Goldfarb (2015)

December 27, 2015

CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

(also known as Expert Opinion)

 

 

KEY
C = clinician

NA = not applicable

MIT = Melodic Intonation Therapy.

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

 

 

Source: Goldfarb, R. (2015). Modifying Melodic Intonation Therapy. Journal of Communication Disorders, Deafness & Hearing Aids, 3 (2). ARTICLE: http://dx.doi.org/10.4172/2375-4427.1000132   REVIEW:

 

Reviewer(s): pmh

 

Date: December 24, 2015

 

Overall Assigned Grade: F (because there are no supporting data, the highest grade is 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: This article was designed to be comment; there was no attempt to provide original data. The author thoughtfully described problems he noted in a previously published case study involving the administration of Melodic Intonation Therapy (MIT) by a spouse and provided potential solutions for the problems. The changes could result in increasing effectiveness of MIT by easing protocol delivery strategies of volunteers (e.g., family members) and SLP assistants as well as by facilitating generalization.

 

 

  1. Was there a review of the literature supporting components of the intervention? No

 

 

  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? Yes

 

 

  1. Description of outcome measures:

 

  • Are outcome measures suggested? No

 

 

  1. Was generalization addressed? Yes. The author noted that the context of MIT is artificial. He recommended that procedures be included that facilitate the transfer of skills from the artificial context to more natural contexts.

 

 

  1. Was maintenance addressed? No

 

 

SUMMARY OF INTERVENTION

 

 

PURPOSE: To describe MIT and some of its modifications and to explain some of the music theory that serves as a basis for MIT.

 

POPULATION: Aphasia (Broca’s, nonfluent); Adult

 

MODALITY TARGETED: Production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED (do not list the specific

 

ELEMENTS OF PROSODY USED AS INTERVENTION: music (intonation/melody, rhythm)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: expressive language

 

DOSAGE: for original MIT 75-90 hours of intervention were recommended; Goldfarb’s earlier case study appeared to involve the recommended number of hours, 2 times a week for 1 hour sessions at the university with spouse as administrator and up to 5 one-hour sessions per week at home administered by the spouse. The spouse was observed 1 time per week at home and all home sessions were recorded to insure treatment fidelity.

 

ADMINISTRATOR: for original MIT—SLP; for Goldfarb’s earlier case study administrator was the spouse

 

MAJOR COMPONENTS:

 

  • This audience for this article is clinicians (Cs) with a working knowledge of MIT.

 

  • The author described problems he noted in a previously published case study and provided potential solutions for the problems. The solutions involved (1) changing selected melodic patterns, (2) changing selected intoned questions directed to P, and (3) adding generalization procedures.

 

CHANGING OF SELECTED MELODIC PATTERNS

 

– For Level I, Step 4 the melodic pattern was changed because the prescribed pattern elicited a stereotyped response from the P. Instead the administrator replicated the stress patterns that would be observed in conversational speech.

 

 

CHANGING SELECTED INTONED QUESTIONS

 

– For I, Step 5 the elicitation questions were changed to conversational speech because when the administrator intoned the questions, the P responded by imitating the intoned questions rather than answering them.

 

 

ADDING GENERALIZATION PROCEDURES

 

– The original MIT procedures do not focus on transferring skills from structured contexts to more natural, conversational contexts. The authors recommended that procedures be added that focus on responding to verbal stimuli and internal stimuli that are observed in home contexts.

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Persicke et al. (2013)

December 19, 2015

EBP THERAPY ANALYSIS for

Single Subject Designs

 

NOTES:

The summary of the intervention procedure(s) can be viewed by scrolling about two-thirds of the way down on this page.

 

Key:

ASD = Autism Spectrum Disorder

C = Clinician

EBP = evidence-based practice

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

SOURCE: Persicke, A., Tarbox, J., Ranick, J., St. Clair, M. (2013). Teaching children with autism to detect and respond to sarcasm. Research in Autism Spectrum Disorders, 7, 193-198.

 

REVIEWER(S): pmh

 

DATE: December 12, 2015

 

ASSIGNED OVERALL GRADE: B (Based on the design, the highest possible grade was A-. )

 

TAKE AWAY: This single subject experimental design investigation provides good support of an intervention teaching children with Autism Spectrum Disorders (ASD) to comprehend sarcasm.

                                                                                                                       

 

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

 

 

  1. What type of evidence was identified?
  • What type of single subject design was used? Single Subject Experimental Design with Specific Client Multiple ABA designs

                                                                                                           

  • What was the level of support associated with the type of evidence Level = A-

                                                                                                           

 

  1. Was phase of treatment concealed? (answer Yes, No, or Unclear to each of the questions)
  • from participants? No
  • from clinicians? No
  • from data analyzers? Unclear

 

 

  1. Were the participants (Ps) adequately described? No

 

  • How many Ps were involved in the study? 3

 

— The CONTROLLED characteristics included

  • diagnosis: Autism

 

— The DESCRIBED characteristics included

  • age: 6 and 7 years old
  • gender: based on names they were males
  • parental involvement: improved understanding of sarcasm was a priority with parents and supervisors
  • current therapy: 2 to 10 hours a week of behavioral therapy; sarcasm was not targeted outside the investigation’s interventions
  • previous therapy: had been receiving behavioral in-home for 3 to 4 years; no direct work on sarcasm but all participants (Ps) had received training on the following skills (p. 195)

     – prosody

     – body language

     – facial expression

     – physical context of conversation

     – conversational audience

     – desires

     – emotions

     – sensory perspective taking

     – cause and effect

     – preferences

     – knowing

     – beliefs

     – intentions                                

                                                 

  • Were the communication problems adequately described? No
  • The disorder type was Communication Disorder associated with Autism Spectrum Disorder (ASD)

 

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Yes

 

  • 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

 

 

  1. Did the design include appropriate controls? Yes

 

  • Were baseline/preintervention data collected on all behaviors? Yes

 

  • Did probes/intervention data include untrained stimuli? Yes

 

  • Did probes/intervention data include trained stimuli? No

 

  • Was the data collection continuous? Yes

 

  • Were different treatment counterbalanced or randomized? NA

 

 

  1. Were the outcome measures appropriate and meaningful? Yes

 

– The outcome/dependent variable was

 

OUTCOME: Increased accuracy in responding to sarcastic comments in conversation

 

– The outcome was subjective.

                                                       

– The outcome was NOT objective                                                         

 

  • The reliability data for the outcome (Increased accuracy in responding to sarcastic comments in conversation) was

     – averaged across 36% of the sessions;

     – interobserver reliability was 99.4%;

     – the lowest interobserver reliability for a session was 97%.

 

 

  1. Results:

 

Did the target behavior(s) improve when treated? Yes

 

– The overall quality of improvement for the outcome (Increased accuracy in responding to sarcastic comments in conversation) strong.

 

 

  1. Description of baseline:

 

Were baseline data provided? Yes

  • OUTCOME: Increased accuracy in responding to sarcastic comments in conversation

Reggie had 3 baseline sessions

     – Hans had 4 baseline sessions

     – Kevin had 5 baseline sessions

 

Was baseline low and stable? Baseline was low and stable for all 2 Ps. One of the Ps display minimal variability.

 

Was the percentage of nonoverlapping data (PND) provided? No. However, this reviewer calculated PND

 

– What was the PND and what level of effectiveness does it suggest?

 

  • OUTCOME: Increased accuracy in responding to sarcastic comments in conversation

Reggie – PND = 100% — highly effective

     – Hans – PND = 90% — highly effective

     – Kevin – PND = 100%– highly effective

 

 

  1. What is the clinical significanceNA. Not provided.

 

  1. Was information about treatment fidelity adequate? No. The investigators reported that treatment fidelity was monitored but no data were provided.

 

 

  1. Were maintenance data reported? Yes
  • For 2 of the Ps, follow-up assessments were administered 1, 2, and 3 months after the post therapy phase. Both Ps maintained accurate performances.

 

 

  1. Were generalization data reported? Yes
  • All Ps were assessed using untrained stimuli, in untrained contexts, and with interacters who were not present during intervention. In each case, the Ps produced correct responses at a rate similar to trained cases.

 

 

  1. Brief description of the design:
  • Three boys diagnosed with ASD were subjects in a single subject experimental design investigation.
  • The investigation involved a staggered ABA design in which the Ps were administered 3, 4, or 5 sessions of preintervention (baseline) assessment.
  • The intervention consisted of 11 or 12 session administered by C.
  • The postintervention phase involved 7 post therapy sessions for all the Ps and an additional 3 session of follow-up assessment for 2 of the Ps. The postintervention phase involved procedures similar to the preintervention phase as well as generalization tasks.
  • The assessment for the pre and post intervention phases involved observing Ps’ reactions to sarcastic comments made by the clinician (C) during conversation.

 

 

ASSIGNED OVERALL GRADE OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: B

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of a program designed to increase the comprehension of sarcastic remarks in conversation

 

POPULATION: Autism Spectrum Disorders

 

MODALITY TARGETED: comprehension

 

ELEMENTS OF PROSODY USED AS INTERVENTION: overall intonation (specific elements of intonation were not identified)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: sarcasm

 

DOSAGE: 30 min per session, 2 to 3 times a week for a total of 11-12 sessions.

 

ADMINISTRATOR: “therapist” or parent (during Phase II)

 

MAJOR COMPONENTS:

 

  • Intervention progressed from contrived activities to conversation. It included generalization to untrained stimuli and contexts.

 

  • Treatment, for the most part, occurred in the home, although generalization activities could occur in the community

 

  • Treatment sessions lasted about 30 minutes. Pre-and Post – intervention sessions lasted about an hour.

 

PHASE 1—Rules and Videos

 

  • The clinician (C) provided

– rules

– models

– examples

– leading questions

– feedback (praise for correct responses; leading questions for incorrect responses)

– exaggerated cues (intense intonation and facial cues)

– brief videos of sarcastic remarks in context

 

  • C asked questions after the viewing of the videos focusing on cues P might use to determine if the comment was sarcastic and to provide P with a repertoire of questions to ask himself when determining if a comment was sarcastic or sincere.

 

  • C gradually faded the exaggerated intonation and facial cues.

 

  • Criterion = 80% for 3 sessions (2 Ps achieved criterion in 3 session; 1 P achieved criterion in 1 session.)

 

  • The investigators noted that it was not clear that this phase was essential due to the high rate of achieving criterion.

 

PHASE II – In Vivo Training

 

  • Each session involved 10 – 12 trials

 

  • At the beginning of each session, C stated the rule and directed P to restate it.

 

  • C produced sarcastic comments during conversation.

 

  • If P responded appropriately to the sarcasm, C praised him. If he was incorrect, C asked leading questions as in Phase I.

 

  • P’s intonation and facial expression were exaggerated in the first session, faded in the second session, and eliminated in the third session.

 

  • In each session, one -half the sarcastic stimuli were novel sentences and one-half had been used previously.

 

  • Intervention was administered in the home, in a park (for generalization), or in a coffeehouse (for generalization).

 

  • Administrators during this phase were therapists and parents/nannies. Parents and nannies were reported to be trained by the therapists.

 

  • Criterion = 80% for 3 sessions (2 Ps achieved criterion in 3 session; 1 P achieved criterion in 1 session.)

 


Lee & Son (2005)

December 7, 2015

EBP THERAPY ANALYSIS

Treatment Groups

 

 

Note: Scroll about two-thirds of the way down the page to read the summary of the procedure(s).

 

Key:

C = Clinician

EBP = evidence-based practice

GRBAS Scale = Grade, Rough, Breathiness, Asthenic, Strained Scale

MTD = muscle tension dysphonia

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SFo = speaking fundamental frequency

SLP = speech–language pathologist

 

 

SOURCE: Lee, E-K, & Son, Y-I. (2005). Muscle tension dysphonia in children: Voice characteristics and outcome of voice therapy. International Journal of Pediatric Otorhinolaryngology, 69, 911-917. doi: 10.1016/j.ijporl.2005.01.030

 

REVIEWER(S): pmh

 

DATE: December 5, 2015

 

ASSIGNED GRADE FOR OVERALL QUALITY: C- (The highest possible grade based on the design is C.)

 

TAKE AWAY: Korean speaking children with muscle tension dysphonia (MTD) received therapy targeting awareness, relaxation, breathing, phonation, and homework. The results of this retrospective, descriptive, single group investigation revealed that children with a diagnosis of MTD are amenable to intervention and that marked progress was noted in voice quality and pitch as well as in reducing hypercontraction.

 

 

  1. What type of evidence was identified?

                                                                                                           

– What was the type of evidence? Retrospective, Single Group with Pre- and Post-Testing

                                                                                                           

– What was the level of support associated with the type of evidence? Level = C

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there was more than one group, were participants (Ps) randomly assigned to groups? Not Applicable (NA), there was only one group.
  • If there were groups and Ps were not randomly assigned to groups, were members of groups carefully matched? NA

                                                                    

 

  1. Was administration of intervention status concealed?
  • from participants? No
  • from clinicians? No
  • from analyzers? No

                                                                    

 

  1. Was the group adequately described? Yes

 

– How many Ps were involved in the study?

 

  • total # of Ps: 8; records were examined for 8 consecutive male children with MTD
  • # of groups: 1

 

– The P characteristics that were controlled (i.e., inclusion/exclusion criteria) included

  • age: children
  • gender: all male

 

– The P characteristics were described included

  • age: 4.2 to 12.2 years, mean = 7.5 years
  • Onset: 4 months previous to several years (see Table 1)
  • Previous intervention: no previous voice therapy; no previous medication for the voice symptoms
  • Associated medical findings: vocal nodules (7 participants, P); post upper respiratory infection (2Ps)
  • Comorbid communication problems: articulation disorder (1P); dysfluency (1P)

 

– Were the groups similar before intervention began? NA

                                                         

– Were the communication problems adequately described? Yes

  • disorder type: voice problem, MTD
  • functional level: A speech-language pathologist (SLP) perceptually rated Ps using the Grade, Rough, Breathiness, Asthenic, Strained (GRBAS) Scale. The following voice problems were noted:

– severe hoarseness – all Ps

– strained voice – all Ps

– breathiness – all Ps to varying degrees

– pitch problems – 6 Ps (e.g., diplophonia, high/low pitch, pitch breaks)

– phonation breaks – 2 Ps

– aphonia – 2 Ps

  • other

– vocal nodules—7Ps

– false vocal fold approximation

– decreased vibration of true vocal folds

– incomplete glottal closure

 

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

  • Did the group maintain at least 80% of their original members? Yes

                                                               

  • Were data from outliers removed from the study? No, but some data were lost due to technical or procedural issues.

 

 

  1. Were the groups controlled acceptably? NA

                                                                                                             

 

  1. Were the outcomes measure appropriate and meaningful? Yes

                                                                                                             

– The outcomes (dependent variables) were

 

PERCEPTUAL OUTCOMES

  • OUTCOME #1: Improved performance on the Grade portion of the GRBAS scale
  • OUTCOME #2: Improved performance on the Rough portion of the GRBAS scale
  • OUTCOME #3: Improved performance on the Breathiness portion of the GRBAS scale
  • OUTCOME #4: Improved performance on the Asthenic portion of the GRBAS scale
  • OUTCOME #5: Improved performance on the Strained portion of the GRBAS scale

 

ACOUSTIC OUTCOMES

  • OUTCOME #6: Improved speaking fundamental frequency (SFo)
  • OUTCOME #7: Reduced rate of jitter
  • OUTCOME #8: Reduced rate of shimmer
  • OUTCOME #9: Reduced noise to harmonic ratio (NHR)

 

STROBOSCOPIC OUTCOME

  • OUTCOME #10: Improved vocal fold function/status

 

– The subjective outcome measures were

 

PERCEPTUAL OUTCOMES

  • OUTCOME #1: Improved performance on the Grade portion of the GRBAS scale
  • OUTCOME #2: Improved performance on the Rough portion of the GRBAS scale
  • OUTCOME #3: Improved performance on the Breathiness portion of the GRBAS scale
  • OUTCOME #4: Improved performance on the Asthenic portion of the GRBAS scale
  • OUTCOME #5: Improved performance on the Strained portion of the GRBAS scale

 

STROBOSCOPIC OUTCOME

  • OUTCOME #10: Improved vocal fold function/status

 

The objective outcome measures were

 

ACOUSTIC OUTCOMES

  • OUTCOME #6: Improved speaking fundamental frequency (SFo)
  • OUTCOME #7: Reduced rate of jitter
  • OUTCOME #8: Reduced rate of shimmer
  • OUTCOME #9: Reduced noise to harmonic ratio (NHR)

                                         

 

  1. Were reliability measures provided?
  • Interobserver for analyzers? No
  • Intraobserver for analyzers? No
  • Treatment fidelity for clinicians? No

 

 

  1. What were the descriptive results (i.e., there was no statistical analysis)?

 

– Summary Of Important Results

 

 

PRE AND POST TREATMENT ONLY ANALYSES

 

PERCEPTUAL OUTCOMES—Descriptive Results Only

  • OUTCOME #1: Improved performance on the Grade portion of the GRBAS scale – Marked improvement noted
  • OUTCOME #2: Improved performance on the Rough portion of the GRBAS scale—Improvement noted
  • OUTCOME #3: Improved performance on the Breathiness portion of the GRBAS scale—Improvement noted
  • OUTCOME #4: Improved performance on the Asthenic portion of the GRBAS scale—Improvement noted
  • OUTCOME #5: Improved performance on the Strained portion of the GRBAS scale– Marked improvement noted

 

ACOUSTIC OUTCOMES—Descriptive Results Only

  • OUTCOME #6: Improved speaking fundamental frequency (SFo) — Low or high pitch returned to normal range; P using 2 pitches converted to a single stable pitch.
  • OUTCOME #7: Reduced rate of jitter—6Ps of the 7Ps with complete data reduced rate of jitter; investigators described jitter as being stabilized
  • OUTCOME #8: Reduced rate of shimmer–5Ps of the 7Ps with complete data reduced rate of shimmer; investigators described shimmer as being stabilized
  • OUTCOME #9: Reduced noise to harmonic ratio (NHR)– 6P of the 7Ps with complete data reduced rate of shimmer; investigators described NHR as being stabilized

 

STROBOSCOPIC OUTCOME—Descriptive Results Only

  • OUTCOME #10: Improved vocal fold function/status —4P of the 4Ps with complete data presented with improved vocal fold function/status; investigators described reduced anterioposterior contraction and reduction in nodule siz2

 

– What was the statistical test used to determine significance? NA, there were no statistical analyses

 

– Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significanceNA, no measures of clinical significance were reported.

 

 

  1. Were maintenance data reported? Yes
  • The investigators contacted the parents of 5 the Ps 2 ½ years after the completion of the intervention via the phone.
  • The parents reported that

– voice quality continued to be unstrained (5Ps)

– no abnormally high or low SFo (5Ps)

– no pitch or phonation breaks (5Ps)

– breathy voice quality continued to be reduced (4Ps)

– multiple voice abuse episodes (1P)

 

 

  1. Were generalization data reported? Yes. The investigators focused part of treatment on carrying over what was learned in therapy to outside the clinic. Therefore, the maintenance data (item #11) could also be considered generalization data.

 

 

  1. Describe briefly the experimental design of the investigation.
  • Investigators reviewed files until they identified 8 consecutive Korean speaking children who had been diagnosed with MTD, received intervention, and had been assessed pre and post intervention with a battery of perceptual, acoustic, and stroboscopic measures.
  • The intervention targeted awareness, relaxation, breathing, and phonation as well as assigned homework.
  • The investigators interviewed by phone the parents of 5Ps 2 ½ years after the end of intervention to assess maintenance.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C-

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of an intervention for MTD in children.

 

POPULATION: Muscle tension dystonia (MTD), Voice problems; Children

 

MODALITY TARGETED: expressive

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: pitch

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: voice quality (hoarseness, roughness, aphonia, diplophonia, etc.)

 

DOSAGE: 1 or 2 times a week, 30 minute sessions, for 1 to 2 ½ months

 

ADMINISTRATOR: SLP with homework by family

 

MAJOR COMPONENTS:

 

  • Intervention involved targeting awareness, relaxation, breathing, phonation, and encouraging family involvement at home (homework)

 

  • AWARENESS:

– The clinician (C) worked with the P and his family to develop an awareness of his voice problem(s) by reviewing recordings of the P’s speech.

– C worked with P so that he was able to identify voice problems on recordings.

– C described vocal abuse and good vocal hygiene.

 

  • RELAXATION:

– C described excessive muscle tension and provided visual and kinesthetic feedback to the P.

– C provided manual circumlaryngeal massage to the P.

 

  • BREATHING:

– C provided respiration training.

 

  • PHONATION:

– C directed P to hum and then feel the vibrations in his nose and neck.

– C instructed P to practice vocalizing vowels preceded by /h/ by

  • sighing,
  • producing the vowel, and
  • noting the easy-onset of the /h/ as opposed to his habitual harsh onset.

– C gradually increased the length and complexity of utterances.

– C encouraged P to self-monitor.

– C engaged P in role playing.

 

  • HOMEWORK:

– C encouraged family members to attend sessions.

– C asked family members to monitor P’s behavior and to complete homework assignments.

– The homework assignments included practicing skills used in therapy to communication outside the clinic.