Effect of digital game intervention on cognitive functions in older adults: a multiple baseline single case experimental design study.

BACKGROUND: Residents in nursing homes are prone to cognitive decline affecting memory, visuospatial cognition, and executive functions. Cognitive decline can lead to dementia, necessitating prioritized intervention. METHODS: The current study aimed to investigate whether an intervention using a digital game was effective for preserving and improving the cognitive function of residents in nursing homes. An intervention study was conducted using a single-case AB design with multiple baselines. The participants in the study were five older adults aged 65 and over who do not play digital games regularly. The study ran for 15 weeks, including a baseline (phase A) and an intervention phase (phase B). Phase A had five baselines (5 to 9 weeks) with random participant assignment. In phase B, participants engaged in a digital game (Space Invaders) individually. Cognitive function was assessed as the outcome, measured using the Brain Assessment (performed on a tablet through the Internet) at 16 measurement points. Four of five participants (two female and two male) were included in the analysis, using visual inspection and Bayesian statistics with multi-level modeling. RESULTS: Visual inspection of the graphs revealed cognitive function score improvements after the intervention for most layers in terms of memory of numbers, memory of words, mental rotation test (visuospatial ability), and total scores in the Brain Assessment. These effects were also significant in the analysis by multi-level modeling. CONCLUSIONS: The results suggest that the use of digital games may be effective for preserving and improving cognitive function among residents of nursing home. TRIAL REGISTRATION: This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000048677; public title: Effect of a Digital Game Intervention for Cognitive Functions in Older People; registration date: August 30, 2022).

Speech-to-text intervention to support text production among students with writing difficulties: a single-case study in nordic countries.

Studies report that speech-to-text applications (STT) may support students with writing difficulties in text production. However, existing research is sparse, shows mixed results, and lacks information on STT interventions and their applicability in schools. Therefore, this study aimed to investigate whether a systematic and intensive assistive technology intervention focusing on STT can improve text production. A modified multiple-baseline across-subject design was used involving eight middle school students, four Norwegian and four Swedish. Their STT-produced narrative texts were collected during and after the intervention and the productivity, accuracy, and text quality were analysed. Keyboarding was the baseline control condition. The results demonstrated that seven of the eight students increased text productivity and that the proportion of word-level accuracy was maintained or improved. The use of punctuation progressed in participants with poor baseline skills. Most students' STT-produced texts had at least a similar ratio of meaningfulness and text quality as keyboarding. However, the magnitude of the changes and development patterns varied, with three students showing the most notable impacts. In conclusion, this study's intervention seemed beneficial in initially instructing STT, and the progress monitoring guided individually adapted future interventions such as balancing productivity and formal language aspects. Removing the spelling barrier with STT provided an opportunity for students to improve their higher-order skills, such as vocabulary diversity and overall text quality. Furthermore, visible progress, such as the ability to produce longer texts, might motivate continued STT usage. However, such development may not always be immediate.

Speech-to-text (STT) may be an effective tool for developing text production in students with severe reading and writing difficulties. For example, enhanced text length can provide teachers with more material for feedback, guiding students towards improved text production.Text-to-speech may further enhance the usefulness of STT in text production by facilitating the revision process through listening to produced sentences and texts.By continuously monitoring students' STT usage and text production, teachers can tailor the content for further interventions to address individual needs such as sentence construction and text planning.Early STT intervention seems beneficial, allowing more time to practise advanced skills in text production when bypassing spelling.

Promoting Reciprocal Relationships with Flexibility, Coaching, and Teaching (PRRFCT Match): A Virtual Parent-Mediated Intervention Package for Young Children with Developmental Disabilities.

This study aimed to evaluate Promoting Reciprocal Relationships with Flexibility, Coaching, and Teaching (PRRFCT Match), a parent-mediated naturalistic developmental behavioral intervention package. An expansion from an earlier pilot study (see Kunze et al., 2021), PRRFCT Match incorporates virtual coaching between a novice coach and parent to implement evidence-based, applied behavior analytic (ABA) techniques during play to increase engagement and decrease unengaged behavior exhibited by their young child with developmental delays (26-50 months old). Ten parent-child dyads were matched with a coach in this concurrent multiple baseline design across participants. Simulating the clinical training level of a novice early interventionist, nine graduate student clinicians received training as coaches on PRRFCT Match implementation and weekly supervision by a research team member. All aspects of training and intervention were delivered virtually. A visual analysis of the data combined with Tau-U revealed a strong basic effect between clinician coaching and parent strategy use. For child participants, a visual analysis and Tau-U results suggest that most increased engagement and decreased their unengaged behavior during the intervention. High variability, overlap, and high engagement at baseline are discussed. This study shows promise for the PRRFCT Match intervention package. The ABA technologies mediated by parents during play increased child engagement and decreased unengagement for most participants.

Replication of a single-case design cross-situational statistically based word learning treatment for late talking children.

PURPOSE: Late talking children are at risk of ongoing language impairment. This intervention study replicated and extended research based on cross-situational statistical learning principles. METHOD: Three late talking children (age 24-32 months) were enrolled into the concurrent multiple baseline single-case experimental intervention study. The intervention consisted of 16 sessions over eight/nine weeks, including 10-11 pairs of target and control words (three per session). Children heard the target words a minimum of 64 times per session, in sentences with high linguistic variability in varied play activities. RESULT: All children increased production of target words and expressive vocabulary, with statistically significant differences between word acquisition in baseline and intervention phases. One of the three children learnt statistically significantly more target words than control words. CONCLUSION: The results replicated the findings of previous research for some but not all of the participants, providing individual evidence that this approach has promise as a therapy technique for late talking children.

Reading intervention for students with intellectual disabilities without functional speech who require augmentative and alternative communication: a multiple single-case design with four randomized baselines.

BACKGROUND: Literacy is one of the most important skills a students can achieve, as it provides access to information and communication. Unfortunately, literacy skills are not easily acquired, especially for students with intellectual disabilities who require augmentative and alternative communication (AAC). There are many barriers to literacy acquisition, some due to low expectations from parents and teachers and lack of evidence-based reading programs and reading materials adapted for AAC. Barriers as a result of extensive support needs is also a real factor. This trial aims to deliver reading instructions to 40 students with intellectual disabilities who require AAC and contribute in the debate on how to best support this population through reading instructions to maximizes their reading skills. METHODOLOGY: Forty non-verbal or minimally verbal students (age 6-14) with intellectual disabilities who require AAC will be part of a reading intervention with a multiple single-case design with four randomized baselines. The intervention period will last for 18 months and will commence in March 2023. The students will receive the intervention in a one-to-one format, working systematically with a reading material that contains phonological awareness and decoding tasks based on the Accessible Literacy Learning (ALL) developed by Janice Light and David McNaughton. All the teachers will be trained to deliver the reading intervention. DISCUSSION: The reading material "Lesing for alle" (Reading for all) is based on and follow the strategies behind the research of ALL. The current trial will through a reading intervention contribute to move beyond only teaching sight words and combine several reading components such as sound blending, letter-sound correspondence, phoneme segmentation, shared reading, recognition of sight words, and decoding. The strategies and methods in use is built on the existing science of reading, especially what has been effective in teaching reading for students with intellectual disabilities who require AAC. There is limited generalizability of prior findings in reading-related phonological processing interventions to different populations of them who use AAC specially outside of the USA. More research is needed to understand how programs designed to improve reading skills across other settings understand the program's long-term effects and to study the effectiveness when delivered by educators who are not speech language therapists or researchers. TRIAL REGISTRATION: NCT05709405 . Registered 23 January 2023.

Between-case standardized mean differences: Flexible methods for single-case designs.

Single-case designs (SCDs) are a class of research methods for evaluating the effects of academic and behavioral interventions in educational and clinical settings. Although visual analysis is typically the first and main method for analysis of data from SCDs, quantitative methods are useful for synthesizing results and drawing systematic generalizations across bodies of single-case research. Researchers who are interested in synthesizing findings across SCDs and between-group designs might consider using the between-case standardized mean difference (BC-SMD) effect size, which aims to put results from both types of studies into a common metric. Currently available BC-SMD methods are limited to treatment reversal designs with replication across participants and across-participant multiple baseline designs, yet more complex designs are sometimes used in practice. In this study, we extend available BC-SMD methods to several variations of the multiple baseline design, including the replicated multiple baseline across behaviors or settings, the clustered multiple baseline design, and the multivariate multiple baseline across participants. For each variation, we describe methods for estimating BC-SMD effect sizes and illustrate our proposed approach by re-analyzing data from a published SCD study.

Systematic Review of Descriptions and Justifications Provided for Single-Case Quantification Techniques.

There are currently a multitude of quantification techniques that have been developed for use with single-case designs. As a result, choosing an appropriate quantification technique can be overwhelming and it can be difficult for researchers to properly describe and justify their use of quantification techniques. However, providing clear descriptions and justifications is important for enhancing the credibility of single-case research, and allowing others to evaluate the appropriateness of the quantification technique used. The aim of this systematic literature review is to provide an overview of the quantification techniques that are used to analyze single-case designs, with a focus on the descriptions and justifications that are provided. A total of 290 quantifications occurred across 218 articles, and the descriptions and justifications that were provided for the quantification techniques that were used are systematically examined. Results show that certain quantification techniques, such as the non-overlap indices, are more commonly used. Descriptions and justifications provided for using the quantification techniques are sometimes vague or subjective. Single-case researchers are encouraged to complement visual analysis with the use of quantification techniques for which they can provide objective and appropriate descriptions and justifications, and are encouraged to use tools to guide their choice of quantification techniques.

Strategies to reduce low-value care - An applied behavior analysis using a single-case design.

Introduction: Implementation science has traditionally focused on the implementation of evidence-based practices, but the field has increasingly recognized the importance of addressing de-implementation (i.e., the process of reducing low-value care). Most studies on de-implementation strategies have used a combination of strategies without addressing factors that sustain the use of LVC and there is a lack of information about which strategies are most effective and what mechanisms of change might underlie these strategies. Applied behavior analysis is an approach that could be a potential method to gain insights into the mechanisms of de-implementation strategies to reduce LVC. Three research questions are addressed in this study: What contingencies (three-term contingencies or rule-governing behavior) related to the use of LVC can be found in a local context and what strategies can be developed based on an analysis of these contingencies?; Do these strategies change targeted behaviors?; How do the participants describe the strategies' contingencies and the feasibility of the applied behavior analysis approach? Materials and methods: In this study, we used applied behavior analysis to analyze contingencies that maintain behaviors related to a chosen LVC, the unnecessary use of x-rays for knee arthrosis within a primary care center. Based on this analysis, strategies were developed and evaluated using a single-case design and a qualitative analysis of interview data. Results: Two strategies were developed: a lecture and feedback meetings. The results from the single-case data were inconclusive but some of the findings may indicate a behavior change in the expected direction. Such a conclusion is supported by interview data showing that participants perceived an effect in response to both strategies. Conclusion: The findings illustrate how applied behavior analysis can be used to analyze contingencies related to the use of LVC and to design strategies for de-implementation. It also shows an effect of the targeted behaviors even though the quantitative results are inconclusive. The strategies used in this study could be further improved to target the contingencies better by structuring the feedback meetings better and including more precise feedback.

A Visual Aid and Objective Rule Encompassing the Data Features of Visual Analysis.

Visual analysis of single-case research is commonly described as a gold standard, but it is often unreliable. Thus, an objective tool for applying visual analysis is necessary, as an alternative to the Conservative Dual Criterion, which presents some drawbacks. The proposed free web-based tool enables assessing change in trend and level between two adjacent phases, while taking data variability into account. The application of the tool results in (a) a dichotomous decision regarding the presence or absence of an immediate effect, a progressive or delayed effect, or an overall effect and (b) a quantification of overlap. The proposal is evaluated by applying it to both real and simulated data, obtaining favorable results. The visual aid and the objective rules are expected to make visual analysis more consistent, but they are not intended as a substitute for the analysts' judgment, as a formal test of statistical significance, or as a tool for assessing social validity.

Using AB Designs With Nonoverlap Effect Size Measures to Support Clinical Decision-Making: A Monte Carlo Validation.

Single-case experimental designs often require extended baselines or the withdrawal of treatment, which may not be feasible or ethical in some practical settings. The quasi-experimental AB design is a potential alternative, but more research is needed on its validity. The purpose of our study was to examine the validity of using nonoverlap measures of effect size to detect changes in AB designs using simulated data. In our analyses, we determined thresholds for three effect size measures beyond which the type I error rate would remain below 0.05 and then examined whether using these thresholds would provide sufficient power. Overall, our analyses show that some effect size measures may provide adequate control over type I error rate and sufficient power when analyzing data from AB designs. In sum, our results suggest that practitioners may use quasi-experimental AB designs in combination with effect size to rigorously assess progress in practice.

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.

Is ACT-Informed Exposure a Viable Treatment for Excoriation Disorder? A Multiple Baseline Study.

This study piloted the use of ACT-informed exposure as an adjunct to habit reversal training (HRT) for excoriation disorder (ExD). Using a nonconcurrent multiple baseline single case design, four participants completed sessions of exposure and HRT. Repeated measures and self-report data were collected on skin picking and psychological flexibility. Two participants completed HRT followed by exposure, and two participants completed exposure followed by HRT. Results support the effectiveness of HRT in reducing picking. Results suggest exposure may have some impact in reducing picking, but effects were weaker compared to HRT. Contrary to predictions, repeated measures and self-report data did not indicate consistent improvement in psychological flexibility during exposure phases. As any reduction in picking may be clinically meaningful and all participants maintained gains at follow-up, there is some indication that exposure may be a second-line treatment worth further study. Limitations and future areas of research are discussed.

Waiting for baseline stability in single-case designs: Is it worth the time and effort?

Researchers and practitioners often use single-case designs (SCDs), or n-of-1 trials, to develop and validate novel treatments. Standards and guidelines have been published to provide guidance as to how to implement SCDs, but many of their recommendations are not derived from the research literature. For example, one of these recommendations suggests that researchers and practitioners should wait for baseline stability prior to introducing an independent variable. However, this recommendation is not strongly supported by empirical evidence. To address this issue, we used Monte Carlo simulations to generate graphs with fixed, response-guided, and random baseline lengths while manipulating trend and variability. Then, our analyses compared the type I error rate and power produced by two methods of analysis: the conservative dual-criteria method (a structured visual aid) and a support vector classifier (a model derived from machine learning). The conservative dual-criteria method produced fewer errors when using response-guided decision-making (i.e., waiting for stability) and random baseline lengths. In contrast, waiting for stability did not reduce decision-making errors with the support vector classifier. Our findings question the necessity of waiting for baseline stability when using SCDs with machine learning, but the study must be replicated with other designs and graph parameters that change over time to support our results.

Using Attachment and Biobehavioral Catch-up with young children with developmental delays: A multiple-baseline trial of attachment, sensitivity, and cortisol.

The Attachment and Biobehavioral Catchup intervention potentially offsets psychosocial risks facing dyads in which children have intellectual disability or developmental delays. In this single-case multiple-baseline study the efficacy of this intervention was tested across three such South African families. Maternal sensitivity, attachment security, and child affect regulation were measured weekly during a baseline and intervention period, using the Ainsworth Maternal Sensitivity Scales, Attachment Q-sort and salivary cortisol, respectively. Furthermore, post-intervention interviews invited parents' and intervenors' evaluations of the intervention. Visual analysis broadly indicated improvement in maternal sensitivity and attachment security across subjects over time following the introduction of the intervention, although randomisation tests were not statistically significant. Effects on affect regulation were not clearly observed and may have been influenced by case-specific variables. Parent-participants and intervenors also identified particularly helpful contributions from the intervention. Findings underscore the importance of individual-level effects evaluation, especially when implementing interventions outside the original population.

Evaluation of the Integrated Therapy Model in Preschool Education for Children with Autism Spectrum Disorder in China.

The Integrated Therapy Model is a practice framework designed to promote multi-disciplinary collaboration to accommodate the holistic needs of children with special education needs. This study evaluated the effectiveness of the model adopted in a pilot preschool in China on children with autism spectrum disorder (ASD). A single-case, ABAB reversal design was employed with three children with ASD, and data were collected using direct observation and semi-structured interviews. The results demonstrated that while the model piloted in China was effective at improving fine motor ability, gross motor ability, imitation and problem behavior, it had mild to questionable effects on self-care and independent living capacity. The implications for the practice and for research on preschool interventions in mainland China is discussed.

The unified protocol for transdiagnostic treatment of emotional disorders for misophonia: a pilot trial exploring acceptability and efficacy.

Introduction: Misophonia is a recently defined disorder characterized by distressing responses to everyday sounds, such as chewing or sniffling. Individuals with misophonia experience significant functional impairment but have limited options for evidenced-based behavioral treatment. To address this gap in the literature, the current pilot trial explored the acceptability and efficacy of a transdiagnostic cognitive-behavioral approach to treating symptoms of misophonia. Methods: This trial was conducted in two studies: In Study 1, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) was delivered to eight patients in order to receive feedback to guide revisions to the treatment to suit this population. In Study 2, ten patients received the revised UP treatment to explore its acceptability and preliminary efficacy. This study used a single-case experimental design with multiple baselines, randomizing patients to either a 2-week baseline or 4-week baseline prior to the 16 weeks of treatment, followed by four weeks of follow-up. Results: The findings from these studies suggested that patients found both the original and adapted versions of the UP to be acceptable and taught them skills for how to manage their misophonia symptoms. Importantly, the findings also suggested that the UP can help remediate symptoms of misophonia, particularly the emotional and behavioral responses. Discussion: These findings provide preliminary evidence that this transdiagnostic treatment for emotional disorders can improve symptoms of misophonia in adults.

Threats to Internal Validity in Multiple-Baseline Design Variations.

Multiple baseline designs-both concurrent and nonconcurrent-are the predominant experimental design in modern applied behavior analytic research and are increasingly employed in other disciplines. In the past, there was significant controversy regarding the relative rigor of concurrent and nonconcurrent multiple baseline designs. The consensus in recent textbooks and methodological papers is that nonconcurrent designs are less rigorous than concurrent designs because of their presumed limited ability to address the threat of coincidental events (i.e., history). This skepticism of nonconcurrent designs stems from an emphasis on the importance of across-tier comparisons and relatively low importance placed on replicated within-tier comparisons for addressing threats to internal validity and establishing experimental control. In this article, we argue that the primary reliance on across-tier comparisons and the resulting deprecation of nonconcurrent designs are not well-justified. In this article, we first define multiple baseline designs, describe common threats to internal validity, and delineate the two bases for controlling these threats. Second, we briefly summarize historical methodological writing and current textbook treatment of these designs. Third, we explore how concurrent and nonconcurrent multiple baselines address each of the main threats to internal validity. Finally, we make recommendations for more rigorous use, reporting, and evaluation of multiple baseline designs.

Honoring Uncontrolled Events: Commentary on Slocum et al.

In this special section of Perspectives on Behavior Science, Slocum et al. (2022) provide a summary of the logic and protocol for the construction, implementation, and analysis of single-case multiple-baseline designs. A major contribution of this article is a reassessment of the nonconcurrent multiple baseline design as a credible approach to documenting experimental control. In this commentary we provide considerations for readers as they approach the Slocum et al. article and suggest that although the resurrection of nonconcurrent multiple-baseline designs to a higher status is warranted, researchers will find more control for threats to internal validity in concurrent multiple-baseline designs, and the concurrent format should remain the preferred option.

Revisiting an Analysis of Threats to Internal Validity in Multiple Baseline Designs.

In our previous article on threats to internal validity of multiple baseline design variations (Slocum et al., 2022), we argued that nonconcurrent multiple baseline designs (NCMB) are capable of rigorously demonstrating experimental control and should be considered equivalent to concurrent multiple baselines (CMB) in terms of internal validity. We were fortunate to receive five excellent commentaries on our article from experts in single-subject research design-four of whom endorsed the conclusion that NCMBs should be considered strong experimental designs capable of demonstrating experimental control. In the current article, we address the most salient points made in the five commentaries by further elaborating and clarifying the logic described in our original article. We address arguments related to classic threats including maturation, testing and session experience, and coincidental events (history). We rebut the notion that although NCMBs are strong, CMBs provide an increment of additional control and discuss the application of probability-based analysis of the likelihood of threats to internal validity. We conclude by emphasizing our agreement with many of the commentaries that selection of single-case experimental designs should be based on the myriad subtleties of research priorities and contextual factors rather than on a decontextualized hierarchy of designs.

Assessment of the Effectiveness of an Exposure Technique Intervention in a Case of Amaxophobia

Amaxophobia, or driving phobia, is an anxiety disorder; more specifically a situational phobia (SP). Main symptoms of SP may include an excessive and irrational fear to certain stimuli, to which exposure produces high anxiety levels, as well as the development of avoidance mechanisms or confrontation, at the expense of a high distress. Its prognosis is chronic in the absence of treatment, but empirical evidence reveals a high efficacy of psychological interventions based on exposure techniques. The case of a 47 years old female requesting treatment for an intense driving fear is presented. The assessment was made through an ad hoc self-report of anxiogenic episodes, the Short Form Health Survey (SF-12), the General Health Questionnaire (GHQ-28), the Perceived Stress Scale (PSS-14), the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI). It was conducted a cognitive-behavioral intervention based on imagination and real life exposure techniques, along with breathing and relaxation techniques. After 10 sessions her anxiety levels and her negative affects decreased significantly, allowing her to resume driving and revealing the efficacy of the intervention (AU)