Учебники / Voice Disorders and Their Management Freeman 2000

his vocal behaviour has on others and if so, how does he adjust his own voice accordingly? Vocal decoding and encoding play a major role in overall pragmatic success. It is also essential that we find out whether the young child has the language concepts necessary to understand the instructions we might give him when we are presenting tasks to assess expressive voice use. One key concept is that of continuity. During tests involving prolongations of sounds (e.g. MPT and S/Z ratio) we use instructions such as ‘Keep going as long as you can.’ We need to make these tasks less abstract (Champley and Andrews, 1993) if we are to obtain accurate information. If a child does not demonstrate an awareness of key receptive concepts, this information allows us to teach them at the beginning of treatment (Flynn and Andrews, 1990).

During assessment we must also be concerned about stimulability. Under what conditions can we elicit changes in the voice? What models, auditory, visual and tactile cues appear to evoke improvements in the vocal pattern? During a task such as Maximum Phonation Time, for example, we are interested in a number of pieces of information. We provide a number of trials to time the length of a prolonged vowel. We learn whether successive trials result in increased length, what cues are needed and whether the vibratory pattern can be sustained more evenly at certain times or not at all. Are there episodes of diplophonia, aphonia and pitch breaks? Are these consistent or intermittent?

Voice quality on tasks such as high-quiet singing and vowel prolongation are usually compared with loud, mid-range singing and vowel prolongation. When the folds are swollen or if additive lesions such as nodules are present, the quality is poorest when the voice is soft and high, and best when it is loud, at mid range or lower and effortful. A more comprehensive account of voice stimulability techniques is found in Andrews (1991). It is important to obtain detailed information about stimulability, as this provides us with the information to design treatment goals effectively. The status of the child’s awareness of key concepts and knowledge of relevant linguistic terms leads us to develop appropriate general and specific awareness goals. The child’s responsiveness to voice stimulability tasks guides our formulation of the voice production goals for behavioural modification. (For a sample pre-test/post-test for children see Appendix 6.1.)

Let us look now at some of the behaviours a child like Billy may demonstrate.

Respiration

1.Quick shallow inhalation (shoulder movement)

2.Inefficient exhalation phase (3 secs duration)

3.Inappropriate use of replenishing breaths (taken at random when air is depleted)

Phonation

1.Hard glottal attacks (on vowel initial words)

2.Hoarse effortful quality (severe and constant)

3.Inability to prolong an even vibratory pattern (frequent aphonia)

4.Vocal variability limited to loudness increases (observable tension)

Psychosocial

1.Talks too much; does not take turns

2.Gets attention by loud talking

3.Does not adjust voice to situation or feedback

Making decisions about treatment

When designing the treatment programme, the clinician considers the child’s current status and level of function and develops a rationale and a plan. Children, unlike most adults, will usually need to be taught some specific reasons why they need to work on their voices. In most cases this must be preceded by some general awareness training, so that they understand exactly what voice is. If we plunge directly into the production phase without first focusing attention, the child does not have a cognitive or perceptual framework that will support the new learning. A child like Billy, for example, does not automatically know that voice is the raw material from which words are fashioned. Nor could he understand that description. We would need to begin with some activities about the distinctive features of voices that allow us to identify the user. Birds chirp, dogs bark, cats meow (see Flynn and Andrews, 1990) and the sounds they make help us to identify them. Similarly, even when human speakers say the same words, we can tell who they are by the way they say those words. For instance, the baby brother and the grandfather may both be saying ‘Bye bye’ but if Billy is asked to point to the picture of the person talking he can demonstrate his awareness of voice differences between those two speakers. After learning that people have different voices, and that voices are unique, Billy can then be taught to attend to some specific characteristics of voice that are relevant to his own behaviour. This is the specific awareness phase of the treatment programme. It usually works well if a child learns the key concepts (e.g. tight/loose; easy/hard; rough/smooth; shoulders up/shoulders down) by focusing first on other people’s behaviours. It seems effective to teach new information and to contrast appropriate versus inappropriate behaviours in a story format. See, for example,

stories where one character, the hero, embodies a set of positive behaviours compared with an anti-hero who demonstrates the negative ones. The child learns to identify the differences specifically, as well as some of the reasons why appropriate behaviours are effective (Andrews, 1991, 1994).

Clinical experience suggests that stories need to be simple, with developmentally appropriate language concepts and themes. The rationale for changes in behaviour are illustrated through the effects of the positive behaviours on the characters themselves and on others. The hero should be a powerful figure who gets what he or she wants, who is listened to and liked, who feels and sounds good and so on. As a child absorbs the information in the stories and learns to describe why certain results occurred because of the behaviours used, the link between cause and effect is established. This is part of the scaffold that is then in place before the production phase of the programme plan is implemented.

Now let us see how we can translate this information into goals for Billy. We first must decide on an approach. Shall we work on each area separately or shall we try to teach Billy about the overall pattern of behaviours, combining information from all three areas? Since Billy is only five years old, a gestalt approach may work best, as we can integrate various manifestations of the effort he expends and relate it to behaviours subsumed under our three areas. We can use a story format to teach the information and help him to perceive the differences in effortful versus non-effortful behaviours. Shall we use the terms ‘easy’ and ‘tight’ for our basic contrast? We could apply those terms to the neck, shoulders, voice, breathing and so on. We could demonstrate the meaning of those words with reference to relaxed or tense arms, neck muscles, word onsets, etc. Also, the phonetic configuration allows for the words themselves to be produced smoothly (‘easy’) and jerkily (‘tight’). Thus, these terms seem to be flexible enough and simple enough for us to use them to achieve what we need. Let us now formulate a general awareness goal. The general awareness phase of therapy is where we orient the child to the overall area we want to address. It also includes learning the language concepts to be used in the specific awareness and production phases of therapy. We will formulate only one illustrative example of a general awareness goal although, of course, more than one would be used in Billy’s treatment programme.

General Awareness Phase

Goal: Billy will identify ‘easy’ versus ‘tight’ arm movements with 100% accuracy when the clinician demonstrates.

See Appendix 6.2 for pictures of arms.

Strategy: Today we are going to read a story about arms. Look at these pictures of children playing. Look at their arms. How many arms does each child have? How many arms do you have? Yes, you and I both have two arms and aren’t we lucky we do? We use our arms a lot. One thing we do with our arms is to hug. I bet your mother hugs you a lot as you are a very huggable boy. Mums like to hug their children. Sometimes we get a tight hug and sometimes a kind of easy hug. Watch while I give myself a hug. This is a tight one, see my arm muscles are tight. Now I’ll give myself an easy hug. Look at these pictures of lots of different people hugging. Notice that some are very tight hugs and some are loose, easy hugs. Different kinds of hugs make us feel different things.

See Appendix 6.3 for pictures of hugs.

Now let’s look at some other ways we use our arms. Here is a woman waving. Who is she waving at I wonder? Is that the Queen? Some of these people are making big, easy waving movements. They seem very laid back and relaxed. But look here, this person is waving in a very tight sort of way. Watch me make a tight wave, I think I am trying to stop someone doing something I don’t like. See the frown on my face? It makes my face look tight too. I have a tight arm and a tight face. I’ll even make a tight mouth and jaw. Don’t I look as if I’m in a bad mood!! Someone needs to tell me to ‘take it easy’. Here is a picture of a soldier. Doesn’t he have tight arms? Let’s both stand up and make tight arms like the soldier.

See Appendix 6.4 for pictures of people waving.

Now I will play a guessing game with you. I will do things with my arms and fingers and you guess whether I feel ‘easy’ or ‘tight’. I don’t think I’ll be able to trick you.

The preceding example of a general awareness goal and strategy shows how we begin to build the scaffold to support the learning we hope to produce when we begin specific awareness activities.

In the specific awareness phase we begin to focus the child’s attention on behaviours relevant to his own voice pattern. At first we direct his attention to what others are doing. Note that, by design, they are demonstrating behaviours Billy himself exhibits. Although it seems obvious to us Billy will probably be totally unaware of this similarity.

Specific Awareness Phase

Goal: Billy will identify ‘easy’ and ‘tight’ breathing during inhalation, modelled by the clinician (100% accuracy).

See Appendix 6.5 for pictures of Hal and Ed.

Strategy: Here is a story about Hal and Ed. Look, here is a picture of Hal and here’s one of Ed. Everyone likes Hal. He’s friendly and easy-going and he has a very happy face, don’t you think? He’s a good runner and swimmer too. He says it’s because he takes very big deep breaths so he always has plenty of air. When his friends ask ‘How do you do it, Hal?’ he just smiles his easy smile and says, ‘I just take deep easy breaths like this. See my chest and tummy move easily in and out. The trick is not to move your shoulders. I never have tight shoulders.’ The other boys were glad that Hal shared his secret about easy breathing with them. They tried it and it worked for them too. It even made them feel good too – easy and calm. The only boy who couldn’t get it right was Ed. Poor Ed, he tried and tried, but his shoulders were so tight and he kept moving them higher and higher when he breathed in. What advice would you give to poor Ed?

Now I will do some breathing and you tell me if it is easy breathing like Hal, or tight breathing like Ed. Let’s make it a guessing game.

After Billy has learned to discriminate between ‘easy’ and ‘tight’ breathing and can also describe the specific characteristics of each pattern, we can proceed to the production phase, i.e. asking Billy himself to produce the behaviours. Since we are using a gestalt approach we might tie some hard attacks into the next activity since we have chosen the names ‘Hal’ and ‘Ed’ to allow for this. Because ‘Hal’ begins with the high glottal air flow /h/ and ‘Ed’ begins with a vowel, it will be a maximal contrast.

Production Phase

Goal: Billy will imitate respiratory and phonatory patterns associated with the characters Hal and Ed. (Given instructions, model and cues and with 70% accuracy.)

Strategy: Let’s play a game today where we act like Hal and Ed. Remember them? Hal is the great runner and swimmer who taught the other boys his easy breathing trick. He says the best thing is never to move the shoulders. ‘Don’t ever have tight shoulders,’ Hal says. Ed couldn’t do it, could he ? Do you remember all the trouble Ed had? I’ll be Ed. Tell me again what I should do to breathe like Hal. Yes, that’s right, easy deep breaths down low, not high tight shoulders. Oh, that feels better. I feel calm when I do Hal’s sort of breathing. I’ll say ‘Hello Hal’ as I breathe out. It feels tickly when I feel it on my hand. Can you do that? Of course you can. You breathe just like Hal. Even your voice sounds easy. Listen while I imitate Ed. When he breathes out he says ‘Ed’ all tight and jerky. He sounds

uptight too. Let’s do it together Hal’s way. It feels good when it’s easy. Now we’ll do ‘Hello Hal’ three times and see if we can do easy breathing each time. I’ll go first and you catch me if I’m tight. Watch carefully and help me.

Substituting appropriate vocal options

In the preceding section there are examples of some goals and strategies for Billy to illustrate how we teach young children the background information they need to support successful modification of their own behaviour. The approach we adopt with children is different from that used with adults but the modification techniques are, of course, similar. Examples of stories that can be used with children are presented in Andrews (1994). In this section we will explore some of the appropriate vocal patterns that can be presented to Billy as alternatives to inappropriate behaviours.

Whenever there is a need to improve the carrying power of the voice, and as an alternative to increased laryngeal effort, it is wise to substitute improved resonance. This is why a child like Billy, with a laryngeal constraint, is taught the ‘front of the mouth’ voice. The ‘facial buzz’ is emphasized both as a distraction from effortful laryngeal behaviour and as a resonance booster.

Practice materials loaded with voiced continuants are used so that chanting and continuous smooth vibration throughout an entire utterance can be achieved. See Andrews and Summers (1991) and Andrews (1995).

It is also helpful to remember that depending on the child’s symptoms we can use reflexive behaviours in order to facilitate vocal tract adjustments. Once the vibrating column of air leaves the larynx it is modified by the shape of the acoustic tube it passes through. Voice training depends to a large extent on how an individual can be taught to make positive adjustments to the vocal tract. Reflexive movements are used as triggers to create an awareness of these adjustments. Swallowing, for example, lowers and relaxes the larynx, lengthening the tract. Yawning relaxes and widens the pharynx and a yawn-sigh facilitates openness and relaxation. The size of the oral cavity, tongue position and velar movement are also critical to vocal tract configuration and ultimately the appropriate balance of vocal resonance. This is why mouth opening, jaw relaxation and specific phonetic combinations in practice materials are frequently employed in the production phase of therapy.

A child like Billy also needs to be taught to expand his vocal options with regard to vocal variety. Getting and holding attention are often limited to increasing effort and loudness by many hyperfunctional voice users. If we want him to avoid effortful loud voice use, we must give him

more acceptable ways to be expressive. The clinician may expand his vocal repertoire by teaching him about ‘voice pictures’ (Andrews, 1991). The use of variation of rate, duration, pauses, pitch changes, facial expression and body language ensures he isn’t limited to high risk methods of getting attention.

Additional production goals and practice materials for Billy

These may include:

Goal: Billy will focus his voice (‘front of the mouth’ voice) by humming and feeling the facial buzz when given a model and instructions (95% accuracy).

Goal: Billy will produce words loaded with voiced continuant consonants when presented with flash cards (85% accuracy on 10 word list) emphasizing frontal tone focus.

Goal: Billy will complete a sentence using the carrier phrase ‘My mom mails me –-’ given picture stimuli (85% frontal tone focus on 15 words).

Warm-ups to practise (mouth gym)

Phrases (link words to avoid hard onsets on vowel initial words)

Word List (no devoicing of buzzy sounds)

Carry Over Phase

Goal: Billy will use his frontal tone focus every time he answers the phone at home and says the word ‘hello’.

Strategy: Family members will phone him and reinforce him.

Goal: Billy will identify words in his school reading book that are easy to say in his ‘front of the mouth’ voice. He will write them down and bring them to his therapy session.

Strategy: Teacher will ask Billy to say the words in class (after clinician has worked on them with him) and reinforce him appropriately.

Goal: Billy will practise a short joke in therapy (to share with family and friends) using his ‘front of the mouth’ voice.

The brief illustrative example of Billy’s goals and strategies shows how a child with either chronic or acute vocal fold changes could be helped to produce his voice using improved ‘facial buzz’ to supplement a less than optimal laryngeal buzz. This is the type of positive compensatory technique that is frequently effective with children with a variety of laryngeal and/or respiratory constraints. By substituting a positive compensatory technique the clinician is able to reduce the negative compensations of increased effort and tension in the laryngeal mechanism. Throughout the entire programme Billy would also work concurrently on respiratory and psychodynamic goals.

Conclusion

Therapy for children with laryngeal disorders, like all types of therapy for children, works best when it is tailored to fit the individual child’s developmental level, needs and lifestyle. There are many approaches that work well and the most important aspect is to design each treatment programme so that it is relevant to each individual child and his or her own special world. In this chapter the example of Billy has been used to provide one perspective on the clinical problem-solving process we go through as we build an individualized voice treatment plan for a young child.

Appendix 6.1: Pre-Test/Post-Test Items

Quality during prolongation of /a/ (Circle items that apply.)