Aphasiology

ISSN: 0268-7038 (Print) 1464-5041 (Online) Journal homepage: http://www.tandfonline.com/loi/paph20

Melodic intonation therapy applied to the

production of questions in aphasia
Shannon C. Mauszycki, Christina Nessler & Julie L. Wambaugh
To cite this article: Shannon C. Mauszycki, Christina Nessler & Julie L. Wambaugh (2015):
Melodic intonation therapy applied to the production of questions in aphasia, Aphasiology,
DOI: 10.1080/02687038.2015.1109049
To link to this article: http://dx.doi.org/10.1080/02687038.2015.1109049

Published online: 11 Nov 2015.

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Date: 17 March 2016, At: 00:52

Aphasiology, 2015
http://dx.doi.org/10.1080/02687038.2015.1109049

Melodic intonation therapy applied to the production of questions

in aphasia
Shannon C. Mauszyckia,b*, Christina Nesslera and Julie L. Wambaugha,b
a

Aphasia/Apraxia Research Program, VA Salt Lake City Health Care System, Salt Lake City, UT, USA;
b
Department of Communication Sciences & Disorders, University of Utah, Salt Lake City, UT, USA

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(Received 9 July 2015; accepted 9 October 2015)

Background: Melodic intonation therapy (MIT) is a treatment approach used to facilitate verbal production in adults with aphasia by combining melodic intoning and
rhythmic tapping. Although MIT was developed in the early 1970s, there is limited
empirical evidence documenting specific behavioural outcomes.
Aims: Two individuals with chronic Brocas aphasia and acquired apraxia of speech
received MIT applied to wh-questions in the context of multiple baseline designs.
Methods & Procedures: Linguistic principles were applied to the selection of items
used for treatment and measurement of generalisation effects. The dependent variables
were (a) production of wh-questions and (b) articulatory accuracy via percentage of
consonants correct in the production of wh-questions.
Results: For Participant 1, there was an increase in the production of wh-questions for only
one wh-morpheme which was maintained at 6 weeks post-treatment. For Participant 2,
there was an increase in production of wh-questions for two wh-morphemes; however,
performance was variable and declined by 6 weeks post-treatment. For both participants,
there were modest gains in percentage of consonants correct for treated and generalisation
items at 6 weeks post-treatment.
Conclusions: There were limited gains in the production of wh-questions for both
participants with the application of MIT. However, there were modest gains in
percentage of consonants correct. MIT as applied in this investigation to wh-questions
utilising linguistic principles did not result in improvement in the formulation and
production of wh-questions, but treatment did have positive effects on articulatory
accuracy for treatment and generalisation items. Additional research is needed to
further examine the efficacy of MIT for outcomes involving both language and speech
production.
Keywords: aphasia; apraxia of speech; treatment; MIT

Aphasia is a disruption of language that most often occurs following a stroke. Severity of
aphasia may range from very mild difficulties with word-finding to a complete inability to
produce and/or understand language. Melodic intonation therapy (MIT) is a treatment
approach developed to increase verbal output in adults with aphasia (Albert, Sparks, &
Helm, 1973; Helm-Estabrooks & Albert, 2004; Helm-Estabrooks, Nicholas, & Morgan,
1989; Sparks, Helm, & Albert, 1974; Sparks & Holland, 1976). The approach employs
melodic intoning and rhythmic tapping to facilitate verbal production of language.
MIT (Albert et al., 1973) was developed in the early 1970s as a behavioural therapy for
moderate to severe nonfluent aphasia. Its creators hypothesised that MITs effects result from
*Corresponding author. Email: shannon.mauszycki@utah.edu
This work was authored as part of the Contributors official duties as an Employee of the United States Government and is
therefore a work of the United States Government. In accordance with 17 U.S.C. 105, no copyright protection is available for
such works under U.S. Law.

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S.C. Mauszycki et al.

the right cerebral hemispheres dominance for musical abilities and speech prosody (Sparks
et al., 1974). MIT is a hierarchically structured treatment approach that employs melodic
intoning, slowed rate of production, hand-tapping, therapist modelling, and repeated practice
to facilitate productive verbal language. Treatment involves an ongoing progression through
multiple levels of practice wherein the therapists modelling and participation is gradually
faded. MIT has typically focused on production of functional phrases (Sparks, 2008).
Initial MIT reports concentrated on documenting gains and developing/describing
procedural aspects of treatment in case studies and small n investigations (Albert
et al., 1973; Laughlin, Naeser, & Gordon, 1979; Sparks & Holland, 1976; Sparks et al.,
1974). The potential for MIT to engage the right hemisphere stimulated an early structural
imaging study of site of lesion associated with different MIT outcomes (Naeser & HelmEstabrooks, 1985). More recently, functional imaging has been increasingly applied to the
study of MITs effects (2009; Belin et al., 1996; Breier, Randle, Maher, & Papanicolaou,
2010; Schlaug, Marchina, & Norton, 2008; Vines, Norton, & Schlaug, 2011). Findings
have varied across and within investigations in terms of functional imaging findings and
changes in patterns of activity associated with MIT; it appears that positive response to
MIT may be associated with changes in the intact left hemisphere areas (e.g., Breier et al.,
2010) or right hemisphere areas (e.g., Schlaug et al., 2009).
Despite the increase in MIT investigations, much of the functional imaging research
has only reported improvements in formal test scores (Bonakdarpour, Eftekharzadeh, &
Ashayeri, 2003; Sparks et al., 1974) and production of content (Schlaug et al., 2008; van
der Meulen, van de Sandt-Koenderman, Heijenbrok-Kal, Visch-Brink, & Ribbers, 2014;
Zumbansen, Peretz, & Hbert, 2014). Much of this renewed attention appears to be related
to MITs potential for engaging both the right and left hemispheres, which is of interest in
terms of neurorehabilitation and neuroimaging. Even with the long-term availability of
MIT and the resurgence of MIT research, there is a surprising lack of empirical evidence
documenting specific behavioural outcomes.
There is a growing body of research incorporating linguistic principles in the treatment
of aphasia (see Thompson and Shapiro (2007) for a review). The application of linguistic
principles has resulted in positive treatment findings as well as positive generalisation
effects (Thompson, Shapiro, & Roberts, 1993; Thompson, Shapiro, Tait, Jacobs, &
Schneider, 1996; Thompson et al., 1997). The effects of these principles when incorporated into treatment will be discussed including the role they may have in MIT. It is also
thought that MIT has the potential to improve the symptoms of acquired apraxia of speech
(AOS). Therefore, the possible benefits of MIT on speech production will be explored.
Finally, research has found positive generalisation effects with MIT (Hough, 2010;
Schlaug et al., 2008; van der Meulen et al., 2014; Zumbansen et al., 2014); however
the reported findings have varied across studies. Results from MIT studies reporting
positive generalisation effects will be reviewed.
Research has found linguistic theories informative in understanding how normal sentence
processing operates in order to determine deficits that occur in aphasia. The use of linguistic
theories and the principles they provide have been helpful in guiding the treatment of aphasia,
specifically sentence production deficits (Shapiro & Thompson, 1994; Thompson & Shapiro,
1994; Thompson et al., 1996, 1997). One approach applying linguistic principles has involved
training the production of wh-questions requiring argument (i.e., who & what questions) and
auxiliary movement (i.e., when & where questions). Investigators found that controlling and
manipulating specific lexical and syntactic elements in treatment resulted in positive treatment
and generalisation effects for trained and untrained production tasks (Thompson et al., 1993,
1996).

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Aphasiology

Findings by Thompson and colleagues have gone beyond positive results for trained
and untrained production tasks, but have also found positive generalisation effects in
discourse tasks (Thompson et al., 1996, 1997). Sentence production treatments that have
not incorporated linguistic principles have resulted in poor outcomes in terms of generalisation (Schwartz, Saffran, Fink, Myers, & Martin, 1994; Wambaugh & Thompson,
1989). It appears that linguistic specific treatment guided by linguistic principles is
efficacious for training sentence production in aphasia. MIT has not been developed to
take advantage of a large body of research concerning application of linguistic principles
to aphasia treatment. It is possible that the application of linguistic principles to MIT could
improve treatment outcomes.
MIT has the potential to positively impact speech production in speakers with AOS,
who tend to also present with Brocas aphasia (i.e., the type of aphasia for which MIT was
developed). AOS is a motor speech disorder of neurologic origin that is characterised by
slowed rate of speech, difficulties in sound production, and disrupted prosody (McNeil,
Robin, & Schmidt, 2009). It may be difficult to separate the effects of AOS from aphasia
relative to the contribution of each to a patients communication disorder. MIT is
relatively unique in that it may be appropriate for the treatment of both aphasia and AOS.
Elements of MIT, such as modelling, repeated practice, hand-tapping, and slowing rate
of speech production, have all been shown to improve articulation in AOS (Ballard et al.,
2015; Wambaugh, Duffy, McNeil, Robin, & Rogers, 2006). However, there have only
been anecdotal accounts of gains in articulatory accuracy following MIT (Sparks &
Holland, 1976) with reports that clinicians have been using a phonological form of
MIT per Sparks (2008) without data provided.
The effects of MIT on AOS have rarely been examined. A study by Vines and
colleagues examined the effects of MIT in conjunction with transcranial direct current
stimulation (Vines et al., 2011). Findings revealed reductions in a measure of duration of
speech/language production, which authors inferred as an increase in speech fluency. An
investigation by Zumbansen et al. (2014) measured number of syllables correct pre- vs.
post-treatment in their investigation examining MIT in a treatment comparison involving
three participants with Brocas aphasia and moderate to severe AOS. Findings revealed an
increase in number of syllables correct for all three treatments, but there were similar
gains in the number of syllables correct for both trained and untrained stimulus items
following MIT for one participant. There were greater gains in number of syllables correct
for only the trained items for the other two treatment approaches. It appears likely that
speech improvements should occur with MIT, but data concerning MITs effects on
speech production are limited.
Positive generalisation effects of MIT have been reported (e.g., Schlaug et al., 2008;
van der Meulen et al., 2014; Zumbansen et al., 2014), but it is difficult to ascertain the
specifics of this generalisation. That is, rarely have the treatment stimuli, the measurement
conditions, and individual findings been described sufficiently to allow determination of
patterns of generalisation within or across participants. An exception to this pervasive lack
of detail regarding measurement and reporting of outcomes is a recent report by Hough
(2010) in which a modified version of MIT was examined utilising a single-subject
experimental design. Changes in production of trained and untrained phrases were
reported across the course of the investigation, along with results of three measures of
functional communication. Positive changes were reported for the ASHA Functional
Assessment of Communication Skills (ASHA FACS; Frattali, Thompson, Holland,
Wohl, & Ferketic, 1995), the ASHA Quality of Communication Life Scales (ASHA
QCL; Paul et al., 2003), and the Communicative Effectiveness Index (Lomas et al.,

S.C. Mauszycki et al.

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1989). This investigation is the only report to systematically address functional communication changes with MIT.
Hough (2010) reported that training of automatic phrases such as I love you and
good morning did not result in generalisation to self-generated phrases such as time for
email and I need my cane. However, she did find that training of self-generated phrases
resulted in increased accuracy of production of non-trained self-generated phrases.
Unfortunately, she did not describe the features of utterances that improved and those
that did not.
If MIT is to have real clinical utility, clinicians must have information concerning
specific expected outcomes, like those described by Hough. The phrases that were trained
and measured by Hough (2010) are typical of those used with MIT since its inception (i.e.,
short sentences and phrases of a functional nature). However, as early as 1976, Sparks and
Holland (1976) envisioned an expanded application of MIT:
It is clear that careful attention to grammatical structure of the language units is now in order,
perhaps in terms of gradual increase of linguistic complexity, perhaps in terms of linguistic
spontaneity by using a changing lexicon in appropriate slots of controlled and defined
sentence types, or perhaps in some other as yet unspecified way. Not only may consideration
of grammatical structure improve the efficiency of MIT for the severely impaired aphasic, it
may also establish usefulness for less severely impaired subjects. (p. 291)

Systematic development of MIT has not occurred as suggested by Sparks and Holland
(1976) despite the emergence of a compelling literature concerning the application of
linguistic principles to aphasia treatment (Thompson & Shapiro, 2007). As discussed
earlier, linguistic theory has been applied successfully with other treatments for nonfluent
aphasia/agrammatism in terms of promoting and explaining generalisation. Although MIT
was developed to improve functional utterance production, as noted by Sparks and
Holland (1976), such a focus is not incompatible with the incorporation of linguistic
principles. Application of linguistic principles to the selection of treatment items and
items used to measure generalisation may enhance MITs effects. Certainly, consideration
of linguistic factors should facilitate our understanding of MITs outcomes so that its
effects may be more predictable.
An investigation with one speaker with chronic moderate to severe Brocas aphasia
and AOS due to a stroke was conducted to determine the feasibility of applying MIT with
stimuli selected according to linguistic principles (Wilkinson, Wambaugh, & Nessler,
2011). The participants verbal and written productive language was agrammatic and
typically consisted of single words or short phrases, with a predominance of nouns. Her
speech was characterised by symptoms consistent with a diagnosis of AOS (McNeil et al.,
2009).
Findings revealed that high levels of production accuracy on trained constructions
were achieved with 1622 treatment sessions (per treatment phase), with generalisation to
untrained constructions becoming evident after approximately 12 sessions. These findings
demonstrate that MIT can be applied in a linguistically principled manner. Furthermore,
acquisition and generalisation findings were strong.
The purpose of the present investigation is to further develop and systematically
examine the effects of MIT by applying linguistic principles to treatment and generalisation stimuli for two individuals with chronic aphasia and AOS. Outcomes of treatment
will be measured in terms of changes in measures of sentence production and accuracy of
articulation.

Aphasiology

The specific experimental questions to be addressed are as follows:

(1) Will treatment result in improved production of trained wh-questions measured
during probes?
(2) Will treatment result in improved production of untrained, syntactically similar
wh-questions measured during probes?
(3) Will treatment result in increased articulatory accuracy as measured by per cent
consonants correct in trained and untrained productions?

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Methods
Participants
Two individuals with chronic, stroke-induced aphasia and AOS served as participants.
Participant characteristics are summarised in Table 1. Medical records indicated that each
of the participants aphasia and AOS resulted from a single episode, left hemisphere
stroke.
The participants were one female and one male, ages 51 and 53, respectively, and both
were native English speakers. Each passed a pure tone hearing screening at 35 dB at 500,
1000, and 2000 Hz for at least one ear, unaided. Both participants demonstrated performance within normal limits on the Test of Nonverbal Intelligence-3 (Brown, Sherbenou, &
Johnsen, 1997). Participants had self-reported negative histories for alcohol and substance
abuse and neurological conditions other than stroke which was verified through existing
medical records. Both individuals lived in their own home with their spouse.
Participants presented with agrammatic aphasia and received the diagnosis of Brocas
aphasia based on their performance on the Western Aphasia Battery (WAB; Kertesz, 1982).
The participants productive verbal language was comprised primarily of single word
utterances. The participants did not exhibit any symptoms of dysarthria as described by
Duffy (2013). Therefore, no sensorimotor abnormalities in strength, speed, range, steadiness, tone, or accuracy of movement required for speech production specifically involving
respiration, phonation, resonation, articulation, and prosody were observed (Duffy, 2013).
Each participant exhibited characteristics that were consistent with those recommended for candidates for MIT: good auditory comprehension, poor repetition ability, a
paucity of verbal output, effortful speech production, emotional stability, and strong
motivation for therapy (Sparks, 2008).
The presence of AOS was determined using the diagnostic criteria described by
McNeil et al. (2009; McNeil, Robin, & Schmidt, 1997). Speech samples were obtained
from each participant employing the following elicitation tasks: (1) Increasing word
length and repeated trials subtests of the Apraxia Battery for Adults, 2nd edition (ABA2; Dabul, 2000); (2) narrative and procedural discourse tasks (Nicholas & Brookshire,
1993); (3) Assessment of Intelligibility of Dysarthric Speech (AIDs; Yorkston &
Beukelman, 1981); (4) consonant production probe (Wambaugh, Kalinyak-Fliszar, West,
& Doyle, 1998); (5) sentence repetition (Wambaugh, West, & Doyle, 1998); and (6)
multisyllabic word repetition (Mauszycki & Wambaugh, 2008). The following behaviours
deemed necessary for the diagnosis of AOS were demonstrated by both participants: slow
rate of speech production (including syllable segregation), sound errors that were relatively consistent in type and location across repeated trials, sound errors that were
predominately sound distortions, and prosodic abnormalities.

Participant characteristics.

Female L MCA
ischemic
Male
L Basal Ganglia hemorrhagic with intraventricular
hemorrhage & L frontal lobe hematoma

CVA location/type

53

51

Age

237

76

Months post
onset of stroke

MCA: middle cerebral artery; L: left; R: right; nH/L: non-Hispanic/Latino; UE: upper extremity; LE: lower extremity.

P2

P1

Participant Gender

Table 1.

14

12

Years of
education

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Premorbid
handiness

White-nH/L

White-nH/L

Race/
ethnicity

R
R
R
R

UE
LE
UE
LE

Hemiparesis

6
S.C. Mauszycki et al.

Aphasiology
Table 2.

Pre-treatment assessment results.

Measure

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Western Aphasia Battery

AQ
Type
Porch Index of Communicative Ability
Overall percentile
Verbal percentile
Auditory percentile
Reading percentile
Test of Adolescent/Adult Word Finding
Total raw score
% Comprehension
Verb & Sentence Test
Sentence construction
Sentence Anagram w/ pictures
Sentence Anagram w/o picture
Test of Nonverbal Intelligence3
Percentile
Reading Comprehension Battery for Aphasia
Word-visual
Word-auditory
Word-semantic
Functional reading
Sentence-picture
Assessment of Intelligibility of
Dysarthric Speech (% single word)
Estimated AOS severity

Participant 1

Participant 2

59.0
Brocas

60.8
Brocas

52
51
35
45

49
48
64
44

55/107
95%

8/107
95%

6/20
9/20
12/20

4/20
10/20
6/20

26th

34th

10/10
10/10
9/10
8/10
9/19
66%

7/10
10/10
9/10
3/10
8/10
78%

Moderate

Moderate

The participants word-level intelligibility scores ranged from 66% to 78% as scored
using orthographic transcription (Yorkston & Beukelman, 1981). The severity of AOS
was estimated on the basis of intelligibility and prevalence of sound production errors and
both participants were considered to have moderate AOS. Pre-treatment assessment
results are presented in Table 2.

Experimental design
A multiple baseline design (MBD) across behaviours and participants was used to
examine the effects of treatment. Accuracy of production of target wh-questions was
measured repeatedly with two sets of experimental wh-morphemes in the baseline phase.
Then, treatment was extended to one set of stimuli while probing continued with both
sets. Following 20 treatment sessions, treatment was applied to the second set of stimuli
for 20 sessions while probing continued with both sets. Maintenance and follow-up
probes were also completed.

Baseline phase
During baseline, wh-questions were elicited in response to two sets of stimulus items.
Prior to beginning the study, a minimum number of baseline probes for the first participant

S.C. Mauszycki et al.

was designated as 5 and an additional baseline probe for the second participant specifically for the experimental design of MBD across participants.

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Treatment phase
Following baseline, MIT was applied sequentially to both experimental sets of stimuli.
During the treatment phase, the experimental treatment items in both sets of stimuli were
probed every two treatment sessions. The generalisation items for both sets of stimuli
were also probed every two treatment sessions. However, these probes were conducted on
alternating days in order to counterbalance the probing schedule. All probes were conducted prior the days treatment session. All experimental stimulus items (i.e., treatment
and generalisation items for both sets) were probed at the conclusion of treatment for each
experimental set.

Maintenance and follow-up phases

When treatment was applied to the second set of wh-questions, probes continued with the
previously treated set of wh-questions on the same schedule outlined earlier (i.e., every
two treatment sessions) for both the treatment and generalisation items. Follow-up probes
were completed for all experimental stimuli items (i.e., treatment and generalisation items
for both sets) at 2, 4, and 6 weeks post treatment.

Experimental stimuli and probe procedures

Experimental stimuli
A set of 32 wh-questions were developed representing argument movement and adjunct
movement modelled after research conducted by Thompson et al. (1996). Argument
movement stimuli consisted of who and what questions and adjunct movement
stimuli consisted of when and where questions. For each target wh-morpheme (i.e.,
who, what, when, where), there were eight questions designated as treatment items to
measure the acquisition effects of treatment. A set of 20 wh-questions were developed
representing the same argument and adjunct movements described earlier. Five questions
for each wh-morpheme (i.e., who, what, when, where) were used to measure response
generalisation.
See Appendix 1 for a list of treatment and generalisation stimuli for each whmorpheme.
Treatment application with each experimental treatment set was counterbalanced
across the two participants. Participant 1 was first treated on wh-morphemes what and
who and then was treated on wh-morphemes when and where. Participant 2 was treated on
wh-morphemes in the reverse order.

Probe procedures
Production of target questions were elicited in probes using a declarative sentence in
conjunction with a prompting question. The examiner would say and present in writing
The nurse is pushing the baby and then the examiner would verbally say You want to
know the person pushing the baby, so you ask? aiming to elicit the following target
question: Who is the nurse pushing? The declarative sentences that corresponded to the

Aphasiology

target questions were elicited one at a time and were randomised across question type. All
responses were audio recorded as well as broadly transcribed by the examiner.

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Dependent variables
The accuracy of the production of target questions in response to the examiners questions
during probes served as the primary dependent variable. Each response received a binary
score (i.e., correct or incorrect). However, each response was also assigned a qualitative
score ranging from 0 to 11 (see Appendix 2) for the purpose of error type analysis.
Responses with all correct constituents or missing minor functor words were scored as
correct (i.e., scored as a 10 or above on the qualitative scoring scale). All other responses
were scored as incorrect (i.e., scored as a 9 or below based on the scoring scale).
Productions were scored online and then the scoring was verified using the audio
recordings. The percentage of sentences correctly produced was calculated for each set
of stimuli with separate calculations for treatment and generalisation items.
Percentage of Consonants Correct (PCC) served as a secondary dependent variable
and was computed for each target question for the four wh-morphemes for both treatment
and generalisation items in the final three baseline probes, final probe for each treatment
phase, and 6-week follow-up probe. PCC was the number of consonants articulated
correctly in probes as determined by an examiner that was not involved in the study
and was blinded to conditions (pre-treatment, treatment, or post-treatment). A scoring
template was created for each question in which the target consonants were identified.
Using audio recordings, the examiner scored each consonant as correct/incorrect and was
not limited in the number of times the audio recording could be replayed. To be scored as
correct, the consonant was required to be produced accurately in the correct location
within the word. If an entire word was omitted, all consonants for that word were scored
as incorrect. Words were not required to be in the correct order of the question, however,
omissions, substitutions, additions, and distortions were scored as incorrect. The correct
wh-word had to be used correctly in order to be counted as correct in the calculation of
PCC (e.g., target what what [correct with 2 points for PCC for this word; target what
where [incorrect with 0 points for PCC for this word]). PCC was calculated based on
total number of target consonants for both the eight treatment questions and the five
generalisation questions for the four wh-morphemes.

Reliability
Point-to-point reliability was calculated for scoring of target questions in probes. For both
participants, 20% of probes were quasi-randomly selected so that all phases of the study
were represented. The reliability examiner independently scored the selected probes by
assigning a qualitative score which then indicated a binary score for each item (i.e., 10 or
above considered correct or 9 and below considered incorrect) for each target question
from the verified transcription.
Each probe selected for reliability purposes was verified by an examiner not
involved in the study and blinded to conditions (e.g., pre-treatment, treatment, posttreatment). An speech langauge pathologist (SLP) involved in the study, but who did not
conduct the probe, completed the qualitative rescoring of each target question. The
average agreement for binary scoring for each probe was 97% across participants and
agreement across probes ranged from 85% to 100%.

10

S.C. Mauszycki et al.

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Point-to-point reliability was calculated for scoring of PCC. For both participants,
20% of probes were quasi-randomly selected. The reliability examiner independently
rescored each consonant as correct/incorrect using the identical procedures outlined earlier. The average agreement for scoring PCC was 98% with a range of 97% to 100%.

Treatment
A modified MIT hierarchy was randomly applied to one set of 16 target questions (8 per
target type) and then treatment was applied to another set of 16 target questions. Each set
of items received 20 treatment sessions. The detailed modified MIT protocol is provided
in Appendix 3.
Each of the 16 treatment items was submitted to the modified MIT hierarchy, one to
two times in random order in each treatment session. If participants achieved 80%
accuracy for each of the six steps of the treatment hierarchy during two consecutive
treatment sessions, then step 1 of the hierarchy was revised. An example of the revised
treatment steps for a stimulus item is provided in Appendix 4.
Participants were scheduled for treatment three times per week and were seen in their
homes. The conditions were quiet and free of distractions with comfortable seating
arrangement with table space for anagrams. Treatment sessions (excluding probes) ranged
from approximately 45 to 60 minutes. Treatment was administered by ASHA-certified
SLPs. Each participant was assigned two SLPs who shared treatment and testing
responsibilities.
Treatment fidelity. Twenty per cent of all treatment sessions were quasi-randomly selected
(balanced across SLPs) for calculation of accuracy of administration of treatment. An
examiner who had not administered the selected treatment session used the audio recording
to determine the accuracy of administration of each treatment step. The number of occasions a
treatment step was administered correctly was determined and divided by the total number of
treatment steps. The mean accuracy of treatment administration was 97% (range of 92% to
100%).

Results
Production accuracy of target wh-questions
Data representing the percentage of correctly produced wh-questions during probes are
presented in Figures 1 and 2 for Participants 1 and 2, respectively. Within each figure,
graphs 1 and 3 represent percentage of correctly produced wh-questions in probes for
treatment items (i.e., what and who or when and where). Also in the figure, graphs 2 and 4
show percentage of correctly produced wh-questions during probes for non-trained items
(i.e., generalisation). The order of the graphs from top to bottom in each figure indicates
the order of application of treatment to the sets of wh-morphemes.

Participant 1
In Figure 1, Participant 1 received treatment applied first to wh-morphemes what and who
and then to wh-morphemes when and where. In graph 1 (in Figure 1), baseline probe
values for treated items for what ranged from 0% to 100% and for who baseline probe
values were 0%. With the application of treatment, accuracy for forming questions for

11

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Aphasiology

Figure 1. The percentage of Wh-questions produced correctly for each Wh-morpheme for treated
and untreated stimuli for Participant 1.

what was at 100% accuracy by treatment probe 3 and remained at a high percentage of
accuracy for the remainder of the treatment probes. During the maintenance phase (i.e.,
treatment of the subsequent set of wh-morphemes), probe values for what ranged from
88% to 100% accuracy. The accuracy of forming questions for who was 0% for 9 of the

S.C. Mauszycki et al.

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12

Figure 2. The percentage of Wh-questions produced correctly for each Wh-morpheme for treated
and untreated stimuli for Participant 2.

11 treatment probes and performance remained at 0% for the bulk of the maintenance
phase. Follow-up probes at 2, 4, and 6 weeks post-treatment revealed that Participant 1
maintained a high level of accuracy for what with probe values ranging between 88% and
100%, however accuracy for who remained at 0%.
The probe performance for non-trained items of what and who are displayed on graph
2 in Figure 1 for Participant 1. For the wh-morpheme what, baseline values ranged from

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Aphasiology

13

0% to 60%. With the application of treatment, probe accuracy was 100% by treatment
probe 4 for what non-treated items and accuracy remained high for the subsequent
treatment probes. During the maintenance phase, probe performance for what ranged
between 80% and 100% accuracy. At the three post-treatment intervals of 2, 4, and 6
weeks, the accuracy of forming questions for what was at 100%. Baseline values for who
non-treated items were at 0% accuracy and remained at that level with the application of
treatment and during the maintenance phase. The three follow-up probes also revealed 0%
accuracy for the production of questions comprised of generalisation items for who.
For Participant 1, treatment was then applied to when and where as seen in graph 3 in
Figure 1. The baseline of the production of questions for both when and where was 0%
accuracy across the extended probing interval while treatment occurred with the other set
of wh-morphemes. There was no change in performance for either wh-morpheme when
and where with the application of treatment. Performance was identical for generalisation
items of when and where with 0% accuracy across both baseline and treatment phases
(graph 4 of Figure 1). This same pattern of performance continued for when and where on
follow-up probes conducted at 2, 4, and 6 weeks for both treated and untreated items.
Participant 2
In Figure 2, Participant 2 received treatment applied to wh-morphemes when and where
and then to wh-morphemes what and who. In graph 1 (in Figure 2), baseline values for
when ranged from 0% to 13% accuracy and values for where were at 0% accuracy.
Following the application of modified MIT, the accuracy of forming questions for when
ranged from 0% to 88% and for where values ranged from 0% to 63%. For both when and
where mean performance was 46% accuracy for the final three probes of the treatment
phase. During the maintenance phase of treatment (i.e., treatment of the subsequent set of
wh-morphomes), the accuracy for forming questions for when ranged from 38% to 100%
with a mean performance of 79% for the final three probes. During the maintenance phase
for where, probe performance ranged from 0% to 63% with a mean of 8% accuracy over
the final three probes. Follow-up probes conducted at 2, 4, and 6 weeks post-treatment,
the accuracy of forming questions for when remained well above baseline performance.
However there was a sharp decline in performance for when at 6 weeks. For where,
accuracy levels at 2, 4, and 6 weeks post-treatment were similar to baseline performance
which ranged from 0% to 13% accuracy.
On graph 2 in Figure 2, the data for the non-treated items for when and where are
presented. For the wh-morpheme when the baseline values ranged from 0% to 20%.
Following the application of treatment, probe accuracy ranged from 0% to 80% for when
with a mean of 60% accuracy for the final three probes. During the maintenance phase, the
accuracy for forming questions for when ranged from 0% to 100% with a mean performance of 33% for the final three probes for non-treated items. For the wh-morpheme where,
baseline values were at 0% accuracy and with application of treatment probe performance
ranged from 0% to 80% with a mean accuracy of 47% for the final three probes for the
where non-trained items. The accuracy for forming questions for where ranged from 0% to
40% with a mean of 13% accuracy during the maintenance phase. Follow-up probes
conducted at 2, 4, and 6 weeks post-treatment for when non-treated items revealed a
sharp decline in accuracy, specifically 20% accuracy at 4 and 6 weeks. Probe performance
for where non-treated items at the three follow-up intervals fell to 0% accuracy.
For Participant 2, treatment was then applied to wh-morphemes what and who as seen
on graph 3 in Figure 2. Baseline values for what treatment items ranged from 0% to 38%

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and with the application of treatment, probe performance ranged from 0% to 13%
accuracy with a mean of 4% for the final three probes. For the wh-morpheme who
treatment items, baseline values ranged from 0% to 25% and with the application of
treatment probe performance remained similar to baseline performance with 0% to 25%
accuracy with a mean of 0% for the final three probes. Follow-up probes conducted at 2,
4, and 6 weeks post-treatment revealed that probe performance returned to 0% for both
wh-morphemes what and who.
A comparable pattern of performance was observed for the non-treatment items for
what and who displayed in graph 4 in Figure 2. For both wh-morphemes what and who,
baseline values ranged from 0% to 20% and with the application of treatment probe
performance fell to 0% accuracy. At 2, 4, and 6 weeks post-treatment probe performance
for both what and who wh-morphemes was similar to baseline performance with values
ranging from 0% to 20% accuracy.

Percent consonants correct

The PCC values for the final three baseline probes, final probe for each treatment
phase, and 6-week follow-up probe are shown in Table 3. Values are presented for
each wh-morpheme separated by treatment and non-treatment stimuli (i.e.,
generalisation).
Table 3.

Participant

Per cent consonants correct.

Baseline Baseline Baseline Mean
*probe 1 *probe 2 *probe 3 baseline

Participant 1
Treatment Items
What questions
81%
Who questions
67%
When questions
56%
Where questions
47%
Generalisation items
What questions
69%
Who questions
64%
When questions
49%
Where questions
50%
Participant 2
Treatment items
What questions
35%
Who questions
30%
When questions
48%
Where questions
45%
Generalisation
items
What questions
56%
Who questions
36%
When questions
62%
Where questions
40%

End of
treatment
phase 1

End of
treatment
phase 2

Followup 6
weeks

57%
60%
53%
59%

82%
60%
55%
53%

73%
62%
55%
53%

89%**
66%**
61%
60%

88%
75%
68%**
66%**

89%
72%
68%
63%

56%
71%
44%
33%

78%
66%
57%
44%

68%
67%
50%
42%

84%
70%
56%
54%

84%
77%
58%
60%

84%
73%
64%
54%

35%
43%
53%
43%

29%
40%
44%
46%

33%
38%
48%
45%

54%
69%
79%**
74%**

67%**
64%**
78%
70%

56%
70%
74%
60%

38%
48%
38%
48%

49%
57%
53%
44%

48%
47%
51%
44%

60%
59%
78%
85%

29%
48%
76%
42%

64%
64%
82%
63%

* Final three baseline probes.

** The treated Wh-morphemes for that phase of treatment.
Note: Bold values are greater than the highest baseline value.

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Aphasiology

15

Participant 1 demonstrated relatively moderate levels of accuracy in the three pretreatment baseline samples with PCC ranging from 47% to 82% for treatment items and
33% to 78% for non-treatment items. After treatment was initiated, there was a 1% to
12% increase in PCC for treatment items ranging from 60% to 89% accuracy and for nontreatment items ranging from 54% to 84% accuracy. At 6 weeks post-treatment, PCC
values were maintained above baseline levels ranging between 63% and 89% accuracy for
treatment items and 54% to 84% for non-treatment items.
Participant 2s PCC values ranged from 29% to 53% for treatment items and from
36% to 62% for non-treatment items in the baseline condition. Following treatment, there
was a 2% to 37% increase in PCC values with treatment items ranging from 54% to 79%
accuracy and non-treatment items ranging between 59% and 85% accuracy after the first
treatment phase. However, after the second phase of treatment the gains in PCC were not
maintained for three of the four wh-morphemes for non-treatment items with values
ranging from 29% to 76%. Yet at 6 weeks post-treatment, values for PCC were well
above baseline levels for non-treatment items with accuracy ranging between 63% and
82% as well as treatment items with accuracy ranging between 56% and 74%.
Discussion
The purpose of this investigation was to examine effects of MIT applied to stimuli based
on linguistic principles in the formulation and production of wh-questions including
articulatory accuracy for treated and generalisation stimuli. For both participants in this
study, there were limited gains in the production of wh-questions in response to a
declarative statement as measured during probes. However, both participants had modest
gains in articulatory accuracy for treated and generalisation stimuli.
Participant 1 had improved accuracy for one out of the four wh-morphemes that were
trained in this investigation. For this individual, the wh-morpheme that resulted in
improvement (i.e., what) appeared to be the participants default response in probes thus
resulting in high levels of accuracy for both treated and non-treated items for that whmorpheme that was maintained at post-treatment intervals. This individual was able to
create and produce wh-questions for all four trained wh-morphemes with high levels of
accuracy during treatment including meeting criterion for using the revised treatment
protocol (i.e., two consecutive treatment sessions with 80% accuracy or greater on all
treatment steps) for both sets of wh-morphemes. However, the skills acquired in treatment
did not carry over to probe performance. Although the revised treatment protocol was
established to resemble probe procedures (i.e., independently formulating and producing
wh-questions), it did not result in any increase in accuracy for the other three whmorphemes during probes.
Participant 2 had gains in accuracy for creating and producing wh-questions for the
first set of treated wh-morphemes (i.e., when and where). However, his probe performance
was variable during both the treatment and maintenance phases with a significant decline
at 6 weeks post-treatment particularly for when. After analysing treatment data, Participant
2 struggled on step 1 for treatment set 1with an average of 75% accuracy. It appears that
Participant 2 had difficulty with selecting and/or movement of the sentence constituents to
construct the correct wh-question requiring adjunct movement (i.e., errors of co-referencing). A co-referencing error is when the speaker selects the correct wh-morpheme, but
improper co-reference is established between the wh-morpheme and moved noun phrase
(i.e., the trace is not established for the proper noun phrase [e.g., Who is the cop chasing
the fugitive? instead of Who is the cop chasing?]) (Thompson et al., 1996). Findings from

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16

S.C. Mauszycki et al.

Thompson et al. (1996) uncovered similar errors of co-referencing for three of their
participants during the initial treatment sessions. However, over the course of treatment,
errors of co-referencing declined for their three participants.
For treatment set 2 (i.e., what and who), Participant 2 had greater difficulty on step 2
(i.e., intoning target wh-question) with an average of 78% accuracy. It appears that
Participant 2 was able to successfully form wh-questions involving wh-morphemes
what and who, but struggled to produce wh-questions involving these two wh-morphemes
even with the clinicians model prior to his attempt at intoning. Frequently, he would
misselect among the four wh-morphemes in his attempt to produce/intone the wh-question. Thompson et al. (1996) found that four of their seven participants also exhibited whmorpheme selection errors. Investigators applied discrimination/production training as
part of treatment resulting in a decline of wh-morpheme selection errors. Examining
Participant 2s treatment performance provides some insight into his performance on
probes for each treatment set as well as additional tasks that could be combined with
MIT to promote the formulation and production of wh-questions (see later for further
discussion).
Findings in this investigation differed from those of Wilkinson et al. (2011) who also
applied linguistic principles to MIT. Wilkinson and colleagues had positive treatment
effects for the two wh-morphemes that were directly treated as well as generalisation to
two similar, but untrained wh-morphemes. That is treatment of who resulted in
improvement of wh-questions for what and treatment of when resulted in improvement of wh-questions for where. The findings by Wilkinson et al. are similar to those of
Thompson et al. (1996) in which a linguistic-based treatment of wh-questions via argument and adjunct movement resulted in improvement for additional wh-questions involving argument and adjunct movement that were not directly trained.
The differences in findings in the present study and those of Wilkinson et al. (2011)
may be due to probe procedures. In the present investigation, stimuli for all wh-morphemes were randomised and probed. Whereas the probes conducted in the previous
investigation by Wilkinson et al. were probed by each wh-morpheme with stimuli
randomised within each wh-morpheme set and order of wh-morpheme sets randomised.
Furthermore, the treatment steps involved in the present investigation and those for
Wilkinson et al. (2011) were similar, in particular there was only one treatment step
involved in creating and producing a wh-question from a declarative sentence. Perhaps if
additional treatment steps were included targeting specific thematic roles as well as whmorpheme discrimination tasks similar to steps/tasks used by Thompson et al. (1996),
treatment incorporating MIT might help in promoting greater acquisition and carryover
for language outcomes.
To date, there has been limited examination of the effects of MIT on articulatory
accuracy. Both participants in this investigation had modest gains in articulatory accuracy
over the course of the study for treated and non-treated stimuli measured via PCC. The
improvements observed in articulatory accuracy were maintained at 6 weeks post-treatment. In this study, it appears that MIT had a positive impact on articulation accuracy.
Findings in this investigation are similar to those of Zumbansen et al. (2014) that found
improvement in articulatory accuracy in both trained and non-trained items for one
participant following MIT. MIT is comprised of many elements (i.e., modelling, repeated
practice, hand-tapping, slow rate of speech) that have been found to positively impact the
symptoms of AOS (Ballard et al., 2015; Wambaugh et al., 2006); therefore, articulatory
accuracy should be an outcome measure for MIT.

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There is research showing positive treatment effects for MIT in improving language
production for trained and untrained stimuli (Hough, 2010) and production of content
(Schlaug et al., 2008; van der Meulen et al., 2014; Zumbansen et al., 2014). It has also
been shown that MIT has the potential to improve speech production (Zumbansen et al.,
2014), which includes findings from the present study. However, additional research
examining behavioural outcomes of MIT is needed.
This study represents one of the first investigations to examine the effects of MIT applying
stimuli selected according to linguistic principles measuring both language and speech outcomes. Treatment resulted in minimal improvement in the production of wh-questions for two
individuals with chronic aphasia and AOS. However, both participants exhibited improvement in articulatory accuracy as a result of treatment. Additional research is needed to further
examine the efficacy of MIT, specifically behavioural outcomes for both language and speech.
Acknowledgements
Thanks are extended to Lindsey Shumway (formerly Wilkinson) for her contribution to our initial
MIT study. Thanks are also extended to Rosalea Cameron and Nicole Dingus for their assistance
with this project.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This research was supported by the Department of Veterans Affairs, Rehabilitation Research and
Development.

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Appendix 1. Treatment and generalisation stimuli

What Treatment Stimuli

Declarative sentence
1. The lady is knitting a sweater.
2. The boy is raking the lawn.
3. The cop is writing a ticket.
4. The dog is licking a bone.
5. The girl is peeling an orange.
6. The maid is folding the sheets.
7. The man is paying the bill.
8. The chef is cooking the meat.
What Generalisation Stimuli
Declarative sentence
1. The lady is typing a letter.
2. The guy is building a house.
3. The boy is riding the bike.
4. The man is lighting a candle.
5. The waiter is pouring a drink.
Who Treatment Stimuli
Declarative sentence
1. The cop is chasing the fugitive.
2. The woman is carrying the child.
3. The man is kissing the woman.
4. The woman is hugging the child.
5. The waiter is asking the couple.
6. The mom is feeding the baby.
7. The man is paying the clerk.
8. The mother is rocking the baby.

Wh1.
2.
3.
4.
5.
6.
7.
8.

target sentence
What is the lady knitting?
What is the boy raking?
What is the cop writing?
What is the dog licking?
What is the girl peeling?
What is the maid folding?
What is the man paying?
What is the chef cooking?

Wh1.
2.
3.
4.
5.

target sentence
What is the lady typing?
What is the guy building?
What is the boy riding?
What is the man lighting?
What is the waiter pouring?

Wh1.
2.
3.
4.
5.
6.
7.
8.

target sentence
Who is the cop chasing?
Who is the woman carrying?
Who is the man kissing?
Who is the woman hugging?
Who is the waiter asking?
Who is the mom feeding?
Who is the man paying?
Who is the mother rocking?
(continued )

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Appendix 1. (Continued).
Who Generalisation Stimuli
Declarative sentence
1. The farmer is teaching the student.
2. The dog is biting the boy.
3. The girl is changing the baby.
4. The lady is helping the man.
5. The boy is hiding the girl.
Where Treatment Stimuli
Declarative sentence
1. The cop is knocking on the door.
2. The boat is sinking in the lake.
3. The man is begging on the corner.
4. The ice is melting on the floor.
5. The boy is sitting on the chair.
6. The lady is sewing in the shop.
7. The cow is eating in the barn.
8. The bunny is jumping in the field.
Where Generalisation Stimuli
Declarative sentence
1. The fish is swimming in the tank.
2. The food is rotting in the sun.
3. The meat is burning on the grill.
4. The ball is bouncing in the park.
5. The ship is sailing on the sea.
When Treatment Stimuli
Declarative sentence
1. The dog is barking all night.
2. The boy is fishing after school.
3. The man is shaving before work.
4. The girl is dancing during the play.
5. The whale is diving during the show.
6. The farmer is yawning in the morning.
7. The bird is singing in the spring.
8. The sun is shining all day.
When Generalisation Stimuli
Declarative sentence
1. The nun is praying in the morning.
2. The cat is hiding all day.
3. The baby is crying during the movie.
4. The moon is rising in the evening.
5. The lady is reading after work.

Wh1.
2.
3.
4.
5.

target sentence
Who is the farmer teaching?
Who is the dog biting?
Who is the girl changing?
Who is the lady helping?
Who is the boy hiding?

Wh1.
2.
3.
4.
5.
6.
7.
8.

target sentence
Where is the cop knocking?
Where is the boat sinking?
Where is the man begging?
Where is the ice melting?
Where is the boy sitting?
Where is the lady sewing?
Where is the cow eating?
Where is the bunny jumping?

Wh1.
2.
3.
4.
5.

target sentence
Where is the fish swimming?
Where is the food rotting?
Where is the meat burning?
Where is the ball bouncing?
Where is the ship sailing?

Wh1.
2.
3.
4.
5.
6.
7.
8.

target sentence
When is the dog barking?
When is the boy fishing?
When is the man shaving?
When is the girl dancing?
When is the whale diving?
When is the farmer yawning?
When is the bird singing?
When is the sun shining?

Wh1.
2.
3.
4.
5.

target sentence
When is the nun praying?
When is the cat hiding?
When is the baby crying?
When is the moon rising?
When is the lady reading?

Appendix 2. Qualitative scoring system

Declarative Sentence Example: The Nurse is pushing the baby. You want to know the person
pushing the baby, so you ask? Correct Response: Who is the nurse pushing?
Responses Scored as Correct
11Correct wh-morpheme, functors, subject, and verb (correctly inflected).
Who is the nurse pushing?
10Correct wh-morpheme, subject, and verb (correctly inflected).
Functors omitted/incorrect.
Who nurse pushing?

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21

Responses Scored as Incorrect

9Correct wh-morpheme and verb but argument addition or substitution.
Who pushing baby? or Who nurse pushing baby?
8Correct wh-morpheme and verb only.
Who pushing?
7Correct wh-morpheme and adjunct or argument only.
Who nurse? or Who baby?
7bCorrect wh-morpheme but incorrect/absent verb and subject.
Who is the man hitting?

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6Incorrect wh-morpheme but semantically correct (functors optional).

When nurse pushing?
5Incorrect wh-morpheme and argument substitution or addition.
When pushing baby? or When baby pushing?
4Incorrect wh-morpheme with appropriate verb.
When pushing?
3Incorrect wh-morpheme and adjunct or argument only.
Who nurse? or Who baby?
3bIncorrect/absent wh-morpheme, verb, and subject
When is the man?
2No wh-morpheme but semantically appropriate selections.
Nurse pushing baby.
1Single word.
Cry.
0No Response.

Appendix 3. Treatment hierarchy

Step 1: TherapistVerbally presents a declarative sentence along with anagrams. Whmorphemes (e.g., what & who) are also provided as anagrams. Therapist then
asks the participant to use anagrams to create a wh-question for sentence presented (e.g., The nurse is pushing the baby, you want to know the person pushing
the baby, so you ask?).
the nurse

is
WHAT

pushing

the baby

WHO

If participant correctly creates a wh-question for sentence presented give feedback and go to Step 2

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S.C. Mauszycki et al.

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If participant incorrectly creates a wh-question (i.e., wrong wh-morpheme

selected in creating a wh-question) give feedback and go to Step 1b
Step 1b: First, the Therapist points to the correct wh-morpheme and gives a definition of
the wh-morpheme (e.g., who means person, you want to know the person
pushing the baby, so you ask?). Then the Therapist shows the transformation
from a declarative sentence to the question with correct wh-morpheme using
anagrams. Go to Step 2
Step 2: Therapistintones the target question along with hand tapping. Then the
participant repeats the target sentence by intoning along with hand tapping.
If correct, give feedback and go to Step 3
If incorrect, give feedback and then Therapist intones the target question again
along with hand tapping. Then unison intoning of the target question with hand
tapping by Therapist and Participant with fading by Therapist. Go to Step 3
Step 3: Therapistproduces target question using sprechgesang along with hand tapping. Then the participant repeats the target sentence using sprechgesang and
hand tapping.
If correct, give feedback and go to Step 4
If incorrect, give feedback and then Therapist produces target question using
sprechgesang along with hand tapping. Then unison production of target question
using sprechgesang along with hand tapping by Therapist and Participant. Go
to Step 4
Step 4: Therapist produces target question using normal speech prosody. Participant
repeats target question using normal speech prosody.
If correct, give feedback and go to Step 5
If incorrect, give feedback and go to Step 3
Step 5: Therapist poses the declarative sentence with normal speech prosody (The nurse is
pushing the baby. You want to know the person pushing the baby, so you ask. . .).
Participant answers with target wh-question with normal speech prosody.
If correct, give feedback and go to the next item
If incorrect, give feedback, go to Step 4

Appendix 4. Revised treatment hierarchy

Revised Step 1: Therapist verbally presents a declarative sentence along with anagrams.
Wh-morphemes (e.g., what & who) are also provided as anagrams face
down (e.g., The nurse is pushing the baby, you want to know the person
pushing the baby, so you ask?).
Therapist then asks the participant to use anagrams to create a whquestion for the sentence presented.
the nurse

is

pushing

the baby

Aphasiology

23

If the participant correctly creates the wh-question using anagrams, go

to revised step 1a
Therapist asks the participant to verbally produce their wh-question.
If participant produced wh-question correctly, provide feedback and go
to revised step 1a
If the participant is unable to create or incorrectly creates a wh-questions
using anagrams, provide feedback and go to treatment steps 1b through
step 6 as outlined in treatment hierarchy in Appendix 3.

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Revised Step 1a: Therapist asks the participant to verbally produce their wh-question. If
participant produced wh-question correctly, provide feedback, go to
revised step 1b
If the participant is unable to verbally produce the wh-question, go to
treatment steps 1b through step 6 as outlined in the treatment hierarchy
in Appendix 3.
Revised step 1b: Therapist requests a subsequent production of the participants whquestion. If participant correctly produces a subsequent repetition of
their wh-questions then go to the next item.
If the participant is unable to verbally produce a subsequent repetition
of their wh-question, go to treatment steps 1b through step 6 as outlined in the treatment hierarchy in Appendix 3.