During the specific awareness phase of therapy, the child is taught to focus on specific behaviors, discriminate be- tween behaviors, and describe pertinent behavioral characteristics. This creates a perceptual and linguistic framework that prepares the child to modify criti- cal behaviors during the subsequent production phase of therapy. Four goals for patient C included:
n Identification of abusive vocal behav-
iors exhibited by others
n Description of the salient characteris-
tics of vocal behaviors
n Discrimination of differences be-
tween appropriate and inappropriate behaviors
n Explanation of ways inappropriate
behaviors can be avoided or changed Targets
Respiration
n Use lower chest breathing n Use more replenishing breaths
n Eliminate unnecessary upper torso
movement.
Phonation
n Use easy onsets
n Use easy breathy quality (clear qual-
ity is not realistic until the nodules are resolved)
n Decrease tension
n Decrease loudness level in conversa-
tional speech
n Employ vocal variety (not only in-
creased loudness).
Interpersonal
n Increase question asking
82 Voice Therapy: Clinical Case Studies
n Use “other” referenced statements in
addition to “self” referenced ones.
Resonance
n Improve resonance
n Increase articulatory precision.
Because patient C needed to mod- ify a number of different behaviors sub- sumed under 4 different areas, the cli- nician decided to present the behaviors as a set or a gestalt. Consequently, the appropriate behaviors were associated with one storybook character and the inappropriate behaviors with another. The “beautiful ballerina’s” voice was relaxed and “airy” and her lips danced when she used them. She made music by a humming on the front of her face, and the music was carried over into the voice as she chanted words. The ballerina voice was characterized by appropriate breathing patterns, easy onsets, resonance, and lack of laryngeal tension. The voice was light and musi- cal and easy to listen to. Listeners felt relaxed and pleased when they heard it.
In contrast, laryngeal effort, hard glottal attacks, excessive loudness, and inefficient breathing patterns character- ized “tense Tessie’s” voice. Patient C was given ample opportunity to iden- tify the 2 patterns and their effects on listeners during discussion of stories. Sample Stories
1. The beautiful ballerina came onto the stage wearing a frothy white tutu. She breathed deeply and her lower chest swelled with the air. She stood with her lovely head, neck, and shoulders relaxed and poised. The audience admired her patient,
restful posture and relaxed expres- sion. As she began to dance she hummed to the music and the bones of her face vibrated. “Hmmmm” she hummed as she glided smoothly across the flower-strewn stage under the glittering chandelier.
Answer these questions:
n Describe how the ballerina
breathes.
n How does she hum?
n Explain how she keeps her body
relaxed.
2. Tense Tessie tightens her jaw and neck and raises her shoulders when she breathes in. She pushes hard with her throat and makes a little click or grunt on phrases such as
I’m always eager. But everywhere I go. I jerk instead of glide. I feel all stiff, you know! Answer these questions:
n Can you tell Tessie what she must
do to breathe more efficiently?
n How can she relax her neck? n Can you tell which words Tessie
makes with a hard start? Sample Activity
When your teacher tells you an action, do it the way tense Tessie would do it and then do it the way the beautiful bal- lerina does it. Explain the difference.
Production Phase
During the production phase of ther- apy, patient C learned to produce and
Primary and Secondary Muscle Tension Dysphonia 83
monitor target vocal behaviors in struc- tured and controlled situations. Initially, cues and monitoring were provided by the clinician. Gradually, however, the patient learned to assume more and more of this responsibility. For this patient, the production goals were sequenced as follows:
1. Produce each target behavior cor- rectly (in isolation):
n with instructions, cues, and pre-
sentation of the model
n with instructions and cues n with instructions
n spontaneously
2. Prolong and repeat the target be- havior.
3. Stop and start the target behavior at will.
4. Demonstrate both the appropri- ate and inappropriate forms of the behavior (negative practice).
5. Produce the target behavior, vary- ing length of utterance:
n isolated sounds n syllables
n words n phrases n sentences
6. Produce the target behavior, vary- ing the complexity of processing:
n imitation
n automatic responses
n limited repertoire of responses n simple self-generated responses n complex self-generated responses
7. Produce the target behavior, vary- ing the timing of the response:
n predictable response time n unpredictable response time
8. Describe the characteristics of one’s own production in terms of the following:
n preparatory set n strategies used n reactions of self n reactions of others
9. Monitor one’s own production:
n when cued verbally n when cued nonverbally n after practicing aloud n after thinking about it first n spontaneously Sample Materials Facilitating Techniques Yawn-sigh Humming Chanting Facilitating Contexts
n Minimal pairs to teach breathy onset.
“Think” the [h] in the second word of the following pairs:
whose ooze hear ear hair air has as his is how ow ha ah hoe oh heel eel high eye hobo oboe
n Words and phrases containing only vow-
84 Voice Therapy: Clinical Case Studies
for continuity of tone and maximum vibration of facial structures:
/z/ /l/ /m/ zulus lovely Maisie zoo lazy Molly Zoro long mowing Zelma lions money zero lying Moses
/v/ /th/ Vivian them violin those Vera there vision these Volvo then n Sentences
Mow the lawn. Move the Volvo. Vivian is lazy.
The lions were lying in the zoo. Molly loves violins.
My mom never loses money. Noses are nozzles.
I was living in Germany then. Zionsville is near there. Nellie is never nosy.
n Words, phrases, and sentences loaded
with “front” sounds to promote artic- ulatory movement and forward tone focus: Words: 1. whirl 2. bounce 3. jump 4. wobble 5. tap 6. tumble 7. topple 8. toddle 9. pretty 10. dainty Sentences:
1. Pop goes the weasel.
2. Pitter patter water splatters. 3. Fit as a fiddle.
4. Tap with your toes.
5. Pearl buttons to button up. 6. Touch Tilly’s white tulle tutu. 7. Leap up and down.
8. Tiptoe through the tulips. 9. Puppies snap and yip and yap. 10. You yell at little lizards.
Sample Activities
1. Be the dancing teacher and “sing” as you count for the ballerinas to practice at the bar: “One and two and three and four.”
2. Play “singing Simon says,” and sing the instructions for dance movements.
3. Look at this stack of cards with the names of foods (ie, eggs, apples, onions). Use the carrier phrase “I eat” and make a sentence with each card in the stack. You get 1 point for each word you say with an easy onset. Try lengthening the vowel sound.
4. Find the sounds that will help you vibrate your voice on the front of your face. (“I’ll say some words, and you tell me which sounds helped you when you repeated the words.”)
The Carryover Phase
The clinician arranged with the teacher for patient C to present some of her “sci-
Primary and Secondary Muscle Tension Dysphonia 85
ence projects” in her school classroom. Patient C enjoyed the opportunities for attention as she explained and demon- strated some of the information she had learned about respiration. The teacher also implemented a unit on “voice pic- tures” into her classroom curriculum and provided opportunities for patient C to be the “expert” on how to make pictures with her voice without talking loudly or in a tense manner. The patient dem- onstrated “high jumps,” and “broad jumps,” and “long worms,” and “soft fur” using vocal variety, and she served as the judge when the teacher organized a “voice-picture” competition. The patient also starred in another classroom activ- ity where picture cards were used. For example, 2 cards, one with a bird (blue jay) and one with a letter (blue J), were held up. The listeners had to identify to which card patient C was referring.
The patient’s mother routinely observed therapy sessions and observed the ways in which the clinician insisted on mature, direct interpersonal interac- tions. The mother also met for several sessions alone with the clinician and the school psychologist so that she could talk about ways to help the patient at home. The teacher and the parents agreed to give the patient lots of atten- tion and praise when she used mature, nonabusive vocal strategies.
Patient C’s father agreed to read stories with his daughter each evening before bedtime and to reinforce appro- priate voice use. For example, he used phrases such as, “I really like these times when we talk quietly together. You make me see the pictures in my head, and the stories come alive for me,” and “you have the prettiest ‘quiet voice’ I know.” The parents set up rules during mealtimes to ensure that everyone had a
turn to talk and that loud interruptions and shouting down other siblings was not reinforced. When patient C lapsed into her immature, manipulative pat- terns of interacting, the parents calmly said, “Let’s replay that in a more grown- up way.”
Fortunately, patient C’s parents understood the importance of address- ing the psychosocial issues underlying their daughter’s vocal behavior. Their commitment to change and, not coin- cidentally, patient C’s progress were remarkable. From the outset, their inter- est in their daughter’s well-being was reinforced, and the clinician served as a facilitator encouraging them to expand their range of parenting skills. Patient C attended therapy for 2 years, twice weekly for 45-minute sessions. After she was dismissed from therapy, she was followed for 1 year to ensure that gains were maintained.
When travel distance required to receive voice therapy is prohibitive or there is lack of local professional speech- language pathology services, remote treatment may be a solution. In the following case, Lisa Kelchner describes the use of a telehealth approach in treating a child with MTD secondary to early bilateral vocal fold lesions.
Case Study 10
Lisa N. Kelchner
Treatment of Secondary MTD in a Child With Early Bilateral Lesions: A Telehealth Approach
86 Voice Therapy: Clinical Case Studies
Case History
A 10-year-old male “Sam” was referred to a pediatric voice center after being seen by his pediatrician. This was Sam’s second referral to the center in 2 years. Sam has a history of intermittent hoarse- ness secondary to vocal exuberance in the form of loud talking and forceful yelling. The previous laryngeal exam of 2 years ago revealed mild bilateral vocal fold edema, erythema, and mild evidence of LPR. At that time, vocal hygiene education was provided, but the recommendations for therapy were not heeded.
During this exam Sam’s parents report his hoarseness was getting worse as was his throat clearing and coughing. In the time since his first visit Sam has been placed on Ritalin for management of his recently diagnosed attention- deficit/hyperactivity disorder (ADHD). Although he is now on the proper ther- apeutic dosage, there was a period of 3 months when he was demonstrating chronic throat clearing and vocal tics, a known side effect of Ritalin. The vocal tics have mostly subsided after his devel- opmental pediatrician adjusted (down) the dose. Sam also suffers periodic upper and lower respiratory infections and has a known allergy to cats. This allergy is treated with over-the-counter medications as needed and environmen- tal controls. Sam’s hearing and vision were within normal limits. There were no other major medical concerns.