Matsuda & Yamamoto (2013)

January 29, 2015

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:

ASD = autism spectrum disorders

C = Clinician

CA = chronological age

CARS = Childhood Autism Rating Scale

EBP = evidence-based practice

MA = mental age

MTS = matching to sample

NA = not applicable

P = Patient or Participant

pmh = Patricia Hargrove, blog developer

SLP = speech–language pathologist

 

 

SOURCE: Matsuda, S., & Yamamoto, J. (2013). Intervention for increasing comprehension of affective prosody in children with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 938-946.

 

REVIEWER(S): pmh

 

DATE: January 26, 2015

ASSIGNED OVERALL GRADE: B (The highest possible grade was A-.)

 

TAKE AWAY: The investigators used 4 single-subject experimental design (multiple baseline across participants) studies to explore the effectiveness of a cross-modal matching to sample (MTS) intervention designed to improve the comprehension of affective prosody of Japanese children diagnosed with autism spectrum disorders (ASD.) The results indicate that the children improved their rate of correct responses to an adult’s direction to indicate which picture represented a targeted emotion produced using a single word.

                                                                                                           

 

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

 

 

  1. What type of evidence was identified?
  • What type of single subject design was used? Single Subject Experimental Design with Specific Clients – Multiple Baseline—across participants

                                                                                                           

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

                                                                                                           

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

 

 

  1. Were the participants adequately described? Yes

How many participants were involved in the study? 4

– The following characteristics/variables were described:

  • age: 3 to 7 years (mean = 5 years, 6 months)
  • gender: all male
  • cognitive skills: on the Kyoto Scale of Psychological Development

– Ken (Chronological Age, CA, = 4-10) Mental Age (MA) = 2-11

– Taro (CA = 7-0) MA = 6-7

– Jiro (CA = 7-3) MA = 6-8

– Kazu (CA 3-7) MA = 2-11

  • level of severity of autism: on the Childhood Autism Rating Scale (CARS)

– Ken: severe

– Taro: mild/moderate

Jiro: severe

– Kazu: mild/moderate                 

  • educational level of participant:

– Ken: regular kindergarten

– Taro: in regular class in elementary school

– Jiro: in regular class in elementary school

– Kazu: regular kindergarten

                                                 

– Were the communication problems adequately described? No

  • The communication disorder type was not provided.

                                                                                                                       

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

 

 

  1. Did the design include appropriate controls? Yes
  • Were baseline/preintervention data collected on all behaviors? Yes
  • Did probes/intervention data include untrained data? No
  • Did probes/intervention data include trained data? Yes
  • Was the data collection continuous? Yes
  • Were different treatment counterbalanced or randomized? Not Applicable

 

  1. Was the outcome measure appropriate and meaningful? Yes
  • List the outcome was

OUTCOME: Percentage of correct responses to request to match affective prosody (happy, angry, surprised, sad) to pictures depicting emotions

  • The outcome was subjective.
  • The outcome was not objective.
  • The following reliability data were reported:

OUTCOME: Percentage of correct responses to request to match affective prosody (happy, angry, surprised, sad) to pictures depicting emotions using a single Japanese word using a single Japanese word

   – Individual interobserver reliability for each participant (P): percentage of agreement ranged from 95% to 100%; Kendall’s W ranged from 0.99 to 1.00

 

  1. Results:
  • Did the target behavior improve when it was treated? Yes
  • For each of the Ps, the overall quality of improvement was

OUTCOME: Percentage of correct responses to request to match affective prosody (happy, angry, surprised, sad) to pictures depicting emotions using a single Japanese word—

– Ken: strong

– Taro: moderate

– Jiro: strong

– Kazu: moderate

  1. Description of baseline:
  • Were baseline data provided? Yes, the number of baseline session for each P were

– Ken: 3

– Taro: 5

– Jiro: 6

– Kazu: 7

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

– Ken: low, stable

– Taro: moderate, stable

– Jiro: low-moderate, variable

– Kazu: moderate, variable

(continue numbering as needed)

  • What was the percentage of nonoverlapping data (PND)?

NOTE: The PND was calculated by the reviewer, not the investigators. It should be considered to be an approximation because it was derived from Figure 1.

– Ken: 100%– highly effective

– Taro: 100%– highly effective

– Jiro: 92%– highly effective

– Kazu: 100%– highly effective

 

 

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

 

  1. Was information about treatment fidelity adequate? Not Provided. However, because the prosody was presented live by a Japanese speaking male, measures of the accuracy of portrayal of the emotion in the picture cards can be found in the appendix. Overall, productions were moderately accurate.

 

  1. Were maintenance data reported? Yes
  • 3Ps maintained gains at the first one-week follow up. One P initially did not and was administered a second round of intervention. After the second round of intervention, that P maintained his progress.
  • All 4 Ps maintained gains following the termination of therapy.

 

 

  1. Were generalization data reported? Yes
  • Generalization was measured after the successful completion of all post testing (post-training probes, one week follow up, one month follow up). The generalization consisted of changing of the speaker from male to female.
  • A male speaker administered (live) all pretests, treatment sessions, and post tests.
  • A female speaker (live) administered the generalization tests.
  • All the Ps maintained a high percentage of correct responses during generalization.

 

  1. Brief description of the design:
  • This investigation consisted of 4 single subject experimental design studies (multiple baseline across participants.)
  • Prior to the experimental procedures, the investigators administered procedures to insure that the Ps could (1) follow intervention procedure (i.e., cross modal matching procedures and (2) match pictures of facial expressions to other pictures representing the same expressions.
  • Four prosodic affects/facial expressions were targeted in intervention: happy, surprised, angry, and sad.
  • During baseline, the male clinician (C) placed all 4 pictures of facial expression on the table. He then produced the targeted Japanese word using one of the 4 prosodic affects.
  • Data from the baseline was used as pretesting scores and to guide the selection of training pairs. During training only 2 cards were placed in front of the child: the card representing the emotion that had the highest percentage of correct responses and another emotion.
  • Following the achievement of the criterion for intervention, C administered post-test probes. If P reached the post-testing criteria, intervention was terminated.
  • If a P did not reach criterion, he received additional therapy. One P did not reach criterion at the first post-test probe. He did, however, achieve criterion on the second round of post-test probes.
  • After post-test probes, C administered 2 rounds of follow-up post tests. Three of the 4 Ps achieved criterion on the first follow-up post-test which was administered one week after the termination of intervention. The P who did not reach criterion was administered another round of intervention. (Following that additional round, the P passed criteria for post-test probes and a subsequent one-week follow-up.)
  • One month after the termination of intervention, C administered a one-month follow up post-test. All Ps achieved criterion.
  • Following the passing of the one-month follow-up post test, a female speaker administered a generalization tests across 2 sessions.

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: ___B______

 

 

SUMMARY OF INTERVENTION

 

PURPOSE: To determine if cross modal matching to sample intervention can improve the receptive prosody of Japanese children diagnosed with ASD.

POPULATION: Autism Spectrum Disorders

 

MODALITY TARGETED: Receptive

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: prosodic affect

DOSAGE: unclear

 

ADMINISTRATOR: probably a psychologist

 

STIMULI: auditory, visual

 

MAJOR COMPONENTS:

BACKGROUND

  • Four emotions/affects were treated: happy, surprised, angry, and sad.
  • The investigators employed a cross-model matching-to-sample two-choice training procedure.
  • The cross-modal portion of the procedure involved using auditory (the C’s production of a single Japanese word using a targeted prosodic affect) and visual (pictures depicting facial expressions signaling the targeted affect) stimuli.
  • The matching-to-sample portion of the procedure involved requiring the P to point to or hand to the C the picture representing the affect the C has just produced.
  • The two-choice portion of the procedure involved selected only 2 emotions to train at a time. Because up to four emotions were treated for each P, the investigators developed a strategy for pairing emotions/affects.
  • Overall there were 5 major portions of the experiments: pre-assessment, baseline, two-choice intervention, post –tests, and generalization tests.
  • During baseline, the investigators identified the strongest (highest percentage of correct comprehension responses) and the weakest (lowest percentage of correct comprehension responses) emotions/affects. In the pairings, the strong emotions were paired with weak emotions. Each of the different pairings of emotions was considered a “Phase” of treatment. Only one pairing was worked on in a Phase.
  • Criterion for moving from one Phase to the next was 100% correct responding for 2 treatment sessions in a row.
  • Criterion for termination of treatment was an average of 90% correct responding for each of the post-tests (post-test probes, 1-week generalization, and 3-week generalization).

PROCEDURES

  • C placed two cards depicting 2 emotions in front of P.
  • C directed P to select the card that represents (says) the targeted emotion/affect.
  • C produced the single Japanese target word using the targeted emotion/affect.
  • During the first Phase of this training, C was allowed to show his face to P while he was producing the targeted word and prosodic emotion/affect. This was not permitted for subsequent Phases.
  • If P responded to the direction, C enthusiastically provided positive feedback verbally and gesturally (i.e., high-fives, handshaking.)
  • If P failed to respond, C waited 5 seconds and readministered the direction.
  • If P responded incorrectly to the direction or failed to respond a second time, C pointed to the correct card, said “This is the correct one”, and prompted P to hand him the card.
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Van Nuffelen (2011)

September 22, 2014

CRITIQUE OF UNSUPPORTED PROCEDURAL DESCRIPTIONS

KEY:

C = clinician

DAF = delayed auditory feedback

P = patient or participant

pmh = Patricia Hargrove, blog developer

SLP = speech-language pathologist

Source: Van Nuffelen, G. (2011). Speech prosody in dysarthria. In V. Stojanovik & J. Setter (Eds.), Speech prosody in atypical populations: Assessment and remediation (pp. 147- 167). Surry, UK: J & R Press.

 

Reviewer(s): pmh

 

Date: September 21, 2014

 

Overall Assigned Grade (because there are no primary supporting data, the highest grade will be F): F

 

Level of Evidence: F = Expert Opinion, no supporting evidence for the effectiveness of the intervention although the author may provide secondary evidence supporting components of the intervention.

 

Take Away: As the author notes, despite the common perception of dysarthria as an adult issue, children also can exhibit one or more forms of dysarthria. The   focus of this chapter was on using prosody to improve intelligibility (ability of a listen to understand a verbal message without context) and comprehensibility (ability of a listen to understand a verbal message in context) in adults or children with dysarthria.

The author provides background information about prosody’s relevance to speech-language pathology and analyzes assessment procedures (these will be reviewed in this blog at a later date when we add a section on assessment issues.) This review is concerned with the recommendations for using prosody to improve intelligibility and/or comprehensibility. Prior to working on expressive prosody, the author recommends that receptive prosody be targeted if assessment suggests this is skill is a challenge. The author provides techniques and content for treating intonation, stress, and rate as they relate to intelligibility/comprehensibility.

    

  1. Was there review of the literature supporting components of the intervention? Narrative Review

 

  1. Were the specific procedures/components of the intervention tied to the reviewed literature? Yes

 

  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:
  • Outcome #1: to improve receptive prosody
  • Outcome #2: to improve stress and intonation by chunking utterances into appropriate syntactic units
  • Outcome #3: to increase the length of breath groups that correspond with syntactic units
  • Outcome #4: to use stress to differentiate word classes
  • Outcome #5: to use stress to emphasize appropriately a word in an utterance
  • Outcome #6: to use intonation to differentiate speech acts
  • Outcome #7– to produce utterance with appropriate affective prosody
  • Outcome #8– to produce a speaking rate that optimizes intelligibility/comprehensibility

 

  1. Was generalization addressed? No

 

  1. Was maintenance addressed? No

 

 

SUMMARY OF INTERVENTION

 

Description of Intervention #1to improve receptive prosody (specific intervention procedures and content were not provided)

 

POPULATION: Dysarthria; Adult, Child

TARGETS: to differentiate acceptable and unacceptable productions of examples of prosodic patterns

TECHNIQUES: feedback from C (clinician)

STIMULI: auditory, audio-recordings

 

ADMINISTRATOR: SLP

 

PROCEDURES

  1. C plays audio recordings of examples of prosodic patterns.
  2. P (patient) judges if the example is correct or incorrect.
  3. C provides feedback to the P regarding the accuracy of the judgment.

RATIONALE/SUPPORT FOR INTERVENTION: The author cited research indicating that receptive prosody is co-located in the brain with certain forms of dysarthria. Accordingly, there is a possibility that some speakers with dysarthria such as those with spastic dysarthria or upper motor neuron dysarthria may also have a receptive prosodic problem. There is only limited research about the receptive prosodic skills of speakers with dysarthria so it is important to insure that receptive prosodic skills are intact. Also, among children with high-functioning autism, there is a significant correlation between receptive and expressive prosody. (Logical support)

Description of Intervention #2 to improve stress and intonation by chunking utterances into appropriate syntactic units

 

POPULATION: Dysarthria; Adult, Child

 

TARGETS: matching of the production of breath units with syntactic units.

TECHNIQUES: behavioral instruction/metalinguistics, modeling, visual feedback

STIMULI: auditory, visual

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • The following are general ideas for treating prosody and specific ideas for treating chunking/phrasing listed in the chapter.

– C identifies the typical length of P’s breath group

– C guides P to produce utterances with pauses associated with a breath group at a syntactic boundaries.

– C uses the following techniques:

  1. behavioral descriptions/metalinguistics
  2. modeling

iii. visual feedback using instruments that acoustically measure pauses.

RATIONALE/SUPPORT FOR INTERVENTION: Speakers with dysarthria can have short breath groups. If pausing to breath does not correspond with a syntactic boundary, intelligibility problems can occur. (Logical support)

Description of Intervention #3— to increase the length of breath groups that correspond with syntactic units

 

POPULATION: Dysarthria; Adult, Child

 

TARGETS: breath units

TECHNIQUES: behavioral descriptions/metalinguistics, modeling, visual feedback using instruments that acoustically measure duration.

STIMULI: auditory, visual

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • The following are general ideas for treating prosody and specific ideas for lengthening breath groups listed in the chapter.

– C identifies the typical length of P’s breath group

– C guides P to produce longer breath groups.

– C uses the following techniques:

  1. behavioral descriptions/metalinguistics
  2. modeling

iii. visual feedback using instruments that acoustically measure duration.

RATIONALE/SUPPORT FOR INTERVENTION: Speakers with dysarthria can have short breath groups. Increasing the length of breath groups can increase the length of utterances and, perhaps, intelligibility/comprehensibility. (Logical support)

Description of Intervention #4—to use stress to differentiate word classes

 

POPULATION: Dysarthria; Adult, Child

 

TARGETS: production of lexical stress (e.g., ob JECT versus OB ject)

TECHNIQUES: behavioral descriptions/metalinguistics; modeling; contrastive stress drills; visual feedback using instruments that acoustically measure intensity, frequency, duration.

STIMULI: auditory, visual

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • The following are general ideas for treating prosody and specific ideas for improving lexical stress listed in the chapter.

– C presents contrastive stress drills in which minimal pair words for P to produce that differ only in location of stress (“RE ject” versus “re JECT”)

– C uses the following techniques:

  1. behavioral descriptions/metalinguistics
  2. modeling

iii. visual feedback using instruments that acoustically measure duration, intensity, pause, and frequency.

RATIONALE/SUPPORT FOR INTERVENTION: Improving lexical stress assists the listener in understanding what the speaker is intending. (Logical support)

Description of Intervention #5–to use stress to emphasize appropriately a word in an utterance

 

POPULATION: Dysarthria; Adult, Child

 

TARGETS: phrasal/sentence stress

TECHNIQUES: behavioral descriptions/metalinguistics; modeling; contrastive stress drills; visual feedback using instruments that acoustically measure intensity, frequency, and duration.

STIMULI: auditory, visual

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • The following are general ideas for treating prosody and specific ideas for improving phrasal stress listed in the chapter.

– C presents contrastive stress drills in which minimal pair sentences which P will produce will differ only in location of stress (e.g., “DAVID took the money” versus “David took the MONEY”)

– C uses the following techniques:

  1. behavioral descriptions/metalinguistics
  2. modeling

iii. visual feedback using instruments that acoustically measure duration, intensity, pause, and frequency.

RATIONALE/SUPPORT FOR INTERVENTION: The speaker should stress the word that he/she believes is the most important word in the sentence for the listener. (Logical support)

Description of Intervention #6—to use intonation to differentiate speech acts

 

POPULATION: Dysarthria; Adult, Child

 

TARGETS: intonation, intonation terminal contour

TECHNIQUES: behavioral descriptions/metalinguistics; modeling; contrastive stress drills; visual feedback using instruments that acoustically measure frequency

STIMULI: auditory, visual

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • The following are general ideas for treating prosody and specific ideas for improving intonation listed in the chapter.

– C presents contrastive stress drills in which minimal pair sentences which P will produce will differ only in the intonation (terminal contour) signaling different speech acts (e.g., “David took the money.” versus “David took the money?”)

– C uses the following techniques:

  1. behavioral descriptions/metalinguistics
  2. modeling

iii. visual feedback using instruments that acoustically measure frequency.

Description of Intervention #7– to produce utterance with appropriate affective prosody

 

POPULATION: Dysarthria; Adult, Child

 

TARGETS: affective prosody

TECHNIQUES: behavioral descriptions/metalinguistics; modeling; contrastive stress drills; visual feedback using instruments that acoustically measure frequency, intensity, pause, and duration

STIMULI: auditory, visual

 

ADMINISTRATOR: SLP

 

PROCEDURES:

  • The following are general ideas for treating prosody and specific ideas for improving affective prosody listed in the chapter.

– C presents contrastive stress drills in which minimal pair sentences which P will produce will differ only in the intonation (terminal contour) signaling different emotions (e.g., happy, sad, angry)

– C uses the following techniques:

  1. behavioral descriptions/metalinguistics
  2. modeling

iii. visual feedback using instruments that acoustically measure frequency.

Description of Intervention #8– to produce a speaking rate that optimizes intelligibility/comprehensibility

 

POPULATION: Dysarthria; Adult, Child

 

TARGETS: rate, intelligibility, comprehensibility

TECHNIQUES: behavioral description/metalingustics, speaking slower on demand, pacing, alphabet board, hand or finger tapping, delayed auditory feedback

STIMULI: auditory, visual, tactile/kinesthetic

 

ADMINISTRATOR:

 

PROCEDURES:

  • To reduce the rate of speech, the clinician may focus on
  1. reducing articulation rate
  2. inserting additional, syntactically appropriate pauses
  3. increasing the length/duration of pauses
  • The author described several approaches for slowing speech rate”
  1. Speaking slower on demand—C instructs P to talk at a specific percentage of his/her typical speaking rate (e.g., one-third P’s normal rate).
  1. Pacing – C directs P’s attention to a device (e.g., pacing board, metronome, Facilitator of Metronomic Pacing by Key Elemetrics, or the computer software Pacer) and asks P to talk saying a word or syllable for each square on the pacing board or in time with the metronome or computer program.
  1. Alphabet Board – P points to the first letter of each word when speaking.
  1. Hand or Finger Tapping – P taps for each intended syllable when speaking.
  1. Delayed Auditory Feedback (DAF) –C identifies the optimal delay time and then directs P to talk while wearing the DAF device..

RATIONALE/SUPPORT FOR INTERVENTION: Logical—

  • Rather than normalizing the rate of speech, the target should be to produce speech at a rate that optimizes intelligibility/comprehensibility. At this point, there is no strategy that has been identified as superior for all Ps. Rather, Cs should identify the strategy that works for the individual P insuring that it improves intelligibility/comprehensibility.
  • Of the approaches for reducing rate, the author presented the following rationales:
  1. reducing articulation rate—a number of studies support that this increases articulatory precision (distinctiveness) but research is contradictory as to whether reducing rate increases intelligibility
  2. inserting additional, syntactically appropriate pauses—this may improve comprehensibility by highlighting syntactic and/or word boundaries or by giving the listener additional time to interpret the utterance
  3. increasing the length/duration of pauses–—this may improve comprehensibility by highlighting syntactic and/or word boundaries or by giving the listener additional time to interpret the utterance
  • The author presented the following support for the techniques for slowing speech rate”
  1. Speaking slower on demand—The author cited research to support this approach but her own previously reported research did not yield significant changes in articulation rate, pause duration, or pause frequency.
  2. Pacing –The author cited her own previously reported research indicating a significant decrease articulation in rate and significant increases in total pause duration and pause frequency.
  3. Alphabet Board –The author cited her own previously reported research indicating significant decreases in articulation rate and pause frequency and significant increases in mean and total pause duration.
  4. Hand or Finger Tapping – The author cited her own previously reported research indicating a significant a decrease articulation in rate and a significant increase pause frequency.
  5. Delayed Auditory Feedback (DAF) – The author cited her own previously reported research indicating a significant decrease articulation rate.

 

CONTRAINDICATIONS FOR USE OF THE INTERVENTION—see above


Ferre et al. (2011)

December 21, 2013

SECONDARY REVIEW CRITIQUE

Source: Ferré, P., Ska, B., Lajoie, C., Bleau, C., & Joanette, Y. (2011). Clinical focus on prosodic, discursive and pragmatic treatment for right hemisphere damaged adults: What’s right? Rehabilitation Research and Practice, 2011.   doi:10.1155/2011/131820

 

Reviewer(s):  pmh

 

Date:  12.19. 13

 

Overall Assigned Grade:  D (Because this was a narrative review, the highest possible grade was D; see Level of Evidence.)

 

Level of Evidence:  D

 

Take Away:  This article addressed the nature of disorders, assessment, and intervention associated with different aspects of communication (i.e., prosody, discourse, semantics, pragmatics) effected by Right Hemisphere Damage (RHD). This review is concerned only with prosodic intervention. The authors briefly reviewed 4 sources concerned with prosodic intervention. Overall, the sources involved a small number of participants; nevertheless, some of the interventions show promise.

 

What type of secondary review?  Narrative Review 

 

1.  Were the results valid? Yes

a.  Was the review based on a clinically sound clinical question? Unclear/variable

b.  Did the reviewers clearly describe reasonable criteria for inclusion and exclusion of literature in the review (i.e., sources)? No.  They did not provide criteria.    

c.  Authors noted that they reviewed the following resources: (place X next to the appropriate resources)  The authors did not reference resources they used to identify the sources that were reviewed.

d.  Did the sources involve only English language publications?  No

e.  Did the sources include unpublished studies? Yes

f.  Was the time frame for the publication of the sources sufficient?  Yes

g.  Did the reviewers identify the level of evidence of the sources? No

h.  Did the reviewers describe procedures used to evaluate the validity of each of the sources?  No

i.  Was there evidence that a specific, predetermined strategy was used to evaluate the sources?  No

j.  Did the reviewers or review teams rate the sources independently? Unclear

k.  Were interrater reliability data provided?  No

l.  If the reviewers provided interrater reliability data, list them:  NA

m.  If there were no interrater reliability data, was an alternate means to insure reliability described?  No

n.  Were assessments of sources sufficiently reliable?  Not Applicable

o.  Was the information provided sufficient for the reader to undertake a replication?  No

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

q.  Were there a sufficient number of sources?  No

2.  Description of outcome measures:

•  Outcome #1:  Improved productive emotional prosody (Leon et al. 2005; 2008)

•  Outcome #2:  Improved production and comprehension of emotional and linguistic prosody (Guillet, 2009)

•  Outcome #3:  Improved production and comprehension of emotional prosody and improved production of linguistic prosody  (Bleau, 2010)

•  Outcome #4:  To use semantics in place of emotional prosody to signal affective intent (Wymer et al, 2002)

 

3.  Description of results:

a.  What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? Not applicable. EBP measures were not provided or summarized.

b.  Summarize overall findings of the secondary review:

•  Only limited research pertaining to prosodic intervention exists. Because of the limited research, clinicians are advised to consider the following guidelines:

1.  Add tasks that sensitize Ps to the existence of prosodic problems and their impact on communication.

2.  Treatment should be organized in a hierarchy moving from easy to difficult.

3.  Consider P’s cognitive  (memory, attention, flexibility) limitations.  

 

c.  Were the results precise?  No

d.  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? Not Applicable

 

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

f.  For the most part, were the results similar from source to source?  Yes  

g.  Were the results in the same direction?  Yes. Most of the summaries that reported evidence had positive outcomes.

h.  Did a forest plot indicate homogeneity?  Not Applicable

i.  Was heterogeneity of results explored?  No

j.  Were the findings reasonable in view of the current literature? Yes, but this reviewer is aware of other sources which  authors did not analyze/summarize.

 

k.  Were negative outcomes noted?  Yes

                                                                                                                   

4.  Were maintenance data reported?  No

 

 

SUMMARY OF INTERVENTION

 

Prosodic Targets:   affective prosody

Nonprosodic Targets:  linguistic

 

For each procedure detailed in the review, provide the following information:

Description of Procedure associated with Outcome #1

•  Outcome #1:  Improved productive emotional prosody (Leon et al. 2005; 2008)

— Two approaches that were described briefly:

1.  motor-imitative:  C elicits imitations from P using a 6-step hierarchy

2.  cognitive-linguistic approach:  C assists P in reestablishing the link between affect and intonation production

 

•  Evidence Supporting Procedure:

— Both approaches yielded some improvement.

 

•  Evidence Contraindicating Procedure:

—  The sources had few Ps.

—  Experimental design not clear.

Description of Procedure associated with Outcome #2

•  Outcome #2:  Improved production and comprehension of emotional and linguistic prosody (Guillet, 2009)

—  The intervention involved 3 considerations that were only listed (i. e, they were not described):

1.  awareness

2.  hierarchy

3.  awareness of cognitive impairment

–  The different phases of intervention were described only briefly:

1.  discrimination of linguistic and emotional phrases

2.  receptive phase in which C directed P to “identify words and sentences, with and without respect of syntactic boundaries”  (p. 4)

3.  productive phase in which C directed P to

a.  imitate using acceptable intonation

b.  read using acceptable intonation

c.  generate  conversations using acceptable intonation

 

•  Evidence Supporting Procedure

— 2 Ps with RHD evidenced significant improvement on measures associated with receptive and expressive linguistic and affective prosody

— Family members/caregivers reported improvement in activities of daily living

 

•  Evidence Contraindicating Procedure

— Small N.

— Experimental design not clear

Description of Procedure associated with Outcome #3

•  Outcome #3:  Improved production and comprehension of emotional prosody and improved production of linguistic prosody  (Bleau, 2010)

— Same procedures as Outcome #2 with the addition of visual feedback for phases 2 and 3

 

•  Evidence Supporting Procedure:

—  Case study yield improvement in production and comprehension of emotional prosody and in the production of linguistic prosody but not in the comprehension of linguistic prosody.

 

•  Evidence Contraindicating Procedure:

—  Only 1 P.

—  Case study

Description of Procedure associated with Outcome #4

•  Outcome #4:  To use semantics in place of emotional prosody to signal affective intent (Wymer et al, 2002)

— Ps compensate for prosodic disorders with existing sematic skills to signal affect.

— Family members and caregivers should be aware of the impact of neurological damage on communication.

 

•  Evidence Supporting Procedure:

—  None

 

•  Evidence Contraindicating Procedure:

—  No outcome data provided


Wymer et al.(2002)

December 4, 2013

Source:  Wymer, J. H., Lindman, L. S., & Booksh, R. L. (2002). A neuropsychological  perspective of aprosody: Features, function, assessment, and treatment. Applied Neuropsychology, 9, 37-47.

 

Reviewer(s):  pmh

 

Date:  12.02.13

 

Overall Assigned Grade: D  (Highest possible grade was D because this was a traditional or narrative review of the literature.)

 

Level of Evidence:  D

 

Take Away:  This review is over 10 years old but was current for publication date. The investigators covered variety of topics related to aprosodia, this analysis and summary will only be concerned with the section relevant to treatment. The authors described issues related to aprosodia intervention and provided practical recommendation:  treating prosodic aspects of communication, using compensatory strategies, and adapting to aprosodia.

 

What type of secondary review?  Narrative Review 

 

1.  Were the results valid? Yes. This was a traditional (narrative) review.  Therefore, many of the features listed below were not described, or possibly even not considered, in the review.

 

a.  Was the review based on a clinically sound clinical question?  Unclear

b.  Did the reviewers clearly describe reasonable criteria for inclusion and exclusion of literature in the review (i.e., sources)?  No       

c.  Authors noted that they reviewed the following resources: (place X next to the appropriate resources):  Resource search was not described

d.  Did the sources involve only English language publications?  Yes

e.  Did the sources include unpublished studies?  No

f.  Was the time frame for the publication of the sources sufficient?  Yes

g.  Did the reviewers identify the level of evidence of the sources?  No

h.  Did the reviewers describe procedures used to evaluate the validity of each of the sources?  No

i.  Was there evidence that a specific, predetermined strategy was used to evaluate the sources?  No

j.  Did the reviewers or review teams rate the sources independently?  No

k.  Were interrater reliability data provided?  No

l.  If the reviewers provided interrater reliability data, list them:  NA

m.  If there were no interrater reliability data, was an alternate means to insure reliability described?  No

n.  Were assessments of sources sufficiently reliable?  Unclear

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

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

q.  Were there a sufficient number of sources?  No

2.  Description of outcome measures:

NOTE: Because this was a traditional (narrative) review of the literature, a priori outcomes were not identified.  Listed below are outcomes and, if appropriate, associated reviewed sources

 

Outcome #1: Improve or recover prosodic speech and gesture by

a.  Reducing inappropriate laughing or crying (Ross, 1981)

b.  Improving intonation, fluency, and the ability to produce melodies (Cohen et al., 1994)

c.  Improving prosodic pitch patterns and facial gestures associated with affective states (Stringer, 1996)

 

Outcome #2:  Develop compensatory skills (i.e., maximize preserved communication skills)

a.  For Ps with intact comprehension but impaired production of prosody (no sources)

b.  For Ps with impaired prosodic comprehension  (no sources)

Outcome #3: Adapt to the prosodic impairment (Ps and/or their families)

a.  Avoid misinterpretation of prosodic communications by providing

1. education to P and his/her family about emotion and social issues associated with aprosodia (no sources)

2.  support to P and his/her family regarding problems associated with aprosodia (no sources)

 

3.  Description of results:

 

a.  What evidence-based practice (EBP) measures were used to represent the magnitude of the treatment/effect size? (Place an X next to all that apply)  NA

b.  Summarize overall findings of the secondary review:

•  At the time of publication, there was limited research concerned with the treatment of aprosodia. The authors recommended adapting treatment goals for aphasia to aprosodia and considering pharmacological and biofeedback treatments. In addition, they emphasized the importance of considering the effect of aprosodia on interpersonal relationships.

 

c.  Were the results precise?  No

d.  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?  Not Applicable 

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

f.  For the most part, were the results similar from source to source?  Yes.  There were only a  few studies and they had different outcomes; nevertheless all were reported to be successful/

g.  Were the results in the same direction?  Yes 

h.  Did a forest plot indicate homogeneity?  Not Applicable

i.  Was heterogeneity of results explored?  No 

j.  Were the findings reasonable in view of the current literature?  Yes

k.  Were negative outcomes noted?  No  

                                                                                                                   

4.  Were maintenance data reported?  Yes. One of the studies (Stringer, 1996) reported sustained progress 2 months after intervention.

 

 

SUMMARY OF INTERVENTION

 

Prosodic Targets:  intonation, fluency, affective prosody

Description of Outcome #1 Procedures— Improve or recover prosodic speech and gesture.

1.  Reduce inappropriate laughing or crying (Ross, 1981)

–  In case studies, Ross (1981) reported that antidepressants were helpful.  No data were provided in this secondary review

2.  Improve intonation, fluency, and ability to produce melodies

–  Cohen et al. (1994), in the case study of a 7 year old with aprosodia and a seizure disorder, antiseizure medication reduced expressive aprosodia.  This secondary review provided no supporting data but the following were reported to improve: intonation, fluency, melody

3.  Improve prosodic pitch patterns and facial gestures associated with affective states

–  In a case study, Stringer (1996), reported on the use of biofeedback (pitch tracings) and C comments to provide feedback to the P on the accuracy of modeled phrases depicting selected affective states. Reportedly, P improved significantly following 2 months of intervention and the gains were maintained at the 2 month post-intervention follow-up.

 

Evidence Supporting Outcome Procedure #1—Case studies

 

Evidence Contraindicating Procedure #1— The empirical support provided in this secondary review was minimal.

 

 

Description of Outcome #2 Procedures— Develop compensatory skills (i.e., maximize preserved communication skills)

 

1.  For, Ps with intact comprehension but impaired production of prosody the authors recommended that Cs focus on alternative strategies for conveying prosodic information such as word choice and observing listeners to ascertain that the intended affect was conveyed. This secondary review provided no supporting evidence for this recommendation.

2.  For Ps with impaired prosodic comprehension, Cs should insure that Ps have interpreted affective messages appropriately with specific attention to the avoidance of Ps’ over reliance on a single prosodic feature. Although, this secondary review provided no supporting evidence for this recommendation, the authors provided references indicating that this is a strategy that some Ps with aprosodia may use.

3.  Also, for Ps with impaired prosodic comprehension, Cs can direct  Ps’ attention to the context when they are interpreting affective prosody. This secondary review provided no supporting evidence for this recommendation.

4.  Finally, for Ps with impaired prosodic comprehension, Cs should remind P that face-to-face communication is the preferred mode of communication. This secondary review provided no supporting evidence for this recommendation.

 

Evidence Supporting Procedure #2— No evidence

 

Evidence Contraindicating Procedure #2 These were recommendations only. No empirical support was provided in this secondary review for these procedures.

Description of Outcome #3 Procedures Adapt to the prosodic impairment (Ps and/or their families)

•  Avoid misinterpretation of prosodic communications by providing

a.  education to P and his/her family about emotion and social issues associated with aprosodia (no sources)

b.  support to P and his/her family regarding problems associated with aprosodia (no sources)

Evidence Supporting Procedure #3—  No evidence

 

 

Evidence Contraindicating Procedure #3—  These were recommendations only. No empirical support was provided in this secondary review for these procedures.

 

 


Samuelsson (2010)

August 29, 2013

Single Subject Research

Source: Samuelsson, C. (2010) Prosody intervention for children. In H. Roddam & J. Skeat (eds.) Embedding evidence-based practice in speech and language therapy: International examples (pp. 189-194). Chichester, UK: Wiley-Blackwell .

 

Reviewer(s):   pmh

 

Date:  8.16.13

 

Overall Assigned Grade:  C (The brevity of chapter resulted in the omission of much information.)

Level of Evidence:  A-

 

Take Away:  This very brief chapter consists of a description of a strategy for decision-making about prosodic intervention in a context of having little or no evidence supporting a particular approach. A brief presentation of a single subject experimental design study was provided illustrating the process.

 

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

 

2.  What type of evidence was identified?                              

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

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

                                                                                                           

3.  Was phase of treatment concealed?

a.  from participants?  No

b.  from clinicians?  No

c.  from data analyzers?  No

 

4.  Were the participants adequately described?  Yes

a.  How many participants were involved in the study? 1

b.  The following characteristics were described

•  age:  4 years

•  gender:  m

•  expressive language:  WNL

•  receptive language:  WNL

•  Language:  Swedish

c.  Were the communication problems adequately described?  Yes          

•  The disorder types were  phonological disorder, prosodic disorder

•  Other aspects of communication were

–  problems with prosodic production at the word level, phase level, and discourse level on an instrument designed to assess Swedish prosody.

  –  prosodic perception was stronger than prosodic production 

                                                                                                                       

5.  Was membership in treatment maintained throughout the study? Not applicable

a.  If there was more than one participant, did at least 80% of the participants remain in the study?  Not  applicable

b.  Were any data removed from the study?  No. Data were not removed. However, due to the brief nature of the chapter, only summary statements were made. No specific data were reported.

 

6.  Did the design include appropriate controls?  Unclear. This was only a brief presentation.

a.  Were baseline/preintervention data collected on all behaviors?  Yes

b.  Did probes/intervention data include untrained data?  Yes

c.  Did probes/intervention data include trained data?  No

d.  Was the data collection continuous?  No

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were

  OUTCOME #1:  To improve prosody at the word level on a specific assessment instrument

  OUTCOME #2:  To improve prosody at the phrase level on a specific assessment instrument

  OUTCOME #3:  To improve prosody at the discourse level on a specific assessment instrument

b.  All of the outcomes were subjective.

c.  None of the outcomes were objective.

d.  None of the outcomes were associated with reliability data.

 

8.  Results:

a.  Did the target behavior improve when it was treated?  Yes. No specific data were reported. The characterizations were descriptive and provided in the prose of the chapter.

b.  The  overall quality of improvement was

OUTCOME #1:  To improve prosody at the word level on a specific assessment instrument  Effective

OUTCOME #2:  To improve prosody at the phrase level on a specific assessment instrument  Effective

OUTCOME #3:  To improve prosody at the discourse level on a specific assessment instrument  Slight improvement

9.  Description of baseline:

 

a.  Were baseline data provided? Yes

  OUTCOME #1:  To improve prosody at the word level on a specific assessment instrument:  3 times over 9 weeks

OUTCOME #2:  To improve prosody at the phrase level on a specific assessment instrument:  3 times over 9 weeks

OUTCOME #3:  To improve prosody at the discourse level on a specific assessment instrument:  3 times over 9 weeks

(continue numbering as needed)

 b.  Was baseline low and stable?

NOTE:  Data were not provided, but in the prose, the investigator described nature of baseline data.  The investigator described the prosodic problems as stable over the baseline period.

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

 

11.  Was information about treatment fidelity adequate?  Not Provided

 

12.  Were maintenance data reported?  Yes. Follow up administration of the assessment instrument revealed that the results were stable with some slight improvement.

 

13.  Were generalization data reported?  No. However, the assessment instrument involved word, phrase, and discourse contexts.

 

OVERALL RATING OF THE QUALITY OF SUPPORT FOR THE INTERVENTION: C

 

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate the effectiveness of a prosodic intervention designed to improve the prosodic skills of a child who speaks Swedish

POPULATION:  phonological disorder, prosodic disorder (Swedish)

 

MODALITY TARGETED:  comprehension and production

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED: lexical stress, phrasal stress, intonation

DOSAGE:  6 one-hour sessions plus homework

 

ADMINISTRATOR:  SLP and family

 

STIMULI:  auditory and visual

 

MAJOR COMPONENTS:

•  Basic Goal:  improve prosody at the word, phase, and discourse level

•  Intermediate Goal:  to produce prosodic contrasts at the word, phrase, and discourse level

WORD LEVEL

•  This was the main focus of intervention.

•  Intervention involved perception and production. Because P had stronger perception, perception was used to facilitate production.

•  C presented P with minimal pairs in Swedish. The two Swedish words differed in pitch direction (tonal word accent) and/or stress.  (The investigator provided illustrations of Swedish minimal pairs.)

PHRASAL LEVEL

•  Target: phrasal stress and intonation of real and nonsense sentence

•  P imitated C’s production of a real or nonsense sentences

DISCOURSE LEVEL
•  C recorded P’s discourse.

•  P listened to the recordings focusing on prosody.

•  It is assumed P discussed his production of prosody.

 


Kouri & Winn (2006)

July 6, 2013

EBP THERAPY ANALYSIS

Comparing Treatment of Groups

 SOURCE:  Kouri, T. A., & Winn, J. (2006). Lexical learning in sung and spoken story script contexts. Child Language Teaching and Therapy, 22, 293-313.

 REVIEWER(S):  pmh

 DATE:  6.25.13

ASSIGNED GRADE FOR OVERALL QUALITY:  C+

TAKE AWAY:  This brief (2 session) investigation provides moderate support for the use of sung scripts for increasing the number of spontaneous verbalizations by  preschool children with developmental delay and/or language delay.

 1.  What type of evidence was identified?

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

b.  What was the level of support associated with the type of evidence?  Level = C+   

 

 2.  Group membership determination:                                     

a.  If there were groups, were participants randomly assigned to groups?  N/A

b.  If there were groups and participants were not randomly assigned to groups, were members of groups carefully matched?  N/A

3.  Was administration of intervention status concealed? 

a.  from participants?  No

b.  from clinicians?  No

c.  from analyzers?  No

 

4.  Were the groups adequately described?  Yes

a.         How many participants were involved in the study?

•  total # of participant:   16

•  # of groups:  1  (initially there were 2 groups, SLI and developmentally delayed (DD), since there were no significant differences between groups the data were collapsed

•  # of participants in each group:  16

b.  The following variables were  actively controlled (i.e., inclusion/exclusion criteria) or described:  

CONTROLLED:                                                                                          

•  Hearing:  WNL

•  Vision:  WNL

•  Neuromotor skills:  WNL

DESCRIBED

•  age:  3 years 6 months – 5 years, 1 month (mean 4 years, 1 month)

•  expressive and receptive language skills:

–  expressive and/or receptive language delays of at least 12 months or

     –  1.5 SD below the mean on at least one of the following tests

          •  Battelle Developmental Inventory (BDI)

          •  Sequenced Inventory of Communication Development Revised- R (SICD-R)

          •  Clinical Evaluation of Language Fundamentals-Preschool (CELF-P)

          •  Preschool Language Scale-3 (PLS-3)

•  receptive language:

•  MLU:  1.17- 2.79 morphemes (mean = 2.00)

c.   Were the groups similar before intervention began?  Not Applicable

d.  Were the communication problems adequately described?  Yes

•  disorder type:

     –  4 P = significant expressive  and receptive language delays

–  12 Ps mildly developmentally delayed (>1.5 SD below mean on at least one subtest of the BDI) and depressed communication scores

•  functional level

 

5.  Was membership in groups maintained throughout the study?

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

b.  Were data from outliers removed from the study?  No

 

6.   Were the groups controlled acceptably?   NA, only one group.

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  The outcomes were                                    

 OUTCOME #1:  To increase the number of elicited productions of targeted nonsense words  (production probe)

  OUTCOME #2:  To increase the number of specific correct targeted nonsense items pointed to on request (comprehension probe)

  OUTCOME #3:  To increase the number of correct responses to requests to point to  items that were not targeted in the treatment session but resemble the targeted nonsense items (generalization probe—similar item)

  OUTCOME #4:  To increase the number of unsolicited verbalizations (spontaneous imitations, deferred imitation, true spontaneous productions (generalizations—unsolicited verbalizations)

b.  All the outcome measures were subjective.

c.  None of the outcome measures were objective.

 

8.  Were reliability measures provided?                                   

a.  Interobserver for analyzers?  Yes

•  OUTCOME #1:  To increase the number of elicited productions of targeted nonsense words  (production probe)  93%

•  Combined  OUTCOME #2:  To increase the number of specific correct targeted nonsense items pointed to on request (comprehension probe) and OUTCOME #3:  To increase the number of correct responses to requests to point to  items that were not targeted in the treatment session but resemble the targeted nonsense items (generalization probe—similar item)  100%

•  OUTCOME #4:  To increase the number of unsolicited verbalizations (spontaneous imitations, deferred imitation, true spontaneous productions (generalizations—unsolicited verbalizations)  82%

b.  Intraobserver for analyzers?  No

c.  Treatment fidelity for clinicians?  No

 

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

a.

•  Treatment And Foil/Comparison/No Treatment Group Comparison NA

•  Pre Vs Post Treatment for different conditions

OUTCOME #1:  To increase the number of elicited productions of targeted nonsense words  (production probe) Significantly (p <0.01) more targets were produced during session 2 compared to session 1 for both conditions

OUTCOME #2:  To increase the number of specific correct targeted nonsense items pointed to on request (comprehension probe)  No significant differences

OUTCOME #3:  To increase the number of correct responses to requests to point to items that were not targeted in the treatment session but resemble the targeted nonsense items (generalization probe—similar item)  No significant differences

OUTCOME #4:  To increase the number of unsolicited verbalizations (spontaneous imitations, deferred imitation, true spontaneous productions (generalizations—unsolicited verbalizations) Sung condition yielded significantly more (p = 0.05) spontaneously imitated nontarget words in session 2.

b.  What was the statistical test used to determine significance? ANOVA for all outcomes

c.  Was confidence interval (CI) provided?  No

                                   

10.  What is the clinical significance? 

a.  Results of EBP testing—Authors only provided EBP measure for Outcome #4

•  Standardized Mean Difference:   

     – OUTCOME #4:  To increase the number of unsolicited verbalizations (spontaneous imitations, deferred imitation, true spontaneous productions (generalizations—unsolicited verbalizations)  d = 0.80

b.  Interpretation of EBP testing.

•  Large/Strong:

     –  OUTCOME #4:  To increase the number of unsolicited verbalizations (spontaneous imitations, deferred imitation, true spontaneous productions (generalizations—unsolicited verbalizations)

 

11.  Were maintenance data reported?  No

12.  Were generalization data reported?  Yes. Outcomes 3 and 4 were concerned with generalization.  Of the outcomes measured only Outcome 4 (production of spontaneous nontarget words) achieved statistical significance.

 ASSIGNED GRADE FOR OVERALL QUALITY OF EXTERNAL EVIDENCE: _C+__

SUMMARY OF INTERVENTION 

PURPOSE:  To investigate the difference of sung and spoken input on quick incidental word learning (QUIL)

POPULATION:  developmental disability and/or language delay (preschoolers)

MODALITY TARGETED:  production and comprehension

 ELEMENTS OF PROSODY USED AS INTERVENTION:  music—intonation, rhythm

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  comprehension and production of lexical items

DOSAGE:  2 individual 50-60 minute sessions (within 5 days of one another)

ADMINISTRATOR:  SLP (student with strong musical background)

STIMULI:  visual, auditory, tactile

GOAL ATTACK STRATEGY:  vertical

MAJOR COMPONENTS:

•  Investigators provided scripts and (nonsense) word lists in appendices.

•  There were 2 conditions:  spoken and sung.  All Ps were exposed to both.

SPOKEN CONDITION:

•  C spoke the script and acted it out with Gumby characters three times (2 live voice and one recorded voice)

•  C presented 2 more recorded spoken versions of the script provided the characters to P to manipulate.

•  If necessary, C redirected P by pointing to objects or even stopping the story and helping P to refocus. The story was resumed when P was attending.

•  C controlled spoken presentations for rate and loudness.

SUNG CONDITION:

•  C sang the script and acted out the script with Gumby characters three times (2 live singing and one recorded singing)

•  C presented 2 more recorded versions of the sung script and provided the characters to P to manipulate.

•  If necessary, C redirected P by pointing to objects or even stopping the story and helping P to refocus.  The story was resumed when P was attending.

•  C controlled presentations for rate, loudness, and “musical uniformity”.


Bornhofen & McDonald (2008)

June 7, 2013

Comparing Treatment of Groups

 

SOURCE:  Bornhofen, C., & McDonald, S. (2008). Comparing strategies for treating emotional perception deficits in traumatic brain injury. Journal of Head Trauma Rehabilitation, 103-115.

 

REVIEWER(S):  pmh

 

DATE: 5.07.13

ASSIGNED GRADE FOR OVERALL QUALITY:  C+

 

TAKE AWAY:  This investigation focused on overall emotional perception; a small number of outcomes are concerned affective prosody as it is only one component of emotional perception. Although this may be interpreted as a disadvantage, the interventions more closely replicate daily living compared to interventions that  focus solely on one aspect of emotional perception (e.g., prosody).  Overall, the findings revealed some success with respect to emotional perception and some generalization outcomes.

 

1.  What type of evidence was identified?

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

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

                                                                                                           

2.  Group membership determination:

a.  If there were groups, were participants randomly assigned to groups?  Yes

3.  Was administration of intervention status concealed? 

a.  from participants?  No

b.  from clinicians?  No

c.  from analyzers?  Variable. The post  intervention analyzers were blind to group membership.

 

4.  Were the groups adequately described?  Yes

a.         How many participants were involved in the study?

•  total # of participant:  18

•  # of groups: 3

•  # of participants in each group:  6, 6, 6

•  List names of groups:     EL (Errorless Learning), SIT (Self-instruction training), WL (Waitlist)

b.  The following variables were actively controlled:

INCLUSION CRITERIA:

•  severe TBI

•  post traumic amnesia at least 1 day

•  reports of social/interactional problems

•  at least 6 months post trauma

•  at least 2 SD below mean on pretests of social perception

EXCLUSION CRITERIA:

•  history of psychosis or severe depression

•  below borderline cognitive functioning

–  The following characteristics were descriptors:

(no significant differences on measures with asterisk*; remember the N is small!)

•  mean age*:  43.75; 35.4; 31.2 

•  gender:  17m, 1f

•  cognitive skills:  

     –  85.3; 93; 86.6 (mean Weschler Test of Adult Reading scores as a measure of premorbid cognition)

     –  6; 5.4; 5.8 (mean SS Logical Memory I)

     –  5.75; 5.4; 6.6 (mean SS Logical Memory II)

     –  5; 7.4; 6,6 (mean SS Similarities)

     –  6.5; 7; 7.4 (mean SS Matrix Reasoning)

     –  6.25; 6.8; 4.2 (mean SS Letter-Number Sequencing)

     –  6; 5.4; 5.8 (mean SS Symbol Search)

•  face recognition:   (mean adjusted score Benton Face Recognition Test)

     –  6; 5.4; 5.8

•  educational level of clients:  8.75; 11.4; 10.8 (mean years)

•  months post onset:  60; 79.6; 148.2  (mean)

•  days of posttraumatic amnesia:  73.25; 32.5; 80.8 (mean)

c.   Were the groups similar before intervention began?  Unclear  _x__.  Although investigators found no significant differences among groups for pretest characteristics, there was considerable range in the preintervention scores for the 3 groups.   (Remember, there were only 6 members in each group.)

d.  Were the communication problems adequately described?  No

•  disorder type:  social interaction problems associated with TBI

 

5.  Was membership in groups maintained throughout the study?

a.  Did each of the groups maintain at least 80% of their original members?  No. EL maintained 67%  ; SIT maintained   83%; WL maintained 67%

b.  Were data from outliers removed from the study?  No

 

6.   Were the groups controlled acceptably?

a.  Was there a no intervention group?  Yes

b.  Was there a foil intervention group? No

c.  Was there a comparison group?  Yes

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

 

7.  Were the outcomes measure appropriate and meaningful?  Yes

a.  Outcomes (dependent variables):

INTERVENTION OUTCOMES      

  OUTCOME #1: Performance on the Facial Expression Same/Different Task

  OUTCOME #2: Performance on the Facial Expression Naming Task (label chosen from a list of 7 emotions)

  OUTCOME #3: Performance of the Facial Expression Matching Task

  OUTCOME #4: Performance on task in which actor enacted an emotion and P selected label from a list of 7 words (cues were only nonverbal)

  OUTCOME #5: Increased ability to interpret social inferences from emotional expression (TASIT, pt 2)

  OUTCOME #6:  Increased ability to differentiate sarcasm and lies (TASIT, pt 3)

GENERALIZATION OUTCOMES

  OUTCOME #7:  Self-report of overall psycho-social functioning (Sydney Psychosocial Reintegration Scale)

  OUTCOME #8:  Self-report of depression (Depression Anxiety Stress Scales)

  OUTCOME #9:  Relative of overall psycho-social functioning (Sydney Psychosocial Reintegration Scale)

  OUTCOME #10: Relative’s ranking of negative and positive behaviors seen in clinical populations   (Katz Adjustment Scale- Relative form)

  OUTCOME #11:  Relative reporting of positive and negative social behaviors (Social Performance Survey Schedule)

b.  All of the outcome measures were subjective.

c.  None of the outcome measures were objective.

 

8.  Were reliability measures provided?

a.  Interobserver for analyzers?  No

b.  Intraobserver for analyzers?  No

c.  Treatment fidelity for clinicians?  Yes.  Two trained raters viewed 8 randomly ordered intervention sessions and assessed whether selected C behaviors occurred. The investigators reported that the raters achieved good interrater reliability.  The raters’ scoring indicated that  EL intervention behaviors were markedly more likely to occur during EL sessions and SIT behaviors were more common in SIT sessions.  Nonspecific intervention techniques (e.g., C displayed warmth and caring) were observed at equal rates in EL and in SIT sessions.    

 

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

a.   PRE VS POST TREATMENT: INTERVENTION OUTCOMES WITH REPORTED SIGNIFICANT DIFFERENCES:

  OUTCOME #3: Performance of the Facial Expression Matching Task— Form A of Test; EL and SIT; pre vs post (p ≤ 0.05); pre vs 1 month follow up (both < 0.01);

  OUTCOME #5: Increased ability to interpret social inferences from emotional expression (TASIT, pt 2)—SIT Form A; pre vs post (p ≤ 0.05)

  OUTCOME #11:  Relative reporting of positive and negative social behaviors (Social Performance Survey Schedule) SIT—positive behaviors; pre vs post (p ≤ 0.05)

b.  What was the statistical test used to determine significance:  ANOVA and the investigator corrected for the small N by using Ley’s  procedure.  See page 107 and  appendix.

c.  Were confidence interval (CI) provided?  No

                                               

10.  What is the clinical significance? 

a.  Results of EBP testing

•  ETA:   using Cohen’s guidelines the clinical differences (≥ 0.20) were reported

INTERVENTION OUTCOMES      

  OUTCOME #1: Performance on the Facial Expression Same/Different Task—EL (0.42) and SIT ( 0.33) for Form A but not Form B;  pre vs post   

  OUTCOME #2: Performance on the Facial Expression Naming Task (label chosen from a list of 7 emotions  Pre vs Post: SIT form A (0.25)

  OUTCOME #3: Performance of the Facial Expression Matching Task ) Pre vs Post:  EL for form A (0.76), for B (0.21); SIT for form A (0.55) for form B (0.25)

  OUTCOME #4: Performance on task in which actor enacted an emotion and P selected label from a list of 7 words (cues were only nonverbal)-TASIT, pt 1) Pre vs Post:  SIT for form B (0.24)

  OUTCOME #5: Increased ability to interpret social inferences from emotional expression (TASIT, pt 2)   Pre vs Post:  SIT for form A  (0.47)

GENERALIZATION OUTCOMES

  OUTCOME #8:  Self-report of depression (Depression Anxiety Stress Scales) Pre vs Post:  EL (0.30)

  OUTCOME #10: Relative’s ranking of negative and positive behaviors seen in clinical populations   (Katz Adjustment Scale- Relative form) Pre vs Post:  Positive Scale –EL (0.43)

b.  Interpretation of EBP testing.  

 Large: none

•  Moderate:  Outcome #3

•  Small:  Outcomes #1. 2, 3, 4, 5, 8, 11

•  No:  Outcomes # 1, 2, 4, 6, 7, 9, 10

  OUTCOME #1: Performance on the Facial Expression Same/Different Task—EL (small) and SIT ( small ) for Form A but not Form B –no

  OUTCOME #2: Performance on the Facial Expression Naming Task (label chosen from a list of 7 emotions  Pre vs Post: SIT form A (small); form B (no)

  OUTCOME #3: Performance of the Facial Expression Matching Task — Pre vs Post:  EL for form A (moderate), for B (small); SIT for form A (moderate) for form B (0.25)

  OUTCOME #4: Performance on task in which actor enacted an emotion and P selected label from a list of 7 words (cues were only nonverbal)-TASIT, pt 1) Pre vs Post:  SIT for form B (small); form A (no)

  OUTCOME #5: Increased ability to interpret social inferences from emotional expression (TASIT, pt 2)   Pre vs Post:  SIT for form A  (small)

  OUTCOME #6:  Increased ability to differentiate sarcasm and lies (TASIT, pt 3) No

GENERALIZATION OUTCOMES

  OUTCOME #7:  Self-report of overall psycho-social functioning (Sydney Psychosocial Reintegration Scale)  No

  OUTCOME #8:  Self-report of depression (Depression Anxiety Stress Scales) Pre vs Post:  EL (small)

  OUTCOME #9:  Relative of overall psycho-social functioning (Sydney Psychosocial Reintegration Scale)  No

  OUTCOME #10: Relative’s ranking of negative and positive behaviors seen in clinical populations   (Katz Adjustment Scale- Relative form) No

  OUTCOME #11:  Relative reporting of positive and negative social behaviors (Social Performance Survey Schedule)  Pre vs Post:  Positive Scale –EL (small)

 

11.  Were maintenance data reported?  Yes.  Outcomes were measured  1 month and 6 months after post testing. Only the Matching Facial Expressions task form A  (Outcome #3) yielded a significant difference and a clinically significant (large and moderate) difference at 1 month post intervention. This degree of improvement was not maintained at 6 months. In addition, the differences were no longer significantly different.

 

12.  Were generalization data reported? Yes. Outcomes #7 through #11 are generalization outcomes. Outcomes #8 and #11 showed small clinically significant improvement.

 

NOTE:  the N was very small.

 

ASSIGNED GRADE FOR QUALITY OF EXTERNAL EVIDENCE:  C+

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To compare two interventions for improving emotional perception.

POPULATION:  adults with severe traumatic brain injury

 

MODALITY TARGETED:  receptive

 

ELEMENTS/FUNCTIONS OF PROSODY TARGETED:  affective prosody

 

OTHER TARGETS:  overall emotional perception

DOSAGE:  2 ½ hour sessions, 1 time a week, 10 weeks; small group (2 or 3 Ps)

 

ADMINISTRATOR:  therapist (probably not an SLP)

 

STIMULI:  Not clear

GOAL ATTACK STRATEGY:  Not clear

 

MAJOR COMPONENTS:

 

The 2 intervention approaches* were

1.  Effortless Learning (EL)

2.  Self-Instruction Training (SIT)

1.  EL

•  The task involved teaching Ps to  identify an affective state using prosody, facial expression, and body language as cues.

• C

  – discouraged P from guessing during sessions (e.g., C always provided a “not sure” option for P during treatment),

  – designed sessions to progress gradually from easy to more difficult discriminations, and

  – provided extensive practice of each phase of treatment to provide high rate of correct responses.

•  C immediately corrected errors.

•  C initially provided exaggerated cues for the different emotions and gradually faded to more subtle cues.

2.  SIT

•  C presented an acronym (WALTER) to P to facilitate problem solving with respect to emotional perception.

  – the following is quoted from p. 107 of article

  1.  What am I deciding about?

  2.  What do I already know about it?

  3.  What do I need to look/listen for?

  4.  Try out my answer.

  5.  Evaluate how it went.**

  6.  Reward myself for having a go.**

• P practiced using “WALTER” while making increasing difficult discriminations during intervention

*  at the time of publication, the investigators were preparing a manuscript describing more thoroughly the interventions.

** this are optional steps.