EBP THERAPY ANALYSIS for
Single Subject Designs
SOURCE: Grube, M. M., & Smith, D. S. (1989). Paralinguistic intonation-rhythm intervention with a developmental stutterer. Journal of Fluency Disorders, 14, 185-208.
ASSIGNED OVERALL GRADE: D
TAKE AWAY: This clearly written case study provides strong documentation about the administration of prosody-based intervention to reduce the stuttering of a 5 year-old boy. The design of the study prevented the investigators from claiming that the treatment was effective but the child evidenced marked improvement during and following intervention.
1. The focus of the research was Clinical Research.
2. What type of evidence was identified?
a. What type of single subject design was used? Case Study: Description with Pre and Post Test Results as well as session-by- session data
b. What was the level of support associated with the type of evidence?
Level = D+
3. Was phase of treatment concealed?
a. from participants? No
b. from clinicians? No
c. from data analyzers? No
4. Were the participants adequately described? Yes
a. How many participants were involved in the study? 1
b. The following characteristics were or described:
• age: 5 years
• gender: m
c. Were the communication problems adequately described? Yes
• The disorder type was stuttering
• Other aspects of communication that were described:
– 97% of disfluencies were repetitions
• 93% of the multisyllabic repetitions involved 2 or 3 word units (e.g., “how about,” “well you know”)
• 7% of multisyllabic repetitions were multisyllabic words (e.g., “because.”)
– 3% of the disfluencies were prolongations
– locus of 78% of the disfluencies was initial syllable or initial word.
– locus of 22% of disfluencies was connector words
– investigators noted pauses and they perceived uncertainty during P’s production of disfluencies. They attributed this to word finding problems.
– 82% of the P’s utterances were perceived to be monotone (slight pitch variation) with appropriate stress patterns.
– P used the same intonation pattern for statements, questions, and exclamations.
– As P’s rate increased his intonation deteriorated.
– P produced atypical inhalation and exhalation patterns during disfluencies:
• P inhaled an excessive amount of air before speaking and then exhaled quickly giving the impression of running out of breath after the second or third syllable.
– When P produced four or more repetitions, he evidenced
• tension in neck muscles and face
• especially on the left side of his mouth
5. Was membership in treatment maintained throughout the study? Not applicable
a. If there was more than one participant, did at least 80% of the participants remain in the study? NA
b. Were any data removed from the study? No
6. Did the design include appropriate controls? No, this was a case study.
a. Were baseline/preintervention data collected on all behaviors? Yes
b. Did probes/intervention data include untrained data? Yes
c. Did probes/intervention data include trained data? No
d. Was the data collection continuous? Yes
e. Were different treatment counterbalanced or randomized? Not Applicable
7. Were the outcomes measure appropriate and meaningful? Yes
a. The outcomes
OUTCOME #1: Number of monosyllabic repetitions in a 10 minute spontaneous speech sample
OUTCOME #2: Number of multisyllabic repetitions in a 10 minute spontaneous speech sample
OUTCOME #3: Number of prolongations in a 10 minute spontaneous speech sample
OUTCOME #4: Number of word finding difficulties in a 10 minute spontaneous speech sample
b. The outcomes that are subjective are Outcomes #1-4
c. None of the outcomes are objective.
d. None of the outcome measures had reliability data.
a. Did the target behaviors improve when it was treated? Yes
b. The overall quality of improvement for each of the outcome measures was
OUTCOME #1: Number of monosyllabic repetitions in a 10 minute spontaneous speech sample –strong
OUTCOME #2: Number of multisyllabic repetitions in a 10 minute spontaneous speech sample — strong
OUTCOME #3: Number of prolongations in a 10 minute spontaneous speech sample — strong
OUTCOME #4: Number of word finding difficulties in a 10 minute spontaneous speech sample –strong
9. Description of baseline:
a. Were baseline data provided? No. However, preintervention data were provided. These data were extracted from the samples collected before the first therapy session.
b. Was baseline low and stable? NA
c. What was the percentage of nonoverlapping data (PND)?
NOTE: The reviewers calculated PND using the data from the samples collected in the pre-intervention data of the first session as the baseline and the post intervention sample for each of the treatment sessions
OUTCOME #1: Number of monosyllabic repetitions in a 10 minute spontaneous speech sample PND = 86%
OUTCOME #2: Number of multisyllabic repetitions in a 10 minute spontaneous speech sample PND = 64%
OUTCOME #3: Number of prolongations in a 10 minute spontaneous speech sample PND = 100%
OUTCOME #4: Number of word finding difficulties in a 10 minute spontaneous speech sample PND = 100%
d. Does inspection of data suggest that the treatment was effective?
OUTCOME #1: Number of monosyllabic repetitions in a 10 minute spontaneous speech sample fairly effective
OUTCOME #2: Number of multisyllabic repetitions in a 10 minute spontaneous speech sample questionable effectiveness
OUTCOME #3: Number of prolongations in a 10 minute spontaneous speech sample highly effective
OUTCOME #4: Number of word finding difficulties in a 10 minute spontaneous speech sample highly effective
10. What was the magnitude of the treatment effect? NA
11. Was information about treatment fidelity adequate? Not Provided
12. Were maintenance data reported? Yes. The investigators elicited speech samples one month after the end therapy. They extracted outcome data from this sample. The P continued to improve on all the outcomes following the termination of therapy. The only exception to this was the prolongation outcome (Outcome #3) which was extinguished at the end of therapy and remained so one month after therapy.
13. Were generalization data reported? Yes. The outcomes were extracted from spontaneous samples and treatment involved imitated or elicited utterances. This should be considered generalization. The results indicated that P was successful in generalizing all the outcomes.
OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: D
SUMMARY OF INTERVENTION
PURPOSE: To investigate the effectiveness of focusing on intonation paired with motor movement in reducing stuttering.
NOTE: There was a second purpose that will not be discussed fully here—to determine if upper body movement or lower body movement is more effective in reducing stuttering.
POPULATION: stuttering (child)
MODALITY TARGETED: expression
ELEMENTS/FUNCTIONS OF PROSODY TARGETED: intonation (overall, terminal contour)
ELEMENTS OF PROSODY USED AS INTERVENTION: intonation, loudness
OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: fluency (monosyllabic repetitions, multisyllabic repetitions, prolongations), word finding
DOSAGE: 1 hour sessions, 14 sessions (12 treatment , 2 following treatment for data collection only),
STIMULI: auditory, visual, motor, tactile, kinesthetic
GOAL ATTACK STRATEGY: cyclical – Two cycles; each cycle had 3 sessions each of upper and lower body movement; one intonation pattern was the focus of sessions. The structure of single cycle was
Session 1- Upper body movement plus declaratives
Session 2- Upper body movement plus interrogatives
Session 3- Upper body movement plus exclamations
Session 4- Lower body movement plus declaratives
Session 5- Lower body movement plus interrogatives
Session 6- Lower body movement plus exclamations
• 10 minute speech sample for assessment
• 2 minutes of auditory stimulation
• treatment session (56 minutes)
• 2 minutes of auditory stimulation
• 10 minute speech sample for assessment
• P listened through earphones to C’s reading of sentences with the targeted intonation pattern.
• While listening to the C’s reading, the P was encouraged to color or complete a puzzle.
Upper and Lower Body Motor Movements Associated with Intonation
• Involves the pairing of a pitch change with a motor movement
• Upper body motions are
– declarative pitch pattern = hands down
– interrogative pitch pattern = hands up
– exclamatory pitch pattern = hands crashing together
• Lower body motions are carried out on a set of stairs
– falling pitch pattern = down a step
– rising pitch pattern = up a step
– level pitch (monopitch) pattern = remains on a step
• Intervention began with one word and as P met criteria (100% accuracy) targeted word length increased.
Prosodic Procedures—for each session, P targets a specific intonation pattern
• C models the targeted utterance with the targeted intonation and pairs the modeling with motor movements by moving C’s hands to represent the appropriate motor movement or moving on the steps with C to the appropriate location. (C and P are touching.)
• C and P produce the targeted utterance and intonation in unison when enacting the appropriate motor movement described in Step 1. (C and P are touching.)
• P produces the targeted utterance and intonation independently while enacting the motor movements with C. (C and P are touching.)
• P produces the targeted utterance, intonation, and motor movement. C is simultaneously enacting the motor movement but is neither vocalizing nor touching P.
• P produces the targeted utterance, intonation, and motor movement. C only observes P’s actions.
• P produces the targeted utterance and intonation but does not include motor movement.
1. The investigators did not detect a difference between the effectiveness of upper and lower body movements.
2. The investigators indicated that this approach may not be appropriate for older children and adults who may have more strongly habituated dysfluencies.