EPISODE 87

[INTRODUCTION]

[0:00:05] MBH: Thanks for joining us at Keys for SLPs, opening new doors for speech-language pathologists to better serve clients throughout the lifespan. A weekly audio course and podcast from speechtherapypd.com. I'm your host, Mary Beth Hines, a curious SLP who embraces lifelong learning.

Keys for SLPs brings you experts in the field of speech-language pathology, as well as collaborative professionals, patients, and caregivers to discuss therapy strategies, research, challenges, triumphs, and career opportunities. Engage with a range of practitioners from young innovators to pioneers in the field as we discuss a variety of topics to help the inspired clinician thrive.

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[EPISODE]

[0:01:24] MBH: Welcome to this episode of Keys for SLPs, Keys to Taking the Fear Out of Voice Therapy. I am Mary Beth Hines. Before we get started, we have a few items to mention. Here are the financial and non-financial disclosures. I am the host of Keys for SLPs and receive compensation from speechtherapypd.com. Louise Pinkerton receives a salary from the University of Iowa. She is the owner of Louise Pinkerton Voice Services. Louise receives an honorarium from speechtherapypd.com for her podcast appearance.

Here are our learning objectives for today. Describe limiting factors that result in SLPs being reluctant to provide voice therapy. Two, identify steps to take prior to referring a person to a voice specialist, or ENT. Three, explain the importance of identifying and treating voice disorders in the school.

Now, we welcome our guest today, Louise Pinkerton, MM, MA, CCC-SLP. Louise is a clinical singing voice specialist, a clinical assistant professor coordinating voice services at the University of Iowa Student Clinic, and a speech-language pathologist for the LGBTQ clinic at University of Iowa Hospitals and Clinics. She provides voice and upper airway services across the lifespan, rehabilitation for professional voice users, and gender-affirming training.

Her professional and research interests include voice perception and training perceptual skills, culturally sensitive practice, graduate student supervision, and group voice therapy and training. Louise earned a master's degree in speech-language pathology from the University of Iowa and voice performance degrees from Indiana University and the University of North Dakota. Louise has a certificate in Vocology from the University of Utah and the National Center for Voice and Speech. She has presented at several voice conferences and received numerous singing awards. She is a soprano with professional opera and musical theater experience and training vocal pedagogy for classical and contemporary commercial music.

For 20 years, Louise taught singing privately at the University of North Dakota and Minnesota State University Moorhead. Louise, we are so happy to have you here on Keys for SLPs to talk about taking the fear out of voice therapy.

[0:03:58] LP: Thank you, Mary Beth. I'm so excited to be here to talk to you. I think voice is so exciting and I wish everyone was excited about it.

[0:04:05] MBH: Will you tell us about yourself and your journey as an SLP that led you to have a specialty in voice?

[0:04:12] LP: Well, you got a lot of the highlights in my bio. Obviously, I have a big background in voice coming from the vocal performance world, or the voice teaching world. I had actually done that and done the teaching until, when was it? 2012 is when I started my journey to be an SLP. I just got to a point career-wise where I wanted something different. I looked at lots of different options and went, ÒOh, speech pathology sounds really cool and I can still do voice stuff.Ó I did post back and then I came here to Iowa and did my masters. Then I was working at a health system where I did actually acute rehab and outpatient services and served as a regional person doing voice, voice treatment, and providing that specialty to the area.

Then I had the opportunity to come do supervision at Iowa and be able to specifically be teaching people how to do voice. That really lines up with what I want because I think voice is something that so many people are concerned about, or are like, ÒThat's not my thing. I'm never ever going to do that.Ó I think if you're an SLP, you're probably capable of doing this. You just might need to learn some more things and get experience.

[0:05:32] MBH: Well, and I'm so happy that we're talking about that today because you really have outlined it well. You've had such an interesting career. A little plug for our next podcast here. Louise is going to join us for another podcast about career and career changes, and she'll take us through some of her decision-making process in that episode. Just wanted to plug that in. All right. Tell us what you mean exactly about when you say, taking the fear out of voice therapy.

[0:06:05] LP: Yeah. I draw this from particularly working with my graduate students, because they work with me for a one-semester rotation. Sometimes it's even their first semester in graduate school. A lot of people are very reticent, or concerned, or worried, or we're in the third week right now and I had somebody tell me, ÒI'm still feeling lost.Ó The truth is, in your third week of voice therapy, yup, you're probably still feeling lost. It's an area of therapy that we can't just read the book and apply it. We can't just read an article and do it. You have to have a whole other set of skills related to listening and related to demonstrating and really be thinking about the anatomy and physiology and what's going on.

For most SLPs, that's going to be different. I can go read up on script training for aphasia and then I can probably implement it pretty quickly. If you don't do voice therapy and you go read an article on semi-occluded vocal tract exercises, you might be done with it and go, ÒWhat?Ó Because you need to hear it. You need to see it. You need to try it. It requires an extra skill set. It's complex thinking for diagnostics. 

Also, most SLPs have really limited training in this. There are people working today that may never have been required to take a voice disorders class. For a lot of people, that voice disorders class in grad school was the only experience they had with voice. They may have never treated a client. They may have never had the opportunity through their work, because it is a low-incidence disorder. Very, very important to the people it affects. But I can't remember if it's incidents or prevalence, but it's about 6%. That's not very high.

[0:08:00] MBH: No, it's not. Also, a lot of people, even if they did take a voice course and a voice disorders course in graduate school, or even undergrad, if they don't use it, it's the thing if you don't use it, you lose it, because it is so hands-on.

[0:08:18] LP: Absolutely. Absolutely. I know there are things from voice teaching that I've completely forgotten, because I just haven't done it as much since then.

[0:08:29] MBH: Then also, it's complex physiologically and acoustically.

[0:08:34] LP: Oh, absolutely. Part of what we're doing in a lot of voice therapy is helping people manage to change registers, which is having the thyroid cartilage move correctly. You need to be thinking about that. At what point does it make sense for that transition to happen and can you hear it and can you recognize it? Then acoustically, I think particularly, when you get into working with the singers and performers, what Ð is the output producing what they need? What do you know acoustically about how we make vowels in the high range, that you're going to need to think about and adjust with that client? Again, it's just another level. Because vowels, formants actually stop existing before the sopranos are done.

[0:09:22] MBH: So much for me to learn about it. Okay. Now that we know what holds people back, what can SLPs do about overcoming this fear? When we say SLPs, we're not talking about a voice specialist. We're talking about SLPs who are generalists, or who might specialize, but then they have some voice clients come along their caseload and they really want to focus on that. Or, let's say, and we're going to get into it a little bit more at the end, I know. Let's say, they're school-based SLPs and they really don't see voice clients that frequently.

[0:10:00] LP: Yeah. I think one of the first things is just to acknowledge it's possible. This is something I could do, or I could learn to do. I also think people sometimes get stuck on that, but I don't know what musical notes are. It's wonderful now, because there are apps that will label the keys of the piano by letters and numbers. Really then, you're just pressing buttons. There are ways to work around that. Say, this is possible, this is something I could do.

What I recommend then is look at your current practice and see where you run into voice. Because voice disorders, yes, they can happen isolated, but there are other disorders that have a voice component. I mean, think about dysarthria. Dysarthria, some of the defining factors are a strained voice or a weak voice. That vocal function is part of it. Actually, in treating the dysarthria, you're treating the voice as well. That can be a great place to start listening, to start observing, to start seeing, okay, I'm using this dysarthria strategy and I've improved the voice quality. What might be the relationship there?

I also find that there are some programmatic voice programs, or systems Speak Out! and LSVT LOUD are two of them. I should say, I'm actually certified in both. We left that off the disclosures. They are very regimented and will teach you everything you need to know to do it. Then you do the same thing every time. Your clients will be different enough to vary it there. That can be a really great way to get experience. Just build your ear, build your modeling with that structure and support.

Then, I'd also say, the next thing is I mentioned listening a couple times. It's starting to build your listening skills or your critical listening. Just pay attention to the people around you. Is there anybody whose voice makes you wonder? Or I think of it as for me, a red flag goes up. ÒOh, I wonder what's happening here.Ó One of my professors had what he called the ped mall rule. We have a pedestrian mall here in Iowa City. He said, if a voice would catch his attention when he was just there being social at the ped mall, then that was his baseline for it being a disorder. It would actually get his attention. Then he applied that idea in the voice clinic when evaluating people. Because you can also be too critical. That was my problem in the beginning. I'm like, ÒThat voice isn't perfect. We should do something about it.Ó

[0:12:47] MBH: Well, and of course, you came from a background where voice perfection was the goal.

[0:12:52] LP: Yeah. If you can start to get an idea of what's normal, or what's typical, or what's expected, then you're in a better place to notice what is not. Most of us in the beginning, will rate voice disorders much more severe than they are till we build up that knowledge. Still, if you can go typical, not typical. That's a really great place to be. Note, I'm not using a lot of jargon right now. I think voice in particular in speech-language pathology has tons of jargon. It has tons of technical and anatomical terms.

Then if you get into singing and acting, you have all sorts of different aspects from those fields that have infused it. I could talk about it and make absolutely no sense to someone who doesn't know the area. That is really hard to come into that world.

[0:13:44] MBH: That puts the fear in it. Oh, you're going to say the wrong word. You're going to use the wrong jargon. Oh, you're not going to sound knowledgeable.

[0:13:50] LP: Or, someone's going to say something to me and I won't know what they mean, so I won't know how to respond. Yeah. I was actually at a webinar last night about voice registers. We were talking about that whole thing that we have three, or four, probably two more different sets of terminology to describe how the voice transitions. They're all valid but for different reasons. Yeah, it can be hard. It can be really hard to wade your way through that. Or be like, well, I don't remember all my anatomy and I've got to wade through this medical terminology.

I think in the beginning, build your ear, build your awareness, build your modeling. You can then start attaching those terms to things you've become familiar with. That's a lot easier to go, ÒOh, chest voice is the sound I make when I'm doing this,Ó because you have a reference.

[0:14:46] MBH: Really understanding what is typical and then acknowledging when you hear a difference. If you have that Ð let's say, you're a school-based SLP. At the very minimum, what is it that you want to document?

[0:15:03] LP: Well, I think the first thing is that this voice doesn't sound like a student's peers. Same for adult. Is somebody different than their peer group? In the schools, we know that's one of the factors for being able to get care is that it doesn't match. It doesn't fit what we would expect. We'll talk later about some of the implications for kids in the schools related to voice. But that's the first thing. If you were to walk in a normal fourth-grade classroom, this is not what I would expect to hear. Documenting that there's a difference.

You don't need technical terms to document there's a difference. What do you hear? We as a society don't train people to listen. We have tons of color words. We don't have a lot of sound words. Does it seem like they're working really hard? Is it too soft? Does it sound breathy? Even some of those are actually technical. It's just, what do you hear? We also want to know like, how long it's been happening. Sometimes voice problems come from an instigating event. There was an event that happened and then the disorder follows. Sometimes it's really gradual. Those would be important things for the ENT to know when they're trying to make a diagnosis.

Another thing that's really important is, is it all the time? Is this happening all the time when the child's in the classroom, when they're talking one on one with the teacher, when they're out on the playground? Is it always there? Or is it one of those, oh, it only shows up on the playground in PE when they're really loud. That's great information, because it sheds light on what's happening, because we change what we do when we get loud. What's happening when the child makes that shift physically to create that sound that's not typical?

We also want to document how it affects the person, because that's a key thing. You can have someone with what I would call a severe voice disorder. But if it doesn't bother them and they don't care and it's not something like cancer that would hurt them in another way, it doesn't need treated, if people are good with it. Now, I would argue later that I think a child with a voice disorder, there are educational reasons we need to deal with it, even if they're okay with it. I still think it's important to note, does this really bother the fourth grader who's like, ÒI sound different than all my friends. People aren't talking to me, because they can't hear me.Ó Those are big things. Also, the last one would be, is there any pain with it? That leads us a couple of different directions for diagnoses.

[0:17:52] MBH: As far as whether it's bothering the person, if it's not bothering the person, but they're using their voice in a way that's going to cause more problems down the line, like, they're going to contribute to vocal nodules, for example, what would be your take on that?

[0:18:10] LP: Yeah. The hard part is predicting that. The thing is, somebody can go their entire life with nodules. That partially comes down to, does it make sense for this person to put the time and energy into doing voice therapy, to avoid something if they're not concerned about it? Again, nodules are not going to kill you. Nodules are not going to be painful. They're going to change the voice quality. They could potentially, like later in life, actually be, I suppose, an aspiration risk. What we find is that if people don't have buy-in for voice therapy, you're probably not going to make much progress anyway.

[0:18:52] MBH: Exactly. Exactly. Yeah. Yeah. That's a very good point. All right. Okay. You have seen this person at your clinic, at your school, wherever you are, and you have decided, yes, they definitely need a referral. There's definitely a difference, and they're interested in making a change, and so you need a referral to the ENT, or to a laryngologist.

[0:19:25] LP: Yeah, let's talk about that. The first thing is, we can't know what's going on inside until we actually look at the vocal folds. Voice disorders can sound very similar. Muscle tension dysphonia, which is all about the physiology, nodules, polyps, cancer, can potentially all sound very similar. We've got to get somebody looking in there. SLPs can, if they have the training, but we can't do a medical diagnosis. That's why we need our ear, nose, and throat doctors or our ENTs.

Within that ENT practice, there are specialists called laryngologists. They are particularly interested in the larynx, for swallowing, for voice, for cancer, for all of those things. Like SLPs, you have generalists that are going to do all of it, and you have people that are going to be ear folks, or nose folks, or tonsils folks. Just like we specialize. It doesn't mean they can't do the other things. It just means that they're really into something else.

One of the issues is if you're finding a laryngologist, they are probably going to be at a specialty voice clinic, that is probably at a large medical facility, that is probably difficult to assess, or access for most of our clients. Odds are the first person that we'll see your student, or client is a generalist ENT. There's nothing wrong with that. I am a big fan of access to care. If that ENT finds a problem beyond what they know, they will often refer on to a laryngologist. Sometimes that ENT will be like, ÒYeah, those are nodules.Ó Then you can move forward with your plan of care. That can be really helpful. 

The other thing is it's a great idea, especially if you're working with a generalist ENT to build a relationship with them because sometimes what we as SLPs want is different than what they're looking for. I have an example of a child I was working with, and I really wanted to check out the velopharyngeal port function. Now, what we're looking at is whether it closes, right? We want it to close, so the nasal passages cut off, so people can make oral sounds. I told the ENT, ÒI really appreciate it if you could check out the velopharyngeal port function for this child. I'm not hearing what I would expect, and we've got extra nasality or hypernasality coming through.Ó

My expectation was he would do a nasoendoscopy. You put a scope in so it can look right at the velopharyngeal port, and then you have people do high-pressure sounds, ÒPuh, puh, puh, puh, puh. Tuh, tuh, tuh, tuh, tuh,Ó and see whether it opens. Or a ÒSss,Ó and see if you get bubbling air through the velopharyngeal port. Well, ENTs don't necessarily think about that. He was thinking about breathing. For breathing, you want the velopharyngeal port to be wide open. The report I got back was, yeah, the velopharyngeal port is open. No problems. It was one of those, we were coming through our different lenses, and I needed something completely different.

[0:22:51] MBH: Yes. He was saying, itÕs open. The patient can breathe out of their nose.

[0:22:56] LP: Yes, absolutely.

[0:22:58] MBH: Which, of course, is most important for life, right? Breathing comes first, but you already knew that he could breathe, or she could breathe, they could breathe. Yeah.

[0:23:07] LP: Exactly. Exactly. It's one of those, as you learn what you're looking for, it can help to be specific with the ENT. If you have a relationship with them, then it doesn't come across as I'm trying to tell you to do your job. Making them across as, there's something very specific I want to know about. Here's what I'm looking for.

[0:23:30] MBH: I don't think all ENTs understand that speech therapists, or SLPs have the voice training. Some think only the specialized vocal therapists have that training. What is your comment on that?

[0:23:50] LP: Well, I think that's a really good point. One of the things you could do is there's no credentials right now to call yourself a voice therapist, or voice clinician. You can certainly reach out and let ENTs know and be like, ÒThis is part of what I do. If you have any clients, you can refer them to me. Or this is something I'm building as part of my practice. I would love for us to talk about how we could collaborate, or connect.Ó But just advocating for that, certainly. I would love it if all generalist SLPs in medical settings were comfortable doing voice, and if all SLPs in the schools were comfortable identifying voice disorders. I think that'd be awesome.

[0:24:37] MBH: Mm-hmm. Mm-hmm. I recently had a conversation with an ENT, and he made the comment that only SLPs with PhDs could do voice. I just let it go, because of the context that we were in. Since that conversation, I'm being like, ÒWhoa. Actually, I'm talking to Louise Pinkerton this week, and she's explaining that all SLPs can be comfortable doing some voice therapy. It's just to the degree.Ó

[0:25:07] LP: Yeah, absolutely. I don't have a PhD. I mean, I have two master's degrees, but no PhD. There are some people that say, the dual masters where you have a master's in speech and a master's in vocal performance is really important for treating singers. I go back and forth on that, because you have people that come from theater that are very knowledgeable about performance voice. You have people that have just studied it really intently and they can potentially do that higher level of professional voice use.

The short answer to me is that not everyone has access to someone with that background. I would rather somebody is getting basic therapy and able to do work and make changes than none. Sometimes if we set super high bars for who can do this work, the answer becomes that the client gets none.

[0:26:06] MBH: Okay. All right. When you do make that referral and you want to appear credible at the ENT, what do you want to include?

[0:26:16] LP: Yeah. I think the things we talked about before, this voice sounds atypical. Here are the things you noticed about it. It can be in plain language. Honestly, if you use speech jargon, not all the ENTs would get it, because we have different jargon. A little bit about the history, a little bit about how it presents. When, where, if there's any particular context. How it affects the person and then the presence of pain, or tension also. If you've noticed that somebody's throat is really tight, or their jaw is really tight, that would be good information. 

Certainly, if it's someone with the history of cleft palate, they don't necessarily tie together exactly, but because there might be some issues with the oral cavity, definitely, you could share that. What do you want to know? You want to know how the vocal folds look. Often, what I will say is, I'm referring this client for visualization of the vocal folds for a diagnosis, or for a medical diagnosis. Then here's what I've noticed. Because that's really the gold standard. We got to see the cords before we can treat, so we do the right treatment.

[0:27:37] MBH: Mm hmm. Okay. Before we dive into what to do when working with people in the schools, let's talk a little bit about what the voice specialist SLP, the board certification process and how that all works.

[0:27:53] LP: Yeah. Right now, anybody can say they're a voice specialist, because it's a self-designated, I don't know, on a riff, it's the wrong word. It's a self-designated label. I feel comfortable doing it because I taught voice a really long time. I have a couple of degrees in vocal performance. I've studied vocal pedagogy and performance for a very, very long time. Then I did specialty experiences and additional education in it. If somebody doesn't have that, you can still, again, gain experience and label yourself as such.

At the moment, we do not have board certification for the specialty of voice and upper airway disorders. That, however, is in process. ASHA has approved it at a certain level, and then recently, there was a call for people to be part of the process of establishing that board. I think that's something that's coming. That'll give us a really great idea of what the minimum expected is. That to me was a really big mindset shift.

I was actually developing a independent study a couple summers ago on professional voice rehabilitation. I was like, okay, so which students do I allow to take it? Because if I did the dual degree thing, there were two. Then a mutual friend of ours actually said, ÒWell, wait a second. What's the minimum?Ó All of a sudden it was, well, are they interested in it? Do they have a little bit of background? All of a sudden, the person that had been a music major for one year was actually a really good candidate for the course. Or someone who was a string player, who knew music and was just really interested in it. It, number one, really expanded the number of people that took it, but they all did fine. Yeah. Definitely, I think board certification is going to give us an idea of what our minimal expectations are to be a specialist in that. Yeah.

Another option is the Pan American Vocology Association has something called a recognized vocolologist. That is a multidisciplinary designation. You actually have to demonstrate a certain level of expertise across three different areas of voice, whether it's research, music, conducting, speech pathology. Then you receive this recognition. I don't know what that's going to mean going forward for SLPs, but it's certainly something to look into. They have an awesome study guide that really gives you all of this information about voice and especially the science parts of it. The thing is, we self-identify right now as people that do voice. There are plenty of generalists out there that do great work.

[0:30:56] MBH: It is within the scope of practice, as long as you are qualified.

[0:31:01] LP: Yeah, absolutely. Absolutely.

[0:31:02] MBH: To date. Yeah.

[0:31:04] LP: Yeah. For generalists, I think the key thing is that you know when you don't know enough, so that you can refer on when it's like, okay, ÒI've really thought this through. I've used my critical thinking. I've done the things I know how to do, and we're not making progress, or we've hit a roadblock, or this is way beyond what I've dealt with.Ó Being able to note that and get people to the specialist is really important also.

[0:31:30] MBH: Mm-hmm. As far as accessibility to specialists, is voice rehabilitation something for the professional, or for a complicated case, is that something where that requires a specialist? Is that something that can be done through telepractice?

[0:31:50] LP: It depends on how things go. I have definitely done voice work telepractice. Actually, did work with one of those really complex cases for someone who was Ð they lived a mile from a distant state that I'm certified in, so they drove across the border. We were able to provide therapy, because no one from that specialty clinic was certified, or licensed near where she was. That was a really difficult case. We were able to make it work. It might be more effective in person, but that doesn't make it ineffective.

The big thing we're worried about is that Medicare is going to stop accepting SLPs doing telehealth at the end of this calendar year, and what is that going to mean for other insurance companies? It's appropriate, it's effective, it's currently paid for by most companies, we'll have to see.

[0:32:47] MBH: Yeah. We'll have to see. Okay. All right. We've bounced into schools and we've bounced out, so let's bounce back in. What are the special considerations for school-based SLPs?

[0:33:03] LP: Yeah. I think school-based SLPs have an incredible job and they have an incredibly difficult job, because you've got to be ready for everything and then you're doing it with tight schedules and minimal resources and on your own in the building most of the time. I hate the idea of adding one more thing, but I also love the idea that these are people that are managing a lot already and can probably manage tweaking in their ears a little bit. Voice disorders happen everywhere and that means especially in schools. Children's voices, because they're higher are actually more likely to develop nodules, because high voices Ð

[0:33:43] MBH: Interesting.

[0:33:43] LP: - are more at risk for nodules.

[0:33:45] MBH: Okay. Can you jump into the physiology of that a little bit, because they're higher? 

[0:33:51] LP: Yeah. I also realized, I've been throwing out vocal fold nodules a lot and didn't explain it. When the vocal folds are vibrating, they're going to come together. There's a portion in the midline. It's actually, officially the middle of the anterior two-thirds of the vocal folds. Anyway, in the middle of the membrane is vocal fold. The vocal folds can touch. If you have a lot of vibrations, they're going to touch more often. In some cases, the vocal folds don't like that, so they get irritated and they'll start to change the tissue and the skin. I usually liken it to a blister, or a blister that can become a callous.

What happens then is you have these bumps on each of the vocal folds, so they can't come together, because they should come together like this and they're going to come together like this. You're going to have air leaking through those gaps. What happens is if you are an extroverted person, which many children are, you are more likely to get vocal fold nodules. If you have a higher voice, your vocal folds vibrate at a higher frequency, because I'm probably at about 220 hertz right now. That's 220 vibrations per second.

Well, kidsÕ voices are going to be at my level or higher. Because they vibrate so much more and make contact so much more, higher voices are more likely to get nodules, because it's a friction thing. It's a physical contact thing.

[0:35:30] MBH: Okay. Thank you for that very clear explanation.

[0:35:34] LP: You're welcome. Again, plain language, it gets Ð Yeah. Yeah. It's not uncommon. We also, with some of our really complex kids that are coming to the schools with history, premature birth and major medical issues, it's not uncommon that they might have voice as a component. For children that have cerebral palsy and speech communication is something they're working on, we actually have some voice things we can do to help with that. What it really helps is intelligibility. That can really benefit the quality of life for these kids. 

Sometimes there is this idea that kids will grow out of voice disorders. I've worked with kids that have not grown out of them. I've worked with others that once they're out of the situation that generated it, they're fine. I had one little girl who, she had nodules and she was in a preschool that was very, very noisy. When she went to her dad's where she didn't go to that preschool, she would come back with her voice back to normal.

[0:36:46] MBH: Oh, so interesting.

[0:36:48] LP: It was very closely related to voice use. When she got into kindergarten, it all evened out, because she wasn't exposed to that environment where she had to be so loud. Now, I would like to think therapy helped with that. It's something that maybe she would have recovered just fine, once she got away from it. I also have somebody on my case right now who's seven, who's had a problematic voice quality for years. This is someone that once the vocal cords were looked at, it's nodules. I think they've been there so long that they weren't going to just go away on their own.

[0:37:26] MBH: Okay. How's that person doing with therapy?

[0:37:32] LP: He loves it. We have a special program we're doing that's for kids. He works really hard. He's able to make a clear sound now. Our challenge is generalizing because he has said so many years of using the old voice and everywhere he goes, he's associated that with the old voice. We're really pushing generalizing right now.

[0:37:54] MBH: Well, and your identity is so tied to your voice. Even if you don't love your voice, your identity is tied to it.

[0:38:02] LP: Very true. Very true. That can be so hard for people to change. Kids also can't verbalize that really well. Yeah. Yeah.

[0:38:12] MBH: Okay, go ahead.

[0:38:14] LP: Yeah. I was also going to jump to the idea that school SLPs are experts in voice, even if they don't see themselves in that way. Because if you think about all the people that are in a school, who knows anything about voice? Maybe the music teacher. Okay. But keep in mind, that the music teacher might be a pianist that does a little bit of singing, or they might be a singer and their school didn't require them to learn a lot about how the voice functions. The SLP is the one that knows about problems. That teacher might be the only person in that student's world that has any idea that what they sound like isn't expected, or could be a problem.

Also, the same for teachers. You might be the one that can say, ÒHey, how's your voice doing? Did you ever think about doing something about that?Ó Because we've definitely found that as much as we try and provide information to teachers, because they're one of the highest risk populations, it is very hard in the moment when someone has a voice disorder for them to connect all the dots and get where they need to go.

[0:39:26] MBH: Right. We all know how busy teachers are.

[0:39:30] LP: Yeah, absolutely. As SLPs, we shouldn't be going out there and being like, ÒHey, your voice sounds funny. You should fix it.Ó You can find ways to be like, well, let's do at one of the all-faculty meetings, or on one of the collaboration days, let's do a 10-minute thing on vocal health for the teachers, that you as the SLP could do. I did one of those during one of my externships, and all of a sudden, people were asking me questions afterwards. It opens the door to allow people to come to you.

Or if somebody is like, even just remembers later, ÒOh, this speech person knows about voice and my voice hurts. Maybe I'll ask them for advice.Ó Because you're more likely to ask a colleague, right?

[0:40:17] MBH: Exactly.

[0:40:18] LP: Yeah. We can be a great resource in the school system. I would also add that remember, that pediatricians and primary care providers are generalists, too. Their exposure to voice disorders is going to be probably less than yours. I had someone who was a faculty member in a medical school I was working with on voice therapy. I'll be honest, I expected him to know more than he did, because we all specialize, and voice is not a huge thing in typical medical school. We don't want to rely on the pediatrician, or primary care provider to be the person who notices everything.

[0:41:03] MBH: Mm-hmm. Good point. Let's talk about accommodations for students, as well as for teachers.

[0:41:13] LP: Yeah. Sometimes the best thing to do is find a compensatory strategy, or do things, especially with teachers that will avoid the problem in the first place. We know that for teachers, I'll start their amplification, can be really helpful. I know a lot of schools have moved to just general classroom amplification. This is great for the students and it's great for the teacher. It means they don't have to raise their voice. They don't have to be loud as often.

Now, if somebody has a voice disorder and they sound awful, amplification won't make it sound better, but it means they don't have to talk loud with the voice problem. That can be really great in helping them manage either before, or after they have a voice diagnosis. It can definitely be something that a teacher asks for as an accommodation. I've seen that in a couple of different settings where there's a wearable amplifier. You can have a little speaker that you poke on your belt and wear a mic set, and then the teacher could take it around to all the classrooms they were in.

Some voice disorders will not be fixable. We talked about nodules and nodules generally speaking, can be treated with therapy, or in worst case scenarios, there are some surgical interventions. But again, I would leave that to the laryngologist and the specialist SLPs. There are some things, somebody has vocal fold paralysis that has not recovered after a year, that may be a permanent change. Or I worked with a young woman who actually had had her vocal fold cut when she was born because they were paralyzed in the middle. You can't breathe if your vocal folds aren't open.

An emergency choice was made, but that had a long-term effect on her voice because they weren't going to vibrate. You have to have the two of them together to vibrate, and the one side had lost its attachment. She went all the way to middle school before getting accommodations.

[0:43:27] MBH: Wow.

[0:43:28] LP: Because everyone was just like, ÒWell, her voice is really bad. We're waiting till she's grown to do some treatment options to see whether we can get the voice back.Ó The thing is, her voice had been so soft, she was almost unintelligible, since she was a baby. That's a situation where even if we know we want to do some therapy later, she could have been wearing a body amplifier since kindergarten. I mean, in this case, it was just so sad, because her friend group was non-existent.

[0:44:03] MBH: You can't talk to your friends. Yeah.

[0:44:06] LP: Yeah. People couldn't understand her and they didn't want to take the time, generally speaking.

[0:44:11] MBH: Well, I have to ask you, because I know all the listeners are probably thinking what I'm thinking. Well, and maybe they have heard of this, but I haven't heard of a child being born with vocal fold paralysis. Was it limited? Was the paralysis limited to the vocal folds, or was there other paralysis?

[0:44:31] LP: Yeah. No, it was just limited to the vocal folds. I really don't know the details on the etiology of that because I dealt on the back end of it. I know by the time I saw her. Usually, what paralysis means is the retinoid cartilages that open and close the vocal folds are stuck in a position. Hers, they were stuck with them closed. By the time I saw her, the retinoids were moving, but when you brought the one together, we had this vocal fold just flapping in the breeze, because it wasn't being pulled over.

[0:45:03] MBH: Okay. She could get some sound, but very limited, because the airway was so open.

[0:45:10] LP: Yup. The vocal folds, actually, really need just a very precise setup to vibrate. We really weren't getting the vocal folds to vibrate at all. It just, we couldn't get that one side to either, if it could stay in the middle and the other side could bounce against it, we could get a sound. But she hadn't used her voice really much at all. It was very hard as a teenager to develop that.

[0:45:41] MBH: How did therapy go in that case?

[0:45:44] LP: It was a really challenging voice situation, I think, for anybody. It was a really challenging voice situation, I think for anybody. Then, she also had developmental delay. She was hard for me to understand, too. She was very, very shy. It wasn't an ideal situation for someone who was ready to jump in and try new things. We were able to make some progress and I was able to get like, we did get pitches and we were able to get a tiny range. I couldn't figure out why the range was so small. 

We had a couple range of pitches. It was a little bit louder. We were able to start transferring that a little bit to speech. Then she went and got scoped. What the ENT found out is what we were doing is we were getting her retinoids to vibrate. Her retinoids were producing a frequency. They're not designed to have a range, so we didn't have any range there. What happened in this case is she'd actually had a medical procedure to try and help with the vibrations. There really had been this dichotomy. This is one of those cases where I feel like, I didn't serve the client well in retrospect. The dichotomy was, the family and school and doctor wanted her to either talk, or do amplification. Or, they wanted her to talk with the typical voice, or do amplification.

I accepted that without really thinking about it. Our goal is either typical phonation, or get her an amplifier, so she can be understood. There's also a middle ground though. I think part of this was I was early as an SLP and got blocked in by what other people suggested. There's a middle ground, and oftentimes, we don't want people to do this, but you can actually get people to vibrate their false vocal folds. ItÕs sometimes called a monster sound. Or, let me see if I can demonstrate it. I can't demonstrate it. Never mind. But it sounds very growly. It's very low. It would sound very mature for a child. Oftentimes, we teach people away from that.

Well, she didn't have functioning vocal folds. That phonation would have been loud enough for her to be understood, even if the quality was not the same as her peers. I overlooked that. Everyone she worked with before me overlooked that. But then, she hadn't really worked with a specialist before. I really feel I didn't serve her, because I got blinded to the either we get typical, or we do an accommodation. Yeah, that was a very interesting case and I feel a really complex one, given what had gone on physiologically or anatomically.

[0:48:33] MBH: Yeah. Yeah. Well, yeah, that's a good lesson to us all. Just because the people around you who might be your mentors are thinking one way, you might be a young SLP and able to do some out-of-the-box thinking, where you're really putting the patient first. What was best for the patient? Not the family, not the school, but for the patient or the student. Well, don't be so hard on yourself, Louise.

[0:49:00] LP: Well, thank you. Thank you. It's one of those that seems so obvious now. It seems so obvious.

[0:49:07] MBH: Well, I mean the amplification seems so obvious as in preschool, the amplification would have helped somewhat. It wasn't going to fix it, but it could have helped and it's so important for socialization that someone can communicate and be heard.

[0:49:22] LP: Absolutely.

[0:49:23] MBH: All right. Think accommodations, think outside the box. What about some research we talked about when we talked before, when we were prepping, about kids who have voice disorders are disciplined more frequently?

[0:49:42] LP: Yeah. This is where we can start getting into saying, that a voice disorder affects someone's education. I think there's number one, the obvious one of anything, that restricts participation. We'll get to the article in just a second. Don't forget that PE and music, and sometimes theater, drama classes, or speech classes, those are curricular. I've had people be like, ÒNo, you can't treat it, because it doesn't affect them in class.Ó Well, if they can't sing in music class, that's curricular. We can definitely find applications. Or if it reduces their participation, or if they can't do a class presentation, that is all curricular.

Then let's think about the influence on the child, the psychosocial aspects. Yeah, there's research to show that kids with voice disorders who sound different, they sound like they have dysphonia, are disciplined more. I mean, think what that does to the kid. We have a whole body of research about the kids that are different and get treated differently in school settings, have diverse outcomes. What are we doing to that child? I think elementary school, but I'm sure it goes all the way through. But what are we doing to that third grader, if all of a sudden, they develop a voice disorder and their teachers treat them differently? Ooh, what did I do wrong? The kidÕs going to process it that way.

Also, when they've done research of people listening to dysphonic voices and typical voices and they ask what kind of person this is, people with voice disorders are given negative attributes. Just listening to the voice quality, people say a person's not as nice when they have dysphonia.

[0:51:30] MBH: Really? I mean, thatÕs very interesting. That was with kids? Was that research with kids and adults, or just adults?

[0:51:38] LP: That one was with adults. I don't know that we could separate that bias though. Yeah, that somebody different is not as nice. Yeah.

[0:51:49] MBH: Yeah. Even if it is an unconscious bias. But in this case, it was a stated bias. It was a conscious bias. Yeah.

[0:51:57] LP: Yeah. Yeah, they actually asked and people were like, ÒYeah. That person's not as nice.Ó There were all sorts of different things. I can't remember the details of it, but the negative attributes went to the people with voice disorders. Just so everybody knows, it wasn't about beauty of voice. A typical voice that was just fine and normal was fine. You don't have to be perfect.

[0:52:20] MBH: Okay. Yes, we mentioned recess, music, discussions in class, class presentations, and then the psychosocial, self-esteem, self-identity. Those are also important to the development of the whole person. For anyone who needs to argue this in an IEP meeting, it definitely affects education.

[0:52:47] LP: Absolutely. The tricky thing is because a lot of people are uncomfortable with voice, I don't think we have a big, broad discussion about it. Those of us that do voice talk about it and think about it and there are some nice articles about it, but I don't know that it's gone to the general population of school SLPs. ItÕs within our scope. It's important for these kids. Yeah.

[0:53:14] MBH: Oh, go ahead.

[0:53:14] LP: I was going to say, I will tell you there is a big roadblock, and we should talk about that just a little bit. Because one of the things we said earlier is if someone's got a voice disorder, we need to see the vocal folds. That means they need to go to an ENT. There are financial, at least my understanding, because I've never worked in the schools. I did an externship, but didn't work in the schools. My understanding is that when a special education provider, or the SLP says a child needs a medical evaluation, that it is then the school's financial responsibility.

I have not gone through the process. I know people have. But we have to figure out that process of we've got something that affects the child academically and socially. We need this scope. How do we negotiate that? Especially in situations where parents might not have really great insurance, or cover going to a specialist. I think if this is something that you're interested in doing and finding out at your setting, I would go to ASHA. There's some really nice articles. ASHA voice in the schools. Some of them are in the list of resources here. I would suggest finding a peer mentor. Find another school SLP who has gone through the process. That's going to help you get some of the ideas and see what you can do.

[0:54:48] MBH: Yeah. Yeah. Talk about equal access to services. It's really not fair for someone who doesn't have good insurance, who is at a public school, compared to someone whose parents do have good insurance, they can get the services at the school. Yeah. What a conundrum.

[0:55:08] LP: Absolutely.

[0:55:10] MBH: All right. You're going to provide those resources and we'll include them as a handout for this course.

[0:55:18] LP: Yeah, we can do that.

[0:55:20] MBH: Okay. Okay. What other resources Ð well, actually, let's go back. You need the ENT diagnosis. Let's say, you get that. Then you need to demonstrate the impact and meet IEP qualifications?

[0:55:33] LP: Yup.

[0:55:34] MBH: Okay.

[0:55:35] LP: Certainly, also, you need the parents to sign off on it. Some parents may not think it's a big deal. That also comes into the whole, you may think it's really important. You may know it's having an impact. But if it's not something that's going to hurt the child in broader ways and the parents are absolutely against it, it may not be something you can facilitate. That's okay too, because you tried. You made people aware of it when they wouldn't have otherwise been aware. But then, it has to go through the whole IEP process, which should have parent input in it.

[0:56:13] MBH: Exactly. Exactly. Right. Okay. You will share those resources. Do you want to mention any other resources that you think might be helpful to SLPs, either in the schools, or generalists?

[0:56:30] LP: Yeah. I think there's a lot of great continuing education videos out there these days. If I can, or actually, can I mention SpeechTherapyPD, because I recently got to see your library and it's really good.

[0:56:43] MBH: Oh, yes, yes, yes.

[0:56:44] LP: Okay.

[0:56:45] MBH: Please do.

[0:56:46] LP: Yeah. I think the place to go is to look at continuing education videos. With this, you need to hear things and you need to try things out and you need to see how the information is applied. I find video continuing education courses to be great. Speechtherapypd.com, I got to browse their library recently, really has a lot of voice stuff, breaking out on a variety of techniques. I think there's one even on meta therapy concepts, which is really important, or at least in my opinion. That's a great way to start building your toolbox. Because a lot of speech therapy is okay, I know this is a disorder. I know this is a behavior I want to foster. What tool do I have that will get us there? You can build your toolbox by learning different techniques.

ASHA has one on Voice in the Schools, has the variety of other ones on voice. There's one on low-tech voice evaluations, like to do our part. You do not have to have a Stroboscopy tower and Visi-Pitch to evaluate voice. Those are really just two. I know there are tons of wonderful continuing education platforms that have voice-focused courses. 

Then also, like I said, LSVT LOUD and Speak Out! are very regimented programs. If you like structure, that could be a way to start. If you're in the schools, LSVT LOUD has research that you can use it with kids, and particularly the cerebral palsy. Get some nice results for those kids. 

Or also, they're starting to do case studies with children with autism that speak very softly. Usually, we're thinking about those kids being too loud, but some of them are too soft. That can be really nice.

[0:58:48] MBH: Thank you. Excellent resources. All right, so anything else that you would like to add? We have a minute or two here more.

[0:58:58] LP: I would just encourage anybody that's thinking about doing voice to learn more. I believe you are capable of it. I believe you can find ways to work around, not matching pitch. I believe you can quickly learn how to provide pitch models from a keyboard, or an iPad. We want to think about what you providing these services does for access to care. Because if you're not doing it, who's the next closest? Sometimes the next closest is going to be three hours away. Or maybe even more, depending on where you're at. Or like, here, my next closest is about a 10-minute walk away, but it just depends. If not you, who's going to do this? Even if you can just be identifying people and pointing them to the right resources when they come for help, that's very valuable, too.

[0:59:59] MBH: Well, thank you. Thank you. Good advice. Much appreciated. Well, thank you, Louise. We truly appreciate the information you provided about voice. You really provided a blueprint for SLPs who are generalists, or those who are in the schools working with a variety of disorders and developmental-related communication issues. We really appreciate everything that you've provided for us, and we look forward to our next episode with you, where you're going to share a little bit about your career journey and a little bit of advice for people who are thinking of a job, or career change.

[1:00:42] LP: Well, thank you so much for having me. I want to get people excited about voice. Yeah, I think talking about transitions is a good thing because we're all going to have them.

[1:00:52] MBH: Yes, yes. Well, you've gotten me excited about voice. Thank you and we look forward to seeing you soon. Thanks everybody for your participation. Take care.

[END OF EPISODE]

[1:01:02] MBH: Thanks for joining us here at Keys for SLPs, providing keys to open new doors to better serve our clients throughout the lifespan. Remember to go to speechtherapypd.com to learn more about earning ASHA CEUs for this episode and more. Thanks for your positive reviews and support. I would love for you to write a quick review and subscribe. Keep up the good work.

[END]
KFSP 82		Transcript

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