Check-in/Check-out (CICO) is an intervention designed to improve behavioral outcomes for students identified as at-risk for school failure. Core principles of the intervention include clearly defined behavioral expectations and rules, precorrections for meeting behavioral expectations, high rates of feedback and reinforcement for demonstration of desired behavior, use of data to monitor outcomes, and a system for school-to- home communication. The purpose of this investigation was to use the 2014 Council for Exceptional Children’s quality indicators and standards for establishing evidence-based practices in special education to review the existing research for CICO. Implications regarding the use of different sets of quality indicators to evaluate extant research are provided, and recommendations for future research are discussed.
Measuring treatment effects when an individual’s pretreatment performance is improving poses a challenge for single-case experimental designs. It may be difficult to determine whether improvement is due to the treatment or due to the preexisting baseline trend. Tau-U is a popular single-case effect size statistic that purports to control for baseline trend. However, despite its strengths, Tau-U has substantial limitations: Its values are inflated and not bound between –1 and +1, it cannot be visually graphed, and its relatively weak method of trend control leads to unacceptable levels of Type I error wherein ineffective treatments appear effective. An improved effect size statistic based on rank correlation and robust regression, Baseline Corrected Tau, is proposed and field-tested with both published and simulated single-case time series. A web-based calculator for Baseline Corrected Tau is also introduced for use by single-case investigators.
The Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders is a cognitive-behavioral intervention designed to treat the range of anxiety, depressive, and related disorders. Thus far, the UP treatment modules have only been studied when they are delivered in their entirety and presented in a standard sequence. To personalize the presentation of the UP modules for a given patient’s presentation (e.g., providing the modules in a varied order, dropping irrelevant modules), it is first necessary to establish that each module leads to change in the skill it is designed to promote, and that these changes can occur in the absence of the other modules. Using a multiple baseline design in accordance with the single-case reporting guidelines in behavioral interventions (SCRIBE), eight patients with heterogeneous emotional disorders were randomly assigned to a 1- or 3-week baseline assessment phase followed by four sessions of one of four UP modules (psychoeducation, emotional awareness, cognitive flexibility, and countering emotional behaviors). Results provide preliminary support for the notion that each UP module under study leads to change in its associated skill in the absence of the other modules (five of eight patients demonstrated reliable change in the module-specific skill). In addition, exploratory analyses suggest that the emotion awareness training and cognitive flexibility modules appeared to exhibit change specific to their associated skills, psychoeducation, and countering emotional behaviors demonstrated somewhat more broad-based change across skills.
Providing noncontingent access to a stimulus until an individual displays behavioral indicators of satiation has been used to determine when an abolishing operation is in effect, but there has been variation in its application in the literature. Four males diagnosed with autism spectrum disorder with tangibly maintained challenging behavior participated in this study. Individualized behavioral indicators were identified and verified to determine when each participant was finished playing with his/her preferred item. Three presession conditions were manipulated including restricted access to the tangible stimulus for 30 min, access to the tangible stimulus until the display of one behavioral indicator, and access to the tangible stimulus until the display of three behavioral indicators. Each presession condition was followed by a tangible condition of the functional analysis to measure challenging behavior. Results indicated that presession access to a tangible stimulus until the display of three behavioral indicators produced a greater abative effect on challenging behavior than one behavioral indicator.
Quantitative synthesis of data from single-case designs (SCDs) is becoming increasingly common in psychology and education journals. Because researchers do not ordinarily report numerical data in addition to graphical displays, reliance on plot digitizing tools is often a necessary component of this research. Intercoder reliability of data extraction is a commonly overlooked, but potentially important, step of this process. The purpose of this study was to examine the intercoder reliability and validity of WebPlotDigitizer (Rohatgi, 2015), a web-based plot digitizing tool for extracting data from a variety of plots, including XY coordinates of interrupted time-series data. Two coders extracted 3,596 data points from 168 data series in 36 graphs across 18 studies. Results indicated high levels of intercoder reliability and validity. Implications of and recommendations based on these results are discussed in relation to researchers involved in quantitative synthesis of data from SCDs.
One potential limitation of functional communication training (FCT) is that after the functional communication response (FCR) is taught, the response may be emitted at high rates or inappropriate times. Thus, schedule thinning is often necessary. Previous research has demonstrated that multiple schedules can facilitate schedule thinning by establishing discriminative control of the communication response while maintaining low rates of problem behavior. To date, most applied research evaluating the clinical utility of multiple schedules has done so in the context of behavior maintained by positive reinforcement (e.g., attention or tangible items). This study examined the use of a multiple schedule with alternating Fixed Ratio (FR 1)/extinction (EXT) components for two individuals with developmental disabilities who emitted escape-maintained problem behavior. Although problem behavior remained low during all FCT and multiple schedule phases, the use of the multiple schedule alone did not result in discriminated manding.
Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD); however, little is known about the relationship between treatment intensity and treatment outcomes. The current study was designed to evaluate this relationship. Participants included 726 children, ages 1.5 to 12 years old, receiving community-based behavioral intervention services. Results indicated a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. Specifically, 35% of the variance in mastery of learning objectives was accounted for by treatment hours using standard linear regression, and 60% of variance was accounted for using artificial neural networks. These results add to the existing support for higher intensity treatment for children with ASD.
Barlow et al. published the unified protocol (UP) for transdiagnostic treatment of emotional disorders, focusing on common pathological factors across a variety of diagnoses. The limited UP research to date suggests that this treatment may be particularly useful for anxiety disorders. However, it has largely been evaluated only in individual treatment format. The current study examined the effectiveness of the UP treatment in a group format, with individuals with comorbid anxiety disorder symptoms. Twenty-six individuals with clinically significant anxiety symptoms in at least two of the following areas, social anxiety, worry, or panic, participated in a 14-week manualized group treatment using the UP. Significant decreases were found on general anxiety, worry, social anxiety, panic, depression, and negative and positive affect. The UP may hold promise for a transdiagnostic group treatment of comorbid anxiety symptoms, but further examination of this treatment is warranted.
The present study examined changes in child and family mealtime patterns before and after intensive behavioral feeding intervention at a multidisciplinary hospital-based program for 50 children. At preintervention and postintervention, caregivers completed surveys to report child feeding goals and the About Your Child’s Eating scale (AYCE). In addition, at postintervention, each caregiver rated intervention effectiveness for his or her child’s feeding goals identified at preintervention and provided intervention satisfaction ratings. Results revealed that caregivers perceived all three AYCE family mealtime patterns to improve from preintervention to postintervention, the majority of caregivers rated intervention as being effective for improving the specific child feeding goals identified at preintervention, and caregivers gave high satisfaction ratings for the intervention.
The present article aims to present a series of software developments in the quantitative analysis of data obtained via single-case experimental designs (SCEDs), as well as the tutorial describing these developments. The tutorial focuses on software implementations based on freely available platforms such as R and aims to bring statistical advances closer to applied researchers and help them become autonomous agents in the data analysis stage of a study. The range of analyses dealt with in the tutorial is illustrated on a typical single-case dataset, relying heavily on graphical data representations. We illustrate how visual and quantitative analyses can be used jointly, giving complementary information and helping the researcher decide whether there is an intervention effect, how large it is, and whether it is practically significant. To help applied researchers in the use of the analyses, we have organized the data in the different ways required by the different analytical procedures and made these data available online. We also provide Internet links to all free software available, as well as all the main references to the analytical techniques. Finally, we suggest that appropriate and informative data analysis is likely to be a step forward in documenting and communicating results and also for increasing the scientific credibility of SCEDs.
There are significant challenges in addressing the mental health needs of college students. The current study tested an acceptance and commitment therapy (ACT), web-based self-help program to treat a broad range of psychological problems students struggle with. A sample of 79 college students was randomized to web-based ACT or a waitlist condition, with assessments at baseline and posttreatment. Results indicated adequate acceptability and program engagement for the ACT website. Relative to waitlist, participants receiving ACT improved on overall distress, general anxiety, social anxiety, depression, academic concerns, and positive mental health. There were no between-group effects on eating concerns, alcohol use, or hostility, or on some key ACT process of change measures. ACT participants improved more on mindful acceptance and obstruction to valued living, both of which mediated treatment outcomes. Results are discussed in the context of lessons learned with the website prototype, and areas for further research are presented.
Restricted and repetitive behavior is a central feature of autism spectrum disorder (ASD), with such behaviors often resulting in lack of reinforcement in social contexts. The present study investigated training multiple exemplars of target behaviors and the utilization of lag schedules of reinforcement in the context of social skills training to promote appropriate and varied social behavior in children with ASD. Five participants with ASD between the ages of 7 and 9 attended a twice-weekly social skills group for 8 weeks. A multiple probe design across skills was utilized to assess intervention effects. During baseline, participants demonstrated low levels of skill accuracy and low appropriate variability in responding. During continuous reinforcement with one trained exemplar, skill accuracy increased while appropriate variability remained low. Training of three exemplars of target skills resulted in minimal improvements in appropriate variability. Introduction of a Lag 2 schedule with three trained exemplars was generally associated with increased appropriate variability. Further appropriate variability was observed during Lag 4 with three trained exemplars. Limitations and implications are discussed.
Panic disorder and agoraphobia are both characterized by avoidance behaviors, which are known correlates of treatment discontinuation. The aim of this exploratory study is to distinguish the profile of participants suffering from panic disorder with agoraphobia that complete treatment from those who discontinue therapy by assessing four categories of predictor variables: the severity of the disorder, sociodemographic variables, participants’ expectations, and dyadic adjustment. The sample included 77 individuals diagnosed with panic disorder with agoraphobia who completed a series of questionnaires and participated in a cognitive-behavioral group therapy consisting of 14 weekly sessions. Hierarchical linear regression analyses revealed the importance of anxiety, prognosis, and role expectations as well as some individual variables as predictors of therapeutic dropout, either before or during treatment. Among the most common reasons given by the 29 participants who discontinued therapy were scheduling conflicts, dissatisfaction with treatment, and conflicts with their marital partner. These results suggest that expectations and dyadic relationships have an impact on therapeutic discontinuation. The clinical implications of these findings are discussed.
The present study evaluated the effectiveness of two variations of a token economy for reducing disruptive behavior within a general education classroom. One variation involved a group contingency in which tokens were removed contingent on disruptive behavior (response cost), and the other variation involved a group contingency in which tokens were gained according to a differential reinforcement of other behavior schedule. Two elementary school teachers and their students participated. Results indicated that both procedures were effective in reducing the overall number of students disrupting; however, both teachers and students indicated a greater preference for the response cost condition. Implications for the use of these behavior management strategies in the classroom are discussed in terms of effectiveness and ease of implementation.
We conducted a series of studies on multiple forms of repetitive behavior displayed by four children with autism spectrum disorder. Study 1 showed that each participant’s highest probability repetitive behavior persisted in the absence of social consequences, thereby meeting the functional definition of stereotypy. Study 2 showed that preferred, structurally matched stimulation decreased each participant’s targeted (highest probability) stereotypy, as well as their non-targeted (lower probability) stereotypy. Study 3 showed that for three participants, non-contingent access to preferred stimulation decreased immediate and, to some extent, subsequent engagement in targeted and non-targeted stereotypy. For the fourth participant, non-contingent access to preferred stimulation decreased immediate engagement in the targeted stereotypy, but increased subsequent engagement in non-targeted stereotypy; this subsequent increase was attenuated by reducing the duration of access to the preferred stimulus. Study 4 showed that a trial-based differential reinforcement of other behavior (DRO) procedure systematically increased the period of time for which the targeted stereotypy was not displayed for three of three participants. In addition, results showed that the participants’ non-targeted stereotypy either decreased or was unchanged when DRO was provided for the targeted stereotypy.
This study assessed whether nine persons with advanced Alzheimer’s disease would learn to engage in leg responses (exercise) with the support of a technology-aided program, which provided (a) preferred stimulation contingent on the leg responses and (b) verbal reminders/prompts in case of no responding. The study was conducted according to a non-concurrent multiple baseline design across participants and involved sessions of 5 min. During the baseline, the participants’ mean frequencies of leg responses ranged from zero to slightly above two per session. During the intervention, those frequencies ranged from nearly 10 to nearly 17 per session. The mean frequencies of prompts varied across participants from about two to more than seven per session. In addition to the increase in leg responses, participants showed an increase in signs of positive personal involvement (e.g., smiles and positive verbalizations) during the intervention sessions as compared with the baseline sessions. The applicability and potential benefits of the program in daily contexts are discussed.
In this study, we extended the literature on negatively-reinforced mands by teaching multiple novel, socially appropriate alternative mands to two young children with autism spectrum disorder (ASD). First, we replaced existing mands (e.g., pushing away) with two novel, socially appropriate, negatively-reinforced mands. Next, we examined responding under immediate- and delayed-reinforcement conditions to assess resurgence to existing mands and to determine whether the function of the communicative behavior influences the consistency with which different mands are emitted. Finally, we examined generalization to different social partners. Our data suggest that both children acquired the new mands and used them to avoid nonpreferred items. Resurgence to existing mands during delayed-reinforcement conditions was documented for one child, and the sequence in which mands were emitted within a response class was not influenced by the function of the communicative behavior. Generalization data indicate that both children emitted the new mands and one of the two children alternated between the two mands with a social partner who was not involved in the training. We discuss the importance of teaching multiple negatively-reinforced alternative mands to children with autism in applied settings.
Single-case experimental designs (SCEDs) have been increasingly used in recent years to inform the development and validation of effective interventions in the behavioral sciences. An important aspect of this work has been the extension of meta-analytic and other statistical innovations to SCED data. Standard practice within SCED methods is to display data graphically, which requires subsequent users to extract the data, either manually or using data extraction programs. Previous research has examined issues of reliability and validity of data extraction programs in the past, but typically at an aggregate level. Little is known, however, about the coding of individual data points. We focused on four different software programs that can be used for this purpose (i.e., Ungraph, DataThief, WebPlotDigitizer, and XYit), and examined the reliability of numeric coding, the validity compared with real data, and overall program usability. This study indicates that the reliability and validity of the retrieved data are independent of the specific software program, but are dependent on the individual single-case study graphs. Differences were found in program usability in terms of user friendliness, data retrieval time, and license costs. Ungraph and WebPlotDigitizer received the highest usability scores. DataThief was perceived as unacceptable and the time needed to retrieve the data was double that of the other three programs. WebPlotDigitizer was the only program free to use. As a consequence, WebPlotDigitizer turned out to be the best option in terms of usability, time to retrieve the data, and costs, although the usability scores of Ungraph were also strong.
In terms of the transdiagnostic model of eating disorders, Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED) share the same distinctive psychopathology. However, empirical evidence showing similarities between these eating disorder diagnoses for core symptoms is scarce, and the role of weight status is unclear. Data from a total of 168 female participants were collected between April 2004 and April 2008, at an outpatient unit specialized in eating disorder treatment. Core symptoms of eating disorders were measured via self-report questionnaires. In particular, women with BED and BN showed similar patterns of core symptomatology compared with AN. However, when body mass index (BMI) was considered in the analyses, there were no differences between the three diagnostic groups in relation to body image. Differences in eating behavior are not solely triggered by weight differences, whereas body image disturbances are a transdiagnostic phenomenon among EDs and should also be considered in the treatment of BED.
Prior studies indicate extinguished fear often partially returns when participants are later tested outside the extinction context. Cues carried from the extinction context to the test context sometimes reduce return of fear, but it is unclear whether such extinction cues (ECs) reduce return of fear of public speaking. Here we assessed return of fear of public speaking, and whether either of two types of ECs can attenuate it. Participants gave speeches of increasing difficulty during an exposure practice session and were tested 2 days later in a different context. Testing occurred in the presence of physical ECs, after mentally rehearsing the exposure session, or without either reminder. Practice reduced fear of public speaking, but fear partially returned at test. Neither physical nor mental ECs reduced partial return of fear of public speaking. The return of extinguished fear of public speaking, although small, was reliable, but not appreciably sensitive to presence of ECs.
Previous research on visual analysis has reported low levels of interrater agreement. However, many of these studies have methodological limitations (e.g., use of AB designs, undefined judgment task) that may have negatively influenced agreement. Our primary purpose was to evaluate whether agreement would be higher than previously reported if we addressed these weaknesses. Our secondary purposes were to investigate agreement at the tier level (i.e., the AB comparison) and at the functional relation level in multiple baseline designs and to examine the relationship between raters’ decisions at each of these levels. We asked experts (N = 52) to make judgments about changes in the dependent variable in individual tiers and about the presence of an overall functional relation in 31 multiple baseline graphs. Our results indicate that interrater agreement was just at or just below minimally adequate levels for both types of decisions and that agreement at the individual tier level often resulted in agreement about the overall functional relation. We report additional findings and discuss implications for practice and future research.
This study evaluated the effects of Group Triple P with Chinese parents on parenting and child outcomes as well as outcomes relating to child academic learning in Mainland China. Participants were 81 Chinese parents and their children in Shanghai, who were randomly allocated to an intervention group or wait-list control group. Parents in the intervention condition received Group Triple P training, and parents and children were assessed at three/two time points. Compared with the control group, parents in the intervention group reported significant improvements in child adjustment problems, parenting practices, parental adjustment, and parenting self-efficacy at post-assessment. Moreover, there was a significant increase in parents’ satisfaction with children’s academic achievement and a reduction in children’s academic problem behaviors at post-intervention. All these effects were maintained at 6-month follow-up. There was also a significant increase in the child report of positive parenting at post-intervention.
More than four decades of research on instructional pacing has yielded varying and, in some cases, conflicting findings. The purpose of this meta-analysis was to synthesize single-case research design (SCRD) studies on instructional pacing to determine the relative benefits of brisker or slower pacing. Participants were children and youth with and without disabilities in educational settings, excluding higher education. Tau-U, a non-parametric statistic for analyzing data in SCRD studies, was used to determine effect size estimates. The article extraction yielded 13 instructional pacing studies meeting contemporary standards for high quality SCRD research. Eleven of the 13 studies reported small to large magnitude effects when two or more pacing parameters were compared, suggesting that instructional pacing is a robust instructional variable. Brisker instructional pacing with brief inter-trial interval (ITI) produced small increases in correct responding and medium to large reductions in challenging behavior compared with extended ITI. Slower instructional pacing with extended wait-time produced small increases in correct responding, but also produced small increases in challenging behavior compared with brief wait-time. Neither brief ITI nor extended wait-time meets recently established thresholds for evidence-based practice, highlighting the need for further instructional pacing research.
Individuals with public speaking anxiety (PSA) experience fear and avoidance that can cause extreme distress, impaired speaking performance, and associated problems in psychosocial functioning. Most extant interventions for PSA emphasize anxiety reduction rather than enhancing behavioral performance. We compared the efficacy of two brief cognitive-behavioral interventions, a traditional cognitive-behavior treatment (tCBT) and an acceptance-based behavior treatment (ABBT), on public speaking performance and anxiety in a clinical sample of persons with PSA. The effects of treatment on prefrontal brain activation were also examined. Participants (n = 21) were randomized to 90 min of an ABBT or a tCBT intervention. Assessments took place at pre- and post-treatment and included self-rated anxiety and observer-rated performance measures, a behavioral assessment, and prefrontal cortical activity measurements using functional near-infrared spectroscopy (fNIRS). Exploratory results indicated that participants in the ABBT condition experienced greater improvements in observer-rated performance relative to those in the tCBT condition, while those in the tCBT condition experienced greater reductions in subjective anxiety levels. Individuals in the ABBT condition also exhibited a trend toward greater treatment-related reductions in blood volume in the left dorsolateral prefrontal cortex relative to those who received tCBT. Overall, these findings preliminarily suggest that acceptance-based treatments may free more cognitive resources in comparison with tCBT, possibly resulting in greater improvements in objectively rated behavioral performances for ABBT interventions.
Individuals at risk for suicide experience periods of emotional, enduring, and vivid thoughts about their death by suicide and frequently report violent daydreams about death. Daydreaming is associated with forgetfulness and memory impairments. However, no studies have examined whether suicidal ideation is associated with deficits in everyday memory capabilities and whether violent daydreaming may influence these relationships. This study tested these hypotheses in a sample of 512 young adults. Self-report measures of subjective everyday memory capabilities, violent daydreaming, and suicidal ideation were administered. Results indicated that suicidal ideation and violent daydreaming were each significantly associated with greater impairments in everyday memory retrieval and everyday memory encoding (i.e., attentional tracking). Furthermore, violent daydreaming accounted for the relationship between suicidal ideation and impairments in everyday memory retrieval and memory encoding. Notably, findings remained after controlling for gender and depressive symptoms, a robust predictor of memory impairments. Implications and limitations are discussed.
Different combinations of immediate and delayed consequences differentially affect choice. Basic research has found that nonhuman animals are more likely to choose an alternative that produces an immediate reinforcer that is followed by a delayed punisher as the delay to punishment increases. The purpose of the current effort was to examine the choices of three individuals with autism when they were given the choice between receiving a larger amount of preferred food followed by a mild, delayed verbal punisher and a smaller amount of the preferred food. A secondary purpose was to determine whether signal presence and duration would affect the efficacy of the punisher (i.e., whether children would be more likely to select the smaller reward that was not followed by a delayed punisher). Results were idiosyncratic across children and highlight the need to evaluate choice under multiple arrangements.
Students with emotional and behavioral disorders and students considered at risk often have social deficits. Although social skills interventions are often provided to this student population, there are some concerns regarding how these interventions are conceived and provided. One possible way to improve the effectiveness of social skills interventions is to use functional behavior assessment data to tailor the interventions to a student’s individual needs and the contexts in which social skills deficits and problem behaviors occur. This approach is commonly referred to as replacement behavior training. In this study, the literature on function-based replacement behavior interventions is systematically reviewed. In addition, studies are evaluated according to the What Works Clearinghouse design and evidence standards for single-case research. Although this research base does not meet the What Works Clearinghouse replication standards, function-based replacement behavior interventions appear to be a promising practice for addressing problem behaviors. Implications for practice, areas for future research, and study limitations are discussed.
Our primary purpose in this study was to examine the structure of a response class when new members are acquired through mand training. To do this, we replaced existing mands (e.g., reaching) in three children with autism with two new functionally equivalent mands. Next, we examined their responding under immediate- and delayed-reinforcement conditions. Then, we assessed generalization to novel social partners. We employed a reversal design to examine the effectiveness of mand training and to assess responding under both immediate- and delayed-reinforcement conditions. Our results suggest that all children acquired the new mands and that two of the children emitted these responses as replacements when the social partner did not provide access to the reinforcer contingent on the child’s first mand. Generalization data indicate that all three children emitted the new mands and two of the children alternated between the new mands with novel social partners. We discuss the clinical implications and the conceptual significance of teaching multiple replacement mands to children with autism and severe language delays.
Anxiety sensitivity (AS), defined as the extent to which individuals believe that anxiety-related sensations have harmful consequences, is associated with smoking processes and poorer clinical outcomes among trauma-exposed smokers. Yet the specific mechanisms underlying this association are unclear. Smoking-specific avoidance and inflexibility is a construct implicated in multiple manifestations of mood regulation that may underlie smoking behavior. The current study examined the explanatory role of smoking-specific avoidance and inflexibility in terms of the relation between AS and indices of smoking behavior among trauma-exposed smokers. The sample consisted of 217 treatment-seeking adult smokers (44% female; M age = 37.8; SD = 13.2; age range: 18-65 years), who were exposed to at least one lifetime Criterion A trauma event (Diagnostic and Statistical Manual of Mental Disorders [4th ed., text rev.; DSM-IV-TR] Criterion A for trauma exposure). Bootstrap analysis (5,000 re-samples) revealed that AS was indirectly related to the (a) number of cigarettes smoked per day, (b) number of years being a daily smoker, (c) number of failed quit attempts, and (d) heaviness of smoking index among trauma-exposed smokers through its relation with smoking-specific avoidance and inflexibility. These findings provide initial evidence suggesting that smoking-specific avoidance and inflexibility may be an important construct in better understanding AS–smoking relations among trauma-exposed smokers. Future work is needed to explore the extent to which smoking-specific avoidance and inflexibility account for relations between AS and other smoking processes (e.g., withdrawal, cessation outcome) in the context of trauma and smoking comorbidity.
The current study examined cardiac denial and psychological predictors (i.e., depression, anxiety) of health outcomes including medical nonadherence and physical health in a sample of 80 adults with congenital heart disease (ACHD). Results indicated that denial of impact was elevated in this patient group compared with reference groups, and denial was negatively associated with depression and anxiety at ps < .01. Results indicated that depression, anxiety, and denial predicted unique variance in medical nonadherence, and gender moderated the relationships between these psychological factors and nonadherence. For depression, men and women showed similar relationships between depression and nonadherence at high levels of depression; however, at low levels of depression (i.e., a more normal mood state), men were less adherent compared with women. For anxiety, men and women did not differ in adherence at low levels of anxiety; however, men experiencing high anxiety were less adherent compared with women experiencing high anxiety. Implications of this study are discussed including the role of gender and denial and the impact of denial functioning to reduce negative affect. Depression was the only significant predictor of physical functioning. Results of this study suggest that psychological interventions aimed at depression and anxiety may function differently across gender to improve patient medical adherence and improve physical functioning in ACHD.
For practitioners, the use of single-case experimental designs (SCEDs) in the research literature raises an important question: How many single-case experiments are enough to have sufficient confidence that an intervention will be effective with an individual from a given population? Although standards have been proposed to address this question, current guidelines do not appear to be strongly grounded in theory or empirical research. The purpose of our article is to address this issue by presenting guidelines to facilitate evidence-based decisions by adopting a simple statistical approach to quantify the support for interventions that have been validated using SCEDs. Specifically, we propose the use of success rates as a supplement to support evidence-based decisions. The proposed methodology allows practitioners to aggregate the results from single-case experiments to estimate the probability that a given intervention will produce a successful outcome. We also discuss considerations and limitations associated with this approach.
Homeless individuals smoke at high rates relative to the general population and are at heightened risk of tobacco-related illnesses and poor health-related quality of life (HRQoL). Homeless smokers also report low subjective social status (SSS) or perceived social standing relative to others. SSS may contribute to poor HRQoL, potentially through perceived stress. The current study examined the role of perceived stress in the association of SSS and HRQoL among 227 (70.9% male, Mage = 43.2) homeless smokers. Participants completed self-report measures of SSS, perceived stress, and HRQoL. Perceived stress partially explained the relation between SSS (United States and Community) and HRQoL in covariate-adjusted analyses. Results suggested that perceived stress is a pathway through which SSS contributes to HRQoL among homeless smokers. Findings broaden current understanding of the impact of social disadvantage and perceived stress on HRQoL among homeless smokers.
This study tested whether distress tolerance, body image, and body mass index (BMI) predicted adherence to a yoga intervention. Participants were 27 women who participated in a yoga intervention as part of a randomized controlled trial. Attendance and distress tolerance were assessed weekly, and body image and BMI were measured at baseline. Multilevel modeling revealed a three-way interaction of distress tolerance, BMI, and body image (p < .001). For participants with few body image concerns, distress tolerance was positively associated with adherence regardless of BMI (p = .009). However, for those with poor body image, increases in distress tolerance were associated with increases in adherence among overweight participants (p < .001) but lower adherence among obese participants (p = .007). Distress tolerance may be implicated in adherence to a yoga intervention, although its effects may be dependent on body image concerns, BMI, and their interaction. Research and clinical implications are discussed.
Students referred to treatment after violating campus drug policies represent a high-risk group. Identification of factors related to these students’ cannabis use could inform prevention and treatment efforts. Distress tolerance (DT) is negatively related to substance-related behaviors and may be related to high-risk cannabis use vulnerability factors that can impact treatment outcome. Thus, the current study tested whether DT was related to cannabis use frequency, cannabis-related problems, and motivation to change cannabis use among 88 students referred for treatment after violating campus cannabis policies. DT was robustly, negatively related to cannabis use and related problems. DT was also significantly, negatively correlated with coping, conformity, and expansion motives. DT was directly and indirectly related to cannabis problems via coping (not conformity or expansion) motives. Motives did not mediate the relation of DT to cannabis use frequency. DT may be an important target in treatment with students who violate campus cannabis policies.
Pain and tobacco smoking are highly prevalent and comorbid conditions that impose considerable burdens on individuals and health care systems. A recently proposed reciprocal model suggests that these conditions interact in a bidirectional manner, resulting in greater pain and the maintenance of tobacco addiction. Anxiety and depression are common among smokers in pain and have been identified as central mechanisms of interest. There is emerging evidence that smokers with anxiety/depression may experience more severe pain and functional impairment, greater pain-induced motivation to smoke, and increased sensitivity to pain during periods of smoking abstinence. Based on empirical findings, we hypothesize that these experiences may engender expectations that abstaining from smoking will exacerbate both pain and negative affect, thus eroding self-efficacy for smoking cessation and increasing perceived barriers to quitting. The goal of this narrative review is to examine the role of anxiety/depression in complex pain–smoking relations so as to advance evolving theoretical perspectives and inform the development of tailored interventions.
The current study used a novel real-time data capture strategy, ecological momentary assessment (EMA), to examine whether within-day variability in stress and context leads to exacerbations in asthma symptomatology in the everyday lives of ethnic minority adolescents. Low-income Hispanic adolescents (N = 20; 7th-12th grade; 54% male) with chronic asthma completed 7 days of EMA on smartphones, with an average of five assessments per day during non-school time. EMA surveys queried about where (e.g., home, outdoors) and with whom (e.g., alone, with friends) participants were at the time of the prompt. EMA surveys also assessed over the past few hours whether participants had experienced specific stressors (e.g., being teased, arguing with anyone), asthma symptoms (e.g., wheezing, coughing), or used an asthma inhaler. Multilevel models tested the independent relations of specific stressors and context to subsequent asthma symptoms adjusting for age, gender, and chronological day in the study. Being outdoors, experiencing disagreements with parents, teasing, and arguing were associated with more severe self-reported asthma symptoms in the next few hours (ps < .05). Being alone and having too much to do were unrelated to the experience of subsequent self-reported asthma symptoms. Using a novel real-time data capture strategy, results provide preliminary evidence that being outdoors and experiencing social stressors may induce asthma symptoms in low-income Hispanic children and adolescents with chronic asthma. The results of this preliminary study can serve as a basis for larger epidemiological and intervention studies.
The current study utilized the intersectionality framework to explore whether smoking outcome expectancies (i.e., cognitions about the anticipated effects of smoking) were predicted by gender and ethnicity, and the gender-by-ethnicity interaction. In a cross-sectional design, daily smokers from the general community (32.2% women; non-Hispanic African American [n = 175], non-Hispanic White [n = 109], or Hispanic [n = 26]) completed self-report measures on smoking expectancies and other co-factors. Results showed that women reported greater negative reinforcement (i.e., anticipated smoking-induced negative affect reduction) and weight control (i.e., anticipated smoking-induced appetite/weight suppression) expectancies than men. Hispanic (vs. African American or White) smokers endorsed greater negative reinforcement expectancies. A gender-by-ethnicity interaction was found for weight control expectancies, such that White women reported greater weight control expectancies than White men, but no gender differences among African American and Hispanic smokers were found. These findings suggest that gender, ethnicity, and their intersectionality should be considered in research on cognitive mechanisms that may contribute to tobacco-related health disparities.
Anxiety sensitivity, particularly the physical concerns domain, is associated with more problematic asthma symptoms and greater functional limitations. It has been theorized that anxiety sensitivity fosters greater reactivity to asthma-related physical sensations; however, this theory has yet to be empirically tested. Thus, the present investigation sought to examine the role of anxiety sensitivity–physical concerns in terms of affective and physical reactivity to asthma-like symptoms. Participants were 101 undergraduates with asthma (76.2% female, Mage = 19.69 years, SD = 3.77 years, range = 18-49 years) who completed self-report measures and a straw-breathing task. Results indicated that after controlling for the effects of gender, asthma control (i.e., how well one’s asthma symptoms are managed or controlled), and negative affectivity, greater levels of anxiety sensitivity–physical concerns significantly predicted greater anxiety (4.7% unique variance) and asthma symptoms (6.9% unique variance) and lower levels of lung function (4.4% unique variance) after the straw-breathing task. These findings suggest that individuals with asthma who are fearful of physiological arousal are a particularly "at-risk" population for poor asthma outcomes because of this greater reactivity and could benefit from interventions targeting anxiety sensitivity.
Individuals with elevated levels of anxiety sensitivity (AS) may be motivated to avoid aversive emotional or physical states, and therefore may have greater difficulty achieving healthy behavioral change. This may be particularly true for exercise, which produces many of the somatic sensations within the domain of AS concerns. Cross-sectional studies show a negative association between AS and exercise. However, little is known about how AS may prospectively affect attempts at behavior change in individuals who are motivated to increase their exercise. We recruited 145 young adults who self-identified as having a desire to increase their exercise behavior. Participants completed a web survey assessing AS and additional variables identified as important for behavior change—impulsivity, grit, perceived behavioral control, and action planning—and set a specific goal for exercising in the next week. One week later, a second survey assessed participants’ success in meeting their exercise goals. We hypothesized that individuals with higher AS would choose lower exercise goals and would complete less exercise at the second survey. AS was not significantly associated with exercise goal level, but significantly and negatively predicted exercise at Time 2 and was the only variable to offer significant prediction beyond consideration of baseline exercise levels. These results underscore the importance of considering AS in relation to health behavior intentions. This is particularly apt given the absence of prediction offered by other traditional predictors of behavior change.
Few studies have sought to understand the concurrent relationship between cognitive and affective processes on alcohol use and negative alcohol-related consequences, despite both being identified as predictive risk factors in the college population. More research is needed to understand the relationships between identified factors of problem drinking among this at-risk population. The purpose of this study was to test if the relationship between psychological distress and problem drinking among university students (N = 284; M–age = 19.77) was mediated by negative affect regulation strategies and positive alcohol-related expectancies. Two latent mediation models of problem drinking were tested using structural equation modeling (SEM). The parsimonious three-path mediated latent model was supported by the data, as evidenced by several model fit indices. Furthermore, the alternate saturated model provided similar fit to the data, but contained several direct relationships that were not statistically significant. The relationship between psychological distress and problem drinking was mediated by an extended contributory chain, including negative affect regulation and positive alcohol-related expectancies. Implications for prevention and treatment, as well as future directions, are discussed.
This study evaluated the effects of noncontingent social interaction (SI) on immediate and subsequent engagement in vocal and motor stereotypy in three children with autism. During SI, a therapist delivered continuous interaction in the form of reading aloud from a Kindle™ e-reader. Results showed that when compared with a no-interaction baseline sequence, SI decreased immediate engagement vocal stereotypy for all three participants without increasing subsequent engagement for any participant. Furthermore, SI also increased immediate engagement in motor stereotypy for one participant, decreased immediate engagement in motor stereotypy for two participants, but did not increase subsequent engagement in motor stereotypy for any participant. Some clinical implications and limitations of the findings are discussed.
Research has shown that motor and vocal tics fluctuate in frequency, intensity, and form in response to environmental and contextual cues. Behavioral models have proposed that some of the variation in tics may reflect context-dependent interactive learning processes such that once tics are performed, they are influenced by environmental contingencies. The current study describes the results of a function-based assessment of tics (FBAT) from a recently completed study comparing Comprehensive Behavioral Intervention for Tics (CBIT) with supportive psychotherapy. The current study describes the frequency with which antecedent and consequence variables were reported to exacerbate tics and the relationships between these functional variables and sample baseline characteristics, comorbidities, and measures of tic severity. Results showed that tic-exacerbating antecedents and consequences were nearly ubiquitous in a sample of children with chronic tic disorder. In addition, functional variables were related to baseline measures of comorbid internalizing symptoms and specific measures of tic severity.
In light of descriptive accounts of attenuating effects of physical activity on tics, we used an experimental design to assess the impact of an acute bout of aerobic exercise on tic expression in young people (N = 18) with Tourette Syndrome (TS). We compared video-based tic frequency estimates obtained during an exercise session with tic rates obtained during pre-exercise (baseline) and post-exercise interview-based sessions. Results showed significantly reduced tic rates during the exercise session compared with baseline, suggesting that acute exercise has an attenuating effect on tics. Tic rates also remained reduced relative to baseline during the post-exercise session, likely reflecting a sustained effect of exercise on tic reduction. Parallel to the observed tic attenuation, exercise also had a beneficial impact on self-reported anxiety and mood levels. The present findings provide novel empirical evidence for the beneficial effect of exercise on TS symptomatology bearing important research and clinical implications.
Various reviews of the effects of sensory integration therapy (SIT) have concluded that such interventions fail to reduce stereotypy. However, a new, and as yet untested, SIT iteration, an inflatable wearable vest known as the Snug Vest purports to decrease such repetitive behavior. In the current study, three children who emitted different forms of stereotypy participated in an alternating treatments design in which each participant wore a fully inflated vest and either a fully deflated vest or no vest. The results of the study show that the Snug Vest failed to reduce any participants’ stereotypy. We highlight our findings in the context of professional practice and discuss several potential limitations.
Tourette syndrome (TS) is marked by the chronic presence of motor and vocal tics that are usually accompanied by aversive sensory experiences called "premonitory urges." Phenomenological accounts suggest that these urges occur before tics and diminish following their occurrence. This has led some to suggest that tics are negatively reinforced by removal of premonitory urges. This hypothesis has proven difficult to test experimentally, however, due in part to challenges in measuring premonitory urge strength. We tested predictions of the negative reinforcement conceptualization of premonitory urges using novel experimental tactics within the context of the "tic detector" paradigm. We compared tic rates and ratings of premonitory urge strength exhibited by youth with TS or chronic tic disorder under free-to-tic baseline (BL), reinforced tic suppression (RTS), and reinforced tic suppression with escape (RTS + E) conditions. Results were consistent with previous research and hypotheses of the present study. Participants rated the strength of their premonitory urges as higher during RTS conditions than during BL conditions. Within RTS + E conditions, tic rates were higher during escape portions when the contingency supporting tic suppression was inactive than during components where the contingency was active, and ratings of urge strength were higher at the onset of break periods than at the offset. All participants engaged in some level of escape from reinforced suppression during the course of the experiment. Results of this study support the notion that tics may be negatively reinforced by removal of aversive premonitory urges. Future directions for basic and clinical research are discussed.
This study examined therapeutic mechanisms of action at the single-participant level in a behavior therapy (BT) for youth depression. By controlling for non-specific early responses, identifying potential mechanisms of action a priori, taking frequent measures of hypothesized mechanisms and dependent variables, rigorously evaluating internal validity, and using a variety of analytic methods, a unique model for analysis of potential mediators was created. Eleven children (M age = 9.84) meeting criteria on the Children’s Depression Rating Scale–Revised (M = 55.36) and Children’s Depression Inventory (M = 23.45) received non-directive therapy (NDT), followed by BT for those still displaying significant symptoms. Four participants (36%) had a clinically significant response to NDT. For the remaining seven, statistically significant changes in depressive symptoms and family interactions during the BT interval were found at the group level. At the single-participant level, evidence suggesting that outcome was at least partially mediated by changes in treatment targets was obtained for four of seven (57%). As the field further embraces efforts to learn not only whether treatments work but also how they work, the single-participant approach to evaluating mediators provides a useful framework for evaluating theories of therapeutic change.
Stress is the contextual variable most commonly implicated in tic exacerbations. However, research examining associations between tics, stressors, and the biological stress response has yielded mixed results. This study examined whether tics occur at a greater frequency during discrete periods of heightened physiological arousal. Children with co-occurring tic and anxiety disorders (n = 8) completed two stress-induction tasks (discussion of family conflict, public speech). Observational (tic frequencies) and physiological (heart rate [HR]) data were synchronized using The Observer XT, and tic frequencies were compared across periods of high and low HR. Tic frequencies across the entire experiment did not increase during periods of higher HR. During the speech task, tic frequencies were significantly lower during periods of higher HR. Results suggest that tic exacerbations may not be associated with heightened physiological arousal and highlight the need for further tic research using integrated measurement of behavioral and biological processes.
Living with a person who experiences mental health problems can have an adverse effect on well-being. The aim of this study is to evaluate the effectiveness of a psychological treatment for relatives of people with mental health problems, byusing an interrupted time-series design. The sample comprised 20 individuals, who completed assessment measures at baseline and 6 months later. Sixteen of these participants then received the treatment and were assessed again at the end of the program. There were no significant changes in outcomes between the baseline and the second assessments done 6 months later and there were significant improvements in well-being following treatment The program shows promise as a treatment for relatives of people with mental health problems and therefore warrants further evaluation in more controlled studies.
Accumulating data indicate a common occurrence of tic exacerbations and periods of psychosocial stress. Patients with Tourette’s syndrome (TS) also exhibit aberrant markers of hypothalamic-pituitary-adrenal (HPA) axis activation. Based on these findings, a functional relationship between stress and tic disorders has been suggested, but the underlying mechanism of how stress may affect tic pathology remains to be elucidated. We suggest that dopaminergic and noradrenergic neurotransmission as well as immunology play a crucial role in mediating this relationship. Two possibilities of causal direction might be assumed: (a) psychosocial stress might lead to an exacerbation of tics via activation of HPA axis and subsequent changes in neurotransmission or immunology and (b) TS-related abnormalities in neurotransmission or immunology result in a higher vulnerability of affected patients to respond to psychosocial stress with a strong activation of the HPA axis. It may also be the case that both assumptions hold true and interact with each other.
The current research set out to investigate whether adolescents who self-reported high or low levels of depressive symptomatology would demonstrate differential sensitivity to changing contingencies as a function of accurate/inaccurate (Experiment 1) or pliance/tracking instructions (Experiment 2). Following a screening procedure, students were divided into two groups and instructed on how to respond during a simple learning task. In Experiment 1, we observed a characteristic set of outcomes that were contingent upon the type of instructional control provided and levels of depressive symptomatology reported. Whereas accurate instructions resulted in quick and efficient learning (schedule sensitivity) regardless of depressive symptomatology, inaccurate instructions lead to problematic rule-following in the high depressive symptom group. Experiment 2 revealed that schedule insensitivity effects can be further augmented when participants who report depressive symptoms are equipped with a set of superordinate pliance instructions. In contrast, students in the tracking condition showed increasing adaptation to the changing contingencies throughout the study.
The current study investigated the effects of a Video Self-Modeling (VSM) intervention on the compliance and aggressive behavior of three children placed in a psychiatric hospital. Each participant viewed brief video clips of himself following simple adult instructions just prior to the school’s morning session and the unit’s afternoon free period. A multiple baseline design across settings was used to evaluate the effects of the VSM intervention on compliance with staff instructions and aggressive behavior on the hospital unit and in the hospital-based classroom. All three participants exhibited higher levels of compliance and fewer aggressive episodes during the intervention condition, and the effects were generally maintained when the intervention was withdrawn. Hospital staff reported at the conclusion of the study that the VSM intervention was easy to implement and beneficial for all participants. Taken altogether, the results suggest VSM is a promising, socially acceptable, and proactive intervention approach for improving the behavior of noncompliant children.
First-year students in higher education deal with an increasing number of mental health issues. Cost-effective and time-efficient programs that ease transitions and reduce risk of depression are needed. To date, programs informed by both cognitive-behavioral and acceptance-based-behavioral therapy (ABBT) approaches have produced some positive outcomes, but methodological limitations limit their utility. The aim of the present study was to address some of these limitations, by developing and preliminary testing the efficacy of a one-session ABBT intervention with first-year undergraduates and first-year law students. Ninety-eight first-year students were randomly assigned to receive either a single-session 90-min ABBT workshop within their first month of school or to a waitlist control condition. Students who received the intervention reported significantly less depression and more acceptance. Moreover, increase in acceptance over the course of the semester was associated with reductions in depression. Implications of these findings for future interventions are discussed.
Depression and social anxiety disorder (SAD) are highly comorbid, resulting in greater severity and functional impairment compared with each disorder alone. Although recently transdiagnostic treatments have been developed, no known treatments have addressed this comorbidity pattern specifically. Preliminary support exists for acceptance-based approaches for depression and SAD separately, and they may be more efficacious for comorbid depression and anxiety compared with traditional cognitive-behavioral approaches. The aim of the current study was to develop and pilot test an integrated acceptance-based behavioral treatment for depression and comorbid SAD. Participants included 38 patients seeking pharmacotherapy at an outpatient psychiatry practice, who received 16 individual sessions of the therapy. Results showed significant improvement in symptoms, functioning, and processes from pre- to post-treatment, as well as high satisfaction with the treatment. These results support the preliminary acceptability, feasibility, and effectiveness of this treatment in a typical outpatient psychiatry practice, and suggest that further research on this treatment in larger randomized trials is warranted.
We evaluated the feasibility and acceptability of a 2-week-long ecological momentary intervention (EMI), delivered via personal digital assistants (PDAs), to improve treatment adherence in bipolar disorder. EMIs use mobile technology to deliver treatment as clients engage in their typical daily routines, in their usual settings. Overall, participants (N = 14) stated that EMI sessions were helpful, user-friendly, and engaging, and reported satisfaction with the timing and burden of sessions, as well as the method of delivery. All participants completed the study, and all PDAs were returned undamaged. On average, participants completed 92% of EMI sessions. Although this study was not designed to assess efficacy, depression scores decreased significantly over the study period and data suggest relatively high rates of treatment adherence; missed medication was reported 3% of the time and three participants reported missing a total of six mental health appointments. Negative feedback largely involved technical and logistical issues, many of which are easily addressable. These preliminary findings add to the growing body of literature indicating that mobile-technology-assisted interventions are feasible to implement and acceptable to patients with serious mental illnesses.
We developed a measure of reasons to refrain from nonsuicidal self-injury (NSSI), the Reasons to Stop Self-Injury Questionnaire (RSSIQ), and examined how such reasons are associated with vulnerability versus resiliency for NSSI. Following qualitative item generation, we explored the factor structure, reliability, and convergent validity of the RSSIQ in 218 self-injuring undergraduates. In Study 2, we confirmed the hierarchical factor structure in 146 self-injuring individuals. In Study 3, we examined the incremental predictive validity of the RSSIQ. These studies resulted in a 40-item inventory with nine subscales and two higher-order factors. Resiliency-related reasons to stop NSSI were associated with greater hopefulness, social support, and adaptive coping, and prospectively protected against NSSI 3 months later, while vulnerability-related reasons were associated with greater psychopathology and dysfunctional coping, and predicted more chronic and severe NSSI. These studies, and the RSSIQ, can enhance the assessment and treatment of NSSI by clarifying motivations to stop NSSI.
The concept of motivational operations exerts an increasing influence on the understanding and assessment of problem behavior in people with intellectual and developmental disability. In this systematic review of 59 methodologically robust studies of the influence of motivational operations in negative reinforcement paradigms in this population, we identify themes related to situational and biological variables that have implications for assessment, intervention, and further research. There is now good evidence that motivational operations of differing origins influence negatively reinforced problem behavior, and that these might be subject to manipulation to facilitate favorable outcomes. There is also good evidence that some biological variables warrant consideration in assessment procedures as they predispose the person’s behavior to be influenced by specific motivational operations. The implications for assessment and intervention are made explicit with reference to variables that are open to manipulation or that require further research and conceptualization within causal models.
Individuals with developmental disabilities may engage in automatically reinforced behaviors that may interfere with learning opportunities. Manipulation of motivating operations has been shown to reduce automatically maintained behavior in some individuals. Considering behavioral indicators of satiation may assist in identifying the point at which an abolishing operation has begun to effect behavior. The purpose of this study was to evaluate the effects of pre-session satiation of automatic reinforcement on subsequent levels of stereotypy and activity engagement during group activities for three males ages 5 to 13 years with developmental disabilities. Following functional analyses with analogue conditions, an alternating treatment design compared a pre-session access to stereotypy condition with a no-pre-session access condition prior to group activity sessions. Results indicated that pre-session satiation of the putative reinforcer produced by stereotypy was effective in decreasing stereotypy and increasing activity engagement during subsequent group activities for all participants. These findings add to the literature supporting the effectiveness of abolishing operations to decrease automatically maintained stereotypy.
The number of individuals who meet diagnostic criteria for posttraumatic stress disorder (PTSD) is a small percentage of those exposed to trauma; many youth who do not meet criteria for PTSD continue to experience problematic posttraumatic stress (PTS) symptomology. Acceptance and commitment therapy (ACT) has shown preliminary effectiveness in the treatment of adult PTSD, but its effectiveness in treating PTS in youth is unknown. Using a multiple-baseline design, this study investigated the effectiveness of 10 weeks of ACT to treat PTS in youth. Four adolescents from a community sample and three adolescents from a residential sample participated. The Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA), Child PTSD Symptom Scale (CPSS), and Comprehensive Quality of Life Scale were completed at pretreatment, posttreatment, and 3-month follow-up. Individuals reported baseline data for 7 to 66 days. Symptom and process measures were completed at each session. Results revealed a decrease in PTS symptomology across both samples with mean reductions in self-reported PTS symptomology at posttreatment of 69% and 81% for the community and residential samples, respectively, and an overall 68% and 84% respective reduction at follow-up. Reductions in clinician rated measures of PTSD were observed for all participants with mean reductions of 57% and 61% in the community and residential samples at posttreatment, and 71% and 60% at follow-up, respectively. Results provide preliminary support for ACT as a treatment for adolescent PTS. Empirical and clinical implications as well as limitations and future directions are discussed.
A wide variety of effect sizes (ESs) has been used in the single-case design literature. Several researchers have "stress tested" these ESs by subjecting them to various degrees of problem data (e.g., autocorrelation, slope), resulting in the conditions by which different ESs can be considered valid. However, on the back end, few researchers have considered how prevalent and severe these problems are in extant data and as a result, how concerned applied researchers should be. The current study extracted and aggregated indicators of violations of normality and independence across four domains of educational study. Significant violations were found in total and across fields, including low levels of autocorrelation and moderate levels of absolute trend. These violations affect the selection and interpretation of ESs at the individual study level and for meta-analysis. Implications and recommendations are discussed.
The current project was an initial attempt to develop assessment procedures for distinguishing between obsessive-compulsive (OC) and stereotypic behavior and evaluate the impact of different treatments for these behaviors. Two individuals with autism, one with repetitive behavior characteristic of OC behavior and one with repetitive behavior not characteristic of OC behavior, participated in the study. In Experiment 1, given that individuals with Obsessive-Compulsive Disorder (OCD) report experiencing unpleasant urges that are relieved when they perform compulsive actions, an attempt was made to identify these experiences by measuring heart rate and affect when access to repetitive behavior was restricted and allowed. In Experiment 2, a multiple schedules treatment was conducted with each participant, and in Experiment 3, the participant with autism and OC behavior completed exposure and response prevention (ERP) treatment. The overall results across studies suggest that one potential way to discriminate between OC behavior and stereotypy in nonvocal children with autism is to consider the topography of repetitive behavior along with changes in physiology and affect. In addition, it may be worth considering the use of ERP, a traditional treatment for OCD, to treat repetitive behavior maintained by automatic reinforcement if treatments that provide access to repetitive behavior are not effective.
This study investigated the effects of the Good Behavior Game (GBG) on classwide off-task behavior in two ninth-grade basic algebra resource classes. Ten students with a variety of disabilities, in two classrooms, and their special education resource teacher participated in this study. A reversal design was employed, in which the special education teacher implemented GBG compared to typical practice-algebra readiness instruction. Results showed that classwide off-task behavior decreased in the GBG conditions compared to the baseline and reversal conditions. Fidelity measures indicated that the teacher implemented GBG with fidelity. Students and the teacher rated GBG favorably. Overall findings support the use of GBG for reducing classwide off-task behavior. Implications for practice and future research directions are presented.
Concurrent panic disorder with agoraphobia (PDA) and generalized anxiety disorder (GAD) are the most common diagnostic occurrences among anxiety disorders. This particular comorbidity is associated with significant impairments in quality of life (QOL). The current study sought to investigate the efficacy of a combined cognitive-behavioral psychotherapy that addressed both conditions compared with a conventional psychotherapy, which attends solely to the primary disorder. The hypotheses postulated firstly, that both treatment conditions would lead to improvements in participants’ QOL and secondly, that the combined therapy would lead to greater QOL ameliorations. Twenty-five participants with comorbid PDA/GAD diagnoses were evaluated with a number of clinical interviews and self-report questionnaires, and were provided with either conventional or combined cognitive-behavioral psychotherapy, which consisted of 14 one-hour weekly sessions. Participants were once again evaluated in the same fashion 2-weeks after the completion of the psychotherapy. The results revealed that both conditions led to significant improvements in participants’ QOL, but that the two groups did not significantly differ in terms of the effect on QOL. The results also reveal that the two conditions did not significantly differ in terms of their effect on PDA and GAD symptomatology or psychiatric comorbidity. The results demonstrate that the combined psychotherapy, which addresses both conditions simultaneously, is similar to the conventional psychotherapy employed for the primary disorder in terms of QOL enhancement, symptom severity, and comorbidity reduction.
The generalization of relapse-prevention skills of 10 males residing at a state facility for sexual offenders diagnosed with an intellectual disability was assessed in the community using three different experimental probes: (a) treatment staff (TS), (b) nontreatment staff (NTS), and (c) community adults (CAs). Results indicated a decrease in compliance from the TS to NTS and CAs, with the lowest levels of generalization displayed by offenders who were older and displayed a wider range of paraphilias. The degree of generalization also varied as a function of the contingencies for prevention-plan noncompliance, with higher rates of generalization occurring for violations that were more severely consequated. The implications of the findings for future research in promoting the generalization of relapse-prevention skills of sexual offenders, in general, and those who also exhibit intellectual disabilities, in particular, are discussed.
In Tourette syndrome (TS), tics are characteristically preceded by subjective bodily experiences referred to as premonitory sensations. Premonitory sensory phenomena play a key role in behavior therapy for tics, the success of which has also been suggested to be related to inhibitory functioning. We investigated whether TS was associated with altered internal physiological awareness and how this may interact with the neuropsychological characteristics of TS. We compared the awareness of bodily sensations and inhibitory functioning in 18 adult patients with uncomplicated TS and 18 healthy controls. We also explored relationships between these factors, tic severity, and premonitory sensations. Patients with TS exhibited significantly higher scores on the Private Body Consciousness (PBC) scale and inhibitory deficits on traditional and emotional Stroop tests. PBC scores were not correlated with premonitory sensations or tic severity. However, inhibitory functioning was negatively related to PBC scores and premonitory sensations. Relationships between inhibitory performance and tic severity were complex. In conclusion, patients with TS exhibit increased PBC in addition to inhibitory deficits. Aspects of inhibitory functioning are related to PBC, premonitory sensations, and tic severity. Complex interplay between neuropsychological and neurophysiological mechanisms could therefore determine tic severity and the success of behavioral treatments.
We evaluated the separate and combined effects of the antecedent manipulations of effective instruction delivery and time-in, as well as the effects of the addition of the consequent manipulation of contingent praise in a compliance training package for four elementary students displaying low levels of compliance. Four teachers were trained to introduce these components sequentially in multiple baseline across-participants designs for each of two pairs of students. All students increased compliance from below 40% during baseline to between 84% and 96% in the final treatment phase. Support was demonstrated for the separate and independent effects of the positive antecedent components of effective instruction delivery and time-in, when used alone and in combination. The addition of contingent praise either increased compliance slightly or maintained it at already high levels. Treatment integrity and implications for practitioners and school personnel are discussed, including the effectiveness and simplicity of these procedures, while also offering positive, non-coercive approaches to increasing student compliance.
Most patients with Tourette syndrome (TS) report experiencing subjective bodily sensations termed premonitory urges, before they have a tic. This study investigated relationships between premonitory urges and tic severity, depression, anxiety, obsessions, compulsions, and attention problems. We also explored possible differences between patients with and without comorbid conditions. Finally, we explored whether premonitory urges impacted on perceived quality of life (QoL). One hundred adult outpatients (70 males; mean age 32 years) were recruited from a specialist TS clinic. Fifty percent exhibited comorbid diagnoses, the most common of which were obsessive-compulsive disorder (23%), attention-deficit hyperactivity disorder (15%), anxiety (6%), and depression (5%). For the entire sample, premonitory urges were significantly related to clinical symptoms, especially obsessive-compulsive symptoms and anxiety, and were significantly negatively related to QoL scores. Premonitory urges had a strong negative correlation with QoL in patients with "pure" TS (no comorbidities), while this relationship was weaker for patients with comorbid conditions, who reported stronger or more frequent premonitory urges in association with greater anxiety. These findings may imply that slightly different psychological factors drive self-reported premonitory urge ratings in patients with and without comorbidities and that the perceived influence of distressing premonitory urges on wellbeing is less important in the context of comorbid symptomatology. As premonitory urges are related to QoL, they should be taken into account during evaluation of treatment efficacy, especially in cases with "pure" TS.
Greater self-regulatory behavior usage is associated with greater weight loss within behavioral weight loss treatments. Hedonic hunger (i.e., susceptibility to environmental food cues) may impede successful behavior change and weight loss. Adult men and women (N = 111, body mass index M ± SD = 35.89 ± 6.97 kg/m2) were assessed before and after a 15-week lifestyle change weight loss program with a partial meal-replacement diet. From pre- to post-treatment, reported weight control behavior usage improved and hedonic hunger decreased, and these changes were inversely related. Individuals with higher hedonic hunger scores at baseline showed the greatest weight loss. Similarly, participants with lower baseline use of weight control behaviors lost more weight, and increased weight control behavior usage was associated with greater weight loss—particularly among individuals with low baseline hedonic hunger. Further study is warranted regarding the significance of hedonic hunger in weight loss treatments.
We evaluated functional communication training (FCT) combined with a chained schedule of reinforcement procedure for the treatment of challenging behavior exhibited by two individuals diagnosed with Asperger syndrome and autism. Following functional analyses that suggested that challenging behavior served multiple functions for both participants, we implemented FCT in which mands for a discriminative stimulus (SD; wristband) were reinforced with access to the SD and all three functional reinforcers. Next, we modified the procedure by incorporating delays to increase ease of implementation and promote toleration of delays to reinforcement. Last, we made additional modifications to the procedure by incorporating a chained schedule of reinforcement such that (a) mands for the wristband were reinforced with access to the wristband and (b) specific mands for respective functional reinforcers were reinforced in the presence of the wristband. The results showed that the procedure successfully treated challenging behavior with multiple functions. Future directions in the evaluation and development of treatments that simultaneously address multiple functions are discussed.
Major depressive disorder (MDD) is the most common psychiatric disorder in breast cancer patients. The prevalence of suicidal ideation in breast cancer patients is considerable, and relative to the general population, the prevalence of completed suicide is elevated, particularly in cancer patients with MDD. A major component of suicide prevention is effective treatment of MDD. Although some research has explored the utility of psychotherapy with breast cancer patients, only three trials have explored the benefits of behavior therapy in patients with well-diagnosed MDD and there has been no systematic investigation of the potential benefits of psychotherapy toward reducing suicidal ideation in breast cancer patients. As a follow-up to a recently completed randomized trial, this study examined the efficacy of 8 weeks of behavioral activation treatment for depression (BATD) and problem-solving therapy (PST) in reducing depression and suicidal ideation, as well as increasing hopefulness in breast cancer patients with MDD (n = 80). Across both treatments, GEE analyses revealed decreased depression and suicidal ideation and increased hopefulness at posttreatment, results that were maintained at 12-month follow-up. Moreover, follow-up patient contact at approximately 2 years posttreatment yielded no indication of completed suicide. Although these data are preliminary, BATD and PST may represent practical approaches to decrease suicidal ideation in depressed breast cancer patients.
Four articles examining methodological applications of exposure therapy and its limited dissemination were briefly reviewed. Methodological articles included those by Abramowitz et al., Gryczkowski et al., and Weiner and McKay, which addressed couple-treatment of obsessive compulsive disorder (OCD), modification of evidence-based anxiety treatments for children, and novel exposure methods for depersonalization and derealization, respectively. The creative aspects of these innovations are highlighted as well as historical parallels in the empirical literature for anxiety and other clinical phenomena. Underutilization and limited dissemination concerns are discussed in the context of the fourth article and as related to the field as a whole. A unique concept, exposaphobia, is hypothesized to explain the lack of clinicians’ utilization of this technique, due to their own anxiety-driven inhibitions in using it. Suggestions for the future of exposure research and dissemination are made.
The aim of this research was to examine the efficacy of two cognitive-behavioral treatment modalities for panic disorder (PD) with nocturnal panic (NP). The first study was conducted to determine whether conventional CBT for PD was effective for PD with NP in three participants. A second study sought to explore whether a CBT adapted to NP would lead to different clinical outcomes in three other participants. A multiple-baseline single-case design across individuals was used in both studies. Treatment outcome was assessed with standardized clinician ratings, self-report questionnaires, and daily self-monitoring. Results revealed that both the conventional and the adapted treatments showed a faster decrease in NPs versus daytime panics and significant clinical changes in all measures for up to a year after therapy. Hence, the changes brought about by the adapted treatment seemed to be similar to those obtained using conventional treatment. In light of these results, it can be presumed that conventional strategies may be sufficient for the treatment of NP. These observations raise questions regarding the real need to adapt treatments specifically to NP.
The trial-based functional analysis (FA) is a promising approach to identification of behavioral function and is especially suited for use in educational settings. Not all studies on trial-based FA have included teachers as therapists, and those studies that have, included minimal information on teacher training. The purpose of this study was to determine whether teachers trained via an in-service training would be able to conduct trial-based FAs with high procedural integrity. We trained four teachers to conduct trial-based FAs using a combination of didactic teaching and practice with feedback. All four teachers improved performance following training. Performance remained above baseline levels during an in situ maintenance condition, but for three of four teachers, additional feedback was required to recapture performance observed immediately following training.
Clinical safety is a dominant concern for human services organizations serving people with intellectual and developmental disabilities (IDD) and high-risk challenging behaviors. This article is a descriptive analysis of components that comprised an injury-reduction intervention among direct-care staff at a specialized school. Using a behavior-based safety approach, intervention was associated with fewer staff injuries and more weeks without injury reports. The article focuses on systems-level strategies and recommendations for future research and practice.
Anxiety disorders are highly prevalent among individuals with dementia and have a significant negative impact on their lives. Peaceful Mind is a form of cognitive-behavioral therapy for anxiety in persons with dementia. The Peaceful Mind manual was developed, piloted, and modified over 2 years. In an open trial and a small randomized, controlled trial, it decreased anxiety and caregiver distress. The treatment meets the unique needs of individuals with dementia by emphasizing behavioral rather than cognitive interventions, slowing the pace, limiting the material to be learned, increasing repetition and practice, using cues to stimulate memory, including a friend or family member in treatment as a coach, and providing sessions in the home. The manual presented here includes modules that teach specific skills, including awareness, breathing, calming self-statements, increasing activity, and sleep management, as well as general suggestions for treatment delivery.
This study evaluated the probability of generating false positives with A-B graphs. We generated 1,000 graphs consisting of three stable A-phase data points at 25% and three random B-phase data points; 1,000 graphs consisting of three stable A-phase data points at 50% and three random B-phase data points; and 1,000 graphs consisting of three random A-phase data points and three random B-phase data points. Results indicate that false positives were produced for (a) a relatively high percentage of graphs containing nonrandom data points in the A phase and (b) less than 2% of graphs containing random data points in both the A and B phases. These findings suggest that A-B designs may be a stronger clinical tool for evaluating the effects of interventions than previously recognized.