Preston et al. (2013)

September 1, 2021

EBP THERAPY ANALYSIS for 

Single Case Designs

NOTES:  

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

Key:

 C =  Clinician

 CAS =  Childhood Apraxia of Speech

 CELF-4  Clinical Evaluation of Language Fundamentals-4 

 CTOPP =  Comprehensive Test of Phonological Processing 

 EBP =  evidence-based practice

 EVT2 =  Expressive Vocabulary Test 2nd ed 

 NA = not applicable 

 P =  Patient or Participant

 PCC =  Percent Consonants Correct 

 pmh =  Patricia Hargrove, blog developer

 PPVT =  Peabody Picture Vocabulary Test 

 SLP =  speech–language pathologist

 SS =  Standard Score 

 VMPAC =  Verbal Motor Production Assessment for Children 

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

REVIEWER(S):  pmh

DATE:  September 1, 2021

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

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

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

2.  What type of evidence was identified?                              

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

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

3.  Was the phase of treatment concealed?                           

•  from participants?  No 

•  from clinicians?  No 

•  from data analyzers?  Yes

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

–  How many Ps were involved in the study?  6

–  CONTROLLED CHARACTERISTICS:

•  age: children

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

•  diagnosis: Childhood Apraxia of Speech (CAS)

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

•  articulation/phonology:

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

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

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

          ∞ metathesis or migration errors  

–  DESCRIBED CHARACTERISTICS: 

•  age:  9 to 15 years

•  gender:  All male

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

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

•  expressive language:

     – Expressive Vocabulary Test 2nd Ed (EVT2)

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

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

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

•  articulation/phonology:

     – GFTA2 = <40 to 69

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

     – PCC- Late-8: 19% to 81%

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

     – CTOPP – Blending SS = 4 to 10                    

•  oral-motor skills:

     – VMPAC Focal Oral Motor = 87to 98

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

•  Other clinical concerns:

     – Pervasive Developmental Disorder

     – Attention Deficit Hyperactivity Disorder

     – Language Impairment

     – Reading Disability

     – Trisomy 8

     – limb apraxia

     – dysarthria

     – velopharyngeal incompetence

     – history of otitis media with effusion

     – hypernasality

–  Were the communication problems adequately described? Yes 

–  Disorder type:  Childhood Apraxia of Speech

–  Other aspects of communication that were described:  

     • severity ranged from mild to severe

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

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

6.  Did the design include appropriate controls?  Yes 

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

  Did probes/intervention data include untrained stimuli?  Yes 

  Did probes/intervention data include trained stimuli?  Yes 

•  Was the data collection continuous?  Yes

•  Were different treatment counterbalanced or randomized?  

7.  Were the outcome measures appropriate and meaningful? Yes

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

•  OUTCOME #2: Performance on the GFTA

•  All of the outcomes were subjective.

•  None of the outcomes were objective.

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

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

8.  Results:

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

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

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

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

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

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

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

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

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

∞  OUTCOME #2: Performance on the GFTA-2

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

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

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

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

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

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

numbering as needed)

9.  Description of baseline: 

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

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

•  OUTCOME #1:

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

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

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

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

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

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

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

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

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

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

          ∞ highly effective – 2 targets

          ∞ fairly effective – 1 target

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

          ∞ highly effective – 4 targets

          ∞ fairly effective – 2 targets

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

          ∞ highly effective – 2 targets

          ∞ questionable effectiveness – 1 targets

          ∞  unreliable/ineffective – 2 targets

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

          ∞ highly effective – 4 targets

          ∞ fairly effective – 1 target

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

          ∞ highly effective – 6 targets

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

          ∞ highly effective – 6 targets

10.  What is the clinical significance

  OUTCOME #1: 

•  magnitude of effect for all treated target:

     – U002 = total for all targets = 3.2

     – U005 = total for all targets = 2.6

     – U007 = total for all targets = 4.0

     – U008 = total for all targets = 2.1

     – U009 = total for all targets = 2.2

     – U012 = total for all targets = 2.7

•  measure calculated: standardized mean difference

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

11.  Was information about treatment fidelity adequate?  No 

12.  Were maintenance data reported?  Yes 

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

• Overall maintenance for the Ps was reported as 

     – U002 = retained accuracy for 2 of 3 treated target

     – U005 = maintained accuracy for 5 of 6 treated targets

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

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

     – U009 = maintained accuracy for 6 of 6 treated targets

     – U012 = maintained accuracy for 6 of 6 treated targets

13.  Were generalization data reported? Yes  

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

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

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

14.  Brief description of the design:

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

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

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

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

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

SUMMARY OF INTERVENTION

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

POPULATION:  Childhood Apraxia of Speech; Adults

MODALITY TARGETED:  production

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

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  speech sounds

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

ADMINISTRATOR:  SLP

MAJOR COMPONENTS:

• Schedule:

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

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

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

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

     – 10 minutes of probe tasks

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

• Ultrasound treatment procedures:

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

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

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

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

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

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

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

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

     – Some special techniques included

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

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

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

• Table-top activities

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


McCabe et al. (2014)

February 24, 2021

EBP THERAPY ANALYSIS for 

Single Case Designs

NOTES:  

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

Key:

 C =  Clinician

 CAS =  Childhood Apraxia of Speech

CTPP =  Comprehensive Test of Phonological Processing 

 EBP =  evidence-based practice

 KP =  used knowledge of performance 

 NA = not applicable 

 P =  Patient or Participant

 pmh =  Patricia Hargrove, blog developer

 PCC =  Percent Consonants Correct 

 PND =  Percentage of Nonoverlapping Data 

 PPVT = Peabody Picture Vocabulary Test 

 PVC =  Percent Vowels Correct

 ReST =  Rapid Syllable Transition Training

 SLP =  speech–language pathologist

 SS =  Standard Score

TAP =  Test of Auditory Processing

 WNL =  within normal limits 

SOURCE:  McCabe, P., Macdonald-D’Silva, A. G., van Rees, L., Ballard, K. J., & Arciuli, J. (2014).  Orthographically sensitive treatment for dysprosody in children with childhood apraxia of speech using ReST intervention. Developmental Neurorehabilitation, 17 (2), 137-146. DOI: 10.3109/17518423.2014.906002 

REVIEWER:  pmh

DATE: February 24, 2021

ASSIGNED OVERALL GRADE:  B+  The highest grade possible based on the design of this investigation is A-   (Single-case experimental design). The Assigned Overall Grade is not a judgment about the quality of the intervention; it is rating of the evidence presented in the investigation.

TAKE AWAY:  This investigation explored the effectiveness of Rapid Syllable Transition Training (ReST) on the production of lexical stress in the speech of 4 children diagnosed with Childhood Apraxia of Speech (CAS). Using an AB design, the investigators identified changes from pre- to post- treatment and retention, 4 weeks after the termination of the intervention. The findings suggest that lexical stress improved as the following the intervention and that the changes are maintained.

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

2.  What type of evidence was identified?                              

–  What  type of single subject design was used? Single Subject Experimental Design with Specific Clients: AB 

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

3.  Was phase of treatment concealed?                                              

•  from participants?  No 

•  from clinicians?  No 

•  from data analyzers?  No 

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

–  How many Ps were involved in the study?  4

–  CONTROLLED CHARCTERISTICS:    

•  expressive language: sample of at least 50 utterances

•  receptive language: within normal limits (WNL)

•  diagnosis: CAS

•  hearing level: WNL

•  comorbid developmental or genetic problems: excluded

•  oral motor skills: WNL for structure, strength, muscle tone, and reflexes

–  DESCRIBED CHARACTERISTICS:

•  age:  55 to 8-6

•  gender:  4m                                   

•  expressive language:

     – Clinical Evaluation of Language Fundamentals (4th ed; CELF) Expressive Language Index: Standard Score (SS) = 53-80

•  receptive language: 

     – Peabody Picture Vocabulary Test (PPVT):  SS = 90-117

     – CELF Receptive Language Index:  SS = 96-105

     – Test of Auditory Processing (3rd ed; TAP) Word Discrimination:  SS = 5-9

     – Test of Auditory Processing (3rd ed; TAP) Word Memory:  SS = 6-12

•  literacy:

     – Woodcock Reading Mastery Test-Revised Basic Skills Cluster:  SS = 88-127

     – Woodcock Reading Mastery Test-Revised Word Identification:  SS = 90-129

     – Woodcock Reading Mastery Test-Revised Word Attack:  SS = 81-121

     – Woodcock Reading Mastery Test-Revised Lower Case Letters Checklist percent: = 48-94

     – Comprehensive Test of Phonological Processing (CTPP) Phonological Awareness Composite Score:  SS = 64-106

     – CTPP Phonological Memory Composite Score:  SS = 70-91

     – CTPP Memory for Digits:  SS = 6-10

     – CTPP Non-word Repetition Score:  SS = 4-9

     – CTPP Rapid Naming Composite Score:  SS = 91-136

     – Neale Analysis of Reading Ability (3rd ed; NARA-3)

          ∞ Accuracy: Reading Age  <6 – 7.7 years

          ∞ Comprehension: Reading Age  6.3 to 7.5 years

          ∞ Rate: Reading Age  6.8 – >13

–  Were the communication problems adequately described? Yes

•  Disorder type: Childhood Apraxia of Speech

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

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

6.  Did the design include appropriate controls?  Yes 

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

  Did probes/intervention data include untrained stimuli?  Yes 

•  Did probes/intervention data include trained stimuli?  Yes 

•  Was the data collection continuous?  Yes_x__, for several of the outcomes.  

•  Were different treatment counterbalanced or randomized?  NA  

7.  Were the outcome measures appropriate and meaningful? 

•  OUTCOME #1: Prosodic (lexical stress) accuracy of targeted bisyllable pseudo words during treatment sessions

•  OUTCOME #2: Segmental accuracy of targeted bisyllable pseudo words during treatment sessions

•  OUTCOME #3: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation) of trained targets

•  OUTCOME #4: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation) of untrained targets

•  OUTCOME #5: Percent Vowels Correct (PVC) in connected speech

•  OUTCOME #6: Percent Consonants Correct (PCC) in connected speech

•  OUTCOME #7: Percent correct stress patterns in connected speech

•  OUTCOME #8: PPVT Standard Score (this was a foil outcome; that is, improvement was not expected)

–  All of the outcomes that were subjective.

–  None of the outcomes were objective.

–  RELIABILITY DATA:

•  Inter-rater reliability of accuracy (stress and segmental) of clinician’s (C’s) judgment of participant’s (P’s) productions: 88%

•  Intra-rater reliability of accuracy (stress and segmental) of C’s judgment of P’s productions: 93%

•  Inter-rater reliability of phonemic transcriptions: 83% to 90%

•  Intra-rater reliability of phonemic transcriptions: 95% to 97%

  Treatment fidelity: 75% to 83% (errors tended to be related to delaying feedback

8.  Results:

–  Did the target behavior(s) improve when treated?  Yes, for the most part, but none of the Ps in this investigation achieve Mastery in the 12 sessions.

–  DESCRIPTION OF RESULTS

•  OUTCOME #1: Prosodic (lexical stress) accuracy of targeted bisyllable pseudo words during treatment sessions: Strong Improvement

     ∞ P1 = baseline = below 10%; final session = 66%   

     ∞ P2 = baseline = below 30%; final session = 82%   

     ∞ P3 = baseline = 15%; penultimate session = 75%

     ∞ P4 = baseline = around 30%; final 3 sessions = averaged 79%

•  OUTCOME #2: Segmental accuracy of targeted bisyllable pseudo words during treatment sessions:  Moderate to strong improvement

     ∞ P1 = baseline = below 10%; final session = 66%   

     ∞ P2 = baseline = below 10%; final 3 sessions = 39% to 59%   

     ∞ P3 = baseline = about 50%; penultimate session = 75%

     ∞ P4 = baseline = around 50%; final 3 sessions = averaged 79%   

•  OUTCOME #3: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation)  of trained targets: Moderate improvement

     ∞ P1 = baseline =  0%       ; final probes = 10%; retention probe = 50-60%

     ∞ P2 = baseline =  0%; final probe = about 40%; retention probe = about 30%

     ∞ P3 = baseline = 20% or under; final probe = about 50%; retention probe= about 40%

     ∞ P4 = baseline = about 20%; final probe = about 40%; retention probe = about 40%

•  OUTCOME #4: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation) of untrained targets: Limited improvement

     ∞ P1 = baseline =   0%; final probe = 0%; retention probe = under 20%

     ∞ P2 = baseline = under 10%; final probe = about 30%; retention probe = 0%

     ∞ P3 = baseline = 20% or under; final probe = about 30%; retention probe = about 30%

     ∞ P4 = baseline = 0% to 40%; final probe = about 20%; retention probe = about 40%. 

•  OUTCOME #5: Percent Vowels Correct (PVC) in connected speech: Limited improvement

     ∞ P1 = pretreatment = 74%; post treatment = 81%; retention = 80%      

     ∞ P2 = pretreatment = 78%; post treatment = 87%; retention = 87%      

     ∞ P3 = pretreatment = 90%; post treatment = 88%; retention = 92%

     ∞ P4 = pretreatment = 85%; post treatment = 84%; retention = 91%

•  OUTCOME #6: Percent Consonants Correct (PCC) in connected speech:  Limited improvement to ineffective

     ∞ P1 = pretreatment = 81%; post treatment = 80%; retention = 54%

     ∞ P2 = pretreatment = 95%; post treatment = 95%; retention = 88%

     ∞ P3 = pretreatment = 70%; post treatment = 86%; retention = 74%

     ∞ P4 = pretreatment = 60%; post treatment = 70%; retention = 66%

•  OUTCOME #7: Percent correct stress patterns in connected speech: Limited to moderate improvement

     ∞ P1 = pretreatment = 46%; post treatment = 43%; retention = 70%

     ∞ P2 = pretreatment = 53%; post treatment = 81; retention = 76%      

     ∞ P3 = pretreatment = 79%; post treatment = 77%; retention = 85%     

     ∞ P4 = pretreatment = 64%; post treatment = 68%; retention = 83%     

•  OUTCOME #8: PPVT Standard Score (this was a foil outcome; that is, improvement was not expected) Ineffective

     ∞ P1 = pretreatment = 90; post treatment = 84   

     ∞ P2 = pretreatment = 90; post treatment = 96   

     ∞ P3 = pretreatment = 91; post treatment = 90   

     ∞ P4 = pretreatment = 117; final session = 119  

9.  Description of baseline: 

–  Were baseline data provided?  Variable

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

•  OUTCOME #3: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation)  of trained targets: Baseline low and stable for all P

•  OUTCOME #4: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation) of untrained targets: Baseline was low and stable for Ps 1, 2, and 3 but not 4.

  Was the percentage of nonoverlapping data (PND) provided? 

Yes  _____  No  ________  Only for the following Outcome-

•  OUTCOME #3: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation) of trained targets: 

     – PND for P1 = 75% (fairly effective)

     – PND for P2 = 100% (highly effective)

     – PND for P3 = 75% (fairly effective)

     – PND for P4 = 100% (highly effective)

•  OUTCOME #4: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation) of untrained targets: 

     – PND for P1 = 25% (unreliable/ineffective)

     – PND for P2 = 25% (unreliable/ineffective)

     – PND for P3 = 75% (fairly effective)

     – PND for P4 = 0% (unreliable/ineffective)

10.  What is the clinical significance?  NA

11.  Was information about treatment fidelity adequate?  Yes. The investigators calculated treatment fidelity for each of the Ps. It ranged from 75% to 83% with errors tending to be related to delaying feedback.

12.  Were maintenance data reported?  Yes. Four weeks after the post treatment assessments, retention was measured for selected outcomes. The amount of retention varied based on the outcome and individual Ps.

     – OUTCOME #3: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation)  of trained targets

     ∞ Strong retention for P1and P4.

     ∞ Moderate retention for P2 and P3 

     – OUTCOME #4: Percent perceptual accuracy (target perceived as having both correct prosody and correct articulation) of untrained targets:

     ∞ Limited retention P4 

     ∞ Strong retention P4 (perhaps P1

     ∞ Failure to retain P2  

•  OUTCOME #5: Percent Vowels Correct (PVC) in connected speech

     ∞ all Ps strong 

•  OUTCOME #6: Percent Consonants Correct (PCC) in connected speech

     ∞ Failure –retention was markedly lower than pretreatment  for P1 

     ∞ Strong retention (P2)

     ∞ Limited retention (P3, P4)  

•  OUTCOME #7: Percent correct stress patterns in connected speech:

     ∞ Strong retention (all Ps)

13.  Were generalization data reported? Yes

•  There were 3 types of generalization data: 

     – performance on trained verse untrained probes at selected intervals (baseline and probes), 

     – performance in connected speech, 

     – performance on the PPVT before and after treatment. 

•  Performance on trained verse untrained probes at selected intervals (baseline and intervention probes): The percent overall accuracy of trained and untrained targets during baseline was similar for all Ps. However, the percent overall accuracy of trained targets exceeded baseline for all Ps for intervention probes. 

•  All Ps increased their percent of correct stress in connected speech during retention testing, although connected speech was not targeted during treatment.

•  None of the Ps increased their PPVT scores from the beginning to the end of treatment. This was not expected because this was considered to be a foil measure.

14.  Brief description of the design:

• The authors provided supplementary data online in addition to the information in the Results section. Only the data presented in the article are described in this review.

• The investigators administered ReST to 4 children who had been diagnosed with CAS. performance in connected speech.

• The investigators measured selected outcomes at a series of 3 baseline and 3 probe sessions as well at a retention session, 4 weeks following treatment. Other outcomes were measured before and after treatment.

• The analysis of the data included visual analysis as well as the calculation of PND.

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

SUMMARY OF INTERVENTION

PURPOSE: To explore the effectiveness of ReST in improving the production of lexical stress

POPULATION:  Childhood Apraxia of Speech (CAS); children

MODALITY TARGETED:  production

ELEMENTS/FUNCTIONS OF PROSODY TARGETED:  lexical stress

ELEMENTS OF PROSODY USED AS INTERVENTION:  stress, duration, rate

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  articulation 

OTHER TARGETS:  a foil target of receptive vocabulary 

DOSAGE:  60 minute individual sessions, 4 sessions per week for 3 weeks (12 sessions); homework was not assigned.

ADMINISTRATOR:  SLP

STIMULI: pseudowords 

MAJOR COMPONENTS:

• The focus of ReST is the production of bisyllable nonsense words with stress patterns (Strong-Weak, SW, or Weak-Strong, WS). Because previous research has indicated that even children as young as 5 (the youngest P in this investigation) have a tendency to produce certain pseudo words as SW or WS, the tendencies were adhered to in the construction of pseudowords for the targets and probe stimuli. 

• Treatment session consisted of pre-practice (10-20 minutes) and practice (40-50 minutes) phases.

PRE-PRACTICE PHASE 

• In place of the terms Weak and Strong, the clinician (C) used Short and Long. 

• C presented a bisyllable pseudoword target to the participant (P) randomly and asked P to identify the pseudoword as Long-Short or Short-Long.

• C corrected P if the wrong stress pattern was identified.

• C then modeled the target word and requested P to produce it. 

• C provided 100% feedback regarding the accuracy of the stress pattern produced by P. If P’s production of stressing was in error, C used knowledge of performance (KP) feedback and described how P should modify the production (e.g., “Try to make the first part even shorter”, p 140).

• C was also allowed to provide other cues such as hand clapping or shaping to facilitate correct production.

• Regarding the segmental accuracy of the target (not the primary focus of this investigation), C provided knowledge of results (KR) feedback. That is C only indicated whether the speech sound production was correct or incorrect.

• When P produced 5 correct consecutive trials, C proceeded to the Practice Phase

PRACTICE PHASE

• C presented the treatment targets (19 bisyllable pseudo words) in random order within sets to allow for the production of at least 100 pseudowords per session. 

• Depending on the P’s reading level, P either read aloud a pseudoword or imitated C’s production of the C reading aloud the pseudoword.

• Three to 5 seconds after P’s attempt, C provided KR feedback on the combined prosodic and segmental accuracy at the 50% level.

• Mastery was defined as 80% correct performance over 3 consecutive sessions. (Typically developing children can achieve this in 3 to 4 sessions.) None of the Ps in this investigation achieve Mastery in the 12 sessions.

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


Thomas et al. (2016)

June 25, 2020

 

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

KP = knowledge of performance

KR = knowledge of response

NA =  not applicable

P =  Patient or Participant

pmh =  Patricia Hargrove, blog developer

SLP =  speech–language pathologist

ReST =  Rapid Syllable Transitions (treatment)

WNL =  within normal limits

 

SOURCE:  Thomas, D. C., McCabe. P., Ballard, K. J., & Lincoln, M.  Telehealth delivery of Rapid Syllable Transitions (ReST) treatment for childhood apraxia of speech. International Journal of Language and Communication Disorders, 51, 654-671.

 

REVIEWER(S):  pmh

 

DATE:  June 22, 2020

 

ASSIGNED OVERALL GRADE:  A-  The highest possible grade for this investigation is A- based on its design. The Assigned Overall Grade reflects the strength of the evidence supporting the intervention described her and should not be construed to be a judgment about the quality of the intervention.

 

TAKE AWAY:  This preliminary investigation used a multiple baseline across participants design to explore the effectiveness of administering Rapid Syllable Transitions (ReST) treatment to children with childhood apraxia of speech (CAS) using telehealth delivery procedures. Each of the participants made progress on imitation tasks in which the target response was correct production of speech sounds, lexical stress, and smooth transitions between speech sounds.

 

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

 

  1. What type of evidence was identified?
  • Whattype of single subject design was used?  Single Subject Experimental Design with Specific Client – 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 (Ps) adequately described? No
  • How many Ps were involved in the study?5 

 

–  CONTROLLED CHARACTERISTICS 

  • language: Australian English
  • receptive language:within normal limits (WNL)
  • oral structure: WNL
  • diagnosis:CAS

     –  for Ps under 11 years, greater than 40% inconsistency on the Diagnostic Evaluation of Articulation and Phonology; for Ps 11 years or older greater than 30% inconsistency on 3 administrations  of 25 words from the Test of Polysyllables,  and

     –  evidence of syllable transition difficulty (at least 10 words with syllable segregation problems on the Test of Polysyllables), and

     –  at least 15% stress mismatches on the Test of Polysyllables.

  • hearing level:WNL

 

–  DESCRIBED CHARACTERISITICS

  • age:5:5 to 11:2
  • gender:4m; 1f                            
  • expressive language:standardized score range =  63 to 112
  • receptive language:standardized score range =  75 to 106
  • receptive vocabulary:standardized score range = 88 to 108
  • auditory perception:all WNL
  • articulation (production):standardized score range = 45-79; severity of impairment ranged from mild t0 severe
  • articulatory inconsistency: all inconsistent
  • Polysyllable production:

–  % consonants correct:  36% to 85%

–  % vowels correct:  50% to 91%

–  % phonemes correct:  42% to 87%

–  % stress patterns errors:  26% to 77%

–  % syllable segregations:  20% to 25%

  • previous speech therapy:all Ps had received

                                                 

–  Were the communication problems adequately described?  Yes

  • Disorder type: Childhood Apraxia of Speech (CAS)

 

                                                                                                                       

  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?Data were Provided Only for Some Outcomes
  • Did probes/intervention data include untrained stimuli?Yes
  • Did probes/intervention data include trained stimuli?Yes
  • Was the data collection continuous? No
  • Were different treatment counterbalanced or randomized? NA

 

  1. Were the outcome measures appropriate and meaningful?  Yes
  • OUTCOME #1: Imitation of treated pseduowords (correct production = correct sounds, lexical stress, smooth transitions between sounds)
  • OUTCOME #2: Imitation of treated pseduowords in phrases (correct production = correct sounds, lexical stress, smooth transitions between sounds)
  • OUTCOME #3: Imitation of untreated pseduowords (correct production = correct sounds, lexical stress, smooth transitions between sounds)
  • OUTCOME #4: Imitation of untreated real words(correct production = correct sounds, lexical stress, smooth transitions between sounds)
  • OUTCOME #5: Imitation of unrelated, untreated speech sound (i.e., control)
  • OUTCOME #6: Clinician’s rating of technology following each session
  • OUTCOME #7: Rating of satisfaction (convenience, perception of child motivation, overall satisfaction) 4 weeks after the termination of therapy

–  ALL the outcomes are subjective. 

–  NONE of the outcomes are objective.

–  Intra-rater reliability (averaged percentage) for judging correctness:

     Pseudowords (probes) = 92%

     Real words (probes)  = 91.9%

     Control sounds (probes) = 93.5%

     Treatment items = 91%

 

–  Inter-rater reliability (averaged percentage) for judging correctness:

     Pseudowords (probes) = 89%

     Real words (probes)  = 87.3%

     Control sounds (probes) = 81.5%

     Treatment items = 88%

 

–  Intra-rater reliability (averaged percentage) of broad phonemic transcription:

     Pseudowords (probes) = 89.4%

     Real words (probes)  = 82.5%

     Control sounds (probes) = 92.8%

     Treatment items = 95%

 

–  Inter-rater reliability (averaged percentage) of broad phonemic transcription:

     Pseudowords (probes) = 84.9%

     Real words (probes)  = 78.5%

     Control sounds (probes) = 80.5%

     Treatment items = 94%

 

  1. Results:

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

  • OUTCOME #1: Imitation of treated pseduowords (correct production = correct sounds, lexical stress, smooth transitions between sounds) Strong evidence of change; all Ps improved
  • OUTCOME #2: Imitation of treated pseduowords in phrases (correct production = correct sounds, lexical stress, smooth transitions between sounds) Moderate evidence of change; 2 of 4 treated Ps improved
  • OUTCOME #3: Imitation of untreated pseduowords (correct production = correct sounds, lexical stress, smooth transitions between sounds) Strong evidence of change; 4 of 4 treated Ps improved
  • OUTCOME #4: Imitation of untreated real words (correct production = correct sounds, lexical stress, smooth transitions between sounds) Strong evidence of change; 3 of 3 treated Ps improved
  • OUTCOME #5: Imitation of unrelated, untreated speech sound (i.e., control) Moderate evidence of lack of change as control; 4 of 5 Ps did not differ significantly from baseline
  • OUTCOME #6: Clinician’s rating of technology following each session –61% of the sessions were reported to experience technical difficulties but only 1 session  (of 113)  was cancelled.
  • . OUTCOME #7: Rating of satisfaction (convenience, perception of child motivation, overall satisfaction) 4 weeks after the termination of therapy Parents reported satisfaction with the teletherapy with an average score of 9.5 0ut of a possible 10 and that teletherapy was convenient (9.7/10) . Clinicians were somewhat less satisfied (8.75/10) but they found teletherapy to be convenient (9.25/10).

 

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

Baseline was provided for Outcomes 1 though 5. The number of sessions that comprised baseline differed for the Ps from 3 to 6 sessions. This was enacted as a control measure.

  • Was baseline low and stable? Yes.                                                 
  • Was the percentage of nonoverlapping data (PND) provided? No

 

  1. What is the clinical significance?

–  OUTCOME #1:  Imitation of treated pseduowords (correct production = correct sounds, lexical stress, smooth transitions between sounds)

  • magnitude of effect: range 3.59 to 21.24
  • measure calculated:Cohen’s d2
  • interpretation: strong

 

–  OUTCOME #2:  Imitation of treated pseduowords in phrases (correct production = correct sounds, lexical stress, smooth transitions between sounds)

  • magnitude of effect:2.00 to 2.30
  • measure calculated:Cohen’s d2
  • interpretation: strong

–  OUTCOME #3:  Imitation of untreated pseduowords (correct production = correct sounds, lexical stress, smooth transitions between sounds)

  • magnitude of effect: 1.79 to 13.16
  • measure calculated:Cohen’s d2
  • interpretation: strong

  OUTCOME #4:  Imitation of untreated real words (correct production = correct sounds, lexical stress, smooth transitions between sounds)

  • magnitude of effect:3.12 to 6.34
  • measure calculated:Cohen’s d2
  • interpretation: strong

  OUTCOME #5:  Imitation of unrelated, untreated speech sound (i.e., control)

  • magnitude of effect:0 to 1.63
  • measure calculated:Cohen’s d2
  • interpretation: ineffective to strong

 

  1. Was information about treatment fidelity adequate? Yes
  • Average fidelity for the sessions that were sampled was 96% with a range of 75% to 100%. The earliest samples yielded the lowest fidelity.

 

  1. Were maintenance data reported? Yes
  • 4 of the 5 Ps maintained or improved performance on treated and untreated probes.
  • 1 P’s performance was variable.
  • Statistical analysis revealed that the maintenance data was stable across the 3 follow-up sessions (1 week, 4,weeks, 4 months).

 

  1. Were generalization data reported?Yes
  • All the Ps generalized from treated to untreated stimuli.

 

  1. Brief description of the design:
  • The investigators explored the effectiveness of the online video conferencing (telehealth) using Rapid Syllable Transitions (ReST) to treat children with CAS.
  • The investigators used a multiple baseline across participants design to assess effectiveness.
  • ReST treatment was administered to 5 children diagnosed with CAS.
  • The investigators administered a battery of tests prior to the intervention and they probed the Ps’ ability to imitate trained and pseudowords, untrained real words, and control speech sounds before the initiation of treatment, before sessions 5 and 9, as well as 1 week post intervention, 4 weeks post intervention, and 4 months post intervention.

 

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

 

SUMMARY OF INTERVENTION

 

PURPOSE:  To investigate the effectiveness of Rapid Syllable Transitions (ReST) using video conferencing.

POPULATION:  Childhood Apraxia of Speech (CAS)

MODALITY TARGETED:  production

ELEMENTS OF PROSODY USED TO TREAT NONPROSODIC TARGET: lexical stress, transitions (concordance)

ELEMENTS/FUNCTIONS OF PROSODY TARGETED:  lexical stress, transitions (concordance)

OTHER ASPECTS OF LANGUAGE/COMMUNICATION TARGETED:  speech sound accuracy

DOSAGE:  4 times a week for 3 weeks

ADMINISTRATOR:  Speech-language pathologists (SLPs) or supervised students training to be SLPs.

MAJOR COMPONENTS:

 

Telehealth Procedures

  • The investigators described the video conferencing instrumentation they used including headsets and microphones.
  • Prior to the initiation of treatment, each clinician and participant pair familiarized themselves with the instrumentation and videoconferencing equipment for one or two sessions. The content of the familiarization sessions involved games.

 

ReST

 

  • Correct performance = correct speech sounds, lexical stress, smooth transitions between sounds

 

Pre-Practice Phase (25 minutes sessions 1,2 and when a new treatment level was initiated; 10 minutes other sessions)

  • To provide the standard of correct performance

 

  1. The clinician (C) displayed one of 20 treatment stimuli on a card.
  2. C modeled the targeted word.
  3. The participant (P) imitated the word.
  4. C provided knowledge of performance (KP) feedback which involved
    1. A description of any errors (e.g., The second syllable was stressed. Try stressing the first syllable by making it longer.)
  5. C assisted P in achieving a correct response by providing cues such as
    1. Dividing words into syllables and then producing them as a single unit
    2. Representing visually the relative duration of syllables within a targeted word with magnets or blocks of different sizes.
    3. Encouraging a slower speaking rate.
    4. Describing articulatory placement of targeted speech sounds.
  6. The criterion for moving to the Practice Phase of Treatment was 5 correctly produced targets with modeling and shaping.

 

Practice Phase

  1. The target was 100 trials per session (5 trials each of the 20 treatment words; the words were presented in random order by sets).
  2. C presented a written form of the targeted word and modeled the targeted production.
  3. P attempted to imitate the modeled word using the modeled speech sounds, lexical stress, and smooth transitions between sounds.
  4. Following a 3 to 5 second delay, C provided knowledge of response (KR) feedback (i.e., feedback as to whether the imitation was correct or incorrect) to P on a 50% schedule.
  5. After each set of 20 trials, C provided a 2-minute break to P.
  6. Ps progressed from one level of target complexity to the next when they met the criterion of 80% or greater correct items in 2 consecutive treatment sessions.

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