Sometimes our university training doesn’t leave us feeling confident treating pediatric voice disorders. Which makes it intimidating, to say the least, when you’re faced with a child with a voice disorder. You might even feel like you’ve landed in a foreign country where you don’t speak the language.

Been there, done that! The good news is

• You know more than you think you do.
• There are lots of accessible resources for you.
• This podcast sheds some light on where to begin and what to consider.

Here’s a sample from episode 73
“When you have a client like this, you can go down a rabbit hole investigating what the symptoms of various syndromes are and what the ramifications of this or that surgery are. I did that a little until I realized I wasn’t going to find an answer. The answer was to just try. It’s like throwing a noodle against the wall to see what sticks.”

Tune in to hear a success story about a client with complex communication needs. 

— Useful Links —

ASAH Voice Disorders 

Semi-Occluded Vocal Tract Exercises

Straw Phonation While Blowing Bubbles

Bite Blocks  

Reusable Jumbo Straws  

Natural Language Acquisition on the Autism Spectrum (for statistics on “non-verbal” children)  

Real Changes in Spoken Language with Sketch and Speak

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Denise: Welcome to The Speech Umbrella, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Denise Stratton, a pediatric speech language pathologist of 30 plus years. I’m closer to the end of my career than the beginning, and along the way, I’ve worked long and hard to become a better therapist.

Join me as we explore the many topics that fall under our umbrellas as SLPs. I want to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Hello, welcome to episode 73 of the Speech Umbrella podcast. Before we get into today’s topic, I want to put in a plug for the last episode, which was an interview with Dr. Teresa Ukrainetz. I realize that there are some sound distortions in a couple of places that we just couldn’t correct, but please don’t let that distract you from Dr. Ukrainetz’s very important message about teaching children with language impairments to speak with exactness. You know, when you’re interviewing online and dealing with bandwidth and internet issues, that’s just the nature of the beast sometimes. This is just an occasional problem, but I wanted to let you know that every podcast has a transcription available at thespeechumbrella.com for your convenience.

Okay, so let’s move on to today’s episode. I’m calling this Pediatric Voice Therapy, Not a Foreign Country After All. Once upon a time I was wary of pediatric voice therapy. I took the view almost that it was a foreign country and I didn’t speak the language and sure I had a class in university, but I really didn’t know what to do. Then I inadvertently ended up with an honest to goodness voice client and found out it was something I could do. The truth is, the more I learn about our vast field, the more commonality I see among disorders and the more confidence I get that we really do know how to treat the wide variety of disorders that we meet in our field.

Today’s episode is all about one client, and an unusual one at that, but his story shares commonality with many clients, and what’s really important is that his symptoms and his treatment plan could be effective for a number of clients. Here’s what we’re going to cover today: a brief definition of voice disorders, the background of this client who I’m calling Sam, the connection between motor movement and voice, my treatment plan and the outcomes. Here’s what I hope you get from today’s episode, the confidence to work with voice issues in the pediatric population.

Now, I fully recognize there are particular situations in which a client needs a super specialist. We have SLPs who work very specifically with vocal performers and who themselves have a background of vocal performance and that’s not the kind of voice therapy I’m referring to. Sam is a child with complex communication needs and he just needed an SLP to look at the whole child and find the root of his problem. If I can do it, you can do it. Now what a difference it has made for Sam.

So what is a voice disorder? This is straight from ASHA’s website: a voice disorder occurs when voice quality, pitch, and loudness differ or inappropriate for an individual’s age, gender, cultural background, or geographic location. So as they describe Sam, you’ll see that a voice disorder does fit Sam’s condition, although he has many diagnoses.

This story begins when Sam’s mother contacted me, she had heard about PROMPT therapy and thought Sam might learn to speak a little bit more with this approach. At this point, he had a few spoken words, he signed and he used a communication device. Sam has been diagnosed with Smith-Magenis Syndrome with Autism Spectrum Disorder as an infant. He had laryngomalacia, he’s been diagnosed with Choanal Atresia, and that’s just a partial list, so you get the idea. Complex communication needs and health issues. He has had extensive surgeries to open and repair his airway. He had surgery to correct a lip and tongue tie, and on the case history form his mother noted his voice quality and that he really had too many surgeries for her to list.

But when I saw this kiddo, he had decent articulation placement skills, but little or no true phonation. So when he did speak, it came out in a whisper. He could scream. So that was a good sign that he had phonation on a reflexive level. And I saw a child who was very motivated to speak, but didn’t have the motor ability to use his voice.

When I say decent articulation placement skills, I mean, he could whisper or say a number of early consonants, like the D, the T K G H Y, and even S. Significantly, he couldn’t say M or N. When you have a client like this, you can go down a rabbit hole investigating what the symptoms of various syndromes are and what the ramifications of this or that surgery are, and I did that a little bit until I realized I wasn’t gonna find an answer.

And the answer was to just try. It’s like throw a noodle against the wall and see what sticks. Now here’s what I did know. 40% of kids on the autism spectrum disorder who have been considered nonverbal are severely challenged with motor planning. And Sam was challenged with motor planning and his movements were slow and stiff and uncoordinated. He had not been receiving OT or PT for some time because of Covid interrupting those services. I knew he had reflexive phonation, which was evident when he yelled, and it was quite powerful. As his mom put it, he has a set of pipes, but he didn’t have voluntary control of that phonation. He had decent motor planning for his lips and his tongue, but his jaw was really stiff as far as opening and closing. That’s understandable because he also had surgery on jaw. His attempts to imitate words were impressive, even though they were whispered.

So I felt one of the keys to his speech was happening below the vocal folds. The key to his speech was in his core, because he was so stiff when he moved. He really didn’t bend over very well. He didn’t bend from the knees. He couldn’t hop, he couldn’t run. He needed to move to excel and to pair his exhalations with voicing. So here’s the game plan I made. I needed to educate his parents about the vital importance of PT and OT therapy and how the core powers the voice. And by the way, his mom did get him into physical therapy.

I needed to do lots of physical activity with him. He loved to play basketball, so that was great. And take advantage of his exhalations and shape them into voiced utterances. So when we played ball, not just basketball, all kinds of balls, he retrieved all the balls in our games. because that movement helped him so much, just bending down and having to get the ball and at first he’d look at me like, you’re gonna get it. I’m like, no, you get it, Sam. That was kind of great. I didn’t have to run around the room picking up the balls. Sam got to do it. I want to mention here that I have treated many children who have had some degree of difficulty with voluntary phonation, and some running and some jumping, imitating animal sounds and such was enough to help them access their voices.

In my mind, I didn’t actually categorize them as voice clients, because we moved so quickly from that stage, from that phonation stage to working on articulation goals. But as we see in Sam’s case, it’s not exactly clearly defined. When are we doing voice therapy? When are we doing articulation with a client like him?

And it really doesn’t matter so much as long as you’re treating their symptoms. With Sam, I realized he needed more than the physical movement to work on his core. He also needed to get his vocal folds working. And by the way, his mother told me to go for it as far as voice therapy goes. And Sam’s ENT said he didn’t have vocal fold damage, so I was good there. I did my due diligence there. Here’s where I felt a bit intimidated, and here’s where I first realized I needed a really specific technique for voice therapy. So I went to ASHA’s website. I found semi occluded vocal track exercises, which sounded like that would be the right thing for Sam, and I dove in, so that sounds really long, right?

Semi-occluded vocal track exercises. Well, they involve narrowing at any superglottic point along the vocal tract in order to maximize interaction between vocal fold vibration, that’s sound production, and the vocal tract, the sound filter, and to produce resonant voice. Okay, that sounds really intimidating. Just reading that sounded a little intimidating to me, but in reality, if you can teach a kid to lip trill and to blow bubbles in water with a straw, you are doing semi occluded vocal tract exercises. Those were the two main exercises that I chose to do. That’s not a complete list of what you could do. I needed to start with large diameter straws because he couldn’t blow bubbles with a regular straw at first.

And I got those online and I got plastic ones that were reusable. And so that’s where we started. And from there we graduated to regular diameter straws. There are a number of videos on YouTube demonstrating how to do straw phonation so there, I’ll just direct you there. And lip trills, well… that’s a lip trill, okay? You don’t need a YouTube video to show you how to do a lip trill. And other things I did, and some of these I’m still doing, I used bite blocks to help him open his jaw wider. And if you’re not familiar with bite blocks, they’re a series of gradually larger and larger blocks that you can stick in a client’s mouth, one on each side to help them get their jaw more and more open.

Which he couldn’t do it first, his jaw was really, really stiff. And now he can have the largest bite blocks in his mouth and he can say, ah, and I can even take them out. And he can still open his jaw wide and say, ah, so that’s great. And his ah, sound is more consistent. It’s stronger because he can open his jaw wider that just helps it.

And we’ve also practiced just saying the mmm sound, the M sound and prolonging it. And first that was really, really hard for him, but I still remember the first day he said a really clear M with true phonation, it didn’t come out all hoarse, it didn’t come out all strangled sounding. It was just a really beautiful, clear, mmm, and it was just a sound I had never heard from him before.

And so we walk into the waiting room after the session was over and he says mmm for his mom and she almost started crying. It was just like, that’s your voice, that’s your real voice. And by the way, we are still working on the mmm sound because he can’t say it in very many words yet. It turns into a b sound instead of the mmm, but we are working on it.

And it’s just amazing that he can even say an mmm, it was so hard to get here. Some of the other things that have worked, I found, um, that a stiff foam ball, when he pushed it together with his hands, that engaged his core and he said the word push and he actually said it with phonation, just because of the effort he was making when he was pushing the sides of the ball in.

And so that was just the accidental discovery cuz we were playing ball. And I was like, oh, okay, we are gonna do this. And then I used his vowels that he did have to shape other vowels. So ooh was one of the first vows he could say and truly use his voice with it. And if you can drop your jaw a little bit, ooh becomes ohh. He could also say, uh, rather early on, and as I taught him to drop his jaw, uh, turned into ahh, again, using the bite blocks, that helped too. And really the secret to his ahh, besides the bite blocks, he was imitating a monkey. One day we were doing a monkey puzzle and he did a ooh-ooh ahh-ahh, kinda like that, the ahh was barely there.

I was like, oh, we are so doing this monkey puzzle over and over and over again. And he just got better and better. Ooh-ooh ahh-ahh, ooh-ooh ahh-ahh, until the ahh became really strong and then he could separate the ahh from the ooh. Many of these discoveries I made just as things happened in the therapy session and then I took advantage of them and grabbed onto them and say, we are gonna do this again because this is working.

And now that he can say ahh, He can say bah for ball, which is a word he couldn’t say before, but he absolutely loves to play ball, so that’s so helpful for him. This took a lot of patience. I realized it only took me a few minutes to describe it, but this was incremental. Tiny, tiny steps a little bit at a time as his voice begin to emerge, and it’s still an ongoing process, but he’s building endurance now. He’s stringing sounds together. For example, the ABCs. His mom sent me a video of him singing the ABCs in the bathtub, so I can’t share it with you, but talk about a happy little boy. He is singing at the top of his lungs and his voice isn’t breaking after A, you know, his A, B, C. He’s getting three or four sounds in a row before his voice breaks and then he is coming back in.

So that was just amazing to hear. Counting. He loves to count as a child on the spectrum does, loves ABCs, loves the numbers, so he is stringing words together. He’s maintaining phonation. We still have a ways to go. As I said, M is still hard in some words, N is not a sound he can say yet, but we’re just working on it.

He is speaking often. He often puts three words together. His voice kind of comes and goes, but he’s just improving. He’s really a vocal communicator now, and his behavior has improved so much. I don’t know the last time I saw a tantrum and they used to be pretty frequent in the therapy room, I know that he still has some tantrums at home, but hey, he’s a kid. He now prefers speaking over signing or using his communication device, and I never, ever discouraged that. I always signed with him if he wanted to sign, but he just finds it more efficient to speak now. He learns vocabulary without being taught. He just absorbs that. And so he’s an efficient communicator. Using his voice makes him happy.

So here’s the takeaway. Always look at motor issues when you’re faced with a nonverbal client or clients who can’t access their phonation. And when you’re faced with a client with complex communication needs and with maybe some voice therapy needs, you can do this kind of therapy. The resources are out there. They’re on ASHA, and it shares ground with so much that we already know how to do. I mean, the lip trills, and the straw blowing phonation, and just the moving around the room, those are all things that we can do. And all we had to do with him was just understand that we take this little tiny success today and we build on it and we take this little tiny success and we build on it some more, and that’s what we do every single day.

So it was not as intimidating as I thought it would be, and it has had a huge, huge effect on Sam’s life. So taking my tagline, when you master the simple, the complex takes care of itself, well, Sam has complex communication needs and health issues, but the treatment, the treatment was so simple. Lip trills, straw phonation, working on the mmm sound, building endurance… Truly, when you master the simple, the complex does take care of itself. Thanks for listening and talk to you next time.

Thanks for listening to The Speech Umbrella. We invite you to sign up for the free resource library at thespeechumbrella.com. You’ll get access to some of Denise’s best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level. All this is for free at thespeechumbrella.com. If you’ve enjoyed this podcast, subscribe and please leave us a review on Apple Podcasts and other podcast directories.