Leanne Togher

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

Rating scales that assess methodological quality of clinical trials provide a means to critically appraise the literature. Scales are currently available to rate randomised and non-randomised controlled trials, but there are none that assess single-subject designs. The Single-Case Experimental Design (SCED) Scale was developed for this purpose and evaluated for reliability. Six clinical researchers who were trained and experienced in rating methodological quality of clinical trials developed the scale and participated in reliability studies. The SCED Scale is an 11-item rating scale for single-subject designs, of which 10 items are used to assess methodological quality and use of statistical analysis. The scale was developed and refined over a 3-year period. Content validity was addressed by identifying items to reduce the main sources of bias in single-case methodology as stipulated by authorities in the field, which were empirically tested against 85 published reports. Inter-rater reliability was assessed using a random sample of 20/312 single-subject reports archived in the Psychological Database of Brain Impairment Treatment Efficacy (PsycBITETM). Inter-rater reliability for the total score was excellent, both for individual raters (overall ICC = 0.84; 95% confidence interval 0.73–0.92) and for consensus ratings between pairs of raters (overall ICC = 0.88; 95% confidence interval 0.78–0.95). Item reliability was fair to excellent for consensus ratings between pairs of raters (range k = 0.48 to 1.00). The results were replicated with two independent novice raters who were trained in the use of the scale (ICC = 0.88, 95% confidence interval 0.73–0.95). The SCED Scale thus provides a brief and valid evaluation of methodological quality of single-subject designs, with the total score demonstrating excellent inter-rater reliability using both individual and consensus ratings. Items from the scale can also be used as a checklist in the design, reporting and critical appraisal of single-subject designs, thereby assisting to improve standards of single-case methodology.

Social participation for older people with aphasia: The impact of communication disability on friendships

Abstract Purpose: The language changes experienced by a person with aphasia following a stroke often have sudden and longlasting negative impact on friendships. Friendship relationships are core to social engagement, quality of life, and emotional well-being. The aims of this study were to describe everyday communication with friends for older people with and without aphasia and to examine the nature of actual friendship conversations involving a person with aphasia. Method: This naturalistic inquiry drew data from two phases of research: a participant observation study of 30 older Australians, 15 of whom had aphasia following a stroke, and a collective case study using stimulated recall to examine friendship conversations involving an older person with aphasia. Results: People with aphasia communicated with fewer friends and had smaller social networks. “Friendship” was a core domain of communication for older people and participation in leisure and educational activities was focal in everyday communication with friends. Case study data of conversations between three older people with aphasia and their friends illuminated features of “time,” the role of humour, and friends having shared interests. Conclusion: Aphasia has been found to impact on friendships. A need exists for research and intervention programs to address communication with friends for older people with aphasia.

Social Skills Treatment for People With Severe, Chronic Acquired Brain Injuries: A Multicenter Trial

OBJECTIVE To determine whether social skills deficits including unskilled, inappropriate behavior, problems reading social cues (social perception), and mood disturbances (such as depression and anxiety) could be remediated after severe traumatic brain injuries. DESIGN Randomized controlled trial comparing a social skills program with social activity alone or with waitlist control. Several participants were reassigned after randomization. SETTING Hospital outpatient and community facilities. PARTICIPANTS Fifty-one outpatients from 3 brain injury units in Sydney, Australia, with severe, chronic acquired brain injuries were recruited. A total of 39 people (13 in skills training, 13 in social activity, 13 in waitlist) completed all phases of the study. INTERVENTION Twelve-week social skills treatment program encompassing weekly 3-hour group sessions focused on shaping social behavior and remediating social perception and 1-hour individual sessions to address psychologic issues with mood, self-esteem, etc. MAIN OUTCOME MEASURES Primary outcomes were: (1) social behavior during encounters with a confederate as rated on the Behaviorally Referenced Rating System of Intermediary Social Skills-Revised (BRISS-R), (2) social perception as measured by The Awareness of Social Inference Test, and (3) depression and anxiety as measured by the Depression, Anxiety and Stress Scale. Secondary outcomes were: relative report on social behavior and participation using: the Katz Adjustment Scale-R1; the Social Performance Survey Schedule; the La Trobe Communication Questionnaire; and the Sydney Psychosocial Reintegration Scale (both relative and self-report). RESULTS Repeated-measures analysis of variance indicated that social activity alone did not lead to improved performance relative to waitlist (placebo effect) on any outcome variable. On the other hand, the skills training group improved differentially on the Partner Directed Behavior Scale of the BRISS-R, specifically the self-centered behavior and partner involvement behavior subscales. No treatment effects were found for the remaining primary outcomes (social perception, emotional adjustment) or for secondary outcome variables (relative and self-report measures of social function). CONCLUSIONS This study suggested that treatment effects after social skills training in people with severe, chronic brain injuries are modest and are limited to direct measures of social behavior.

Revision of a method quality rating scale for single-case experimental designs and n-of-1 trials: The 15-item Risk of Bias in N-of-1 Trials (RoBiNT) Scale

Recent literature suggests a revival of interest in single-case methodology (e.g., the randomised n-of-1 trial is now considered Level 1 evidence for treatment decision purposes by the Oxford Centre for Evidence-Based Medicine). Consequently, the availability of tools to critically appraise single-case reports is of great importance. We report on a major revision of our method quality instrument, the Single-Case Experimental Design Scale. Three changes resulted in a radically revised instrument, now entitled the Risk of Bias in N-of-1 Trials (RoBiNT) Scale: (i) item content was revised and increased to 15 items, (ii) two subscales were developed for internal validity (IV; 7 items) and external validity and interpretation (EVI; 8 items), and (iii) the scoring system was changed from a 2-point to 3-point scale to accommodate currently accepted standards. Psychometric evaluation indicated that the RoBiNT Scale showed evidence of construct (discriminative) validity. Inter-rater reliability was excellent, for pairs of both experienced and trained novice raters. Intraclass correlation coefficients of summary scores for individual (experienced) raters: ICCTotalScore = .90, ICCIVSubscale = .88, ICCEVISubscale = .87; individual (novice) raters: ICCTotalScore = .88, ICCIVSubscale = .87, ICCEVISubscale = .93; consensus ratings between experienced and novice raters (ICCTotalScore = .95, ICCIVSubscale = .93, ICCEVISubscale = .93. The RoBiNT Scale thus shows sound psychometric properties and provides a comprehensive yet efficient examination of important features of single-case methodology.

Analysing discourse in the traumatic brain injury population: telephone interactions with different communication partners

A range of discourse analyses are effective in identifying features which are aberrant following traumatic brain injury (TBI). We examined the exchanges of five traumatically brain-injured subjects and five matched controls across four speaking situations which included speaking to a therapist, to the bus timetable information service, to the police, and to their mothers on the telephone. Transcripts were analysed using the exchange structure analysis of systemic functional grammar. This analysis provided an indication of information giving (K1 moves per minute); information requesting and receiving (K2 moves per minute) and the amount of negotiation that was needed for the messages to be conveyed (dynamic moves per minute). Results indicated that the TBI subjects performed differently across the four conditions, and were differentiated from the matched controls on a number of measures. The role of different communication partners is also addressed. Communication partners were noted to interact differently with TBI subjects when compared with controls. This included increased information-giving to control subjects; more requests for information by police from TBI subjects and a greater use of dynamic moves by therapists with controls. The potential of exchange structure analysis is discussed as a useful way of examining the discourse of TBI subjects and their communication partners. Exchange structure analysis highlighted the dynamic nature of information exchange and the subtle ways speakers responded to familiarity and power imbalance in social interaction. This study has implications for family and community education regarding communication with people with TBI.

Peer-Mediated Teaching and Augmentative and Alternative Communication for Preschool-Aged Children with Autism.

Abstract Background The aim of this study was to assess the effectiveness of two communication interventions for preschool-aged children with autism. Method Six typically developing peers were taught to implement peer-mediated naturalistic teaching, with and without a speech generating device (SGD), during play sessions with 3 classmates with autism in three preschools. Generalisation probes were conducted during mealtimes at the preschools. A multiple baseline design was used to assess the outcomes of the two intervention conditions. Results All 3 children with autism increased their communicative behaviours immediately following the introduction of the two interventions, and generalised these increases to mealtime interactions with their peers. However, only 1 child maintained these increases in communication. Conclusion These results provide preliminary evidence for the effectiveness of combining peer-mediated naturalistic teaching with the use of SGDs for preschool-aged children with autism. Suggestions for improving the maintenance of intervention effects are provided.

INCOG Recommendations for Management of Cognition Following Traumatic Brain Injury, Part IV: Cognitive Communication

Introduction:Cognitive-communication disorders are common in individuals with traumatic brain injury (TBI) and can have a major impact on long-term outcome. Guidelines for evidence-informed rehabilitation are needed, thus an international group of researchers and clinicians (known as INCOG) convened to develop recommendations for assessment and intervention. Methods:An expert panel met to select appropriate recommendations for assessment and treatment of cognitive-communication disorders based on available literature. To promote implementation, the team developed decision algorithms incorporating the recommendations, based on inclusion and exclusion criteria of published trials, and then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to best practice recommendations. Results:Rehabilitation of individuals with cognitive-communication disorders should consider premorbid communication status; be individualized to the persons needs, goals, and skills; provide training in use of assistive technology where appropriate; include training of communication partners; and occur in context to minimize the need for generalization. Evidence supports treatment of social communication problems in a group format. Conclusion:There is strong evidence for person-centered treatment of cognitive-communication disorders and use of instructional strategies such as errorless learning, metacognitive strategy training, and group treatment. Future studies should include tests of alternative service delivery models and development of participation-level outcome measures.

Discourse sampling in the 21st century.

This paper examines the importance of evaluating discourse in individuals with a neurogenic language disorder. Discourse analysis is acknowledged as an important tool for speech-language pathologists, although it is often not the assessment tool of choice due to its apparent time-consuming nature and the overwhelming number of options available. The wide range of analyses available to clinicians such as the number of T-units and total words produced or Pragmatic Protocol checklists make it difficult to choose assessment measures. Even more difficult is the decision of where to direct treatment efforts. This paper aims to show that there are a number of levels of discourse analysis available to clinicians and that it is possible to sample a number of different genres in a clinical setting. The significance of the communication partners contribution is discussed, particularly with regard to the limitations of the therapeutic interaction and the need to assess clients with a range of communication partners. The discourse opportunities we make available to people with communication problems will influence what is possible for them. To achieve this, the benefits of a theory of linguistic analysis, namely, Systemic Functional Linguistics (SFL) [Halliday, M. A. K. (1994). An introduction to functional grammar (2nd ed.). London: Edward Amold.] will be explored.

INCOG Recommendations for management of cognition following traumatic brain injury. Part II: Attention and information processing speed

Introduction:Traumatic brain injury, due to its diffuse nature and high frequency of injury to frontotemporal and midbrain reticular activating systems, may cause disruption in many aspects of attention: arousal, selective attention, speed of information processing, and strategic control of attention, including sustained attention, shifting and dividing of attention, and working memory. An international team of researchers and clinicians (known as INCOG) convened to develop recommendations for the management of attentional problems. Methods:The experts selected recommendations from published guidelines and then reviewed literature to ensure that recommendations were current. Decision algorithms incorporating the recommendations based on inclusion and exclusion criteria of published trials were developed. The team then prioritized recommendations for implementation and developed audit criteria to evaluate adherence to these best practices. Results:The recommendations and discussion highlight that metacognitive strategy training focused on functional everyday activities is appropriate. Appropriate use of dual task training, environmental modifications, and cognitive behavioral therapy is also discussed. There is insufficient evidence to support mindfulness meditation and practice on de-contextualized computer-based tasks for attention. Administration of the medication methylphenidate should be considered to improve information-processing speed. Conclusion:The INCOG recommendations for rehabilitation of attention provide up-to-date guidance for clinicians treating people with traumatic brain injury.

The Single-Case Reporting Guideline In BEhavioural Interventions (SCRIBE) 2016 Statement

Reporting guidelines, such as the Consolidated Standards of Reporting Trials (CONSORT) Statement, improve the reporting of research in the medical literature (Turner et al., 2012). Many such guidelines exist, and the CONSORT Extension to Nonpharmacological Trials (Boutron et al., 2008) provides suitable guidance for reporting between-groups intervention studies in the behavioral sciences. The CONSORT Extension for N-of-1 Trials (CENT 2015) was developed for multiple crossover trials with single individuals in the medical sciences (Shamseer et al., 2015; Vohra et al., 2015), but there is no reporting guideline in the CONSORT tradition for single-case research used in the behavioral sciences. We developed the Single-Case Reporting guideline In Behavioral interventions (SCRIBE) 2016 to meet this need. This Statement article describes the methodology of the development of the SCRIBE 2016, along with the outcome of 2 Delphi surveys and a consensus meeting of experts. We present the resulting 26-item SCRIBE 2016 checklist. The article complements the more detailed SCRIBE 2016 Explanation and Elaboration article (Tate et al., 2016) that provides a rationale for each of the items and examples of adequate reporting from the literature. Both these resources will assist authors to prepare reports of single-case research with clarity, completeness, accuracy, and transparency. They will also provide journal reviewers and editors with a practical checklist against which such reports may be critically evaluated.