Helfrich-Miller (1994)

EBP THERAPY ANALYSIS for

Single Subject Designs

 

SOURCE:  Helfrich-Miller, K. R. (1994). A clinical perspective: Melodic intonation therapy for developmental apraxia. Clinics in Communication Disorders, 4, 175-182.

 

REVIEWER(S):  pmh

 

DATE:  10.25.13

 

ASSIGNED OVERALL GRADE:  D- (Highest possible grade, based on design,  was D+.)

 

TAKE AWAY:  The investigator provided a clear description of modified melodic intonation therapy (MIT) procedures for the treatment of childhood apraxia of speech (CAS). The illustrative case studies provide initial (limited) support for the use of MIT in conjunction with other speech therapies.

 

1.  What was the focus of the research?  Clinical Research

                                                                                                           

2.  What type of evidence was identified?                              

a.  What  type of single subject design was used?  Case Studies – Program Description(s) with Case Illustration(s)     

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?  List here:  3

b.  Were the following characteristics/variables actively controlled or described?

The characteristics that were described include

•  age:  20 months to 8 years (at evaluation);  2 years, 9 months- 8 years (initiation of MIT)

•  gender:  m (3)

•  cognitive skills:  WNL (1); no information (2)

•  expressive language:  WNL (1);  delayed (1); no information (1)

•  receptive language:  WNL (3)

•  hearing:  WNL (2); no information (1)

•  previous therapy:  none- 4 years

c.  Were the communication problems adequately described? Yes           

•  List the disorder type(s):  childhood apraxia of speech (CAS)

•  The following oral motor problems were noted:

–  poor voluntary tongue control (1)

     –  limited lip  puckering (2)

     –  problems with rapid alternating movements (1)

     –  facial asymmetry: (1)

     –   multiple substitutions and omissions: (3)

     –  final consonant omission: (1)

     –  omission of grammatical morphemes:  (1)

     –  articulatory groping:  (1)

     –  speech sound sequencing challenges:  (3)

 

                                                                                                                       

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?  Not applicable

b.  Were any data removed from the study?  No

 

6.  Did the design include appropriate controls?  No.  These were case studies.

a.  Were baseline/preintervention data collected on all behaviors?  No

b.  Did probes/intervention data include untrained data?  No 

c.  Did probes/intervention data include trained data?  No

d.  Was the data collection continuous?  No  

e.  Were different treatment counterbalanced or randomized? Not Applicable

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

(NOTE:  The specific outcomes varied with the cases.  The following represent general outcomes.)

  OUTCOME #1:  Increase production of correct consonants

  OUTCOME #2:  Increase accuracy of articulatory sequences

  OUTCOME #3:  Increase length and complexity of sentences—only for 1 P;

OUTCOME #4:  Generalize acquired speech sound skills to conversation

b.  All of the outcomes were subjective.

c.  None of the outcomes were objective.

d.  None of  the outcome measures were associated with reliability data.

 

8.  Results:

a.  Did the target behavior improve when it was treated?  Yes_

b.  The overall quality of improvement for each of the outcomes was

  OUTCOME #1:  Increase production of correct consonants–strong

  OUTCOME #2:  Increase accuracy of articulatory sequences—strong

OUTCOME #3:  Increase length and complexity of sentences—only for 1 P; progress was strong—at the end of program  he was speaking in complex sentences.  He was 5 years 7 months at the time.

OUTCOME #4:  Generalize acquired speech sound skills to conversation—varied; stong (1P); moderate (1P), no information

9.  Description of baseline:

a.  Were baseline data provided?  No

 

10.  What was the magnitude of the treatment effect?  NA

 

11.  Was information about treatment fidelity adequate?  No

 

12.  Were maintenance data reported?  Yes. For one of the Ps, the investigator reported that his speech and language skills were WNL at age 11. Although the other the Ps improved during MIT, they required ongoing therapy.

 

13.  Were generalization data reported? Yes.  One P’s production of speech sounds in conversation was WNL; another P made progress on speech sound targets but the investigator reported that intelligibility decreased in conversation; for the final P there was no information.

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION:  D-

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To describe underlying foundations of Melodic Intonation Therapy (MIT) and provide 3 cases studies illustrating its procedures and outcomes.

POPULATION:  Childhood Apraxia of Speech (CAS); children

 

MODALITY TARGETED:  expression

 

ELEMENTS OF PROSODY USED AS INTERVENTION:  intonation (melodic line), tempo, rhythm, stress

 

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  production of speech sounds, speech sound sequences and speech sounds in conversation; production of sequences of words in sentences

DOSAGE:  varied

•  1 year (1P)

•  weekly sessions, 41 sessions (1P)

•  47 session (1P)

 

ADMINISTRATOR:  SLP

 

STIMULI:   visual (signing) and auditory stimuli

GOAL ATTACK STRATEGY:  vertical

 

MAJOR COMPONENTS:

•  MIT was used as an adjunct to speech-language therapy.

•  Procedures thoroughly described in prose and tables.  The investigator also provided relevant references.

•  MIT was developed for adults with aphasia.  Helfrich-Miller adapted MIT for children with CAS.

•  Overall, MIT involves modifying/simplifying speech prosody of target by

– slowing rate and prolonging utterances

– exaggerating intonation

– exaggerating stress

•  This adaption of MIT includes signing (Signed English) and child appropriate sentence length and complexity.

•  The intervention begins with maximum support for child (unison signing and intoning).  C gradually fades cues until P can answer questions using normal prosody.

•  Although 10 – 20 different utterances are targeted in each session, the target behavior is sequencing of words, not specific phrases.  However, the utterances should be functional and appropriate for the P.

•  Criterion for moving through steps in a phase is usually 90% correct (mean) over 10 sessions.

•  The steps within a phase and the different phases involve modifications of

–  length of utterance

–  phonemic complexity

–  dependency on C

–  age appropriate syntactic complexity

PHASE I

•  Target =  2-3 word utterances; focus is on vowels and bilabial consonants; avoids grammatical morphemes; sample target:  “more money,”

•  Procedures

Step I:

– C: intones and signs utterance 2 times

– P:  no response is required

Step 2:

– Unison intoning and signing with C and P

Step 3:

– Unison intoning and signing with C and P.

– C begins to fade his/her involvement.

Step 4:

– C intones and signs, then P intones (signing is optional).

Step 5:

– C asks a question, using intoned speech.

– P responds with an intoned answer (signing is optional).

PHASE II

•  Target =  4-5 word utterances; adds alveolars, glottal, and sibilants; can include possessive, plural, and contractions; sample target:  “I don’t like it.”

•  Procedures

–  6 second delays are introduced in this phase as are back-up in which P is given an extra trial in the case of error responses.

Step I:

– C: intones and signs utterance.

– P:  no response is required.

Step 2:

– C intones and signs.

– P intones in unison with C, signing is optional.

– C gradually fades vocalizations at the end of utterances.

Step 3:

– C introduces a 6 second delay and back ups in this step. If P’s response is incorrect, C moves back to Step 2 with the same utterance.

– C intones and signs an utterance.

– C waits 6 seconds before cueing P to intone the utterance.

– P intones the utterance; signing is optional

Step 4:

– C asks a question, using intoned speech.

– P responds with an intoned answer (signing is optional).

– C asks a question, using intoned speech.  The question is designed so that P will  answer only the last words of the target utterance.

– P intones the last words of the target utterance.

– The back-up here would be Step 3.

PHASE III

•  Target =  increase to maximum complexity in phonology , morphology, and syntax; sample target:  “Where is my coat?”

•  Procedures

–  C introduces “Sprechgesang.”  This is also called speech song and involves producing a more speech-like pattern in the utterance which still retaining a song quality (perhaps, Rex Harrison in “My Fair Lady.”)

Step 1:

– C provides a 6 second delay and back ups in this step. If P’s response is incorrect, C moves back to unison intonation and then fading by C.

– C intones and signs an utterance.

– C waits 6 seconds before cueing P to intone the utterance.

– P intones the utterance ands signing.

Step 2:

– C presents the targeted utterance using Sprechgesang.

– No response is required of P.

Step 3:

– C and P produce the utterance in Sprechgesang accompanied by signing.

– C gradually fades vocalization at the end of an utterance.

– If a Back-up is required, C reintroduces Step 2.

Step 4:

– C presents the target utterance using normal prosody.  C does not sign.

– P imitates using normal prosody.

– If a Back-up is required, C reintroduces Step 3.

Step 5:

– C presents a question designed to elicit the target utterance using normal prosody.  C does not sign.

– C cues P to respond after a 6 second delay.

– P responds using normal prosody.

– If a Back-up is required, C reintroduces Step 4.

Step 6:

– C asks a question, using normal prosody that is designed so that P will answer only the last words of the target utterance.

– P produces the last words of the target utterance using normal prosody.

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