Voice Therapy for Elementary School-Age Children Bridget A

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

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

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

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

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

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

Important Indicators of a Voice Problem o HOARSENESS o STRIDOR o DYSPNEA

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

Hoarseness o o o 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.

Normal Vocal Folds Next

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

Treatment Objectives o o Increase Hygiene Awareness Increase General Awareness of Voice Reduce Laryngeal Tension Improve Production n Respiratory Laryngeal Supralaryngeal

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

Objectives 1. 2. 3. 4. 5. 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.

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

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

Hygiene (Boone Voice Program)

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

Objectives 1. 2. 3. 4. 5. 6. 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.

Objective: Identify target pitch o Pretend you have a voice house. n n n 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.

o 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

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

Objectives 1. 2. 3. 4. 5. 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.

Objectives: Increase awareness of tense & relaxed states 1. 2. 3. 4. 5. 6. 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.

o Rag Doll 1. 2. 3. 4. 5. 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.

Objective: Demonstrate Activities to Produce Relaxed Speech Production

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

Objectives 1. 2. 3. 4. 5. 6. 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.

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).

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

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

Target: Resonance o 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”

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

Target: Resonance

Other proficiency goals… 1. 2. 3. 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.

Intervention Models 1. 2. 3. 4. 5. 6. 7. 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.

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. , Mc. Clain, 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 (2 nd 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.

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 lowcost solution. Language, Speech, and Hearing Services in Schools, 23, 353 -360.

References Mc. Namara, 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.