of change in cognitive behavioral therapy (CBT) for individuals with BN and BED. However, many individuals who undergo CBT fail to adequately reduce dietary restraint during treatment, perhaps owing to difficulty in using treatment skills (eg, regular eating) to reduce dietary restraint during their daily lives. The SenseSupport system, a novel just-in-time, adaptive intervention (JITAI) system that uses continuous glucose monitoring to detect periods of dietary restraint, may improve CBT to reduce dietary restraint during treatment by providing real-time interventions. This study aimed to describe the feasibility, acceptability, and initial evaluation of SenseSupport. We presented feasibility, acceptability, target engagement, and initial treatment outcome data from a small trial using an ABAB (A=continuous glucose monitoring data sharing and JITAIs-Off, B=continuous glucose monitoring data sharing and JITAIs-On) design (in which JITAIs were turned on for 2 weeks and then turned off for 2 weeks throughout the treatment). Participants (N=30) were individuals with BED or BN engaging in ≥3 episodes of ≥5 hours without eating per week at baseline. Participants received 12 sessions of CBT and wore continuous glucose monitors to detect eating behaviors and inform the delivery of JITAIs. Participants completed 4 assessments and reported eating disorder behaviors, dietary restraint, and barriers to app use weekly throughout treatment. Retention was high (25/30, 83% after treatment). However, the rates of continuous glucose monitoring data collection were low (67.4% of expected glucose data were collected), and therapists and participants reported frequent app-related issues. Participants reported that the SenseSupport system was comfortable, minimally disruptive, and easy to use. The only form of dietary restraint that decreased significantly more rapidly during JITAIs-On periods relative to JITAIs-Off periods was the desire for an empty stomach (t43=1.69; P=.049; Cohen d=0.25). There was also a trend toward greater decrease in overall restraint during JITAs-On periods compared with JITAIs-Off periods, but these results were not statistically significant (t43=1.60; P=.06; Cohen d=0.24). There was no significant difference in change in the frequency of binge eating during JITAIs-On periods compared with JITAIs-Off periods (P=.23). Participants demonstrated clinically significant, large decreases in binge eating (t24=10.36; P<.001; Cohen d=2.07), compensatory behaviors (t24=3.40; P=.001; Cohen d=0.68), and global eating pathology (t24=6.25; P<.001; Cohen d=1.25) from pre- to posttreatment. This study describes the successful development and implementation of the first intervention system combining passive continuous glucose monitors and JITAIs to augment CBT for binge-spectrum eating disorders. Despite the lower-than-anticipated collection of glucose data, the high acceptability and promising treatment outcomes suggest that the SenseSupport system warrants additional investigation via future, fully powered clinical trials. ClinicalTrials.gov NCT04126694; https://clinicaltrials.gov/ct2/show/NCT04126694.

Implementing the classroom password game via telehealth among students with intellectual disabilities

AbstractEducational institutions are constantly aiming to better meet the academic needs of individuals with disabilities. As more students with disabilities attend postsecondary education settings researchers need to better understand how to apply both academic and behavioral interventions to better serve this population. Group contingencies are widely popular among educational settings to increase academic engagement and manage classroom behavior. More specifically, the classroom password is an independent group contingency intervention, often utilized in classroom settings to increase academic engagement and decrease disruptive and off‐task behaviors. Utilizing a single case design withdrawal design, researchers sought to evaluate the effectiveness of the classroom password intervention to increase academic engagement and decrease disruptive and off‐task behavior. Due to the COVID‐19 pandemic, researchers utilized the classroom password via telehealth. Overall, the current study's results demonstrate that the intervention was effective at increasing academic engagement and decreasing disruptive and off‐task behavior. Furthermore, the intervention was rated high for social validity among most participants. Future studies should continue to explore the effectiveness, generalizability, and maintenance of these results.

Pelatihan Pelajar Hebat Untuk Menurunkan Perilaku Tidak Disiplin Siswa SMP Negeri 1 Yogyakarta

Some students often display unruly behaviors during in classroom environment. This situation may hinder the class from achieving national education objectives. This study aimed to examine the effectiveness of Excellent Student Training in lowering the prevalence of undisciplined behaviors among students. This study was conducted at SMP Negeri 1 Yogyakarta. It used an experimental approach with the single case A-B-A withdrawal design. Researchers implemented the visual conservative dual-criterion (CDC) method for the data analysis. Based on the unruly behavior graph, it was found that the Excellent Student Training is effective for reducing unruly behavior incidence.

Requesting Help Module Interface Design on Key Partial Video with Action and Augmented Reality for Children with Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) have marked difficulty with vocabulary, lack of language, or shortcomings with their ability to organize their oral expression; thus, they cannot effectively communicate with others. In particular, people with moderate or severe disabilities cannot systematically narrate an incident and cannot follow pragmatic rules provided by others. Their attempts at standard everyday conversation lead to cognitive problems. When children with ASD are faced with difficult circumstances, they are usually unable to seek help from others, which in turn can result in their being unable to communicate effectively. This research focused on three child participants with ASD and language disorders. The goal was to strengthen the effectiveness of their requesting help and to organize their oral expression, to use requesting help modules, to remove static key images, and to use augmented reality (AR) combined with the dynamic video clips in key partial video with action (KPV). This study developed request-assistance training in conjunction with an auto organizational menu (AOM), multiple case studies and withdrawal designs, training-response methods, and a comparison of outcomes. The proposed AR sentence intervention effectively increased the children’s desire to communicate with others and the accuracy rate of their help requests, and increased their level of communication. We conclude that the interface of our requesting help modules is efficacious enough to assist children with ASD at different levels. The proposed AR sentence intervention helps them build scenarios by themselves, helps them organize communication with their peers, and assists them to request help.

The Effect of the Fidget Cube on Classroom Behavior among Students with Perceived Attention Difficulties.

Fidget toys, one class of sensory-based interventions, enjoy favorable coverage in popular media outlets supporting their impact on attention, memory, and stress. However, there is minimal data supporting their use in the classroom. The present study used an ABAB withdrawal design to investigate the impact of noncontingent access to a commercially available fidget toy, the Fidget Cube, on academically engaged behavior, off-task behavior, Fidget Cube engagement, math problems attempted, and math problems completed accurately during independent seatwork. Participants were three 3rd-graders referred for having attention difficulties. Results indicated that noncontingent access to the Fidget Cube during independent seatwork did not improve study outcomes. Participants engaged with the Fidget Cube less in the second intervention phase than the first. Results suggest school personnel should consider alternative strategies for students with perceived attention difficulties. Limitations of the study are discussed, along with future directions for research.

Evaluation of the Good Behavior Game Using ClassDojo in Secondary Classrooms

Effective classroom management skills are critical in supporting students’ academic, social, and behavior development in schools. However, teachers often report support with classroom management as their greatest need. Given this concern, effective and efficient strategies are needed for teachers and school staff dealing with classwide behavioral difficulties. The purpose of this study was to assess the effects of the Good Behavior Game utilizing ClassDojo on classwide academically engaged and disruptive behavior. A withdrawal design was used to evaluate the effects of the intervention on the behavior of students in four seventh and eighth grade classrooms. Measures of teacher perception of social validity and student perception of acceptability were also obtained. Overall, results indicated the intervention procedures were effective at increasing student academic engagement across four secondary classrooms, were considered socially valid by participating teachers, and were acceptable to secondary students. Impact Statement Few studies have evaluated class wide interventions in secondary settings, despite a clear need for such supports. The current study found the Good Behavior Game to be effective when implemented with ClassDojo, with procedures found to be socially valid by teachers and students.

Preventing Challenging Behavior Using Physical Activity With Young Children

Antecedent exercise (AE) is an intervention used to promote moderate-to-vigorous physical activity and improve subsequent behavior in non-exercise contexts. We used withdrawal and multitreatment single case research designs to compare the effects of baseline, AE alone, and AE + visual supports condition. Two preschool-age boys participated in this study. A masked secondary observer recorded interobserver agreement data for 100% of sessions; these data were continually monitored to detect biases. For one participant, AE alone was sufficient to reduce instances of challenging behavior during morning circle time. For the other participant, AE + visual supports was more effective than AE alone. These results point to the need for continued, rigorous research on the nuances of antecedent interventions for young children who demonstrate challenging behaviors. AE is but one such intervention requiring further investigation into for whom and under what conditions it might be effective.

Supplementing Social Skills Training With Tootling to Simultaneously Enhance First-Grade Students’ Performance of Two Social Skills

While social skills training allows students to acquire social skills, often it does not enhance their performance of those skills outside the social skills training context. A withdrawal design was used to determine if a modified Tootling intervention could enhance at-risk, first-grade students’ performance of two recently trained social skills (complimenting and encouraging) as they played. Following social skills training, baseline data was collected as students played a modified Jenga game in small groups. During the intervention phase, a Tootling intervention was added and the class earned a group reward contingent upon their reports of peers engaging in these recently trained social skills. After Tootling was withdrawn, it was reinstated. Analysis of class-wide data shows immediate and large (effect size estimates) increases in compliments and encouragements each time Tootling was applied, and an immediate decrease when Tootling was withdrawn. These findings suggest that the modified Tootling intervention enhanced performance of these social skills while students played. Discussion focuses on future research designed to determine if Tootling can cause meaningful increases in social skill development by increasing students’ performance of social skills across social contexts. Impact Statement Social skills training allows students to acquire social skills, but typically does not result in students performing these behaviors in other social contexts. A peer-mediated intervention known as Tootling, which involves students being reinforced for reporting classmates’ performance of recently trained social skills (i.e., providing encouragements and compliments), caused large and immediate increases in first-grade students’ performance of these prosocial behaviors as they engaged in a small-group game.

Opioid trials: time for a new approach? Enriched enrollment randomized gradual withdrawal designs.

Opioid trials: time for a new approach? Enriched enrollment randomized gradual withdrawal designs.

Parent-Implemented Behavior Interventions via Telehealth for Older Children and Adolescents.

Children and adolescents with intellectual and developmental disabilities (IDD) are more likely to engage in challenging and interfering behavior than their typically developing peers, which has been linked to many negative outcomes. The most effective interventions to address challenging and interfering behavior incorporate function-based assessments, which are used to develop individualized behavior interventions. Functional communication training (FCT) is an evidence-based practice to decrease challenging and interfering behavior that can be taught to parents using behavioral parent training (BPT); however, there are limited skilled professionals who can develop interventions and train parents. Telehealth can enable greater access to these professionals. This study used withdrawal designs to determine whether high parent treatment fidelity resulted in decreased challenging and interfering behavior and increased appropriate replacement behavior. Three participants (8–17 years) were included in the study, and their parents served as interventionists during mealtime, toothbrushing, and room cleaning. Data were analyzed using visual analysis. Each parent achieved high treatment fidelity with one session of BPT and bug-in-ear coaching. All participants had a decrease in challenging and interfering behavior and an increase in functional communication responses (FCRs) upon the introduction of the intervention with reliable reversals. All parents reported high social validity. Results and implications for practice and future research are discussed.

A Positive Version of the Good Behavior Game in a Self-Contained Classroom for EBD: Effects on Individual Student Behavior

A within-participant withdrawal design was used to examine the effects of a positive version of the Good Behavior Game (GBG) for three students in an elementary special education classroom for students with emotional or behavioral disorders (EBD). Results indicated immediate improvements in disruptive behavior and academic engagement for all three students when the GBG was implemented which was generally replicated in the second intervention phase for academic engagement. Tau- U effect sizes ranged from .76 to .95 indicating large and very large effects for both behaviors for two students and academic engagement for the third student, but Tau- U for the third student’s disruptive behavior was .32 (considered not effective). Two students exhibited slight decreasing trends in academic engagement behavior and increasing trends in disruptive behavior near the end of intervention phases. A preliminary within-session analysis also suggested students’ behavior was generally better in intervention phases both during and not during the GBG when compared with their baseline levels of behavior. Social validity information suggested generally positive teacher and student perceptions about the GBG initially, with less positive student perceptions 10 weeks following the conclusion of the study. The teacher reported implementing the GBG 5 times over the 10 weeks following the conclusion of the study.

Effects of Class-Wide Choice Making on the Behaviour of Students with Mild Intellectual Disability

ABSTRACT In general, behavioural intervention is a more effective form of treatment. By the way, several behavioural interventions were studied in the education field to support and prevent students’ behaviour among them choice making. An ABAB withdrawal design was used to examine the effects of class-wide choice making on the engagement and disruptive behaviours of 12 students with mild intellectual disability enrolled in a two self-contained physical activity classes. Intervention was implemented in an ordinary context and applied at the class-wide level by applying a curricular modification. To measure the variables studied, direct observation was used to collect data from videos of filmed sessions by applying a code unit-grid. Data were analysed using quantitative methodologies. For class ‘1ʹ and ‘2ʹ, an increase in engagement and a decrease in disruptive behaviour was observed at the implementation of intervention B1 compared to baseline A1 (p < 0.001). Likewise, an increase in engagement and a decrease in disruptive behaviour was observed in the second implementation of intervention B2 compared to baseline A2 and A1 (p < 0.001). The implementation of the opportunity of choice at the class-wide level for the two physical activity self-contained classes yielded an increased engagement rate and a decrease in disruptive behaviour.

Increasing reciprocal social interactions using collaborative art activities: An intervention for children with complex communication needs and their peers

Purpose: Children with complex communication needs who require augmentative and alternative communication (AAC) strategies to communicate have difficulty participating in interactions with their peers. Integrating a collaborative learning framework with art activities may facilitate social interactions between children with complex communication needs and their peers. Method: A single-subject withdrawal design was utilised to examine the impact of collaborative art activities on reciprocal social interactions between 2 dyads of participants with complex communication needs and their same-age peers. Additional dependent variables included the roles of participants with complex communication needs in interactions (initiator or responder), AAC modalities (unaided, aided, natural speech), and engagement. Result:Tau-U calculations for Dyad 1 demonstrated 64% improvement from baseline, indicating moderate effects with the collaborative art activity (Intervention One) and 100% improvement, indicating strong effects following the activity enhanced with photography (Intervention Two). Dyad 2 demonstrated 100% improvement from baseline following Intervention One and 96% improvement following Intervention Two, indicating strong effects. Conclusion: Both collaborative art activities demonstrated potential for facilitating social interactions for children with complex communication needs and their peers.

Efficacy and Safety of Intranasal Esketamine in Treatment-Resistant Depression in Adults: A Systematic Review.

Intranasal form of esketamine, the S-enantiomer of racemic ketamine, was approved by the US FDA in 2019 for treatment-resistant depression (TRD) in adults. Since intranasal esketamine is a newly approved drug with a novel mechanism of action, much still remains unknown in regard to its use in TRD. The objective of this study is to systematically review the latest existing evidence on intranasal esketamine, and provide a better insight into its safety and efficacy in TRD in adults.PubMed, MEDLINE (through PubMed), and Google Scholar were systematically searched from 2016 to 2021, using automation tools. After removal of duplicates and screening on the basis of title/abstract, eligibility criteria were applied and quality appraisal was done independently by two reviewers.A total of 10 studies were selected for the final review which included five clinical trials (three short-term trials, one withdrawal design relapse prevention study, and one long-term study), three post hoc studies, one case/non-case study, and one review article. Out of three short-term clinical trials, only one demonstrated a statistically significant difference between treatment with esketamine plus oral antidepressant (OAD) vs placebo plus OAD. The result of the relapse prevention study showed significantly delayed relapse of depressive symptoms in esketamine plus OAD arm when compared to placebo plus OAD arm. Similarly, the result of the long-term clinical trial showed that the improvement in depressive symptoms was found to be sustained in those using esketamine. The most common adverse effects of esketamine included nausea, dizziness, dissociation, headache, vertigo, somnolence, and dysgeusia (altered sense of taste); most were mild-moderate in severity. One case/non-case study reported rare adverse effects including panic attacks, mania, ataxia, akathisia, self-harm ideation, increased loquacity (talkativeness), and autoscopy.Intranasal esketamine has shown efficacy in reducing depressive symptoms in clinical trials, but the clinical meaningfulness of the treatment effect in the real-world population still needs to be explored. Although the safety profile of esketamine appears to be favorable in most clinical trials, some serious side effects are being reported to the FDA Adverse Event Reporting System, and therefore requires further investigation. More robust clinical trials, especially long-term randomized controlled trials are needed which can help provide a better assessment on the efficacy and safety of intranasal esketamine in the treatment of TRD.

Reducing Stereotypies for a Student With Deafblindness

Introduction: Little is known about the effects of specific behavioral strategies to reduce stereotypy and self-injury for learners with sensory impairments and additional disabilities. Method: A single-subject, multi-treatment withdrawal design was used to test the isolated and combined effects of physical prompting to engage in object manipulation of preferred items, contingent reinforcement, and response blocking on target hand-related stereotypy and object manipulation for one 9-year-old boy with deafblindness and additional disabilities. Results: A functional relation was observed to show that hand-related stereotypy decreased due to prompting and reinforcement of object manipulation. Adding response blocking had inconsistent positive effects on stereotypy, and a functional relation was not observed. Prompting alone did not appear to increase object manipulation until contingent reinforcement was added, and response blocking did not appear to have an additive effect to increase object manipulation. Discussion: Results contradict findings of the replicated study and indicate need for further research, including research carried out in natural environments. Implications for Practitioners: Practitioners can use this research to justify the application of differential reinforcement of incompatible behavior using functional activities that result in meaningful reinforcement for students.

The Effect of Video Self-Modeling for Black Boys with Challenging Behaviors in an Urban Setting

Black boys generally have the most disparate outcomes (i.e. exclusionary punishment and office referrals) in regard to discipline in schools, which necessitates the need for interventions to help alleviate this issue. As such, the purpose of this study was to examine the effectiveness of a video self-modeling (VSM) intervention on students’ challenging behaviors in an urban school setting. Utilizing an A-B-A-B withdrawal design, four Black boys in elementary school participated in the intervention. Results of visual analysis and Tau-U (Zion −1, p = 0.0018; DeAndre −1, p = 0.0027; and Malik = −0.6775, p = 0.0343) indicated significant and positive effects of VSM in relation to students’ behavior. Furthermore, teachers found the intervention to be acceptable based on the Intervention Rating Profile-15 (IRP-15). Future research and implications for the use of video self-modeling in urban schools are discussed.

Evaluating the independent group contingency: “Mystery Student” on improving behaviors in head start classrooms

AbstractAn increasing number of preschool children exhibit challenging behavior in the classroom. Children enrolled in Head Start are particularly at risk for emotional and behavioral disorders due to numerous risk factors they face. Unfortunately, some preschool teachers are ill‐equipped to manage the challenging behaviors that preschool children exhibit. The current study investigated the effects of an independent group contingency, the Mystery Student Intervention, on improving preschool children's classroom behaviors. An ABAB withdrawal design was employed to determine the Mystery Student Intervention's effectiveness for decreasing disruptive behaviors and increasing appropriate behaviors in three Head Start classrooms. Results indicated that class‐wide aggregate disruptive behavior decreased, and appropriate behavior increased during the intervention phases for all three classrooms. Furthermore, teachers rated the Mystery Student Intervention as socially valid. Results of this study add to the limited research base on group contingencies in preschool settings.

Quantitative Techniques and Graphical Representations for Interpreting Results from Alternating Treatment Design.

Multiple quantitative methods for single-case experimental design data have been applied to multiple-baseline, withdrawal, and reversal designs. The advanced data analytic techniques historically applied to single-case design data are primarily applicable to designs that involve clear sequential phases such as repeated measurement during baseline and treatment phases, but these techniques may not be valid for alternating treatment design (ATD) data where two or more treatments are rapidly alternated. Some recently proposed data analytic techniques applicable to ATD are reviewed. For ATDs with random assignment of condition ordering, the Edgington's randomization test is one type of inferential statistical technique that can complement descriptive data analytic techniques for comparing data paths and for assessing the consistency of effects across blocks in which different conditions are being compared. In addition, several recently developed graphical representations are presented, alongside the commonly used time series line graph. The quantitative and graphical data analytic techniques are illustrated with two previously published data sets. Apart from discussing the potential advantages provided by each of these data analytic techniques, barriers to applying them are reduced by disseminating open access software to quantify or graph data from ATDs.

Resolving Long-Standing Uncertainty about the Clinical Efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) to Relieve Pain: A Comprehensive Review of Factors Influencing Outcome.

Pain is managed using a biopsychosocial approach and pharmacological and non-pharmacological treatments. Transcutaneous electrical nerve stimulation (TENS) is a technique whereby pulsed electrical currents are administered through the intact surface of the skin with the intention of alleviating pain, akin to ‘electrically rubbing pain away’. Despite over 50 years of published research, uncertainty about the clinical efficacy of TENS remains. The purpose of this comprehensive review is to critically appraise clinical research on TENS to inform future strategies to resolve the ‘efficacy-impasse’. The principles and practices of TENS are described to provide context for readers unfamiliar with TENS treatment. The findings of systematic reviews evaluating TENS are described from a historical perspective to provide context for a critical evaluation of factors influencing the outcomes of randomized controlled trials (RCTs); including sample populations, outcome measures, TENS techniques, and comparator interventions. Three possibilities are offered to resolve the impasse. Firstly, to conduct large multi-centered RCTs using an enriched enrolment with randomized withdrawal design, that incorporates a ‘run-in phase’ to screen for potential TENS responders and to optimise TENS treatment according to individual need. Secondly, to meta-analyze published RCT data, irrespective of type of pain, to determine whether TENS reduces the intensity of pain during stimulation, and to include a detailed assessment of levels of certainty and precision. Thirdly, to concede that it may be impossible to determine efficacy due to insurmountable methodological, logistical and financial challenges. The consequences to clinicians, policy makers and funders of this third scenario are discussed. I argue that patients will continue to use TENS irrespective of the views of clinicians, policy makers, funders or guideline panel recommendations, because TENS is readily available without prescription; TENS generates a pleasant sensory experience that is similar to easing pain using warming and cooling techniques; and technological developments such as smart wearable TENS devices will improve usability in the future. Thus, research is needed on how best to integrate TENS into existing pain management strategies by analyzing data of TENS usage by expert-patients in real-world settings.