Cognitive Mechanisms in Pediatric Voice Therapy - An Initial Examination

INTRODUCTION

Voice disorders are a common communication disorder in children. Behavioral voice therapy is recommended by both Otolaryngologists and Speech-Language Pathologists as a first-line approach for treatment of benign vocal fold lesions that affect children in large numbers. However, the role of cognitive mechanisms critical to voice therapy have not yet been explored.

OBJECTIVE

This proof-of-concept study aims to provide preliminary data on the potential relation between cognitive abilities and behavioral results of voice therapy for children with benign phonotraumatic vocal fold lesions.

METHODS

Six children (4;05 -9;02 years) diagnosed with vocal fold nodules completed a battery of cognitive tests from the NEuroPSYchological (NEPSY-II) Assessment and a standard course of "Adventures in Voice" therapy. Recordings pre and post intervention were analyzed acoustically using the Cepstral Spectral Index of Dysphonia (CSID) and perceptually using visual analog scales (VAS) for severity and resonance separately. Raw and age-corrected scaled scores from the NEPSY-II were then examined for their possible relation to voice outcomes.

RESULTS

Multiple cognitive functions correlated with voice outcomes. Raw score measures for Design Fluency, Inhibition, Fingertip Tapping, and Narrative Memory correlated favorably with all voice outcome measures. Age correlated with all NEPSY-II raw scores and perceptual voice outcome measures. Scaled scores for Auditory Attention, Design Fluency, Fingertip Tapping (Dominant hand), and Narrative Memory correlated with all voice outcome measures.

CONCLUSION

Results suggest that there is merit to further investigation of the relation between cognitive skills and their development and voice treatment outcomes in children with benign phonotraumatic lesions. Future studies with larger samples will build on present findings.

Comparative Analysis of Two Methods of Perceptual Voice Assessment

OBJECTIVES

The primary aim was to compare two methods for perceptual evaluation of voice - paired comparison (PC) and visual analog scale (VAS) ratings. Secondary aims were to assess the correspondence between two dimensions of voice- overall severity of voice quality and resonant voice, and to investigate the influence of rater experience on perceptual rating scores and rating confidence scores.

STUDY DESIGN

Experimental design.

METHODS

Voice samples from six children (pre and post therapy) were rated by 15 Speech-Language Pathologists specialized in voice. Raters completed four tasks corresponding to the two rating methods and voice qualities: PC-severity, PC-resonance, VAS-severity, and VAS-resonance. For PC tasks, raters chose the better of two voice samples (better voice quality or better resonance, depending on the task) and indicated the degree of confidence in each choice. Rating and confidence score were combined to produce a number on a 1-10 scale (PC-confidence adjusted). VAS ratings involved rating voices on a scale for degree of severity and resonance, respectively.

RESULTS

PC-confidence adjusted and VAS ratings were moderately correlated for overall severity and also vocal resonance. VAS ratings were normally distributed and had greater rater consistency than PC-confidence adjusted ratings. VAS scores reliably predicted binary PC choices (choice of voice sample only). Overall severity and vocal resonance were weakly correlated and rater experience was not linearly related to rating scores or confidence.

CONCLUSIONS

Results suggest that the VAS rating method holds advantages over PC, including normally distributed ratings, superior consistency of ratings, and the ability to provide more finely grained detail regarding the auditory perception of voice. Overall severity and vocal resonance were not redundant in the current data set, suggesting that resonant voice and overall severity are not isomorphic. Finally, the number of years of clinical experience was not linearly related to perceptual ratings or rating confidence.

Investigating the cepstral acoustic characteristics of voice in healthy children

OBJECTIVES

This study aimed to determine the cepstral acoustic parameters that vary depending on age and gender in vocally healthy children, and to establish normative data for cepstral analysis.

BACKGROUND

Cepstral measurements are among the strongest predictors of auditory-perceptual evaluation of voice and differentiate between healthy and dysphonic voices. More spesificially, ceptral peak prominence is accepted to be as a strong acoustic predictor of breathiness and overall severity of dysphonia. Cepstral measures determine voice quality reliably not only in sustained vowel samples but also in running speech samples. Determining the parameters related to the acoustic profile of children with normal voices can lead us to a better understanding of the effect of changes in the larynx and vocal fold structure during growth and development. There is a limited number of norm studies examining the cepstral acoustic properties of pediatric voice. Determining norm-specific values and clinical guidelines of cepstral acoustics according to the age and gender in vocally healthy children are utmost important.

METHODS

A total of 160 vocally healthy children were divided into the following four age groups: Group-I included children within the age range of 4-7 years, Group-II included 7-11 years, Group-III 11-14 years, and Group-IV included children within the age range of 14-18 years. An equal number of male and female participants were assigned to each group. PENTAX Medical CSL Model 4500 was used for recording all tasks. For acoustic analysis, Multi-Dimensional Voice Program and Analysis of Dysphonia in Speech and Voice were used.

RESULTS

Cepstral Peak Prominence (CPP), Cepstral Peak Prominence Standard Deviation (CPP SD), and Low-To-High Spectral Ratio (L/H Ratio) increased with age. It is found that the CPP parameter of all-voiced sentences and nasal-weighted sentences increased with age in boys, while no significant pattern was observed in any sample for girls. For L/H ratio, it can be said that there is a general increase with age in all speech samples, except for the vowel-weighted and voiceless plosive sentence samples, evident especially in the group above the age of 15 years. This study concluded that the CPP SD parameter in the vowel-weighted sentences increased with age in boys. It was also noticed in this study that CPP F0 standard deviation (SD) intervals were narrower in vowel-weighted, easy onset, and voiceless plosive sentence samples than in all-voiced, hard glottal attack and nasal-weighted sentence samples.

CONCLUSION

This study established cepstral acoustic normative values for a wide age range of the pediatric population. It is thought that age and gender specific cepstral acoustic findings presented in this study contributed to the related literature. In addition, to our knowledge, this is the first study that provides a normative cepstral acoustic database of the CAPE-V/Turkish sentences in the pediatric population.

The Effect of Parental Smoking on Voice-Related Quality of Life in the Pediatric Population

OBJECTIVES

Exposure to cigarette smoke has significant effects on the respiratory mucosa. However, little is known about the effects of household smoke exposure on children's voice-related quality of life. The aim of this study was to elucidate the effect of parental smoking (PS) on voice-related quality of life in the pediatric population.

SUBJECTS AND METHODS

The Pediatric Voice-related Quality of Life (PVRQoL) instrument was administered to the parents of 104 healthy children without any known voice disorder. The children were evaluated in two groups. The first group of children had no PS history and no household smoke exposure (non-PS group), in the second group, at least one parent of the child consumed tobacco products in the house (PS group). Social emotional and physical functional subdomains of the PVRQoL were also calculated.

RESULTS

A total of 104 surveys were analyzed. The overall percentage of dysphonia in the PS group was 23.6%, whereas it was 6.1% in the non-PS group. The mean PVRQoL scores were 89.1 (±13.8) in the PS group and 97.7 (±4.7) in the non-PS group (P < 0.001). The mean physical functional-PVRQoL score was 35.4 (±7.2) in the PS group and 39.0 (±6.0) in the non-PS group. The mean social emotional-PVRQoL scores were 51.2 (±9.3) in the PS group and 57.2 (±5.6) in the non-PS group. The overall voice quality was significantly lower in the PS group than in the non-PS group.

CONCLUSION

Exposure to PS has negative effects on voice-related quality of life in children that cannot be underestimated. Parents should be informed about the detrimental effects of passive smoking on the voice quality of their children. Inclusion of items in pediatric voice surveys about PS that lead to dysphonia would be suggested.

One-Year Follow-Up of a Vocal Hygiene Program for School-Age Children

OBJECTIVE

This study investigated the effects of a school-based vocal hygiene education program "Green Voice for School" on promoting knowledge of healthy voice use for primary school students.

METHODS

Thirty-nine grade 4 and 5 students from local primary schools participated in the "Green Voice for School" program. Students received 6 weekly vocal hygiene training sessions with the aim of enhancing their voice care knowledge. Their voice care knowledge was assessed by a 15-item questionnaire. Students' voice care knowledge was examined before training, immediately after, and 1 year after completion of the program.

RESULTS

Students showed significant improvements in their voice care knowledge immediately after they received the vocal hygiene training sessions. Such improvements were maintained 1 year after the students completed training.

CONCLUSIONS

The results suggest that "Green Voice for School", a school-based vocal hygiene education program, can be effective in promoting long-term improvements of voice care knowledge in school-age children.

The Effects of Age and Gender on Laryngeal Aerodynamics in the Children Population

OBJECTIVES

Normal voice can be differentiated from dysphonic voices by comparing their characteristics using an established normative database. Pediatric normative data using the Phonatory Aerodynamic System (PAS) have been established in a preliminary study for English-speaking children. However, aerodynamic measures, including physical characteristics varying by geographic region, race, and culture, must be investigated between children with different native languages. Aerodynamic analysis of connected speech requires the collection of language-specific samples and the establishment of language-specific norms. Thus, the main purpose of the present study was to establish pediatric normative data using the PAS for a large pediatric population of healthy Turkish-speaking children of 4-17.11 years of age. Another research aim was to determine age-dependent and/or gender-dependent aerodynamic parameters for this pediatric population.

METHODS

In total, 120 children were divided into four age groups: Group I, 4-5.11 years; Group II, 6-9.11 years; Group III, 10-13.11 years; and Group IV, 14-17.11 years. An equal number of male and female participants were assigned to each group. The PENTAX Medical PAS Model 6600 was used. Descriptive statistics for 56 parameters across six protocols were expressed as mean, standard deviation, and range values. Each protocol was analyzed for age, gender, and age-gender interaction.

RESULTS

Age was the most predominant factor, affecting 37 of the 56 aerodynamic parameters investigated. Gender and age-gender factors were observed at an equal frequency, each affecting 16 parameters. Pitch-related parameters were the most altered parameters in each protocol. Age-gender interaction was observed in parameters related to the expiratory airflow.

CONCLUSIONS

This study established the normative values of phonatoary aerodynamics for a large pediatric population with a wide age range and developed a normative database for healthy Turkish-speaking children. This is the first study to investigate running speech protocol in aerodynamic assessment.

Speaking Voice in Children and Adolescents: Normative Data and Associations with BMI, Tanner Stage, and Singing Activity

OBJECTIVES

The aim of this study was to establish normative data concerning the speaking voice of children and adolescents for clinical diagnostics.

STUDY DESIGN

Population-based mixed cross-sectional and longitudinal childhood cohort study.

METHODS

Normative data measuring the speaking voice profile of 1352 male and 1274 female participants aged 6 to 17 years were collected. To evaluate the voice range, five different intensity levels as the quietest voicing speaking voice (Level I), conversational voice (Level II), classroom voice (Level III), shouting voice (Level IV), and again the quietest speaking voice (Level V) were investigated. Multivariable analyses were performed to describe the effects of body mass index, Tanner stage, and singing activity on the outcome variables.

RESULTS

A clear distinction in frequencies and sound pressure levels between the five different voice levels can be found in both genders. In females the mean fundamental frequency of the conversational voice lowers from 223.3 to 205.8 Hz. In male participants it lowers from 223.3 to 102.3 Hz. The most substantial decrease in the fundamental frequency of the speaking voice in boys occurs at 13.5 years. Girls show an almost continuous decline in their fundamental frequency. Only the Tanner stage showed significant positive relationships with the grade of lowering of the fundamental frequency in both sexes.

CONCLUSIONS

It was shown that the investigation of the speaking voice using predefined intensity-levels represents a feasible examination for children and adolescents. This study provides reference data on the range and age-adjusted normative values of the speaking voice.

Speech task effects on acoustic measure of fundamental frequency in Cantonese-speaking children

OBJECTIVES

Speaking fundamental frequency (F0) is a voice measure frequently used to document changes in vocal performance over time. Knowing the intra-subject variability of speaking F0 has implications on its clinical usefulness. The present study examined the speaking F0 elicited from three speech tasks in Cantonese-speaking children. The study also compared the variability of speaking F0 elicited from different speech tasks.

METHODS

Fifty-six vocally healthy Cantonese-speaking children (31 boys and 25 girls) aged between 7.0 and 10.11 years participated. For each child, speaking F0 was elicited using speech tasks at three linguistic levels (sustained vowel /a/ prolongation, reading aloud a sentence and passage). Two types of variability, within-session (trial-to-trial) and across-session (test-retest) variability, were compared across speech tasks.

RESULTS AND CONCLUSIONS

Significant differences in mean speaking F0 values were found between speech tasks. Mean speaking F0 value elicited from sustained vowel phonations was significantly higher than those elicited from the connected speech tasks. The variability of speaking F0 was higher in sustained vowel prolongation than that in connected speech.

Parent and Child Responses to the Pediatric Voice-Related Quality-of-Life Questionnaire

OBJECTIVES

When assessing pediatric dysphonia, there are different approaches that can be taken in gathering a subjective view of the impact voice difficulties have on a child. Most valid questionnaires require parent-proxy reporting, although it has become increasingly important to gather the views of children themselves. This study reports a pilot study of an adaptation to the Pediatric Voice-Related Quality-of-Life Questionnaire (PVRQoL).

METHODS

A total of 24 parent and child dyads were recruited from a tertiary pediatric voice clinic. Children were aged between 3 years and 8 months and 15 years and 3 months. Parents completed the existing PVRQoL questionnaire, whereas their children were given a child-adapted version. Follow-up completion of the child questionnaire was conducted after a 2-week period.

RESULTS

There was a good correlation between the two time periods when children completed the adapted PVRQoL and also between parent and child responses. Of particular interest, however, was the different ratings on individual items by parents and their children with parents tending to overestimate the extent to which their children may be emotionally affected by their voice disorder.

CONCLUSIONS

This study shows that children have much to tell about their own voice-related quality of life, so our conclusion is that they should also be self-assessed. The PVRQoL when adapted for use with children offers an additional insight that can be gathered in a relatively short timeframe and be considered with other assessments of vocal function.

Measurement of glottal cycle characteristics between children and adults: physiological variations

OBJECTIVES

The aim of this study was to quantify phases of the vibratory cycle using measurements of glottal cycle quotients and glottal cycle derivatives, in typically developing prepubertal children and young adults with the use of high-speed digital imaging (HSDI).

METHODS

Vocal fold vibrations were recorded from 27 children (age range 5-9 years) and 35 adults (age range 21-45 years), with HSDI at 4000 frames per second for sustained phonation. Glottal area waveform measures of Open Quotient, Closing Quotient, Speed Index (SI), Rate Quotient, and Asymmetry Quotient (AsyQ) were computed. Glottal cycle derivatives of Amplitude Quotient (AQ) and Maximum Area Declination Rate (MADR) were also computed. Group differences (adult females, adult males, and children) were statistically investigated for mean and standard deviation values of the glottal cycle quotients and glottal cycle derivatives.

RESULTS

Children exhibited higher values of SI and AsyQ and lower values of MADR compared with adult males. Children exhibited the highest mean value and lowest variability in AQ compared with adult males and females. Adult males showed lower values of SI, AsyQ, AQ, and higher values of MADR compared with adult females.

CONCLUSIONS

Glottal cycle vibratory motion in children is functionally different compared with adult males and females, suggesting the need for development of children specific norms for both normal and disordered voice qualities.