133 Case study challenging behavior 6 that day, (8) had self-injured and (9) had been physically aggressive. The participant followed dialectical behavior therapy from mid-2019 until mid-2021, which consisted of weekly group sessions with other clients, one-on-one sessions with a therapist and 24-hour telephone consultation. During these individual sessions, therapist and participant discussed recent self-injurious and aggressive incidents registered in the diary. The participant continued to complete her self-ratings on a daily basis, even when therapy was paused due to Covid-19 restrictions. This was not because she was told to – she felt that she benefitted from daily self-reflections in the app. In total, she completed her diaries for a period of 560 days and was rewarded with a gift card for her long-term dedication. Informed consent was obtained from the participant and her legal guardian to (1) present and analyze the aforementioned daily diary entries and (2) to access the records (i.e., electronic client files) to perform supplementary qualitative analyses about therapeutical context and care professional’s perspective on her functioning. This electronic health system is a routine procedure in which care professionals describe multiple times per day, the provided care, implemented measures and any relevant daily events concerning the participant. The records of the 560-day self-rating period were retrieved and any information that could be traced back (names of people, cities, organizations, locations) were replaced by codes such ‘Person A’ or ‘City B’. Her clinical team (clinician and closest care professionals) approved aforementioned procedures beforehand. The Ethical Committee Social Sciences of Radboud University and the Ethics committee of the care organization judged that the research was conducted in accordance with the Declaration of Helsinki. Figure 2 Visualization of our three-step-approach to this case-study. 2.3 Design We employed a mixed-methods triangulation design study with both qualitative and quantitative data (Creswell & Clark, 2017). The study had a three-step approach based on complex systems theory (Figure 2). First, we obtained a comprehensive summary of the participant’s daily life through qualitative analyses of the daily caretaker records. These qualitative findings were then quantified, to then be integrated with quantitative daily self-reports. Secondly, we described the trajectory of her selfreported challenging behaviors by identifying transition-points and characterizing
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