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Language-Based Learning Disability and Literacy in a School-Aged Student

and included many detailed points or dialogue, AD’s decoding decreased and her accuracy in identifying the main idea decreased. In addition, written language was a particular area of weakness when paired with a reading assignment, which is often required in daily classroom activities and homework. Therefore, the focus of intervention was improved reading comprehension and writing using TWA + PLANS. AD was motivated using this strategy and demonstrated increased accuracy and length of written language. At the start of the academic year, AD required verbal prompts and maximal clinician support to identify and implement the steps of TWA + PLANS. Over the course of the academic year, as AD’s knowledge and familiarity with this st rategy increased, the level of support and verbal prompts provided gradually decreased. Currently, AD independently identifies all steps of TWA + PLANS and requires minimal support to implement the strategy to identify and write the main ideas and supporting details from grade-level text in a three- to four-paragraph essay.

22.7 Key Points

●

School-aged children are expected to participate in academic discourse in both spoken and written modalities using decontextualized language.

●

Underlying language deficits can significantly impact literacy, including decoding, reading comprehension, spelling, and written language.

●

Using a cognitive apprenticeship model, such as self-regulated strategy development, speech-language pathologists can help support students comprehensive development of the writing process through supported reading and writing.

Suggested Readings

[1] Graham S, McKeown D, Kiuhara S, Harris KR. A meta-analysis of writing in-

struction for students in elementary grades. J Educ Psychol. 2012; 104(4): 879–896

[2] Harris KR, Graham S, Mason LH. Improving the writing performance, knowl-

edge, and motivation of struggling writers in second grade: The eﬀects of self-regulated strategy development. Am Educ Res J. 2006; 43:295–340

[3] Graham S, Harris KR. Strategy instruction and the teaching of writing: A

meta-analysis. In: MacArthur C, Graham S, Fitzgerald J, eds. Handbook of Writing Research. New York, NY: Guilford; 2006:187-207

References

[1] Harris KR, Graham S, Mason LH, Friedlander B. Powerful Writing Strategies

for All Students. Baltimore, MD: Brookes; 2008.

Global Language Impairment in a Preschooler with Autism

23 Global Language Impairment in a Preschooler with Autism

Jennifer C. Friberg and Savannah P. Little

23.1 Introduction

Global language impairment is common in autism, with delays observed in pragmatics, semantics, syntax, and morphology development. Young children with autism may display lack of joint attention, eye gaze, expression, use of gestures, and a general lack of flexibility with language. Because these deficits impact on how language is employed to listen and to verbally communicate, these language disorders are termed global impairments.

23.2 Clinical History and Description

BW was a 39-month-old female child who was recently evaluated by a pediatrician for suspicion of autism. She was eventually given a diagnosis of autism due to specific observable behaviors (repetitive motions) and what was considered to be significant communication concerns. BW had never been evaluated by a speech-language pathologist (SLP). BW’s mother reports that she “isn’t a good communicator,” struggling to make her wants and needs known with “meltdowns” when she is not understood.

23.3 Clinical Testing

Clinical testing began with classroom observation. BW had diﬃculty establishing joint attention, disengaging with most tasks that involved social interaction with other peers or adults. She tended to fixate on her favorite objects (e.g., a flashlight) for extended periods of time. BW followed simple, one-step directions that referenced classroom routines, but needed verbal cueing from peers and the teacher to do so. BW was observed to request during this observation, saying “pencil” when asked what she needed during art time. BW’s verbal output was restricted to one- to two-word utterances, containing mostly nouns and verbs in common word categories (e.g., animals, food words). The MacArthur Bates Communicative Development Inventory naire was sent home for BW’s mother to complete. This questionnaire confirmed that similar word usage was employedat home.

Following classroom observation, play-based assessment quantified BW’s communication skills in social contexts. A language sample was collected during snack time, which revealed diﬃculties with vocabulary and grammar. Her vocabulary lacked diversity; a 0.26 type-token ratio (TTR) was observed. TTR is a measurement of lexical diversity in a child’s spontaneous speech. TTR is calculated by dividing the total number of diﬀerent words used by the total number of words a child says in a given language sample. TTR scores can range from 0 to 1, and the higher the ratio, the higher the degree of word varia-

question-

tion in a child’s natural speech. BW’s TTR was considered low. BW used verbal language to request or refuse. No commenting or use of social words (e.g., hello, please) was noted. BW’s language was characterized by one- to two-word utterances, with a mean length of utterance of 1.47. BW also struggled to take turns or display appropriate proximity with peers. Her gross motor skills appeared intact, but some fine motor deficits were evident (e.g., inability to grasp snack crackers in a pincer grasp).

The Preschool Language Scales, 5th Edition,

istered. Her standard scores were as follows:

●

Auditory comprehension = 68.

●

Expressive communication = 63.

●

Total communication = 65.

This assessment was completed over the course of 2 weeks in 5- to 15-minute increments to minimize the potential for attentional and/or behavioral issues to negatively aﬀect her score. Even with this testing approach, BW was not compliant or attentive for all parts of testing; thus, results from this standardized assessment may represent a minimal estimate of BW’s communication skills.

was also admin-

23.4 Questions and Answers for the Reader

1. Joint attention is considered critical for language development and use because:

a) Shared attention between a speaker and the listener is the

foundation for successful communication and learning.

b) Joint attention allows for children to focus intently on an

object of personal interest in isolation.

c) Joint attention is a skill that is innate in all children and is

therefore something that does not need to be taught to any child.

d) Af ter learning vocabulary and grammar, children develop

joint attention skills that allow them to participate in con-

versations with adults and peers. Answer: a is correct. If a child lacks joint attention skills, she or he is not able to actively attend to another person. Children learn language primarily through exposure to language via conversation, direct labeling, and/or observations of others using language. Thus, a child who lacks joint attention misses out on important opportunities to learn language due to social disengagement. b is incorrect. Joint attention necessitates shared focus with a social partner and cannot occur in isolation. c is incorrect. Joint attention develops by engaging with others socially. For children with autism, this skill often has to be directly taught so that intervention can be most eﬀective.

Global Language Impairment in a Preschooler with Autism

d is incorrect. Joint attention is the driving force behind vocabulary or grammar acquisition and, as such, must be established in the first year of life for a child to acquire language competency that eventually allows for conversational skills to develop.

2. Social skills instruction to increase pragmatic language functioning in children with autism is thought to be most eﬀective when it occurs: a) Primarily with other children with autism or other dis-

abilities.

b) Across naturalistic settings in and out of the classroom

over the course of each day.

c) When children are engaged in 1:1 intervention with the

SLP. d) Via consultative intervention only. Answer:b is correct. As social situations arise throughout the day, teaching pragmatic language skills to support these interactions as they occur is important. Additionally, if pragmatic language skills are modeled in varied settings, with a range of communication partners throughout the day, children with autism are better able to generalize these skills to use them independently. a is incorrect. Children with autism should be exposed to neurotypically developing peers as language models to encourage age-appropriate social interactions/pragmatic language use. c is incorrect. Intervention such as this represents a social/ conversational environment that does not mirror the natural contexts where children with autism need to use social language skills. The best outcomes for facilitating social language occur when SLPs and others take advantage of teachable moments in the context of commonplace social experiences. d is incorrect. Consultation is often a component of intervention to provide training and support for other individuals (e.g., teachers, parents, teacher’s aids) seeking to engage socially with a child with a pragmatic language disorder. That said, it is rarely the only service delivery model that should be used, as direct teaching and support from the SLP is necessary to facilitate the social language skills vital to eﬀective communication.

3. BW’s annual review is approaching at school, and her case manager recommends reassessment. She specifically asks for results from at least one standardized test. Considering BW’s previous assessment history, how might you proceed? a) Administer a standardized test as specified in the exam-

iner’s manual, making no accommodations for BW.

b) Administer a standardized test as specified in the exam-

iner’s manual, but calculate her standard scores using norms for a child 1 year younger so that you can account for her language disorder.

c) Use dynamic assessment to administer the standardized

test to BW, making accommodations for her as needed (e.g., modifying questions, materials, cues) to gather data to inform intervention planning.

d) Administer a standardized test as specified in the exam-

iner’s manual but report age–equivalent scores only (no standard scores) to allow a diﬀerent perspective of BW’s functional language skills.

Answer:c is correct. Dynamic assessment allows the SLP to modify the content, instructions, materials, etc. of the test being administered to observe language use by individualizing the testing experience for a child who is less responsive to the structured environment necessary for administration of an assessment in a standardized fashion. Data collected via dynamic assessment are typically very supportive of intervention planning. b is incorrect. Because standard scores are calculated by comparing a test taker to his or her peers, the practice of comparing a child with a disorder to a chronologically younger peer is not valid and should never be used. a is incorrect. As BW’s eligibility for services is not in question, the need to administer a standardized test with no accommodations is questionable, as data collected in this manner will likely yield data that underestimate BW’s language competency. Rather, other forms of assessment should be considered to maximize the value of the information collected. d is incorrect. Age-equivalent scores are considered to be “developmental” scores rather than scores of relative standing. Thus, age-equivalent scores do not allow for comparisons of a student’s performance within or across tests. Additionally, because of how they are computed, age-equivalent scores are considered to be inaccurate and should not be used to describe a child’s competency in language or any other developmental area.

23.5 Description of Disorder and Recommended Treatment

BW presented with a language disorder that impacted receptive, expressive, and pragmatic language skills. These deficits, which impacted her ability to encode, decode, and eﬀectively engage with others to share information, were consistent with her medical diagnosis of autism. The Individuals with Disabilities Education Act of Mental Disorders-5th Edition (DSM-5) trum of behaviors observed in autism. Both entities identify autism as a disorder characterized by significant verbal, nonverbal, and social communication deficits; stereotypical and repetitive activities and motor movements; insistence on sameness and adversity to environmental change; and abnormal sensory processing, which results in unusual responses to sensory stimuli.

Intervention for BW focused on play-based approaches within classroom settings to improve pragmatic and expressive language skills. Treatment predominantly followed a social interactionist approach to improve and expand vocabulary, follow classroom and home routines, improve joint attention, and increase functional communication (i.e., expression of wants, needs, feelings, and preferences). For work on mastery of rote concepts such as shapes, colors, letters, and numbers, a behavioral approach was implemented with a focus on stimuli (material to be taught), responses (verbal communication from BW), and positive reinforcement (from the SLP) to teach concepts while reducing problem behaviors. ▶ Fig. 23.1 illustrates the interaction and overlap between these approaches, which,

and the Diagnostic and Statistical Manual

both define the spec-

Global Language Impairment in a Preschooler with Autism

Fig. 23.1 Integration of potential treatment priorities by theoretical approach. This figure illustrates the similarities and differences in the types of skills targeted when different theoretical approaches are used as part of a language intervention plan. Optimally, these different approaches will be complimentary, with social and behavioral learning integrating for functional, generalized communication across academic and social contexts.

when implemented together, should lead to increased language competency in social and academic settings.

Additionally, BW’s teachers and parents were trained on the approaches used as part of treatment to support generalization of skills and concepts from language intervention across home and school environments.

23.6 Outcome

After 3 months of treatment, BW made observable classroom improvements. She followed most daily classroom routines (i.e., bathroom, snack time) with verbal directions and visual aids (e.g., matching picture cards with a schedule board). She frequently verbalized two– to three-word utterances 50% of the time to comment and to state her likes/dislikes to her teachers and classmates. BW interacted more appropriately with her classmates by taking turns. Parallel play was emerging in structured activities. Although problem behaviors persisted, their frequency and severity decreased, leading to successful social interaction with her peers.

BW’s parents reported that she employed more diverse lan- guage at home, incorporating some pronouns, more adjectives, and diﬀerent verb tenses into conversational speech. They also reported that her behavioral outbursts decreased, as they are now able to understand more of her communication attempts and needs, and have successfully implemented approaches suggested by the teacher and SLP at home.

BW was evaluated by the school occupational therapist (OT), physical therapist, and school psychologist and was eligible for special education services and occupational therapy. BW’s

teacher reported that she improved in her developmental play skills, such as completing puzzles, sorting colors, and identifying shapes. She manipulated writing and coloring pencils with OT-developed accommodations. Supports will be implemented as long as needed in an eﬀort to allow BW to function as independently as possible within her home and school settings.

23.7 Key Points

●

BW’s language was consistent with a global language delay because she struggles to use expressive, receptive, and pragmatic language to meet her needs.

●

Assessment for BW was diﬃcult due to her lack of joint attention. A variety of approaches and measures were needed to triangulate observations and form a clear picture of BW’s strengths and weaknesses, relative to communication.

●

Treatment for BW’s language disorder incorporated a variety of approaches to serve diﬀerent needs: teaching, socializing, and generalizing.

●

BW’s problem behaviors and repetitive actions impacted her ability to learn, socialize, and function within her classroom. Pairing the social interactionist and behavioral models in her therapy sessions helped decrease her problem behaviors and increase her language abilities.

Suggested Readings

[1] Burton KD, Wolfberg P, Eds. Learners on the Autism Spectrum: Preparing

Highly Qualified Educators and Related Practitioners. 2nd ed. Shawnee Mission, KS: AAPC Publishing; 2014

Global Language Impairment in a Preschooler with Autism

[2] Prelock PA, McCauley RJ, Eds. Treatment of Autism Spectrum Disorders: Evi-

dence-Based Intervention Strategies for Communication and Social Interaction. Baltimore, MD: Brookes Publishing; 2012

References

[1] Fenson L, Marchman VA, Thal DJ, Dale PS, Reznick JS, Bates E. MacArthur-

Bates Communicative Development Inventories. Baltimore, MD: Brookes Publishing; 2007

[2] Zimmerman IL, Steiner BS, Pond RE. Preschool Language Scales. 5th ed. San

Antonio, TX: Pearson; 2011 [3] Individuals with Disabilities Education Act, 20U.S.C. § 1400 (2004) [4] American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013

Voice Care for the Child Who Is Post–Airway Reconstruction: Special Challenges

24 Voice Care for the Child Who Is Post–Airway Reconstruction: Special Challenges

Lisa N. Kelchner, Susan Baker Brehm, and Barbara Weinrich

24.1 Introduction

Caring for children who have a voice disorder secondary to airway reconstruction requires specific knowledge of the repaired anatomy and physiology, its potential for successful behavioral manipulation and change, and the capacity of the child and his/her family to participate in the recommended treatment. The larynx may be so scarred that the source of vibration involves structures other than the true vocal folds (TVFs). Often, these children have complex medical histories, and during their early years, voice quality is not a priority. However, as the child develops and his/her overall health becomes more stable, voice quality essential to eﬀective communication and educational achievement increases in importance. Collaborative assessment and treatment that includes speech-language pathology, pediatric otolaryngology, educators, and family members is essential for these children.

24.2 Clinical History and Description

JD, a 12-year-old girl, was born at 27 weeks and required 3 weeks of endotracheal intubation and subsequent tracheotomy for long-term airway management. At age 3 years, she underwent airway reconstruc tion (anterior costal cartilage graft) and was decannulated 2 months later. Her parents described her postsurgical voice as weak and airy. Her medical history included bronchopulmonary dysplasia and asthma. She was followed by an otolaryngologist and speech-language pathologist for voice, reflux, and airway protection issues until age 5 years. Her parents reported that her only remaining complaint was her voice and diﬃculty being understood. She looked forward to college and eventually becoming a teacher. All other developmental milestones were adjusted or typical, and she had no persistent health issues other than a very occasional episode of asthma.

The Consensus Auditory Perceptual Evaluation of Voice

(CAPE-V) the perceptual qualities of overall severity (OS), roughness (R), breathiness (B), strain (S), pitch (P), and loud ness (L). The higher number rating is equivalent to increased severity. Ratings for JD were: OS= 60; R = 40; B = 55; S = 40; P =57 (low); L =58 (soft). Intermittent ventricular fold phonation was detected perceptually.

Acoustic measures were obtained utilizing a Computerized Speech Laboratory (CSL; Model 4500; PENTAX Medical). Initially, JD was asked to sustain /a/ for 5 seconds. Visual inspection of a nar row-band spectrogram of the vowel revealed a type 2 acoustic signal, as depicted in ▶ Fig. 24.1. Some variability in the voice signal was noted with bursts of both type 1 and t ype 3 signal productions. Intensity level of a sustained vowel was 63 dB/SPL, which is within a normal-to-low range for this production. JD’s maximum phonation time was 7 seconds, which is a shorter duration than expected, indicating limitations in respiratory support and/or laryngeal valving. However, generally, if a patient can sustain a vowel for 5 seconds, conversational phrasing is not impacted.

Aerodynamic measures were obtained utilizing the Phonatory Aerodynamic System (PAS; Pentax Medical). The system consists of an airflow mask connected to a pneumotach to obtain measures of airflow characteristics during speech. Mean airflow rate was 196.6 mL/s. Estimated subglottic pressure (Psub) is quantified through an intraoral pressure tube. Average peak airflow during a syllable train of /pa-pa-pa…/was

13.13 cm H

Laryngeal imaging was performed using both rigid and flexible endoscopes. JD’s left TVF was scarred along the posterior portion and the mobility of the left cricoarytenoid (CA) joint was restricted. The right TVF appearance and CA joint motion appeared normal. A large posterior gap was noted with diﬃculty maintaining closure of the anterior two-thirds of the TVFs during brief periods of sustained phonation. ▶ Fig. 24.2, a still

is a 100-mm visual analog scale clinicians use to rate

O, which was higher than average given JD’sage.

24.3 Clinical Testing

Pediatric Voice Handicap Index (pVHI): The pVHI,1a parentproxy voice handicapping index, was administered to JD’s mother, who recorded the following scores for her daughter: Functional—17/28, with the highest scores related to being understood in a noisy environment, being asked to repeat herself, and voice diﬃculties restricting personal, educational, and social activities; Physical—9/36, with the highest scores relating to running out of air while speaking and using excessive strain/ yell; and Emotional—6/28, with the highest scores for frustration and embarrassment.

Fig. 24.1 Baseline narrow-band spectrogram. Note the presence of subharmonics between harmonics. Voice sample was a sustained /ah/.

Voice Care for the Child Who Is Post–Airway Reconstruction: Special Challenges

Fig. 24.2 JD’s baseline endoscopy. Note the scarred, thin left TVF.

photo from JD’s endoscopic exam taken while the TVFs were abducted, shows the scarred and shortened left TVF and healthy right TVF. In an eﬀort to improve glottic closure, a tendency for moderate-to-severe compression of the ventricular folds was observed such that intermittent ventricular phonation was noted, indicating a mixed phonation source. Of note, discreet stroboscopic ratings were not made due to issues of acoustic fidelity and signal tracking (predominant type 2 signal). During brief periods of more periodic signal and improved tracking, a mildly reduced mucosal wave across the surface of the right TVF was observed.

Direct examination under anesthesia included palpation of the joints and close inspection of the TVFs. Restricted mobility of the left CA joint and scarring of the posterior portion of the left TVF were confirmed. The subglottic airway was patent.

24.4 Questions and Answers for the Reader

1. A type 2 signal indicates:

a) Harmonics in this voice signal are not at all distinguish-

able.

b) Harmonics can be clearly viewed, but subharmonics are

also obser ved.

c) The interpretation of the acoustic measures (e.g., average

; frequency range) associated with this voice signal are

reliable.

d) The equipment on which you captured and analyzed the

signal needs to be checked.

Answer: b is correct. Using a narrow-band spec trogram, the presence of harmonics is definitely detectable but the presence of subharmonics indicates the presence of noise in the voice signal. In this case, the multiple sources of vibration and incomplete glottis closure (resulting in increased air turbulence) are generating the noise in this child’s voice signal.

a is incorrect. Using a narrow-band spectrogram to visualize and analyze the sustained vowel voice segment, inability to distinguish any harmonics would be seen on a type 3 voice signal.

c is incorrect. Using a narrow-band spectrogram, the presence of the subharmonics calls into question the reliability of the interpretation of acoustic values. If acoustic values are reported, they should note they were done so in this context.

d is incorrect. If you are collecting and analyzing voice signal data using standard protocols and appropriate settings, identifying a voice signal as type 2 is not an indication of any equipment issue. Type 2 signals are often associated with varying degrees of dysphonia.

2. What do the reported airflow measures tell you about the

work of voicing this young woman must use on a daily basis to be understood?

a) That she is having to force her voice to be heard and

understood.

b) They are of little value since she has a unilateral restricted

arytenoid joint mobility.

c) They are a direct indication of the degree of scarring of

the left TVF.

d) They are always found in someone who also has a type 2

voice signal.

Answer: a is correct . Although 196 mL/s is considered within an appropriate average airflow range for her age, it is on the high end of the normal. It suggests that she is not able to adequately valve the larynx during phonation. It may be why her maximum sustained phonation is short. Likewise, her elevated average estimated subglottal pressure is indicative of hyperfunction during speech production. This corresponds to the report of vocal and general fatigue during conversation.

b is incorrect. Using standard protocols and procedures, collecting airflow measures on individuals with suspected or reported incomplete glottic closure is appropriate and helpful in quantifying the degree of laryngeal incompetence and eﬀort used during connected speech.

c is incorrect. Although scar ring can impact glottic closure and phonatory function, there is no reported correspondence of presence of scarring on the TVFs and alteration of airflow measures.

d is incorrect. Although both type 2 signals and elevated airflow values may be found in the same individual, type 2 signals may be found in individuals with normal or restricted airflow measures.

3. What does the presence of mixed voice source mean?

a) There is no such thing. There can be only one source of

vibration within the larynx: the TVFs.

b) The individual has a unique talent that allows him/her to

switch between glottic and supraglottic phonation.

c) The individual is also using an augmentative or amplifica-

tion device to generate speech.

d) To accomplish voicing, the individual uses such eﬀort that

other laryngeal structures, such as the ventricular folds, are compressed and as such are in the phonatory airstream and able to vibrate.

Answer: d is correct. The use of supraglottal structures as a sound source during phonation is often observed when there is incomplete closure of the TVFs and this is what we refer to as an individual having a mixed sound source. In some instances, all structures (supraglottic and TVFs) may vibrate simultaneously or you can have periods where one vibration source dominates. It often has to do with the degree of impairment and subsequent eﬀort. In some children post–airway reconstruction, the TVFs are so scarred that they are unable to vibrate at all and only supraglottic structures are used.

Voice Care for the Child Who Is Post–Airway Reconstruction: Special Challenges

a is incorrect. In most typical healthy larynges, only the TVFs vibrate during sustained phonation and connected speech. In a damaged, repaired, or otherwise structurally altered larynx, other structures can be compressed and vibrate on the phonatory airstream.

b is incorrect. Although some individuals and certain performers can control and switch between true and ventricular fold vibration, that is not what we refer to in this instance. In this case, a mixed voicing source is an unintended consequence of the original airway injury and subsequent reconstruction.

c is incorrect. If an individual also uses an augmentative communication device and amplification, it is termed as such and they are not referred to as having a mixed phonation source.

24.5 Description of Disorder and Recommended Treatment

At the time of evaluation, JD and her parents were suﬃciently concerned and wanted to pursue options for voice therapy, especially given her near ing her teenage years. It is not unusual for parents of children with a history of complex airway conditions to wait until the child is older before seeking treatment. JD’s parents expressed a particular concern that her voice was low and rough for a female. JD also complained of vocal fatigue during conversation and was tired of people asking her to repeat herself. Voice therapy was recommended with the longterm goal of improving voice quality using behavioral therapy techniques and possible surgical intervention in the form of injection augmentation.

Behavioral therapy included use of techniques intended to reduce laryngeal tension and regional hyperfunct ion and maximize closure of the TVF edges during sustained phonation. Therapeutic strategies included general voice use and hygiene counseling, semi-occluded vocal tract(SOVT) exercises, modified vocal function exercises (e.g., sustained /o/ and /i/ on limited pitches), and amplification for noisy environments, particularly in school.

24.5.1 Voice Use and Vocal Hygiene

Vocal behaviors were identified for modification and/or reduction. These behaviors consisted primarily of straining to project her voice in noisy environments, but also included frequent throat clearing, minimal water intake, and moderate caﬀeine intake. Using a daily record form (yes/no response) to monitor vocal hygiene behaviors, JD and her family noted these behaviors in an eﬀort to appropriately alter the behavior. These tasks were discussed in each session, and progress toward modification/reduction of each behavior was noted. A personal amplifier was introduced early on in treatment to reduce the need to strain in the classroom and noisy environments.

24.5.2 Semi-Occluded Vocal Tract Exercises

SOVT Exercises3were utilized to increase vocal eﬃciency and minimize laryngeal tension and hyperfunction, while maximiz-

ing vocal fold closure. During each session, lip buzzes were used as warm-up exercises in an eﬀort to improve breath support and engage the vocal folds, thereby improving and increasing the amplitude of the mucosal wave of the TVFs. This exercise also helped isolate the TVFs as the primary source of vibration. Initially, a comfortable note was used, followed by slow glides extending up and down the pitch range. Nasal consonants were used in the semi-occluded exercises, with emphasis on abdominal support and reduction of pressed voice, which increases a light, buzzing voice. This maneuver also diminished ventricular fold compression and overall laryngeal eﬀort during therapy tasks. Straw phonation included straws of various sizes placed between the lips and phonating /ol/ for pitch glides, followed by musical notes for simple tunes. Flow phonation techniques included cup bubble blowing and gargling sounds followed by voicing /m-m-m/, /m/ + vowel syllables, words with initial nasal phoneme, and continuous speech tasks using eﬃcient voicing. A marked contrast in vocal quality was evident after the fourth week when JD was able to use less tension, suggesting there was more engagement of the TVFs and less lateral-medial compression of the ventricular folds.

24.5.3 Modified Vocal Function Exercises

After JD was consistently successful in reducing ventricular fold vibration, four steps of vocal function exercises mented to improve the tone focus to an anterior, oral position and improve breath support for sustained tones. First, the vowel /i/ was produced with a nasal tone for as long as possible. Initially, JD was able to comfortably sustain phonation for only 7 seconds. The next two steps entailed lip buzzes that were used to glide up (stretching the vocal folds) and glide down (contracting the vocal folds). L ast, three notes were chosen (low pitch-comfortable pitch-high pitch) to produce /ol/ as softly as possible for as long as possible. Maximum tone clarit y was emphasized. The sustained tones were all timed and recorded on a daily record form. Over the course of therapy, JD was able to increase her times to an average of 13 seconds. The ability to sustain phonation was an indicator of improved glottic closure and control of respiratory support. Transfer from sustained vowels to improved function to conversational speech in all settings was a challenge. Phrasing and breath control to support increasingly longer segments of connected speech were practiced in and outside of therapy sessions. Intelligibility of connected speech in quiet during therapy improved from 50% to 75%. With amplification, her intelligibility in noisier environments improved to 90%.

were imple-

24.6 Outcome

After 2 months of using the above-mentioned therapeutic strategies during weekly sessions and with a consistent home program, JD made moderate progress to reduce overall laryngeal hyperfunction, eliminating a “mixed” voice source and increasing sustained TVF phonation. She also improved her loudness. On repeat pVHI, her functional score was 12/28, with

Voice Care for the Child Who Is Post–Airway Reconstruction: Special Challenges

the highest scores still related to being understood in a noisy environment; the score for physical dropped 3 points to 6/36, with the highest scores relating to still using excessive strain at times; and emotional fell to 2/28, demonstrating fewer issues with frustration and embarrassment.

The repeat CAPE-V revealed changes in perceptual ratings of OS = 50; R= 25; B = 55; S = 40; P = 30 (low); L = 35 (soft). Ratings related to breathiness and strain remained the least changed, and JD continued to complain of vocal fatigue and not being understood well in the classroom without amplification (and she expressed an interest in stopping the use of the amplifier due to social concerns). Acoustic measures revealed a greater degree of type 1 and 2 signals, with no type 3 signals captured during sustained phonation. Airflow volume measures (mean airflow rate= 170 mL/s) remained elevated within the normal range but reduced from JD’s baseline. Psub was 9.35 cm H

indicating a reduction from baseline, revealing slight improvement. Repeat stroboscopic examination revealed less ventricular compression and improved glottic closure; however, the combination of reduced left joint motion and posterior left TVF scarring resulted in a persistent large posterior gap during glottic closure. Based on these residual deficits, the treating team, JD, and her parents wished to proceed with augmentation injection of the posterior left TVF to assist with closure of the posterior gap. Augmentation provided improved closure, resulting in increased loudness and improved intelligibility.

24.7 Key Points

●

Intelligibility in noise and perceived eﬀort are key outcome measures in voice therapy, especially in individuals with structural airway changes.

●

Despite chronic dysphonia due to underlying structural and physiologic alterations, a coordinated medical/surgical and behavioral intervention can benefit the pediatric patient.

●

A variety of voice therapy techniques and recommendations for voice use and care are often needed in the treatment of pediatric voice disorders.