Dworkin (1991)

CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

 

Note:

  • The summaries for the procedures begin about 10% of the way down this page.
  • The summaries are brief. Readers who cannot access the original book and would like more thorough procedural descriptions should contact the reviewer at patricia.hargrove@mnsu.edu

 

Key:

bpm = beats per minute

C = clinician

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

Source: Dworkin, J. P. (1991). Motor speech disorders: A treatment guide. St. Louis, MO: Mosby. (Chapter 7: The Treatment of Prosody, pp. 303 – 343)

 

Reviewer(s): pmh

 

Date: November 18, 2014

 

Overall Assigned Grade (because there are no supporting data, the highest grade will be F)   F

 

Level of Evidence: F = Expert Opinion, no supporting evidence for the effectiveness of the intervention although the author may provide secondary evidence supporting components of the intervention.

 

Take Away: Dworkin provides explicit instructions concerning establishing baseline, administering procedures, recording data, and advancing/discontinuing for each exercise. The exercises are logically ordered and linguistic complexity (from single vowels to spontaneous conversation) increases as the patient (P) moves through the treatment hierarchy. Dworkin describes treatments for the following aspects of prosody: pitch, loudness, rate of speech, intonation, and stress.

 

  1. Was there a review of the literature supporting components of the intervention? No, not applicable.

 

 

  1. Were the specific procedures/components of the intervention tied to the reviewed literature? No

 

 

  1. Was the intervention based on clinically sound clinical procedures? Yes
  1. Did the author(s) provide a rationale for components of the intervention? No

 

  1. Description of outcome measures:

The following are general outcomes associated with Dworkin’s treatment hierarchy. Each of these outcomes have multiple “exercises” to achieve the overall outcome.

  • Outcome #1: Improved pitch level and variability
  • Outcome #2: Improved pitch level and variability
  • Outcome #3: Increased speaking rate
  • Outcome #4: Decreased speaking rate
  • Outcome #5: Appropriate use of speaking rate variations
  • Outcome #6: Improved intonation
  • Outcome #7: Improved use of stress

 

  1. Was generalization addressed? Yes. Several of the exercises contained “steps” focusing on transferring skills to everyday conversation.

 

 

  1. Was maintenance addressed? No

 

 

SUMMARY OF INTERVENTIONS

 

 

For each intervention detailed in the chapter, only brief summaries of the procedures are provided. For more information, access the chapter. Readers who cannot access the original book and would like more thorough procedural descriptions of procedures should contact the reviewer at patricia.hargrove@mnsu.edu

Description of Intervention #1—Improved pitch level and variability

 

POPULATION: motor speech disorders

 

TARGETS: pitch level, pitch variability

 

TECHNIQUES: collection of baseline data, modeling, reviewing, discussion of objectives, recording data, use of visual/graphic cues, oral reading (reading aloud), conversation

 

STIMULI: auditory, visual, gestural/motor

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • There are 6 exercises for this outcome. Dworkin’s labels (p. 341) for the 6 exercises are
  1. Discrimination and listening training (p. 306)
  2. Low versus high vocalizations with vowel pairs (p. 308)
  3. High versus low vocalizations with vowel pairs (p. 309)
  4. Singing the scale (p. 310)
  5. Variations during reading (p. 310)
  6. Practice pitch control in conversation (p. 311)
  • The exercises tend to follow a common format:

– Exercises begin with the collection of baseline data. Dworkin clearly describes procedures for collecting baseline data for each of the exercises and for deciding whether a response is correct or incorrect. In addition, he provides a form for recording data.

– Depending on the exercise, clinicians (Cs) may draw the baseline from a sample task from the procedures, ask the patient (P) to describe pictures or narrate a story, or engage the P in conversation.

– Dworkin provides guides regarding whether or not to proceed through the exercise or to advance to another exercise based.

– Although the content changes based on the exercise, Dworkin recommends the use of certain common procedures:

  • describing/discussing terminology
  • modeling of targets by C
  • cueing pitch changes with manual gestures such as stairstep hand gestures
  • audio recording of P responses and replaying the recordings for the P and C to review and discuss
  • preparing written passages with or without (depending on the step and exercise) symbols signifying when/where P should change pitch level. The symbols may involve arrows, color coding, or writing select words above or below the line.
  • gradual increasing of complexity and/or difficulty (e.g., for the discrimination exercise #1, the pairs of vowels that are compared become closer in pitch as the exercise progresses)

– Dworkin describes procedures collecting data during the exercise, the number of trials that should be administered, and the requirements for progressing to the next exercise or terminating treatment for the exercise.

RATIONALE/SUPPORT FOR INTERVENTION: Logical

 

CONTRAINDICATIONS FOR USE OF THE INTERVENTION:

  • Dworkin notes that Cs should monitor the voice quality of Ps to prevent inappropriate voice quality or negative changes in other aspects of prosody/voice.

Description of Intervention #2— Improved loudness level and variability

 

POPULATION: motor speech disorders

 

TARGETS: loudness level, loudness variability

TECHNIQUES: collection of baseline data, modeling, reviewing, discussion of objectives, recording data, use of visual/graphic cues, oral reading (reading aloud), conversation

STIMULI: auditory, visual, kinesthetic

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • There are 9 exercises for this outcome. Dworkin’s labels (p. 341) for the 9 exercises are
  1. Discrimination and listening training (p. 312)
  2. Soft versus loud vocalizations with vowel pairs (p. 312)
  3. Loud vocalizations with vowel pairs (p. 313)
  4. Prolongation of /m/ with a ½ inch straw using the See-Scape Device (p. 313)
  5. Prolongation of /m/ with a ¾ inch straw using the See-Scape Device (p. 314)
  6. Prolongation of /m/ with a 1 inch straw using the See-Scape Device (p. 314)
  7. Prolongation of /m/ with a 1½ inch straw using the See-Scape Device (p. 314)
  8. Loudness variation during sounds, words, and sentences using a V-U meter (p. 314)
  9. Practice in conversation with a V-U meter (p. 315)
  • The exercises tend to follow a common format:

– Exercises begin with the collection of baseline data. Dworkin clearly describes procedures for collecting baseline data for each of the exercises and for deciding whether a response is correct or incorrect. In addition, he provides a form for recording data.

– Depending on the exercise, clinicians (Cs) may base the baseline on a sample task from the procedures which follow, ask the patient (P) to describe pictures or narrate a story, or engage the P in conversation.

– Dworkin provides guides regarding whether or not to proceed through the exercise or to advance to another exercise

– Although the content changes based on the outcome, Dworkin recommends the use of certain common procedures:

  • describing/discussing terminology and the physiological basis of loudness,
  • modeling of targets by C
  • using the See-Scape Device which was available at the time from Pro-Ed and straws of varying lengths to provide feedback to Ps regarding the effort needed to achieve specified loudness levels
  • using a V-U meter to provide feedback regarding loudness levels
  • recording P responses and replaying the recordings for the P and C to review and discuss
  • preparing written passages for P to read aloud
  • gradual increasing of complexity and/or difficulty of target resp (e.g., for the exercise #9, the targets progress from vowels to short sentences)

– Dworkin describes procedures for collecting data during the exercise, the number of trials that should be administered, and the requirements for progressing to the next exercise or terminating treatment for the exercise.

RATIONALE/SUPPORT FOR INTERVENTION: Logical

CONTRAINDICATIONS FOR USE OF THE INTERVENTION: Ps who have not profited from the previous treatment of articulation, phonation, resonation, and/or respiration are at risk for failure in loudness exercises

Description of Intervention #3— Increased speaking rate

 

POPULATION: motor speech disorders

 

TARGETS: rate of speech

TECHNIQUES: collection of baseline data, modeling, reviewing, discussion of objectives, recording data, metronome, oral reading (reading aloud), conversation

STIMULI: auditory

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • There are 6 exercises for this outcome. Dworkin’s labels (p. 341) for the 6 exercises are
  1. Discrimination and listening training (p. 317)
  2. Recitation of the alphabet to 150 bpm of the metronome (p. 318)
  3. Counting repeatedly 1-10 to 150 bpm of the metronome (p. 320)
  4. Producing familiar phrases, sentences, and passages to 150 bpm of the metronome (p. 321)
  5. Producing unfamiliar phrases, sentences, and passage without the aid of the metronome (p. 322)
  6. Practice increased rate in conversation (p. 323)
  • The exercises tend to follow a common format:

– Exercises begin with the collection of baseline data. Dworkin clearly describes procedures for collecting baseline data for each of the exercises and for deciding whether a response is correct or incorrect. In addition, he provides a form for recording data.

– Dworkin provides rate norms and procedures for calculating rate and converting rates to percentiles to allow for clearer data analysis. In addition, he describes a 7-point scale representing the quality of rate variability within a passage.

– Depending on the exercise, Cs may base the baseline on a sample task from the procedures which follow, ask the P to describe pictures or narrate a story, or engage the P in conversation.

– Dworkin provides guides regarding whether or not to proceed through the exercise or to advance to another exercise based.

– Although the content changes based on the outcome, Dworkin recommends the use of certain common procedures:

  • describing/discussing terminology and the interrelationships between speaking rate and intelligibility, phonation, respiration, and resonance.
  • discussing the following objective with P: to increase rate of speech to improve intelligibility and reduce the effort needed by the listener to interpret speech.
  • modeling of targets by C
  • recording P responses and replaying the recordings for the P and C to review and discuss
  • presenting written passages which P will read aloud at the designated rate of speech

– Dworkin describes procedures collecting data during the exercise, the number of trials that should be administered, and the requirements for progressing to the next exercise or terminating treatment for the exercise.

 

RATIONALE/SUPPORT FOR INTERVENTION: Logical

Description of Intervention #4— Decreased speaking rate

 

POPULATION: motor speech disorders

 

TARGETS: rate of speech

TECHNIQUES: collection of baseline data, modeling, reviewing, discussion of objectives, recording data, use of metronome, visual/graphic cues, oral reading (reading aloud), conversation

STIMULI: auditory, visual, gesture/motor

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • There are 6 exercises for this outcome. The numbers start with #7 here because I am using Dworkin’s numbering system to assist readers in finding the exercise should they consult the source. (Note that Dworkin does not list 7a and 7b separately, I have added the letters for clarity, I hope.) Dworkin’s labels (p. 341) for the 6 exercises are

7a. Discrimination and listening training (p. 323 and 317.)

7b. Recitation of the alphabet to 100 bpm of the metronome (p. 324)

  1. Counting repeatedly 1-10 using 100 bpm from the metronome (p. 324)
  2. Producing familiar phrases, sentences, and passages to 100 bpm of the metronome (p. 324)
  3. Producing unfamiliar phrases, sentences, and passage without the aid of the metronome supplemented by pause and duration markers (p. 326)
  4. Practice decreased rate in conversation (p. 326)
  • The exercises tend to follow a common format:

– Exercises begin with the collection of baseline data. Dworkin clearly describes procedures for collecting baseline data for each of the exercises and for deciding whether a response is correct or incorrect. In addition, he provides a form for recording data.

– Dworkin provides rate norms and procedures for calculating rate and converting rates to percentiles to allow for clearer data analysis. In addition, he describes a 7-point scale representing the quality of rate variability within a passage.

– Depending on the exercise, Cs may base the baseline on a sample task from the procedures which follow, ask P to describe pictures/narrate a story, or engage the P in conversation.

– Dworkin provides guides regarding whether or not to proceed through the exercise or to advance to another exercise based.

– Although the content changes based on the outcome, Dworkin recommends the use of certain common procedures:

  • describing/discussing terminology and the interrelationships between speaking rate and intelligibility, phonation, respiration, and resonance.
  • discussing the following objective with P: to decrease rate of speech to improve articulatory precision and intelligibility and reduce the effort needed by the listener to interpret speech.
  • explaining to P that his/her optimal rate is likely to be slower than the norm.
  • modeling of targets by C
  • providing metronome as a support in achieving a target rate
  • recording P responses and replaying the recordings for the P and C to review and discuss
  • presenting written passages which P will read aloud (with or without visual gues/graphics) at the designated rate of speech
  • providing addition cues to facilitate a reduced rate of speech should other strategies fail to be effective
  1. Modifying an index card with slits so that moving the opening over a sentence allows only one or two words to be in view at a time.
  2. Tapping a finger or foot in time with the targeted production of words
  3. Using other pacing devices such as pacing board, a pegboard, or pieces of Velco attached to the P’s thumb and the index finger. P can tap the Velcroed fingers together thereby slowing the targeted rate of speech.
  • gradual increasing of linguistic complexity and/or difficulty.

– Dworkin describes procedures collecting data during the exercise, the number of trials that should be administered, and the requirements for progressing to the next exercise or terminating treatment for the exercise.

RATIONALE/SUPPORT FOR INTERVENTION: Logical

Description of Intervention #5– Appropriate use of speaking rate variations

 

POPULATION: motor speech disorders

 

TARGETS: variability of speaking rate

TECHNIQUES: collection of baseline data, modeling, reviewing, discussion of objectives, recording data, visual/graphic cues, oral reading (reading aloud), conversation

STIMULI: auditory, visual

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • There are 2 exercises for this outcome. The numbers start with #12 here because I am using Dworkin’s numbering system to assist readers in finding the exercise should they consult the source. Dworkin’s labels (p. 341) for the 2 exercises are
  1. Familiar reading material with different speech limit symbols
  2. Practice rate modulation in conversation
  • The exercises tend to follow a common format:

– Exercises begin with the collection of baseline data. Dworkin clearly describes procedures for collecting baseline data for each of the exercises and for deciding whether a response is correct or incorrect. In addition, he provides a form for recording data.

– Dworkin provides rate norms and procedures for calculating rate and converting rates to percentiles to allow for clearer data analysis. In addition, he describes a 7-point scale representing the quality of rate variability within a passage.

– Cs may base the baseline on a reading aloud task or conversational samples.

– Dworkin provides guides regarding whether or not to proceed through the exercise or to advance to another exercise based.

– Dworkin recommends discussing with the P the objective of transferring the ability to vary rate in conversation appropriately

– Dworkin recommends the use of certain common procedures:

  • describing/discussing the scoring methods with the P
  • modeling of targets by C
  • recording P responses and replaying the recordings for the P and C to review and discuss
  • presenting written passages which P will read aloud (with or without visual cues/graphics) at the designated rate of speech. The reading materials should be familiar to the P (e.g., short stories, familiar quotations, passages from familiar religious writings, if appropriate.)

– Dworkin describes procedures collecting data during the exercise, the number of trials that should be administered, and the requirements for progressing to the next exercise or terminating treatment for the exercise.

RATIONALE/SUPPORT FOR INTERVENTION: Logical

Description of Intervention #6— Improved intonation

 

POPULATION: motor speech disorders

 

TARGETS: intonation

TECHNIQUES: reviewing, discussion of objectives/prosodic patterns, recording of P responses, visual/graphic cues, oral reading (reading aloud), negative practice

STIMULI: auditory, visual/graphics

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • There are 5 exercises for this outcome. Dworkin’s labels (p. 341) for the 5 exercises are
  1. Practice statements with pitch markers (p. 329).
  2. Practice simple questions with pitch markers (p. 330).
  3. Practice complex questions with pitch markers (p. 331).
  4. Practice questions calling for repetition with pitch markers (p. 333).
  5. Practice phrases with pitch markers (p. 333).
  • The exercises tend to follow a common format:

– Dworkin uses 3 different pitch levels in this intervention: low, modal, and high.

– Dworkin notes that Ps with motor speech disorders often use inappropriate pitch levels at the end of phrases. Therefore, objectives from this intervention focus on phrase ending but changes within the phrase are not excluded from treatment.

– C explains to P that speakers

  • mark the most important word in a phrase with the highest pitch
  • mark the end of declarative sentences with a low pitch
  • mark the end of simple yes/no questions with rising glide
  • mark the end of questions that request information (other than yes/no) from the listener with rise on the most important word and then a drop for the end of the sentence. Dworkin calls them “complex sentences; ” they tend to begin with Wh words.
  • mark questions sentences that function to request the repetition of previously provided information or to request a confirmation (e.g., “When do you plan to graduate?”) with high pitch levels at the beginning and end of the sentence.

– C discusses the ramifications of failing to use the above conventions:

  • listener confusion with the intent of the speaker
  • the listener having difficulty tracking upcoming information

– C presents written sentences. Depending on the exercise, the type of sentence varies:

  1. Simple and complex declarative sentences will have visual cues regarding the pitch level. Dworkin recommends using numbers and line graphics to communicate targets. For example:

3                                ______

|           |

2   The dinner   was |   very | tasty.

|

1                                             |______

  1. Simple questions will be prepared in a manner similar to “A” but there will be a gliding rise on the last word/syllable. Dworkin notes that in some cases the rise should be even higher than level 3 in “A.”
  1. Complex questions also are prepared in a manner similar to “A” but the graphics differ. In this case, the sentence begins with a Wh word, the most important word is stressed with a pitch rise, and then the last word has pitch fall.

3                     ______

|         |

2   What was |   very | tasty?

|

1                                 |______

  1. Repetition or confirmation questions may have a rising or high pitch at the beginning and end of the sentence and a fall in the middle.

3   _____                   ______

|                   |

2   What | was very | tasty?

|                   |

1             |__________|

– The sentences that C prepares can have the same wording but different emphasized words to highlight the differing potential interpretations.

– The final exercise involves P reading aloud paragraphs that C has printed with graphics signaling pitch level of each word/syllable.

– P reads aloud targeted sentences.

– C audio records the readings and after each sentence discusses the productions with P.

– C may introduce negative practice with the complex sentences to illustrate the different reactions listeners may have to prosodic patterns for simple and complex questions.

RATIONALE/SUPPORT FOR INTERVENTION: Logical

 

CONTRAINDICATIONS FOR USE OF THE INTERVENTION: Ps who struggle with pitch and/or loudness interventions are at risk for failure in intonation intervention.

Description of Intervention #7— Improved use of stress

 

POPULATION: motor speech disorders

 

TARGETS: stress-sentence, stress-emphatic, stress- lexical

TECHNIQUES: collection of baseline data, modeling, reviewing, discussion of objectives, recording data, visual/graphic cues, oral reading (reading aloud), conversation, contrastive stress drills, negative practice, discrimination

STIMULI: auditory, visual/graphic

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • There are 6 exercises for this outcome. Dworkin’s labels (p. 341) for the 6 exercises are
  1. Practice phrases with stress and phrase markers (p. 335)
  2. Practice general sentences with primary and secondary stress and pause markers (p. 336)
  3. Practice sentence embellishment with same markers (p. 337)
  4. Practice stress control in conversation (p. 337)
  5. Supplements for vocal expressiveness and meaning alterations (p. 338)
  6. Contrastive stress drills (p. 339)
  • The exercises tend to follow a common format:

– Most of the exercises begin with the collection of baseline data; the exceptions are exercises 5 and 6. Dworkin clearly describes procedures for collecting baseline data from spontaneous conversation and/or read sentences using a 7-point scale or correct/incorrect judgments. Also, he provides a form for recording data.

– Dworkin provides guides regarding whether or not to proceed through the exercise or to advance to another exercise based.

– Although the content changes based on the outcome, Dworkin recommends the use of certain common procedures:

  • describing/discussing terminology as well as the objectives
  • modeling of correct and, at times, incorrect targets by C
  • P’s discriminating of correct and incorrect models by C
  • C introducing og contrastive stress drills in which P answers a series of questions from C using the same sentence. Each question requires that P stress a different word in order to be considered “appropriate.”
  • cueing appropriate/targeted lexical stress (e.g., ‘pep per versus pep ‘per) and phrasal/sentence stress (Sue and ‘John versus ‘Sue and John) by providing P with index cards with sentences/phrases marked for some of all of the following depending on the exercise: primary stress, secondary stress, pauses
  • depending on the exercise, C gradually increase increasing of complexity of the content (e.g., for exercise #1, the content involves single words and for exercise #4 the content involves conversation.)
  • P reading of individual aloud sentences
  • P reading aloud minimal pair sentences in which the sentences differ in stress level, stress location, and pausing.
  • negative practice by P
  • recording P responses and replaying the recordings for P and C to review and discuss P’s responses
  • if P produces an incorrect response, he/she should attempt it again. Only a total of 3 attempts is recommended.
  • during the contrastive stress drills, some Ps may benefit from tapping each word or syllable with a finger, hand, or foot. The most important word should receive emphasis prosodically and with tapping.

– Dworkin describes procedures collecting data during the exercise, the number of trials that should be administered, and the requirements for progressing to the next exercise or terminating treatment for the exercise.

RATIONALE/SUPPORT FOR INTERVENTION: Logical

CONTRAINDICATIONS FOR USE OF THE INTERVENTION: Success with previous interventions should be the basis of this intervention. Poor outcomes in the previous interventions are predictive of poor outcomes for stress intervention.

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