Preston et al. (2013)

September 1, 2021

EBP THERAPY ANALYSIS for 

Single Case 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:

 C =  Clinician

 CAS =  Childhood Apraxia of Speech

 CELF-4  Clinical Evaluation of Language Fundamentals-4 

 CTOPP =  Comprehensive Test of Phonological Processing 

 EBP =  evidence-based practice

 EVT2 =  Expressive Vocabulary Test 2nd ed 

 NA = not applicable 

 P =  Patient or Participant

 PCC =  Percent Consonants Correct 

 pmh =  Patricia Hargrove, blog developer

 PPVT =  Peabody Picture Vocabulary Test 

 SLP =  speech–language pathologist

 SS =  Standard Score 

 VMPAC =  Verbal Motor Production Assessment for Children 

SOURCE: Preston, J. L., Brick, N., & Landi, N. (2013). Ultrasound biofeedback treatment for persisting childhood apraxia of speech. American Journal of Speech-Language Pathology, 22, 627-643. DOI: 10.1044/1058-0360(2013/12-0139)

REVIEWER(S):  pmh

DATE:  September 1, 2021

ASSIGNED OVERALL GRADE:  B+ The highest possible Assigned Overall Grade, based on the design of the investigation (multiple baseline across behaviors with 6 participants, Ps), is A-. The Assigned Overall Grade should not be interpreted as a judgment of the quality of the intervention, rather it describes the quality of the evidence supporting the intervention.

TAKE AWAY:  This preliminary investigation explored the effectiveness of ultrasound biofeedback paired with prosodic manipulation in improving the speech sound production of 9- to 15-year-old children diagnosed with CAS using a multiple baseline across behaviors experimental design. Six children participated in the investigation. All the participants (Ps) displayed at least some improvement in their ability imitate targeted sound sequences over the course of the 18-session program.

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

2.  What type of evidence was identified?                              

– What  type of single subject design was used? Single Subject Experimental Design with Specific Client– Multiple Baseline           

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

3.  Was the phase of treatment concealed?                           

•  from participants?  No 

•  from clinicians?  No 

•  from data analyzers?  Yes

4.  Were the participants (Ps) adequately described? Yes

–  How many Ps were involved in the study?  6

–  CONTROLLED CHARACTERISTICS:

•  age: children

•  current therapy:  All Ps were enrolled in speech-language therapy in their respective schools. School SLPs agreed to focus on targets other than articulation of the target sounds during the investigation.

•  diagnosis: Childhood Apraxia of Speech (CAS)

•  score on Sequencing subtest: below 85% from the Verbal Motor Production Assessment for Children (VMPAC)

•  articulation/phonology:

     – at least 1.5 standard deviations below the mean on the Goldman-Fristoe Test of Articulation 2 (GFTA2)

     – evidence of the following speech sound errors elicited from a variety of tasks (p. 629)

          ∞ omissions or additions of sounds/syllables in phonologically complex words

          ∞ metathesis or migration errors  

–  DESCRIBED CHARACTERISTICS: 

•  age:  9 to 15 years

•  gender:  All male

•  cognitive skills:  Weschler Abbreviated Scales of Intelligence- Reasoning (T score) = 39 to 65

•  receptive language:  Peabody Picture Vocabulary Test (PPVT) = Standard Score (SS) = 78-123

•  expressive language:

     – Expressive Vocabulary Test 2nd Ed (EVT2)

     – Clinical Evaluation of Language Fundamentals-4  (CELF-4) – Formulated Sentences  SS = 4 to 8

     – CELF-4 – Recalling Sentences SS = 1-13

•  speech sound errors:  All Ps produced rhotic errors; some produced other errors

•  articulation/phonology:

     – GFTA2 = <40 to 69

     – Percent Consonants Correct (PCC) = 65% to 97%

     – PCC- Late-8: 19% to 81%

     – Comprehensive Test of Phonological Processing (CTOPP)- Elision SS = 3 to 12

     – CTOPP – Blending SS = 4 to 10                    

•  oral-motor skills:

     – VMPAC Focal Oral Motor = 87to 98

•  educational level of parents:  At least on parent of each P attended college

•  Other clinical concerns:

     – Pervasive Developmental Disorder

     – Attention Deficit Hyperactivity Disorder

     – Language Impairment

     – Reading Disability

     – Trisomy 8

     – limb apraxia

     – dysarthria

     – velopharyngeal incompetence

     – history of otitis media with effusion

     – hypernasality

–  Were the communication problems adequately described? Yes 

–  Disorder type:  Childhood Apraxia of Speech

–  Other aspects of communication that were described:  

     • severity ranged from mild to severe

5.  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 

6.  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?  Yes 

•  Was the data collection continuous?  Yes

•  Were different treatment counterbalanced or randomized?  

7.  Were the outcome measures appropriate and meaningful? Yes

•  OUTCOME #1: Percent accuracy of each of 8 individually predetermined sound sequences per child

•  OUTCOME #2: Performance on the GFTA

•  All of the outcomes were subjective.

•  None of the outcomes were objective.

•  One of the outcome measures was associated with reliability data: 

     –  OUTCOME #1: Percent accuracy of each of 8 individually predetermined sound sequences per child: Interrater agreement for judgments of probe accuracy ranged from 79.3% to 91.5%. (NOTE: the perecent accuracy used for all probe data was the average between 2 listeners.)

8.  Results:

•  Did the target behaviors improve when treated?  Yes, for the most part

•  The overall quality of improvement for each of the each of the P for each of the outcomes was 

∞  OUTCOME #1: Percent accuracy of each of 8 individually predetermined sound sequences per child

     – U002 = limited success (achieved performance criterion of 80% accuracy on 2 of 3 targets)

     – U005 = moderate success (achieved performance criterion of 80% accuracy on 4 of 6 targets)

     – U007 = limited success (achieved performance criterion of 80% accuracy on 3 of 5 targets)

     – U008 = strong success (achieved performance criterion of 80% accuracy on 4 of 5 targets)

     – U009 = strong success (achieved performance criterion of 80% accuracy on 5 of 6 targets)

     – U012 = strong success (achieved performance criterion of 80% accuracy on 6 of 6 targets)

∞  OUTCOME #2: Performance on the GFTA-2

     – U002 = limited: points increase from pre-testing to 2 months post-testing: 1.1

     – U005 = strong: increase from pre-testing to 2 months post-testing: 4.5

     – U007 = limited: increase from pre-testing to 2 months post-testing: 1.2

     – U008 = moderate: increase from pre-testing to 2 months post-testing: 1.5

     – U009 = moderate: increase from pre-testing to 2 months post-testing: 2.5

     – U012 = strong increase from pre-testing to 2 months post-testing: 3.3

numbering as needed)

9.  Description of baseline: 

•  Were baseline data provided?  Yes, eight target sequences were generated for each P based on his speech sound patterns. Each of 8 target sequences were probed at baseline, at each treatment session, and at a 2-month follow-up session.

∞  Was baseline low (or high, as appropriate) and stable?

•  OUTCOME #1:

     – U002 = 2 of the 3 treated sound sequences were low and stable

     – U005 = 1 of the 6 treated sound sequences were low and stable

     – U007 = 3 of the 5 treated sound sequences were low and stable

     – U008 = 2 of the 5 treated sound sequences were low and stable

     – U009 = 1 of the 5 treated sound sequences were low and stable

     – U012 = 1 of the 6 treated sound sequences were low and stabl

  Was the percentage of nonoverlapping data (PND) provided?  Yes

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

  OUTCOME #1: : Percent accuracy of each of 8 individually predetermined sound sequences per child. (NOTE: The range of PNDs for each of the sound sequences treated during the intervention is reported. The number in parentheses represents the number of different sound sequences treated during the intervention.)

     – U002 = 83% to 100% (3). The interpretation of the PND  scores is 

          ∞ highly effective – 2 targets

          ∞ fairly effective – 1 target

     – U005 = 73% to 100% (6). The interpretation of the PND  scores is 

          ∞ highly effective – 4 targets

          ∞ fairly effective – 2 targets

     – U007 = 0% to 100% (5). The interpretation of the PND  scores is 

          ∞ highly effective – 2 targets

          ∞ questionable effectiveness – 1 targets

          ∞  unreliable/ineffective – 2 targets

     – U008 = 71% to 100% (5). The interpretation of the PND  scores is 

          ∞ highly effective – 4 targets

          ∞ fairly effective – 1 target

     – U009 = 100% (6). The interpretation of the PND scores is 

          ∞ highly effective – 6 targets

     – U012 = 100% (6). The interpretation of the PND scores is 

          ∞ highly effective – 6 targets

10.  What is the clinical significance

  OUTCOME #1: 

•  magnitude of effect for all treated target:

     – U002 = total for all targets = 3.2

     – U005 = total for all targets = 2.6

     – U007 = total for all targets = 4.0

     – U008 = total for all targets = 2.1

     – U009 = total for all targets = 2.2

     – U012 = total for all targets = 2.7

•  measure calculated: standardized mean difference

•  interpretation: each P improved at least 2 standard deviations from baseline on the production of treated sequences; strong improvement

11.  Was information about treatment fidelity adequate?  No 

12.  Were maintenance data reported?  Yes 

• Two months after the cessation of treatment, a research assistant, who was blind to the treatment status of the Ps, administered follow-up session. In the follow-up session, the research assistant administered the GFTA-2, 17 sentences, and the individualized probes from the pretest and treatment sessions.

• Overall maintenance for the Ps was reported as 

     – U002 = retained accuracy for 2 of 3 treated target

     – U005 = maintained accuracy for 5 of 6 treated targets

     – U007 = maintained accuracy for 2 of 2 successfully treated targets

     – U008 = maintained high accuracy for 2 of 5 treated targets; maintained moderate amount of accuracy for 3 of 5 treated targets

     – U009 = maintained accuracy for 6 of 6 treated targets

     – U012 = maintained accuracy for 6 of 6 treated targets

13.  Were generalization data reported? Yes  

• Sixty-four words were administered at the end of each session as well as at baseline, and post-treatment session. These 64 words were 8 examples of the 8 individualized targets for 8 Ps. One-half of the words were treated and the other half were not treated. Therefore, to progress from one sound sequence to the next by achieving 80% correct productions of probes for 2 sessions, P needed to generalize. 

• Across all the Ps,31 sound sequences were treated with 23 (76.7%) achieving criterion of 80% correct productions over 2 consecutive sessions.

• In addition, GFTA-2 scores and the 17-item sentence list increased significantly.

14.  Brief description of the design:

• Six children with childhood apraxia of speech (CAS) received treatment which included biofeedback.

• The investigation involved a multiple baseline across behaviors experimental design.

• To assess program effectiveness, the children were assessed during baseline, following each session, and two months after the termination of therapy using imitative probes without feedback containing treated and untreated stimuli.

• The GFTA-2 and a 17-item sentence list also were administered to assess effectiveness. 

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

SUMMARY OF INTERVENTION

PURPOSE:  To explore the effectiveness of a treatment program that includes biofeedback for Childhood Apraxia of Speech 

POPULATION:  Childhood Apraxia of Speech; Adults

MODALITY TARGETED:  production

ELEMENTS OF PROSODY USED AS INTERVENTION:  rate, intonation, loudness

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  speech sounds

DOSAGE:  18 sessions, administered over 10 to 16 weeks, 2 session per week, 1 hour sessions

ADMINISTRATOR:  SLP

MAJOR COMPONENTS:

• Schedule:

     – 15 minutes for ultrasound training for sound sequence #1 (e.g., /ar/)

     – 8 to 10 minutes of tabletop activities for sound sequence #1 (e.g., /ar/)

     – 15 minutes for ultrasound training for sound sequence #2 (e.g., /kl/)

     – 8 to 10 minutes of tabletop activities for sound sequence #2 (e.g., /kl/)

     – 10 minutes of probe tasks

 • Probe tasks: these tasks could be different each session because they changed as the P achieved criterion for a sound sequence.

• Ultrasound treatment procedures:

     – The purpose of the ultrasound procedure was to provide real-time visual feedback regarding the placement and movement of the tongue.

     – An ultrasound transducer was placed under the P’s chin. To keep the transducer in place (1) the P held it in place or (2) the P leaned on a microphone stand and a clamp held the transducer in place.

     – The view (i.e., sagittal or coronal) of the ultrasound differed based on the nature of the sound sequence.

     – The clinician (C) described the targeted tongue movements and placements. If applicable, C designed a transparency to place on the monitor to identify targets. 

     – For the most part, the P’s rate of speech was slowed to allow for interpretation of the visual feedback.

     – In addition to the visual feedback, C also provided verbal feedback (e.g., descriptions) and shaping.

     – C first focused on the target sound in isolation or in syllable, using the biofeedback and descriptions to facilitate production. Once P produced 5 consecutive productions of the target sound in isolation or syllable during the 15-minute treatment phase, C changed the target to syllables or words, as appropriate. 

     – For each of a session’s target sound sequences, 8 or 9 words (mono- or multi- syllabic) were identified for treatment. Only 4 of these words were included in that session’s probe task.

     – Some special techniques included

          ∞ For multisyllabic targets: backwards chaining. When working on the syllable sequence /re/, once “race” was produced accurately, the multisyllabic word “erase” was targeted.

           ∞ For production of the target sequence in a phrase:  the target sequence was included at the beginning or end of a phrase. Biofeedback focused on the production of the word with the target sequence (e.g., “race to the store” or “the turtle won the race” for the target sequence /re/) 

     – The prosodic component of the training involved providing prosodic cues during practice to facilitate accurate production of the sound sequences. The prosodic cues focused on recommendations to modify rate, intonation, or loudness of the target. The C did NOT provide feedback regarding the C’s production of prosody; that is, feedback remained focused on tongue movement accuracy.

• Table-top activities

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