EBP THERAPY ANALYSIS for
Single Subject Designs
Note: The summary of the intervention procedure(s) can be viewed by scrolling about two-thirds of the way down on this page.
C = Clinician
CI = cochlear implant
EBP = evidence-based practice
GLMM = Generalized Linear Mixed Model
HI = hearing impairment
NA = not applicable
MT = music therapy
P = Patient or Participant
PC = play condition
pmh = Patricia Hargrove, blog developer
SLP = speech–language pathologist
WNL = within normal limits
SOURCE: Kerem, D. (2009). The effect of music therapy on spontaneous communicative interactions of young children with cochlear implants (Unpublished doctoral dissertation). Aalborg University, Denmark.
DATE: July 31, 2015
ASSIGNED OVERALL GRADE: B+
TAKE AWAY: Young Hebrew speaking children with cochlear implants (CI) produced significantly more early communicative behaviors (turn taking, imitation, initiation, synchronization) in music therapy as opposed to play sessions.
- What type of research? Clinical Research
- What type of evidence was identified?
– What type of single subject design was used? Single Subject Experimental Design with Specific Clients – ABAB –crossover design: multiple cases
– What was the level of support associated with the type of evidence?
Level = __A-____
- Was phase of treatment concealed?
– from participants? No
– from clinicians? No
– from data analyzers? No but some of the reliability judgments were made by observers who were not privy to the intent of the investigation.
- Were the participants clearly described? Yes
– How many participants were involved in the study?
– CONTROLLED characteristics/variables
- age: between 2 and 3 years
- disabilities: other than hearing impairment (HI) no know disabilities
- speech awareness threshold: no poorer than 40 dB while using the cochlear implant (CI)
- parents’ hearing: within normal limits (WNL)
- parents’ facility with Hebrew: Working knowledge
- parents’ cognitive skills: WNL
- parents’ psychological skills: none
– DESCRIBED characteristics/variables
- age at onset of investigation: 24- 36 months
- age at implantation: 16- 31 months
- implant manufacturer: Cochlear (4); Advanced Bionics (1)
- implant: Nucleus 24 (3); Freedom Contour (1); HiRes 90k (1)
- speech processor: Sprint (2); Freedom (2); Platinum (1)
- gender: 1m; 4f
- educational placement: Kindergarten for children with HI (3); Kindergarten for children with normal hearing (2); all participants (Ps) attended 6 days a week
- current speech therapy: 2 sessions a week individual therapy (2); 3 sessions a week individual therapy (1); combined individual, 7 times a week, and group, 3 times a week (2); one half hour session per week with a speech-language pathologist (2)
- age at diagnosis of HI: At birth (2); 6 months (1); 7 months (1); during first year (1)
- etiology of HI: Genetic (2); Unknown (2); Congenital Cytomegalovirus (1)
- occupation of parent: stay at home mother (2); Yeshiva teacher (1); Kindergarten teacher assistant (1); Yeshiva student (2); Logistics manager (1); not provided (2)
- educational level of parents: 11 years (1); 12 years (2); 14 years (1); not provided (6)
- age of parent at beginning of research: 40 years (1); 28 years (1); 25 years (1); 28 years (1); not provided (6)
– Were the communication problems adequately described? No. Since the intervention targeted spontaneous communication interactions it can be assumed that the Ps were low verbal or even nonverbal.
- Was membership in treatment maintained throughout the study? No. One of the five participants withdrew the intervention after 11 weeks. Her data were included in the results.
– If there was more than one participant, did at least 80% of the participants remain in the study? Yes
– Were any data removed from the study? No
- Did the design include appropriate controls? Yes
– Were baseline/preintervention data collected on all behaviors? No
– Did probes/intervention data include untrained data? No
– Did probes/intervention data include trained data? No
– Was the data collection continuous? No
– Were different treatment counterbalanced or randomized? Yes, it was randomized
- Were the outcomes measure appropriate and meaningful? Yes
– The outcomes related to communication were
OUTCOME #1: Frequency of imitation
OUTCOME #2: Frequency of initiation
OUTCOME #3: Frequency of spontaneous synchronization
OUTCOME #4: Frequency of spontaneous turn taking
OUTCOME #5: Duration of spontaneous synchronization
OUTCOME #6: Duration of spontaneous turn taking
OUTCOME #7: Number of events of spontaneous turn-taking
– All the outcomes were subjective.
– None of the outcomes were objective.
– All the outcome measures are associated with reliability data:
OUTCOME #1: Frequency of imitation: 0.99
OUTCOME #2: Frequency of initiation: 0.94
OUTCOME #3: Frequency of spontaneous synchronization: 0.93
OUTCOME #4: Frequency of spontaneous turn taking: 0.96
OUTCOME #5: Duration of spontaneous synchronization: 0.76
OUTCOME #6: Duration of spontaneous turn taking: 0.91
OUTCOME #7: Number of events of spontaneous turn-taking: 0.91
– Did the target behavior improve when it was treated? Yes
– The quality of improvement for each of the outcomes was
OUTCOME #1: Frequency of imitation: Strong
OUTCOME #2: Frequency of initiation: Strong
OUTCOME #3: Frequency of spontaneous synchronization: Strong
OUTCOME #4: Frequency of spontaneous turn taking: Moderate
OUTCOME #5: Duration of spontaneous synchronization: Strong
OUTCOME #6: Duration of spontaneous turn taking: Strong
OUTCOME #7: Number of events of spontaneous turn-taking: Strong
– INFERENTIAL STATISTICAL ANALYSIS
- What statistical analyses were used? ANOVA; Generalized Linear Mixed Model (GLMM)
- The results of inferential statistical analysis with significance of p ≤ 0.05:
OUTCOME #1: Frequency of imitation: Significantly more in Music therapy (MT) than in play condition (PC.)
OUTCOME #2: Frequency of initiation: Significantly more in MT than PC.
OUTCOME #3: Frequency of spontaneous synchronization: Significantly more in MT than in PC.
OUTCOME #4: Frequency of spontaneous turn taking: Significantly more in MT than in PC as well as significantly more in the undirected portions of MT and PC
OUTCOME #5: Duration of spontaneous synchronization: Significantly longer in MT than in PC and in undirected part of the sessions compared to the directed part of the sessions.
OUTCOME #6: Duration of spontaneous turn-taking: Significantly more in MT than in PC as well as significantly more in the undirected portions of MT and PC
OUTCOME #7: Number of events of spontaneous turn-taking: Significantly more in MT than in PC and significantly more in undirected compared to directed part of the intervention.
- What analysis strategy was used? Boxplot/box-whisker diagram
- The results of descriptive analysis reveal
OUTCOME #1: Frequency of imitation: much greater incidence in MT
OUTCOME #2: Frequency of initiation: much greater incidence in MT
OUTCOME #3: Frequency of spontaneous synchronization: markedly greater incidence in MT
OUTCOME #4: Frequency of spontaneous turn taking: noticeably more in MT than in PC and much greater incidence in undirected portions of interventions
OUTCOME #5: Duration of spontaneous synchronization: markedly longer MT than in PC and in undirected portions as opposed to directed portions of interventions
OUTCOME #6: Duration of spontaneous turn-taking: much greater in MT than in PC as well as in undirected portions of both interventions.
OUTCOME #7: Number of events of spontaneous turn-taking: much greater incidence in MT
- Description of baseline:
– Were baseline data provided? No
– What was the percentage of nonoverlapping data (PND)? Individual data points were not provided
- What was the magnitude of the treatment effect? NA
- Was information about treatment fidelity adequate? Yes. Overall adherence to targeted protocol guidelines was 0.89 (Cohen’s Kappa) which is considered outstanding (p. 143.)
- Were maintenance data reported?
- Were generalization data reported? No
- Brief description of the design:
- The investigators use a mixed qualitative and quantitative design.
- The overall study design was a within-subject (repeated measure) design in which 5 Ps were treated with a single case design (ABAB.) Each A represented a set of 4 PC sessions and each B represented a set of 4 MT sessions.
- Ps were randomly assigned to different orders of the A (PC) and B (MT) sessions. Two Ps were assigned to the ABAB order and 3 Ps were assigned to the BABA order.
- Although the data for 5 Ps were analyzed, one of the Ps dropped out of the investigation after 11 sessions.
- There were 2 treatment conditions: PC and MT. Each of the conditions was divided into 2 parts: directed and undirected procedures.
- Thus, this was a 2×2 (treatment conditions x procedure type) with repeated measures.
- The results were analyzed using parametric statistics (ANOVA; Generalized Linear Mixed Model (GLMM) and quantitative analysis (Boxplot/box-whisker diagram).
OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: B+
SUMMARY OF INTERVENTION
PURPOSE: To investigate the effectiveness of music therapy on early communication skills of 2 to 3 year olds with cochlear implants.
POPULATION: Cochlear implants; Children
MODALITY TARGETED: production
ELEMENTS OF PROSODY USED AS INTERVENTION music therapy (rhythm, tempo/timing, duration, accent/stress, dynamics/loudness, intonation, pause)
OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: turn-taking, imitation, initiation, communicative synchronization
OTHER TARGETS: The following behaviors were analyzed in the investigation but they are not reported in this review: responsiveness to music, parental responses to a questionnaire, parental satisfaction, parental responses to interviews
DOSAGE: 20 minute sessions; one time week; each set lasted 4 weeks for a total of 16 weeks. Each session was divided into two 10-minute parts: directed/Music Therapist led and undirected/unstructured or child led.
ADMINISTRATOR: Music Therapist
- There were 2 treatment conditions: PC and MT.
- Each session was divided into 2 parts: undirected and directed. For the most part, the order of the 2 parts of a session was randomized (i. e., the first session of each set started with a directed part.)
- The similar items were used in the 2 treatment conditions.
- For the most part, mothers were in attendance during intervention sessions.
- Appendix A of the dissertation contains specific treatment guidelines. The information listed below is a brief summary of each of the interventions and their (2) parts.
PLAY CONDITION (PC)
- Sessions began with a ritual verbal beginning and ended with a ritual verbal ending.
- The Clinician (C, was also a Music Therapist in this and the other sessions) guided P through a number of play activities.
- C facilitated P’s achieving mastery of targeted play activities.
- C facilitated the play behaviors by engaging P using surprise and enjoyable activities.
- The targeted play activities included
– Inset puzzles
– Doll play
– Preparation of a meal
– Duplo block play
- C followed P’s led in play activities.
- C supported P’s play activities by being responsive, turn-taking, imitating, and matching C’s behaviors and vocalizations.
- The activities could include those listed in the Directed PC if initiated by P.
MUSIC THERAPY (MT)
- Sessions began with a ritual sung beginning and ended with a ritual sung ending.
- C lead musical experiences for P by targeting specific activities/tasks and facilitating P’s achievement of the tasks.
- The target musical activities/tasks included
– Vocal rhythm games
– Percussion instrument playing
– Recorded music listening
- C followed P’s lead in exploring musical instruments and vocalization.
- C facilitated P’s exploration using turn-taking, imitation, and matching.
- The activities/tasks could include those in Direct MT