Pediatric

Hyperfunctional
Voice Therapy
in the School Setting
Megan Brey & Nicole Compty
Objectives
1. Understand what vocal fold
hyperfunction is and who is at risk
2. Understand the role of the school-based
SLP in the assessment process
3. Understand the treatment approaches
and techniques for voice therapy in the
schools

What is Vocal Hyperfunction?
Occurs when a child is using too much physical effort and muscle force
during speaking
Prevalence
o Voice disorders are the most common communication disorder
across the lifespan, affecting more than five million school-aged
children annually in the United States alone.
o 1/3 of SLP report serving children with voice and resonance
disorders
Oddly, only 1% of elementary children with voice problems
receive treatment by SLPs in the schools (Abbot, 2013, P. 81).



Why does it matter?
Voice disorders in children have been shown to
negatively impact:
Social development
Self-esteem & fear of conversing
Academic performance
Communicative effectiveness
Participation in music and/or physical
education
(Sapienza et. al., 2013)
Behavioral Risk Factors
A history or presence of:
vocal performance
athletic activity
vocal overactivity
o shouting
o yelling
o throat clearing
poor diet choices/ hydration
smoke exposure
psychological disorder
(Kelchner et. al., 2014)
Medical or Physical Risk Factors
Prolonged intubation
Tracheostomy tube
Laryngeal cleft
Congentical aerodigestive
disorder
Arnold Chiari malformation
CNS disorder
Gastroesophageal reflux
disease
Lower Airway Disease

Allergies
Connective tissue disease
Frequent upper airway
infections
Craniofacial anomalies
Multiple medications
Swallowing problems
Upper/lower airway
obstruction
Psychological disorder
(Kelchner et. al., 2014)
Signs and Symptoms
Hoarseness*
Breathiness
Harsh, raspy sound
Pitch that is too high
Pitch that is too low
Voice that is too loud
Voice that is too soft
Voice loss
Vocal fry
Diplophonia
Notable, persistent voice change after
athletic performance or social activity
Chronic cough/throat clearing
Change in swallowing
Difficulty breathing
Pain when voicing
Psychological difficulty or trauma
Teachers or peers reporting difficulty
understanding the child
Change in social interaction and/or
classroom participation
(Kelchner et. al., 2014)
Impact on Voice
Laryngitis
Contact Ulcers
Nodules
Cysts
Polyps

Assessment in the Schools
The challenge for clinicians is to understand how the underlying
pathophysiology of disease processes affect vocal function and the childs
behavior in order to provide effective therapeutic techniques. (Sapienza et.
al., 2004, p. 328)

Family members and/or teachers are usually the first to detect
SLP must conduct a screening before child can be referred for more
extensive examination
o If screening reveals abnormal findings, the SLP will refer the child to
a physician for a laryngeal examination
Establish diagnosis
If behavioral voice therapy is indicated, child is referred back to
the school-based SLP and an IEP is developed
(Lee et. al., 2004; Oates et. al., 2008)

Quick-Screen
May be used for speakers of all ages (preschool through adult)
Can be administered in 5-10 minutes
Measures of respiration, phonation, resonance, and vocal
range/flexibility
Provides appropriate language for vocal behaviors that the SLP may
not observe of identify without it
o Can be useful for reporting findings or writing IEP goals
Perceptual characteristics of the voice are judged by listening to the
child speak
o Engage in topics of interest
Examiner responds to a checklist of items/observations
Additional checklist of functional indicators that can be given to parents,
teachers, or other caregivers
(Lee et. al., 2004)
Video link: http://vimeo.com/84772144

Traditional Therapy vs. Emerging Models
Dont Approach/ Indirect
o Skinnerian
Hygiene-focused
o Identify and reduce vocal
abuse
o Often restrictive
Difficult for carry over into
spontaneous speech
Do Approach/ Direct
Hygiene and hydration
May include:
o Improve VF closure and
decrease tension
o Improve resonance
o Belly Breathing (breath
support)
o Vocal function exercises
(Stemple)
o Lessac-Madsen Resonant
Voice Therapy (Verdolini)

Intervention

(Kelchner et al. 2014; Sapienza et. al.,, 2012; Theis, 2014)
Including the Child
Training self-awareness
o Self-judgement of productions
o Rating scales
Increasing motivation
o Cool factor
o Limiting parent criticism

(Mcallister, 2013; Theis, 2014)

Vocal Function Exercises
Goal: coordination of systems involved in
voice
Respiration, phonation and resonance
Focus on forward placement, quiet
phonation, and the least amount of
effort
Hierarchy of vocal function exercises
(Kelchner et. al., 2014; Theis et. al., 2014)

Lessac-Madsen Resonant Voice Therapy
Goal: awareness and achievement of
barely abducted, barely adducted glottal
configuration
Barely aBducted = decreased
respiratory effort
Barely aDducted = sensation of facial
vibration?
(Theis, 2014; Abbott, 2013)

Conclusion...
As an SLP, we have a unique role in voice
disorders, especially in the school systems
Advocate for the child
Motivator for the multidisciplinary team
Leader of dissemination of information

References
Abbott, K. V. (2013). Some Guiding Principles in Emerging Models of Voice Therapy for Children. Seminars in Speech and Language, 34(2), 80-93.
An Eclectic Approach to Preschool Voice Therapy. (n.d.). ADVANCE for Speech-Language Pathologists and Audiologists. Retrieved April 29, 2014, from http://speech-language-pathology-
audiology.advanceweb.com/Multimedia/Cover-Story/An-Eclectic-Approach-to-Preschool-Voice-Therapy.aspx
Hooper, C. R. (2004). Treatment Of Voice Disorders In Children. Language, Speech, and Hearing Services in Schools, 35(4), 320-326.
Kelchner, L. N., Brehm, S. B., & Weinrich, B. D. (2014). Pediatric voice: a modern, collaborative approach to care. San Diego: Plural Publishing.
Klein, M., & Krasner, Y. (n.d.). Treatment. Vocal Hyperfunction in Children. Retrieved April 29, 2014, from http://vocalhyperfunctioninchildren.weebly.com/treatment.html
Lee, L., Stemple, J., Glaze, L., & Kelchner, L. (2004). Quick Screen For Voice And Supplementary Documents For Identifying Pediatric Voice Disorders. Language, Speech, and Hearing Services in Schools, 35(4),
308-319.
Mcallister, A., & Sjlander, P. (2013). Children's Voice and Voice Disorders. Seminars in Speech and Language, 34(02), 071-079.
Nierengarten, M. B. (n.d.). Voice Disorders in Children Require a Team Approach. ENT Today. Retrieved April 29, 2014, from
http://www.enttoday.org/details/article/1478889/Voice_Disorders_in_Children_Require_a_Team_Approach.html
Oates, J. & Winkworth, A. (2008). Current knowledge, controversies and future directions in hyperfunctional voice disorders.International Journal of Speech-Language Pathology, 10(4), 267-277.
Ruddy, B., Lewis, V., & Sapienza, C. (2013). The Role of the Speech-Language Pathologist in the Schools for the Treatment of Voice Disorders: Working within the Framework of the Individuals with Disabilities
Education Improvement Act. Seminars in Speech and Language, 34(02), 055-062.
Sapienza, C., & Ruddy, B. H. (2012).Voice Disorders (2 ed.). San Diego: Plural Publishing Inc.
Theis, S. M., & Melton, S.D. (2014). Pediatric Voice Therapy: Why, What, and How. [Powerpoint Slides]. Retrieved from: http://www.asha.org/Events/convention/handouts/2008/1905_Melton_Sarah/