Voice Therapy for Elementary School-Age Children

1. Voice Therapy for Elementary School-Age Children Bridget A. Russell, PhD, CCC-SLP Associate Professor Department Communication Disorders & Sciences State University of New York at Fredonia

2. What are Voice Disorders? • Abnormal pitch, loudness and/or vocal quality resulting from a disordered laryngeal, respiratory and/or vocal tract functioning (Ramig & Verdolini, 1998).

3. Incidence of Voice Disorders in Children • Prevalence in school-age children? • 2% - 23% (Deal, et al. 1976, Silverman , & Zimmer, 1975) • More conservative estimates… • 6% – 10% (Boyle, 2000; Hirschberg, et. al., 1995) • Leeper (1992)- 38% of elementary students have chronic hoarseness

4. Children Treated for Voice Disorders • School SLP’s- 2% - 4% of caseload (Kahane & Mayo, 1989) • Wilson (1987) only 1% of children with voice disorders are seen by SLP’s

5. Do children need voice treatment? • Voice disorders persist without treatment (Powell, 1989) • 59% of ENT’s prefer voice therapy to surgery • Reduction of nodule size with therapy (Deal et al., 1976) • Influences adult perception • More negative, aggressive & behavior problems • Influences peers the same (Lass et al., 1991)

6. Pediatric Voice Classification • Acquired • Chronic laryngitis • Laryngeal trauma • Hyperfunction w/o lesion • Vocal nodules • Vocal polyps • Contact ulcers • VF paralysis • Congenital • VF Paralysis • Laryngeal stenosis • Laryngomalacia • Laryngocele • Webbing • Anterior laryngeal cleft

7. Important Indicators of a Voice Problem • HOARSENESS • STRIDOR • DYSPNEA

8. Stridor & Dyspnea STRIDOR: high pitched, noisy respiration; stridor can be inspiratory, expiratory, or biphasic. DYSPNEA: difficult, labored breathing. **Stridor and Dyspnea are signs of airway obstruction and require prompt medical evaluation

9. Hoarseness • Most common symptom of dysphonia • Hoarseness- perception of abnormal voice quality occurring when vocal fold closure is incomplete during phonation. • Because of incomplete glottal closure during phonation, turbulent airflow occurs, adding a noise component to the glottal signal.

10. Normal Vocal Folds Next

11. Vocal Nodules Nodules are the most common type of abuse-related dysphonia among children

12. Treatment Objectives • Increase Hygiene Awareness • Increase General Awareness of Voice • Reduce Laryngeal Tension • Improve Production • Respiratory • Laryngeal • Supralaryngeal

13. Hygiene Awareness Proficiency: Use Nonabusive Vocal Practices in Everyday Speaking Situations.

14. Objectives • Identify characteristics of atypical voices (e.g. breathy, harsh, low, aphonic episodes, pitch breaks, etc.) • Identify and describe how the voice should sound. • Identify behaviors that cause voice problems. • Role play alternative behaviors to vocally abusive practices. • Use alternative behaviors to yelling and screaming in everyday situations.

15. Identify behaviors causing voice problems • Have child cut out or color in good and bad vocal behaviors. • Voice notebook

16. Activity to help identify vocally abusive behaviors (non-speech).

17. Hygiene (Boone Voice Program)

18. Hygiene (Boone Voice Program)

19. Hygiene (Boone Voice Program)

20. Hygiene (Boone Voice Program)

21. Hygiene (Boone Voice Program)

22. Proficiency: Awareness and Discrimination of Factors Related to Voice Problem. General Awareness

23. Objectives • Increase motivation for self-improvement • Identify physical behaviors that contribute to inappropriate voice (posture, breathing, muscular tension). • Identify lifestyle factors that contribute to inappropriate voice (e.g. noisy environment, sleeping or eating habits, air pollution, etc.). • Identify interpersonal behaviors that contribute to inappropriate voice (e.g. talking too much, ignoring feedback, competing for attention). • Identify target pitch, loudness or rate range. • Discriminate target/error pitch, loudness, or rate.

24. Objective: Identify target pitch • Pretend you have a voice house. • Your highest voice is in the attic • Lowest voice in the basement • Regular voice lives in the middle Taken from: Using your voice wisely & well: Vocal Awareness Activities for Children (2004), Flynn et al.

25. Target Pitch cont. • Add other tasks: • Now say your name in three different ways- • In the middle of the house • In your attic • In your basement

26. Musculoskeletal Tension Reduction Proficiency: Apply Relaxation Strategies for Optimal Use of Vocal Mechanism.

27. Objectives • Understand concepts of tension and relaxation. • Increase awareness of tense and relaxed states in the body. • Increase various relaxation strategies (e.g. deep breathing, physical, visual, and mental exercises) • Use relaxation techniques in structures speech situations. • Use relaxation strategies during everyday and stressful activities.

28. Objectives: Increase awareness of tense & relaxed states • Have child lie on the floor on their back with hands at their sides. • When body part is named, tighten it, then let go or release the muscles. • Hold all body parts for 5 seconds and then let go. • Do body parts in this order: Forehead, eyes, cheeks, nose, tongue, mouth, whole face, shoulders, chest, arms, top par, then bottom, fingers (start with pinky and progress to thumb) stomach, tops of legs, bottom of legs, and toes. • Then tighten their whole body and exhale slowly. • Then count to ten and remain relaxed.

29. Rag Doll • Stand up and bend over at the waist. • Head should be close the knees and the arms should dangle. • Head should be hanging limply. • Next you should bounce up and down slightly with your body not moving more than 6 inches up and down. • You should resemble a rag doll.

30. Objective: Demonstrate Activities to Produce Relaxed Speech Production

31. Production: Respiration Proficiency: Use Appropriate Respiration and Phrasing Patterns in Spontaneous Speech.

32. Objectives • Understand the concept of inhalation. • Increase the amount of air in the inhalation phase. • Understand the concept of abdominal versus upper chest breathing. • Identify inappropriate replenishing breath patterns. • Identify appropriate places for replenishing breaths. • Increase limited variety of phrasing, pitch, loudness, or rate in speech patterns.

33. Objectives: Understand the concept of inhalation • Use this story with picture manual: • This is how your voice is made. • The air from your lungs comes up your windpipe (or this tube) and makes your vocal folds vibrate when they are together. • Put your hand on your throat and say “ah”. Can you feel your vocal cords vibrate. Taken from: “A voice lost and found.” (Boone, 1980).

34. Experimenting with breath! • Make a pinwheel or buy one. • You can make pinwheel spin with air from your lungs. • Take a deep breath and blow hard (identify breath from lower chest) • How long can you make your pinwheel go on one breath (time it-competition) • Stop and start- Try saying /p/, what happens? Whole alphabet.

35. Production: Resonance Proficiency: To establish forward voice and Improve vibratory sensations in the face

36. Target: Resonance • Cue: “I want you to hum and feel the vibrations in your face. Notice how you are not pushing from your larynx but achieving a resonant, clear, vocal tone”

37. Target: Resonance-:nasal vs. oral Goals: to promote both nasal and oral resonance and to reduce laryngeal focus Background: Once the patient is able to hum and maintain forward focus, practice adding a vowel Cue: “Say the following syllables. Start with a hum to focus your voice and produce the vowel with an open throat. Think about opening the space in the back of your throat to produce the vowel” Examples: mmmmmaaaaaa mmmmmmaaay mmmmmeeeeee mmmmmooooo

38. Target: Resonance

39. Other proficiency goals… • Use appropriate Pitch, Loudness, and Rate in Everyday Speaking Situations • Use Interpersonal Skills to Decrease Vocal Stress in Everyday Speaking Situations. • Use Appropriate Onset of Voice in Everyday Speaking Situations.

40. Intervention Models • Consultation. • Collaborative Programs (e.g. with music teachers). • Classroom lessons for entire class • Science and health projects associated with voice. • Materials that parents can use to teach vocal awareness at home. • In service programs for teachers to encourage innovative “voice lessons” in the classroom. • Voice treatment programs, with small groups or in peer dyads, or one on one.

41. References American Speech-Language Hearing Association. (2000). Guidelines for the roles and responsibilities of school-based speech-language pathologist. Rockville, MD: Author American Speech-Language Hearing Association. (2003). IDEA and Your Caseload: A Template for Eligibility and Dismissal Criteria for Students Ages 3 to 21. Rockville, MD: Author Boyle, B. (2000). Voice disorders in school children. Support for Learning, 15, 71-75. Deal, R., McClain, B., & Sudderth, J. (1976). Identification, evaluation, therapy, and follow-up for children with vocal nodules in a public school setting. Journal of Speech and Hearing Disorders, 41, 390-397. Eckel, F.C. & Boone, D.R. (1981). The S/Z ratio as an indicator of laryngeal pathology. Journal of Speech & Hearing Disorders, 46:2, 147-149. Flynn, P.T., Andrews, M.L., & Cabot, B.M. (2004). Using your voice wisely and well: Vocal awareness activities for children (2nd edition). Hirschberg, J., Dejonckere, P., Hirano, M., Mori, K., Schultz-Coulon, H., & Vrticka, K. (1995). Symposium: Voice Disorders in Children. International Journal of Pediatric Otorhinolaryngology, 32 (Suppl.), 109-125.

42. References Hooper, C.R. (2004). Treatment of voice disorder in children. Language, Speech, and Hearing Services in the Schools, 35, 320-326. Kahane, J. & Mayo, R. (1989). The need for aggressive pursuit of healthy childhood voices. Language, Speech, and Hearing Services in the Schools, 20, 102-107. Lass, N.J., Ruscello, D.M., Bradshaw, K.H. & Blankenship, B.L. (1991). Adolescents’ perceptions of normal and voice disordered children. Journal of Communication Disorders, 24, 267-274. Lee, L., Stemple, J.C., Glaze, L., & Kelchner, L.N. (2004). Quick screen for voice and supplementary documents for identifying pediatric voice disorders. Language, Speech, and Hearing Services in Schools, 35, 308-319. Leeper, L.H. (1992). Diagnostic evaluation of children with voice disorders: A low-cost solution. Language, Speech, and Hearing Services in Schools, 23, 353-360.

43. References McNamara, A.P. & Perry, C.K. (1987). Vocal abuse prevention practices: A national survey of school-based speech-language pathologists. Language, Speech and hearing Services in the Schools, 25, 105-111. Ramig, L.O., & Verdolini, K. (1998). Treatment efficacy: Voice Disorders. Journal of Speech, Hearing and Language Research. Sapienza, C.M., Hoffman-Ruddy, B., & Baker, S. (2004). Laryngeal Structure and Function in the pediatric larynx: Clinical Applications. Language, Speech, and Hearing Services in Schools, 35, 299-307.