Single-case experimental designs: a systematic review of published research and current standards

Efficacy of a parent-based treatment for children and adolescents with obsessive-compulsive disorder: Protocol of a multiple baseline, single-case experimental design study

Background

Pediatric obsessive-compulsive disorder (OCD) is a severely impairing disorder, associated with high levels of family accommodation (FA). Approximately 40 % of youth do not benefit from first-line treatment options (cognitive behavioral therapy or pharmacotherapy). Supportive Parenting for Anxious Childhood Emotions (SPACE) is a parent-based treatment, teaching parents to reduce FA and increase supportive parenting, thereby aiming to improve the child's OCD. This article presents the protocol of a multiple baseline single-case experimental design (SCED) study to test the efficacy of SPACE in reducing OCD severity and FA in youth with OCD.

Methods

This SCED consists of a baseline, treatment, and follow-up phase. In total 25 youth (7-18 years) with OCD, who previously received cognitive behavioral therapy (CBT) unsuccessfully, aborted treatment early, or were not able to receive CBT due to too high levels of OCD/anxiety, and their parents will be included. They will be randomly allocated to one of three baseline phase options (4, 6 or 8 weeks). The treatment phase consists of 12 weekly sessions of SPACE with parents. Throughout all phases, OCD severity and FA will be briefly assessed thrice a week. Standard clinical measurements assessing OCD severity and FA and secondary parameters will be conducted at six timepoints, till 6 months follow-up.

Conclusion

Combining the innovative SPACE treatment with a SCED provides detailed insight into the relationship between OCD and FA over time. Studying this in clinical practice in complex cases that are normally understudied, helps to improve more personalized care for youth with OCD.

Eye movement desensitization and reprocessing for posttraumatic stress disorder following acquired brain injury: A multiple baseline single case experimental design study across four cases

Posttraumatic stress disorder (PTSD) is prevalent in individuals with acquired brain injury (ABI). This study investigated the effectiveness and applicability of Eye Movement Desensitization and Reprocessing (EMDR) for PTSD in individuals with ABI. Data were collected using a non-concurrent multiple baseline single case experimental design (SCED), with a baseline, treatment, maintenance, and 3-month follow-up phase, across four cases. EMDR treatment was provided using a manualized standard EMDR protocol. The primary outcome was PTSD symptoms. Secondary outcomes were general mental health and cognitive functions. Visual analyses, TAU-U analyses, and analyses using the Reliable Change Index were performed. All four participants (two with TBI, two with stroke) showed a significant decrease in PTSD symptoms, which continued in maintenance and was retained at follow-up. The participants no longer fulfilled criteria for PTSD classification and showed reliable improvement in PTSD severity score post-treatment and at follow-up. No adverse events occurred and no adjustments in EMDR protocol were necessary. There was no consistent improvement in general mental health nor a consistent improvement in cognitive functioning. This study provided empirical support for the effectiveness and applicability of EMDR for PTSD in four participants with stroke or TBI.

Intervention research in anorexia nervosa - a plea for single case experimental designs

Anorexia nervosa (AN) is a severe eating disorder and among the mental disorders with the highest mortality rate. To date, not much is known about its development and maintenance, and treatment outcomes are improvable. At the same time, research on psychological interventions for AN is a complicated endeavor, often characterized by small sample sizes and methodological heterogeneity, which impedes the comparison and evaluation of treatment outcomes. In this paper, several population-related, therapist-related and methodological challenges that may be encountered during research on psychological interventions for AN are discussed. The use of single case experimental designs (SCEDs), which could account for several of these challenges, is suggested as a complementary approach to current methods of assessing treatment efficacy. The use of SCEDs could be beneficial to the field, by contributing to the knowledge about AN and to the development and evaluation of better treatments, which are sorely needed.

The Effect of the Virtual Reality-Based Biofeedback Intervention DEEP on Stress, Emotional Tension, and Anger in Forensic Psychiatric Inpatients: Mixed Methods Single-Case Experimental Design

BACKGROUND

Decreasing aggression through stress reduction is an important part of forensic psychiatric treatment. DEEP is an experience-based virtual reality intervention that uses biofeedback to train diaphragmatic breathing and increase relaxation. Although DEEP has shown promising results in reducing stress and anxiety in students and adolescents in special education, it has not been examined in forensic psychiatric populations.

OBJECTIVE

This study aimed to evaluate DEEP's potential to reduce stress, emotional tension, and anger in forensic psychiatric inpatients.

METHODS

A mixed methods, alternating treatment, single-case experimental design was conducted with 6 Dutch forensic inpatients. For 20 days, participants engaged in 4 DEEP sessions. Experience sampling was used for continuous monitoring of stress, emotional tension, and anger twice daily. A repeated linear mixed model was used as a primary statistical approach for analyzing the experience sampling data as well as visual analyses. Finally, semistructured interviews were conducted with participants and health care professionals to compare quantitative with qualitative results.

RESULTS

Of the 6 participants, 3 (50%) completed all 4 DEEP sessions, while the other 3 (50%) missed one session due to technical difficulties or absence from the inpatient clinic. P1 showed a significant reduction of stress after session 2 (β=-.865; P=.005). No significant changes over time were found, although an experienced effect was reported during the interviews. P2 showed no significant results. They reported the sessions as being repetitive, with no experienced effect. P3 showed a momentary increase of emotional tension after the first session (β=-.053; P=.002), but no changes were observed over time. No experienced effects were reported in the interview. P4 did not show significant results over time, and was hesitant to report clear experienced effects. P5 showed a significant decline of emotional tension (β=-.012; P=.006), stress (β=-.014; P=.007), and anger (β=-.007; P=.02) over time. They also reported short-term experienced effects in the interview. P6 showed a significant decline of stress over time (β=-.029; P<.001) and reported experiencing substantial effects. Finally, health care professionals reported a relaxing effect of DEEP in their patients but did not expect many long-term effects because no clear behavioral changes were observed.

CONCLUSIONS

DEEP shows promise in teaching deep breathing techniques to forensic psychiatric inpatients, potentially decreasing stress, emotional tension, and anger in some patients. However, DEEP is not a one-size-fits-all intervention that supports every patient because the effectiveness on the outcome measures varied among participants. To increase effectiveness, emphasis should be put on supporting patients to transfer deep breathing skills into their daily lives. This highlights the importance for the structural integration of DEEP into current treatment protocols.

Guidelines for evaluating and reporting social isolation and loneliness interventions

Given the unpleasant nature of social isolation and loneliness (SIL) and their negative effects on health and wellbeing, interventions are needed. However, persistent issues in the design, evaluation, and reporting of SIL interventions preclude conclusive evidence and commentary on the effectiveness of SIL interventions. Here, we propose guidelines for evaluating SIL interventions, firstly by operationalising them into two categories: (1) interventions aiming to reduce SIL as a primary outcome and (2) interventions aiming to improve non-SIL outcomes in the lives of individuals experiencing SIL. Secondly, we evaluate instruments for measuring SIL and research designs for studying intervention effectiveness. Thirdly, guidelines for reporting information about the intervention, study design, results, and discussion in SIL intervention studies are presented. These guidelines will help researchers to better and more consistently report on SIL interventions and improve comparability of SIL interventions, ultimately contributing to the improvement of interventions and to the mitigation of SIL.

Case Reports in the Integration of Technology with Cognitive Rehabilitation for Individuals with Memory Concerns and Their Care Partners

OBJECTIVE

Technology can be combined with psychological interventions to support older adults with memory concerns. Using a bi-phasic design, cognitive rehabilitation (CR) was integrated with off-the-shelf technology and delivered to two people with cognitive impairment, and one care partner.

METHOD

Pre- and post-intervention assessments were completed for all participants. Individuals with memory problems received pre- and post-intervention remote neuropsychological assessment (i.e., Rey auditory verbal learning test; mental alternations test; animal fluency), and the hospital anxiety and depression scale (HADS). The care partner completed the HADS, Zarit burden interview, and neuropsychiatric inventory questionnaire. Change metrics incorporated reliable change indices where possible. Goals were tracked using the Canadian occupation performance measure; these data were analyzed through visual inspection. A research journal (used to document intervention process) was analyzed thematically.

RESULTS

Results cautiously suggested our integration was feasible and acceptable across several technologies and varying goals. Across participants, significant changes in goal progress suggested the integration of technology with CR successfully facilitated goal performance and satisfaction. The research journal underscored the importance of a visual component, intervention flexibility, and a strong therapeutic alliance in integrating technology and CR.

CONCLUSIONS

CR and technology present a promising avenue for supporting people living with cognitive impairment. Further exploration of technology and CR with a range of etiologies and target goals is warranted.

Augmented Depression Therapy for young adults: A mixed methods randomised multiple baseline case series evaluation

Augmented Depression Therapy (ADepT) is an individual psychotherapy for depression, which has been shown to be effective in the general adult population. A randomised multiple baseline case series evaluated the feasibility, acceptability, and effectiveness of ADepT in young adults (aged 20-24). Eleven depressed young adults were recruited from a UK university wellbeing service to receive ADepT during the COVID-19 pandemic, with outcomes evaluated relative to pre-specified continuation targets. All participants received a minimum adequate treatment dose (>60% target); 89% judged ADepT as acceptable and satisfactory and would recommend it to others (>60% target); only 9% showed reliable deterioration for depression or wellbeing (meeting <30% target); and there were no trial- or treatment-related serious adverse events. Qualitative interviews revealed most participants were satisfied with and experienced benefits from ADepT. At post-treatment, reliable improvement was shown by 33% of participants for depression and 67% of participants for wellbeing (not meeting target of both >60%), with medium effect size improvements for depression (g = 0.78) and large effect size improvement for wellbeing (g = 0.93; not meeting target of both >0.80). ADepT is feasible, acceptable, and safe in young adults but may require modification to maximise effectiveness. Further research outside of the COVID-19 pandemic is warranted.

Riding waves to improve functioning: a quantitative evaluation of a Surf Week in individuals with chronic phase brain injury with six months follow-up

PURPOSE

Environmental enrichment seems to enable people in the chronic phase of acquired brain injury (ABI) to experience new functional abilities and motor/coping strategies and consequently to become more adaptable which might prevent/reverse functional decline. This study describes the influence of a five-days Surf Week program on participants on physical function, self-efficacy, functional balance performance and self-perceived recovery.

MATERIALS AND METHODS

A multiple-baseline single-case design was used. Adults participating in the Surf Week in chronic phase of ABI were eligible to participate. Participants completed a battery of tests monitoring physical function, self-efficacy, functional balance performance and self-perceived recovery. This battery was repeated 5 times over a 1-year period, two times pre-Surf Week, three times post-Surf Week. Visual data inspection with two non-overlap methods were used to determine if patients showed sustained improvement in outcomes post-intervention.

RESULTS

A moderate to strong indication for improvements on physical function, functional balance performance and self-perceived recovery exists till six months follow-up. No indication was observed on self-efficacy till six months follow-up.

CONCLUSIONS

A five-days Surf Week is a physically, cognitively and socially intensive stimulating activity that can positively challenge individuals after ABI and seems to improve physical functioning, functional balance performance and self-perceived recovery.

Mindful With Your Baby/Toddler: A Single Case Design (SCD) Study

Transitioning to motherhood comes with new and intensive tasks that may cause parental stress, low parental self-efficacy, and internalizing problems. This can in turn negatively affect the mother-child relationship. Mindful with your Baby/Toddler (MwyB/T) is a mindfulness-based intervention for parents of young children experiencing parental stress and internalizing problems. Previous evaluative studies showed promising results, but methodology of these studies was limited. The current study used a single case design, including a baseline, intervention, posttest, and follow-up phase, to evaluate the effectiveness of MwyB/T. Ten participants were included and completed daily administered personalized items and validated questionnaires measuring mindfulness, mindful parenting, parental self-efficacy, internalizing problems, and parental stress, for 10 participants. Personalized items were first coded into themes and then assessed using visual analysis and descriptive effect size measures. Reliable change indices were computed for the questionnaires. All mothers improved on personalized items, with most improving on most (or all) of their items. On the questionnaires the majority of mothers improved. Results indicate that MwyB/T could benefit mothers with various intervention goals. More research is needed on the role of personalized items, both as a research measure and an as a possible additional element of interventions.

State of the Science: The Hierarchical Taxonomy of Psychopathology (HiTOP)

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a dimensional framework for psychopathology advanced by a consortium of nosologists. In the HiTOP system, psychopathology is grouped hierarchically from super-spectra, spectra, and subfactors at the upper levels to homogeneous symptom components and maladaptive traits and their constituent symptoms, and maladaptive behaviors at the lower levels. HiTOP has the potential to improve clinical outcomes by planning treatment based on symptom severity rather than heterogeneous diagnoses, targeting treatment across different levels of the hierarchy, and assessing distress and impairment separately from the observed symptom profile. Assessments can be performed according to this framework with the recently developed HiTOP-Self-Report (HiTOP-SR). Examples of how to use HiTOP in clinical practice are provided for the internalizing spectrum, including the use of the Unified Protocol and other modularized treatments, measurement-based care, psychopharmacology, and in traditionally underserved populations. Future directions are discussed in this State of the Science review including HiTOP's use in further developing transdiagnostic treatments, extending the model to include other information such as environmental factors, establishing the treatment utility of clinical assessment for the HiTOP-SR, developing new treatments, and disseminating the model.

Psychiatric neuroimaging designs for individualised, cohort, and population studies

Psychiatric neuroimaging faces challenges to rigour and reproducibility that prompt reconsideration of the relative strengths and limitations of study designs. Owing to high resource demands and varying inferential goals, current designs differentially emphasise sample size, measurement breadth, and longitudinal assessments. In this overview and perspective, we provide a guide to the current landscape of psychiatric neuroimaging study designs with respect to this balance of scientific goals and resource constraints. Through a heuristic data cube contrasting key design features, we discuss a resulting trade-off among small sample, precision longitudinal studies (e.g., individualised studies and cohorts) and large sample, minimally longitudinal, population studies. Precision studies support tests of within-person mechanisms, via intervention and tracking of longitudinal course. Population studies support tests of generalisation across multifaceted individual differences. A proposed reciprocal validation model (RVM) aims to recursively leverage these complementary designs in sequence to accumulate evidence, optimise relative strengths, and build towards improved long-term clinical utility.

From the Individual to the Group: Using Idiographic Analyses and Two-Stage Random Effects Meta-Analysis to Obtain Population Level Inferences for within-Person Processes

In psychology, the use of portable technology and wearable devices to ease participant burden in data collection is on the rise. This creates increased interest in collecting real-time or near real-time data from individuals within their natural environments. As a result, vast amounts of observational time series data are generated. Often, motivation for collecting this data hinges on understanding within-person processes that underlie psychological phenomena. Motivated by the body of Dr. Peter Molenaar's life work calling for analytical approaches that consider potential heterogeneity and non-ergodicity, the focus of this paper is on using idiographic analyses to generate population inferences for within-person processes. Meta-analysis techniques using one-stage and two-stage random effects meta-analysis as implemented in single-case experimental designs are presented. The case for preferring a two-stage approach for meta-analysis of single-subject observational time series data is made and demonstrated using an empirical example. This provides a novel implementation of the methodology as prior implementations focus on applications to short time series with experimental designs. Inspired by Dr. Molenaar's work, we describe how an approach, two-stage random effects meta-analysis (2SRE-MA), aligns with recent calls to consider idiographic approaches when making population-level inferences regarding within-person processes.

Pathways to personalized medicine-Embracing heterogeneity for progress in clinical therapeutics research in Alzheimer's disease

Biological and clinical heterogeneity is a major challenge in research for developing new treatments for Alzheimer's disease (AD). AD may be defined by its amyloid beta and tau pathologies, but we recognize that mixed pathologies are common, and that diverse genetics, central nervous system (CNS) and systemic pathophysiological processes, and environmental/experiential factors contribute to AD's diverse clinical and neuropathological features. All these factors are rational targets for therapeutic development; indeed, there are hundreds of candidate pharmacological, dietary, neurostimulation, and lifestyle interventions that show benefits in homogeneous laboratory models. Conventional clinical trial designs accommodate heterogeneity poorly, and this may be one reason that progress in translating candidate interventions has been so difficult. We review the challenges of AD's heterogeneity for the clinical trials enterprise. We then discuss how advances in repeatable biomarkers and digital phenotyping enable novel "single-case" and adaptive trial designs to accelerate therapeutics development, moving us closer to personalized research and medicine for AD. HIGHLIGHTS: Alzheimer's disease is diverse in its clinical features, course, risks, and biology. Typical randomized controlled trials are exclusive and necessarily large to attain arm comparability with broad outcomes. Repeated blood biomarkers and digital tracking can improve outcome measure precision and sensitivity. This enables the use of novel "single-case" and adaptive trial designs for inclusivity, rigor, and efficiency.

Impact of a Pilates intervention on physical function in children with generalised joint hypermobility and chronic musculoskeletal pain: A single-case experimental design

AIM

To assess the impact of a Physiotherapist-led Pilates Intervention for school aged children with Generalised Joint Hypermobility (GJH) on pain, physical function and Health Related Quality of Life (HRQoL).

METHODS

Three children aged 8-12 years with GJH participated in an 8 week Physiotherapist-led Pilates Intervention within a single-case experimental design (multiple baseline design). Repeated measures were collected during baseline, intervention, withdrawal and follow-up, for: (i) pain, (ii) physical function as measured by muscle strength, postural control, fatigue and activity levels and (iii) HRQoL.

RESULTS

Within the intervention phase, two children showed reduced fatigue and one child improved in muscle group strength of hip abduction (gluteus medius) and scapula adduction/rotation (rhomboideus major/minor) and HRQoL. No improvements were seen in pain or postural control. Within the early withdrawal phase all children showed improved strength for at least two muscle groups and one child showed reduced fatigue, pain (worst in last week) and improved postural control (functional reach lateral).

CONCLUSIONS

Pilates may provide an effective intervention for children with GJH to reduce fatigue and improve muscle strength and HRQoL. Limited conclusions can be made regarding pain and postural control. Further research with a longer Pilates duration is needed to confirm the dose and benefits for this population.

A Systematic Quality Review of Single-Case Experimental Designs Using Acceptance and Commitment Therapy in Adult Clinical Populations

Recent publications within Contextual Behavioral Science provided a rationale for the expansion of intervention efficacy research using methods that capture idiographic factors and processes. We conducted a systematic review of the use and quality of single-case experimental designs (SCED) within the Acceptance and Commitment Therapy (ACT) literature in adult clinical populations. The systematic review was conducted according to PRISMA guidelines and the databases CINAHL, MEDLINE, PsycINFO, PsycArticles and OpenGrey were searched for peer-reviewed articles. Further studies were sought through review of reference lists of all full text studies. Studies were assessed against What Works Clearinghouse (WWC) single-case design standards. Twenty-six studies met eligibility criteria and were conducted within research teams all implementing multiple-baseline designs. Twenty-four studies did not meet WWC standards with most failing to ensure a degree of concurrence across participants. The extent of randomisation methods was also captured. The review highlights the sparsity of SCEDs within ACT literature in clinical populations and current methodological practices. Limitations of the review and implications for future research are discussed.

Advancing randomized controlled trial methodologies: The place of innovative trial design in eating disorders research

Randomized controlled trials can be used to generate evidence on the efficacy and safety of new treatments in eating disorders research. Many of the trials previously conducted in this area have been deemed to be of low quality, in part due to a number of practical constraints. This article provides an overview of established and more innovative clinical trial designs, accompanied by pertinent examples, to highlight how design choices can enhance flexibility and improve efficiency of both resource allocation and participant involvement. Trial designs include individually randomized, cluster randomized, and designs with randomizations at multiple time points and/or addressing several research questions (master protocol studies). Design features include the use of adaptations and considerations for pragmatic or registry-based trials. The appropriate choice of trial design, together with rigorous trial conduct, reporting and analysis, can establish high-quality evidence to advance knowledge in the field. It is anticipated that this article will provide a broad and contemporary introduction to trial designs and will help researchers make informed trial design choices for improved testing of new interventions in eating disorders. PUBLIC SIGNIFICANCE: There is a paucity of high quality randomized controlled trials that have been conducted in eating disorders, highlighting the need to identify where efficiency gains in trial design may be possible to advance the eating disorder research field. We provide an overview of some key trial designs and features which may offer solutions to practical constraints and increase trial efficiency.

The effect of novel Head and Trunk Control Rehabilitation (HATCoRe) device in children with cerebral palsy: Single-Subject multiple baseline protocol

Objective

Head and trunk control is essential for enhancing engagement and participation by improving visual integration, respiration, oromotor skill, arm control, and self-care. Our study protocol aims to investigate the effect of novel Head And Trunk Control Rehabilitation (HATCoRe) device on promoting head and trunk control in children with Cerebral Palsy (CP).

Method

This single subject multiple baseline design trial will include six children with CP aged two to 10 years, exhibiting delayed head and trunk control, having Gross Motor Function Classification System level IV and V will be enrolled. Participants will be randomly assigned to 4-, 6-, or 8-weeks baseline phases followed by 16-week intervention phase with HATCoRe device, for 30-45 min thrice weekly; and follow-up phase of 9 weeks. The study will span for 29 to 33 weeks. An experienced pediatric physiotherapist, blinded to the baseline duration, will assess the outcome measures through 15 to 19 observations. Structured visual analysis will be used supplemented with the celeration line approach to detect statistically significant change.

Impact

HATCoRe device can enable health-care professionals to objectively measure head movement trajectories in children with CP. If proven effective, clinicians may utilize this device to create interactive and child engaging sessions.

A Description of Missing Data in Single-Case Experimental Designs Studies and an Evaluation of Single Imputation Methods

Missing data is inevitable in single-case experimental designs (SCEDs) studies due to repeated measures over a period of time. Despite this fact, SCEDs implementers such as researchers, teachers, clinicians, and school psychologists usually ignore missing data in their studies. Performing analyses without considering missing data in an intervention study using SCEDs or a meta-analysis study including SCEDs studies in a topic can lead to biased results and affect the validity of individual or overall results. In addition, missingness can undermine the generalizability of SCEDs studies. Considering these drawbacks, this study aims to give descriptive and advisory information to SCEDs practitioners and researchers about missing data in single-case data. To accomplish this task, the study presents information about missing data mechanisms, item level and unit level missing data, planned missing data designs, drawbacks of ignoring missing data in SCEDs, and missing data handling methods. Since single imputation methods among missing data handling methods do not require complicated statistical knowledge, are easy to use, and hence are more likely to be used by practitioners and researchers, the present study evaluates single imputation methods in terms of intervention effect sizes and missing data rates by using a real and hypothetical data sample. This study encourages SCEDs implementers, and also meta-analysts to use some of the single imputation methods to increase the generalizability and validity of the study results in case they encounter missing data in their studies.

Prolonged exposure treatment for post-traumatic stress disorder: Single case studies in a sample of adults with mild intellectual disabilities

BACKGROUND

Post-traumatic stress disorder (PTSD) is common in adults with intellectual disabilities. Often there are additional disorders such as substance use, mood and anxiety disorders. The current study focuses on the feasibility and initial efficacy of prolonged exposure (PE) for PTSD in adults with mild intellectual disabilities. The secondary effect of PE on additional mood, anxiety and substance use disorders is also examined.

METHODS

A single case experimental design (N = 12) with an A (baseline)-B (intervention) phase including a follow-up measurement after 3 months was conducted. Time series and single time points measurements were performed.

RESULTS

Six participants dropped-out. The results showed a significant decrease in PTSD symptoms and a significant decrease in additional symptoms (social avoidance, anxiety and stress), among participants who completed treatment.

CONCLUSION

PE appears to be a feasible and effective treatment for PTSD in some adults with mild intellectual disabilities. Suggestions emerge from this study to make standard PE treatment more appropriate for adults with mild intellectual disabilities. Further research is needed to reduce drop-out in trauma treatment. Some suggestions for this are made in this study. Treatment of PTSD with PE did not appear to affect comorbid mood disorders. Further research is needed.

Type I error rates and power of two randomization test procedures for the changing criterion design

Single-case experimental design (SCED) data can be analyzed following different approaches. One of the first historically proposed options is randomizations tests, benefiting from the inclusion of randomization in the design: a desirable methodological feature. Randomization tests have become more feasible with the availability of computational resources, and such tests have been proposed for all major types of SCEDs: multiple-baseline, reversal/withdrawal, alternating treatments, and changing criterion designs. The focus of the current text is on the last of these, given that they have not been the subject of any previous simulation study. Specifically, we estimate type I error rates and statistical power for two different randomization procedures applicable to changing criterion designs: the phase change moment randomization and the blocked alternating criterion randomization. We include different series lengths, number of phases, levels of autocorrelation, and random variability. The results suggest that type I error rates are generally controlled and that sufficient power can be achieved with as few as 28-30 measurements for independent data, although more measurements are needed in case of positive autocorrelation. The presence of a reversal to a previous criterion level is beneficial. R code is provided for carrying out randomization tests following the two randomization procedures.

How to assess and take into account trend in single-case experimental design data

One of the data features that are expected to be assessed when analyzing single-case experimental designs (SCED) data is trend. The current text deals with four different questions that applied researchers can ask themselves when assessing trend and especially when dealing with improving baseline trend: (a) What options exist for assessing the presence of trend?; (b) Once assessed, what criterion can be followed for deciding whether it is necessary to control for baseline trend?; (c) What strategy can be followed for controlling for baseline trend?; and (d) How to proceed in case there is baseline trend only in some A-B comparisons? Several options are reviewed for each of these questions in the context of real data, and tentative recommendations are provided. A new user-friendly website is developed to implement the options for fitting a trend line and a criterion for selecting a specific technique for that purpose. Trend-related and more general data analytical recommendations are provided for applied researchers.Trial registration: ClinicalTrials.gov identifier: NCT04560777.

Rise of single-case experimental designs: A historical overview of the necessity of single-case methodology

ABSTRACTWindelband ([1894]1980) advocated that two approaches are used for accumulating scientific knowledge. The first is the idiographic approach that derives knowledge from a single unit, and the second is the nomothetic approach that accumulates knowledge of a group. Given these two approaches, the former matches case studies while the latter is more appropriate with experimental group studies. Scientists have criticized both methodologies for their various limitations. Later, the single-case methodology emerged as an alternative that potentially allays these limitations. In this context, this narrative review aims to describe the historical roots of single-case experimental designs (SCEDs) that have emerged to eliminate the tension of nomothetic and idiographic approaches over time. First, the review focuses on the emergence of SCEDs. Second, the strengths and challenges of SCEDs are reviewed, including those to address the limitations of group experimental and case studies. Third, the use and analyses of SCEDs are outlined, considering their current status. Fourth, this narrative review continues to delineate the dissemination of SCEDs in the modern scientific world. As a result, SCEDs can be evaluated as a method that has the potential to overcome the issues encountered in case description and group experimental research. Thus, that helps accumulate nomothetic and idiographic knowledge in determining evidence-based practices.

ABkPowerCalculator: An App to Compute Power for Balanced (AB)k Single Case Experimental Designs

Single case experimental designs are an important research design in behavioral and medical research. Although there are design standards prescribed by the What Works Clearinghouse for single case experimental designs, these standards do not include statistically derived power computations. Recently we derived the equations for computing power for (AB)k designs. However, these computations and the software code in R may not be accessible to applied researchers who are most likely to want to compute power for their studies. Therefore, we have developed an (AB)k power calculator Shiny App (https://abkpowercalculator.shinyapps.io/ABkpowercalculator/) that researchers can use with no software training. These power computations assume that the researcher would be interested in fitting multilevel models with autocorrelations or conduct similar analyses. The purpose of this software contribution is to briefly explain how power is derived for balanced (AB)k designs and to elaborate on how to use the Shiny App. The app works well on not just computers but mobile phones without installing the R program. We believe this can be a valuable tool for practitioners and applied researchers who want to plan their single case studies with sufficient power to detect appropriate effect sizes.

Characteristics of Missing Data in Single-Case Experimental Designs: An Investigation of Published Data

Single-case experimental designs (SCEDs) have grown in popularity in the fields such as education, psychology, medicine, and rehabilitation. Although SCEDs are valid experimental designs for determining evidence-based practices, they encounter some challenges in analyses of data. One of these challenges, missing data, is likely to be occurred frequently in SCEDs research due to repeated measurements over time. Since missing data is a critical factor that can weaken the validity and generalizability of a study, it is important to determine the characteristics of missing data in SCEDs, which are especially conducted with a small number of participants. In this regard, this study aimed to describe missing data features in SCEDs studies in detail. To accomplish this goal, 465 published SCEDs studies within the recent 5 years in six journals were included in the investigation. The overall results showed that the prevalence of missing data among SCEDs articles in at least one phase, as at least one data point, was approximately 30%. In addition, the results indicated that the missing data rates were above 10% within most studies where missing data occurred. Although missing data is so common in SCEDs research, only a handful of studies (5%) have handled missing data; however, their methods are traditional. In analyzing SCEDs data, several methods are proposed considering missing data ratios in the literature. Therefore, missing data rates determined in this study results can shed light on the analyses of SCEDs data with proper methods by improving the validity and generalizability of study results.

Brief individual experiential schema therapy in adult outpatients with cluster C personality disorders: Does it work?

This study investigated the effectiveness of brief individual experiential schema therapy (ST) in 12 adult outpatients with cluster C personality disorders (PD) using randomised multiple baseline design. Waitlist period was followed by five explorative sessions, 18 experiential ST sessions, two treatment follow-up (FU) booster sessions and a 6-month FU assessment. Overall well-being (ORS), behavioural treatment goals and negative core beliefs were assessed 60-91 times, global symptomatic distress (BSI) six times. PD severity (SCID-5-PD) was pre-post-analysed. Randomisation and non-parametric tests showed large significant effects (d = 1.08-2.38, r = .53-.66) on all outcomes at treatment-FU and 6-month FU assessment. This is the first study providing preliminary evidence of effectiveness of brief individual experiential ST for patients with cluster C PD, tentatively challenging the common tenet that long treatment duration is required. Due to limitations, replication is recommended.

Examining the normality assumption of a design-comparable effect size in single-case designs

What Works Clearinghouse (WWC, 2022) recommends a design-comparable effect size (D-CES; i.e., gAB) to gauge an intervention in single-case experimental design (SCED) studies, or to synthesize findings in meta-analysis. So far, no research has examined gAB's performance under non-normal distributions. This study expanded Pustejovsky et al. (2014) to investigate the impact of data distributions, number of cases (m), number of measurements (N), within-case reliability or intra-class correlation (ρ), ratio of variance components (λ), and autocorrelation (ϕ) on gAB in multiple-baseline (MB) design. The performance of gAB was assessed by relative bias (RB), relative bias of variance (RBV), MSE, and coverage rate of 95% CIs (CR). Findings revealed that gAB was unbiased even under non-normal distributions. gAB's variance was generally overestimated, and its 95% CI was over-covered, especially when distributions were normal or nearly normal combined with small m and N. Large imprecision of gAB occurred when m was small and ρ was large. According to the ANOVA results, data distributions contributed to approximately 49% of variance in RB and 25% of variance in both RBV and CR. m and ρ each contributed to 34% of variance in MSE. We recommend gAB for MB studies and meta-analysis with N ≥ 16 and when either (1) data distributions are normal or nearly normal, m = 6, and ρ = 0.6 or 0.8, or (2) data distributions are mildly or moderately non-normal, m ≥ 4, and ρ = 0.2, 0.4, or 0.6. The paper concludes with a discussion of gAB's applicability and design-comparability, and sound reporting practices of ES indices.

Power analysis for idiographic (within-subject) clinical trials: Implications for treatments of rare conditions and precision medicine

Power analysis informs a priori planning of behavioral and medical research, including for randomized clinical trials that are nomothetic (i.e., studies designed to infer results to the general population based on interindividual variabilities). Far fewer investigations and resources are available for power analysis of clinical trials that follow an idiographic approach, which emphasizes intraindividual variabilities between baseline (control) phase versus one or more treatment phases. We tested the impact on statistical power to detect treatment outcomes of four idiographic trial design factors that are under researchers' control, assuming a multiple baseline design: sample size, number of observations per participant, proportion of observations in the baseline phase, and competing statistical models (i.e., hierarchical modeling versus piecewise regression). We also tested the impact of four factors that are largely outside of researchers' control: population size, proportion of intraindividual variability due to residual error, treatment effect size, and form of outcomes during the treatment phase (phase jump versus gradual change). Monte Carlo simulations using all combinations of the factors were sampled with replacement from finite populations of 200, 1750, and 3500 participants. Analyses characterized the unique relative impact of each factor individually and all two-factor combinations, holding all others constant. Each factor impacted power, with the greatest impact being from larger treatment effect sizes, followed respectively by more observations per participant, larger samples, less residual variance, and the unexpected improvement in power associated with assigning closer to 50% of observations to the baseline phase. This study's techniques and R package better enable a priori rigorous design of idiographic clinical trials for rare diseases, precision medicine, and other small-sample studies.

Pediatric Tube Weaning: A Meta-Analysis of Factors Contributing to Success

Approximately 3-10% of children have severe feeding issues, and some require enteral/tube nutrition to grow and thrive. For many children, tube feeding is temporary, making efficacious interventions for tube weaning essential. We conducted a systematic review and meta-analysis of tube weaning treatments. Outcomes included percentage of participants completely weaned from the tube, and mean percentage of kilocalories consumed orally following treatment. Data were extracted from 42 studies, including cohort studies and single-subject research design studies. We evaluated moderators of treatment success, including treatment setting, use of behavioral approaches, use of hunger provocation, and use of a multidisciplinary approach. Results indicated that, after treatment, children received significantly more calories orally, and 67-69% of children were fully weaned. These analyses suggest that current interventions are generally effective; however, variability within treatments exist. Prospective randomized clinical trials are needed to understand effective components of weaning interventions.

Does the choice of a linear trend-assessment technique matter in the context of single-case data?

Trend is one of the data aspects that is an object of assessment in the context of single-case experimental designs. This assessment can be performed both visually and quantitatively. Given that trend, just like other relevant data features such as level, immediacy, or overlap does not have a single operative definition, a comparison among the existing alternatives is necessary. Previous studies have included illustrations of differences between trend-line fitting techniques using real data. In the current study, I carry out a simulation to study the degree to which different trend-line fitting techniques lead to different degrees of bias, mean square error, and statistical power for a variety of quantifications that entail trend lines. The simulation involves generating both continuous and count data, for several phase lengths, degrees of autocorrelation, and effect sizes (change in level and change in slope). The results suggest that, in general, ordinary least squares estimation performs well in terms of relative bias and mean square error. Especially, a quantification of slope change is associated with better statistical results than quantifying an average difference between conditions on the basis of a projected baseline trend. In contrast, the performance of the split-middle (bisplit) technique is less than optimal.

Transition States in Single Case Experimental Designs

The continuation of a baseline pattern of responding into a treatment phase, sometimes referred to as a "transition state," can obscure interpretation of data depicted in single-case experimental designs (SCEDs). For example, when using visual analysis, transition states may lead to the conclusion that the treatment is ineffective. Likewise, the inclusion of overlapping data points in some statistical analyses may lead to conclusions that the treatment had a small effect size and give rise to publication bias. This study reviewed 20 volumes in a journal that publishes primarily SCEDs studies. We defined a transition state as a situation wherein at least the first three consecutive data points of a treatment phase or condition are within the range of the baseline phase or condition. Results indicate that transitions states (a) were present for 7.4% of graphs that met inclusion criteria and (b) occurred for a mean of 4.9 data points before leading to behavior change. We discuss some implications and directions for future research on transition states.

Do not disturb: Visitors' effect on the behavior and welfare of female and male big cats in zoos

The effect of visitor presence on animal behavior needs to be evaluated to ensure the welfare and improve the husbandry of the individuals in zoos. This study aims to assess the effect of visitor presence on the behavior and welfare of pairs of Amur tiger, snow leopard, and Eurasian lynx at Parco Natura Viva, Italy. The study was made of two periods: the baseline, in which the zoo was closed, and the visitor presence period, in which the zoo was opened. Per period and per subject 12 30-min observations were done. Continuous focal animal sampling method was used to collect behavior duration of the big cats. The main results of the study highlighted that, when visitors were present, all felids except for the female lynx were significantly more inactive than in the baseline. Moreover, despite interindividual and inter-species variability in the significance level of findings, natural behaviors such as attentive behavior, exploration/marking, locomotion, and positive social interactions were performed more in the baseline than in the visitor presence period. Finally, when visitors were present, as the studied subjects experienced daily longer exposure to visitors, inactivity increased whereas individual species-typical behaviors (e.g., locomotion) and positive social interactions decreased. Thus, visitors seem to partially alter the behavioral time-budgets of the study big cats, increasing inactivity and decreasing the performance of species-specific behavior, at least in some individuals.

Single-Case Data Analysis: A Practitioner Guide for Accurate and Reliable Decisions

Practitioners frequently use single-case data for decision-making related to behavioral programming and progress monitoring. Visual analysis is an important and primary tool for reporting results of graphed single-case data because it provides immediate, contextualized information. Criticisms exist concerning the objectivity and reliability of the visual analysis process. When practitioners are equipped with knowledge about single-case designs, including threats and safeguards to internal validity, they can make technically accurate conclusions and reliable data-based decisions with relative ease. This paper summarizes single-case experimental design and considerations for professionals to improve the accuracy and reliability of judgments made from single-case data. This paper can also help practitioners to appropriately incorporate single-case research design applications in their practice.

An Examination of Measurement Procedures and Characteristics of Baseline Outcome Data in Single-Case Research

There has been growing interest in using statistical methods to analyze data and estimate effect size indices from studies that use single-case designs (SCDs), as a complement to traditional visual inspection methods. The validity of a statistical method rests on whether its assumptions are plausible representations of the process by which the data were collected, yet there is evidence that some assumptions-particularly regarding normality of error distributions-may be inappropriate for single-case data. To develop more appropriate modeling assumptions and statistical methods, researchers must attend to the features of real SCD data. In this study, we examine several features of SCDs with behavioral outcome measures in order to inform development of statistical methods. Drawing on a corpus of over 300 studies, including approximately 1,800 cases, from seven systematic reviews that cover a range of interventions and outcome constructs, we report the distribution of study designs, distribution of outcome measurement procedures, and features of baseline outcome data distributions for the most common types of measurements used in single-case research. We discuss implications for the development of more realistic assumptions regarding outcome distributions in SCD studies, as well as the design of Monte Carlo simulation studies evaluating the performance of statistical analysis techniques for SCD data.

Consistency in Single-Case ABAB Phase Designs: A Systematic Review

The current article presents a systematic review of consistency in single-case ABAB phase designs. We applied the CONsistency of DAta Patterns (CONDAP) measure to a sample of 460 data sets retrieved from 119 applied studies published over the past 50 years. The main purpose was to (a) identify typical CONDAP values found in published ABAB designs and (b) develop interpretational guidelines for CONDAP to be used for future studies to assess the consistency of data patterns from similar phases. The overall distribution of CONDAP values is right-skewed with several extreme values to the right of the center of the distribution. The B-phase CONDAP values fall within a narrower range than the A-phase CONDAP values. Based on the cumulative distribution of CONDAP values, we offer the following interpretational guidelines in terms of consistency: very high, 0 ≤ CONDAP ≤ 0.5; high, 0.5 < CONDAP ≤ 1; medium, 1 < CONDAP < 1.5; low, 1.5 < CONDAP ≤ 2; very low, CONDAP > 2. We give examples of combining CONDAP benchmarks with visual analysis of single-case ABAB phase designs and conclude that the majority of data patterns (41.2%) in published ABAB phase designs is medium consistent.

The effectiveness of aerobic versus strengthening exercise therapy in individuals with chronic whiplash-associated disorder: a randomised single case experimental design study

PURPOSE

Recent RCTs and meta-analyses compare the effectiveness of different types of exercise for chronic whiplash associated disorder (WAD). This study aimed to verify whether the results of these studies translate to statistically significant and clinically meaningful effects in individual participants.

MATERIALS AND METHODS

A series of replicated randomised single case experimental design studies (SCEDs) with A-B design (A: baseline, B: intervention). Eight participants with chronic WAD (8 female, mean [SD] age 47 [10] years) were randomised into one of four baseline durations (5, 8, 11, and 14 days) and to one of two eight-week exercise interventions (aerobic or strengthening). Daily measures of pain intensity, bothersomeness, and interference were collected during the baseline phase and the intervention phase.

RESULTS

Visual analyses indicated that three participants in the aerobic exercise group meaningfully improved. No improvements were found in the strengthening group. Effect sizes favoured the aerobic exercise group, yet randomisation tests of pooled effects did not show a difference in between-intervention effectiveness.

CONCLUSION

Contrary to our expectations, three out of four participants were nearly pain-free at the end of the aerobic exercise intervention, whereas none of the participants in the strengthening group improved meaningfully. This suggests that aerobic exercise may be favourable for WAD.Implications for RehabilitationOur results suggest that aerobic exercises are favourable over strengthening exercises and may be the preferred option for patients with chronic WAD.We found substantial variability in self-reported outcomes within participants, clinicians should be aware of this in the judgement of treatment effectiveness.

Improving Romantic Relationship Functioning Among Young Men With First-Episode Psychosis: Impact of a Novel Group Intervention

Previous research has highlighted many of the challenges faced by individuals with psychosis in romantic relationships. The present study aimed to evaluate the impact of a novel group intervention for men with first-episode psychosis (FEP) on dating success, romantic and sexual functioning, self-esteem, self-stigma, mentalizing skills, and symptomatology, while using a repeated single-case experimental design and comparing results across two treatment modalities (i.e., in-person or online). Twenty-seven participants from five treatment sites completed a 12-week group intervention. Qualitative data was also collected to assess participants' subjective experiences with the program. In both modalities, significant improvements were observed for romantic functioning, mentalizing skills, and symptomatology, with effect sizes ranging from small to large. Several participants also attended more dates and entered committed relationships after the intervention. Most participants were satisfied with the program and many felt that they had learned new skills and gained confidence in dating. Future research should replicate these findings in larger and more inclusive samples.

Do single-case experimental designs lead to randomised controlled trials of cognitive behavioural therapy interventions for adolescent anxiety and related disorders recommended in the National Institute of Clinical Excellence guidelines? A systematic review

Background

Although Cognitive Behavioural Therapy (CBT) is effective for 60% of adolescents with anxiety disorders, only 36% are in remission post-intervention. This indicates that more effective treatments are needed which should be reflected in the NICE guidelines. We hypothesised that Single-case experimental designs (SCEDs) may provide a framework for accelerating the development of novel interventions. The primary purpose of this review was to investigate whether SCEDs are currently followed by randomised controlled trials (RCTs) of CBT intervention for adolescent anxiety disorders named in the NICE guidelines. The secondary objective was to investigate whether using SCEDs prior to RCTs could be a helpful approach.

Method

For the primary search of SCEDs five databases were used (PsycINFO, PubMed, PsycArticles, Web of Science and ProQuest). Nineteen articles met eligibility criteria including a total of 107 participants. For the secondary search of RCTs named in the NICE guidelines for adolescent anxiety disorders 53 articles met inclusion criteria and were included in the systematic review.

Results

The 19 SCED studies included in the review were conducted with participants with a diverse range of anxiety disorders and across a range of CBT formats. Two of the SCEDs were followed by RCTs, but neither of these were named in the NICE guidelines for anxiety disorders. All of the SCEDs identified were rated as low quality with none meeting the criteria for the highest or second highest quality rating. From the secondary searches, none of the RCTs named in the NICE guide were preceded by SCEDs.

Conclusions

It was concluded that currently SCEDs were not followed by RCTs of CBT interventions named in the NICE guidelines for adolescent anxiety disorders. However, it was suggested that SCEDs may provide an important framework for the development of more effective interventions for adolescents with anxiety.

Treatable brain network biomarkers in children in coma using task and resting-state functional MRI: a case series

The withdrawal of life-sustaining therapies is frequently considered for pediatric patients with severe acute brain injuries who are admitted to the intensive care unit. However, it is worth noting that some children with a resultant poor neurological status may ultimately survive and achieve a positive neurological outcome. Evidence suggests that adults with hidden consciousness may have a more favorable prognosis compared to those without it. Currently, no treatable network disorders have been identified in cases of severe acute brain injury, aside from seizures detectable through an electroencephalogram (EEG) and neurostimulation via amantadine. In this report, we present three cases in which multimodal brain network evaluation played a helpful role in patient care. This evaluation encompassed various assessments such as continuous video EEG, visual-evoked potentials, somatosensory-evoked potentials, auditory brainstem-evoked responses, resting-state functional MRI (rs-fMRI), and passive-based and command-based task-based fMRI. It is worth noting that the latter three evaluations are unique as they have not yet been established as part of the standard care protocol for assessing acute brain injuries in children with suppressed consciousness. The first patient underwent serial fMRIs after experiencing a coma induced by trauma. Subsequently, the patient displayed improvement following the administration of antiseizure medication to address abnormal signals. In the second case, a multimodal brain network evaluation uncovered covert consciousness, a previously undetected condition in a pediatric patient with acute brain injury. In both patients, this discovery potentially influenced decisions concerning the withdrawal of life support. Finally, the third patient serves as a comparative control case, demonstrating the absence of detectable networks. Notably, this patient underwent the first fMRI prior to experiencing brain death as a pediatric patient. Consequently, this case series illustrates the clinical feasibility of employing multimodal brain network evaluation in pediatric patients. This approach holds potential for clinical interventions and may significantly enhance prognostic capabilities beyond what can be achieved through standard testing methods alone.

Sport in prison: social and subjective health outcomes of different sport programs

PURPOSE

The purpose of this study is to examine the effects of four different sport programs on various social and subjective health outcomes among prisoners.

DESIGN/METHODOLOGY/APPROACH

Four different sport programs (endurance, strength, dance-like martial arts, soccer) were provided in 2020 and 2021 in a German prison. Participants completed paper-pencil surveys before and after the sport programs (n = 134 observations), including questions about potential social health (enjoyment of physical activity, interpersonal exchange, interpersonal trust, self-efficacy) and subjective health outcomes (health status, health satisfaction, well-being). Further information such as prisoner characteristics were added to the data.

FINDINGS

Results of regression analyses show that the endurance program had a significant positive effect on interpersonal trust, while the soccer program had a negative effect. Subjective well-being increased significantly after the strength and the soccer program. The weekly sport hours before imprisonment had a positive association with enjoyment of physical activity and interpersonal exchange while being negatively related to health status and health satisfaction. Furthermore, the number of months of imprisonment before the survey, being a young offender, the prisoners' body mass index, educational level and migration background were significantly associated with several social and subjective health outcomes.

ORIGINALITY/VALUE

This study analyzed the effects of different sport programs for prisoners on various social and subjective health outcomes, revealing differences across programs and outcomes. The findings suggest that sport can be a way to enhance prisoners' social and subjective health, ultimately facilitating their rehabilitation process.

A pilot multiple-baseline study of a mobile cognitive behavioral therapy for the treatment of eating disorders in university students

OBJECTIVE

Eating disorders (EDs) are serious psychiatric disorders associated with substantial morbidity and mortality that are prevalent among university students. Because many students do not receive treatment due to lack of access on university campuses, mobile-health (mHealth) adaptations of evidence-based treatments represent an opportunity to increase treatment accessibility and engagement. The purpose of this study was to test the initial efficacy of Building Healthy Eating and Self-Esteem Together for University Students (BEST-U), which is a 10-week mHealth self-guided cognitive-behavioral therapy (CBT-gsh) app that is paired with a brief 25-30-min weekly telehealth coaching, for reducing ED psychopathology in university students.

METHOD

A non-concurrent multiple-baseline design (N = 8) was used to test the efficacy of BEST-U for reducing total ED psychopathology (primary outcome), ED-related behaviors and cognitions (secondary outcomes), and ED-related clinical impairment (secondary outcome). Data were examined using visual analysis and Tau-BC effect-size calculations.

RESULTS

BEST-U significantly reduced total ED psychopathology and binge eating, excessive exercise, and restriction (effect sizes ranged from -0.39 to -0.92). Although body dissatisfaction decreased, it was not significant. There were insufficient numbers of participants engaging in purging to evaluate purging outcomes. Clinical impairment significantly reduced from pre-to-post-treatment.

DISCUSSION

The current study provided initial evidence that BEST-U is a potentially efficacious treatment for reducing ED symptoms and ED-related clinical impairment. Although larger-scale randomized controlled trials are needed, BEST-U may represent an innovative, scalable tool that could reach greater numbers of underserved university students than traditional intervention-delivery models.

PUBLIC SIGNIFICANCE

Using a single-case experimental design, we found evidence for the initial efficacy of a mobile guided-self-help cognitive-behavioral therapy program for university students with non-low weight binge-spectrum eating disorders. Participants reported significant reductions in ED symptoms and impairment after completion of the 10-week program. Guided self-help programs show promise for filling an important need for treatment among university students with an ED.

Integrated cognitive behavioral treatment for substance use and depressive symptoms: a homeless case series and feasibility study

BACKGROUND

Homelessness is associated with high prevalence of psychiatric disorders such as substance use disorders, including alcohol use disorder, and depression.

METHODS

This case series and feasibility trial evaluated a novel integrated cognitive behavioral treatment (ICBT), which was adapted specifically for homeless individuals and developed to treat substance use and depressive symptoms simultaneously. The ICBT was delivered among four homeless individuals enrolled in the Treatment First program (a social services program where treatment is offered in conjunction with temporary transitional housing), who had access to stable and sober housing milieus.

RESULTS

The ICBT was rated high in expectancy of improvement, credibility, and satisfaction, with few treatment-related adverse events, and fairly high treatment retention. At 12 months follow-up, three of four participants were not homeless anymore. Some participants experienced short-term reductions in substance use and/or depressive symptoms.

CONCLUSIONS

The study provided preliminary support that the ICBT can be a feasible and potentially effective treatment for homeless individuals with substance use and/or depressive symptoms. However, the delivery format within the Treatment First program was not feasible. The ICBT could be offered within the social services Housing First program instead (where permanent housing is offered before treatment), or to non-homeless individuals.

TRIAL REGISTRATION

The study was registered retrospectively at ClinicalTrials.gov (NCT05329181).

Comparing Presence and Absence of Initial In-Person Contact and Written Feedback in RE&CBT E-Supervision

This pilot study aims to analyze the effects of the presence and absence of initial in-person contact and written feedback in RE&CBT e-supervision, comparing it on the Supervisory Working Alliance Inventory, the Supervisor Satisfaction Questionnaire, and the Trainee Disclosure Scale. During a period of six months, five supervisees performed ten e-supervision divided into two groups, a control group that did only the initial meetings in-person and an experimental group in which two supervisees completed whole process online. Additionally, in the first five e-supervision, the supervisor reviewed an entire session with written feedback with an additional meeting for each group. In the last five e-supervision, the supervisor only partially reviewed client sessions during supervision. After ten e-supervision, an individual post-interview was conducted with each participant. This study's primary statistical method for calculating and combining effect sizes was Tarlow Baseline Corrected Tau and Open Meta Analyst software. Both groups scored above average on the first two scales, but the disclosure scale had highly irregular and inconsistent patterns. The combined qualitative and quantitative results suggest that novice therapists generally prefer to have their entire sessions reviewed with written feedback and that a single in-person contact is unlikely to influence e-supervision satisfaction and working alliance. Given that there are no adequately validated e-supervision models, this pilot study used a pilot model named Supported Model of Electronic Supervision (SMeS). This model showed potential, but it needs further testing on a larger sample with more clearly operationalized steps. This study experimentally supports the effectiveness of RE&CBT supervision for the first time.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10942-023-00505-2.

Simultaneous assessment and training of an upper-limb amputee using incremental machine-learning-based myocontrol: a single-case experimental design

BACKGROUND

Machine-learning-based myocontrol of prosthetic devices suffers from a high rate of abandonment due to dissatisfaction with the training procedure and with the reliability of day-to-day control. Incremental myocontrol is a promising approach as it allows on-demand updating of the system, thus enforcing continuous interaction with the user. Nevertheless, a long-term study assessing the efficacy of incremental myocontrol is still missing, partially due to the lack of an adequate tool to do so. In this work we close this gap and report about a person with upper-limb absence who learned to control a dexterous hand prosthesis using incremental myocontrol through a novel functional assessment protocol called SATMC (Simultaneous Assessment and Training of Myoelectric Control).

METHODS

The participant was fitted with a custom-made prosthetic setup with a controller based on Ridge Regression with Random Fourier Features (RR-RFF), a non-linear, incremental machine learning method, used to build and progressively update the myocontrol system. During a 13-month user study, the participant performed increasingly complex daily-living tasks, requiring fine bimanual coordination and manipulation with a multi-fingered hand prosthesis, in a realistic laboratory setup. The SATMC was used both to compose the tasks and continually assess the participant's progress. Patient satisfaction was measured using Visual Analog Scales.

RESULTS

Over the course of the study, the participant progressively improved his performance both objectively, e.g., the time required to complete each task became shorter, and subjectively, meaning that his satisfaction improved. The SATMC actively supported the improvement of the participant by progressively increasing the difficulty of the tasks in a structured way. In combination with the incremental RR-RFF allowing for small adjustments when required, the participant was capable of reliably using four actions of the prosthetic hand to perform all required tasks at the end of the study.

CONCLUSIONS

Incremental myocontrol enabled an upper-limb amputee to reliably control a dexterous hand prosthesis while providing a subjectively satisfactory experience. The SATMC can be an effective tool to this aim.

Single-case intervention research design standards: Additional proposed upgrades and future directions

Single-case intervention research design standards have evolved considerably over the past decade. These standards serve the dual role of assisting in single-case design (SCD) intervention research methodology and as guidelines for literature syntheses within a particular research domain. In a recent article (Kratochwill et al., 2021), we argued for a need to clarify key features of these standards. In this article we offer additional recommendations for SCD research and synthesis standards that have been either underdeveloped or missing in the conduct of research and in literature syntheses. Our recommendations are organized into three categories: expanding design standards, expanding evidence standards, and expanding the applications and consistency of SCDs. The recommendations we advance are for consideration for future standards, research design training, and they are especially important to guide the reporting of SCD intervention investigations as they enter the literature-synthesis phase of evidence-based practice initiatives.

The efficacy of mindfulness-based intervention in ameliorating externalizing behaviors and attentional concerns among college students

Objective: The purpose of this study was to investigate the efficacy of a mindfulness-based intervention among college students with externalizing behaviors and attentional problems. Participants: Three students attending their first year in college received mindfulness-based stress reduction (MBSR) intervention and data were collected pre-intervention, during the intervention, post-intervention, and follow-up. Methods: The study utilized a single-case design (SCD). Data were collected via the Conners continuous performance test, Third Edition (CPT-3), the Conners Continuous Auditory Test of Attention (CATA), the Behavioral Assessment Scale for Children, Flex Monitor, Third Edition (BASC-3 FM), and the Mindfulness Attention Awareness Scale (MAAS). Results: Data were analyzed by calculating standard error of the difference, reliable change index, non-overlap of all pairs (NAP), and Tau-U. Conclusions: The results of this study strongly suggest that mindfulness may be an effective intervention for addressing externalizing behaviors and attentional problems among first-year college students.

A Systematic Review of Derived Relational Responding Beyond Coordination in Individuals with Autism and Intellectual and Developmental Disabilities

As interest in derived relational responding has increased, so have the number of investigations evaluating interventions to promote the emergence of derived responding for individuals with autism, as well as other intellectual and developmental disabilities. However, much of the literature has focused on the relation of sameness, and less is known about interventions to facilitate derived responding in other relations. Systematic searches identified 38 studies contained in 30 articles that met inclusion criteria. These studies were analyzed according to their participants, assessment methods, experimental design, content taught, setting, teaching procedures, derived responses, outcomes, and reliability measures. The quality of the studies was measured using the Single Case Analysis and Research Framework (SCARF). The results of the current review indicate that many learners with autism spectrum disorder and other intellectual and developmental disabilities demonstrate derived relational responding beyond the relation of coordination across varied instructional content and teaching methodologies, but the quality and rigor of the published literature requires the results be interpreted with caution, leading to recommendations for future research.

The BEHAVE application as a tool to monitor inclusive interventions for subjects with neurodevelopmental disorders

In the last few years, many educational and therapeutic interventions for young people with neurodevelopmental disorders are based on systematic monitoring of the outcomes. These interventions are typically conducted using single-case experimental designs, (SCEDs) a set of methods aimed at testing the effect of an intervention on a single subject or a small number of subjects. In SCEDs, an effective process of decision-making needs accurate, precise, and reliable data but also that caregivers and health professionals can gather information with minimal effort. The use of Information Communication Technologies in SCEDs can support the process of data collection and analysis, facilitating the collection of accurate and reliable data, providing reports accessible also by non-experts, and promoting interactions and sharing among clinicians, educators, and caregivers. The present paper introduces the BEHAVE application, a web-based highly customizable application, designed to implement SCEDs, supporting both data collection and automatic analysis of the datasets. Moreover, the paper will describe two case studies of kindergarten children with neurodevelopmental disorders, highlighting how the BEHAVE application supported the entire process, from data collection in multiple contexts to decision-making based on the analysis provided by the system. In particular, the paper describes the case studies of Carlo and Dario, two children with severe language and communication impairments, and the inclusive education interventions carried out to maximize their participation in a typical home and school setting increasing their mand repertoire. Results revealed an increase in the mand repertoire in both children who become able to generalize the outcomes to multiple life contexts. The active participation of the caregivers played a crucial role in the ability of children to use the learned skills in settings different from the ones they were learned in.

Assistive technology for adults on the autism spectrum: A systematic survey

While the needs and care for children on the autism spectrum have been widely investigated, the intervention and services available to autistic adults have been overlooked for a long time. This survey paper reviewed 32 articles that described and evaluated assistive technologies that have been developed and evaluated through a complete circle of interactive product design from ideation, prototype, and user evaluation. These assistive technologies aim to improve independence and living quality in autistic adults. We extracted information from the perspective of requirement gathering, technology designing, and effectiveness of evaluation in the design cycle. We found a general lack of requirements-driven design, and the evaluation process was not standardized either. The lack of requirement gathering results in designs purely based on existing literature without targeting actual user needs. Our synthesis of included paper contributes to developing iterative design considerations in assistive technologies for autistic adults. We also suggest that assistive technologies for autistic adults shift some attention from assisting only autistic adults who require at least substantial support to embracing also those who have been living independently but rather have difficulties in social interaction. Assistive technologies for them have the potentials to help them consolidate and enhance their experiences in independent living.

Emotionally focused couple therapy in cancer survivor couples with marital and sexual problems: a replicated single-case experimental design

Objective

The current research examined the effect of Emotionally Focused Couples Therapy (EFCT) on perceived intimacy, affect, and dyadic connection in cancer survivor couples with relationship challenges.

Method

In this longitudinal replicated single-case study, positive and negative affect, intimacy, partner responsiveness, and expression of attachment-based emotional needs were reported every 3 days before and during treatment. Thirteen couples, with one partner having survived colorectal cancer or breast cancer, participated for the full duration of the study. Statistical analysis of the data was performed using randomization tests, piecewise regression, and multilevel analyses.

Results

Adherence to the therapeutic protocol was tested and found adequate. Compared with baseline, significant positive effects on affect variables were found during the therapeutic process. Positive affect increased and negative affect decreased. Partner responsiveness, perceived intimacy, and the expression of attachment-based emotional needs improved, but only in the later phase of treatment. Results at the group level were statistically significant, whereas effects at the individual level were not.

Discussion

This study found positive group-level effects of EFCT on affect and dyadic outcome measures in cancer survivors. The positive results warrant further research, including randomized clinical trials, to replicate these effects of EFCT in cancer survivor couples experiencing marital and sexual problems.