Rating the methodological quality of single-subject designs andn-of-1 trials: Introducing the Single-Case Experimental Design (SCED) Scale

A Meta-Analysis of Anomia Treatment in Bilingual Aphasia: Within- and Cross-Language Generalization and Predictors of the Treatment Outcomes

PURPOSE

The present meta-analysis investigated the efficacy of anomia treatment in bilingual and multilingual persons with aphasia (BPWAs) by assessing the magnitudes of six anomia treatment outcomes. Three of the treatment outcomes pertained to the "trained language": improvement of trained words (treatment effect [TE]), within-language generalization of semantically related untrained words (WLG-Related), and within-language generalization of unrelated words (WLG-Unrelated). Three treatment outcomes were for the "untrained language": improvement of translations of the trained words (cross-language generalization of trained words [CLG-Tx]), cross-language generalization of semantically related untrained words (CLG-Related), and cross-language generalization of unrelated untrained words (CLG-Unrelated). This study also examined participant- and treatment-related predictors of these treatment outcomes.

METHOD

This study is registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42023418147. Nine electronic databases were searched to identify word retrieval treatment studies of poststroke BPWAs of at least 6 months postonset. Pre- and posttreatment single-word naming scores were extracted for each eligible participant and used to calculate effect sizes (within-case Cohen's d) of the six treatment outcomes. Random-effects meta-analyses were conducted to assess weighted mean effect sizes of the treatment outcomes across studies. Multiple linear regression analyses were used to examine the effects of participant-related variables (pretreatment single-word naming and comprehension representing poststroke lexical processing abilities) and treatment-related variables (type, language, and duration). The methodological quality of eligible studies and the risk of bias in this meta-analysis were assessed.

RESULTS

A total of 17 published studies with 39 BPWAs were included in the meta-analysis. The methodological quality of the included studies ranged from fair (n = 4) to good (n = 13). Anomia treatment produced a medium effect size for TE (M = 8.36) and marginally small effect sizes for WLG-Related (M = 1.63), WLG-Unrelated (M = 0.68), and CLG-Tx (M = 1.56). Effect sizes were nonsignificant for CLG-Related and CLG-Unrelated. TE was significantly larger than the other five types of treatment outcomes. TE and WLG-Related effect sizes were larger for BPWAs with milder comprehension or naming impairments and for treatments of longer duration. WLG-Unrelated was larger when BPWAs received phonological treatment than semantic and mixed treatments. The overall risk of bias in the meta-analysis was low with a potential risk of bias present in the study identification process.

CONCLUSIONS

Current anomia treatment practices for bilingual speakers are efficacious in improving trained items but produce marginally small within-language generalization and cross-language generalization to translations of the trained items. These results highlight the need to provide treatment in each language of BPWAs and/or investigate other approaches to promote cross-language generalization. Furthermore, anomia treatment outcomes are influenced by BPWAs' poststroke single-word naming and comprehension abilities as well as treatment duration and the provision of phonological treatment.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25595712.

Characteristics of Moderators in Meta-Analyses of Single-Case Experimental Design Studies

Hierarchical linear modeling (HLM) has been recommended as a meta-analytic technique for the quantitative synthesis of single-case experimental design (SCED) studies. The HLM approach is flexible and can model a variety of different SCED data complexities, such as intervention heterogeneity. A major advantage of using HLM is that participant and-or study characteristics can be incorporated in the model in an attempt to explain intervention heterogeneity. The inclusion of moderators in the context of meta-analysis of SCED studies did not yet receive attention and is in need of methodological research. Prior to extending methodological work validating the hierarchical linear model including moderators at the different levels, an overview of characteristics of moderators typically encountered in the field is needed. This will inform design conditions to be embedded in future methodological studies and ensure that these conditions are realistic and representative for the field of SCED meta-analyses. This study presents the results of systematic review of SCED meta-analyses, with the particular focus on moderator characteristic. The initial search yielded a total of 910 articles and book chapters. After excluding duplicate studies and non peer-reviewed studies, 658 unique peer-reviewed studies were maintained and screened by two independent researchers. Sixty articles met the inclusion criteria and were eligible for data retrieval. The results of the analysis of moderator characteristics retrieved from these 60 meta-analyses are presented. The first part of the results section contains an overview of moderator characteristics per moderator level (within-participant level, participant level, and study level), including the types of moderators, the ratio of the number of moderators relative to the number of units at that level, the measurement scale, and the degree of missing data. The second part of the results section focuses on the metric used to quantify moderator effectiveness and the analysis approach. Based on the results of the systematic review, recommendations are given for conditions to be included in future methodological work.

An Algorithm to Evaluate Methodological Rigor and Risk of Bias in Single-Case Studies

Critical appraisal scales play an important role in evaluating methodological rigor (MR) of between-groups and single-case designs (SCDs). For intervention research this forms an essential basis for ascertaining the strength of evidence. Yet, few such scales provide classifications that take into account the differential weighting of items contributing to internal validity. This study aimed to develop an algorithm derived from the Risk of Bias in N-of-1 Trials (RoBiNT) Scale to classify MR and risk of bias magnitude in SCDs. The algorithm was applied to 46 SCD experiments. Two experiments (4%) were classified as Very High MR, 14 (30%) as High, 5 (11%) as Moderate, 2 (4%) as Fair, 2 (4%) as Low, and 21 (46%) as Very Low. These proportions were comparable to the What Works Clearinghouse classifications: 13 (28%) met standards, 8 (17%) met standards with reservations, and 25 (54%) did not meet standards. There was strong association between the two classification systems.

Probabilistic Reasoning in Homeopathy Practice and its Implications for Clinical Research

The principle of similitude put forward by Hahnemann has challenging practical consequences in the selection of the right homeopathic medicine for a patient. According to this principle, only the medicines that best fit the totality of the symptoms of a given patient are supposed to really cure: this greatly depends on the homeopath's clinical analysis. In addition, a patient's illness may be more or less curable, depending on the characteristics of the disease. In their daily practice, homeopaths typically apply Bayesian reasoning to deal with uncertainty associated with both medicine and disease. We suggest that clinical research on homeopathy would gain by integrating this kind of prior estimation of (1) the probability of a given medicine being effective for that particular patient and (2) the probability of the patient's disease (or symptoms) being curable. We therefore suggest that future trials of N-of-1 design may gain (1) by testing a small number of "best candidate" medicines (instead of one) for a given patient facing a given disease, and (2) by including careful prior estimations of the probabilities that (a) each selected medicine will be efficient for that patient and (b) the patient's disease will be reversible with the medicine.

Behavioral Treatment for Speech and Language in Primary Progressive Aphasia and Primary Progressive Apraxia of Speech: A Systematic Review

Primary progressive aphasia (PPA) and primary progressive apraxia of speech (PPAOS) are neurodegenerative syndromes characterized by progressive decline in language or speech. There is a growing number of studies investigating speech-language interventions for PPA/PPAOS. An updated systematic evaluation of the treatment evidence is warranted to inform best clinical practice and guide future treatment research. We systematically reviewed the evidence for behavioral treatment for speech and language in this population. Reviewed articles were published in peer-reviewed journals through 31 May 2021. We evaluated level of evidence, reporting quality, and risk of bias using a modified version of the American Speech-Language Hearing Association (ASHA) Levels of Evidence, an appraisal point system, additional reporting quality and internal/external validity items, and, as appropriate, the Single Case Experimental Design Scale or the Physiotherapy Evidence Database - PsycBITE Rating Scale for Randomized and Non-Randomized Controlled Trials. Results were synthesized using quantitative summaries and narrative review. A total of 103 studies reported treatment outcomes for 626 individuals with PPA; no studies used the diagnostic label PPAOS. Most studies evaluated interventions for word retrieval. The highest-quality evidence was provided by 45 experimental and quasi-experimental studies (16 controlled group studies, 29 single-subject designs). All (k = 45/45) reported improvement on a primary outcome measure; most reported generalization (k = 34/43), maintenance (k = 34/39), or social validity (k = 17/19) of treatment for at least one participant. The available evidence supports speech-language intervention for persons with PPA; however, treatment for PPAOS awaits systematic investigation. Implications and limitations of the evidence and the review are discussed.

Promising Strategies for Teaching Augmentative and Alternative Communication in Inclusive Educational Settings: A Systematic Review

PURPOSE

The purpose of this article was to conduct a systematic review of the literature on teaching or increasing the use of augmentative and alternative communication (AAC) by students with significant intellectual disabilities and complex communication needs (CCNs) within inclusive school settings.

METHOD

A systematic review of research literature from 1998 to 2022 was completed using multiple electronic databases, as well as citation chaining and cited author reference searches. Three hundred two articles were located with 17 meeting criteria for inclusion in this systematic review. Articles were initially screened by one author for potential inclusion; the remaining 83 were coded by one author and reviewed for consensus by three authors for inclusion in this review. Articles were analyzed and rated regarding both level of research design and quality of methodology.

RESULTS

All studies reported positive outcomes, with students with significant intellectual disabilities and CCN, of AAC intervention implemented in an inclusive setting. Fourteen over 17 studies were single-case designs with an average rating of 76% on the Single-Case Experimental Design measure of methodological quality. Less than half of the studies assessed generalization of subject learning. Review of interventions used in the studies, however, revealed the majority of studies utilized packages of interventions, making it difficult to determine the effectiveness of individual approaches.

CONCLUSIONS

This systematic review indicates there are promising interventions within inclusive settings for improved use of AAC by students with significant intellectual disabilities and CCN. Further research is needed, however, to obtain more data on generalization of student gains as well as to determine which specific interventions might be the most successful for this population of students in inclusive settings.

Incorporating Metacognitive Strategy Training Into Semantic Treatment Promotes Restitutive and Substitutive Gains in Naming: A Single-Subject Investigation

PURPOSE

This study tested the effectiveness of a modified semantic feature analysis (SFA) treatment protocol that incorporated metacognitive strategy training (MST). Regarding its restitutive component, SFA most reliably results in improved word retrieval for treated items and untreated, semantically related items, but evidence of response generalization is often small/inconsistent. Regarding its substitutive component, SFA is thought to facilitate successful communication via habituation of the SFA circumlocution strategy. However, repeated practice with SFA's strategy in the absence of direct MST may not result in independent strategy use and/or generalization. Furthermore, people with aphasia's independent use of the SFA strategy in moments of anomia is presently underreported. To address these limitations, we incorporated MST into SFA and directly measured substitutive outcomes.

METHOD

Four people with aphasia participated in 24 treatment sessions of SFA + MST in a single-subject, A-B experimental design with repeated measurements. We measured word retrieval accuracy, strategy use, and explicit strategy knowledge. We calculated effect sizes to measure changes in word retrieval accuracy and strategy use and used visual inspection to assess gains in explicit strategy knowledge from pre- to posttreatment and retention.

RESULTS

Participants achieved marginally small to medium effects in word retrieval accuracy for treated; untreated, semantically related; and untreated, semantically unrelated items and marginally small to large effects in independent strategy use. Explicit strategy knowledge was variable.

CONCLUSIONS

Across participants, SFA + MST yielded positive changes in word retrieval accuracy or strategy use, or both. Positive changes in word retrieval accuracy were comparable to other SFA studies. Positive changes in strategy use demonstrate preliminary evidence of this treatment's ability to yield restitutive and substitutive gains. Overall, this study offers preliminary evidence of SFA + MST's effectiveness and highlights the importance of directly measuring SFA's substitutive outcomes, which showed that people with aphasia can respond to this treatment in multiple successful ways-not just improved target word production.

Speech Therapy Interventions for Acquired Apraxia of Speech: An Updated Systematic Review

PURPOSE

This systematic review aims to summarize and evaluate the available literature on speech and language therapy interventions for acquired apraxia of speech since 2012.

METHOD

A systematic search in six electronic databases was performed from 2013 to 2020. The following primary outcomes were summarized: (a) improvement in targeted behaviors, (b) generalization, and (c) maintenance of outcomes. Moreover, studies were evaluated for the level of evidence and the clinical phase.

RESULTS

Of the 3,070 records identified, 27 studies were included in this review. The majority of the studies (n = 22) used articulatory kinematic approaches followed by intersystemic facilitation/reorganization treatments (n = 4) and other approaches (n = 1). According to the classes defined in Clinical Practice Guideline Process Manual (Gronseth et al., 2017), one was Class II, 10 were Class III, 10 were Class III-b (fulfill Class III criteria except for independence of assessors' criterion), and five were Class IV. In terms of clinical phase, one study classified as Phase III, 10 as Phase II, and 15 as Phase I.

CONCLUSIONS

Among the interventions for apraxia of speech, articulatory kinematic treatments have become prominent over the last 8 years. Focusing on self-administrated therapies, use of technology for therapy administration and development of treatments that focus on apraxia of speech and aphasia simultaneously were identified as new advancements in the apraxia of speech literature. The methodological quality, clinical phase, and level of evidence of the studies have improved within the past 8 years. Large-scale randomized controlled trials for articulatory kinematic approaches and future studies on other treatment approaches are warranted.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22223785.

Single-Case Experimental Design in Rehabilitation: Basic Concepts, Advantages, and Challenges

ABSTRACT

Single-case experimental design is a family of experimental methods that can be used to examine the efficacy of interventions by testing a small number of patients or cases. This article provides an overview of single-case experimental design research for use in rehabilitation as another option along with traditional group-based research when studying rare cases and rehabilitation interventions of unknown efficacy. Basic concepts related to single-case experimental design and the characteristics of common subtypes ( N-of-1 randomized controlled trial, withdrawal design, multiple-baseline design, multiple-treatment design, changing criterion/intensity design, and alternating treatment design) are introduced. The advantages and disadvantages of each subtype are discussed along with challenges in data analysis and interpretation. Criteria and caveats for interpreting single-case experimental design results and their use in evidence-based practice decisions are discussed. Recommendations are provided for appraising single-case experimental design articles as well as using single-case experimental design principles to improve real-world clinical evaluation.

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.

Examining the Evidence From Single-Case Experimental Designs to Treat Challenging Behaviors Following Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To evaluate evidence on the effectiveness of behavioral interventions using single-case experimental design (SCED) methodology and to identify behavioral interventions with sufficient evidence for possible inclusion in the development of guidelines for the management of challenging behaviors in adults following moderate to severe traumatic brain injury (TBI).

METHODS

As a subinvestigation of a larger systematic review process designed to identify evidence for guidelines development, the current review focused on studies using SCED methodology applied to persons with challenging behaviors following moderate to severe TBI. Articles were identified from a search of the published literature through January 2021, identifying studies in CINAHL, Cochrane Database of Systematic Reviews, EMBASE, MEDLINE/Ovid, and PsycINFO. Articles meeting inclusion criteria were assessed for design rigor to allow for effect size determination. The identified cases were then critically appraised using the RoBiNT (Risk-of-Bias in N-of-1 Trails) Scale to determine strength of evidence for causal inference.

RESULTS

Thirty-four studies met inclusion criteria, with a total of 44 cases evaluated for effect of the treatment intervention on defined target behaviors. Seventeen cases had effect sizes rated as large, 22 cases as medium, 3 cases as small, and 3 as no effect. An observed trend was for large and medium effect sizes to be associated with lower RoBiNT Scale internal validity scores. Randomization, blinded provider and assessor, and assessment of treatment adherence were the internal validity items unlikely to meet criteria.

CONCLUSIONS

SCED methodology was found to produce large and medium effect sizes for behavioral interventions targeting challenging behaviors following moderate to severe TBI. However, the strength of the evidence is limited because of weaknesses in study designs. Most of the studies failed to meet established internal validity criteria designed to reduce risk of bias in SCED studies as such rigor is difficult to establish or often not practical in clinical settings. Suggestions and recommendations are outlined for improving the quality of published cases using SCED methodology, which, in turn, will improve credibility of evidence and better inform the development of treatment guidelines for behavior regulation.

Treatment approaches for pusher behaviour: a scoping review

BACKGROUND

Some individuals with hemiplegia show a postural disorder called pusher behavior. Various underlying theoretical mechanisms have been proposed, thus leading to various treatment approaches.

OBJECTIVES

The aim of this scoping review is to identify and analyze the available evidence on the treatment approaches for pusher behavior.

METHODS

Two independent reviewers conducted a literature search for original studies reporting on treatments for pusher behavior. Studies were searched in PubMed, Scopus, Web of Science, CINAHL and PEDro from their inception to December 2020. Treatment approaches were grouped in homogeneous areas based on the supposed underlying mechanism. To assess the reporting of the interventions, the Template for Intervention Description and Replication (TIDieR) was used.

RESULTS

Thirty-one papers describing 45 interventions were included in the review. Most of the studies were case reports (i.e. including 1 person) (n = 16), followed by randomized controlled trials (n = 5), single subject design trials (n = 5), non-randomized controlled trials (n = 3), and case series (i.e. including more than 1 person) (n = 2). Treatment approaches were grouped into five categories: visual feedback, somatosensory cues, visual-somatosensory integration, brain stimulation, and other nonspecific treatments. The median number of TIDIeR items reported was 7 (range 4 to 10).

CONCLUSION

Pusher behavior is still little-known. Five main categories of treatment approaches based on the alleged etiological underlying mechanisms have been identified. Most of studies are case reports; controlled trials should be further conducted. Intervention reporting should be improved to allow treatment replication in larger trials.

Teleintervention for users of augmentative and alternative communication devices: A systematic review

AIM

To synthesize existing evidence on the effectiveness of speech-language teleinterventions delivered via videoconferencing to users of augmentative and alternative communication (AAC) devices.

METHOD

A systematic literature search was conducted in 10 electronic databases, from inception until August 2021. Included were speech-language teleinterventions delivered by researchers and/or clinicians via videoconferencing to users of AAC devices, without restrictions on chronological age and clinical diagnosis. The quality of the studies included in the review was appraised using the Downs and Black checklist and the Single-Case Experimental Design Scale; risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies - of Interventions and the single-case design risk of bias tools.

RESULTS

Six teleinterventions including 25 participants with a variety of conditions, such as Down syndrome, autism, Rett syndrome, and amyotrophic lateral sclerosis met the inclusion criteria. Five studies used a single-case experimental design and one was a cohort study. Teleinterventions included active consultation (n = 2), functional communication training (n = 2), brain-computer interface (n = 1), and both teleintervention and in-person intervention (n = 1). All teleinterventions reported an increase in participants' independent use of AAC devices during the training sessions compared to baseline, as well as an overall high satisfaction and treatment acceptability.

INTERPRETATION

Speech-language teleinterventions for users of AAC devices show great potential for a successful method of service delivery. Future telehealth studies with larger sample sizes and more robust methodology are strongly encouraged to allow the generalization of results across different populations.

WHAT THIS PAPER ADDS

Individuals can learn to use augmentative and alternative communication (AAC) devices independently during tele-AAC interventions. Service providers and recipients reported an overall high satisfaction and acceptability for AAC services delivered via teleinterventions. Speech-language teleinterventions may be an effective method of providing AAC intervention services.

Motor Speech Interventions for Children With Cerebral Palsy: A Systematic Review

PURPOSE

Dysarthria is common among children with cerebral palsy (CP) and results in poor speech intelligibility and subsequently low communicative participation. Neuroplasticity evidence suggests that adherence to principles of motor learning (PML) improves motor speech intervention outcomes. Motor speech interventions aim to improve speech intelligibility and ultimately facilitate participation, but the effectiveness of these interventions and their inclusion of PML are not clear. Aims are as follows: (a) evaluate the effectiveness motor speech interventions in improving speech intelligibility; (b) summarize the aims, outcome measures, and outcomes relating to the International Classification of Functioning and Disability Child and Youth; and (c) summarize the principles of motor learning used in the intervention.

METHOD

Eight databases were searched, complemented by a hand search. Studies of any level of evidence were included if they used a motor speech intervention and measured speech in children with CP aged 0-18 years. Studies before 2000 or not in English were excluded. The review was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was rated using the Single Case Experimental Design Scale and Physiotherapy Evidence Database-P rating scales. The strength of evidence was evaluated with Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Of 1,036 initial articles, 21 were included. Eight interventions were identified including 131 participants aged 3-18 years. All studies aimed to improve speech intelligibility or articulation and reported improvement at sound, word, or sentence level. One study reported improvements in communicative participation. The strength of evidence ranged from very low to moderate for one intervention. Adherence to PML was inconsistent.

CONCLUSIONS

The quality of evidence is very low to moderate. More research on motor speech interventions that adhere to PML is required.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21817959.

Strengthening parental self-efficacy and resilience: A within-subject experimental study with refugee parents of adolescents

Post-migration stress and parenting adolescents can reduce parental self-efficacy. This study tested the effects of strengthening parental self-efficacy in refugee parents of adolescents and whether this makes parental self-efficacy less impacted by post-migration stressors. Using a within-subject experimental design, experience sampling data were collected in 2019 from 53 refugee parents of adolescents (M_age  = 39.7, SD_age  = 5.59, 73% Syrian, 70% mothers) in the Netherlands. Data were analyzed by dynamic structural equation modeling using interrupted time-series analysis. The single-session personalized intervention strengthened parental self-efficacy (small effect: between case standardized mean difference = 0.09) and made refugee parents less vulnerable to post-migration stressors. Findings suggest that parental self-efficacy is malleable and strengthening it fosters refugee parents' resilience. Replications with longer-term follow-ups are needed.

Effect of mirror therapy in the treatment of phantom limb pain in amputees: A systematic review of randomized placebo-controlled trials does not find any evidence of efficacy

BACKGROUND AND OBJECTIVE

Phantom limb pain (PLP) concerns >50% of amputees and has a negative impact on their rehabilitation, mental health and quality of life. Mirror therapy (MT) is a promising strategy, but its effectiveness remains controversial. We performed a systematic review to: (i) evaluate the effectiveness of MT versus placebo in reducing PLP, and (ii) determine MT effect on disability and quality of life.

DATABASES AND DATA TREATMENT

We selected randomized-controlled trials in five databases (Medline, Cochrane Library, CINAHL, PEDro and Embase) that included patients with unilateral lower or upper limb amputation and PLP and that compared the effects on PLP of MT versus a placebo technique. The primary outcome was PLP intensity changes and the secondary outcomes were PLP duration, frequency, patients' disability and quality of life.

RESULTS

Among the five studies included, only one reported a significant difference between the MT group and control group, with a positive MT effect at week 4. Only one study assessed MT effect on disability and found a significant improvement in the MT group at week 10 and month 6.

CONCLUSIONS

Our systematic review did not allow concluding that MT reduces PLP and disability in amputees. This lack of strong evidence is probably due to (i) the low methodological quality of the included studies, and (ii) the lack of statistical power. Future trials should include a higher number of patients, increase the number and frequency of MT sessions, have a long-term follow-up and improve the methodological quality.

SIGNIFICANCE

Recent meta-analyses concluded that MT is effective for reducing phantom limb pain. Conversely, the present systematic review that included only studies with the best level of evidence did not find any evidence about its effectiveness for this condition. We identified many ways to improve future randomized-controlled trials on this topic: increasing the number of participants, reducing the intra-group heterogeneity, using a suitable placebo and intensifying the MT sessions and frequency.

Stuttering interventions for children, adolescents, and adults: a systematic review as a part of clinical guidelines

INTRODUCTION

Stuttering may have a holistic effect on the quality of life of a person who stutters by limiting participation in social situations, resulting in feelings of isolation and frustration, leading to difficulties in education and employment and increasing the likelihood of mental health problems. Even young children who stutter may have negative experiences of speaking. Therefore, it is important to treat stuttering behavior effectively in both children and adults. The purpose of this paper was to systematically review group and case studies about the effectiveness of behavioral stuttering interventions to provide evidence-based guidelines for clinicians.

METHODS

Systematic data retrieval was conducted in four electronic databases (PsycINFO, CINAHL, PubMed, Cochrane). The assessment of search results was conducted according to predetermined inclusion and exclusion criteria by two independent judges. The methodological quality of each paper was assessed using strict criteria to include only high-quality research.

RESULTS

The search revealed 2293 results, and 38 papers (systematic reviews N=3, group design studies N=21 and case studies N=14) with acceptable methodological quality were included. The data show that there is most evidence about the treatment of early childhood stuttering, very little evidence about school-aged children and some evidence about adults. The most convincing evidence is about the Lidcombe Program in the treatment of young children who stutter, but also other methods have promising evidence. Our data imply that in the treatment of adults who stutter, holistic treatments may influence speech fluency and overall experience of stuttering behavior. Speech restructuring treatments may have a positive effect on overt characteristics of stuttering, but not on covert stuttering behavior.

CONCLUSIONS

The results of this review agree with earlier reviews about the treatment of young children. However, due to different inclusion criteria, this review also shows the benefits of holistic treatment approaches with adults and adolescents.

A Systematic Review of Augmentative and Alternative Communication Interventions for Children Aged From 0 to 6 Years

PURPOSE

This systematic review evaluates the latest available evidence regarding augmentative and alternative communication (AAC) interventions in children from 0 to 6 years old diagnosed with various disabilities.

METHOD

A systematic search was conducted in MEDLINE (OVID), PsycINFO (EBSCO), ERIC (ProQuest), SCIELO (WOS), Teacher Reference Center (EBSCO), and Education Database (ProQuest), and studies on AAC interventions in children from 0 to 6 years old diagnosed with various disabilities were selected independently by two reviewers (A.L.-R. and N.I.M.) according to the purpose of the review.

RESULTS

Twenty-nine of 1,709 studies met the inclusion criteria for this review. The methodological quality of the included studies was assessed, and the characteristics and results of the studies were extracted by a descriptive analysis (O.L.S. and M.O.-V.).

CONCLUSION

This analysis revealed that children with different diagnoses show improvements in expressive and receptive communication, functional communication behaviors, communication participation skills, interaction strategies, and symbol and multisymbol production and comprehension by using various AAC systems.

Are Extended Reality Interventions Effective in Helping Autistic Children to Enhance Their Social Skills? A Systematic Review

Autistic children’s social skills do not always align with those of their neurotypical peers and research suggests that this can negatively impact quality of life. This review aimed to assess the effectiveness of extended reality (XR) interventions in helping autistic children to enhance their social skills. Five electronic databases were systematically searched and seventeen studies were identified. The majority targeted social-emotional reciprocity and were of relatively low quality. There was insufficient evidence to determine whether effects were generalisable, sustained or important to autistic people. Research in this field is in its infancy and evidence of effectiveness should be viewed with caution. Future studies should aim for high-quality, theory-driven research, and involve autistic people to ensure meaningful outcomes.

PROSPERO ID: CRD42021229442

Systematic Review of Discourse and Social Communication Interventions in Traumatic Brain Injury

PURPOSE

This study reviewed the current state of discourse and social communication interventions in traumatic brain injury (TBI) to provide clinically focused guidance about treatment efficacy, treatment approaches by TBI severity, treatment components, and treatment outcome measures.

METHOD

Searches were conducted in five electronic databases and reference lists of topical articles for discourse or social communication interventions in TBI published between 2012 and 2021. Search terms reflected three concepts: TBI, treatment, and cognitive-communication. Studies were evaluated for methodological quality using rating scales specific to study design.

RESULTS

Seven hundred sixty-seven records were identified, culminating in 21 studies for qualitative synthesis. All approaches resulted in improvement posttreatment, but durability and strength of evidence varied. Five treatment components were identified as "essential" for fostering change. Discourse approaches were generally more effective in mild-to-moderate TBI, whereas social communication approaches were more effective in moderate-to-severe TBI. Communication outcome measures were generally more sensitive to change than measures of other domains of functioning.

CONCLUSIONS

The evidence suggests that discourse and social communication treatments are promising for improving communication in TBI. Selection of treatment components and tailoring treatment to the individual are important clinical considerations. Use of at least two proximal outcome measures that evaluate the target behavior and extent of functional generalization may be advantageous. The field would benefit from additional, more rigorous treatment studies to provide a greater understanding of how best to treat cognitive-communicative impairments in people with TBI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19233516.

Metacognitive Treatment in Acquired Brain Injury and Its Applicability to Aphasia: A Systematic Review

Purpose

The purpose of this systematic review is to identify the utility of metacognitive therapeutic intervention for persons with acquired brain injury (ABI), with a focus on persons with aphasia.

Methods

A search of six databases resulted in two hundred and sixty-six unique manuscripts relating to the explicit use of metacognitive treatment for people with ABI. Two independent reviewers rated abstracts for inclusion or exclusion of the study given predetermined criteria. Twenty-nine articles, five of which included people with aphasia, were selected for inclusion in this systematic review. SCED+ and PEDro+ rating scales were used to rate the methodological quality of each study.

Results

Methodological quality of the 29 studies that met inclusion criteria ranged from weak to high quality studies. Three -hundred and sixty-nine individuals with ABI took part in the 29 studies. Varying treatment methods were employed. Outcome measures were inconsistent. Metacognitive treatment has been applied to people with aphasia with positive results, but efficacy of the treatment cannot yet be determined.

Conclusions

Metacognitive therapeutic intervention tends to be effective for persons with acquired brain injury (ABI) despite variability between intervention designs and treatment outcomes across studies. Due to so few studies with participants with aphasia, we were unable to draw conclusions regarding the efficacy of metacognitive treatment for people with aphasia. Further research on the efficacy of metacognitive treatment for this population is warranted.

Systematic Review of Training Communication Partners of Chinese-speaking Persons With Aphasia

Objective

To determine the aims, participants, and outcomes of training communication partners of Chinese-speaking persons with aphasia (PWA).

Data Sources

Sixty search terms related to communication partner training (CPT) in Chinese characters were searched in 8 electronic databases (published 1991-2020).

Study Selection

Journal articles written in Chinese that primarily target the Chinese audience and university theses were selected for review. Studies involving CPT and training to enable communication partner to deliver language tasks were included, but reports without PWA or direct training of communication partners were excluded. A final corpus of 37 articles, representing publications of group studies, case studies, qualitative studies, and opinion articles, were selected for full review.

Data Extraction

For all articles, 2 reviewers independently reviewed abstracts, excluding those without PWA or those that did not involve training of communication partners. One reviewer extracted descriptive data of participants with aphasia, communication partners, intervention details of the intervention (purpose, amount, setting, description), outcome measures, results, and clinical guidelines. A second reviewer performed accuracy verifications.

Data Synthesis

Quality of reviewed articles were classified using the American Academy of Neurology levels of evidence. The current review suggested an evidence base of low to medium quality supporting 2 intervention groups: (1) training partners to deliver therapy tasks and (2) training to improve communication between PWA and their communication partners. There was a higher proportion of persons with acute and subacute aphasia involved in these investigations, suggesting evidence on treatment efficacy of CPT in the acute stage.

Conclusions

Additional high-quality research with a better methodological quality, for example, randomized controlled trials or experimental design, are required to strengthen the current evidence of CPT. This systematic review suggests that the inclusion of studies published in languages other than English may influence the findings of mainstream reviews relating to aphasia.

The Efficacy of Head-Mounted-Display Virtual Reality Intervention to Improve Life Skills of Individuals with Autism Spectrum Disorders: A Systematic Review

Challenges in life skills in individuals with autism spectrum disorders (ASD) are associated with dependency on others and increased isolation from peers. In recent years, interventions using virtual reality (VR) technology have been proposed to improve life skills in ASD populations. This systematic review seeks to evaluate the efficacy of employing VR interventions mediated via head-mounted displays (HMD) for the improvement of life skills in individuals with ASD. Several databases were searched and a narrative synthesis was conducted to examine the findings of the included studies. Eight studies including a total of 58 participants were deemed relevant for this systematic review. The methodological quality of the included studies was assessed via the use of critical appraisal tools. Results were generally positive, with one study reporting statistically significant results, and one study not reporting any change in abilities. The remaining six studies reported varying degrees of life skill improvement. The studies were characterized by methodological issues, such as very low sample sizes. The findings of this systematic review indicate some potential for HMD VR interventions in the improvement of life skills in individuals with ASD. However, this review also highlights the current lack of methodologically strong study designs, which prohibits any firm conclusions. Findings are discussed regarding methodological recommendations for further research as well as practical implications for life skills interventions for individuals with ASD.

A systematic review of early speech interventions for children with cleft palate

BACKGROUND

Children with cleft palate with or without cleft lip (CP±L) are at high risk of problems with early speech sound production, and these difficulties can persist into later childhood. Early intervention could help to reduce the number of children whose problems become persistent. However, much research in the field to date has focused on older children. There is a need to determine if providing intervention during the phase of early typical speech development leads to better outcomes.

AIMS

To review the evidence for the effectiveness of interventions targeting speech, delivered in the first 3 years of life for children with CP±L, and discuss factors such as intervention type, facilitator, dosage, outcome measures and the age of the child.

METHODS & PROCEDURES

The systematic review was registered with PROSPERO (CRD42019121964). Eight bibliographic databases including CINAHL and MEDLINE were searched in August 2018. Studies were included if participants received speech and language interventions before 37 months and if they reported outcomes for speech. Two reviewers independently completed inclusion reviews, quality analysis and data extraction.

OUTCOME & RESULTS

The review included seven papers: one pilot randomized controlled trial, one controlled trial, four cohort studies and one case series report. Interventions largely took a naturalistic approach, namely focused stimulation and milieu teaching. The findings provide preliminary support for naturalistic interventions and suggest that these interventions can be delivered by parents with suitable training. Studies included in the review provided low-strength evidence with variation in both the type of intervention, the manner of delivery and in the risk of bias in the designs used.

CONCLUSIONS & IMPLICATIONS

The papers included in this review suggest that early naturalistic interventions can have positive impacts on the speech development of children with CP±L. However, the reported methodological quality of the publications overall was weak, and the current evidence lacks clarity and specificity in terms of therapy technique, delivery and optimum age of delivery. Future research should use more robust methodological designs to determine whether early speech interventions are beneficial for children born with CP±L.

WHAT THIS PAPER ADDS

What is already known on the subject Children with CP±L show difficulties with early speech development and often have restricted speech sound inventories. They may reach the canonical babbling stage later than children without CP±L and studies have shown that 20% of children with CP±L have speech which is considered unintelligible or barely intelligible at age 5. It has been proposed that early intervention can lessen the impact of CP±L on speech development. However, currently, the evidence for early interventions for children with CP±L is limited, with the majority of studies focusing on children aged 3 years and older. What this paper adds to existing knowledge This paper reviews the evidence for different types of early interventions for speech provided to children born with CP±L and whether these interventions are effective in supporting speech sound development. In this review, early intervention is defined as intervention provided to children in the first 3 years of life. This review describes intervention approaches and how they are delivered for this population. What are the potential or actual clinical implications of this work? In the UK, children born with CP±L and their families are supported by National Health Service (NHS) services over a 20-year period and speech and language therapy sessions may take place over many weeks and months. If providing early intervention in the first 3 years of life is effective, there is the potential for improved speech outcomes in early childhood and a reduced burden of care on children, families and services. This review considers the evidence for early speech intervention for children with CP±L in the first 3 years of life and identifies areas for future research.

Common elements of evidence-based trauma therapy for children and adolescents

Background: Numerous evidence-based trauma therapies for children and adolescents have been developed over several decades to minimize the negative outcomes of post-traumatic stress disorder (PTSD). However, PTSD remains a complex construct and is associated with pervasive problems and high comorbidity. To gain more insight, much could be learnt from the similarities in trauma therapies. Objective: The purpose of this study is to derive common elements from evidence-based trauma therapies for children and adolescents. Method: Therapies were selected from a literature search. Five evidence-based trauma therapies were included in this study. A common element list was created through an existing and modified Delphi method, with a diverse group of Dutch trauma therapists. An element was deemed common when it appeared in three or more of the therapies. The final list was presented to international experts on the included trauma therapies. Results: A substantial commonality of techniques and mechanisms was found across the five evidence-based trauma therapies for children and adolescents, showing a strong overlap between therapies. Conclusion: The identified elements create a basis for research and clinical practice, with regard to targeted trauma therapies tailored to each individual child and his or her support system. This promotes therapy modules that are more flexible and accessible for both therapists and clients, in every environment, from specialized psychiatric units to sites with meagre resources. With current integrated knowledge, we can enhance the effectiveness of child psychiatry and refine trauma therapies.

HIGHLIGHTS

Using a modified Delphi method, a substantial commonality of techniques and mechanisms is found in evidence-based trauma therapies for children and adolescents.Understanding the techniques and mechanisms of trauma therapy could be of help in refining upcoming therapies, and creates a basis for future research.Commonalities promote therapy modules that are more flexible and accessible for both therapists and clients, in environments ranging from specialized psychiatric units to sites with meagre resources.

The rehabilitation of object agnosia and prosopagnosia: A systematic review

BACKGROUND

Agnosia for objects is often overlooked in neuropsychology, especially with respect to rehabilitation. Prosopagnosia has been studied more extensively, yet there have been few attempts at training it. The lack of training protocols may partially be accounted for by their relatively low incidence and specificity to sensory modality. However, finding effective rehabilitations for such deficits may help to reduce their impact on the social and psychological functioning of individuals.

OBJECTIVE

Our aim in this study was to provide clinicians and researchers with useful information with which to conduct new studies on the rehabilitation of object agnosia and prosopagnosia. To accomplish this, we performed a systematic and comprehensive review of the effect of neuropsychological rehabilitation on visual object and prosopagnosia.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. In addition, the Single-Case Experimental Design (SCED) and the Critical Appraisal Skills Programme (CASP) scales were used to assess the quality of reporting.

RESULTS

Seven articles regarding object agnosia, eight articles describing treatments for prosopagnosia, and two articles describing treatments for both deficits were included.

CONCLUSIONS

In the light of the studies reviewed, treatments based on analysis of parts seem effective for object agnosia, while prosopagnosia appears to benefit most from treatments relying on holistic/configural processing. However, more attempts at rehabilitation of face and object agnosia are needed to clarify the mechanisms of these processes and possible rehabilitations. Moreover, a publication bias could mask a broader attempt to find effective treatments for visual agnosia and leaving out studies that are potentially more informative.

Comparing pregabalin and gabapentin for persistent neuropathic pain: A protocol for a pilot N-of-1 trial series

Background

Evidence-based management of neuropathic pain is commonly ineffective due to the large variability in response between cases. Patients often have to trial several drugs before finding one that provides adequate relief, leading to increased costs and worsened outcomes. There is thus a need for tools to guide and streamline prescribing decisions in neuropathic pain. N-of-1 trials provide a potentially precise and economical method of selecting between multiple interventions in an individual patient, and merit a feasibility assessment for use in clinical pain practice.

Aims

We aim to evaluate the feasibility of N-of-1 trials to compare pregabalin and gabapentin for individual presentations of neuropathic pain.

Methods

This is a double-blinded multiple crossover study, with recruitment from existing patients at an outpatient pain clinic in New South Wales, Australia. Participants will undergo three 4-week treatment pairs, comprising 2 weeks of pregabalin (150–600 mg/day) and 2 weeks of gabapentin (900–3600 mg/day), in an individually randomised order. Intervention doses will be derived from participants’ existing treatment dose. Medications will be taken orally three times daily. The primary outcome will be pain intensity; measures will be self-reported daily in patient diaries. After completing all three cycles, participants and their physicians will be presented with the results of the trial to form an informed decision about their treatment.

Discussion

As a stable yet debilitating condition, neuropathic pain is especially amenable to an N-of-1 study design. A successful trial would represent a significant quality of life improvement for the patient, possibly extending over the course of their lifetime.

N-of-1 Trials in Pediatric Oncology: From a Population-Based Approach to Personalized Medicine-A Review

Pediatric oncology is a critical area where the more efficient development of new treatments is urgently needed. The speed of approval of new drugs is still limited by regulatory requirements and a lack of innovative designs appropriate for trials in children. Childhood cancers meet the criteria of rare diseases. Personalized medicine brings it even closer to the horizon of individual cases. Thus, not all the traditional research tools, such as large-scale RCTs, are always suitable or even applicable, mainly due to limited sample sizes. Small samples and traditional versus subject-specific evidence are both distinctive issues in personalized pediatric oncology. Modern analytical approaches and adaptations of the paradigms of evidence are warranted. We have reviewed innovative trial designs and analytical methods developed for small populations, together with individualized approaches, given their applicability to pediatric oncology. We discuss traditional population-based and individualized perspectives of inferences and evidence, and explain the possibilities of using various methods in pediatric personalized oncology. We find that specific derivatives of the original N-of-1 trial design adapted for pediatric personalized oncology may represent an optimal analytical tool for this area of medicine. We conclude that no particular N-of-1 strategy can provide a solution. Rather, a whole range of approaches is needed to satisfy the new inferential and analytical paradigms of modern medicine. We reveal a new view of cancer as continuum model and discuss the "evidence puzzle".

A systematic review of maintenance following intensive therapy programs in chronic post-stroke aphasia: importance of individual response analysis

PURPOSE

Recent evidence supports the benefit of intensive aphasia intervention programs for people with chronic aphasia, yet it is unclear if all participants can expect positive outcomes and for how long therapeutic gains last.

METHODS

We systematically searched for studies investigating intensive interventions in chronic aphasia. To explore individual response rates and maintenance of therapeutic gains we carried out meta-synthesis by calculating and analysing the Standard Error of Measurement and Minimal Detectable Change metrics of six common outcome measures.

RESULTS

Forty-four studies comprising 24 experimental (13 group, 11 single-subject) and 20 non-experimental studies met our inclusion criteria (n = 670). Whereas most group studies reported statistically significant post-therapy improvement and maintenance, analysis of individual participant data (IPD, n = 393) from these studies revealed that only about a third of participants were classified as "immediate responders," of which more than a third had lost their initial immediate gains at follow-up. This pattern did not change when IPD from single-subject studies (n = 49) was added to the analysis. Thus, only 22% of all IPD receiving an intensive intervention improved significantly and maintained their therapy gains.

CONCLUSIONS

Intensive aphasia therapy is effective when measured at the group-level, but many individuals do not respond significantly to the intervention, and even fewer individuals preserve their initial gains. Group study results do not allow prediction of an individual's response to the intervention. Future research should elucidate which factors mediate positive treatment response and maintenance for an individual.Implications for rehabilitationOnly a small proportion (about one fifth in this review) of intensive aphasia treatment program participants respond and maintain their therapy gains, a fact that is obscured by traditional p-value group analysis.A simple clinical decision-making method is presented for evaluating individual therapy gains and their maintenance.For some immediate treatment responders (about one third in this review), gains from intensive therapy programs are unlikely to be maintained in the long-term without additional, ongoing practice.Clinicians should consider the possibility of individual clients losing some of their therapy gains and take proactive steps to support long-term maintenance.

A Systematic Review of Research on Augmentative and Alternative Communication Interventions for Children Aged 6-10 in the Last Decade

Purpose The purpose of this systematic review was to identify, appraise, and critically synthesize the latest available evidence on the effects of augmentative and alternative communication (AAC)-based interventions on communication skills in children aged between 6 and 10 years with mixed diagnoses. Method MEDLINE (OVID), PsycINFO (EBSCO), ERIC (ProQuest), SCIELO (WOS), Teacher Reference Center (EBSCO), and Education Database (ProQuest) were searched. The studies were independently selected by two reviewers for the purposes of the review. The methodological quality of the included studies was assessed, and characteristics and results of the studies were extracted. Results This review included 14 studies from a total of 1,204 found through an electronic search. The AAC interventions studied were effective at improving various outcomes in children with mixed diagnoses. Interventions that focused on narrative skills were the most common type. When considering the quality of the studies, the independence of assessors, data analysis, replication, and generalization of interventions were the weaker areas. Conclusions Interventions analyzed in this review improve communication skills, including phonological awareness, vocabulary, requesting, and developing narrative skills in children aged between 6 and 10 years with mixed diagnoses. The results of one study also indicate that the acquisition of skills using an AAC method is superior when the child prefers the method. Supplemental Material https://doi.org/10.23641/asha.14462256.

Lower spinal postural variability during laptop-work in subjects with cervicogenic headache compared to healthy controls

Spinal postural variability (SPV) is a prerequisite to prevent musculoskeletal complaints during functional tasks. Our objective was to evaluate SPV in cervicogenic headache (CeH) since CeH is characterized by such complaints. A non-randomized repeated-measure design was applied to compare SPV between 18 participants with reporting CeH aged 29–51 years, and 18 matched controls aged 26–52 years during a 30-min-laptop-task. Habitual spinal postures (degrees) of the cervical, thoracic and lumbar spine were analysed using 3D-Vicon motion analysis. SPV, to express variation in mean habitual spinal posture, was deducted from the postural analysis. Mean SPV of each spinal segment was lower in the CeH-group compared to the control-group. Within the CeH-group, SPV of all except one spinal segment (lower-lumbar) was higher compared to the group’s mean SPV. Within the control-group, SPV was more comparable to the group’s mean SPV. SPV differed between groups. Averaging data resulted in decreased SPV in the CeH-group compared to the control-group during the laptop-task. However, the higher within-group-SPV in the CeH-group compared to the group’s mean SPV accentuated more postural heterogeneity. It should be further determined if addressing individual SPV is a relevant intervention.

Is speech and language therapy effective at improving the communication of adults with intellectual disabilities?: A systematic review

BACKGROUND

A significant proportion of adults with intellectual disabilities (ID) experience speech, language and communication difficulties which are associated with poor physical and mental health outcomes. Speech and language therapy (SLT) interventions are an important way to address these communication difficulties, yet there is limited available evidence to provide information about the effectiveness of the different approaches used for this heterogeneous group.

AIMS

To review the evidence available for the effectiveness of SLT interventions aimed at improving communication for adults with ID.

METHODS & PROCEDURES

A systematic search across relevant databases was performed. Information on methodological details of each relevant study, along with descriptions of the SLT interventions employed, were extracted and the Crowe Critical Appraisal Tool (CCAT) was used to assess quality. Findings were discussed in a narrative synthesis grouped by target communication skill.

OUTCOMES & RESULTS

A total of 10 relevant studies met the inclusion criteria. These were predominantly interventions aimed directly at adults with ID to improve speech, increase augmentative and alternative communication (AAC) use and develop interaction skills, with one study addressing work with carers. The included studies were all rated as low quality. There is weak preliminary evidence that SLT input can improve the communication skills of adults with ID.

CONCLUSIONS & IMPLICATIONS

There is insufficient evidence to draw strong conclusions about the effectiveness of SLT in this population. Further high-level evidence across speech, language and communication domains is urgently needed. What this paper adds What is already known on the subject There is limited evidence for community health interventions used with adults with ID. Previous reviews of SLT interventions found a lack of evidence base for this population. Some areas of SLT practice such as AAC have demonstrated potential benefits and other areas including speech work, social communication skills and training for communication partners have some evidence base for children with ID but there is currently insufficient evidence for adults with ID. What this paper adds to existing knowledge The study systematically reviews the current evidence base available when considering the effectiveness of SLT intervention for adults with ID. It provides weak evidence to suggest SLT intervention can improve communication in this population and highlights the need for clinically relevant, robustly designed studies to be undertaken in this field. What are the potential or actual clinical implications of this work? The lack of high-quality studies with sufficient power to draw conclusions about effectiveness means SLTs are not able to base their intervention choices on firm evidence. There is an urgent need to conduct robust research into the effectiveness of SLT interventions for adults with ID.

A Meta-Analysis of Single-Case Research on Applied Behavior Analytic Interventions for People With Down Syndrome

This systematic review evaluates single-case research design studies investigating applied behavior analytic (ABA) interventions for people with Down syndrome (DS). One hundred twenty-five studies examining the efficacy of ABA interventions on increasing skills and/or decreasing challenging behaviors met inclusion criteria. The What Works Clearinghouse standards and Risk of Bias in N-of-1 Trials scale were used to analyze methodological characteristics, and Tau-U effect sizes were calculated. Results suggest the use of ABA-based interventions are promising for behavior change in people with DS. Thirty-six high-quality studies were identified and demonstrated a medium overall effect. A range of outcomes was targeted, primarily involving communication and challenging behavior. These outcomes will guide future research on ABA interventions and DS.

Neural Basis and Motor Imagery Intervention Methodology Based on Neuroimaging Studies in Children With Developmental Coordination Disorders: A Review

Although the neural bases of the brain associated with movement disorders in children with developmental coordination disorder (DCD) are becoming clearer, the information is not sufficient because of the lack of extensive brain function research. Therefore, it is controversial about effective intervention methods focusing on brain function. One of the rehabilitation techniques for movement disorders involves intervention using motor imagery (MI). MI is often used for movement disorders, but most studies involve adults and healthy children, and the MI method for children with DCD has not been studied in detail. Therefore, a review was conducted to clarify the neuroscientific basis of the methodology of intervention using MI for children with DCD. The neuroimaging review included 20 magnetic resonance imaging studies, and the neurorehabilitation review included four MI intervention studies. In addition to previously reported neural bases, our results indicate decreased activity of the bilateral thalamus, decreased connectivity of the sensory-motor cortex and the left posterior middle temporal gyrus, bilateral posterior cingulate cortex, precuneus, cerebellum, and basal ganglia, loss of connectivity superiority in the abovementioned areas. Furthermore, reduction of gray matter volume in the right superior frontal gyrus and middle frontal gyrus, lower fractional anisotropy, and axial diffusivity in regions of white matter pathways were found in DCD. As a result of the review, children with DCD had less activation of the left brain, especially those with mirror neurons system (MNS) and sensory integration functions. On the contrary, the area important for the visual space processing of the right brain was activated. Regarding of characteristic of the MI methods was that children observed a video related to motor skills before the intervention. Also, they performed visual-motor tasks before MI training sessions. Adding action observation during MI activates the MNS, and performing visual-motor tasks activates the basal ganglia. These methods may improve the deactivated brain regions of children with DCD and may be useful as conditioning before starting training. Furthermore, we propose a process for sharing the contents of MI with the therapist in language and determining exercise strategies.

A systematic review of behaviour analytic interventions for young children with intellectual disabilities

BACKGROUND

According to several comprehensive systematic and narrative reviews, interventions based on applied behaviour analysis principles, or behaviour analytic interventions, are considered evidence based for children with autism spectrum disorder (ASD). However, no comprehensive review of the literature related to behaviour analytic interventions for children with intellectual disability (ID) currently exists.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration ID: CRD42018099317), the purpose of this study was to conduct a systematic review of the relevant published literature on the use of behaviour analytic interventions to develop skills in young children (0-8 years) with ID (and without ASD). A preliminary search of the literature identified 1209 potential studies published between January 2000 and April 2020. The review process resulted in 48 articles consisting of 49 studies (i.e. one paper contained two studies) that met the inclusion criteria. Most used single-case research designs. Studies were evaluated on five dimensions of methodological quality based on the Scientific Merit Rating Scale developed by the National Autism Center (NAC). The NAC definitions were also used for the quantity and quality of research evidence required for interventions to be considered established or emerging.

RESULTS

There were a number of limitations to the quality of the body of research. Nevertheless, various behaviour analytic interventions met criteria for being established interventions when used for targeting communication, adaptive and pre-academic skills in young children with ID. Behaviour analytic interventions targeting academic skills met criteria for emerging interventions.

CONCLUSIONS

Although the current literature is limited, results indicate that behaviour analytic interventions may be effectively used to support skill development in children with ID.

A unified framework for bias assessment in clinical research

Methodological flaws, limitations, and inadequate practices in research are well known and pose threats to the internal validity of any research study. However, there are ways of safeguarding research conduct to reduce the chance of research producing distorted results. Numerous tools now exist to assess the incorporation of such safeguards into primary research studies (also known as quality and/or risk-of-bias assessment). These tools typically include a variety of items that are then checked against those implemented in the study. Despite a lot of research in this area, no comprehensive generic classification of safeguards across study designs exist, although attempts have been made to clarify aspects of this. We review the developments in this area as well as use preliminary data from 100 methodological studies to illustrate our proposed approach. We conclude by proposing a new framework for identifying research studies at risk of being biased and the information in this article will promote a unification of the diverse approaches to facilitating bias assessment in clinical research.

Exposure, Relaxation, and Rescripting Therapy for Trauma-Related Nightmares With Psychiatric Inpatients: A Case Series

Research has shown that posttraumatic stress disorder (PTSD) is a highly prevalent diagnosis for psychiatric patients, yet individualized care and treatment is limited in the inpatient acute care sector. Two case studies are presented which examine the use of Exposure, Relaxation, and Rescripting Therapy (ERRT) for chronic trauma-related nightmares, within a private acute care inpatient psychiatric hospital setting. ERRT is empirically supported with efficacy for veteran and civilian populations, however no research to date has been conducted with psychiatric inpatients. Two participants diagnosed with PTSD, suffering distressing trauma-related nightmares, completed ERRT over three sessions during their psychiatric hospital admission, with the aim of reducing the frequency and severity of nightmares and related psychological symptoms. PTSD, depression, sleep quality and quantity, and nightmare frequency and related distress, were measured pre-treatment, during treatment, and follow-up at one, 3 and 6 months. Only one participant reported ongoing nightmares by the third week of the intervention, with both participants reporting an absence of nightmares at the one and 3-month follow-ups, but mixed results by the 6-month follow-up. One participant also reported a reduction in PTSD symptoms and a mild improvement in depression. The results offer some preliminary support for the provision of ERRT for the treatment of trauma-related nightmares for psychiatric inpatients.

The Potential of a Relational Training Intervention to Improve Older Adults' Cognition

Behavioral gerontology rarely focuses on improving older adults' cognitive function. This gap in the literature should be addressed, as our aging population means that greater numbers of older adults are experiencing cognitive decline and reduced functional independence. If cognitive training interventions are to be socially significant, they should target improvements in core executive functions (EFs) that are critical for everyday cognition and functioning independence. Evidence from the cognitive sciences suggests that a cognitive training intervention targeting "relational knowledge" and "cognitive flexibility," which are core EFs, could translate to improvements in cognition and functioning for older adults. Behavioral researchers, interested in the effects of relational training on cognition, have shown a relationship between complex and flexible arbitrarily applicable relational responding (AARRing) and improved performance on measures of intelligence in children and young adults. However, data examining the impact of AARRing on the cognition of older adults are lacking. This article suggests that complex and flexible AARRing may be synonymous with the aforementioned EFs of relational knowledge and cognitive flexibility, and that a behaviorally oriented relational training intervention might improve cognition and functioning for healthy older adults or those experiencing cognitive decline. The article initially presents a brief overview of research in behavioral gerontology and older adult cognition, followed by a detailed explanation of how training complexity and flexibility in AARRing could result in improvements in core EFs. Specific suggestions for designing a relational training intervention and assessing relevant outcomes are provided.

Impact of attachment imagery on paranoia and mood: evidence from two single case studies

Background:

Cognitive behavioural therapy (CBT) for psychosis currently yields modest outcomes and must be improved. Attachment imagery may be an effective means of reducing severity of paranoid beliefs and associated affect. Experimental studies have demonstrated these effects in non-clinical groups. The impact in clinical populations remains untested.

Aims:

This study assessed the impact of a brief attachment imagery task on paranoia and mood, in two people with a diagnosis of schizophrenia.

Method:

Two single case studies are presented. Both participants were working age adults with persecutory delusions. The study utilised an A-B-A design. Participants were recruited for a 6-week period, with a 2- and 3-week baseline respectively, 1-week intervention phase, and follow-up phase matched to duration of baseline. Trait paranoia and attachment were measured at the start of the baseline. State paranoia and affect were measured daily over the 6-week period.

Results:

For both participants, the baseline phase was characterised by high and variable levels of paranoia, which reduced during the intervention phase, with a return to baseline scores at follow-up. We found a similar pattern for negative affect, and the reverse pattern for positive affect.

Conclusions:

Attachment imagery may function as an effective emotion regulation strategy for people with psychosis. Continued use is likely to be needed to maintain gains. This brief task could prove valuable to people needing skills to manage paranoia and mood, and give clinicians confidence that people can manage short-term distress in CBT for psychosis, for example when addressing past trauma.

Strategy-based reading comprehension therapy during early acquired brain injury rehabilitation: preliminary results

Introduction: An evidence-based intervention and service delivery model for early acquired brain injury reading comprehension rehabilitation (involving multiple-strategy, hierarchical reading) was investigated with 3 clients <3 m post onset as part of their brain injury rehabilitation program.Materials and methods: A multiple-baseline single case experimental design was used for each participant, with data analysed using Tau-U. Assessments of reading comprehension (impairment and activity level) were performed pre/post intervention, and at follow-up (3-6 months post-treatment). Participants' perceptions of the intervention and service delivery model were captured via semi-structured interviews.Results: All participants demonstrated improved reading comprehension post-intervention on all formal measures. At follow-up, reading comprehension was grossly maintained by 2 participants. The single case experimental design results (Tau-U) showed moderate-large intervention effect sizes for factual and inferential reading comprehension, two participants had significant (p = 0.01) changes. Participants reported overall positive experiences with the intervention.Conclusion: The intervention and service delivery model were successfully implemented in clinical practice, and preliminary results show the intervention has clinical promise with an early acquired brain injury population.IMPLICATIONS FOR REHABILITATIONCognitive communication reading comprehension deficits occur following acquired brain injury and impact participation during rehabilitation and in the community.An evidence-based intervention for the early rehabilitation of cognitive communication reading comprehension deficits following acquired brain injury has been developed and trialled in clinical practice with adults <3 months post-acquired brain injury, via a series of single-case experimental designs.Improvements in reading comprehension skill and activity/participation occurred for all participants post-intervention; statistically significant changes occurred for 2 of 3 clients.Early rehabilitation of cognitive communication reading comprehension deficits can be successfully implemented as a component of a multidisciplinary rehabilitation program.

Spaced Retrieval and Episodic Memory Training in Alzheimer's Disease

Introduction

This study replicated and extended the findings from the author's previous pilot study to further explore how a spaced retrieval (SR) memory training program might be effectively applied to help persons with Alzheimer’s disease (AD)  improve both short- and long-term recall of recent episodic events.

Methods

A quasi-experimental within-subject group study was conducted with 15 participants with a diagnosis of AD.

Results

Compared to a control condition, all participants were able to spontaneously recall significantly more specific details about trained events, and their recall was significantly enhanced when they were provided with cues. Although the findings indicated that people with AD were able to encode information during training, recall gains diminished by the end of the maintenance period.

Discussion

This study provides evidence that individuals with mild to moderate AD can learn and recall new episodic information through SR training. These findings support the use of SR as an intervention tool to help individuals maintain their functioning in episodic recent memory. However, more research into maintaining the long-term recall of recent episodic events is warranted.

A Systematically Conducted Scoping Review of the Evidence and Fidelity of Treatments for Verb Deficits in Aphasia: Verb-in-Isolation Treatments

Purpose Aphasia research demonstrates increasing interest in the treatment of verb retrieval deficits. This systematically conducted scoping review reports on the level and fidelity of the current evidence for verb treatments; on its effectiveness regarding the production of trained and untrained verbs, functional communication, sentences, and discourse; and on the potential active ingredients. Recommendations to guide clinical decision making and future research are made. Method The computerized database search included studies from January 1980 to September 2018. The level of evidence of each study was documented, as was fidelity in terms of treatment delivery, enactment, and receipt. Studies were also categorized according to the treatment methods used. Results Thirty-seven studies were accepted into the review, and all but 1 constituted a low level of evidence. Thirty-three studies (89%) described treatment in sufficient detail to allow replication, dosage was poorly reported, and the fidelity of treatment was rarely assessed. The most commonly reported treatment techniques were phonological and semantic cueing in 25 (67.5%) and 20 (54%) studies, respectively. Retrieval of trained verbs improved for 80% of participants, and improvements generalized to untrained verbs for 15% of participants. There was not sufficient detail to evaluate the impact of treatment on sentence production, functional communication, and discourse. Conclusions The evidence for verb treatments is predominantly of a low level. There are encouraging findings in terms of treatments being replicable; however, this is tempered by poor monitoring of treatment fidelity. The quality of verb treatment research would be improved by researchers reaching consensus regarding outcome measures (including generalization to, e.g., sentences and discourse) by manualizing treatment to facilitate implementation and exploring the opinions of participants. Finally, while treatment is largely effective in improving production of trained verbs, lack of generalization to untrained items leads to the recommendation that personally relevant verbs are prioritized.

Single-case Design Studies in Children with Cerebral Palsy: A Scoping Review

Aim: To critically evaluate single-case design (SCD) studies performed within the population of children/adolescents with cerebral palsy (CP).Methods: A scoping review of SCD studies of children/adolescents with CP. Demographic, methodological, and statistical data were extracted. Articles were evaluated using the Risk of Bias in N-of-1 Trials (RoBiNT) Scale and the Consolidated Standards of Reporting Trials (CONSORT) extension for N-of-1 trials (CENT 2015). Comments regarding strengths and limitations were analyzed.Results: Studies investigated the effects of a wide range of interventions on various outcomes. Most SCD types were adopted in multiple studies. All studies used visual inspection rather than visual analysis, often complemented with basic statistical descriptives. Risk of bias was high, particularly concerning internal validity. Many CENT items were insufficiently reported. Several benefits and limitations of SCD were identified.Conclusions: The quality of evidence from results of SCD studies needs to be increased through risk of bias reduction.

Re-Evaluating Evidence for Best Practice in Paediatric Speech-Language Pathology

BACKGROUND

Systematic reviews of treatment trials for children with speech and language difficulties often exemplify the limited clinical usefulness of the evidence base, reflecting recent literature in evidence-based medicine. Other studies report that clinicians often fail to seek information about best practice, across the health professions. Consequently, clinical researchers, including those in speech-language pathology, have sought alternative methodologies for determining best practice.

SUMMARY

Some approaches focus on "pragmatic trials," usually as part of existing health services. Others place case management of individuals at the centre of intervention presenting studies of one or more cases, including N-of-1 randomized controlled trials and cross-over group designs. Clinical case studies can provide important theoretical data contributing to our understanding of the development of typical and atypical communication. Precision medicine (also known as personalized medicine) is an emerging approach to building the clinical evidence base that acknowledges the importance of individual genetic and environmental differences between people. With increasing knowledge of aetiological heterogeneity, even within children presenting with the same diagnosis (e.g., childhood apraxia of speech), data reinforce the edict that children are not all born equal. Key Message: This review argues that to understand response to treatment, it is critical to examine child-related factors as well as the variables of the intervention itself.