MY TOP RESOURCES

1. Access to the joint voice clinic

Laryngeal examination of dysphonic children is challenging and yet essential to rule out airway disease and to confirm the dynamics of voice production. I am fortunate to work in a dedicated Voice Clinic with an ENT Consultant who specialises in the medical and surgical management of childrens voices. We see five children per clinic, aged from three years old. Our joint opinion results in a coordinated diagnosis and management plan. Keeping the clinic list limited to only five children allows us to provide the necessary preparation time for successful examination. We aim to use a rigid laryngoscope, which provides excellent views of the larynx and tends to be tolerated well. This is linked to the LaryngoStrobe 2 System (Laryngograph Ltd). Some children will require flexible nasal fiberoptic laryngoscopy. Whilst the majority of speech and language therapists working with dysphonic children will not have immediate access to a Voice Clinic I would recommend that, whether they work in mainstream, special schools or community clinics, they identify the location of their nearest Voice Clinic and ascertain whether the team will accept paediatric cases.

3. Normative voice measures

I constantly need to refer to normative measures for pitch, maximum phonation time, s/z ratios, across the age groups and sexes. Relevant measures can be difficult to come by and will need to be considered against the childs growth measures if they are to be interpreted meaningfully. See reference list for useful texts.

7. Supervision and clinical support networks

Many of the dysphonic children I see have a history of prematurity and a significant population have a co-occurring diagnosis of speech and language delay, behaviour or attention difficulties, dysfluency, dyspraxia and so on. I have had to develop skills in screening for co-occurring speech and language and cognitive problems to ensure that my assessment of a childs voice is based on knowledge of the whole child. I regularly call on the skills of team members to assist in complex assessments and / or seek their advice through supervision systems. Speech and language therapists working with a child at a primary care level are also an invaluable source of support and information. By working collaboratively and sharing assessment findings we can arrive at a robust diagnosis and realistic treatment plan.

Lesley Cavalli works as a member of the speech and language therapy team at Great Ormond Street Hospital in London She specialises in the assessment and management of voice disorders in children and adolescents as well as head and neck surgery Children attend Great Ormond Street for second opinions and for management of both common and more unusual voice problems Lesley also lectures in voice at University College London

4. Voice therapy concept cards

Voice can be quite an abstract concept, particularly for young children. Children can find it hard to tune in to their own sensory feedback systems and thus master control of a specific aspect of their voice. I have found using paired pictorial concept cue cards very useful in developing childrens awareness and control of a specific vocal parameter or skill such as soft onset phonation vs hard glottal attack or loud vs quiet voice. Drawing is not my forte and I have thus tended to develop my set of contrastive picture concept cards for voice therapy from systems marketed at phonology like Metaphon.

8. Developmentally appropriate toys and reward systems

My toy cupboard is finely tuned! Favourite toys for eliciting a voice sample from the younger children include dolls and a tea set, cars and miniature farm and zoo animals. Older children respond well to being involved in the interview process and those that are more easily distracted tend to enjoy drawing. Toys for blowing such as bubbles and whistles are really helpful for looking at breathing and for developing breath control in children post airway reconstruction. Reward systems tend to be basic. Children love choosing stickers at the end of a session and marble runs and posting boxes are effective in building voice therapy skills through structured behavioural reward systems. Time spent researching voice on the internet or working through a simple project on voice can be fun and educational for older children.

5. Vocal Profile Analysis Training

I have found the Vocal Profile Analysis Scheme (Laver et al, 1988), the most comprehensive perceptual assessment tool to use with childrens voice, despite the fact that the training and the assessment form are based on analysis of post pubertal voices. The system considers voice as a product of the entire vocal tract and is really helpful in treatment planning. I dont use the entire form with every child as appointment scheduling does not allow this and neither is it necessary unless we are collecting research data. I have had to modify it a little to include some more unusual voice characteristics that we see as a bi-product of airway reconstruction, for example ventricular band voice or other supraglottic type voices.

2. Instrumental voice analysis systems

Many of the children I see have very disordered voices. Identifying the affected components of the voice (pitch, quality and so on) using perceptual skills alone is tricky. A good tape recorder is essential. I use a Digital Audio Tape (DAT) recorder for collecting voice samples as this maintains a good recording frequency range and allows for dual channel data collection. I use the electrolaryngograph (Fourcin, 1986) with the majority of my patients, mainly as an assessment tool, for confirming measures such as fundamental frequency, but also as a biofeedback tool, for example when working to reestablish voice with children with psychogenic voice loss. The Speechviewer programmes can also be very helpful in providing the necessary encouragement to very young children to provide any voice sample at all! Some of the children I see may also need assessment of their nasal airflow, for example with nasometry. Video recording can also be helpful for raising childrens awareness of their posture and for skills training with the electrolarynx and so on.

9. A quiet clinical room

This can be difficult to come by with all the building works going on around us at the moment, but is essential to obtaining good recordings for reliable perceptual analysis.

6. Access to the internet and library resources

I try to keep up-to-date with new books and relevant papers as they come up. I find the libraries at University College London and the Institute of Child Health very helpful in refining searches on particular topics. When more unusual cases are referred I try and prioritise the time to search the internet for an article that might guide my management. I would access a system such as KA24 (a round the clock service for local NHS employees) to assist my search. I usually find the time to read articles on the bus to and from work. The speech and language therapy students who work with me on research projects and clinical placements frequently direct me to new information and keep me on my toes!

10. Augmentative communication systems

Children who have no voice or a severely disordered voice may be at risk of developmental speech and language delay as well as communicative frustration. It is important to consider mechanisms that will assist their communication and its development. Very young children may need to develop skills in a signing system such as Makaton. Many children with tracheostomies are now routinely fitted with speaking valves. Older children may need to learn to use an electrolarynx and children with pathologically quiet voices may benefit from a voice amplification system. Many voice aids have been developed for adults and their use with children will require careful consideration. Individual assessment is always required to ensure that an aid can be used successfully by the specific child. Supply companies such as Kapitex Healthcare are usually very helpful in attending assessment sessions with the child and their family before a product is purchased. References are listed on p28.

Detail from Edmund Caswells Peter Pan mural at Great Ormond Street Hospital. Reproduced by kind permission of Henny King.

how I

ment including a home-made metronome. The excitement of the arrival of the Reynell Developmental Language Scales, a revolution at the time. Morag says that, The older you get, the more important your past becomes. This is as true for the profession as it is for us as individuals. By recording what we are doing, and sharing our experience, we pay due respect to the pioneers and pave the way for the speech and language therapists of the future. Sometimes, even now, members of our profession are pioneers. Sarah Glenwright has been setting up a speech and language therapy service in mental health. She says that, for a new service, you need at least a month in post with no therapy appointments. You need to find out from other people what services already exist, and how speech and language therapy might fit in, although people are not always clear on this. She suggests shadowing therapists in other areas who are working with a similar client group, and considering a job share arrangement for this kind of development rather than a single person. A specific interest group can also provide much needed support and guidance. In Sarahs case, the mental health SIG is looking at organising a buddy system, and putting together a pack which will cover funding, references and clinical issues. Sarah has had to be very focused as it would have been impossible to do everything at once. Now that her service is up and running, she wants to consider research into what it is that speech and language therapists do that is different from other members of the team. She also wants to look into quality of life outcome measures which will show where we have been able to be effective. As an example, she quotes a 76 year old lady with memory and word finding problems who, following her involvement, has the same problems but is no longer avoiding situations such as going to the hairdresser and using the phone. Sometimes, whatever we try, we feel frustrated and unhappy, and unable to see a way through with particular clients. One of Jo Borrellis clients would say, I want to do _____, and do it now, and this isnt helping me. She found they were both battling to set aims and to be in charge. The solution was transactional analysis, a counselling technique which has concepts consistent with the rehabilitation concepts of progression from dependence to independence. My Top Resources (back page): references
1. Access to the joint voice clinic Laryngograph Ltd, tel 020 7387 7793, www.lx@laryngograph.com 2. Instrumental voice analysis systems Fourcin, A. (1986) Electrolaryngographic assessment of vocal fold function. Journal of Phonetics 14: 435-442. Laryngograph Ltd, tel 020 7387 7793, www.lx@laryngograph.com Speechviewer from PAS UK Ltd, tel 01635 247724.

Sometimes we dont know what a client is capable of because we lack appropriate assessments, training and multidisciplinary teams. Selena Mathie praised the Sensory Modality Assessment and Rehabilitation Technique (SMART) as a consistent and in-depth tool for establishing whether or not a client is in a persistent vegetative state. Her use of television material featuring a young woman was a poignant reminder not to make assumptions based on single visits, assessments or reports. It also showed clearly the tremendous value of music therapy, as music can reach someone in the way other communication cannot.

Passion and determination

Sometimes the difference between success and failure is down to our own passion and determination. This was the case for Mary Greetham & Rachel Baker when they successfully introduced the Picture Exchange Communication System (PECS) to secondary school aged children. Their service delivery model can be applied to any system not just PECS. The speech and language therapists initiated the idea with the head teacher, who arranged the first meeting with staff. Therapists showed the PECS video and related it to children in the school. Targets were set for staff, including having a PECS coordinator in the school, and at the second meeting staff identified four children aged from 14-18 years. The therapists sent a letter to the head and the class teachers giving the times of nine sessions over six weeks with named therapists, the need for a member of staff from the class, the room size and a questionnaire regarding motivators for that child. Staff took on board the need to make resources and symbols for their own classes, and the school have ordered PECS resources. Sometimes a client group is significant, but thin on the ground, and therapists with specialist knowledge even more so, particularly in rural or less heavily populated areas. The North East Regional Dysfluency SIG (known as NERDS) provides support for therapists at any level of experience who are working with people who stammer. They meet every two months, with the focus rotated between paediatric, adult and joint issues. This SIG grew out of a recognition that ongoing support was needed and that, while specialist skills are not available in every trust, access to such support is essential. So far, the SIG has developed a telephone support network and a fluency continuing professional

development module run by specialists which aims to build a portfolio of skills and emphasises practical activities. Eight areas across the north east of England are involved. In future, the SIG is planning to get accreditation for the module, to develop modules for older children and adults, and to run cross-district groups for people who stammer. Sometimes we have an idea but we cant do it on our own. Karen Dixon, Barbara Storey & Colin Sawyer (a speech and language therapist, artist and computer programmer) have developed a multimedia resource which they hope will be the first of many. My own kids and their friends are computer junkies used to games which involve television characters and sell in their thousands. They have tried out Listening and Rhyming and really enjoyed it, both on-screen and in printed-out worksheets. There was a relaxed, informal, supportive atmosphere at this conference, with speakers given time to explore their topic and the audience given time to ask questions about subjects of interest. This was best in the adult-orientated session I attended, where there were smaller numbers of delegates. Poster presentations added to knowledge of the area and the services it is developing, and exhibitors gave delegates hands-on time with their products. Sometimes a conference really works.

Resources
Leaps and Bounds Multimedia Ltd: Phonological Awareness Series Disc 1: Listening and Rhyming is available for 45 tel. 0191 413 1818, e-mail gill.blissett@btopenworld.com. Disc 2: Syllabification will be available in Summer 2004. PECS (including courses): Pyramid Educational Consultants UK Ltd, Pavilion House, 6 Old Steine, Brighton BN1 1EJ, tel 01273 609555, www.pecs.org.uk. Reynell Developmental Language Scales: Now on their third version, completely revised by Susan Edwards, Paul Fletcher, Michael Garman, Arthur Hughes, Carolyn Letts & Indra Sinka, from NFER-Nelson, 451.75, see www.nfer-nelson.co.uk. SMART: Sensory Modality and Rehabilitation Technique by Gill-Thwaites (1997). Details from Royal Hospital for Neurodisability, London, tel. 020 8780 4568. Transactional Analysis: Eric Bernes Games People Play (1970), published by Penguin ISBN 0140027688.
5. Vocal Profile Analysis Training Laver, J., Wirz, S., Mackenzie-Beck, J. & Hiller, S. (1988) Vocal Profiles of Speech Disorders. Research Project. Phonetics Laboratory, Dept of Linguistics, University of Edinburgh. 6. Access to the internet and library resources KA24: http://stlis.thenhs.com/hln/ka24/ UCL library: http://library.hcs.ucl.ac.uk/ ICH library: http://www.ich.ucl.ac.uk/library/ 10. Augmentative communication systems www.makaton.org Kapitex Healthcare Ltd, tel 01937 580211, www.kapitex.com

Kay Elemetrics (1986) Nasometer manual, Kay Elemetrics Corp. USA. 3. Normative voice measures Aronson, A.E. (1990) Clinical voice disorders: an interdisciplinary approach (3rd Ed) New York: Thieme. Baken, R.J. (1996) Clinical Measurement of Speech and Voice. Singular Publishing. Wilson, D. (1987) Voice problems of children. (3rd ed) Baltimore: Williams and Wilkins. Mathieson, L. (2001) (6th Edition) Greene and Mathiesons The Voice

and its Disorders. Whurr. Andrews, M. (1986) Voice Therapy for Children. San Diego: Singular Publishing. Andrews, M. (1995) Manual of Voice Treatment: Paediatrics through Geriatrics. San Diego: Singular. 4. Voice therapy concept cards Dean, E.C., Howell, J., Waters, D. & Reid, J. (1995) Metaphon: A metalinguistic approach to the treatment of phonological disorder in children. Clinical Linguistics and Phonetics 9 (1). (This forms part of a clinical forum on Metaphon, pages 1-58.)

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004