Mahoney (2015)

February 8, 2018

SECONDARY REVIEW CRITIQUE

NOTE: A summary of the reviewed prosody-based interventions can be viewed by scrolling about two-thirds of the way down this page.

KEY:

CAS = Childhood Apraxia of Speech

C = clinician

MIT = Melodic Intonation Therapy

NA = not applicable

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

SR = Systematic Review

VML = Verbal Motor Learning (VML)

 

 

Source: Mahoney. K. (2015). A narrative review of the intervention techniques for childhood apraxia of speech. Undergraduate Review, 11, 81-90. From the institutional repository of Bridgewater State University (Bridgewater, MA.) Retrieved from h7p://vc.bridgew.edu/undergrad_rev/vol11/iss1/15

 

Reviewer(s): pmh

 

Date: February 6, 2018

 

Overall Assigned Grade: C The highest possible Overall Assigned Grade is B which is based on the design of the investigation. The Overall Assigned Grade does not reflect a judgment regarding the quality of the intervention.

 

Level of Evidence: B (Systematic Review with Broad Criteria)

 

Take Away: Although the investigator reviewed 13 sources, only 5 involved prosody in the treatment protocols. These 5 will be the focus of this Secondary Review Critique. The results of the Systematic Review (SR) revealed that 3 of the 5 prosody based interventions resulted in significant improvement.

 

What type of secondary review? Narrative Systematic Review

 

 

  1. Were the results valid?

 

– Was the review based on a clinically sound clinical question? Yes

 

– Did the reviewer clearly describe reasonable criteria for inclusion and exclusion of literature in the review (i.e., sources)?       Yes

 

– The author of the secondary research noted that she reviewed the following resources: internet based databases and ASHA online journals

 

– Did the sources involve only English language publications? Yes

 

– Did the sources include unpublished studies? No

 

– Was the time frame for the publication of the sources sufficient? Yes

 

– Did the author of the secondary research identify the level of evidence of the sources? Yes

 

– Did the authors of the secondary research describe procedures used to evaluate the validity of each of the sources? Yes

∞ The investigator included the following information in the review which was a replication of existing research (see p. 84)

  • reference for source
  • publication year
  • intervention description/categorization
  • number of participants (Ps)
  • age of Ps
  • description of service delivery strategy
  • duration of the intervention
  • Level of Evidence

 

– Was there evidence that a specific, predetermined strategy was used to evaluate the sources? Yes

 

– Did the authors of the secondary research or review teams rate the sources independently? Yes

 

– Were interrater reliability data provided? Yes

 

– Interrater reliability data: 100% interrater agreement for the judgment of Level of Evidence

 

– Were assessments of sources sufficiently reliable? Yes

 

– Was the information provided sufficient for the reader to undertake a replication? Yes

 

– Did the sources that were evaluated involve a sufficient number of participants? No

 

– Were there a sufficient number of sources? No, but this is the current status of literature.

 

  1. Description of outcome measures:

 

— The 5 sources that were concerned used prosody within the treatment protocol and their associated outcomes were

 

  • Outcome for Ballard et al. (2010): average duration for the first 2 syllable of real words

 

  • Outcome for Lagasse (2012): the outcomes were unclear

 

  • Outcomes for Martikainen & Korpilahti (2011): percentage of correct vowels and percentage of correct consonants

 

  • Outcomes McCabe et al. (2014): percentage of correct vowels, percentage of correct consonants, and percentage of correct stress patterns

 

  • Outcomes for Vashdi (2013): word length, vocal intensity, frequency

 

 

  1. Description of results:

 

  • What measures were used to represent the magnitude of the treatment/effect size?  Some of the non-prosodic treatments provided EBP measures, but none of the prosodic treatments provided EBP measures.

 

  • Summary of the findings of the secondary research:

 

– The results of the reviewed sources for treatments involving prosody

 

  • Ballard et al. (2010)

     ∞ The durations of the first 2 syllables of real words were significantly more “normalized” for all 3 Ps. (The statistical test was the Kruskal-Wallis Test.)

 

  • Lagasse (2012)

∞ The outcomes were not provided but it was noted that p was greater than 0.05 for comparisons using the Wilcoxon test.

 

  • Martikainen & Korpilahti (2011)

     ∞ For the percentage of correct vowels, there was a significant improvement for Melodic Intonation Therapy (MIT) training immediately following treatment.

     ∞   For the percentage of correct consonants, there was a significant improvement for Melodic Intonation Therapy (MIT) training 6 weeks after the termination of treatment.

     ∞ Statistical analysis involved the application of Generalized Cochran-Mantel-Haenszel Statistics for Repeated Measures.

 

  • McCabe et al. (2014)

Only raw data were provided by the authors of the source investigation, a summary of the data was not provided in the current SR.

 

  • Vashdi (2013)

Significant improvements were noted for word length (duration), intensity, and frequency. The statistical analysis involved the use of Paired t-tests.

 

  • Were the results precise? Unclear/Variable

 

  • If confidence intervals were provided in the sources, did the reviewers consider whether evaluations would have varied if the “true” value of metrics were at the upper or lower boundary of the confidence interval? NA, confidence intervals were not provided.

 

  • Were the results of individual studies clearly displayed/presented? Yes

 

  • For the most part, were the results similar from source to source? Yes, 4 of the 5 prosody related treatments claimed improvement.

 

  • Were the results in the same direction? Yes, for the most part. Four of the 5 prosody related treatments reported improvement.

 

  • Did a forest plot indicate homogeneity? NA

 

  • Was heterogeneity of results explored? No

 

  • Were the findings reasonable in view of the current literature? Yes
  • Were negative outcomes noted? No

           

                                               

  1. Were maintenance data reported? Yes, for one investigation.
  • Martikainen & Korpilahti (2011) : For the percentage of correct consonants, there was a significant improvement for Melodic Intonation Therapy (MIT) training 6 weeks after the termination of treatment.

 

  1. Were generalization data reported? No

 

 

SUMMARY OF INTERVENTIONS

 

NOTE: The treatment procedures, for the most part, were only named, and not described, in the Secondary Review

 

Ballard et al. (2010)

 

Population: CAS, Children, N = 3 (ages: 7;8 to 10;10)

 

Prosodic Targets: Duration

 

Description of Procedure/Source (Ballard et al., 2010)

  • Design: Single Subject Experimental Design: Multiple Baselines; Behaviors Across Ps (Level of Evidence IIb)
  • Administrator: Graduate Student in SLP, supervised
  • Dosage: individual sessions 50 minutes per session, 2 times a week for 8 weeks (16 sessions)
  • Procedures: enhanced intonation patterns

 

Evidence Supporting Procedure/Source (Ballard et al., 2010)

  • All Ps produced significantly more normalized durations for the first 2 syllables of real words.

 

==========

 

Lagasse (2012)

 

Population: CAS, Children, N = 2 (ages: 5, 6)

 

Prosodic Targets: Outcomes unclear

 

Nonprosodic Targets: Outcomes unclear

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: music (pitch/intonation, tempo, loudness)

 

Description of Procedure/Source Lagasse (2012)

 

  • Design: Single-Subject Design: AB (Level of Evidence: IIb)
  • Administrator: Music Therapist
  • Dosage: in the home, 40 minutes, 1 time a week, 4 weeks; Ps also received SLP services concurrently
  • Procedures: Melodic Intonation Therapy (MIT)

 

Evidence Contraindicating Procedure/Source Lagasse (2012)

  • None of the comparisons achieved significance.

 

======

 

Martikainen & Korpilahti (2011)

 

 

Population: CAS, Children, N = 1 (age: 4;7)

 

 

Nonprosodic Targets: vowels, consonants

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: music (pitch/intonation, tempo, loudness)

 

Description of Procedure/Source Martikainen & Korpilahti (2011)

  • Design: Single-Subject Experimental Design: ABA (Level of Evidence: IIb)
  • Administrator: SLP
  • Dosage: individual sessions, 30 minute sessions, 18 sessions per 6 week block
  • Procedures:

– Investigators administered 6 week long blocks of MIT and the Touch Cue Method. (Only MIT is reported in this review.) There was also a 6 week long withdrawal block and a follow up block.

 

Evidence Supporting Procedure/Source Martikainen & Korpilahti (2011)

– For the percentage of correct vowels, there was a significant improvement for Melodic Intonation Therapy (MIT) training immediately following treatment.

– For the percentage of correct consonants, there was a significant improvement for Melodic Intonation Therapy (MIT) training 6 weeks after the termination of treatment.

 

========

 

McCabe et al. (2014)

 

Population: CAS, Children, N = 4 (ages: 5;5-8;6)

 

Prosodic Targets: stress (lexical)

 

Nonprosodic Targets: consonants, vowels

 

Aspects of Prosody Used in Treatment of Nonprosodic Targets: stress (lexical)

 

Description of Procedure/Source McCabe et al. (2014)

  • Design: Single-Subject Design: AB (Level of Evidence: IIb)
  • Administrator: SLP
  • Dosage: individual sessions, 60 minutes, 4 times a weeks, 3 weeks (12 sessions)
  • Procedures: Administered ReST

Evidence Supporting Procedure/Source McCabe et al. (2014)

– Only raw data were provided by the authors of the sources, a summary of the data was not provided in the current investigation

 

Evidence Contraindicating Procedure/Source McCabe et al. (2014)

– Only raw data were provided by the authors of the sources, a summary of the data was not provided in the current investigation

====

 

Vashdi (2013)

 

Population: CAS, Children, N = 1 (age: 14)

 

Prosodic Targets: intensity, frequency, duration

 

Description of Procedure/Source Vashdi (2013)

  • Design: Case Study (Level of Evidence: III)
  • Administrator: Verbal Motor Learning (VML) Therapist
  • Dosage: individual sessions, 30 minute sessions, 1 time a week. 4 weeks
  • Procedures:

– Administered VML therapy paired with the Distal Dynamic Stabilization Technique

 

Evidence Supporting Procedure/Source Vashdi (2013)

  • Significant improvements were noted for word length (duration), intensity, and frequency.

 

=============================================================

Advertisements

Martikainen & Korpilahti (2011)

November 15, 2017

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

EBP = evidence-based practice

MIT = Melodic Intonation Therapy

NA = not applicable

P = Patient or Participant

PCC = Percentage of Consonants Correct

PMLU = Phonological Mean Length of Utterance

PVC = Percentage of Vowels Correct

PWC = Proportion of Whole-Word Correctness

PWP = Proportion of Whole-Word Proximity

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

WNL = within normal limits

 

SOURCE: Martikainen, A-L, & Korpilahti, P. (2011). Intervention for childhood apraxia of speech: A single-case study. Child Language Teaching and Therapy, 27 (1), 9- 20.

 

REVIEWER(S): pmh

 

DATE: November 14, 2017

 

ASSIGNED OVERALL GRADE: D+   (The highest possible grade, based on the design of the investigation, is D+. The Assigned Overall Grade merely represents the quality of the evidence supporting the intervention and should not be construed to be a comment of the quality of the intervention.

 

TAKE AWAY: The results of this single case study revealed that a combined intervention in which Melodic Intonation Therapy (MIT) followed by a course of the Touch-Cue Method (TCM) resulted in improved speech accuracy in a Finnish-speaking 4-year-old child diagnosed with Childhood Apraxia of Speech (CAS.)

                                                                                                           

    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? Case Study – Description with Pre and Post Test Results                                                                                                  
  • What was the level of support associated with the type of evidence? Level = D+

                                                                                                           

  1. Was phase of treatment concealed?
  • from participants? No
  • from clinicians? No
  • from data analyzers? No

  

  1. Was the participant (P) adequately described? Yes

– How many Ps were involved in the study? List here: 1

– CONTROLLED CHARACTERISTICS          

  • cognitive skills: nonverbal cognitive skills within normal limits (WNL)
  • receptive language: WNL
  • hearing: WNL
  • diagnosis: CAS (8 of 11 speech and nonspeech CAS characteristics)
  • dysarthria: no signs
  • speech related structures: WNL

– DESCRIBED CHARACTERISTICS

  • age: 4;7 at the beginning of the investigation
  • gender: female
  • birth and medical history: WNL

* first word: 12 months but for 6 months she did not use words

  • multiword utterances: 36 months
  • expressive language:

Poor Finnish word naming

     – Phonetic Inventory– all vowels and consonants (except /d, l, r/)

     – Speech Sound errors — inconsistent vowel substitutions and distortions including some nasalization; inconsistent consonant substitutions and omission

     – Limited speech

     – Unintelligible

  • receptive language: WNL
  • family history of speech-language problems: multiple family members
  • age of first referral: 3;5
  • previous speech-language therapy: began 3 months after referral; 12 sessions between 3;8 an 4;6

                                                 

– Were the communication problems adequately described? Yes

  • The disorder type:  CAS
  • Other aspects of communication that were described:

limited, unintelligible speech

     – consonant inventory limited at initial evaluation by beginning of investigation intervention (at 4; 7) only missing /d/, /l/, and /r./

     – at initial evaluation –inconsistent use of vowels, although all Finnish vowels were in the vowel inventory

     – at the beginning of the investigation intervention, the participant (P) errors included:

          ∞ inconsistent errors in spontaneous speech and in imitation of single words

           ∞ consonant omission

           ∞ vowel substitutions and omission as well as nasalizatinon

           ∞ articulatory groping noted in imitation of short sentences but not spontaneous speech and picture naming

          ∞ syllable shapes were simple

           ∞ polysyllabic words reduced

           ∞ inflections omitted

           ∞ could not produce trisyllables in imitated diadochokinetic task but monosyllable repetitions were WNL

           ∞ protruding lips and alternating lip protrusion and retraction task was mildly impaired

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Not applicable, there was only one P.
  • If there was more than one participant, did at least 80% of the participants remain in the study? Not applicable (NA) 
  • Were any data removed from the study? No

 

  1. Did the design include appropriate controls? No, this was a case study.                                                                 
  • 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? No
  • Were different treatments counterbalanced or randomized? NA

  

  1. Were the outcome measures appropriate and meaningful? Yes

– OUTCOMES

  • OUTCOME #1: Percentage of Vowels Correct (PVC) from naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #2: Percentage of Consonants Correct (PCC) from naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #3: Modified Phonological Mean Length of Utterance (PMLU) from naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #4: Proportion of Whole-Word Proximity (PWP) from the naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #5: Proportion of Whole-Word Correctness (PWC) from the naming of pictures modified from the Finnish Articulation Test

 

  • OUTCOME #6: Qualitative analysis of production from the naming of pictures modified from the Finnish Articulation Test

All of the outcomes that were subjective.

None of the outcomes that were objective. 

Interobserver deliability data were collected for the transcription of the words named in from the Finnish Articulation Test: 89% agreement

 

  1. Results:

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

  • OUTCOME #1: Percentage of Vowels Correct (PVC) on the naming of pictures modified from the Finnish Articulation Test:   strong improvement

∞ baseline to end of MIT: improved significantly

∞ end of MIT to end of no treatment phase: improved significantly

∞ end of no treatment phase to end of TCM:

∞   end of TCM to end of follow up: improved significantly

∞ descriptive: week 0 and week 6 (baseline) PVC = 54.8%, 57.8%, respectively; end of the study (week 36)   PVC = 93%

 

  • OUTCOME #2: Percentage of Consonants Correct (PCC) on the naming of pictures modified from the Finnish Articulation Test: strong improvement

∞ baseline to end of MIT: decreased significantly

∞ end of MIT to end of no treatment phase: improved significantly

∞ end of no treatment phase to end of TCM: improved significantly

∞   end of TCM to end of follow up: no significant change

∞ descriptive: week 0 and week 6 (baseline) PCC = 24%, 31.2%, respectively; end of the study (week 36)  PCC = 73.1%

 

  • OUTCOME #3: Modified Phonological Mean Length of Utterance (PMLU) on the naming of pictures modified from the Finnish Articulation Test: moderate improvement

∞ baseline to end of MIT: no significant improvement

∞ end of MIT to end of no treatment phase:  improved significantly

∞ end of no treatment phase to end of TCM: improved significantly

∞   end of TCM to end of follow up: improved significantly

∞ descriptive: week 0 and week 6 (baseline) PMLU = 6.12, 6.38, respectively; end of the study (week 36)  PMLU = 8.80

 

  • OUTCOME #4: Proportion of Whole-Word Proximity (PWP) on the naming of pictures modified from the Finnish Articulation Test: limited improvement

∞ baseline to end of MIT: no significant improvement

∞ end of MIT to end of no treatment phase: no significant improvement

∞ end of no treatment phase to end of TCM: no significant improvement

∞   end of TCM to end of follow up: no significant improvement

∞ descriptive: week 0 and week 6 (baseline) PWP = 0.64, 0.68, respectively; end of the study (week 36)  PWP = 0.91

 

  • OUTCOME #5: Proportion of Whole-Word Correctness (PWC) on the naming of pictures modified from the Finnish Articulation Test: moderate improvement

∞ baseline to end of MIT: no significant improvement

∞ end of MIT to end of no treatment phase: no significant improvement

∞ end of no treatment phase to end of TCM: improved significantly

∞   end of TCM to end of follow up: no significant change

∞ descriptive: week 0 and week 6 (baseline) PWC = 0.17, 0.19, respectively; end of the study (week 36)  PWC = 0.39

 

  • OUTCOME #6: Qualitative analysis of production on the naming of pictures modified from the Finnish Articulation Test: authors reported that phoneme production and sequencing improved (Moderate improvement)

 

  1. Description of baseline:
  • Were baseline data provided? Yes, for Outcomes 1 through 5 there were two baseline session, six weeks apart.                                         
  • Was baseline low (or high, as appropriate) and stable? For Outcomes 1 through 5, all the baselines were low and stable.
  • Was the percentage of nonoverlapping data (PND) provided? No

 

  1. What is the clinical significanceNA

 

  1. Was information about treatment fidelity adequate? Not Provided

 

  1. Were maintenance data reported?  Yes
  • Improvements in Outcomes #1 though 5 were maintained or increased at follow up.

 

  1. Were generalization data reported? Yes, since untrained stimuli were used for all the Outcomes, the Results (item #8) can be viewed as generalization data.

  

  1. Brief description of the design:
  • This single case study explored the effectiveness of administering MIT and TCM sequentially to treat a 4-year old Finnish child who had been diagnosed with CAS.
  • The outcome measures were concerned with consonant and vowel accuracy as well as Whole-word Accuracy and were derived from the picture naming task of the Finnish Articulation Test.
  • The schedule of testing and treatment was

∞ 2 sessions of baseline at Week 0 and Week 6

∞ 6 weeks of MIT running from Week 6 to Week 12.

∞ 6 weeks of no treatment from week 12 to Week 18

∞ 6 weeks of TCM from Week 18 to Week 24

∞ Follow-up assessment (Week 36) after 12 weeks of no treatment (Week 24 to Week 36)

  • The measures were compared from

∞ baseline (Week 6) to end of MIT (Week 12),

∞ end of MIT (week 12) to end of no treatment phase (Week 18),

∞ end of no treatment phase (Week 12) to end of TCM (Week 24), and

∞ end of TCM (Week 24) to end of follow up (Week 36).

 

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

 

SUMMARY OF INTERVENTION

 

PURPOSE: To investigate the effectiveness of a combined treatment program using MIT and TCM

POPULATION: Childhood Apraxia of Speech; Children 

MODALITY TARGETED: production

ELEMENTS OF PROSODY USED AS INTERVENTION: intonation

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: speech sound accuracy; whole word accuracy

DOSAGE: 30 minute sessions, 3 times a week for 6 week (each treatment)

ADMINISTRATOR: SLP

MAJOR COMPONENTS:

  • There were 2 treatments: a modified version of MIT and TCM

 

MELODIC INTONATION THERAPY (MIT)

  • The stimuli for MIT were 3 sentence lists in the Finnish language. Each list

– contained 10 sentences that were 2 to 3 words long

– included topics that were developmentally appropriate

– consisted of bisyllable words which were in the P’s phonetic repertoire. (There was one exception to this final characteristic of the lists.)

  • At the beginning of treatment, the clinician © simultaneously signs Finninsh with the intoned speech. This support is gradually faded as P becomes familiar with the sentences.
  • C models a target sentence 2 times while intoning it.
  • C and the participant (P) intone the target sentence simultaneously.
  • C models the intoned version of the target sentence.
  • P intones the sentence independently. The C can facilitate P’s production if necessary.
  • C asks P a question to elicit the target sentence spontaneously.

 

TOUCH-CUE METHOD (TCM)

  • The practice materials were syllable sequences (nonsense syllables) and meaningful words. The practice materials were made up of any Finnish vowel and the some of following phonemes: /p, k, s, l/.
  • There were 2 phases .

PHASE 1

  • There were 3 steps. All the stimuli were nonsense syllables.
  • Criterion for advancement was 100% correct for 3 consecutive sessions.

PHASE 1—STEP 1

  • P practiced producing a single nonsense syllable /pa/ or a repeated nonsense syllable /papa/.

PHASE 1—STEP 2

  • P practiced producing a nonsense bisyllable with identical vowels but different consonants /paka/.

PHASE 1—STEP 1

  • P practiced producing a nonsense bisyllable with different vowels and different consonants /paku/.

PHASE 2

  • The target stimuli were now meaningful bisyllable words.
  • Criterion for advancement was 90% correct for 3 consecutive sessions.
  • C modeled the target word 2 or 3 times while simultaneously using touch cues to facilitate production.
  • C and P practiced the target word simultaneously 5 to 10 times continuing to use touch cues.
  • Auditory and visual cues were gradually faded until P produced the target word 5 times (while still being assisted with touch cues.)

 

 


Murray et al. (2015)

August 21, 2017

 

 

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

CAS = Childhood Apraxia of Speech

CELF-4 = Clinical Evaluation of Language Fundamentals Edition

CELF-P2 = CELF- Preschool—Second Edition

DEAP = Diagnostic Evaluation of Articulation and Phonology Inconsistency Test

EBP = evidence-based practice

GFTA-2 = Goldman-Fristoe Test of Articulation -2nd Edition

KP feedback = knowledge of performance feedback

KR feedback = knowledge of results feedback (i.e., accuracy only)

n = number

NA = not applicable

NDP3 = Nuffield Dyspraxia Programme-Third Edition

P = Patient or Participant

PCC = Percent Consonants Correct

PPC = Percent Phonemes Correct

PVC = Percent Vowels Correct

pmh = Patricia Hargrove, blog developer

ReST = Rapid Syllable Transition Treatment

SLP = speech–language pathologist

 

 

SOURCE: Murray, E., McCabe, P., & Ballard, K. J. (2015.) A randomized controlled trial for children with Childhood Apraxia of Speech comparing Rapid Syllable Transition Treatment and the Nuffield Dyspraxia Programme-Third Edition. Journal of Speech, Language, and Hearing Research, 58, 669-686.

 

REVIEWER(S): pmh

 

DATE: August 5, 2016

 

ASSIGNED GRADE FOR OVERALL QUALITY: A   (The highest possible grade based on the design of the investigation, Prospective Randomized Group with Controls, was A.)

 

TAKE AWAY: Two treatments (Rapid Syllable Transition Treatment, ReST, and the Nunffield Dyspraxia Programme-Third Edition, NDP3) for Childhood Apraxia of Speech (CAS) resulted in significant improvements in articulation and prosody outcomes immediately following the termination of treatment and at 1 month and 4 month follow-ups. Moreover, gains generalized to untreated stimuli.

 

 

  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

 

                                                                                                           

  1. Group membership determination:

                                                                                                           

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

 

  1. Was administration of intervention status concealed?

                                                                                                           

  • from participants? No

                                                                    

  • from clinicians? No

                                                                    

  • from analyzers? Yes

                                                                    

 

  1. Were the groups adequately described? Yes, however, “no information on race, ethnicity, or socioeconomic status was collected.” (p 673)

 

How many Ps were involved in the study?

 

  • total # of Ps:  26
  • # of groups: 2
  • List names of groups and the # of participants (Ps) in each group:

Rapid Syllable Transition Treatment (ReST) – N = 13

– Nuffield Dyspraxia Programme-Third edition (NDP3) – N= 13

 

  • CONTROLLED P CHARACTERISTICS:

 

– age: between the ages of 4 and 12 years

 

– receptive language: standard score ≥85 for receptive language on the Clinical Evaluation of Language Fundamentals Edition (CELF-4) or the CELF- Preschool—Second Edition (CELF-P2)

 

– native language: at least one parents was a native speaker of Australian English

 

– vision: within normal limits or adjusted to within normal limits

 

  • – hearing: within normal limits or adjusted to within normal limits

 

– diagnosis: Childhood Apraxia of Speech (CAS) with no Co-morbidity

 

  • DESCRIBED P CHARACTERISTIC:

 

– age:

– ReST = 72.6 months

– NDP3 = 62.5 months

 

– gender:

– ReST = 10m; 3f

– NDP3 = 8m; 5f

 

– receptive language (performance on CELF-P2 or CELF-4)

– ReST = 99.3

– NDP3 = 105.3

 

– expressive language (performance on CELF-P2 or CELF-4)

– ReST =   94.8

– NDP3 = 101.6

 

– previous therapy: all participants (Ps) had previous therapy

 

– baseline accuracy on treated items: (NOTE: the stimuli differed in the 2 groups)

– ReST = 10.8

– NDP3 = 30.3

 

– baseline accuracy on untreated real words:

– ReST = 45.7

– NDP3 = 44.0

 

– baseline accuracy on untreated pseudowords:

– ReST = 8.5

– NDP3 = 11.1

 

– baseline imitative accuracy of greater than 3 word utterances

– ReST = 35.2

– NDP3 = 29.8

 

– baseline score on the Diagnostic Evaluation of Articulation and Phonology Inconsistency Test (DEAP)

– ReST = 61.4

– NDP3 = 65.8

 

– baseline score on Single Word Test of Polysyllables—Percent Phonemes Correct (PPC)

– ReST = 53.9

– NDP3 = 50.5

 

– baseline score on Single Word Test of Polysyllables—Percent Vowels Correct (PVC)

– ReST = 51.7

– NDP3 = 50.1

 

– baseline score on Single Word Test of Polysyllables- Percent Consonants Correct (PCC)

– ReST = 56.2

– NDP3 = 51.0

 

– baseline score on Single Word Test of Polysyllables- Percent Lexical Stress matches

– ReST = 10.8

– NDP3 = 9.1

 

– baseline score on the Goldman-Fristoe Test of Articulation -2nd Edition (GFTA-2) –Overall Standard Score

– ReST = 66.0

– NDP3 = 68.2

 

– baseline score on theGFTA-2 — PPC

– ReST = 65.7

– NDP3 = 64.0

 

– baseline score on the GFTA-2 — PVC

– ReST = 71.3

– NDP3 = 66.3

 

– baseline score on the GFTA-2– PCC

– ReST = 57.1

– NDP3 = 56.5

 

– baseline score on the GFTA-2—Percent Lexical Stress Matches

– ReST = 69.2

– NDP3 = 59.9

 

– baseline Severity ratings based on Polysyllabic PCC–Severe

– ReST = number (n) = 5

– NDP3 = n = 7

 

– baseline Severity ratings based on Polysyllabic PCC — Moderate to Severe

– ReST = n = 4

– NDP3 = n = 3

 

– baseline Severity ratings based on Polysyllabic PCC—Mild to Moderate

– ReST = n = 2

– NDP3 = n = 2

 

  • – baseline Severity ratings based on Polysyllabic PCC– Mild

– ReST = n = 2

– NDP3 = n = 1

 

  • Were the groups similar before intervention began? Yes

                                                         

  • Were the communication problems adequately described?

 

  • disorder type: Childhood Apraxia of Speech (CAS) with no co-morbid conditions

 

  • other: see Description of baseline performance above.

 

 

  1. Was membership in groups maintained throughout the study?

                                                                                                             

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

                                                               

  • Were data from outliers removed from the study? No

 

 

  1. Were the groups controlled acceptably? Yes

 

  • Was there a no intervention group? No

                                   

  • Was there a foil intervention group? No

                                   

  • Was there a comparison group? Yes

 

  • Was the time involved in the foil/comparison and the target groups constant? Yes

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

 

PRIMARY OUTCOMES

 

  • OUTCOME #1: Accuracy on treated items: (NOTE: the stimuli differed in the 2 treatment groups)

 

  • OUTCOME #2: Accuracy on untreated real words (generalization outcome)

 

  • OUTCOME #3: Accuracy on untreated pseudowords (generalization outcome)

 

SECONDARY OUTCOMES

 

  • OUTCOME #4: Imitative accuracy of greater than 3 word utterances

 

  • OUTCOME #5: Score on the DEAP Inconsistency Test

 

  • OUTCOME #6: Score on Single Word Test of Polysyllables–PPC

 

  • OUTCOME #7: Score on Single Word Test of Polysyllables—PVC

 

  • OUTCOME #8: Score on Single Word Test of Polysyllables- PCC

 

  • OUTCOME #9: Score on Single Word Test of Polysyllables- Percent Lexical Stress matches

 

  • OUTCOME #10: Score on the GFTA-2 — PPC

 

  • OUTCOME #11: Score on the GFTA-2 — PVC

 

  • OUTCOME #12: Score on the GFTA-2– PCC

 

  • OUTCOME #13: Score on the GFTA-2—Percent Lexical Stress Matches

 

ALL the outcome measures were subjective.

 

NONE of the outcome measures were objective.

                                         

 

  1. Were reliability measures provided? Yes

                                                                                                            

–  Interobserver for analyzers? Yes

 

  • Judgment of correct and incorrect responses during treatment was 99% for articulation (Primary Outcomes.)

 

  • Judgment of correct and incorrect responses during treatment was 89% for prosody (Primary Outcomes.)

 

  • Judgment of phonetic transcriptions of post treatment sessions was 93% (Primary Outcomes.)

 

  • Judgment of phonetic transcriptions of pre treatment sessions was not reported (Primary Outcomes.)

 

  • Overall scoring of the Secondary outcomes was 94%.

 

Intraobserver for analyzers? Yes

 

  • Judgment of correct and incorrect responses during treatment was 99% for articulation (Primary Outcomes.)

 

  • Judgment of correct and incorrect responses during treat,ent was 92% for prosody (Primary Outcomes.)

 

  • Judgment of phonetic transcriptions of pre and post treatment sessions were 97% and 93%, respectively (Primary Outcomes.)

 

  • Overall scoring of the Secondary outcomes was 98%.

 

Treatment fidelity for clinicians? Yes. The treatment protocol was followed 93% of the time. This is combined data across sessions and treatments. Protocol cues, feedback, and repetitions were measured.

 

 

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

 

— What level of significance was required to claim significance? p ≤= 0. 05

 

TREATMENT AND COMPARISON GROUP RESULTS

 

PRIMARY OUTCOMES

 

  • OUTCOME #1: Accuracy on treated items: (NOTE: the stimuli differed in the 2 groups)

– ReST = significantly increased from pretreatment to posttreatment1

– NDP3 = significantly increased from pretreatment to posttreatment1; the gain for this group was larger than the gain for ReST

 

  • OUTCOME #2: Accuracy on untreated real words (generalization outcome)

– ReST and NDP3 = There were significant gains from pretreatment to posttreatment1 for the combined groups. The 2 treatment groups did not differ significantly.

 

  • OUTCOME #3: Accuracy on untreated pseudowords (generalization outcome)

– ReST = significant time main effect and interaction effect from pretreatment to posttreatmen1 revealed large increase with ReST which was significantly larger than NDP3

– NDP3 = significant improvement from pretreatment to posttreatment1 but it was smaller than ReST

 

SECONDARY OUTCOMES

 

  • OUTCOME #4: Imitative accuracy of greater than 3 word utterances

– ReST and NDP3 = The difference between the 2 treatment groups was not significant. There was a small and significant difference from pretreatment to posttreatment1 for the combined groups

 

  • OUTCOME #5: Score on the DEAP Inconsistency Test

– ReST and NDP3 = There was a large and significant difference from pretreatment to posttreatment1 for the combined groups.

 

  • OUTCOME #6: Score on Single Word Test of Polysyllables—PPC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = The differences were not significant

 

  • OUTCOME #7: Score on Single Word Test of Polysyllables—PVC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a large and significant improvement. There was no significant difference between the groups.

 

  • OUTCOME #8: Score on Single Word Test of Polysyllables- PCC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = The differences were not significant.

 

  • OUTCOME #9: Score on Single Word Test of Polysyllables- Percent Lexical Stress matches (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a large and significant improvement. There was no significant difference between the groups.

 

  • OUTCOME #10: Score on the GFTA-2 – PPC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a small and significant improvement. There was no significant difference between the groups.

 

  • OUTCOME #11: Score on the GFTA-2 – PVC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a large and significant improvement. There was no significant difference between the groups.

 

  • OUTCOME #12: Score on the GFTA-2– PCC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a small; and significant improvement. There was no significant difference between the groups.

 

  • OUTCOME #13 Score on the GFTA-2—Percent Lexical Stress Matches (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a large and significant improvement. There was no significant difference between the groups.

 

– What statistical tests were used to determine significance? ANOVA and ANCOVA. In addition to the inferential tests, Cohen’s d; correlational analysis were reported.

 

– Were confidence interval (CI) provided? No

 

 

  1. What is the clinical significance(

 

– EBP measure provided: Standardized Mean Difference

 

– Results of EBP testing and the interpretation:

 

PRIMARY OUTCOMES

 

  • OUTCOME #1: Accuracy on treated items: (NOTE: the stimuli differed in the 2 groups)

– ReST = large treatment effect; d = 1.312

– NDP3 = large treatment effect; d = 2.162

 

  • OUTCOME #2: Accuracy on untreated real words (generalization outcome)

– ReST and NDP3 = There was a significant improvement for both groups. The combined level of improvement was moderate (d = 0.744.)

 

  • OUTCOME #3: Accuracy on untreated pseudowords (generalization outcome)

– ReST = large treatment effect (d = 1.376)

– NDP3 = small treatment effect (d = 0.319)

 

SECONDARY OUTCOMES

 

  • OUTCOME #4: Imitative accuracy of greater than 3 word utterances

– ReST and NDP3 = There was a small and significant difference from pretreatment to posttreatment1 for the combined groups (d = 0.443.)

 

  • OUTCOME #5: Score on the DEAP Inconsistency Test

– ReST and NDP3 = There was a large and significant difference from pretreatment to posttreatment1 for the combined groups (d = 1.14.)

 

  • OUTCOME #7: Score on Single Word Test of Polysyllables—PVC (Note the posttest occurred at posttreatment2 time; there are no data for posttreatment time 1.)

– ReST and NDP3 = There was a large and significant difference from pretreatment to posttreatment2 for the combined groups (d = 1.09.)

 

  • OUTCOME #9: Score on Single Word Test of Polysyllables- Percent Lexical Stress matches (Note the posttest occurred at posttreatment2 time; there are no data for posttreatment time 1.)

– ReST and NDP3 = = For the combined groups there was a large (d = 1.627) and significant improvement.

 

  • OUTCOME #10: Score on the GFTA-2 — PPC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = There was a small and significant difference from pretreatment to posttreatment2 for the combined groups (d = 0.438.)

 

  • OUTCOME #11: Score on the GFTA-2 – PVC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a large (d = 0.805) and significant improvement.

 

  • OUTCOME #12: Score on the GFTA-2– PCC (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a small (d = 0.298) and significant improvement. There was no significant difference between the groups.

 

  • OUTCOME #13 Score on the GFTA-2—Percent Lexical Stress Matches (Note the posttreatment assessment occurred at posttreatment2; there are no data for posttreatment1.)

– ReST and NDP3 = For the combined groups there was a large (d = 1.627) and significant improvement.

 

 

  1. Were maintenance data reported? Yes

 

PRIMARY OUTCOMES

 

  • OUTCOME #1: Accuracy on treated items: (NOTE: the stimuli differed in the 2 groups)

– ReST = significant group x time interactions revealed

  • a small (d = 0.420) gain from posttreatment1 and posttreatment2
  • a small gain (d = 0.463) from posttreatment2 to posttreatment3

     – NDP3 = = significant group x time interactions revealed

  • a small (d = – 0.206) decrease from posttreatment1 and posttreatment2
  • a moderate decrease (-d = 0.688) from posttreatment1 to posttreatment3

 

  • OUTCOME #2: Accuracy on untreated real words (generalization outcome)

– ReST and NDP3 = significant gains from

  • pretreatment to posttreatment2 (d= 0.290, small) and
  • pretreatment to posttreatment3 (d = 0.250, small)

 

 

  • OUTCOME #3: Accuracy on untreated pseudowords (generalization outcome)

– ReST = increased from

  • pretreatment to posttreatment2
  • pretreatment to postreatment3

– NDP3 = increased from

  • pretreatment to posttreatment2
  • pretreatment to postreatment3

 

SECONDARY OUTCOMES

 

  • OUTCOME #4: Imitative accuracy of greater than 3 word utterances

– ReST and NDP3 = There was a small and significant difference from pretreatment to posttreatment1 for the combined groups. The gain was maintained at posttreatment3.

 

  • OUTCOME #5: Score on the DEAP Inconsistency Test

– ReST and NDP3 = The gains remained stable

 

 

 

  1. Were generalization data reported? Yes

 

  • OUTCOME #2: Accuracy on untreated real words (generalization outcome) I

– ReST and NDP3 = There was a significant improvement for the combined groups. The combined level of improvement was moderate (d = 0.744.). The 2 treatment groups did not differ significantly. There also were significant improvements during the follow-up assessments.

  • pretreatment to posttreatment2 (d= 0.290, small) and
  • pretreatment to posttreatment3 (d = 0.250, small)

 

  • OUTCOME #3: Accuracy on untreated pseudowords (generalization outcome)

– ReST = significant time main effect and interaction effect from pretreatment to posttreatmen1 revealed large increase (d = 1.376) with ReST significantly larger than NDP3 (d = 0.319.)

 

 

  1. Describe briefly the experimental design of the investigation.

 

  • 26 children with CAS were randomly assigned to one of 2 treatment groups (ReST or NDP3.)
  • The 26 children were pretested on a variety of measures”

– accuracy of treated real words, untreated real words for generalization, untreated pseudowords for generalization (PRIMARY OUTCOMES)

– imitation of accuracy of 3 or more word combinations, DEAP Inconsistency, Single Word Test of Polysyllables, GFTA-3 (SECONDARY OUTCOMES)

– Severity ratings (DESCRIPTIVE INFORMATION)

– CELF-P2 OR CELF-4 (DESCRIPTIVE INFORMATON)

  • The children in both groups received similar doses of their interventions.
  • Although there were 3 posttreatment assessments, not all outcomes were tested at each of the assessments. The descriptive measures were only assessed at pretreatment.
  • The timing of the posttreatment assessments and the measures that were assessed at that time are

– Posttreatment1 – within1 week of termination of treatment – All Primary Outcomes and Imitative Accuracy of 3 or more word combinations

– Posttreatment2 – 1 month posttreatment – All Primary and Secondary Outcomes

– Posttreatment3 – 4 months posttreatment – All Primary Outcomes Outcomes and Imitative Accuracy of 3 or more word combinations

  • The results of the assessments were subjected to inferential statistical analysis.

 

 

ASSIGNED OVERALL GRADE FOR QUALITY OF EXTERNAL EVIDENCE: A

 

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: to investigate and compare the effectiveness of ReST and NDP3

 

POPULATION: CAS; children

 

MODALITY TARGETED: production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: stress- lexical, transitions (across sounds and syllables—no segregations or hesitations)

 

ELEMENTS OF PROSODY USED AS INTERVENTION: concordance/transitions

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: articulatory accuracy (consonants and vowels), articulatory groping, articulatory consistency

 

 

DOSAGE: 12 one-hour sessions, 4 times a week for 3 weeks; during school vacations

 

ADMINISTRATOR: supervised student speech-language pathologists (SLPs)

 

 

MAJOR COMPONENTS:

 

  • There were 2 treatments (ReST and NDP3); each P received only one treatment.

 

ReST

 

  • At the different stages, Ps produced 20 pseudowords until they achieved the criterion of 80% accuracy over 2 sessions for the targeted stage. Accuracy was defined as appropriated articulation, co-articulation, and prosody.

 

  • The stages were

– 2 syllable pseudowords (C1V1C2V2)

– 3 syllable pseudowords (C1V1C2V2C3V3)

– carrier phases that ended with a 3 syllable pseudoword (Can I have a C1V1C2V2C3V3?)

 

  • Half of all pseudowords were strong-weak-strong stress patterns with the final syllable being /i/ and the other half of the pseudowords were weak-strong-weak stress patterns with the final syllable being /∂/.

 

  • The composition of the pseudowords were individualized based on probes administered prior to pretreatment assessment.

 

  • Each treatment session had 2 Phases: Prepractice and Practice.

 

  • C elicited productions using imitation or (if P was a fluent reader) stimulus cards.

 

  • The Prepractice Phase (10 to 15 minutes of each session) comprised

– P’s production of at least 5 of 20 stimuli

– the following could be used to elicit the correct productions “imitation, phonetic placement cues, tapping out the stress pattern, segmenting and blending, and prosodic cues” (p. 674)

– following each of P’s productions, the clinician (C) provided knowledge of performance (KP) feedback.

 

  • The Practice Phase (approximately 50 minutes of each session) involved

– P’s accurate production with no cues of targets. The criterion was 80% accuracy over 2 consecutive sessions.

– Each session involved 100 trials in which there were 20 targeted/treated items; they were presented 5 times each.

– Each practice session was divided into 5 blocks of each of the 20 targeted/treated items. The items were presented one time in random orders.

– In each block, C provided knowledge of results (KR) feedback using a 50% decreasing schedule.

– If a P did not produce any correct productions in a trial, C added a new block.

 

NDP3

 

  • Cs followed the published NDP3 manual. However, they omitted the initial level of the program that involved oral motor training.

 

  • The Ps’ treatment programs were individualized by Cs who selected 3 goals for each P based on his/her performance on pretreatment assessments. Five targets were selected for each goal.

 

  • Using a game-based activities, C administered treatment for 18 minutes for each of the 3 individualized goals. P produced 30-40 trails per 18 minute session.

 

  • C elicited productions by have P name picture cares.

 

  • To move from one target to another target within a single goal, P was required to produce the target at 90% accuracy.
  • The following treatment techniques were used throughout the sessions:

– verbal instructions

– modeling

– articulation cues

– visual –tactile cues

  • C provided KP and KR feedback after each P production.

 

  • When P produced a correct response, he/she was directed to produce it 3 times which was followed by buy KP and KR feedback.

_______________________________________________________________

 


Beathard & Krout (2008)

April 14, 2017

 

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:

 

ASL = American Sign Language

C = Clinician

CAS = Childhood Apraxia of Speech

EBP = evidence-based practice

f = female

MT = music therapist

NA = not applicable

P = Patient or Participant

PEC Picture Exchange Communication

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

SOURCE: Bearthard, B., & Krout, R. E. (2008). A music therapy clinical case study of a girl with childhood apraxia of speech. The Arts in Psychotherapy, 35, 107-126.

 

REVIEWER(S): pmh

 

DATE: March 30, 2017

 

ASSIGNED OVERALL GRADE: D- (Based on the design of the investigation, the highest possible grade was D+. This overall grade ranks the quality of the evidence and does not reflect a judgment on the value of the intervention.)

 

TAKE AWAY: This case study describes music therapy designed for a child with Childhood Apraxia of Speech. Descriptions of the therapy and its results suggest improvement in some aspects of communication, literacy, and music.

                                                                                                           

 

  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? Case Study

                                                                                                           

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

Level = D+    

                                                                                                           

 

  1. Was phase of treatment concealed?
  • from participants? No
  • from clinicians? No

from data analyzers? No

 

 

  1. Was the participant (P) adequately described? Yes

 

– How many Ps were involved in the study? List here: 1     

 

– DESCRIBED Characteristics:

  • age: 3 years
  • gender: f
  • cognitive skills: at 20 months knew shapes, colors, and numbers 1-10
  • expressive language: did not use speech to communicate but used American Sign Language (ASL)
  • hearing: within normal limits
  • literacy: by 20 months could identify at least ½ of all capital letters
  • sensory skills: some issues including sensitivity to some food
  • previous therapy: at 18 months initiated speech, physical, occupational, and play therapy
  • motor skills: diagnosed with hypotonia
  • neurological status: MRI was within normal limits

                                                 

– Were the communication problems adequately described? No

  • List the disorder type(s): nonverbal, Childhood Apraxia of Speech (CAS); hypotonia
  • List other aspects of communication that were described:

no words were reported prior to interventions described in the case study

before intervention began and after speech therapy had begun at the age of 18 months, P produced the following syllables

  • bah
  • da
  • uh
  • oh
  • puh

– used American Sign Language (ASL)

     – before intervention began, the mother noted the participant (P) loved music

 

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Not applicable, this was a single case study.

                

  • If there was more than one participant, did at least 80% of the participants remain in the study? Not applicable
  • Were any data removed from the study? No

 

 

  1. Did the design include appropriate controls? No, this was a case study.

                                                                      

  • Were baseline/preintervention data collected on all behaviors? No

 

  • Did probes/intervention data include untrained stimuli? No Data were Provided

 

  • Did probes/intervention data include trained stimuli? No Data were Provided

 

  • Was the data collection continuous? No

 

  • Were different treatment counterbalanced or randomized? NA

 

 

  1. Were the outcome measures appropriate and meaningful? Yes

 

– OUTCOME MEASURES

 

  • OUTCOME #1: Communication Skills: Nonverbal and Verbal Skills (comprehension and production)
  • OUTCOME #2: Socialization
  • OUTCOME #3: Cognitive Skills
  • OUTCOME #4: Emotional Status
  • OUTCOME #5: Motor skills
  • OUTCOME #6: Sensory Status
  • OUTCOME #7: Perception and Spatial Skills
  • OUTCOME #8: Responsiveness to Music

 

ALL the outcomes were subjective.

 

NONE of the outcomes were objective.

 

No outcome measures were associated with reliability data.

 

 

  1. Results:

 

Did the target behavior(s) improve when treated? Yes, for the most part.

 

– Quality of improvement associated with the Outcomes was

 

  • OUTCOME #1: Communication Skills: Nonverbal and Verbal Skills (comprehension and production): moderate
  • OUTCOME #2: Socialization: limited
  • OUTCOME #3: Cognitive Skills: moderate
  • OUTCOME #4: Emotional Status: limited
  • OUTCOME #5: Motor skills: insufficient data to make decision
  • OUTCOME #6: Sensory Status: : insufficient data to make decision
  • OUTCOME #7: Perception and Spatial Skills: insufficient data to make decision
  • OUTCOME #8: Responsiveness to Music: moderate

 

 

NOTE: All the results were descriptive and were only provided in the description of each session. Summaries of descriptions of progress for each session are provide below.

 

DURING SESSION 1

 

  • OUTCOME #1: Communication Skills:

– P produced “uh” as a request and produced some ASL signs

– the Clinician (C) describe P as nonverbal

 

  • OUTCOME #2: Socialization

– C noted P gradually became open to engagement

 

  • OUTCOME #3: Cognitive Status

– C noted P was very active throughout the session

 

  • OUTCOME #6: Sensory Status

– C noted P had auditory sensory sensitivity

  • OUTCOME #8: Responsiveness to Music

– C noted P enjoyed music

 

 

SESSION #2

 

  • OUTCOME #1: Communication Skills

– C reported that

  • P’s eye contact and interactions increased
  • P produced /b/ several times
  • used ASL especially for colors

 

  • OUTCOME #3: Cognitive Skills

– C reported that P seemed aware of the relationship between /b/ and the letter “B”

 

  • OUTCOME #4: /Emotional Status

– C reported P

  • was happy throughout the session
  • was eager to attend
  • displayed an increase in eye contact and interactions

 

  • OUTCOME #8: Responsiveness to Music

– C reported P preferred the piano and guitar

 

 

SESSION #3

 

  • OUTCOME #1: Communication Skills:

– P was beginning to use vocalizations when she wanted to play an instrument

– C was able to prompt P to use selected consonants to signal desire to play an instrument

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P

  • enjoyed music
  • preferred the piano over other instruments
  • also liked the Q Chord

 

 

SESSION #4

 

  • OUTCOME #1: Communication Skills

– P used “buh” and “pah” to request musical instruments beginning with the sound.

 

  • OUTCOME #3: Cognitive Skills

– P’s attention span was very short during this session .

 

  • OUTCOME #8: Responsiveness to Music

– P preferred the drum and C used it as a reward during the session

 

 

SESSION #5

 

  • OUTCOME #1: Communication Skills

– P continued to use the initial sound of an instrument to request access to items

 

  • OUTCOME #2: Socialization

– P’s interactions with C continued to improve

 

  • OUTCOME #3: Cognitive Skills

– P’s attention improved.

 

  • OUTCOME #8: Responsiveness to Music

– P preferred the piano. C and P began to take “conversational” turns with instruments.

 

 

SESSION #6

 

  • OUTCOME #2: Socialization

– P’s interactions with C became increasingly playful.

 

  • OUTCOME #3: Cognitive Skills

– Attention continued to improve.

 

  • OUTCOME #8: Responsiveness to Music

– P preferred the Q-Chord and showed a preference to a Beatles song (“Michelle.”)

 

 

SESSION #7

 

  • OUTCOME #3: Cognitive Skills

– Attention level decreased, even for items/activities that previously were of interest.

 

  • OUTCOME #4: Emotional Status

– Some behavioral challenges were noted by the C.

 

  • OUTCOME #8: Responsiveness to Music

– P smiled and giggled to the “Hello” song.

 

 

SESSION #8

 

  • OUTCOME #1: Communication Skills:

– C reported that P increased

  • vocalizations
  • general communication skills (particularly during piano activities)
  • turn taking
  • imitation of syllables from words and portions of the Goodbye song.

 

  • OUTCOME #3: Cognitive Skills

– C reported that P increased attending behaviors

 

  • OUTCOME #8: Responsiveness to Music
  • C reported that P

– increased general communication skills (particularly during piano activities

– increased imitation of syllables from words and portions of the Goodbye song.

 

 

SESSION #9

 

  • OUTCOME #1: Communication Skills:

– C reported the following increases

  • interaction with C
  • turn taking
  • communicating needs with ASL and other gestures

 

  • OUTCOME #2: Socialization

– C reported the following increase: socialization skills

 

  • OUTCOME #3: Cognitive Skills

– C reported the following increase: attentiveness

 

  • OUTCOME #5: Motor skills

– P attempted to draw a face on the dry ease board (which had been modeled in previous sessions.)

 

  • OUTCOME #8: Responsiveness to Music

– C reported the following increase: interest in musical instruments

 

– P continued to prefer the piano.

 

 

SESSION #10

 

  • OUTCOME #1: Communication Skills:

– During the drawing activity P

  • with a single prompt vocalized individual syllables, markers, and blue marker.

– C reported that P demonstrated the following improvements:

  • imitating with mouth and lips syllables during the “Hello” song
  • vocalizing the initial syllable of instruments to signal that she wanted the instrument
  • turn taking
  • imitating mouth and lips for /i/, /e/,and /o/ during the “Old MacDonald” song.

 

  • OUTCOME #2: Socialization

– C reported that P demonstrated the following improvements:

  • turn taking
  • socializing
  • sustaining appropriate eye contact

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P demonstrated the following improvements:

  • imitating with mouth and lips syllables during the “Hello” song
  • imitating mouth and lips for /i/, /e/, and /o/ during the “Old MacDonald” song.

 

 

SESSION #11

 

  • OUTCOME #1: Communication Skills:

– C reported the following improvements:

  • increased communication skills with PEC symbols
  • independently vocalizing an initial sound when requesting an instrument
  • increased turn taking
  • vocalizing the letters of P’s name during the “Whose Name is This?” song

 

  • OUTCOME #2: Socialization

– C reported the following improvements:

  • increased socialization with the PEC symbols
  • increased turn taking

 

  • OUTCOME #8: Responsiveness to Music

– C reported the following improvement: vocalizing the letters of P’s name during the “Whose Name is This?” song

 

SESSION #12

 

  • OUTCOME #1: Communication Skills:

– C reported the following improvements:

  • increased mouthing of the “Hello” song
  • apparent linking of words to parts of the face during the drawing activity

 

  • OUTCOME #2: Socialization

– C reported the following improvement: increased playfulness with the balloons (which later in the session served as a distraction)

 

  • OUTCOME #3: Cognitive Skills

– C reported the following improvements:

  • increased attention
  • apparent linking of words to parts of the face during the drawing activity

 

  • OUTCOME #8: Responsiveness to Music

– C reported the following improvement: increased mouthing of the “Hello” song

 

 

SESSION #13

 

  • OUTCOME #1: Communication Skills:

– C reported the following improvement: increased mouthing of words during the “Hello” song

 

  • OUTCOME #3: Cognitive Skills

– C reported the following improvement: increased attention during the “Hello” song

 

SESSION #14

 

  • OUTCOME #1: Communication Skills:

– C reported the following improvements:

  • increased interactions
  • increased communication during the “Old MacDonald” song
  • increased vocalizations during the “Old MacDonald” song
  • increased following directions during the “Old MacDonald” song

 

  • OUTCOME #2: Socialization

– C reported the following improvements:

  • increased interactions
  • increased enjoyment (such as smiling and laugher) during the “Old MacDonald” song

 

  • OUTCOME #3: Cognitive Skills

– C reported the following improvement: increased attention

 

  • OUTCOME #4: Emotional Status

– C reported the following improvement: increased enjoyment (such as smiling and laugher) during the “Old MacDonald” song

 

  • OUTCOME #5: Motor skills

– C reported the following improvement: increased sitting time

 

  • OUTCOME #8: Responsiveness to Music

– C reported the following improvements:

  • increased enjoyment (such as smiling and laugher) during the “Old MacDonald” song
  • increased communication during the “Old MacDonald” song
  • increased vocalizations during the “Old MacDonald” song
  • increased following direction during the “Old MacDonald” song

 

 

SESSION #15

 

  • OUTCOME #1: Communication Skills

– C reported that P

  • communicated with C upon initially seeing her
  • had increased her verbal ability dramatically over the break
  • vocalized and verbalized sounds and words during the “Old MacDonald” song and other interactions

 

  • OUTCOME #2: Socialization

– C reported that P appeared to be happy to return

 

  • OUTCOME #3: Cognitive Skills

– C reported that P sounded out letters

 

  • OUTCOME #4: Emotional Status

– C reported that P appeared to be happy to return

  • communicated with C upon initially seeing her

 

  • OUTCOME #7: Perception and Spatial Skills

– C reported that appeared to enjoy tasks that included visual aids

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P vocalized and verbalized sounds and words during the “Old MacDonald” song

 

 

SESSION #16

 

  • OUTCOME #1: Communication Skills:

– C reported that

  • vocalization of letter sounds and syllables increased
  • verbalization of words increased
  • P’s responses to questions were more accurate
  • P was more likely to respond at the appropriate time during songs
  • P said “more” when she wanted more music

 

  • OUTCOME #3: Cognitive Skills

– C reported that

  • on-task behavior increased
  • cognitive skills increased
  • P’s responses to questions were more accurate

 

  • OUTCOME #8: Responsiveness to Music

– C reported that

  • P was more likely to respond at the appropriate time during songs
  • P said “more” when she wanted more music

 

 

 

SESSION #17

 

  • Progress was not noted on any of the outcomes for this session.

 

 

SESSION #18

 

  • OUTCOME #1: Communication Skills:

– C reported that P

  • increased vocalizations of sound combinations and parts of words
  • increased overall vocalization attempts

 

  • OUTCOME #3: Cognitive Skills

– C reported that P displayed interest in pairing musical note names with letters

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P

  • displayed interest in the old “Hello” song.
  • displayed interest in the “Letter Tree” song
  • displayed interest in pairing musical note names with letters

 

 

SESSION #19

 

  • OUTCOME #1: Communication Skills:

– C reported that

  • P displayed a preference for the Letter Tree, Name, and Button Song interventions.
  • P increased vocalizations of letter, sound combinations, and parts of words.

 

  • OUTCOME #3: Cognitive Skills

– C reported that

  • P matched a picture of a piano with the piano in the room.
  • P matched verbal and written letters with the names of the musical notes.
  • P displayed a preference for the Letter Tree, Name, and Button Song interventions.

 

  • OUTCOME #8: Responsiveness to Music

– C reported that

  • P matched verbal and written letters with the names of the musical notes.
  • P displayed a preference for the Letter Tree, Name, and Button Song interventions.

 

SESSION #20

 

  • OUTCOME #1: Communication Skills:

– C reported that P

  • increased vocalizations and verbalizations during the “Button” song.
  • counted every ant on every page by vocalizing for each number.
  • while playing the piano, she used hand signals to represent “loud” and “soft.”
  • without models produced vocalizations for several words and sounds.
  • produced babbling/singing

 

  • OUTCOME #3: Cognitive Skills

– C reported that P counted every ant on every page by vocalizing for each number.

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P

  • increased vocalizations and verbalizations during the “Button” song.
  • enjoyed the “Ants Go Marching In” board book/song activity.
  • showed a preference for the piano
  • while playing the piano, she used hand signals to represent “loud” and “soft.

 

 

SESSION #21

 

  • OUTCOME #1: Communication Skills:

– C reported that P

  • independently produced several sounds during “Old MacDonald” but appeared to be frustrated and/or bored.
  • indicated that she wanted to play an instrument by herself by producing a 3 word phrase
  • when playing with the bubbles attempted to say “pop.”

 

  • OUTCOME #3: Cognitive Skills

– C reported that P displayed decreased attention

 

  • OUTCOME #4: Emotional Status

– C reported that P

  • was excited to return to therapy after a 1 month hiatus
  • displayed decreased attention, perhaps due to her excitement
  • enjoyed playing with the bubbles
  • independently produced several sounds during “Old MacDonald” but appeared to be frustrated and/or bored.

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P

  • independently produced several sounds during “Old MacDonald” but appeared to be frustrated and/or bored.
  • indicated that she wanted to play an instrument by herself by producing a 3 word phrase

 

 

SESSION #22

 

  • OUTCOME #1: Communication Skills:

– C reported that P

  • vocalized letter combinations during the “Name” and “Button” songs.
  • vocalized indicated appropriate letters during the “Name” and “Button” songs.
  • drew the letter ‘b’ and produced the sound

 

  • OUTCOME #2: Socialization

– C reported that P displayed increased “participation, energy, smiles, and excited flapping of hands” (p. 114)

 

  • OUTCOME #3: Cognitive Skills

– C reported that P

  • vocalized indicated appropriate letters during the “Name” and “Button” songs.
  • preferred visual and interactive aids
  • drew the letter ‘b’ and produced the sound

 

  • OUTCOME #4: Emotional Status

– C reported that P

  • enjoyed the session
  • displayed increased “participation, energy, smiles, and excited flapping of hands” (p. 114)

 

  • OUTCOME #6: Sensory Status

– C reported that P preferred visual and interactive aids

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P

  • vocalized letter combinations during the “Name” and “Button” songs.
  • vocalized indicated appropriate letters during the “Name” and “Button” songs.

 

 

SESSION #23

 

  • OUTCOME #1: Communication Skills:

– C reported that P

  • displayed improved direction following during the “Bubbles” song
  • increased vocalization skills.

 

  • OUTCOME #3: Cognitive Skills

– C reported that P

  • displayed improved direction following during the “Bubbles” song
  • displayed increased cognitive skills

 

  • OUTCOME #4: Emotional Status

– C reported that P improved her self-control during the “Bubbles” song

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P

  • improved her self-control during the “Bubbles” song
  • displayed improved direction following during the “Bubbles” song

 

 

SESSION #24

 

  • OUTCOME #1: Communication Skills:

– C reported that P did not follow directions

 

  • OUTCOME #2: Socialization

– C reported that P

  • displayed several behavioral challenges during the session

 

  • OUTCOME #3: Cognitive Skills

– C reported that P did not follow directions

 

  • OUTCOME #4: Emotional Status

– C reported that P

  • displayed several behavioral challenges during the session
  • appeared to enjoy the bubble activity

 

  • OUTCOME #8: Responsiveness to Music

– C reported that P played inappropriately with the musical instruments

 

 

OVERALL PROGRESS

 

In the summary of P’s treatment, the investigator noted that P moved from being almost entirely nonverbal to vocalizing (sounds and sound combinations) and verbalizing (i.e., words and a phrase.) She also displayed knowledge of some letter and their associated sounds.

 

 

  1. Description of baseline:

 

  • Were baseline data provided? No

                                               

 

  1. What is the clinical significance? NA, data were not provided.

 

 

  1. 11. Was information about treatment fidelity adequate? Not Provided

 

 

  1. Were maintenance data reported? No

 

 

  1. Were generalization data reported? No

 

 

  1. Brief description of the design:
  • Under the supervision of the second investigator, the first investigator provided music therapy to a child who had been diagnosed with CAS.

 

  • The music therapy treatment approach was described as “data-driven” which the authors described as a combination of “behavioral, improvisational, and creative approaches” (p. 107) including “musical interventions, visual, and interactive aids…as well as engaging, playful dialogue” (p. 107.)

 

  • Supporting data consisted of session notes in which judgments about improvement were noted.

 

ASSIGNED OVERALL GRADE OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: D-

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: to describe a course of music therapy

 

POPULATION: Childhood Apraxia of Speech; Children

 

MODALITY TARGETED: production, comprehension

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: music (pitch, rhythm, timing)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: overall communication skills, literacy

 

OTHER TARGETS: socialization, cognition, attention, emotional status, motor skills, sensory status, perception and spatial skills, responsiveness to music

 

DOSAGE: 1 hours a week, over 9 months (24 sessions dues to breaks)

 

ADMINISTRATOR: music therapist graduate student (MT)

 

MAJOR COMPONENTS:

 

  • The stages of treatment were (p. 109)

– referring the participant (P)

– building rapport

– assessing the P

– determining goals, objectives, targets

– identifying intervention strategies

– developing the intervention plan

– administering the intervention plan

– evaluating P’s progress

– terminating the intervention

 

NOTE: When the authors did not describe the procedure, the sessions are NOT listed below.

 

DEVELOPING RAPPORT AND ASSESSING THE P (Sessions 1-3)

 

SESSION 1:

  • C played musical instruments to get P’s attention and observed her

– likes and dislikes

– communicative strategies

– activity level

 

 

SESSION 2:

  • This was the first session in which the parents observed from outside the room.

 

  • C oriented P to the physical set up.

 

  • C made observations about P’s communication, literacy, and music [reference

 

 

SESSION 3:

  • C continued to observe P during this final session.

 

  • As the result of the observations of during Sessions 1-3, C described the following characteristics of P:

– P was nonverbal

– P had a short attention span

– P’s gross motor development was delayed (e.g., unsteady gait, sitting at the piano was a challenge)

– P displayed sensory sensitivity problems

– P enjoyed music

– P used some ASL signs

– P produced “uh”

 

TREATMENT SESSIONS (SESSIONS 4 -7): EXPLORATION

 

  • C rearranged the room, placing instruments within sight but out of reach.

 

  • Each instrument was labeled with a letter indicating its first sound. The purpose of this was to encourage P to produce the initial sound on an instrument to gain access to it

 

  • C also introduced Picture Exchange Communication (PEC) symbols and a communication board to facilitate requesting.

 

  • Sessions were structured around play and play activities using toys, books, and so forth to encourage sound production and engagement.

 

  • Each week the session involved a theme which included the music therapy activities, the beginning and end of the session were marked by “Hello” and “Goodbye” songs.

 

  • Each session included at least one theme-based new song with visual aids. The songs and added were placed in the P’s songbook.

 

  • Intervention involved a number of treatment approaches.

 

  • C allowed P to explore the therapy room.

 

 

TREATMENT SESSIONS (SESSIONS 8 -14): INTRODUCING

VISUAL AND INTERACTIVE AIDS

 

  • C began to include sound-based activities. Specifically, she used “Sound Box Songs” and “Easy Does It for Apraxia-Preschool Series.”

 

SESSION 8:

  • C increased focus on facilitating interactions (e.g., using toys, visual aids, and bubble.)

 

 

SESSION 9:

  • C focused on drawing on a dry erase board due to P’s interest in the task. The drawing activity was regularly used in subsequent sessions.

 

 

SESSION 11:

  • C continued to add new songs. In this session, she added “Whose Name is This?” which appeared to be of interest to P.

 

 

SESSION 12:

  • C provided several balloon to the session

 

 

SESSION 13:

  • C moved introduction of the balloons to the end of the session.

 

  • C noted that pauses in the music helped to elicit mouthing or vocalizing

 

  • C changed “Welcome” to “Hello” during to drawing activity.

 

 

SESSION 14:

  • The furniture in the therapy room was changed to include child-sized chairs and tables.

 

  • Hand motions used during speech therapy were added to the sessions to facilitate mouthing and vocalizing.

 

  • This was the last session of the Fall Term. Therapy would resume 8 weeks later.

 

 

TREATMENT SESSIONS (SESSIONS 15 -21): VERBALIZATION AND DRAWING

 

  • Therapy was re-initiated after an 8 week winter break. However, there was an additional hiatus between Sessions 20 and 21.

 

SESSION 16:

  • New farm animals were added to the “Old MacDonald” song.

 

 

SESSION 17:

  • C introduced a new “Hello” song.

 

  • Several factors (P’s fatigue, the new song, physical issues) contributed to confusion and limited attention during the session.

 

SESSION 18:

  • C returned to the old “Hello” song.

 

 

SESSION 19:

  • C used flash cards during this session. From the prose, it could be assumed that this intervention had been used previously.

 

 

SESSION 20:

  • C introduced “Ants Go Marching In” board book/song intervention.

 

  • C assisted P in sounding out words of items she wanted.

 

 

SESSION 21:

  • There was a break of 1 month between Session 20 and 21.

 

  • The following changes in intervention plans had been made noted for Session 21 in Session 20 notes.

– include word music in interventions

– include numbers and words for the numbers in modeling

– include written words on Flash Cards

 

– C reported that P

  • was excited to return to therapy after a 1 month hiatus
  • displayed decreased attention, perhaps due to her excitement
  • independently produced several sounds during “Old MacDonald” but appeared to be frustrated and/or bored.
  • indicated that she wanted to play an instrument by herself by producing a 3 word phrase
  • enjoyed playing with the bubbles

¶ when playing with the bubbles attempted to say “pop.”

 

 

TREATMENT SESSIONS (SESSIONS 22-24): TERMINATION

 

 

SESSION 22:

  • C added a new song: the “Easter” song that was paired “with interactive aids” (p. 114.)

 

 

SESSION 23

  • C used the bubble activity as a reward.

 

 

SESSION 24:

  • This was the final session

 

 


Gee (2010)

August 20, 2016

CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

(also known as Expert Opinion)

 

NOTES: A summary of the intervention presented in this article can be found by scrolling approximately ½ way down this page.

 

KEY
C = clinician

CAS = childhood apraxia of speech

NA = not applicable

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

 

 

Source: Gee, S. M. (2010). Pediatric speech-language pathology corner: Improving prosody in childhood apraxia of speech. ARTICLE Retrieved on August 16, 2016 from http://www.pediastaff.com/blog/speech-language-pathology-corner-improving-prosody-in-childhood-apraxia-of-speech-1389 ARTICLE:

 

Reviewer(s): pmh

 

Date: August 18, 2016

 

Overall Assigned Grade: No grade because there are no supporting data.

 

Level of Evidence: 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 brief, thoughtful discussion of role of prosody in the treatment of childhood apraxia of speech (CAS) provides a rationale for targeting prosody relatively early in the intervention process to reduce, or even prevent, the atypical prosody often observed in the speech of children with CAS. The author recommends focusing on coarticulation or concordance which involves the smooth transition from one speech sound to the next.

 

 

  1. Was there a review of the literature supporting components of the intervention? No. This was a very short article.

 

 

  1. Were the specific procedures/components of the intervention tied to the reviewed literature? Not Applicable

 

 

  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? Yes _ ____

 

  • Outcome #1: Production of speech with acceptable coarticulation (smooth transitions between adjacent speech sounds) or concordance

 

 

  1. Was generalization addressed? No

 

 

  1. Was maintenance addressed? No

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To produce speech that has a natural, fluid flow.

 

POPULATION: Childhood Apraxia of Speech; Children

 

MODALITY TARGETED: Production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: concordance/coarticulation, tempo (blending phonemes, pausing), stress (weak strong forms)

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: speech sounds (flapping or voicing of /t/ before unstressed syllables)

 

MAJOR COMPONENTS:

 

  • Initiate prosody intervention when the participant (P) can use CVC syllables to label objects. At this time, intervention should also target the production of 2 syllable words.

 

  • The clinician (C) should model and require P to produce “a” before all single syllable words. (Obviously, this also targets the production of articles, thus preventing the omission of articles in the speech of the P.)

 

  • As the P starts to use 2 word phrases, C should target Verb + Article + Object (e.g., hit a ball) instead of Verb + Object (e.g., hit ball.)

 

  • C models and encourages P to produce /t/ as /d/ when /t/ precedes an unstressed syllable beginning with a vowel in 2 syllable words.

 

  • C models and encourages P to produce the unstressed versions of “a” and “the.”

 

 

 


Helfrich-Miller (1984)

August 24, 2014

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.

 

KEY:

C = clinician

CAS = Childhood Apraxia of Speech

P = participant or patient

pmh = Patricia Hargrove, blog developer

MIT = Melodic Intonation Therapy

NA = not applicable

SLP = speech-language pathologist

 

SOURCE: Helfrich-Miller, K. R. (1984). Melodic Intonation Therapy with developmentally apraxic children. Seminars in Speech and Language, 5, 119-126.

 

REVIEWER(S): pmh

 

DATE: August 23, 2014

 

ASSIGNED OVERALL GRADE: D- (Because the evidence involved summaries of 2 case studies and 1 single subject experimental design, the highest possible grade was D+.)

 

TAKE AWAY: To support this program description of an adaptation of Melodic Intonation Therapy (MIT) to Childhood Apraxia of Speech (CAS) the investigator included 3 brief summaries of previously presented cases. The cases indicate that MIT results in change in articulation measures and one measure of duration and, to a lesser degree, listener perception.

                                                                                                           

 

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

                                                                                                           

 

  1. What type of evidence was identified?
  2. What type of single subject design was used? Case Studie – Program Description with Case Illustrations: summaries of previously reported investigations— 2 of the investigations were case studies; 1 was a single-subject experimental design (time series withdrawal)
  3. What was the level of support associated with the type of evidence?

Level = D+                                                      

 

                                                                                                           

  1. Was phase of treatment concealed?
  2. from participants? No
  3. from clinicians? No
  4. from data analyzers? No

 

 

  1. Were the participants adequately described? No
  2. How many participants were involved in the study? 3
  3. The following characteristics/variables were described:
  • age: 10 years old (1); not provided (2)
  • gender: m (all 3)
  1. Were the communication problems adequately described? No
  • The disorder type was CAS.
  • Other aspects of communication were noy described.

                                                                                                                       

  1. Was membership in treatment maintained throughout the study? Yes
  2. If there was more than one participant, did at least 80% of the participants remain in the study? Yes
  3. Were any data removed from the study? No

 

 

  1. Did the design include appropriate controls? Varied. The case studies did not have adequate controls but the single subject experimental design may have. (Controls were not clearly described.)
  2. Were preintervention data collected on all behaviors? Varied. The summary of the case studies provided this information but the summary of the single subject experimental design did not.
  3. Did probes/intervention data include untrained data? Unclear
  4. Did probes/intervention data include trained data? Unclear
  5. Was the data collection continuous? No
  6. Were different treatment counterbalanced or randomized? Not Applicable

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes
  2. The outcomes were

OUTCOME #1: number of articulation errors (case studies)

OUTCOME #2: percentage of articulation errors (case studies)

OUTCOME #3: vowel duration (single subject experimental design)

OUTCOME #4: percentage duration of the final contour compared to the whole utterance (single subject experimental design)

OUTCOME #5: listener judgment (single subject experimental design)

 

  1. The following outcomes are subjective:

OUTCOME #1: number of articulation errors (case studies)

OUTCOME #2: percentage of articulation errors (case studies)

OUTCOME #5: listener judgment (single subject experimental design)

                                                                                                             

  1. The following outcomes are objective:

OUTCOME #3: vowel duration (single subject experimental design)

OUTCOME #4: percentage duration of the final contour compared to the whole utterance (single subject experimental design)

                                                                                                             

  1. None of the outcome measures are associated with reliability data.

 

 

  1. Results:
  2. Did the target behavior improve when it was treated? Inconsistent
  3. b. The overall quality of improvement was

OUTCOME #1: number of articulation errors (case studies)– moderate

OUTCOME #2: percentage of articulation errors (case studies)– moderate

OUTCOME #3: vowel duration (single subject experimental design)- – unclear but there was a significant difference in pre and post testing

OUTCOME #4: percentage duration of the final contour compared to the whole utterance (single subject experimental design)– ineffective

OUTCOME #5: listener judgment (single subject experimental design)—The investigator noted a trend toward improvement but did not note whether or not the change was significant.

 

 

  1. Description of baseline: Were baseline data provided? No

 

 

  1. What was the magnitude of the treatment effect? NA

 

 

  1. Was information about treatment fidelity adequate? Not Provided

 

 

  1. Were maintenance data reported? Yes. The outcomes associated with the case studies measured maintenance. The investigator measured the Outcomes #1 (number of articulation errors) and #2 (percentage of articulation errors) 6 months after the termination of therapy. The results indicated that gains were maintained for both outcomes.

 

  1. Were generalization data reported? Yes. Since none of the outcomes were direct targets of intervention, all of them could be considered generalization. Accordingly, the findings were

OUTCOME #1: number of articulation errors (case studies)—moderate improvement

OUTCOME #2: percentage of articulation errors (case studies)—moderate improvement

OUTCOME #3: vowel duration (single subject experimental design)- – Results were unclear but there was a significant difference in pre and post testing

OUTCOME #4: percentage duration of the final contour compared to the whole utterance (single subject experimental design)– ineffective

OUTCOME #5: listener judgment (single subject experimental design)—The investigator noted a trend toward improvement but did not note whether or not the change was significant. There was no description of the magnitude of the change.

 

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: D-

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To describe an adaptation of MIT for children with CAS

 

POPULATION: Childhood Apraxia of Speech; Child

 

MODALITY TARGETED: expression

 

ELEMENTS OF PROSODY TREATED: duration

 

ELEMENTS OF PROSODY USED AS INTERVENTION: tempo (rate, duration), rhythm, stress, intonation

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: articulation

 

OTHER TARGETS: listener perception

 

DOSAGE: The investigator reported that average course of treatment using MIT for CAS involves 10-12 months of therapy meeting 3 times a week.

 

ADMINISTRATOR: SLP

 

STIMULI: auditory, visual/gestural

 

MAJOR COMPONENTS:

 

  • MIT focuses on 4 aspects of prosody:
  1. stylized intonation (melodic line)
  2. lengthened tempo (reduced rate)
  3. exaggerated rhythm
  4. exaggerated stress

 

  • It is best to avoid modeling patterns that are similar to known songs.

 

  • Each session includes 10 to 20 target utterances and no 2 consecutive sessions contain the same target utterances.

 

  • C selects a sentence and then moves it through each step associated with the current level of treatment. When P successfully produces the sentence at all the steps of the current level, C switches to the next sentence beginning at Step 1 of that level.

 

  • To move out of a level, P must achieve 90% correct responses in 10 consecutive sessions. Tables 3, 4, and 5 provide criteria for correct response in the different Levels of Instruction.

 

  • There are 3 Levels of Instruction.

 

  • As Ps progress within and through the levels

– utterances increase in complexity

– the phonemic structure of words increases.

– C reduces cueing

– C increases the naturalness of intonation in models and targets.

 

  • Tables 1 and 2 contain criteria and examples for the formulation of target utterances.

 

  • The purpose of MIT is to sequence words and phrases.

 

  • Unlike the original MIT, this adaptation pairs productions with signs (instead of tapping).

 

  • Tables 3, 4, and 5 as well as the accompanying prose in the article, provide detailed descriptions of the program. The following is a summary of those descriptions:

 

LEVEL 1

 

  • If P fails any step with a targeted utterance, that target is terminated and C selects a new utterance.

 

Step 1.   C models and signs the intoned target utterance 2 times and does not require C to imitate.

 

Step 2. C and P produce the targeted intoned utterance and the sign in unison.

 

Step 3. C continues with the targeted intoned utterance but fades the unison cues.

 

Step 4. C models the intoned target utterance and the sign. P imitates the intoned target utterance.

 

Step 5. C asks a question to elicit the intoned target utterance (e.g., “What did you say?”) P produces the intoned target utterance.

 

Step 6. C asks a question to elicit the last words of the intoned target utterance (e.g., if the intoned target utterance was “Buy the ball,” the question could be “What do you want to buy?”)

 

LEVEL 2:

 

Step 1. C models and signs the intoned target utterance 2 times and does not require C to imitate.

 

Step 2. C and P produce the targeted intoned utterance and the sign in unison.

 

Step 3. C continues with the targeted intoned utterance but adds a 6 second delay before P can intone the targeted utterance. If P has trouble with this step, C can use a “back-up” which involves returning to the previous step with the targeted intoned utterance.

 

Step 4. C asks a question to elicit the intoned target utterance (e.g., “What did you say?”) P produces the intoned target utterance.

 

Step 5. C asks a question to elicit the last words of the intoned target utterance (e.g., if the intoned target utterance was “Open the door”, the question could be “What should I open?”)

 

LEVEL 3:

 

Step 1. C models and signs the intoned target utterance, P intones and signs the utterance. If P fails, the “back-up” is unison intonation with C fading the cueing.

 

Step 2. C presents the target utterance using Sprechgesang (or speech song– an intoned production that is not singing) and signing. P is not required to respond.

 

Step 3. C and P, in unison, produce the targeted utterance using Sprechgesang and signing. If P fails, the back up is to repeat Step 2.

 

Step 4. C presents the targeted utterance with normal prosody and no signing. P imitates the targeted utterance with normal prosody.

 

Step 5. C asks a question to elicit the target utterance (e.g., “What did you say?”) P produces the target utterance after a 6 second delay.

 

Step 6. C asks a question to elicit the last words of the target utterance (e.g., if the target utterance was “I want more juice,” the question could be “What do you want?”)

 

 

 


Maas & Farinella (2012)

August 12, 2014

Single Subject Designs

 

Notes:

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

2. Key:

C = clinician

CAS = childhood apraxia of speech

CNT = could not test

DTTC = Dynamic Temporal and Tactile Cueing

ES = effect size

NA = not applicable

P = participant or patient

S = strong syllable

SLP = speech=language pathologist

w = weak syllable

WNL = within normal limits

 

SOURCE: Maas, E., & Farinella, K. A. (2012). Random versus blocked practice in treatment for childhood apraxia of speech. Language, Speech, and Hearing Services in Schools, 55, 561-578.

 

REVIEWER(S): pmh

 

DATE: August 8, 2014

ASSIGNED OVERALL GRADE: B+

 

TAKE AWAY: The focus of these single subject experimental design investigations was to determine if there was an advantage for blocked versus random practice for children with childhood apraxia of speech (CAS). The investigation is relevant to this blog because the intervention involved the manipulation of rate. The investigators included a thorough description of the participants (Ps), intervention, and scoring of P responses to treatment conventions. The intervention was judged to be effective for 3 of the 4 Ps but the results regarding the practice schedule were equivocal.

                                                                                                           

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

                                                                                                           

 

  1. What type of evidence was identified?

a. What type of single subject design was used? Single Subject Experimental Design with Specific Clients- Alternating Treatments Design with Multiple Baselines across Behaviors

                                                                                                           

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

Level = A                                                         

 

                                                                                                           

  1. Was phase of treatment concealed?

a. from participants? No

b. from clinicians? No

c. from data analyzers? Yes

 

 

  1. Were the participants adequately described? Yes

a. How many participants were involved in the study? List here: 4

 

b. The following characteristics were described:

  • age: 5;0 to 7;9
  • gender: 2m; 2f
  • expressive language: moderate delay (2); severe delay (1); could not test (CNT, 1)
  • receptive language: within normal limits (WNL, 2); low- average (1); mild-moderate delay (1)
  • language spoken: all monolingual English speakers
  • Hearing: all WNL
  • Medical/neurological diagnosis: none had diagnoses at the time of the investigation
  • motor skills: limited manual motor skills (1); history of hypotonia and gross/fine motor delay (1)
  • sensory processing skills: impaired (1)

                                                 

c. Were the communication problems adequately described? Yes

  • The disorder type was CAS
  • Other aspects of communication that were described for each of the Ps:

P1

  • inconsistent vowel/consonant substitutions/distortions
  • segmented speech
  • intermittent hypernasality
  • equal and incorrect stress in multisyllabic words
  • reduced intelligibility
  • inconsistent phonological patterns

P2

  • inconsistent vowel/consonant errors
  • articulatory groping
  • intermittent hypernasality
  • breathy/harsh voice quality
  • stereotypical nonword utterance
  • mild left facial asymmetry
  • possible mild unilateral upper motor neuron dysarthria

P3

  • moderate-severe dysarthria (mixed spastic-flaccid)
  • inconsistent consonants/vowels errors
  • speech sound and syllable segmentation
  • intermittent hypernasality
  • intermittent hoarse/breathy voice quality
  • weakness of the tongue
  • prosodic abnormalities (incorrect and equal stress, reduced speech rate)

P4

  • prosodic abnormalities (incorrect and excessive stress, segmentation of syllables)
  • occasional speech sound distortions and vowel errors were occasionally observed

                                                                                                                       

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

a. If there was more than one participant, did at least 80% of the participants remain in the study? Yes

b. Were any data removed from the study? No

 

 

  1. Did the design include appropriate controls? Yes

a. Were baseline collected on all behaviors? Yes

b. Did probes include untrained data? Yes

c. Did probes include trained data? Yes

d. Was the data collection continuous? No

e. Were different treatment counterbalanced or randomized? Yes

  1. f. Was treatment counterbalanced or randomized? Randomized?

 

 

  1. Were the outcomes measure appropriate and meaningful? Yes

a. The outcome:

OUTCOME #1*: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probes

* The investigators designed separate word lists for each P, taking into consideration speech sound error profiles. The following were the targets:

– initial cluster

– 2 syllable words

– 3 syllable words

– final clusters

– final fricative

– final liquids

– initial fricatives

– initial liquids

– 4 syllable Strong-Weak-Strong-Weak (SwSw) words

– 4 syllable wSwS words

– 3 syllable wSw words

– 3 syllable Sww words

b. The outcome was subjective.

c. The outcomes was not objective.                                            

d. The investigators provided outcome reliability data.

e.  The mean interrater reliability ranged from 79% to 87%.

 

  1. Results:
  2. Did the target behavior improve when it was treated? Inconsistent
  3. b.   For

OUTCOME #1: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probes —The overall quality of improvement was moderate

– P1, P3, P4 –improved **

– P2 did not improve

(**NOTE–The findings regarding the relative effectiveness of the practice schedule were equivocal; 2Ps exhibited stronger progress for the blocked schedule and 1P exhibited stronger progress with the random schedule.)

  1. Description of baseline:
  2. Were baseline data provided? Yes

OUTCOME #1: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probes – 3 data points

 

  1. Was baseline low and stable? (The numbers should match the numbers in item 7a.)

OUTCOME #1: For the most part, baseline was low (the highest percentage correct of a target during baseline was approximately 35%) and moderately stable.

                                                                                       

c & d. What was the percentage of nonoverlapping data (PND)?

OUTCOME #1: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probe

  • P1 – PND was 75% to 100% (fairly to highly effective)
  • P2 – PND was 0% for all targets (ineffective)
  • P3 – PND was 0% to 75% (ineffective to fairly effective)
  • P4 – PND was 0% to 50% (ineffective to questionable effectiveness)

 

 

  1. What was the magnitude of the treatment effect.”

 

NOTE: The investigators used an effect size (ES) of 1.00 or more as evidence of effectiveness (p. 567); there was no gradation for effectiveness.

OUTCOME #1: Improved accuracy (speech sound, lexical stress, segmentation/concordance) on target probe

  • P1 – ES was 3.55 (random) and 4.04 (block)
  • P2 – ES was 0.62 (blocked); random could not be calculated because of zero variance.
  • P3 – ES was 3.16 (random) and 1.50 (block)
  • P4 – ES was 1.31 (random) and 1.69 (block)

 

  1. Was information about treatment fidelity adequate? Yes. Treatment fidelity ranged from 61% to 88%. One P was associated with percentages ranging from 61% to 71%. All other Ps had percentages of 75% or above.

 

 

  1. Were maintenance data reported? Yes. There were multiple specific targets for each of the Ps. Although there were some exceptions, for the most part, Ps did not maintain their gains in therapy at a follow-up session one month after termination of the investigation.

 

 

  1. Were generalization data reported? Yes Generalization varied; overall should be described as limited.

 

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: B+

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To improve motor speech learning

POPULATION: Childhood Apraxia of Speech; Child

 

MODALITY TARGETED: expression

 

ELEMENTS OF PROSODY USED AS INTERVENTION: rate

 

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED: speech sounds

DOSAGE: 3 times a week,

 

ADMINISTRATOR: SLP or a graduate clinician

 

STIMULI: visual stimuli (index cards—10 of each target), auditory stimuli, tactile cues

 

MAJOR COMPONENTS:

  • The investigators use Dynamic Temporal and Tactile Cueing (DTTC) as a treatment but they compared using random and blocked practice schedules for their investigation.
  • DTTC includes motor learning, modeling, integral stimulation, drill, focus on core vocabulary, rate reduction, variation in gap between C’s model and P’s attempt, tactile cues, reinforcement, and variation in feedback schedule.
  • Blocked Practice = index cards for the same word were practiced together and then C moved on to the next word
  • Random Practice = C shuffled the all the cards that were to be used for that day’s session

 

  • C provided verbal feedback to P only 60% of the time
  • Steps in DCCT

1. C directs P “Watch me, listen carefully, and repeat after me” (p. 577). C then produces the target word on the index card.

2. When P is correct, C waits 2 to 3 seconds, and either

– provides feedback (60% of the time) and reinforces C tangibly (e.g., stickers or bubbles) and

– goes to the next word.

3. When P is incorrect,

– during feedback trials (60% of the time)

  • C waits 2- 3 seconds
  • C notes that the production was not accurate and describes how it was inaccurate
  • up to 2 times, C and P slowly and simultaneously produce the target word
  • C then fades support by only mouthing the target word during an attempt to produce it
  • C produces the word and P immediately imitates it
  • C waits 2 to 3 seconds before providing feedback

– during No Feedback trials (40% of the time)

  • C waits 2- 3 seconds
  • up to 2 times, C and P slowly and simultaneously produce the target word
  • C then fades support by only mouthing the target word during an attempt to produce it
  • C produces the word and P immediately imitates it
  • C waits 2 to 3 seconds and then says “Now let’s do another one” (p. 577).