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276 The Voice and Voice Therapy
A. Open-Mouth
B. Confidential Voice
C. Relaxation
D. Chewing
5. Establishing a lower pitch for individuals with severe to profound hearing loss might
optimally entail:
A. Visual Feedback
B. Nasal/Glide Stimulation
C. Chant-Talk
D. Inhalation Phonation
CHAPTER 8
THERAPY FOR SPECIFIC
PATIENT POPULATIONS
LEARNING OUTCOMES
After reading this chapter, one should be able to:
●
Understand the laryngeal and voice characteristics of the aging voice and describe
its management.
●
Describe the laryngeal and voice characteristics of pediatric dysphonia and discuss
its management.
●
List the professional voice use populations and deaf and hard of hearing
populations who are at risk for dysphonia and describe the management of
dysphonia in these populations.
●
Discuss the speech and voice management approaches to people seeking gender-
affirming voice therapy.
●
Describe respiratory-based voice problems and their management.
277
278 The Voice and Voice Therapy
e reviewed various voice disorders in Chapters 3 through 5: functional/behavioral,
organic, and neurogenic. In this chapter, however, we consider specific voice conditions
W
chapters. We provide descriptions of the voice problems, with focus given to management strategies and the use of possible voice facilitating approaches. Laryngeal cancer and its management by
the speech-language pathologist (SLP) are presented in Chapter 9. Resonance disorders and their
management are presented in Chapter 10.
Voice Therapy for Specific Populations
The Aging Voice
As discussed in Chapter 1, about one in every six Americans is 65 years or older, and this number
is increasing as the baby boom generation grows older (Harris, 2021). Census results reported
that the age group of 65 to 74 years was the largest of the older age groups, with 33.1 million
people. The age group of 75 to 84 years was about half that but is expected to pick up the pace
in the next decade as baby boomers age into this group. Globally, by 2050, the proportion of
the world’s population over 60 years old will nearly double from 12% to 22% (World Health
Organization, 2021).
et al., 2023). By the year 2050, it is expected that people over age 65 years will constitute 39% of
the speech-language impaired population. Therefore, voice clinicians must continually seek new
methods of prevention, differential diagnosis, and intervention with older adults (Shadden et al.,
2011; Stradtman & Etter, 2022).
prevalence of voice disorders in older adults was observed in institutionalized older adult populations (33%), about twice that reported for the general older adult population (15%). The authors
noted that voice disorders among older individuals are likely multifactorial and could be associated
with a variety of factors, including occupational and socioeconomic factors as well as climate
and environmental factors. Roy and colleagues (2007) interviewed 117 people over age 65 years
using a questionnaire that addressed three areas related to voice disorders: prevalence, potential
risk factors, and psychosocial consequences/effects. They reported that the lifetime prevalence of
a voice disorder in this population was 47%, with 29% of participants reporting a current voice
disorder. Most respondents (60%) reported chronic voice problems persisting for at least 4 weeks.
Seniors who had experienced esophageal reflux, severe neck/back injury, and chronic pain were at
increased risk. Voice-related effort and discomfort, increased anxiety and frustration, and the need
to repeat oneself were specific areas that adversely affected quality of life.
system that cause changes in vocal quality, which can result in dysphonia. Dysphonia due to
the aging process is termed age-related dysphonia, presbyphonia, presbylarynx, or vocal fold atrophy
(Chang et al., 2023; Sauder & Merati, 2018; Wang et al., 2023). Presbyphonia affects about
10% to 20% of older adults (Galluzzi & Garavello, 2018). Common characteristics can include
increased vocal effort, changes in pitch range, volume reduction, vocal fatigue, and breathiness.
and their treatment that do not necessarily fall under the headings provided in previous
Dysphonia is a common problem among older adults, with a prevalence of 19% (Wang
According to a systematic review conducted by Wang and colleagues (2023), the highest
The term presbyphonia refers to aging changes in the anatomy and physiology of the vocal
CHAPTER 8 Therapy for Specific Patient Populations 279
The most common complaint of presbyphonia, though, is hoarseness (Gregory et al., 2012;
Kendall, 2007; Rosow & Pan, 2019). Presbyphonia can reduce communication effectiveness and
overall hinder quality of life for older adults (Stradtman & Etter, 2022). Patients complain of an
inability to project their voice over background noise and of a hoarse voice quality that deteriorates
throughout the day. Visual examination of the larynx may reveal mild bowing of the vocal fold
margins, a spindle-shaped glottis, prominent arytenoid cartilage vocal processes, and vocal
fold edema (Bloch & Behrman, 2001; Pontes et al., 2005). High-speed digital imaging reveals
more anteriorly placed glottal gaps (Ahmad et al., 2012). Electroglottography may reveal predominance of the open phase (Winkler & Sendlmeier, 2006); however, Galluzzi and Garavello (2018)
suggest that presbylarynx is best diagnosed via videolaryngostroboscopy, which may reveal asymmetry of vocal fold vibration due to changes in laryngeal musculature. Presbyphonia is correlated
with poorer health-related quality of life and a tendency to avoid social situations (Costa & Matias,
2005; Golub et al., 2006; Plank et al., 2011; Stradtman & Etter, 2022; Verdonck-de Leeuw &
Mahieu, 2004).
Presbyphonia is not the most common cause of dysphonia in older adults (Chang et al., 2023).
Possible other causes of dysphonia include vocal fold atrophy (with or without vocal fold bowing),
benign vocal fold lesions such as polyps, cysts, laryngitis, malignant vocal fold lesions, muscle
tension dysphonia, tremor, spasmodic dysphonia, Reinke’s edema, and vocal fold immobility. An
examination of 775 patients over the age of 65 years with dysphonia by Davids and colleagues
(2012) indicated that vocal fold atrophy was the most common cause of dysphonia, comprising
25% of cases, followed closely by spasmodic dysphonia (23%) and vocal fold immobility (19%).
Mathew and Shilpa (2019) found the most common causes of dysphonia for 100 patients over
age 65 years were laryngopharyngeal reflux, carcinoma, and presbylaryngis.
With this in mind, a comprehensive evaluation of both the voice and other medical conditions
is essential to differentiate between voice problems caused by other underlying causes versus those
resulting from natural aging. A thorough evaluation is warranted in any older patient presenting
with hoarseness, especially if that hoarseness has lasted greater than 4 weeks. Evaluation includes
videolaryngoscopy with stroboscopy. These diagnostic tools help ensure prompt and accurate
identification and management of dysphonia, ultimately improving patient outcomes (Stachler
et al., 2018). Poor general health correlates to negative objective vocal and laryngeal changes,
showing that physiological age may be a greater factor than chronological age in some patients
with dysphonia. Considering this information, one might well conclude that management and
therapy should be more focused on various disease processes than on aging, per se.
Because the acoustic features of voice are affected by respiratory, phonatory, and resonance
events, each must be appreciated when developing an understanding of the presbyphonic voice
(Baken, 2005; Rapoport et al., 2021; Ringel & Chodzko-Zajko, 1987; Rojas, 2020). One of the
first comprehensive studies reporting age-related changes in speech breathing was conducted in the
late 1980s by Hoit and colleagues (1987, 1989). Across these two seminal studies, the investigators examined speech breathing in 30 males and 30 females in three age groups (25, 50, and 75
years). Speech breathing changes were assessed from both extemporaneous speech and reading.
The major findings of Hoit and Hixon (1987) were that older adult males demonstrated larger
rib cage volume initiations, larger lung volume excursions, and larger lung volume expenditures
per syllable than younger men, particularly during extemporaneous speaking. The major findings
of Hoit and colleagues (1989) were that, compared to younger women, older adult females
280 The Voice and Voice Therapy
demonstrated larger rib cage excursions during reading, increased frequency of inhalation during
reading, increased air expenditure during unphonated intervals during reading, and larger lung
volume initiations during extemporaneous speaking. The speech breathing changes reported by
Hoit and her colleagues correspond with musculoskeletal changes that can impact lung function
during the aging process. These authors suggest that age-related changes to the diaphragm and
the intervertebral disk spaces associated with kyphosis can reduce intrathoracic volumes and thus
diminish the ultimate power source of the voice. Indeed, as we consider changes that occur within
the laryngeal framework, we need to be aware of changes in the respiratory system in older adults
that reduce positive pressures and the amount of air available for voicing (Desjardins et al., 2022).
Much of what we know about the acoustic characteristics of the voice of older speakers comes
from the work of Linville and her colleagues (see Linville & Rens, 2001) and Mueller and his
colleagues (see Caruso & Mueller, 1997) (Table 8–1). Many of their findings correlate well with
what we know about the effects of aging on the larynx and supraglottal vocal tract. See Kahane and
Beckford (1991) for extensive review of this topic. In both men and women, speaking fundamental
frequency (SFF) changes as an individual moves from young adulthood into older age (Rojas et al.,
2020; Santos et al., 2023). However, the pattern of change is quite different for the two genders.
In males, SFF lowers from young adulthood into middle age and then rises again by up to 35 Hz
after the age of 60 years, mostly due to vocal fold atrophy. In contrast, SFF in women remains fairly
constant into middle age and then may lower as much as 35 Hz due to increased vocal fold mass,
TABLE 81. Synopsis of Voice Changes With Advanced Age
Finding Literature Source
Speaking fundamental frequency (SFF) raises in men
and lowers in women.
Maximum phonational frequency range (MPFR) is
reduced in men and women.
SFF is less stable in men and women. Linville et al. (1989); Xue & Deliyski (2001)
Amplitude is less stable in men and women. Linville (1996); Linville et al. (1989); Xue & Deliyski
Standard deviations of SFF and amplitude increase in
men and women.
Maximum intensity of vowel productions is reduced in
men and women.
Perturbation increases (jitter, shimmer, spectral noise)
in men and women.
Formant frequencies are lowered in men. Benjamin (1997); Linville (2002); Linville & Fisher
Awan (2001); Brown et al. (1991); Linville (1996); Xue
& Deliyski (2001)
Hollien et al. (1971); Linville & Korabic (1987);
Ptacek & Sander (1966); Ramig & Ringel (1983)
(2001)
Linville & Fisher (1985); Orlikoff (1990); Xue &
Deliyski (2001)
Morris & Brown (1994)
Awan (2006); Decoster & Debruyne (1997); Ferrand
(2002); Linville (2002); Linville et al. (1989); Xue &
Deliyski (2001).
(1985); Linville & Rens (2001); Liss et al. (1990);
Rastatter & Jacques (1990); Scukanec et al. (1991).
CHAPTER 8 Therapy for Specific Patient Populations 281
most likely due to menopause (Afsah, 2024; Eichhorn et al., 2018; ; Rojas et al., 2020). Maximum
phonational frequency range (MPFR) also appears to be altered by the process of aging. MPFR
constitutes the range of frequencies encompassing both modal and falsetto registers. Postmenopausal (presumably, middle-age) women are able to produce lower basal tones than their younger
or older counterparts; however, this does not significantly expand total MPFR capabilities. At
the other end of the MPFR, a reduction in the ceiling tone is a well-known finding in female
speakers, even for those who have had professional voice training. In men, there does not appear
to be an effect of aging on MPFR. Fundamental frequency and amplitude are reported to be less
stable in older speakers; the standard deviations of these measures also tend to increase with age.
Increased perturbation (that is, jitter, shimmer, spectral noise) in the voice of aging speakers has
also been reported. Speech intensity has also been reported to change with aging. Vocal intensity
during conversational speech has been reported to increase with aging in men but not in women,
and in both genders, reductions of maximum intensity of vowel productions have been reported.
Resonance characteristics of voice vary as a function of aging as well. Centralization of vowels
has been reported to be a tendency of older speakers, and as a result, formant frequencies of
vowels have been shown to differ in older versus younger speakers (Liss et al., 1990). However,
other researchers found alterations in vowel formant frequencies across several decades of life to
be small or in a direction against vowel centralization, suggesting preservation of articulatory
precision in older speakers (Tykalova et al., 2021) or that individuals compensate for age-related
changes in anatomy and physiology (Eichhorn et al., 2018). In addition to investigations into the
effects of aging on formant frequencies, the effect of aging on nasal resonance has been investigated, though not as extensively. Hutchinson and colleagues (1978) reported that nasalance (see
Chapter 10) in 50- to 80-year-old speakers is higher than the norms of younger speakers reported
by Fletcher (1973). Scarsellone and colleagues (1999) reported slightly lower nasalance in older
adult speakers when their maxillary dentures were removed versus when these dentures were in
place, leading these investigators to conclude that existing normative data for nasalance could be
applied to older adult speakers regardless of the status of their maxillary dentition. Finally, Xu and
colleagues (2019) found that nasalance scores for passages containing nasal consonants decreased
with age, although significant increases were observed in nasal cavity volume and nasal patency
with age. These researchers suggested that age-related decreases in nasalance scores may result from
factors other than changes in the nasal cavity.
The larynx undergoes many age-related physiological and structural changes. The laryngeal
muscles begin to atrophy, the elastic fibers of the vocal ligament become thinner, mucous glands
degenerate, laryngeal cartilages ossify, and epithelium thickens (Gregory et al., 2012). These
changes can lead to decreased vocal fold mass, inadequate approximation of the vocal folds, and
other vocal fold alterations that can affect vocal fold function. (See Zraick, Gregg, & Whitehouse
[2006] and Rojas et al. [2019] for comprehensive reviews.) The quality of voice resulting from air
loss, reduced laryngeal tension, tremor, and altered fundamental frequency may allow listeners to
easily differentiate some older adult voices from younger voices.
A number of studies going back to the 1960s have demonstrated a relationship between older
speakers’ chronological age, sex, and vocal characteristics, and listener perceptions of their vocal age
(Linville & Fisher, 1985; Ryan & Burk, 1974; Shipp & Hollien, 1969) From this clinical literature,
a number of conclusions can be drawn. First, young adult listeners are capable of discriminating
between younger and older adult voices with a high degree of accuracy (Huntley etal., 1980;
282 The Voice and Voice Therapy
Ptacek & Sander, 1966), though listeners tend to slightly overestimate the age of younger speakers
and underestimate the age of older speakers (Ryan & Burk, 1974). Second, young adults are also
quite good at distinguishing relatively minor differences in ages of older speakers, for example,
distinguishing among 60-, 70-, and 80-year-olds (Hummert et al., 1999). Third, young adults
have a better than chance ability to estimate within 5 years a speaker’s chronological age (Hollien,
1987). Fourth, listeners are able to reasonably estimate an older speaker’s weight and height from
their voice and can do so almost as well as they can from viewing facial photos (Krauss et al.,
2002). Listeners perceive older speakers more negatively than younger speakers, particularly on
competence dimensions (Hummert et al., 1999).
Management of presbyphonia can involve three treatment approaches, either singly or in
combination: (a) laryngoplasty, (b) thyroplasty, and (c) voice therapy (Johns et al., 2011). Voice
therapy is usually the first-line approach. Stager and Bielamowicz (2024) reported significant voice
improvements immediately following voice therapy for 24 participants with presbylaryngis. The
most common techniques were nasal focus stimulation, straw phonation (Wu & Chan, 2020),
fewer words per breath group, and increasing pitch range. Those participants who completed
therapy (two to five sessions) reported stable voices, supporting voice therapy’s role in maintaining voice function over time. Other approaches reported in the literature are resistance training
exercises with and without expiratory muscles training (Belsky et al., 2021); respiratory muscle
strength training (Desjardins et al., 2022); therapeutic singing (Moon et al., 2022); and lip trills
(Nam et al., 2018). Counseling the patient about the need for good vocal hygiene is helpful.
Direct work on improving respiratory efficiency can help the older person develop better expiratory control, perhaps saying more words per breath. Direct work on increasing the speed of one’s
speech can have a “rejuvenating” effect on the sound of the older patient’s voice. Among the
VFAs we have found useful are auditory feedback, focus, masking, respiration training, and visual
feedback (see Chapter 7). Berg and colleagues (2008) and Desjardins and Bonilha (2020) report
that voice-related quality of life can improve in patients with age-related dysphonia who participate
in voice therapy. If a patient does not respond positively to voice therapy, procedures to improve
glottic closure may be employed. Such procedures are often used to manage vocal fold paralysis (see
PluralPlus
Self-Check
8–1
Chapter 5) and include laryngoplasty and medialization thyroplasty. Future treatments holding
promise include the use of biomaterial systems for vocal fold regeneration (Bartlett et al., 2012;
Coburn et al., 2022).
The Pediatric Voice
As noted in Chapter 1, the prevalence of dysphonia in children is estimated at around 6% to 9%
(Almero et al., 2021). This means that anywhere between 4.4 and 6.6 million American children
have some trouble using their voices. Dysphonia can be detrimental to children both psychosocially and academically (Campano et al., 2023). In the psychosocial realm, studies have revealed
that childhood dysphonia has an adverse effect on the listener’s perception of the child: Children
are judged more negatively with regard to their physical appearance, their personality, and their
cognitive skills by peers and adolescent and adult judges (Lass and colleagues, 1988), including
teachers (Ma & Yu, 2009). It is possible for children to express themselves about the impact of
their voice disorder (Verduyckt et al., 2011). Connor and colleagues (2008, p. 197) have shown
CHAPTER 8 Therapy for Specific Patient Populations 283
that the attitudes of children and adolescents with dysphonia can be negative. In their interviews
with children with dysphonia, these clinical researchers discovered that children and adolescents
often felt that their dysphonic voice received undue attention; anger, sadness, and frustration
were also expressed. Ilic-Savic and Petrovic-Lazic (2023) analyzed the characteristics of quality
of life in children with and without voice disorders using the Pediatric Voice Handicap Index
(p-VHI). Interviews with 100 parents of children in both groups revealed significant differences
in quality of life, with the dysphonic group reporting reduced social, emotional, and functional
parameters. Parents of dysphonic children observed that their children avoided speech situations
due to dissatisfaction with speech as the dominant form of behavior. The authors concluded that
voice and speech disorders can negatively impact the quality of life of children and suggested that
strategies be generated as early as possible to reduce the potential long-term effects.
Academically, some adverse effects of dysphonia on a child’s educational performance can
include limited participation in speaking activities, fear of participating in oral reading activities,
and limited participation in classroom discussion with peer groups. To address reduced academic
performance as a function of dysphonia, Ruddy and Sapienza (2004) describe eligibility decisions for students with dysphonia in school-based settings that fall within the framework of the
Individuals with Disabilities Education Act (IDEA). These authors outline six school-based service
delivery options for the voice-disordered child that are effective under IDEA guidelines (see also
Chapter 6).
Most pediatric voice disorders are benign and voice therapy remains the primary treatment
modality (Adriaansen et al., 2022; Campano et al., 2023; Mudd & Smith, 2021). Given that
these voice disorders are preventable, it stands to reason that vocal health education be part of the
curricula in U.S. public schools. A study by Mathews (2021) evaluated the opinions and current
practices of 115 school-based SLPs and speech-language pathology assistants with respect to the
inclusion of vocal health education in the school curriculum. Reponses revealed that respondents
appreciated the benefits of vocal health education but reported multiple barriers to its inclusion
in schools, including resource constraints, and other priorities, such as academic and curriculum
requirements. The author suggested that by establishing habits that promote a functional and
healthy voice in childhood, individuals may avoid the disruption and discomfort of future,
preventable, voice disorders.
Hseu and colleagues (2023) also reported on barriers to voice therapy in a retrospective review
conducted on 346 children seen at a tertiary voice clinic over 4 years. These authors found that
older age, shorter distance to the therapy site, and increased CAPE-V Overall Severity and Strain
scores were associated with higher likelihood of receiving therapy.
Children differ from adults in the way they produce their voice because pediatric laryngeal
anatomy is distinct from adult laryngeal anatomy. As described in Chapter 2, among those differences are the size of the larynx; the proportion of membranous versus cartilaginous structure; and
the position of the larynx, which in the child lies between the first and third cervical vertebrae,
descending to between the sixth and seventh cervical vertebrae in the adult. The differences in
anatomy are evident in the physiology of the voice. The child may find that their smaller lung
capacity and resonating chambers in relation to an adult’s render a voice that is softer and less versatile than the adult’s (Sapienza & Ruddy, 2018). Children also have smaller laryngeal structures than
adolescents and adults, and thus, pitch range and vocal stamina are reduced (Smith, 2013). The
284 The Voice and Voice Therapy
child may try to compensate for this by placing excessive demands on the voice, thus beginning
a cycle of muscle tension dysphonia, potentially leading to vocal nodules (Boyle, 2000; Hartnick
et al., 2018; Hseu et al., 2021; Schalen & Rydell, 1995) (see Video 8–1).
Video 8–1. Elimination of abuses is critical
not only to the vocal health of older individuals, but across the lifespan. This video
introduces silent cough and sniff-swallow,
two techniques that are designed to replace
coughing and throat clearing. Grand Rounds:
Describe the physiology of silent cough
that reduces the collisional forces of the
vocal folds.
Medical Factors Associated With Pediatric Voice Disorders
Most etiologies underlying dysphonia in children are benign and generally easy to treat (Adriaansen et al., 2024; McMurray, 2003); however, children presenting with hoarse voices must have
a thorough voice evaluation because some voice disorders are life-threatening (see Chapter 4 and
Voice Therapy for Respiratory-Based Voice Problems later in this chapter). Dysphonia, such as
that experienced from laryngeal papilloma, can present a significant and fatal airway obstruction.
Cysts, while not life-threatening, can cause dysphonia by increasing the mass of the vocal fold.
Chapter 6 features a medical history checklist to help the clinician zero in on the factor or factors
that might underlie a dysphonia. For example, repeated otitis media and sinusitis might underlie
allergies or laryngopharyngeal reflux. In fact, laryngopharyngeal reflux disease (LPRD) is increasingly recognized as a factor underlying pediatric dysphonia (Block & Brodsky, 2007; Lechien
etal., 2021). Laryngeal symptoms associated with pediatric LPRD include chronic cough, globus
sensation, throat clearing, and laryngospasm (Karkos et al., 2006; Swain & Choudhury, 2020).
Even though accurate diagnosis of LPRD in children is challenging (Theis & Heatly, 2009,
Singendonk et al., 2018), LPRD should be considered by otolaryngologists (ear, nose, and throat
[ENT] physicians), pulmonologists, gastroenterologists, and SLPs in the differential diagnosis and
subsequent management of pediatric voice disorders (Ford, 2005; Lechien, 2021).
The voice clinician should also ask about the amount of hydration the child is taking in
because poor water intake in combination with caffeinated beverages may cause lethargy and
irritation of the entire body (Alves et al., 2019). Any psychosocial and emotional aspects affecting
the child at home, in school, or elsewhere also need to be addressed because there are links between
psychological and musculoskeletal stress (Desjardins et al., 2022). We once encountered a young
teen who developed significant hypertension of the lips, cheeks, and neck muscles and larynx each
CHAPTER 8 Therapy for Specific Patient Populations 285
time her mother changed her work schedule and left the teen in charge of her younger siblings.
The VFAs in Chapter 7 were effective in rediscovering the voice within the first few minutes, but
it was the underlying psychosocial demands on the teen that were the major issue. In this case, we
referred the family to a child psychiatrist for counseling.
Functional Factors Associated With Pediatric Voice Disorders
Once a medical cause is ruled out, and the child has been diagnosed with a voice disorder of a
functional nature, it is the realm of the SLP, the family, educators, and other individuals important
to the child’s life to identify the environments in which the abuse-misuse occurs and to develop
strategies to reduce these instances of misuse (see Chapter 7). If the child is very young, say,
younger than 5 years of age, parent counseling may be in order. Direct voice therapy with the
child may be deferred until the preschooler is cognitively able to understand the importance of
curbing particular hyperfunctional behaviors, such as yelling and making continuous “funny”
noises. Hartnick and colleagues (2018) studied the effects of indirect versus direct voice therapy
on 114 children aged 6 to 10 years with vocal nodules. Indirect therapy focused on education and
discussion of voice principles, whereas direct therapy involved establishing new voice patterns,
resonance therapy, and modeling. Post-PVRQOL scores showed significant improvements in
quality of life for both groups, although there were no significant differences between approaches.
The overall thrust of voice therapy for vocal hyperfunction in school-age children is identifying their voice abuses and voice misuse (see VFA 8 in Chapter 7) and reducing the occurrence
of such behaviors. For these children, successful voice clinicians must build into their schedules
actual visits to playgrounds, music rooms, churches, after-school care and other venues where the
children spend their day. More than once, we have discovered that the vocal misuse originates in
the child’s classroom itself. Much has been written about the occupational hazards of teaching;
it comes as no surprise that vocal abuse and overuse might be identified in classrooms, which
are notorious for poor acoustics and robust dynamics (Bottalico et al., 2023; McAllister et al.,
2009). When we encounter a classroom situation that appears to be contributing to a dysphonia,
we contact the teacher and ask the teacher to enlist as a partner in a vocal education and hygiene
program. The teacher often views this program as an immediate benefit for all concerned, and we
help the teacher adapt a list of behaviors and rationales that discourage vocal abuse and encourage
“just right voice,” the child’s equivalent of confidential tone. One classroom teacher even allowed
our graduate students to enter the classroom and engage the children in a play depicting healthy
and unhealthy voices. The play concluded with the following list of reminders to maintain a
healthy voice in the future:
1. Build quiet times into one’s day.
2. Walk over to a friend to talk.
3. Drink plenty of water.
4. Select a just right voice buddy to help maintain those good vocal habits.
In our voice clinics, we review the anatomy and physiology of the laryngeal mechanism using
DVDs and Internet-based content, although still photographs are also powerful visual tools to