Patient, Parent, and Speech-Language Pathologists' Perceptions of Pediatric Voice Therapy Through Interviews

Short-Term Effects of Semi-Occluded Vocal Tract Therapy on the Phonation of Children With Vocal Fold Nodules: A Randomized Controlled Trial

PURPOSE

The aim was to determine and compare the short-term effects of two intensive semi-occluded vocal tract (SOVT) programs, "straw phonation" (SP) and "resonant voice therapy" (RVT), on the phonation of children with vocal fold nodules.

METHOD

A pretest-posttest randomized controlled study design was used. Thirty children aged 6-12 years were randomly assigned to the SP group (n = 11), RVT group (n = 11), or control group receiving indirect treatment (n = 8) for their voice problems. All participants received 11 hr of group voice therapy over four consecutive days. A multidimensional voice assessment consisting of both objective (dysphonia severity index and acoustic voice quality index) and subjective (pediatric voice handicap index and perceptual rating of overall severity) measures was performed pre- and posttherapy. Voice therapy effectiveness was evaluated using group-level analyses (linear mixed models) and individual-level analyses to investigate what proportion of participants changed to a clinically relevant degree.

RESULTS

Group-level analyses found no significant Time × Group interactions, indicating that the evolution over time did not differ among the three groups. Within-group effects of time showed a significant and equal improvement in dysphonia severity index in the SP and RVT groups and a significant improvement in perceptual rating of overall severity in the SP group. For dysphonia severity index, individual-level analyses showed that 36% and 45% of participants improved to a clinically relevant degree in the SP and RVT groups, respectively. For acoustic voice quality index, 38% improved to a clinically relevant degree in the SP group.

CONCLUSIONS

Results suggest that short-term intensive SOVT programs may have a positive effect on voice quality and vocal capacities of children with vocal fold nodules. Participants seem to benefit more from a SP program than a RVT program.

Mobile health in communication disorders: willingness to use, attitude, advantages, and challenges from the perspective of patients

INTRODUCTION

Communication disorders are one of the most common disorders that, if not treated in childhood, can cause many social, educational, and psychological problems in adulthood. One of the technologies that can be helpful in these disorders is mobile health (m-Health) technology. This study aims to examine the attitude and willingness to use this technology and compare the advantages and challenges of this technology and face-to-face treatment from the perspective of patients.

METHODS

This descriptive study was conducted with a researcher-made questionnaire and investigated the willingness and attitude of patients with communication disorders to use mobile health technology. The face and content validity of the questionnaire were examined with the help of experts in speech therapy, health information management, and medical informatics. Chi-square, Fisher's exact test, and the Kruskal-Wallis test were used to analyze the relationship between variables. Also, the challenges and advantages of mobile health technology and face-to-face treatment were extracted from the patient's answers and presented in the form of main themes and sub-themes.

RESULTS

One hundred seventy patients participated in this study. The results of this study showed that 57 (33.5%) participants preferred face-to-face visits, 11 (6.5%) preferred m-Health, and 102 (60.0%) preferred the combination of mobile applications and the face-to-face visits method. The results showed a statistically significant relationship between "Residence (rural or urban)", "Having trouble traveling to speech therapy centers", and "Delaying treatment due to lack of access to speech therapists" with treatment methods (face-to-face, mobile health, face to face and mobile health). Accessibility and convenience, treatment efficacy and variety, patient empowerment and confidence, family involvement and support, cost and time efficiency, treatment adherence and completion, and comfort and lifestyle compatibility were six categories related to the advantages of mobile health technology from the point of view of patients with communication disorders. Also, technological challenges, effectiveness and quality concerns, patient experience and engagement, and trust and confidence issues were mobile health challenges from the patients' point of view.

CONCLUSION

The results of this study showed that patients tend to use both face-to-face interactions and mobile health. Integrating both m-Health and traditional methods can optimize speech therapy outcomes. Addressing challenges such as inadequate technological infrastructure and data security is crucial for successful implementation.

Provider and Patient Satisfaction with Telemedicine Voice Therapy During the COVID-19 Pandemic

OBJECTIVES

The COVID-19 pandemic expanded the use of telemedicine, but there is no literature exploring both patient and provider satisfaction specifically in the provision of voice therapy. This study aims to investigate patient and provider satisfaction with virtual voice therapy, its associated factors, and any correlation between the two.

METHODS

Cross-sectional study. Participants included 226 adults who underwent voice therapy delivered via telepractice at the USC Voice Center between April and October 2020. Patients and providers self-reported their level of satisfaction on a visual analog scale (VAS; range 0-100). Patient satisfaction was additionally measured using a previously validated Telemedicine Satisfaction Questionnaire (TSQ; range 1-5), and a binary question about their desire to choose telemedicine over in-person therapy in the future. Three speech-language pathologists rated provider satisfaction for all 226 patients. Patient satisfaction survey was completed by 55 patients. Multivariable linear regression analyses and linear mixed-effects models were used to assess the results.

RESULTS

Patient and provider mean (SD) VAS satisfaction scores were 86.8 (18.6) and 80.6 (19.7), respectively. The mean (SD) TSQ score was 4.4 (0.6). In a multivariable model, patient satisfaction levels were significantly higher for hypofunctional than for hyperfunctional dysphonia diagnoses. Forty-four (73%) patients reported they would prefer telemedicine voice therapy over in-person appointments, which was significantly correlated with internet reliability (P = 0.04). For providers, satisfaction was significantly lower for patients whose diagnosis had changed after initiation of voice therapy (Δ = -16.0 [95% CI: -28.7 to -3.2]) and for encounters with Asian patients compared to White patients (Δ = -11.6 [95% CI: -18.9 to -4.2]). Patient and provider satisfaction scores were weakly correlated (r = 0.19).

CONCLUSIONS

Our findings suggest that virtual voice therapy is not simply an alternative to in-person service, but rather an effective method useful beyond the current pandemic with proper diagnosis and technical support.

Management of Pediatric Voice Disorders: Perceived Knowledge, Attitude, and Practice Patterns Among Otolaryngologists in Southwest China

OBJECTIVE

This study aimed to investigate the knowledge, attitude, and practice patterns of otolaryngologists in Southwest China in managing pediatric dysphonia.

STUDY DESIGN

Cross-sectional survey.

SETTING

An online survey was disseminated between August and September 2023 to hospital-based otolaryngologists in Southwest China.

METHODS

The survey nominated 10 topics within pediatric dysphonia and asked the participants to rate their knowledge and confidence for 10 topics. The attitude toward the importance of managing pediatric dysphonia and its practice patterns for the disorder were also asked.

RESULTS

A total of 334 responses were received. The results showed that otolaryngologists in Southwest China did not receive complete coverage of specific topics within pediatric dysphonia during their specialist training. Their self-rated knowledge sufficiency and confidence for the same topics were relatively neutral, indicating neither negative nor positive self-perceptions of competency. The majority of respondents held the attitude that managing pediatric dysphonia is important, and nominated specific topics within this field for continuing professional education. Common facilitators of practice were clinical skills and knowledge of pediatric dysphonia, and common barriers were the lack of professional guidelines and qualified speech-language pathologists (SLPs) in Southwest China.

CONCLUSION

Otolaryngologists in Southwest China do not receive sufficient training for the management of pediatric dysphonia, however, they perceive this field as important and seek further training from continuing education programs. The findings identified knowledge and training that should be targeted in official training and professional development courses for otolaryngologists who manage pediatric dysphonia without the support of SLPs.

Unpacking the black box of voice therapy: A clinical application and revision of the Motor Learning Classification Framework (MLCF)

PURPOSE

Voice therapy is a complex behavioural intervention. Understanding its components is integral for continued advancement of voice therapy research, translation of evidence into the clinical setting and improved client care. The Motor Learning Classification Framework (MLCF) offers an excellent opportunity for increasing such knowledge, specifically in relation to identifying variables that affect motor learning (ML), an important mechanism hypothesised to bring about voice change during voice therapy. The MLCF has shown promising results in identifying speech-language pathologists' (SLPs) use of ML variables during experimentally controlled voice therapy contexts. The purpose of this study was to test the feasibility of applying the framework in the clinical context of everyday voice therapy practice.

METHOD

Data consisted of two video-recorded voice therapy sessions representing usual voice therapy care. Classification of ML variables used by SLPs during the recorded sessions was attempted based on the MLCF.

RESULT

Several problematic features of the framework were identified. Based on deliberations between the authors of the current paper, the MLCF was revised using an iterative process. This resulted in the construction of an updated version of the framework (MLCF-V2). The MLCF-V2 organises ML strategies into two broad categories: directly observable behaviours and learning processes. The framework incorporates greater consideration of theory and empirical evidence supporting motivational, attentional focus and subjective error estimation influences on ML. Several examples of each ML variable are included as well as an attempt to provide clearer classification instruction.

CONCLUSION

It is anticipated that the MLCF-V2 will provide a more useful and reliable classification for use in future investigations of SLPs' use of ML variables during usual voice therapy practice.

Development and Validation of the Children's Voice Questionnaire (CVQ)

OBJECTIVES

This study developed and validated the children's voice questionnaire (CVQ), a new self-administered instrument for children, and evaluated its internal consistency and reliability.

STUDY DESIGN

Observational, prospective, cross-sectional study.

METHODS

The initial preparation of the CVQ was conducted in four steps. First, individual interviews were conducted with dysphonic and non-dysphonic children and their parents, teachers, and speech pathologists. Second, the responses collected from the interviews were arranged into a comprehensive list of 175 items. Third, this list was reduced to a preliminary 21-item version of the questionnaire, which was tested as a pilot with 254 children. Fourth, a further reduction to 18 items was performed to construct the final version of the CVQ. The questionnaire was then administered to 342 children (73 dysphonic, 269 non-dysphonic) aged 6-18. Simultaneously, the parents of these children completed the pediatric voice handicap index (pVHI). Finally, after 2 weeks, 30 randomly selected children (nine dysphonic, 21 non-dysphonic) completed the CVQ again to evaluate test-retest reliability.

RESULTS

High reliability was found for the CVQ (Cronbach's α = 0.94). Test-retest revealed strong and statistically significant reliability (r = 0.79, P < 0.001). A highly significant group difference was found between the CVQ scores obtained for the dysphonic and non-dysphonic groups (t[78.25] = 6.22, P < 0.001). In addition, significant medium-to-strong positive correlations were found between the children's evaluations using the CVQ and their parents' evaluations using the pVHI (0.59 < r < 0.66, P < 0.01).

CONCLUSIONS

The newly developed CVQ is a valid and reliable instrument. Findings reveal general agreement between children and their parents, but also show that children's perspective on their dysphonia is not equivalent to the parent's perspective. This demonstrates that combining both perspectives provides a more holistic and complete overview of dysphonic children's voice-related quality of life. The self-administered CVQ reliably differentiates dysphonic from non-dysphonic children and may serve as a valuable tool for the initial or ongoing evaluation of children with voice disorders in clinical and research settings.

Parents' Perceptions of and Attitudes Toward Voice Therapy

PURPOSE

This study aimed to investigate Chinese parents' perceptions of pediatric voice disorders to determine their level of health literacy and knowledge gaps to understand the determinants of initiating voice therapy for children with dysphonia.

METHOD

A cross-sectional survey was conducted in three voice clinics in Chengdu, China, from October 1, 2021, to October 1, 2022. Impairment of children's quality of life as perceived by parents was assessed using the pediatric Voice-Related Quality-of-Life (pVRQOL) scale.

RESULTS

Overall, 206 parents whose children were recommended voice therapy were recruited (Mean ± SD age, 35.0 ± 4.62 years; male/female = 1:3). When otolaryngologists recommended that their children with dysphonia initiate voice therapy, most participants had positive responses (n = 176, 85.4%). The mean pVRQOL score was 40.8 in the accept group and 37.6 in the reject group (difference, 1.7; 95% CI, -4.98 1.69). Participants who had a more influential work status, had an only-child, had children with shorter-term voice symptoms, and visited specialized hospitals were more likely to have negative practices related to children's voice therapy (P < 0.05).

CONCLUSIONS

This study represents an important first step in understanding Chinese parents' perceptions of and motivations for initiating voice therapy for their children with dysphonia. Initiation of treatment as recommended in pediatric populations depends on multiple factors, such as the duration of voice symptoms, family structure, and hospital type. It is imperative to promote public health care education on voice therapy among parents, as health care literacy is the primary driving factors in decision-making.

Voice Onset Time in Children With and Without Vocal Fold Nodules

PURPOSE

Voice onset time (VOT) of voiceless consonants provides information on the coordination of the vocal and articulatory systems. This study examined whether vocal-articulatory coordination is affected by the presence of vocal fold nodules (VFNs) in children.

METHOD

The voices of children with VFNs (6-12 years) and age- and gender-matched vocally healthy controls were examined. VOT was calculated as the time between the voiceless stop consonant burst and the vocal onset of the vowel. Measures of the average VOT and VOT variability, defined as the coefficient of variation, were calculated. The acoustic measure of dysphonia, cepstral peak prominence (CPP), was also calculated. CPP provides information about the overall periodicity of the signal, with more dysphonic voices having lower CPP values.

RESULTS

There were no significant differences in either average VOT or VOT variability between the VFN and control groups. VOT variability and average VOT were both significantly predicted by the interaction between Group and CPP. There was a significant negative correlation between CPP and VOT variability in the VFN group, but no significant relationship was found in the control group.

CONCLUSIONS

Unlike previous studies with adults, there were no group differences in average VOT or VOT variability in this study. However, children with VFNs who were more dysphonic had increased VOT variability, suggestive of a relationship between dysphonia severity and control of vocal onset during speech production.

Update on the pediatric adverse vocal behavior voice disorders: a clinical practice review

The main causes of voice disorders in children with adverse vocal behavior include benign lesions of the vocal folds caused by voice abuse or misuses, such as vocal fold nodules, vocal fold polyps, and laryngitis. Long-term voice disorders can affect the physical and mental health of children. Reviewing the literature of the last two decades on "Vocal Fold Nodules," "Vocal Fold Polyp," "Voice disorder," "Voice Abuse," "Voice Misuse," "Pediatrics," and "Children" with the appropriate Boolean operators.  Conclusion: A total of 315 results were returned on an initial PubMed search. All articles from 2000 to 2022 written in English or Chinese were screened. Duplicate articles, those relating to adults only or concerned with the malignant lesion of the vocal cord, were excluded, resulting in 196 articles of interest. Relevant references and books have also been consulted, and we provide a review of the pathogenesis, diagnosis, and treatment of these maladaptive vocal behavioral voice disorders. What is Known: • Hoarseness is the most common voice symptom in children, and there are various causes of hoarseness in children. However, there is a lack of reviews on voice disorders caused by adverse vocal habits in children. • Voice training is a conservative treatment method for children with voice disorders , and it is important to clarify the factors that influence the effectiveness of voice training for children. What is New: • This review of the personality and family characteristics of children with adverse vocal behavioural voice disorders provides a valuable guide to the clinical planning of subsequent treatment. • This article discusses and summarises some of the factors that may influence the effectiveness of voice training in children and collates some of the scales and questionnaires currently used in children that are important in predicting the effectiveness of voice training.

Assessment of Life Quality in Children with Dysphonia Using Modified Pediatric Voice-Related Quality of Life Questionnaire in Serbia

(1) Background: Hoarseness is not uncommon in children, especially at school age, as communication with peers is intensified. It is caused by improper use or overuse of the vocal apparatus. (2) Methods: The study included 85 hoarse children aged 6-12 (study group) and 240 healthy children (control group) of the same age. The study group underwent a detailed medical history, phoniatric examination, larynx fiber endoscopy, allergy treatment and the Pediatric Voice-Related Quality of Life questionnaire, modified by Jasmina Stojanovic. (3) Results: Our modified questionnaire revealed the significance of parental perception of a voice disorder in a child after organized activities. Using our modified questionnaire, we were able to determine the most frequent form of a voice disorder in children-speaking too loudly-is often neglected by the environment and can lead to an overall lower life quality. (4) Conclusions: As the presence of hoarseness impairs the quality of life in the pediatric population, awareness of a voice disorder must be recognized and treated on time to overcome the possible side effects on a child's psychological and emotional development.

Satisfacción usuaria asociada a la atención fonoaudiológica en organizaciones de Salud Familiar y Comunitaria

La satisfacción usuaria representa una dimensión relevante de la calidad en salud y es un ámbito indispensable para la provisión de servicios sanitarios efectivos. El objetivo de este estudio es caracterizar la satisfacción de personas que reciben atención fonoaudiológica en organizaciones de salud familiar y comunitaria. Para ello se realizó un estudio mixto de tipo secuencial explicativo con una fase descriptiva de corte transversal que incluyó el cálculo de frecuencias, complementado con la aplicación de entrevistas semiestructuradas para la identificación de categorías de significado a partir de análisis de contenido. Los resultados respecto con la calidad de la atención percibida el 85% reportó haber sido atendido dentro de tiempos adecuados, un 98,3% informó ser tratado con dignidad y el 85% percibió un incremento en su calidad de vida. En cuanto a las organizaciones de salud el 28,3% reportó haber esperado más de 5 minutos por una atención y un 73,3% que sus sesiones se ejecutaron en periodos de 30 minutos. Desde la calidad técnica y seguridad del usuario un 88,3% comunicó que la atención fue de calidad e igual porcentaje informó que el trabajo en el equipo de salud fue coordinado. Se identificaron tres categorías de significado relacionadas con la escucha activa, la participación social y las adecuaciones socioculturales implementadas. Como conclusión cabe indicarse que existe una elevada satisfacción por parte de personas atendidas por fonoaudiólogos en centros de salud familiar y comunitaria. La descripción de la satisfacción retroalimenta el hacer fonoaudiológico e invita a consolidar acciones alineadas con las estrategias de salud familiar y comunitaria en el territorio.

Personality in Children With Vocal Fold Nodules: A Multitrait Analysis

Purpose Vocal fold nodules (VNs) are bilateral, symmetrical, callous-like lesions secondary to phonotrauma and possibly related to specific personality traits. This case-control study examined the relation between personality and VNs in children within the context of the Trait Theory of VNs. Method Parents of children with VNs (N = 39, M = 7.43, SD = 2.01 years) and two medical control groups (i.e., voice disordered controls, but not VNs [VDCs; N = 40, M = 7.09, SD = 2.01 years] and vocally normal controls [VNCs; N = 40, M = 7.6, SD = 1.54 years]) completed the Inventory of Child Individual Differences, a personality instrument that describes the Big Five superfactors as well as 15 lower order personality traits. Results Children with VNs, as compared with VNCs, were (a) emotionally reactive (i.e., higher N-Neuroticism, p < .005, Cohen's d = 0.53), (b) Antagonistic, Strong-Willed, and less Compliant (i.e., lower A-Agreeableness, p < .014, Cohen's d = 0.59), and (c) Distractible and Disorganized (i.e., lower C-Conscientiousness, p < .009, Cohen's d = 0.62). Both voice disordered groups displayed elevated scores on the personality superfactor of Neuroticism (N; and the "Negative Emotions" lower order trait). Conclusions The combination of personality traits identified in this study (i.e., high N, low A and C) may play a central role in VNs development and possibly attenuate voice therapy success. Children with VNs displayed a similar personality typology as women with VNs, with the exception of elevated Extraversion (E), thereby providing support for the relevance of the Trait Theory of VNs in both children and adults. Clinicians treating children with voice disorders, including VNs, should consider their underlying personality traits in assessment and management.

Evidence-Based Practice in Speech-Language Pathology: Where Are We Now?

Purpose In 2004, American Speech-Language-Hearing Association established its position statement on evidence-based practice (EBP). Since 2008, the Council on Academic Accreditation has required accredited graduate education programs in speech-language pathology to incorporate research methodology and EBP principles into their curricula and clinical practicums. Over the past 15 years, access to EBP resources and employer-led EBP training opportunities have increased. The purpose of this study is to provide an update of how increased exposure to EBP principles affects reported use of EBP and perceived barriers to providing EBP in clinical decision making. Method Three hundred seventeen speech-language pathologists completed an online questionnaire querying their perceptions about EBP, use of EBP in clinical practice, and perceived barriers to incorporating EBP. Participants' responses were analyzed using descriptive and inferential statistics. We used multiple linear regression to examine whether years of practice, degree, EBP exposure during graduate program and clinical fellowship (CF), EBP career training, and average barrier score predicted EBP use. Results Exposure to EBP in graduate school and during the CF, perception of barriers, and EBP career training significantly predicted the use of EBP in clinical practice. Speech-language pathologists identified the three major components of EBP: client preferences, external evidence, and clinical experience as the most frequently turned to sources of EBP. Inadequate time for research and workload/caseload size remain the most significant barriers to EBP implementation. Respondents who indicated time was a barrier were more likely to cite other barriers to implementing EBP. An increase in EBP career training was associated with a decrease in the perception of time as a barrier. Conclusions These findings suggest that explicit training in graduate school and during the CF lays a foundation for EBP principles that is shaped through continued learning opportunities. We documented positive attitudes toward EBP and consistent application of the three components of EBP in clinical practice. Nevertheless, long-standing barriers remain. We suggest that accessible, time-saving resources, a consistent process for posing and answering clinical questions, and on the job support and guidance from employers/organizations are essential to implementing clinical practices that are evidence based. The implications of our findings and suggestions for future research to bridge the research-to-practice gap are discussed.

Listener Perceptions of Women With Voice Disorders: Vocal Stereotyping and Negative Personality Attribution

PURPOSE

The purpose of the study was to determine if the age and amount of background knowledge of listeners affects perceptual judgments of women with voice disorders.

METHOD

Forty participants in three different age groups (children, young adults, and older adults) rated five female voice samples representing various types of dysphonia. One group of young adults had background knowledge of voice disorders based on a graduate-level course in Voice Disorders. A semantic differential scale was used to rate the speakers on 24 attributes.

RESULTS

Results indicated that age of listeners was not a significant factor, and that listeners' ratings depended on the specific type of dysphonia. No significant differences emerged between the perceptions of individuals with and without background knowledge of voice disorders.

DISCUSSION

This study agrees with the findings of similar research showing that listeners judge speakers with voice disorders more negatively than they do those with normal voices. This is so regardless of the age and background knowledge of the listener.