9/15/2014Hey! It works! Evidence-based approachesto voice therapyShelley Von Berg, Ph.D., Associate Professor, CSU, Chico,Workshop goals Discuss assessment and treatment of thosevoice disorders that are hyperfunctional inorigin; Describe the diagnostic probe and explain itsimportance in voice therapy; Explain procedural aspects of selected probes; Generate child voice goals that are easy tooperationally define and to measure.Department of Communication Sciences and [email protected] State Convention, October 2014Muscle Tension DysphoniaVocal nodules and polyps The most prevalent voice disorder in bothchildren and adults. A consequence of vocal hypertension and/orhyperfunction. Considered functional. These functional behaviors over time lead toorganic changes, such as swelling, nodules andpolyps.Vocal Nodules and PolypsVocal Nodules and PolypsNature & Etiology Benign lesions usually occurring at the anteriormiddle third aspect of the vocal fold Nodules are generally bilateral and occur due torepeated and chronic vocal abuse Polyps are generally unilateral and are oftenprecipitated by a single vocal event Both types of lesions are resolved with behavioralvoice therapy (Holmberg, 2001; Yamaguchi, 1986; McFarlane &Watterson, 1990)Vocal quality Often characterized by severe dysphoniaDiplophoniaAir escape and short utterancesLow pitch and rough, breathy and hoarse vocalquality Client often coughs and clears throat andcomplains of globus (sensation of fullness at thelaryngeal level)1

9/15/2014Vocal Nodules and Polyps Patient: 42 year old school teacher and recreationalsinger. Complaints: Upper respiratory infection and sequelaof two months’ duration, accompanied by excessivecoughing, throat clearing. Patient reports heavy vocaluse and vocal fatigue (MTD). Assessment: Perceptually, patient presents with lowspeaking frequency and occasions of fry at the endsof phrases. Endoscopy revealed puffy vocal foldsbilaterally with thick mucus throughout thesupraglottis. Polyp was observed at the medialmargin of the right vocal fold with the rightventricular fold impinging slightly on the TVF.Vocal Nodules and PolypsIntervention Yawn-sigh followed by breathy voice.Breathy voice with open mouth approach.Pitch shift up“Silent” yawn-sigh“Boom”Vocal Nodules and PolypsIntervention Interview patient regarding vocal demandsand vocal overuse. If possible, employambulatory monitoring. Redirection Tone focus Pitch shift up usingnasal glides Silent coughVocal Abuse and Misuse Reductions Replace coughing and throat clearing with sniffswallow and silent cough. Use voice amplification.* Speak and sing within the appropriate pitchrange and loudness. Reduce/eliminate smoking, caffeine and alcoholuse. Monitor exercise behaviors.2

Child VoiceEvaluation &InterventionShelley Von Berg, Ph.D., AssociateProfessor, CSU, Chico, Department ofCommunication Sciences and [email protected] State ConventionOctober 2014Descriptive Terminology Clapping hands Balloons Airflow through palmswith and without marble Audio and videotape childinteracting with parents, siblings and peers. Review videotapes of normal and pathologicvocal folds.Just Right Voice Incorporate “Just Right Voice” theme throughouttherapy, school and home. Child identifies “Just Right Voice” qualities. Just Right Voice goals book is issued to the child.Child, siblings, parents and educators establish goals. May develop thematic books that child can read andcolor; later these books may be incorporated into aplay.Initial Interview with Child and Family Explore organic factors that may underliebehavioral abuse and overuse (URIs, asthma,reduced hearing acuity). Familial influences School activities (large classrooms,playground, choir) Extracurricular– Sports– Martial artsVocal Hygiene Identify times of vocal abuse. Explore alternative methods (gestures,whistling). Increase water intake. Replace coughing and throat clearing withsniff-swallow and silent cough. Designate Quiet Times at home.Pair Clients Visi-Pitch analysis Audiotape or videotape is a suitable alternative Facilitation techniques:Yawn sigh Easy onsetGlottal fry Breathy voiceInhale roseConfidential toneFocusBlendingTongue protrusion /i/Spontaneous speech1

Vocal nodules in a childCommunity Intervention Day One Client, siblings and clinicians perform play. Discussion period (children identify healthyand abusive vocal qualities). Children watch videotape of laryngeal functionand make models of larynges.Community Intervention Day TwoReview play.Screen segments of popular movies and cartoons.Experiment with moist and dry consistencies(noodles, flowers). Create larynges out of construction paper. Teacher may incorporate protocol into lesson plans.The Role of the School-Based SLP Why do many students with voice disordersfail to receive speech services? Because it is thought that their disability doesnot adversely affecteducational performance.Community Intervention Child must be aware of dysphonia. Motivators must be identified. Child should easily demonstratevoice techniques. Sibling, peer, parental and teacher support. Child should be able to monitor and adjustvocal behavior internally.Individuals with Disabilities EducationAct Has “educational performance” ever beendefined in federal regulations? No. But, the Department of Education and theOffice of Special Education Programs, issued anumber of policy letters interpreting thisphrase. Education performance, under IDEA,“Includes effect upon academic and nonacademic areas.”2

Furthermore. . . If the presence of a speech-languageimpairment has been established by a SLPthrough appropriate appraisal procedures, thereceipt of services is not conditional uponacademic performance. A child who isachieving at grade level can still qualify ashaving a speech language disability.Andrews (2002, 593)Sample IEP Worksheet Present level of Education performanceCommunicationBased on:Voice screening and survey*and clinicalobservations. Charlie is a 9-year-old male with gradeappropriate speech and language skills, however, hisvocal quality, pitch and loudness are not withinnormal limits, as measured by the following:*Boone, DR, 2004; Lee, Stemple, Glaze and Kelchner, 2004Impact of Voice Disorders onEducation Dysphonia may seriously limit classroomparticipation Social-emotional implications of a voice disorder aremany Children with a limited number of vocal strategiesmay be evaluated negatively Many occupations demand efficient verbalcommunication skills. Poor voice is more difficult tochange in later lifeAndrews, 2002 (Appendix E, 586-594)Voice Screen Findings Breath support: Charlie presents with too little breathsupport for speech. He produces about 3 words perphrase. Average words per phrase is 8. MPT: Charlie’s MPT is 6 seconds. The average MPTfor same age peers is 16 seconds. Pitch: Charlie presents with a pitch that is belownormal limits for same age peers. His speakingfrequency is about a G3 (196 Hz), which is about40-60 Hz below normal. Quality: Charlie presents with a hoarse voice thatsometimes turns into a whisper. The GRBASrevealed a score of moderate/severe dysphonia.Effects of Disability on Participation inGeneral CurriculumEffects of Disability on Participation inGeneral Curriculum When Charlie contributes in class, it is observed thathis voice is hoarse at least 50% of the time, andaphonic (no voice) 30% of the time. His teacher statesthat he speaks in a “rough” and “low voice,” and thatfrom the week of 3/14- 3/18, he lost his voice onthree occasions. His vocal nodules have been verifiedby a medical doctor. Charlie’s hoarse voice interfereswith his ability to participate in daily educationalinteractions. Priority educational needs: To improve the quality of Charlie’s voice sothat he can participate in all educationalactivities during the day. Measurable Annual Goal: During all oral school activities, Charlie willuse vocal hygiene and voice strategies toproduce a clear, age-appropriate voice 4/5 daysa week for three school weeks.3

Short-term Objectives Charlie will identify and modify vocal abuse andoveruse occasions with 90% accuracy by logging theseevents in his daily “JRV” book. Charlie will discriminate between JRV samples ofhimself and two of his peers with 90% accuracy. Charlie will demonstrate and teach vocal hygiene andvoice strategies to family members and friends, asdocumented in his “JRV” book.Evaluation Plan Charlie’s progress toward annual goals will bemeasured by: Teacher/clinician observations. Voice quality, pitch and loudness datacollected on a weekly basis. Review of Charlie’s JRV book and relatedcharts on a weekly basis. Charlie will engage in JRV when communicatingorally in his classes as measured by his instructors, in8/10 opportunities.ReferencesAndrews, M.L. (2002). Voice Treatment for Children and Adolescents. SanDiego: Singular Publishing Group, Inc.Boone, D.R. (1993). The Boone Voice Program for Children (2nd ed.), Austin,TX: Pro-Ed.Finnegan, D.E. (1984). Maximum phonation time for children with normalvoice. Journal of Communication Disorders, 17, 309-317.Goldman-Eisler, F. (1968). Psycholinguistics: Experiments in spontaneousspeech. New York: Academic Press.Lee, L.L., Stemple, J.C., Glaze, L. Kelchner, L.N. (in press). Quick screen forvoice, and supplementary documents for identifying pediatric voicedisorders. Language Speech and Hearing Services In the Schools.4

9/15/2014What is muscle tension dysphonia (MTD)?Hey, it works!Evidence-based approachesto functional aphoniaShelley Von Berg, Ph.D.Associate Professor and ClinicalInstructorCommunication Sciences and DisordersCSU, [email protected] Patient is an educator who has not been able to workfor 4 months secondary to dysphonia. Fiberoptic evaluation at Stanford revealed muscletension dysphonia. Client currently prescribed with PPIs andantihistamines. Produces voice when she clears throat and laughs. Note normal voice that “chains” off of the throatclear.Why is biofeedback so important? Auditory feedback is supported by motorplanning and programming theory (Duffy,2005). It suggests that humans are able to alter andadapt motor equivalent voice and speechbehaviors through integration of sensoryinformation from peripheral mechanoreceptors. MTD is a persistent dysphonia associated withexcessive laryngeal and related musculoskeletaltension. Tension may result in hyperfunctional trueand/or false vocal fold vibratory patterns.What are diagnostic probes? Boone once wrote that . . . Instead of confronting the client, what is the preferredapproach? Diagnostic probes are strategically selected therapyapproaches designed to target a more optimal vocalresponse from the patient. A large part of voice intervention involvesdetermining which probe(s) elicit the desired vocalresponse.CounselingDigital manipulationPutting the voice problem in its proper perspectivecan often free the patient from overwhelmingconcern. Digital manipulation: Finger pressure can be appliedto the thyroid cartilage for a number of reasons.UVFP, pitch shift down, massage, or to feel fortension.1

9/15/2014Vocal Fold Paralysis InterventionUVFP Onset often sudden, following surgery, endotrachealintubation, viral infections, tumors, trauma. Mostcases are idiopathic Usually unilateral, whereby the paralyzed fold ispositioned at the paramedian Often accompanied by dysphagia Treated with medical procedures or behavioraltherapy. Medical procedures usually deferred for 912 months. May involve muscle nervereinnervation, injecting fold with collagen ormedialization thyroplasty. Case study: Male s/psurgery and radiation forthyroid cancer. Right UVFP. Patient reported dysphoniaand dysphagia Phonation is breathy anddiplophonic. Fo: 104 Hz with RAP of2.98%; shimmer 12.2%Vocal Fold Paralysis Intervention Half-swallow boomHead turnDigital manipulationTone focusPitch shiftTongue protrusion /i/Inhalation phonationNasal-glides (yummy,yummy). Personal amplification systemDigital manipulation Ask the client to phonate. Feel the position andtension of the larynx. Larynx should easily“wiggle”from side to side. In this case of MTD, the larynx was elevated in thepharynx.*See McFarlane, SC, Watterson, TL & Von Berg, S (1999)Behavioral intervention in the presence of unilateral vocalfold paralysis: Indications, diagnosis, techniques andinterpretation Phonoscope, Appendix B, pp 211-215.Focus Kinds of problems: The most common problems wesee in patients with voice disorders is the voicesounding as if it is coming from. . . Good focus of the voice is characterized by the voicecoming from the middle of the mouth. A voice focused high in the head is a more efficientvoice.Elimination of abuses Kinds of problems: In this case, it was coughing andthroat clearing. Time is given early in the assessment process toidentify possible vocal abuses. Ask the client to plot her daily vocal abuses on agraph. Educate in vocal hygiene & silent cough and sniffswallow. See Iowa Phonetics site.2

9/15/2014Head positioning Kinds of problems: Clients with vocal HF oftenexperience a better more relaxed voice by placing thehead in a different position. The best voicing tasks to search for good headposition are the nasal-glides and vowels. Mirror provides good visual biofeedback.Nasal/glide stimulation Kinds of problems: These sounds facilitate easierproduced, better sounding voice in individuals withvocal HF. Studies found that nasal/glides revealed bettervoicing patterns. Clinicians should feel comfortable explaining theresonance changes that occur with nasals and glides.Yawn-sigh Kinds of voice problems: One of the most effectivetherapy techniques for minimizing tension effects ofvocal HF. What is happening physiologically during vocal HF? What happens during yawn-sigh? If the patient can perform the yawn-sigh, what doesthat mean about laryngeal massage?Pitch inflections Kinds of problems: Many clients with vocal HFspeak with little pitch inflection because of throat andmandibular tightness. Pitch inflection up for this client revealed a speakingfrequency more consistent with her age and gender. Nasals are effective for eliciting an easy inflection upwithout hyperfunction.Relaxation Some individuals with vocal HF tend to overreact toenvironmental stressors and operate on “fast idle.” There are a number of approaches to relaxation,including open throat relaxation, and even chewing The client should envision and be conscious of anopen throat during the prolonged inhalation.Redirection Kinds of problems: Clients sometimes have difficulty“finding” their voices, especially after lengthyperiods of dysphonia. Redirection helps the client search for a type ofphonation that is easy and conducive to good voice. Once this is discovered, the sound is redirected into aspeaking voice.3

9/15/2014Chant talk Kinds of problems: Often seen in HF. This techniquereduces the effort in talking. Often preceded by warbles. If client is uncomfortable with this technique, explainthat it is temporary, and is used only to develop arelaxed, easy voice.Amplification Confidential Voice This technique is breathy without turning into awhisper; phonation is reduced in amplitude. Reduces the risk of continued vocal hyperfunction. Confidential voice slows speaking rate and creates amore open, relaxed airway.Auditory feedbackAuditory feedback Kinds of problems: organic, neurogenicand functional. Clients benefit from hearing their voicesimmediately, using a reliable instrument,such as a smart phone, iPad or digitizedplayback system. Novel sentences: Encourages client to think moreabout what she is going to say rather than howshe is going to say it. Counseling: Again, explain the anatomy andphysiology of the laryngeal structure; providevisuals; and imbue confidence in client that she isher own clinician!4

No MoreVocal Abuse!How to make it go awayand make my voice betterThis book belongs to a superheronamed:

This will help me become a voice superhero.I will first learn about my voice, and then Iwill learn what I need to do to make it goback to normal. It is up to me to work hardand battle the things that are not good formy voice and do the things that will help myvoice.

I need to do good things with my voice andstay away from the bad things. If I don’ttake care of my voice, I can get nodules (thevillain). These are like the calluses I get onmy hands, but they are on my vocal folds.They can get angry and become red,swollen, and sore and feel like a sore throat.These nodules can make my voice rough,squeaky or scratchy. These nodules can evenmake it hard for me to talk.

Here are some pictures of what my vocal foldslook like normally and some pictures of what theylook like with nodules.Normal LarynxWhen I am breathing inWhen I am talkingVocal NodulesBreathing inTalking

QUESTIONS ABOUT MY VOICEWhat does my voice sound like to me?Do I like my own voice?Are there times when your voice sounds worse orbetter?Are there times when I yell and scream?

Bad things that can hurt myvoice.-YellingScreamingLoud cryingLoud singingClearing my throat and coughingMaking loud soundsDrinking sodas

Instead of YELLING andSCREAMING I can - Whistle- Wave my hands to my friends- Jump up and down . to get their attentionCan I think of other options thatare QUIET?1.2.3.

Sometimes I may feel like I want toyell because I’m mad or upset, butDON’T!Instead, I will try scribbling or hittinga pillow.Can I think of any other ideas?1.2.3.

Crying loudly is another kind of vocalabuse that hurts my vocal folds. If Iget hurt or I am sad or mad, I will tryto cry softly and not scream.

No loud singingSHHHH If I have to sing in a play at school, orin class or anywhere else, I willremember to sing very softly. Myteacher can help me remember I can also hum or just listen to music.

It hurts my vocal folds themost when I cough and clearmy throat I will swallow or get a drink of waterwhenever I need to cough or clear mythroat.

I will NOT make loud sounds like thesounds of trucks, cars, airplanes oranimals.Hmmmm .Can I think of other ways to makenoises without using my voice?1.2.3.

If I get sick and catch a cold or a sorethroat, I must .1. Get lots of rest and sleep.2. Drink lots and lots of water.3. Not talk unless I have to.And if I get laryngitis and lose mostof my voice, I must Not talk at all!

Remember to not scream or yellCount the times I yelled, screamed,talked over noise, made loud noises,cleared my throat .Dayof the SUN MON TUES WED THURS FRI SATweekWeek#1Week#2Week#3Week#4Week#5TOTAL

When I am playing gameswith friends and family,choose the quiet options!Count the times Dayof the SUN MON TUES WED THURS FRI SATweekWeek#1Week#2Week#3Week#4Week#5TOTAL

How much water, soda andother drinks did I have?Kind ofSUN MON TUES WED THURS FRI TAL

Vocal exercises I completed (Just-right voice, yawn-sigh)Day ofSUNMONTUES WEDTHUR FRItheweekWeek AM PM AM PM AM PM AM PM AM PM AM#1Week#2Week#3Week#4Week#5TOTALSATPMAMPM

DAILY JOURNAL ENTRIESTalk about how my overall vocal performance for each day was 1) Rate (positive) or – (negative).2) Problem areas3) Questions and concerns about the use of my urday

Your Child’s VoiceYour child can use his or her voice in healthy ways or in ways that can beharmful and result in problems. These problems most often occur duringspring season. This is the time for outside play and allergies; and team sportsare often a part of life. It’s natural for children to yell, cheer, shout and maketruck, plane and animal noises while playing. They may even excessivelycough or clear their throats because of summer colds. All of these behaviorscombined cause stress on the vocal folds, and as a result, vocal nodules maydevelop, which are callous-like growths. Nodules tend to interrupt goodvoicing and speech, which could be a problem in school. There are manythings that can be done to reduce the chance of, or eliminate, vocal nodules.The following is a home program that will help you and your child workwith the speech therapist to increase good voice habits.A typical vocal hygiene program will consist of:- Identifying the causes of the vocal problems;- Modifying behaviors that cause distress to the vocal folds; likeyelling;- Learning how to take deep breaths and relax the muscles in thethroat;- Taking time to speak slowly and clearly;- Staying properly hydrated throughout the day;- Avoiding caffeinated beverages, such as sodas, which do not hydratelike water does.

Some general tips that you as a parent can use at home:- Make a list of situations in which your child may misuse his or hervoice.- Become a careful listener (e.g., is there a lot of throat clearing athome or yelling at soccer practice?).- Remind your child to use a softer, gentler voice.- Develop signals to help your child remember to use an appropriatevoice (i.e., based on therapy suggestions).- Suggest alternatives to yelling at sporting events (e.g., noisemakers,signs, clapping).- Discourage the use of non-speech noises while playing (e.g. planesounds, beeping, car noises, etc.).- Turn down radio and TV volume when talking.- Suggest some quiet time activities, if your child is sounding hoarse.- Model good vocal behavior.We will be working on the three facilitating techniques in therapy,which your child will also be working on at home. These include thefollowing:1. Just right voice2. Chant talking3. Yawn-sighEvery day, your child should be quietly practicing these techniques in themorning and at night for a maximum of 10 minutes, so he or she doesn’t get

tired. These times should be referred to as “warm up” and “cool down”times, which will help the processes, become routine.Before beginning the techniques, it is important for your child to work onoverall relaxation of the body. Encourage your child to take a few breathsand relax from his head all the way down to the toes.1. Increasing loudness will involve working with the therapist to find hisbest pitch level. Then your child can practice this at home bysustaining vowel and eventually words and phrases.2. Chant talk is practiced by imitating chants such as monotone singing.Eventually moving towards reading and conversational speech.3. Yawn-sigh technique practice involves beginning to yawn and makingan easy “sigh” on the exhale. Once this is mastered, then openmouthed vowels and words that begin with /h/ will be introduced.Then they can move on to phrases and sentences. The following areexamples of words and sentences that can be used for practice.Yawn-sigh technique: H-Words of One hheardheedhardhihiltheelhashikehingeheat

h Technique: 6-Syllable Sentences1. Come to see our harvest.2. Jimmy’s heart can be fun.3. Harmless games can be fun.4. Play your harmonica.5. Sally hesitated.6. John is heading homeward.7. Can you catch his homerun?8. He hit Herman too hard.9. Hold his hammer for him.10.The food was horrible.

11.We enjoyed his houseboat.12.Hardly anyone left.13.A man is human too.14.Hike over this big hill.15.The cowboy yelled “howdy.”**You will also receive a child anti-vocal abuse booklet and chartpacket and journal. The book is for your child to read and learn abouthis or her voice and vocal behaviors that may cause vocal fold swellingand make the voice sound different. The charts are for your child tocomplete and ask for your help if needed. The charts allow your child tokeep tract and monitor vocal behaviors in hopes he or she will makehealthier voice production choices.

LSHSSClinical ForumQuick Screen for Voice andSupplementary Documents forIdentifying Pediatric Voice DisordersLinda LeeUniversity of Cincinnati, OHJoseph C. StempleBlaine Block Institute for Voice Analysis and Rehabilitation, Dayton, OHLeslie GlazeUniversity of Minnesota, MinneapolisLisa N. KelchnerUniversity of Cincinnati, OHVoice is the product of a combination ofphysiologic activities, including respiration,phonation, and resonance. A voice disorder ispresent when a person’s quality, pitch, and loudness differfrom those of a person’s of similar age, gender, culturalABSTRACT: Three documents are provided to help thespeech-language pathologist (SLP) identify children withvoice disorders and educate family members. The first isa quickly administered screening test that covers multipleaspects of voice, respiration, and resonance. It was testedon 3,000 children in kindergarten and first and fifthgrades, and on 47 preschoolers. The second document isa checklist of functional indicators of voice disorders thatcould be given to parents, teachers, or other caregiversto increase their attention to potential causes of voiceproblems and to provide the SLP with informationpertinent to identification. The final document is abrochure with basic information about voice disordersand the need for medical examination. It may be used tohelp the SLP educate parents, particularly about the needfor laryngeal examination for children who have beenidentified as having a voice problem.KEY WORDS: voice disorders, screening voice, voiceassessment, pediatric voice disorders308background, and geographic location, or when an individualindicates that his or her voice is not sufficient to meetdaily needs, even if it is not perceived as deviant by others(Colton & Casper, 1996; Stemple, Glaze, & Klaben, 2000).The incidence of voice disorders in children is oftenestimated at between 6% and 9% (Boyle, 2000; Hirschberget al., 1995). However, other sources identify ranges of 2%to 23% (Deal, McClain, & Sudderth, 1976; Silverman &Zimmer, 1975). In one study, 38% of elementary school-agedchildren were identified as having chronic hoarseness(Leeper, 1992). Unfortunately, it is estimated that the vastmajority of children with voice disorders are never seen by aspeech-language pathologist (SLP; Kahane & Mayo, 1989),and children with voice disorders only make up between 2%and 4% of an SLP’s caseload (Davis & Harris, 1992).Few studies have identified the type of laryngealpathologies that are most common to children. Dobres, Lee,Stemple, Kretschmer, and Kummer (1990) described theoccurrence of laryngeal pathologies and their distributionacross age, gender, and race in a pediatric sample. Datawere collected on 731 patients seeking evaluation ortreatment at a children’s hospital otolaryngology clinic. Themost frequent laryngeal pathologies were subglotticstenosis, vocal nodules, laryngomalacia, functional dysphonia, and vocal fold paralysis. For the total sample, theseLLANGUAGEANGUAGE, S,PEECHSPEECH, AND, ANDHEARINGHEARINGSERVICESSERVICESIN S CHOOLSIN S CHOOLS Vol. 35 308–319Vol. 35 October 308–3192004 AmericanOctober 04/3504–0308

pathologies were much more common in males than infemales, with the youngest patients (less than 6 years old)identified as having the most pathologies. The distributionof pathologies within the races sampled (Caucasian, AfricanAmerican, and Asian) was similar to that found throughoutthe total sample.Although it has been argued by some that treating voicedisorders in children is unnecessary or even potentiallyharmful (Batza, 1970; Sander, 1989), others have arguedfor the opposite opinion (Kahane & Mayo, 1989; Miller &Madison, 1984). Indeed, Andrews (1991) suggested thatunlike some other developmental disorders, maturationalone does not significantly affect vocal symptoms.Habitual patterns of poor voice use do not, as some havesuggested, disappear at puberty. In other words, children donot outgrow voice disorders.The identification and management of pediatric voicedisorders is important for the child’s educational andpsychosocial development, as well as physical and emotional health. The underlying cause of any dysphonia mustbe determined because voice disorders that share the samequality deviations may have vastly different behavioral,medical, or psychosocial etiologies (see review in Stempleet al., 2000).The majority of children with voice problems areidentified by individuals other than the school SLP (Davis& Harris, 1992). Typically, the teacher, nurse, or a familymember notices that a child has developed an abnormalvoice quality and makes the initial contact with the SLP.These referral sources lack training in making perceptualquality judgments, so they may miss more subtle problemsthat need professional attention. Depending on the task,teachers may or may not be accurate in identifying childrenwith voice deviations (see review in Davis & Harris, 1992),and many parents may assume that the child will outgrowthe disorder. Perceptual voice quality evaluation can bedifficult even for the SLP (Kreiman, Gerratt, Kempster,Erman, & Berke, 1993; Kreiman, Gerratt, Precoda, &Berke, 1992), so depending on untrained persons to identifythese children is less than ideal.One common method of identifying childhood communication disorders is through mass screening. Unfortunately,voice has received scant attention in most speech andlanguage screening tools. For example, the Fluharty-2Preschool Speech and Language Screening Test (Fluharty,2001) has one line for clinician response to voice quality(“sounded normal; recheck may be necessary”). Similarly,one line for description of the voice is allotted on theSpeech-Ease Screening Inventory (Pigott et al., 1985).These conventional one-lin

use vocal hygiene and voice strategies to produce a clear, age-appropriate voice 4/5 days a week for three school weeks. 4 Short-term Objectives Charlie will identify and modify vocal abuse and overuse occasions with 90%