Pediatric Phonatory
Disorders
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Evaluation Procedures
• No standardized test is
available
• Diagnostic results form (5-2)
–respiration
–phonation
–resonance
–high risk factors
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Eliciting Samples of Respiratory Behavior
• Length of inhalation- straw with tissue paper
• Depth of inhalation- Birthday cake candles
• Depth & length of inhalation- blowing through
a straw in a glass of water
• Number of syllables in an exhalation-alphabet
in one breath
• Replenishing breaths- cars need to stop for gas,
trains stop at stations, older children mark
reading passage
3
Eliciting Samples of Phonatory Behavior
• Count from 1-40 softly than loudly
• Sustain the vowel /a/ for as long as they can (about 10
sec.)- “keep going until my pencil stops”
• Produce /s/ and /z/ for as long as they can- “sammy
snake goes /s/”, “keep going until he gets into his
house”, “the motorcycle goes /z/”
• Onset of phonation affected by loudness level- “Uncle
Eddie eats eggs” soft & loud (hard glottal attacks)
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Eliciting Samples of Phonatory Behavior
• Excessive effort- ask child to swallow than
phonate vowel (same muscles used may be
excessive tension)
• Excessive effort due to edema or lesion- best
during loud speech or stressed syllable, (repeat
multisyllabic words, note aphonia on
unstressed syllable- Mississippi, Alabama)
• Vary loudness- soft to loud, police car going
farther away “whoo..”
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Eliciting Samples of Phonatory Behavior
• Vary pitch- sing “Happy Birthday”
• Understands loud vs. soft- big puppet
(loud voice), small puppet (soft voice),
repeat sound, ask child to identify puppet
• Aphonia or adduction problem- loud and
soft description of picture
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Eliciting Samples of Resonance Behaviors
• Hypernasality1) Say [an, am] vigorously- velum up for /a/ and down
for /m,n/, symmetrical movement
2) Sustain nonasal sounds, occlude nostrils (no
difference with adequate v-p closure)
3) Sounds requiring oral breath pressure-“Chip bits of ice”, “Kitty has fleas”, “Freeze the
peas”
-V-P closure problems will show
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Eliciting Samples of Resonance Behaviors
• Hyponasality1) Mouth breather- indicates nasal obstruction
2) Produce nasals with appropriate nasal resonance and
vibration in nasal area?
3) Nasal sentences- “My mommy make me mad”, “My
nose never runs”, do you here proper resonance
4) Inability to hum- nasal obstruction
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Eliciting Samples of Interpersonal Behavior
• Conversation with one or more children- “Some
people say that school should be all summer” (Turn
taking, amount of talking, interruptions)
• Notice feedback- ask children to tell the true
meaning of sentences spoken different ways:
– “I like school” (flat intonation or questioning
inflection)
– “He’s a good person” (negative facial expression,
questioning intonation)
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Eliciting Samples of Interpersonal Behavior
• Interpret vocal patterns used by clinician
pretending to be different people (young
child, elderly person, police officer etc.)
• Sample story & have child tell you why
things happened, retell story (analyze
child’s needs and interests of others)
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Eliciting Samples of Voice During
Conversational Speech
• Describe your best friend.
• Tell me four things you did in school
today.
• Describe the plan of your house. Start at
the front door.
• Tell me about a movie you saw recently.
• Say something you like about yourself.
• What are you looking forward to this
week.
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Professional Voice
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Speech-Language Pathologist’s
Role
• When compared with voice
disorders in a nonperformer, will
the SLP find that there is anything
significantly different about
evaluating and remediating voice
problems in the performer?
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Special Considerations
• Range of vocal activities extends beyond
functional parameters
• Signaled by subtle changes in quality, pitch
range, loudness extreme etc.
• Knowledge of music: styles and vocal
characteristics called for by music school,
composer or dramatist
• Understanding of physical demands
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Goals of Therapy
• Less latitude with respect to desired outcome
• Become familiar with the technical rudiments
of these disciplines, terminology and imagery
• Stage direction, set and costume design
• Special environmental contributors to
professional voice
• Psychosocial pressures: competition, pressure
to succeed, judgment
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Interdisciplinary Voice Team
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Speech-Language PathologistSinging specialist/ Vocal TeacherVoice Scientist or Singing CoachSpeech/Drama CoachPsychologistHypnotherapistPhysicians-
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Evaluation
• Expectations of normal are heightened
• Case history
– description of circumstances
– laryngologist & SLP collect info
– activities in daily professional life
– daily vocal usage patterns
– smoking, passive smoking, alcohol
– type of music (rock, jazz, classical, gospel,
night club, jazz/blues)
– professional career goals
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Evaluation- Examination
• Objective Voice Measures
1. Audio recording (protocol App. IV)
2. Sample of sustained spoken & sung vowels,
conversational speech and reading
3. Acoustic parameters: Fo, jitter, shimmer,
harmonics/noise ratio, percent voicing, physiological
and musical frequency range and maximum
phonation or expiration time
4. Respiration measured by PFT
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Subjective Evaluation
• Respiration
1. Observed in conversational speech
-pattern of breath support
-posture
-phrasing
-respiration
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Subjective Evaluation
• Phonation
1. Voice quality
2. Harsh glottal attacks are counted during
reading
3. Measures of respiratory & phonatory
efficiency are obtained:
-MPT for: /a/, /I/, /u/, /s/, /z/
4. s/z ratio
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Subjective Evaluation
• Resonance
1. Presence of hypo- or hypernasal speech
2. Functional or regional resonance
deviations- reading
3. Tongue position observed during
sustained /a/
4. Posterior tongue tension- responsible for
pharyngeal resonance quality
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Subjective Evaluation
• Articulation
1. General judgment on precision
2. Smooth transition of articulators
3. “hyperfunctional” articulation or tension sites
• Prosody
1. Rhythm, fluency, timing, rate, pauses and
intonation are generally assessed
2. Laryngeal strap tension- demonstrate faulty
flow & blending of words
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Subjective Evaluation
• Sites of muscular tension
1. poor respiratory control
2. tension sites?
• Oral/Facial
1. screening to rule out structure, symmetry,
strength, range of motion or coordination
difficulty
• Singing
1. Unless trained not qualified to evaluate singing
2. observation in consistency of techniques from
singing to speaking
3. checklist
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Therapy
• Designed to have patient feel and
sound better
• Initial focus is on speaking technique
• Facilitate “learning to speak by feel”
• Identify the factors which have
created voce problem
• Education- vocal hygiene, anatomy
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Establishing good vocal hygiene
• Throat clearing
– dry swallow
– small sips of water
– “silent cough”
– pant lightly then swallow
– hum lightly
– laugh lightly & swallow
– talk through the mucous
– vocalize lightly on five-note scales in a
comfortable range on /a/ or slide up an
octave softly on /a/
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Establishing good vocal hygiene
• Whispering
– avoid
– anterior 2/3 approximate
– forced most harmful
• Grunting/ Noisy Vocalizations
– exhale slowly on the exertion phase of exercise
– adduct the vocal folds gently, prior to initiating
each exercise
• Yelling/ Screaming or loud talking
– use whistle or bell
– engage the help from others for monitoring
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Establishing good vocal hygiene
• Noisy environments
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facing the listener
gently overarticulate rather than increase loudness
slowing speaking rate
speak in normal pitch
• Excessive talking
– schedule vocal “naps”. 20 minutes of silence 2-3
times daily
– digital watch alarms to signal reminder to check
vocal behavior
– limit time on telephone
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Establishing good vocal hygiene
• Caffeine consumption
– avoid caffeinated beverages before heavy vocal use
– glass of water for every cup of coffee
• Systematic dryness
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“sing wet- pee pale”
drink water every time you eat
keep water on hand
try bottled water with a twist
• Environmental dryness
– superhydrate prior to air travel
– use humidifier
– moist environment
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Relaxation
• Yawn-sigh
• Improving sensory awareness of soft
palate, muscles of pharynx, and
tongue
• Create open, relaxed pharynx
• Establish a high soft palate position,
useful for oral resonance
improvement
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Range of Motion
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head forward and back
head side to side
looking over each shoulder
shoulder rolls
shoulder shrugs
jaw relaxation
tongue stretch
chewing
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Self-Massage
• Facial massage
• Posterior neck and shoulder
massage
• Body posture & head/neck
alignment
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Breath Control & Support
• Description of breathing
• Count pacing for during breathing
• Differences in support for speaking and
singing
• Warm-up and cool down routines
• Speech breathing for non-speech tasks
• Nonspeech to speech tasks
• Support for ongoing speech
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Easy Onset Exercises
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Negative practice
Single words
Minimal Pairs
Long versus short vowels
delay approach
Downward slide
“Key word” approach
Blending
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Tonal Focus/ Vocal Placement in
Speech
• 2 axis: up/down & front/back
• Difference between pitch &
placement
• Consonants first (alveolar ridge or
anterior)
• Contrast back and front words
• “buzzing” in front of mouth
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Loudness vs. Projection
• Projection- maximizing listener
intelligibility with minimal speaking
effort
• Perception of increased loudness
• Single words (increasing breath support)
• Using speech sounds in phrasing
• Combination
• Prosody
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Warm-up and Cool-Down
• Consistent practice each morning
prepares the vocal mechanism
• Outline of the daily practice
exercises
• Muscular stretch & range of
motion
• Vocalize scales
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• Nonspeech tasks