1 MODULE FOR TWA 402 – GANGGUAN SUARA Assessment–Diagnostic Worksheet For Voice Disorder Of A Child (Ages 5-14 years) Oleh : Rozella J. Sutadisastra, MS, CCC-SLP Speech and Language Pathologist Life Member and Holder of Certificate of Clinical Competence from the American Speech Language Hearing Association ASHA Account Number: 00047449 JURUSAN TERAPI WICARA POLITEKNIK KESEHATAN KEMENKES SURAKARTA KEMENTERIAN KESEHATAN INDONESIA 2017 2 Assessment–Diagnostic Worksheet For Voice Disorder Of A Child (Ages 5-14 years) Name: __________________________ Date of Birth: ____________________ Age: ____________________________ Phone:__________________________ Referred by: _____________________ Parents/guardian: _________________ Address: Assessment done by: ___________________ Date of Assessment: ____________________ Case History given on: _________________ Case History returned on: ______________ Examiner: _____________________________ IKATWI Registration No. ________________ Statement of the Problem: Medical Diagnosis if referred by doctor: Clients can come from two sources: screening and referral 1 Screening children for voice disorder in school, health center, or in the hospital 1) Listen to the child’s voice and note the following. (1) Is her/his voice harsh? (2) Is it hoarse? (3) Is it breathy? (4) Is it too high or too low compared to her/his peers? (5) Is her/his volume abnormally loud? (6) Does he/she strain to talk? (7) Does the child have bad vocal habits (constant clearing of his throat, screeming)? 2) Do the s/r ratio to screen voice quality. The s/z ratio is sustained voice/voiced cognate pair production. It is a measure of respiratory and phonatory efficiency. If the child’s vocal folds are vibrating normally, the child should be able to sustain both voiceless /s/ and voiced /z/ sounds an equal number of seconds. The ratio will be one-to-one (1:1) How to do the the s/z ratio - Ask the client to say /s/ as long as possible on a single breath and time it. Then ask him to say /z/ as long as possible on a single breath and time it. Norm: Normal is 1:1,reflecting equal duration of airflow for /s/ and /z/.Ratio greater than 1.4 indicates that there might be vibratory dysfunction of the vocal folds. Result: ___ Normal ____ Abnormal If a child fails the screening, re-screen within a few weeks. While waiting to screen again, gather info from the teacher and send “Observation of Child’s Voice Use” (Appendix 2A, page 25) to the parent to collect more info. If the child fails the re-screening, refer to an audiologidt or Ear Nose and Throat doctor (THT). Use the sample “Voice Screening Report” (Handout). 2. Referral from a doctor, parents, or client If the child is referred by a doctor, there will be a Medical Diagnosis. Wrtie it here and assess the child right away. If it is a parent referral, inform the parent of the screening results and refer to the ENT. Use the sample “Voice Screening Report” (Handout) 3 I. NON-INSTRUMENTALASSESSMENT A. Pre-Assessment Information 1. Ask the parentsto complete the “Case History” (Appendix 2D, pages 28-29). 2. When the Case History is returned, the Speech Therapist will review it (pp. 18-20). Then the TW will summarize the information from the “Case History.” 1) Ask the parents to describe of the voice problem. It will indicate if the parents are awareof the problem. 2) Ask the onset of the problem. It will indicate if the problem has been for a long time. Ask if the onset was gradual or intermittent. 3) Ask the parents and check the characteristics that are present. (1)How the voice sounds: ___ hoarse ___ breathy ___voice breaks/cracks ___different from peers ___ harsh ___raspy (2)How the child uses his voice: ___ clears throat frequently ___ yells/talks loudly ___ makes funny noises ___ talks too softly ___ talks too loudly ___ whispers ___yells when angry (3)What the symptoms are: ___ Can’t sing high notes ___ Talking makes child tired ___ Voice worse in the morning ___Voice worse with use ___ Tickling/choking sensation ___ Frequent burping ___ Exposed to smoke (4)What the pychodynamic issues related to the child’s problems: ___ Talks too much ___ Aggressive behavior ___ Poor self-esteem ___ Poor listening skills ___ Doesn’t take turns when talking ___ Doesn’t respond when asked to change behavior ___ Doesn’t adapt behavior to the situation ___ Always trying to get attention (5)What specific medical conditions that are related to or cause the voice problem? 4) Information about surgeries 5) Information about medications 6) Information about extra-curricular activities 7) Information about diet 3. Interview the parents and get further information. Write in backof the paper if needed. 1) Medical History 2) Previous evaluation by a primary care physician (dokter umum) and/or ENT (otolaryngologist), including reason for referral to assess the nature of the presenting problem 3) Vocal symptoms and patient complain 4) Check pertinent medical diagnoses –See p. 19 4 5) 6) 7) 8) Asthma Allergies Upper respiratory infections/conditions Gastroesophageal reflux (GERD)/heartburn Hearing loss Frequent laryngitis Frequent sore throats Enlarged tonsils and adenoids Neurologic diseases List of present medications History of surgeries of the larynx or recent surgical intubations Family history of medical conditions that may affect the voice (e.g. cancer, neurologic) Social use of voice– shouting, making sounds while playing B. VOICE ASSESSMENT - Use the Clinical Voice Evaluation Checklist (Appendix 2E, pp. 3032). 1 If the child has not had a hearing testing, perform a hearing screening to determine hearing acuity. Use Hearing Screening Form (Handout) Result: pass/fail If you cannot screenor you need further information about hearing, refer the client to an audiologist or an Ear Nose and Throat (ENT) doctor. The client was referred to __________________ on _________________. 2 Oral-Peripheral Examination - Use Form 6-1, Oral-Peripheral Examination, Interpreting the Oral-Facial Examination, and Common Observation from an Oral-Facial Examination and Possible Clinical Implication (Handouts). Lips Teeth Mandibular movement Hard and soft palate Pharynx Tongue Tonus (tremor or fasciculation) Movement Vertical Lateral Diadochokinetic syllabic rate (norms start at age 6 years) Tension sites Face Mandible Neck General body Summarize findings of the Oral-Peripheral Mechanism examination results. 3 Direct observationwhile obtaining the speech samples 1) Counting 1-10 2) All-voiced sentence: “Where are you going?” 3) Voice onset-offset: “The blue spot is on the key.” 4 Other Procedures: 1) Check Respiration–Use Form 11-3, Identification of Breathing Patterns. (handout) What type of breathing was observed: ____ Clavicular ____ Abdominal ____ Thoracic ____ Shortness of breath 5 ____Audible breathing 2) Check Phonation (Use the Vocal Characteristics Checklist - Form 11.2) (1) Quality – In spontaneous speech, quality is: ____Appropriate ____Breathy ____ Harsh ____ Hoarse Check the abnormalities noted: ____ Phonation breaks within words ____ Pitch breaks (up or down breaks) ____ Loss of voice on more then one word ____ Glottal fry (very low pitched phonation) ____ Diplophonia (two tones at the same time) (2) Onset of Phonation On words with initial vowels, onset of phonation is: ____ Appropriate ____ Breathy ____ Hard attack On beginning sentence with vowels,onset of phonation is: ____ Appropriate ____ Breathy ____ Hard attack (3) Pitch - In spontaneous speech, habitual pitch is: ____ Appropriate for age and sex ____ Too high ____ Too low ____ Starts utterance with adequate pitch but drops too low at the end ____ Can initiate sentences at appropriate pitch ____ Uses good inflection in voice (4) Loudness ____Appropriate for 1 on1 setting ____ Too loud ____ Too soft ____ Can demonstrate control of loudness by counting1-5 from soft to loud, getting a little louder on each number ____ Check the levels of loudness that can be imitated: ____ Library voice (not a whisper) ____ Classroom voice ____ Auditorium voice 3) Resonance (1) To differentiate hypernasality and hyponasality, do these procedures. See p. 22. i. Nose Squeeze Result: ____ hypernasal ____ hyponasal ii. Nanny Daddy Result: ____ hypernasal ____ hyponasal iii. Nose pinch Result: ____ hypernasal ____ hyponasal iv. Counting Result: ____ hypernasal ____ hyponasal (2) Check the behavior observed. ___ Appropriate balance between oral and nasal resonance ___ Spontaneous speech sound hypernasal. ___ Spontaneous speech sound hyponasal. 6 ___ The child sound nasal only in nasal contexts. ___ Tongue carriage appropriate ___ Tongue carriage too far forward ___ Tongue carriage too far back (cul de sac) 4) Voice Measures pp. 22-23 (1) Pitch Range-Ask the child to produce the notes and count the notes he/she can produce. How many notes can the child produce? ______ Results: _____ Normal ____ Abnormal Norm: Normal range for boys and girls between ages 7 and 10 years is 29 musical semitones. (Bohme & Stuchlik 1995) (2) Maximum Phonation Time – Ask the child to say /a/, /i/, and /u/ as long as he/she can. /a/ was sustained for _______ sec ___ Normal ____ Abnormal /i/ was sustained for _______ sec. ___ Normal ____ Abnormal /u/ was sustained for _______ sec. ___ Normal ____ Abnormal Norms: (Launer 1971) Girls age 9 years can sustain for 8 seconds. Boys age 9 years can sustain for 11 seconds. Boys and girls age 12 years can sustain for 12 seconds. (3) Measure the s/z Ratio. It is the measure of respiratory and phonatory efficiency. If the s/z ratio has not been done during the screening, do it. s/z Ratio longest /s/ = seconds = _______s/z ratio longest /z/ = seconds s/z Ratio ___ normal ____ abnormal Norms for S/Z Ratio The ratio is one-to-one. A child or an adult should sustain /s/ and /z/ sounds for equal number of seconds. - A 1.0 ratio with normal duration of productions of /s/ and /z/, (approximately 10 seconds for children and 20-25 seconds for adults) suggests normal respiratory ability and the absence of vocal fold pathology. - A 1.0 ratio with reduced duration of /s/ and /z/ indicates respiratory inefficiency. The client may have a reduced vital capacity or poor control of expiration. - For children: If the ratio is greater than 1.4, the child may have some vibratory dysfunction of the vocal folds. (Swigert, 2005) - If the ratio is greater than 1.4, the child may have vibratory dysfunction of the vocal folds. The child should be referred to the laryngologist. 3. Assess the ability to modify any abnormal respiratory, phonatory, and resonatory behaviors. See Module TWA 402, p. 6. 4. Note the impact of the voice disorder on the child’s ability to participate in activities in school, at home and in the community. See Module TWA 402, p. 6 C. Determine if the voice problem ishyperfunction or hypofunction? 1) Is it hyperfunction (excessive effort and tension)? (1) Mark the following that are affected by tension: Stance and posture (e.g., locked knees, misaligned body) Head position Respiration Upper torso (e.g., shoulders and arms) 7 Neck, face, and mandible (e.g., hyperextension of jaw) Phonation (e.g., smoothness and continuity of voicing) Articulation (e.g., devoicing of sounds) Resonance (e.g., tight jaw reduces size of mouth cavity) Prosody (e.g., jerkiness, omission of unstressed syllables) (2) Check behavioral patterns that are present: Desirable or undesirable accommodation for structural deviations (e.g., congenital malformation, laryngeal web, papilloma, paralysis, velopharyngeal deficits) Result in tissue change Generalized tracheal constriction and adduction and vibration of the false (ventricular) folds Deviant sensory system (e.g. hearing loss, neurological impairment) Social and emotional adjustment (e.g., aggression, anxiety, inappropriate self-concept, faulty learning) Cognitive function (e.g., developmental disability) Component of cerebral dysfunction (e.g., spasticity in children with cerebral palsy) (3) Is it caused by vocal nodule? Most common cause of hyperfunction is vocal nodules. Check the symptoms present: Hoarseness Harshness Periodic aphonia Improved quality when loudness is increased Inefficient inhalation patterns Short duration of exhalation Inefficient use of replenishing breaths Throat clearing Hard glottal attack Observable tension Abusive vocal pattern Dryness of vocal tract Vocal misuse (inappropriate loudness and pitch levels) Vocal variation limited to loudness increases 2) Is it hypofunction (inadequate muscle tone in the laryngeal mechanism and associated structures of systems)? (1) Mark the symptoms present: Breathiness – caused by inadequate closure of laryngeal valve Weak vocal power and intelligibility Reduced vocal endurance (2) Check behavioral patterns that are present: Is it secondary to structural deviations or damage? (e.g., bowing of the folds, neurological impairment, atrophy of folds, post intubation changes, surgeries)? Is it related to accommodation to acute or chronic upper respiratory tract conditions (e.g., soreness or fear of pain)? Is it indicative of social or emotional maladjustment (e.g., reticence, mutism, hysteria, abusive family)? If it is severe, is it necessary to use substitute communication system (e.g., ventricular phonation, artificial larynx, sign language, electronic device)? Is it occurring in combination with altered motor ability and/or sensory feedback (e.g., dysarthria, dyspraxia, impaired hearing, dysphagia)? Is it a component of cerebral dysfunction (e.g., weakness and flaccidity in children with cerebral palsy)? Is it subsequent to prolonged hyperfunction? Is it related to cognitive function (e.g., because of developmental delay) 8 (3) What are affected by hypofunction? ? Tick those affected. Pitch Loudness Quality Breath control Vocal Misuse Vocal Abuse Others II. DIAGNOSIS: A. Summarize the assessment findings by answering the following questions: 1 What is the doctor’s diagnosis? If the child has not been evaluated by a ENT, refer before making your diagnosis. 2 Are there any related medical problems? 3 What is the etiology of the problem? 4 What vocal processes are affected? 1) Respiration 2) Phonation 3) Resonance 4) Voice measures 5) Vocal misuse 6) Is the problem hyperfunction or hypofunction? 3. Is the problem real? 5. How severe is the problem? C. Make the Diagnosis:The child’s voice is within normal limits/The child has a voice disorder. D. Make the prognosis for recovery. Good _____ Not good _____ Prognosis must be made based on the answers to the following questions: 1. Will this person display an improvement in vocal quality without voice therapy? 2. How much improvement can be expected after therapy? 3. How effective will the voice therapy be? 4. How permanent can the improvement shown in therapy going to be? 5. Will continuous therapy be needed to maintain the optimal vocal performance? 6. How long had this person had the voice problem? The longer the problem has existed, the more resistant it is to therapy. 7. What are the etiological factors? 8. Is the cause of the problem identifiable or alterable? 9. What is the variability of the problem? 10 Can the person control and vary pitch, loudness, and quality? 11. Are there any psychological complications due to the problem? 12. Are the client’s auditory skills adequate? 13. What is the degree of the disability? 14. How much cooperation will the family and the environment give? 15. Are there any factors in the environment that reinforce the pattern and encourage the continuance of the voice problem? III. RECOMMENDATION/S. A. It is recommended: There is no need for voice therapy./There is a need for voice therapy. B. Design the treatment plan. 1. Determine the long-term goal/s, short-term goals,and treatment objectives based on the results of the assessment and thenselect the therapy techniques to be used. 1) Long-term Goal/s (p. 49) – Select which one which is appropriate for the child’s voice problem. (1) The child will be able to use voice in all situations without experiencing voice loss, phonation breaks, and/or pitch breaks. 9 (2) The child will present with a voice quality that does not sound different from her/his peers. (3) The child will use adequate balance of oral and nasal resonance in all speaking tasks. 2) Short-term goals - Select which one/s that is appropriate the child’s voice problem. (p. 50) (1) The child will have appropriate medical management of related conditions. (2) The child will eliminate hyperfunctional use of the vocal mechanism. (3) The child will eliminaye abusive vocal behaviors. (4) The child will adopt vocal hygiene techniques. (5) The child will eliminate misue of respiration and will use adequate respiratory support. (6) The child will eliminate misuse of phonation characterizedby inappropriate volume and will use loudess appropirate to the situation. (7) The child will eliminate misue of phonation characterizedby inappropriate pitch and will use optimal pitch in all situations. (8) The child will eliminate misue of phonation characterizedby inappropriate onset and will exhibit appropirate vocal quality/easy onset. (9) The child will eliminate misue of resonance and will use appropriate oral and nasal resonance in a variety of speaking situations. (10) The child will eliminate misuse of resonance and instead will focus phonation/tone appropriately within the mouth and nose area. 3) Treatment Objectives - Choose the appropriate Treatment Objectives from Appendix 4D, p. 57-61. 4)Therapy techniques (1) Hyperfunctional voice – See pp. 70-81. (2) Vocal abuse and vocal hygiene – See pp. 83-100. (3) Respiration –See pp. 101-115. (4) Phonation – See pp. 116-136. (5) Oral-nasal resonance and tone focus– See pp. 137-156. (6) Paradoxical Vocal Fold dysfunciton – See pp. 157-168. 2. Decide the frequency (e.g. two times per week or once a week) and duration of the sessions ( 20, 30 or 45 minutes). 3. Decide the length of treatment - p. 49 1) Improvement in physiology of the vocal mechanism (like vocal nodules) should take 6-8 weeks. 2) For transfer of newly-learned behaviors to all settings, a short period of continued therapy may be require. 4. Check the type of treatment. ____ Individual or group sessions ____ Treatment with or without parents ____ Home program C. Referrals 1 Determine if referral/s to other professional/s is/are necessary (e.g. laryngologist, THT, psychologist, counselor). 2 If it is necessary to refer, make a letter referring the child to another professional. Use “Sample Referral for Medical Evaluation.” (Handout) IV. WRITE THE “VOICE EVALUATION REPORT.” A. Use the form “Diagnostic Report for Voice Disorder of a Child” (handout) to write the report. Include the following in your report: 1 The history and presenting complaint 2 The medical diagnosis 3 Description of the structural and functonal findings 4 Statement of the speech therapist’s diagnosis 10 5 Prognosis 6 Recommendations: 1) The Individual Treatment Plan should include: (1) The long- term goal/s (2) Short-term goals (3) Treatment objectives (4) Therapy techniques 2) Frequency of treatment sessions - ____ times per week for 20, 30 or 45 minutes. 3) Duration of treatment sessions - _____ weeks 4) How will progress be monitored? B. The “ Diagnostic Report for Voice Disorder of a Child” must be given to the parents as soon as possible.The report was given to ____________________________ (Name of person) on _________________ (Date given). V. COMMUNICATE DIAGNOSIS AND RECOMMENDATION/S . A. Make an appointment with the parents of the child. B. Have the “Informing Giving Conference” and communicate your diagnosis and recommendations. __________________________ (Name of the person who attended the informing conference) on _________________ (date of the informing giving conference.) C. Make a letter informing the referring individual of the result of the evaluation. Use “Sample Clinical Correspondence” (Handout) and send it to the referring individual. D. Describe the next steps they have to take. 1 Start treatment. 2 If a referral/s to other professional/s is needed, Inform the parent that and give the letter referring the child to another professional. Use the “Sample Referral for Medical Evaluation.(Handout) Sources: 1. Pritchard Dodge, Ellen. (2000). The Survival Guide for School-Basec Speech-Langiage Pathologists. Canada: Singular Publishing Group. 2. Shipley, Kenneth G. And McAfee, Julie G. (2009). Assessment in Speech-Language Pathology, A Resource Manual. San Diego, California: Singular Publishing Group, Inc. 3. Swigert, Nancy B. The Source For Children’s Voice Disorders (2005).Illinois: LinguiSystems, Inc. rjs/April 2017
