This week I will be writing a series of micro reviews of recent treatment studies. Some of these articles are controversial for different reasons, for example below I discuss issues with single-case reports and later this week I will discuss issues regarding conflict of interest in the publication process.

The Journal of Autism and Developmental Disorders just published a case report on the effectiveness of pressure vests in engagement behaviors during a preschool class in a 57-month-old boy with a diagnosis of developmental delay. The authors used an A-B-A design, in which the researchers observed behavior changes during a baseline (A) after the initiation of treatment (B), and after the termination of treatment (A). The authors did not find any improvements in engagement behaviors with the use of the vest. Does this mean that pressure vests are not effective? NO. The data simply showed that the pressure vest did not help this particular child. Thus, we can not generalize these findings to anyone else.

There is very little more I can say about this study, except to pose the question: why are we still publishing single case studies? The methodology was sound (for a single-case study) and the article well written, and I further appreciate the authors’ efforts in emphasizing the limitations of the single-case nature of their study. So I’m not questioning the authors. My question is to JADD – I can not think of a single reason as to why this type of single case reports should continue be published. Autism is not an extremely rare condition, and pressure vests are not an extremely rare or individualized intervention, both of which could potentially justify a single case report. Thus, the utility of publishing case studies on common conditions/treatments eludes me.

What is the problem with a single case reports? That regardless of the outcome of the study, we simply can not reach any conclusion about the effectiveness of the treatment – thus we learn very little from it. In medicine, case reports are useful to communicate to other physicians/researchers examples of diagnostic and treatment issues of extremely rare conditions or situations (so rare that conducting more externally valid studies would be impossible). In contrast, the utility of case reports of common treatments in very common conditions is more questionable, and it raises a number of ethical issues given the increased access to these type of findings by the general public.

Reichow, B., Barton, E., Good, L., & Wolery, M. (2009). Brief Report: Effects of Pressure Vest Usage on Engagement and Problem Behaviors of a Young Child with Developmental Delays Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-009-0726-3

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5 Responses to Are Pressure Vests Effective? Why do we publish case reports?

  1. I think they can be helpful and do seem to calm my daughter down, but they look like something Hannibal Lecter would be restrained in. Wearing the vest around other kids probably opens up a whole new can of worms.

  2. mamacate says:

    I work as an educational researcher in higher ed, and I have a son with autism (so you know where these issues converge for me). I’m no epidemiologist, but I know how to design a decent study. I was very surprised to read in the book “How To Think Like A Behavior Analyst” a whole section about how single-case designs are the only appropriate methodology for ABA research (not A-B-A, but applied behavior analysis). The idea was that the interventions are tailored to each child and that every intervention is experimental in nature within that child’s case. I’m not saying I agree with it (though it was kind of convincing–as I read it it kind of made sense to me, even though I knew it wasn’t a reasonable approach for any kind of generalizable research). But I think this is actually an issue of disciplines not being able to relate to one another in terms of research methods (I deal with this all the time as I try to get psychologists, sociologists, and engineers to work together).

    I think it’s not much of a leap to imagine using a structured system for designing customized behavioral interventions, and then to test the efficacy of the structured interventions, even if they vary across individuals, across a large group (which of course has been done, at least by Lovaas). But if you look at the ABA journal, it’s all case studies. And I think that is why a lot of insurance companies can get away with calling ABA experimental, which as a parent trying to get coverage, I’d like to see changed!

  3. Do you feel that the tendency to publish single subject designs is due to the historical and continued prevalence of applied behavior analytic (ABA) techniques in autism research? Philosophically, behaviorism holds that experimental results can be generalized across individuals and, indeed, species. Practically, much ABA research is derived from service provision to individuals.

    However, just because we might be able to trace the origins, does not mean that we should endorse the continuation of the practice. The limitations of single-N designs, generally, and of reversal designs in particular, are well established. Journals should not continue to accept such studies when more powerful experimental techniques (with larger samples, random assignment, etc.) can be employed to answer the same research question.

  4. Thank you everyone for the comments. I still don’t quite agree with the basic premise that because a treatment is highly individualized (not the case with pressure vests) then single case designs are the best methodology to assess the effectiveness of the treatment. This was the same philosophy used in traditional psychoanalysis to resist basic effectiveness research. Even in ABA, studies have now been able to show the effectiveness of ABA by integrating the individualized components of ABA within standard randomized treatment methodology. This has been possible because even within the highly individualistic and ‘experimental’ nature of ABA, there is an overarching set of premises that define ABA and can be used in defining treatments and the process of randomization of participants to such treatments.

    Thank you again for the comments. Nestor.

  5. RAJ says:

    I was an occasional contributor to the JADD in the early 1990′s when it was under the editorial leadership of Eric Schopler, primarily critical reviews of original research published in the Journal. Professor Schopler always encouraged contributions by parents.

    I lost interest in the topic when my daughter lost her PDD/NOS diagnosis and had a complete recovery. While I no longer subscribe to the Journal, I do occasionally read their abstracts and the quality of published research under the current editor Fred Volkmar of Yale University has deteriorated in my view.

    One has to only look at the members of the editorial board, a veritable who’s who of genetic theorists, the kind of scientists even Michael Rutter referred to as genetic evangelists.

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