Single Subject Research Design (SSRD)

Bill Miller, PhD, OT UBC School of Rehab Sciences VCHA OT Research Scientist
SSRD Workshop 1

Objectives
Define Single Subject Research Design (SSRD) Rationale for using SSRD Describe several forms of SSRD Discuss the methods of analyses using SSRD Discuss strengths & weaknesses of SSRD
SSRD Workshop 2

Continuum of Research
Quasi-Experimental
(Groups -no random selection)

Case report

Case Study

(Individuals - SSRD)

Experimental
(RCT)

Pre Scientific
SSRD Workshop

Scientific
3

Other Names for SSRD

Single case experimental design Time series design Small-N design Single system designs Within-subject comparison Idiographic research N of one trial
SSRD Workshop 4

SSRD Defined
SSRD involves studying a single individual or system by taking repeated measurements of 1 or more dependent variables and systematically applying & sometimes, withdrawing or varying the independent variable.
(Ottenbacher, 1986; Bloom & Fischer, 1982)
SSRD Workshop 5

Why Chose SSRD?

Demonstrates individual differences Difficulty obtaining adequate power (N) Difficulty obtaining homogeneous group SSRD is relatively easy to do Helps validate practice Demonstrate treatment (tx) effectiveness Great pilot
SSRD Workshop 6

About SSRD
Collection of methods (eg; AB, ABAC) Answers research question or tests hypothesis Involves at least one;
Subject (individual or clinical unit/department) Baseline or A Phase - series of repeated observations or measurements with no intervention Intervention or B Phase - introduction of experimental variable with evaluation to see if change occurs Dependent variable (quantifiable) Independent variable (treatment / intervention)
SSRD Workshop 7

SSRD Phases
Baseline Period of no tx - reflects natural state Provide standard for evaluating tx effect Measurements usually repeated until stability demonstrated 5 or more data points
SSRD Workshop 8

Sample Baseline Phases

12

A)
Behaviour

93.5

93

B)

10

92.5
8

92

91.5

91

90.5
2

90
0 1 2 3 Se s s i o ns 4 5 6

89.5 1 2 3 4 5 6

93

92.5

C)
Behaviour

93

D)

92

92

91.5

91

Behaviour

91

90

90.5

90

89

89.5
88

89

88.5 1 2 3 4 5 6

87

SSRD Workshop

SSRD Phases
Intervention Phase Introduce tx or intervention
= independent variable

Multiple treatments are alright Repeated measurement of dependent variable Phase length should be approximately same as baseline
SSRD Workshop 10

Dependent Variable
Variable of interest needs to be quantifiable Does not require a standardized test
Usually frequency, duration, magnitude i.e. episodes of self-abuse / walk time / pain intensity

Should assess reliability of variable

total % agreement Point by point % agreement kappa

SSRD Workshop

11

Simple Design
A-B
1 baseline + 1 tx phase
10.5 12.5 11.5

Problems
9.5

Limited control over threats to internal validity

units

8.5

7.5

Solution

Replication
6.5 5.5

Add phases Add other tx/interventions Add subjects

A
4.5 1 2 3 4 5 6 7 8 9 10

B
11 12 13 14 15

Time (session)

SSRD Workshop

12

Withdrawal Designs
9

A-B-A
Shows intervention leads to target behaviour (TB) TB disappears when intervention stopped

Units

Problems
Unethical to withdraw tx Reversible target behaviour

A
3 1 2 3 4 5 6 7 8 9 10 11

B
12 13 14 15 16 17 18 19

A
20 21 22 23

Time (sesions)
SSRD Workshop 13

Withdrawal Designs
70

A-B-A-B
- adds an extra tx phase - confidence in tx effect
# of hits

60

50

40

30

Problems - Reversible target behaviour - Unethical to withdraw tx

20

10

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

Days

SSRD Workshop

14

Multiple Treatment Designs

Alternating
Rapid alternation of 2 txs (or tx & placebo) Txs alternated within same session, session to session Advantage = quick results, baseline unnecessary Sequence effect randomizing counterbalance Target must be clear & happen rapidly
96

A
95 94

Oxygen staturation

93

92

91

90 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Daily sessions

SSRD Workshop

15

Multiple Treatment Designs

40

Interactive (A-B-BC-B-BC)
Weight (Kg) and Calories

39

BC

BC

Assess separate & joint effects of 2 or more txs Best to replicate tx Interactions can be tested

38

37

36

35

34 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Days

SSRD Workshop

16

Multiple Baseline Designs

15

Across Subjects /Conditions /Behaviors

Useful when:
Behaviours non-replicable Unethical to withdraw tx

10

Eye Fixation

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

20

15

Facial Posturing
10 5

Uses basic A-B phase design

Measure baseline in all Establish stability Intro tx to 1st subject/condition Intro next tx when previous tx stabilizes

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

15

10

Diaphragmatic Breathing

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

SSRD Workshop

17

SSRD Analysis
Visual analysis most common Assess trends & levels between adjacent phases
Level refers to change in value or magnitude of dependent variable after intervention Trend refers to change in direction
Described as accelerating, decelerating, stable or variable

Another technique Split middle Difference

Uses celeration line to which statistical significance can be explored Also 2 standard deviation method
SSRD Workshop 18

Visual Analysis
12.5

A)

Change in level

B)

Change in trend

11.5

10.5
5

9.5
4

units

8.5

Units
3 2 1 0 1

7.5

6.5

5.5

4.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

10

11

12

13

14

15

Time (session)
SSRD Workshop

Time (sesion)

19

Sample Visual Analyses

How would you describe the following changes?
10.5
10 9

9.5
8

8.5

Behaviours

7.5

Units

6.5
3

5.5
1

4.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

10

11

12

13

14

15

Time (sesion)

Sessions
12 12

10

10

Units

Units
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Time (sesion)

Time (sesion)

SSRD Workshop

20

Split-Middle Technique
20

A
18 16

14

12

10

0 1 2 3 4 5 6 7 8 9

SSRD Workshop
10 11 12 13 14 15 16 17 18 19 20 21

21
22

SSRD, Case Study & Group Designs: Contrast and Comparison

SSRD Subject Hypothesis Own control Test Case Study No control Generate Describes Between Groups Group control Test May control No change Group Similar to groups Few Can be high Significance bt grps
22

Extraneous variable Controls Design flexibility Differences Generalizability Measurement Cost Statistics

Permits change Permits change Individual Limited Individual None

Repeated freq Through-out Low Limited Low None

SSRD Workshop

Useful References
1. 2. Backman CL, Harris SR. Case studies, single-subject research, and N of 1 randomized trials: comparisons and contrasts. Am J Phys Med Rehabil 1999;78:170-6. Backman CL, Harris SR, Chisholm JM, Monette AD. Single-subject research in rehabilitation: a review of studies using AB, withdrawal, multiple baseline and alternating treatments designs. Arch Phys Med Rehabil 1997;78:1145-53. Harris SR. Research techniques for the clinician. In B Connolly & P Montgomery (Eds). Therapeutic Exercise in Developmental Disabilities, Hixson, TX: Chattanooga Group. Gonnella C. Single-subject experimental paradigm as a clinical decision tool. Phys Ther 1989;69:601-9. Guyatt G, Sackett D, Taylor W, Chong J, Roberts R, Pugsley S: Determining optimal therapy: randomized trials in individual patients. N Engl J Med 1986;314:889-892 Kazidin AE. Single-case research designs. New York: Oxford University, 1982. Portney LG, Watkins MP. Single-case experimental designs. Foundations of clinical research: applications to practice (2nd ed). Appleton & Lange, 1993. Sackett DL, Haynes RB, Guyatt GH, Tugwell P: Deciding on the best therapy, in Clinical Epidemiology: A Basic Science for Clinical Medicine, ed 2. Boston, Little, Brown & Co., 1991, pp 187-248 Wolery M, Harris SR. Interpreting results of single-subject research designs. Phys Ther 1982;4:445. Zhan S, Ottenbacher KJ. Single subject research designs for disability research. Disabil Rehabil 2001;23:1-8.

3. 4. 5. 6. 7. 8. 9. 10.

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