Thaut (1985)

June 25, 2016

EBP THERAPY ANALYSIS

Groups 

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

Key:

Auditory Rhythm = a four beat percussion pattern used a cue in a gross motor sequence

C = Clinician

CMPT = Component Mean Performance Time

Ct = Control group

EBP = evidence-based practice

MT = music therapist

MRA = motor rhythm accuracy

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove (blog developer)

SLP = speech–language pathologist

Speech Rhythm = 4 single syllable directions used as a cue in a gross motor sequence

Tx = Treatment group

Tx faded = the Treatment group performance when the auditory rhythm cues were faded

 

SOURCE: Thaut, M. H. (1985). The use of auditory rhythm and rhythmic speech to aid temporal muscular control in children with gross motor dysfunction. Journal of Music Therapy, 22 (3), 108-128.

 

REVIEWER(S): pmh

 

DATE:   June 23, 2016

 

ASSIGNED GRADE FOR OVERALL QUALITY: Not graded because it was clinically related rather than clinical research.

 

TAKE AWAY: This investigation focuses on clinically relevant issues rather than solely on clinical effectiveness. Nevertheless, the investigator found that a short intervention (3 session) of Auditory Rhythm plus Speech Rhythm cues was more successful than Visual Modeling in improving performance of a gross motor sequence.

 

 

  1. What type of evidence was identified?

                                                                                                           

  • What was the type of evidence? Prospective, Randomized Group Design with Controls

                                                                                                           

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

 

  • What was the focus of the research? Clinically Related

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

  • If there was more than one group, were participants (Ps) randomly assigned to groups?

 

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No

                                                                    

  • from clinicians? No

                                                                    

  • from analyzers? Unclear

                                                                    

 

  1. Were the groups adequately described? Variable

 

– How many Ps were involved in the study?

 

  • total # of Ps: 24
  • # of groups: 2
  • List names of groups and the # of participants in each group:

– Treatment (Tx) = 12 Ps

– Control (Ct) = 12 Ps  

 

– The controlled characteristics included.

 

  • age: 3 age brackets with 4 Ps from each of the age brackets in Tx and C groups– 6:0 to 6:11; 7:0 to 7:11; 8:0 to 8:11
  • gender: all Ps were male
  • cognitive skills: no cognitive problems
  • referral source: outside referral source to motor treatment programs at Michigan State; sources were physicians, teachers, therapists
  • motor skills: overall 40th percentile rank on the Bruininks-Oserestsky Test of Motor Proficiency
  • emotional status: no reported problems
  • orthopedic status: no reported problems

 

–   Were the groups similar before intervention began? Yes

 

– Were the communication problems adequately described? Not Applicable (NA

 

 

  1. What were the different conditions for this research?

                                                                                                             

  • Subject (Classification) Groups? No

                                                               

  • Experimental Conditions? Yes

Treatment status: Treatment (Tx) and Control (Ct)

 

  • Criterion/Descriptive Conditions? Yes

– Age: within the Tx and Ct groups there were 3 age groups: 6-year-olds; 7 year-olds, and 8 year-olds

 

 

  1. Were the groups controlled acceptably? Yes

 

 

  1. Were dependent measures appropriate and meaningful? Yes

                                                                                                             

– The dependent/outcome measures were

 

  • OUTCOME #1: Component Mean Performance Time (CMPT) for the execution of 4 repetitions of the following motor sequence

     – preferred foot to the side

     – support foot follows

     – with stationary feet swing arms up

     – with stationary feet swing arms down

  • OUTCOME #2: Average time deviation from CMPT (also called motor rhythm accuracy, MRA)

 

 

Neither of the dependent measures were subjective.

 

Both of the dependent/ outcome measures were objective.

 

 

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? No

 

– Intraobserver for analyzers? No

 

 

– Treatment or test administration fidelity for investigators? No

 

 

  1. Description of design:

 

  • 24 male children with gross motor problems were recruited. Ps were randomly assigned to either the Tx or Ct groups with age counterbalanced so that there were 4 children from each of the age groups (6-, 7-, and 8-year olds) within the Tx and Ct groups.

 

  • The Ps were screened and administered 3 individual intervention sessions over 3 weeks. Each of the intervention sessions involved recording (measurement) and teaching/practice. Ps in both Tx and Ct groups received the same dosage of their respective intervention.

 

  • The outcomes measures were acquired using an electromechanical measurement system. Ps were not recorded during teaching/practice, nor were they wearing the recording equipment.

 

  • The statistical analysis involved a 2 (Tx vs Ct) x 3 (the 3 age groups) analysis of covariance with the baseline score serving as the covariate.

 

  1. What were the results of the statistical (inferential) testing?

 

– RESULTS

 

  • Outcome #2: Average time deviation from CMPT (also called motor rhythm accuracy, MRA)

– Tx was significantly better than Ct

     – Age did not significantly improve performance for Tx or Ct

     – Both groups (Tx and Ct ) improved significantly over the course of the investigation.

     – The investigator also explored whether the improvement in the Tx group could be sustained when the auditory rhythm was faded from treatment (i.e., Tx faded). He determined that

  • There was no significant difference between Tx and Ct when the Tx group was in the faded context (i.e., Tx faded.)
  • Tx was significantly better than Tx faded.
  • Age did not significantly improve performance for Tx faded or Ct
  • Tx faded improved significantly over the course of the investigation.

   – Analysis revealed that there was the shape of the change profiles differed for the Tx and Tx faced scores were increasingly similar through the course of the investigation.

 

 

 

(add additional outcomes as appropriate)

 

– What was the statistical test used to determine significance? Analysis of Covariance; Multivariate Analyses

 

– Were effect sizes provided? No

 

– Were confidence interval (CI) provided? No

 

 

  1. Summary of correlational results: NA

 

 

  1. Summary of descriptive results: Qualitative research— NA

 

 

  1. Brief summary of clinically relevant results:

 

  • Children with gross motor problems responded more positively to Auditory Rhythm plus Speech Rhythm intervention than to Visual Modeling intervention although both groups improved significantly. It is not clear that the differences between the Tx and Ct groups would have been sustained if there had been more treatment sessions.

 

  • When Auditory Rhythm was faded from the intervention, the Ps could not sustain their progress although they continued to perform better than the Visual Modeling (Ct) group. This difference was not significant.

 

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE: NOT GRADED

 

 

 

—————————————————————————————————–

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of a short dose og auditory rhythm and rhythmic speech in improving performance on a gross motor task and whether the skills acquired in the intervention could be sustained when the auditory rhythm cues were removed

 

POPULATION: Gross motor problems; children

 

MODALITY TARGETED: production

 

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rhythm

 

DOSAGE: 3 individual sessions, a week apart, 30 minutes in length

 

ADMINISTRATOR: Music Therapist (MT)

 

MAJOR COMPONENTS:

 

  • The MT administered 3 sessions individual to each of the Ps. For the most part, the format of the sessions was. The only difference is noted in the Baselining during Session #1 and the RECORDING TIME portion of the sessions.

– Session 1:

  • MT recorded baseline by demonstrating the target sequence

and directing P to imitate. Following the initial orientation, MT recorded 4 repetitions of the target sequence.

  • The remainder of the session was devoted to Teaching Time, Practice Time, and Recording Time

∞ TEACHING TIME: MT demonstrated the sequence. (P was not wearing sensors.)

∞ PRACTICE TIME: P practiced the sequence. (P was not wearing sensors.)

∞ RECORDING TIME: P wore sensors and performed the targeted gross motor sequence multiple times. The data collected here was the basis of the statistical analysis.

  • For the Tx group, there were 10 cycles of the targeted gross motor sequence:

– Cycle 1: Practice and orientation. These data were NOT used in data analysis

– Cycles 2, 3, 4, and 5: Cues of Auditory Rhythm and Speech Rhythm were presented. These data were used for the Tx data analysis.

– Cycle 6: Auditory Rhythm cues were faded out, although Speech Rhythms cues remained (i.e., this was Tx faded.) This was practice and orientation and the data were NOT used in data analysis.

– Cycles 7, 8, 9, and 10: Only the Speech Rhythm were presented. These data were used for the Tx faded data analysis.

  • For the Ct group, 10 cycles of the targeted gross motor sequence:

– Cycle 1: Practice and orientation. These data were NOT used in data analysis

– Cycles 2, 3, 4, and 5: MT presented Visual Modeling Rhythm. These data were used for the Ct data analysis.

– Cycle 6, 7, 8, 9, and 10: These data were NOT used in data analysis.

 

  • Although there were only 2 intervention conditions (Tx, Ct), there were actually 3 assessments in each session:

– Tx (Auditory Rhythm plus Speech Rhythm)

– Tx faded (the Tx group in a faded condition with Speech Rhythm only)

– Ct (Visual Modeling only)

 

 

AUDITORY RHYTHM PLUS SPEECH RHYTHM (Tx)

 

  • Both auditory rhythm and speech rhythm cues were presented to the P. They were synchronized and with each set of cues P was expected to perform the targeted sequence in unison with them. This was used for Teaching Time, Practice Time, and Recording Time.

 

  • The MT presented a 4 beat prerecorded percussion pattern (i.e., Auditory Rhythm cues) in unison with speech rhythm cues.

– Beat 1 = a standing tom

– Beat 2 = a timpanetti that was higher pitched than the tom

– Beat 3 = a low pitched temple block

– Beat 4 = a high pitched temple block

 

  • The MT also presented Speech Rhythm cues in unison with the Auditory Rhythm cues. This involved a description of the behavior targeted in the sequence. Each word was chanted and paired with a beat from the Auditory Rhythm cues:

– Step, Close, Up, Down.

– Ps were encouraged to chant while performing the targeted sequence.

 

 

SPEECH RHYTHM only (Tx faded)

 

  • This was not a training/intervention condition (i.e., neither Teaching Time nor Practice Time) but was an assessment condition (i.e., Recording Time.)

 

  • The MT produced Speech Rhythm cues and expected P to enact the targeted gross motor sequence. Speech Rhythm cues involved a description of the behavior targeted in the sequence. Each word was chanted and paired with a beat from the Auditory Rhythm cues:

– Step, Close, Up, Down.

– Ps were encouraged to chant while performing the targeted sequence.

 

 

VISUAL MODELING only (Ct)

 

  • MT modeled the targeted gross motor sequence for the P.

 


Ouellette (2015)

June 8, 2016

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:

AIDS = Assessment of Intelligibility in Dysarthric Speech

C = Clinician

CER = Communication Efficiency Ratio (divide intelligible words per minute by 190—the speaking rate of typical speakers)

EBP = evidence-based practice

f = female

IWPM = Intelligible words per minute

m = male

MT = music therapist

NA = not applicable

P = Patient or Participant

PD = Parkinson’s disease

PDT = Picture Description Task

SLP = speech–language pathologist

UWPM = Unintelligible words per minute

WPM = Words per minute

 

 

SOURCE: Ouellette, J. (2015.) The effect of a Rhythmic Speech Cuing protocol on speech intelligibility in Parkinson’s disease. Unpublished Theses presented to the University of Miami, Miami (FL.) Open Access Thesis. Paper 585. http://scholarlyrepository.miami.edu/oa_theses/585/

 

REVIEWER(S): pmh

 

DATE: June 3, 2016

 

ASSIGNED GRADE FOR OVERALL QUALITY: C- (The highest possible grade for the design, Single Group with Pre-and Post- Testing, associated with this investigation was C+. This grade represents the type of the evidence supporting the intervention, not the quality of the intervention or the paper.)

 

TAKE AWAY: Problems with recruitment resulted in selection of several Ps with Parkinson’s disease (PD) who did not benefit from procedure. Therefore, the results will be described in 2 ways: Group comparison and Description of 1 participant with severe dysarthria. The results suggest that Rhythmic Speech Cuing (RSC) can be useful in improving intelligibility and speaking rate/duration with Ps with severe dysarthria as the result of PD.

 

 

  1. What type of evidence was identified?

                                                                                                           

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

                                                                                                           

  • What was the level of support associated with the type of evidence? 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.

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No

                                                                    

  • from clinicians? No

                                                                    

  • from analyzers? Unclear

                                                                    

 

  1. Were the groups adequately described? Variable ___x____, the general description was acceptable but the description of the speech and language characteristics was sparse.

 

– How many Ps were involved in the study?

 

  • total # of Ps:   5
  • # of groups: 1

 

–   The P characteristics that were CONTROLLED include

  • age: 50 to 85 years
  • hand tapping skills: all Ps could tap hand to an auditory cue
  • location of administration of screener: all at home
  • Intelligibility: screened using self and caregiver ratings on the Speech Intelligibility Inventory: Self-Assessment Form (score of 21-63)
  • language skills: reportedly proficient in English; could follow directions
  • reading: reportedly proficient in English; could read directions
  • social emotional problems: none self-reported
  • hearing: reportedly adequate
  • vision: reported;y adequate
  • medication: all Ps received dopaminergic medication that was stable throughout the investigation
  • diagnosis: recruited from support group of Parkinson’s disease (PD) with “self-reported diagnoses of speech deficiencies resulting from PD” (p. 27)

 

— The P characteristics that were DESCRIBED include

  • age: 55 to 84 years (mean = 71.6)
  • gender: 4m; 1f
  • handedness: right handed
  • Overall Performance on Assessment of Intelligibility of Dysarthric Speech (AIDS): only 1 P performed in the severe range (65%) on initial testing. As noted on page 60, the other Ps had high intelligibility with 97% to 99% and were only mildly affected. (NOTE: this was problematic because the investigator was targeting Ps with severe PD related speech problems for the intervention.)
  • Caregiver intelligibility rating: 21 – 49 (mean = 38.4); all severe range
  • onset of PD: all males reported right side initially affected; female report left side was initially affected
  • age at diagnosis of PD: 49 to 78 years (mean = 65)
  • Side currently most affected: left side (1m, 1f); right side (2m); equally affected (1m)

 

–   Were the groups similar before intervention began? NA

                                                         

– Were the communication problems adequately described?

 

– disorder type: probably hypokinetic dysarthria but this was only assumed; diagnoses were not reported.

 

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

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

                                                               

  • Were data from outliers removed from the study? No

 

 

  1. Were the groups controlled acceptably? NA, there was only one group.

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

                                                                                                             

–   The outcomes were

 

  • OUTCOME #1: Percentage of intelligible speech (number of intelligible words divided by the total number of words) for reading sentences on the AIDS

 

  • OUTCOME #2: Duration of the speech sample for reading sentences on the AIDS (included intraturn pauses but not interterm pauses)

 

  • OUTCOME #3: Words per minute (WPM) for reading sentences on the AIDS (total number of words divided by the duration of the sample)

 

  • OUTCOME #4: Intelligible words per minute (IWPM) for reading sentences on the AIDS (total number of intelligible words divided by the duration of the sample)

 

  • OUTCOME #5: Unintelligible words per minute (UWPM) for reading sentences on the AIDS (total number of unintelligible words divided by the duration of the sample)

 

  • OUTCOME #6: Communication Efficiency Ratio (CER) for reading sentences on the AIDS (dividing IWPM by 190—the speaking rate of typical speakers)

 

  • OUTCOME #7: Rating of number words on a Picture Description Task (PDT) that a listener perceived to be intelligible

 

  • OUTCOME #8: Rating of listeners’ perceived ability to understand the content of descriptions on a PDT

 

 

–  List the SUBJECTIVE outcome measures were

  • OUTCOME #1: Percentage of intelligible speech (number of intelligible words divided by the total number of words) for reading sentences on the AIDS
  • OUTCOME #3: Words per minute (WPM) for reading sentences on the AIDS (total number of words divided by the duration of the sample)
  • OUTCOME #4: Intelligible words per minute (IWPM) for reading sentences on the AIDS (total number of intelligible words divided by the duration of the sample)
  • OUTCOME #5: Unintelligible words per minute (UWPM) for reading sentences on the AIDS (total number of unintelligible words divided by the duration of the sample)
  • OUTCOME #6: Communication Efficiency Ratio (CER) for reading sentences on the AIDS (dividing IWPM by 190—the speaking rate of typical speakers)
  • OUTCOME #7: Rating of number words on a Picture Description Task (PDT) that a listener perceived to be intelligible
  • OUTCOME #8: Rating of listeners’ perceived ability to understand the content of descriptions on a PDT

 

The OBJECTIVE outcome measure was

 

  • OUTCOME #2: Duration of the speech sample for reading sentences on the AIDS (included intraturn pauses but not interterm pauses)

 

 

  1. Were reliability measures provided?

                                                                                                            

– Interobserver for analyzers? Yes

 

  • OUTCOMES #1, 3, 4, 5, 6: overall mean interrater reliability of judge transcriptions, which were used in these outcomes, was 91%
  • OUTCOMES #7 and 8: overall interrater reliability was 90%

 

– Intraobserver for analyzers? No

 

– Treatment fidelity for clinicians? No

 

 

  1. What were the results of the statistical (inferential) testing and/or the description of the results?

 

  • Summary Of Important Results

 

— What level of significance was required to claim significance? p = 0.05

 

 

PRE AND POST TREATMENT ANALYSES

 

  • OUTCOMES #1 through 7: No significant differences
  • OUTCOME #8: Rating of listeners’ perceived ability to understand the content of descriptions on a PDT* —ratings improved significantly

 

* this is the only main effect that was significantly different

 

 

– What were the statistical tesst used to determine significance? ANOVA, Mauchly’s W, Huynh-Feldt correction

 

– Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significance

 

  • The EBP measures were

 

  • Standardized Mean Difference (d)

 

  • Partial Eta Squared (ETA)

 

  • Results of EBP testing and the interpretation:

.

  • OUTCOME #1: Percentage of intelligible speech (number of intelligible words divided by the total number of words) for reading sentences on the AIDS
  • ETA = 0.15 (large effect)
  • d = 0.31 (small effect)

 

  • OUTCOME #2: Duration of the speech sample for reading sentences on

the AIDS (included intraturn pauses but not interterm pauses)

  • ETA = 0.10 (medium)
  • d = 0.14 (no effect)

 

  • OUTCOME #3: Words per minute (WPM) for reading sentences on the AIDS (total number of words divided by the duration of the sample)
  • ETA = 0.21 (large effect)
  • d =  0.10 (no effect)

 

  • OUTCOME #4: Intelligible words per minute (IWPM) for reading sentences on the AIDS (total number of intelligible words divided by the duration of the sample)
  • ETA = 0.14 (large effect)
  • d = 0.10 (no effect)

 

  • OUTCOME #5: Unintelligible words per minute (UWPM) for reading sentences on the AIDS (total number of unintelligible words divided by the duration of the sample)
  • ETA = 0.07 (small effect)
  • d = 0.04 (no effect)

 

  • OUTCOME #6: Communication Efficiency Ratio (CER) for reading sentences on the AIDS (dividing IWPM by 190—the speaking rate of typical speakers)
  • ETA = 0.15 (large effect)
  • d = 0.03 (no effect)

 

  • OUTCOME #7: Rating of number words on a Picture Description Task (PDT) that a listener perceived to be intelligible
  • ETA = 0.27 (large effect)
  • d = 0.42 (small effect)

 

  • OUTCOME #8: Rating of listeners’ perceived ability to understand the content of descriptions on a PDT*
  • ETA = 0.60 (large effect)
  • d = 0.87 (large effect)

 

* the only outcome with main effect that was statistically significant differences

 

DESCRIPTIVE ANALYSIS OF P1

 

NOTE: Because of a problem with the screening instrument, 4 of the 5 Ps did NOT exhibit severe dysarthria which was the initial target of the investigation. As the investigator noted, the treatment procedure was expected to be more effective with severe dysarthria than with mild/moderate dysarthria. This proved the case in this investigation with the 4 Ps with mild/moderate dysarthria often scoring at or near the ceiling on initial outcomes. P1 was severe and the following notes describe his progress.

 

  • The investigator described improvement in all outcomes as “marked.”

– P1 was the only P who displayed a consistent and marked improvement in intelligibility.

– P1 most consistently exhibited a stabilized and improved speaking rate. (In his case, an increase in rate represented an improvement which had been an unanticipated target.)

– P1 and another P produced increased IWPM and decreased UWPM after therapy. P1 showed the most progress of all the Ps on these measures. The progress of the other Ps was variable.

– P1 exhibited the largest increase in CER. Recall, however, the other Ps were close to ceiling on this measure.

– P1 and another P were the only Ps to increase both listener ratings of intelligible words and comprehensibility of content. The other Ps were more variable.

 

  1. Were maintenance data reported? No

 

 

  1. Were generalization data reported? No

 

 

  1. Describe briefly the experimental design of the investigation.

 

  • To investigate the effectiveness of Rhythmic Speech Cuing (RSC) with Ps with severe PD, the investigator screened potential Ps using self and caregiver perceptions of severity. Although the 5 Ps were classified as severe using the screener, subsequent testing on the AIDS revealed that only 1 P was severely affected with the other 4 Ps exhibiting mild dysarthria. Nevertheless, all 5 Ps were enrolled in the investigation.

 

  • The investigator administered AIDS and a picture description task (PDT) in 3 time periods: preintervention, midway through intervention, and post intervention.

 

  • The 25 minute sessions, which were administered 3 times a week, consisted of 20 minutes of RCS and 5 minutes of conversation. Treatment lasted 4 weeks.

 

  • The investigator analyzed the results descriptively and inferentially. She also provided evidence-based practice metrics.

 

  • Possibly because 1 of the 5 Ps (P1) was severely dysarthric, only one of the outcome improved significantly for the group. Accordingly, the investigator described P1’s performances which were assumed to represent the norm for Ps with severe dysarthria.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: C+

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of Rhythmic Speech Suing (RSC) on the speech of Ps with PD.

 

POPULATION: Parkinson’s Disease; Adults

 

MODALITY TARGETED: Expressive

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: speaking rate (Words per minute, duration)

 

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rhythm

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: Intelligibility

 

DOSAGE: 25 minute sessions, 3 times a week, 4 weeks (12 sessions)

 

ADMINISTRATOR: Music Therapist (MT)

 

MAJOR COMPONENTS:

 

  • There were 2 phases to each treatment sessions: RSC and conversation.

 

RHYTHMIC SPEECH CUING (RSC)

 

  • Lasted for 20 minutes of the 25 minute session.

 

  • For each treatment session, 22 sentences were selected from AIDS. Initially, sentences were 5 words in length; as P progressed the length of the sentences increased to 15 words.

 

  • The MT read aloud a sentence at 60% of P’s habitual speaking rate. The reading was accompanied by

– hand tapping and

– beats of a metronome

which were timed to each syllable.

 

  • During the modeling, P watched and listened to the MT’s reading of the sentence as well as hand tapped to the reading of the sentence.

 

  • MT and P read aloud the previously modeled sentence in unison. Hand tapping and the metronome accompanied the reading.

 

  • P spoke the sentence 2 times accompanied by hand tapping and the metronome without the modeling of the MT.

 

  • P spoke the sentence one time with only the metronome as a cue. The MT faded the cue half-way through the sentence.

 

  • P spoke the sentence without cues.

 

CONVERSATION

 

  • This portion of the session lasted 3 to 5 minutes.

 

  • The MT asked the P open ended questions on a topic to encourage him/her to talk.

 

_______________________________________________________________