Practice Patterns of Speech-Language Pathologists in Pediatric Vocal Health Purpose The purpose of this study was to investigate current practices of speech-language pathologists (SLPs) in the management of pediatric vocal health, with specific analysis of the influence of clinical specialty and workplace setting on management approaches. Method American Speech-Language-Hearing Association–certified clinicians providing services within the United States ... Research Article
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Research Article  |   March 16, 2017
Practice Patterns of Speech-Language Pathologists in Pediatric Vocal Health
 
Author Affiliations & Notes
  • Naomi A. Hartley
    Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Wisconsin–Madison
    Wisconsin Institutes of Medical Research, Madison
  • Maia Braden
    Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Wisconsin–Madison
  • Susan L. Thibeault
    Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Wisconsin–Madison
    Wisconsin Institutes of Medical Research, Madison
  • Disclosure: The authors have declared that no competing interests existed at the time of publication.
    Disclosure: The authors have declared that no competing interests existed at the time of publication. ×
  • Naomi A. Hartley and Maia Braden contributed equally to this article.
    Naomi A. Hartley and Maia Braden contributed equally to this article.×
  • Correspondence to Susan L. Thibeault: thibeault@surgery.wisc.edu
  • Editor: Krista Wilkinson
    Editor: Krista Wilkinson×
  • Associate Editor: Julie Barkmeier-Kraemer
    Associate Editor: Julie Barkmeier-Kraemer×
Article Information
Speech, Voice & Prosodic Disorders / Voice Disorders / Speech, Voice & Prosody / Newly Published / Research Article
Research Article   |   March 16, 2017
Practice Patterns of Speech-Language Pathologists in Pediatric Vocal Health
American Journal of Speech-Language Pathology, Newly Published. doi:10.1044/2016_AJSLP-15-0057
History: Received May 20, 2015 , Revised December 14, 2015 , Accepted July 4, 2016
 
American Journal of Speech-Language Pathology, Newly Published. doi:10.1044/2016_AJSLP-15-0057
History: Received May 20, 2015; Revised December 14, 2015; Accepted July 4, 2016

Purpose The purpose of this study was to investigate current practices of speech-language pathologists (SLPs) in the management of pediatric vocal health, with specific analysis of the influence of clinical specialty and workplace setting on management approaches.

Method American Speech-Language-Hearing Association–certified clinicians providing services within the United States (1%–100% voice caseload) completed an anonymous online survey detailing clinician demographics; employment location and service delivery models; approaches to continuing professional development; and specifics of case management, including assessment, treatment, and discharge procedures.

Results Current practice patterns were analyzed for 100 SLPs (0–42 years of experience; 77 self-identifying as voice specialists) providing services in 34 U.S. states across a range of metropolitan and nonmetropolitan workplace settings. In general, SLPs favored a multidisciplinary approach to management; included perceptual, instrumental, and quality of life measures during evaluation; and tailored intervention to the individual using a combination of therapy approaches. In contrast with current practice guidelines, only half reported requiring an otolaryngology evaluation prior to initiating treatment. Both clinical specialty and workplace setting were found to affect practice patterns. SLPs in school settings were significantly less likely to consider themselves voice specialists compared with all other work environments. Those SLPs who considered themselves voice specialists were significantly more likely to utilize voice-specific assessment and treatment approaches.

Conclusion SLP practice largely mirrors current professional practice guidelines; however, potential exists to further enhance client care. To ensure that SLPs are best able to support children in successful communication, further research, education, and advocacy are required.

Contemporary clinical practice guidelines in the area of dysphonia (American Speech-Language-Hearing Association [ASHA], 2004; Royal College of Speech and Language Therapists, 2005; Schwartz et al., 2009) are in apparent agreement on key components of best practice regardless of client age or publishing profession. Multidisciplinary management is considered essential, including examination by a physician and speech-language pathologist (SLP), with preference for specialist clinicians in a dedicated voice clinic. Comprehensive assessment of the individual is reported to require relevant case history and perceptual and objective measures of vocal structure and function (strengths and weaknesses) alongside determination of the impact of dysphonia and individual factors (personal and environmental) on activity, participation, and well-being (ASHA, 2004; Kelchner, Brehm, de Alarcon, & Weinrich, 2012). Review of the wider literature, however, reveals considerable contention surrounding specifics of assessment procedures and timing, need for medical and/or surgical intervention, efficacy of direct and indirect voice therapy approaches, and whether or not such guidelines can and should be applied to pediatric as well as adult clients (Johns, Sataloff, Merati, & Rosen, 2010).
Pediatric dysphonia is a relatively common condition, with prevalence estimates between 1.4% (Bhattacharyya, 2015) and 23.9% (Powell, Filter, & Williams, 1989). Methods of obtaining these prevalence estimates have varied widely; for example, Bhattacharyya (2015) used the National Health Interview Survey to examine the prevalence of children aged 3 to 17 years reporting voice disorders in the past 12 months. Carding, Roulstone, and Northstone (2006)  investigated a large cohort of 8-year-olds and found a prevalence of 6% on the basis of perceptual evaluation and 11% on the basis of parent report. The highest estimate reported in the literature (23.9%) was reported by Powell et al. (1989)  on the basis of a screening of children aged 6 to 10 years in a rural school district. Although the estimates vary, prevalence is similar to other childhood disorders, such as asthma (9.5%; Moorman et al., 2012), stuttering (1.68%; Boyle et al., 2011), specific language impairment (7.4%; Tomblin et al., 1997), and learning disability (7.24%; Boyle et al., 2011). Children report physical and emotional discomfort associated with dysphonia as well as associated negative impacts on education and overall well-being (Connor et al., 2008; Verduyckt, Remacle, Jamart, Benderitter, & Morsomme, 2011; Zur et al., 2007). However, pediatric vocal health is reported to be among the least frequently serviced areas by SLPs (ASHA, 2013, 2014). A recent survey of school-based SLPs by ASHA (2014)  reported voice and/or resonance to be the fourth least serviced area, ahead of selective mutism (18.3%), dysphagia (13.95%), and traumatic brain injury (0.2%); 22% of SLPs regularly provide care in this area (cf. 67.6% fluency, 92.7% articulation/phonology). School-based SLPs have reported confusion regarding eligibility for services for children with voice disorders under the Individuals with Disabilities Education Act (Ruddy & Sapienza, 2004). In addition, it has been reported that school-based SLPs have low self-reports of confidence in their abilities to serve children with voice disorders (Teten, DeVeney, & Friehe, 2015). Each of these may be a factor that influences the number of children seen for voice disorders in schools. Likewise, caseload statistics from SLPs in health care settings (ASHA, 2013) reveal voice to compose just 2% of the average pediatric caseload (4% for SLPs working in outpatient clinics)—higher than only resonance (1%) and unspecified prevention/wellness activities (1%), with the majority of services provided for language (38%) and articulation/phonology (24%).
Recent investigations of SLP practice in pediatrics (ASHA, 2013, 2014; To, Law, & Cheung, 2012; Unicomb, Hewat, Spencer, & Harrison, 2013) suggest that workplace demographics (geographical location and type of facility) and clinician-specific factors (experience, specialty knowledge) are strong influencers of clinical approach—reported by some to surpass clinical need and research evidence (To et al., 2012)—particularly in areas of practice where the literature is perceived to be inadequate to guide decisions relating to service delivery (Unicomb et al., 2013). Whether or not such factors determine current SLP practice in pediatric vocal health is unclear. Single institution reports (Block & Brodsky, 2007; Connelly, Clement, & Kubba, 2009; Mandell, Kay, Dohar, & Yellon, 2004) on specific aspects of management in children provide some insight into variables such as the use of laryngeal visualization, use of medical and/or surgical techniques, and involvement of SLPs in management. However, limited detail is available on the specifics of the assessment and treatment approaches used by SLPs or how this may vary across care settings. For example, Block and Brodsky (2007)  looked at the treatment of children with dysphonia, laryngopharyngeal reflux, vocal fold nodules, and other pathological laryngeal findings. In their retrospective review, evaluation included auditory perceptual evaluation by otolaryngologists and endoscopic exam. Treatment included antireflux therapy and voice therapy alone or in combination. Connelly et al. (2009)  conducted a retrospective chart review of 137 pediatric patients with dysphonia aged 0 to 16 years. Only laryngeal visualization was reported as an assessment technique, and 67% of the children had had some form of laryngeal visualization (mirror exam, flexible laryngoscopy in the office, or diagnostic microlaryngoscopy under general anesthesia), whereas 33% did not and were diagnosed on the basis of history alone. In terms of treatment, 74% of the children diagnosed with “vocal abuse” were referred for voice therapy (Connelly et al., 2009). A study of SLPs and otolaryngologists in Maine examined practice patterns in the evaluation and treatment of children with vocal fold nodules (Allen, Pettit, & Sherblom, 1991). They found that 97% of SLPs identified voice therapy as the best initial treatment for children with new-onset nodules; 26% identified surgery followed by therapy as the optimal treatment for children with established nodules. Ninety-seven percent of SLPs surveyed reported “always” or “frequently” referring pediatric patients to an ear, nose, and throat specialist (ENT) for medical evaluation. They did not examine specific evaluation or therapy approaches. A survey of Australian SLPs (Signorelli, Madill, & McCabe, 2011) asked practicing SLPs about approaches to treatment of vocal fold nodules in children with respect to what strategies were used as well as the degree to which evidence-based practice was used. They found that most respondents used a combination of direct and indirect therapy: 98% used vocal hygiene education, 67% used glottal attack changes, 62% used a yawn–sigh technique, and 51% used resonant voice therapy. A recent survey of Australian SLPs (MacBean, Ford, Madill, Ma, & Rumbach, 2014) sought to address both evaluation and treatment of voice disorders in children, documenting approaches to assessment, treatment, and decision making surrounding discharge. The results are in stark contrast to current clinical guidelines published within the United States: Only one in four Australian SLPs routinely included any form of instrumental assessment (e.g., aerodynamics, acoustics, laryngeal endoscopy), one in five included laryngeal observation (SLP or physician performed), and one in three included quality of life (QOL) scales and/or outcome measures. Service provider type (government, university clinic, private practice, nongovernment organization) and individual clinician skill set in pediatric voice, but not geographical location, were found to be associated with management approach. Australian SLPs reported barriers to implementation of best practice to include restricted access to otolaryngology services, limited funding for equipment, low priority of voice disorders in large caseloads, and perceived shortage of continuing professional education opportunities. The influence of such factors on clinical practice within the United States warrants investigation. Through documentation of current practice patterns in the United States, implementation of clinical guidelines and best practice principles can be examined, guiding future efforts toward topic areas, clinicians, and service providers most likely to benefit from further research, education, and/or advocacy. The current study aimed to document practice patterns of SLPs in the United States in the evaluation and treatment of pediatric voice disorders through examination of the use of assessment tools, sources of clinical information and professional development, therapy strategies, referral patterns, and discharge assessment. Knowledge of current practices and of any existing gaps between practice guidelines, best available evidence, and actual practice can help guide funding decisions in both schools and health care, continuing education, and advocacy for the best patient and student care.
Method
ASHA-certified SLPs from across the United States were invited to complete an anonymous online survey (University of Wisconsin–Madison Qualtrics Survey Hosting Service) regarding clinician demographics, employment location and service delivery models, approaches to continuing professional development, and specifics of case management, including assessment, treatment, and discharge procedures. Participants were recruited through direct mail and e-mails to ASHA members indicating service of pediatric voice advertisements on ASHA online community sites, voice special interest groups, and personal professional networks, including social media. To be eligible for the study, SLPs must have provided services to a pediatric caseload (1%–100% voice related) in the past 6 months within the United States and hold current ASHA certification (Certificate of Clinical Competence in Speech-Language Pathology; CCC-SLP). There were no restrictions on where SLPs were trained (United States or abroad), years of experience, or current workplace. In order to be included in the study, survey responses were required to be complete; surveys remaining incomplete 1 month after the close of the survey were excluded from the study (per consent information). The study was approved by the University of Wisconsin–Madison Education and Social/Behavioral Science Institutional Review Board (IRB 2014-0892).
The study used a modified version of the online survey used to document SLP practice within Australia (see the Appendix). A total of 45 forced-choice and open-ended questions covered personal and professional demographics (age bracket, gender, qualifications, location of SLP training, year of ASHA certification, current employment, specialization in voice, caseload), sources of clinical information and professional development (e.g., journals, workshops, expert opinion), frequency (never, rarely, 50% of the time, often, all of the time) and manner (used alone, used in combination with other techniques, not used) of use of listed assessments (initial evaluation and discharge) and therapy approaches, and involvement of medical specialists (otolaryngology, head and neck surgery) in management. Participants were able to choose other for questions including lists of specific tools and approaches and were given additional opportunity to explain the reasoning where appropriate (e.g., importance of ENT involvement prior to commencing voice therapy with a child). Because there is not currently a board-certified voice specialist designation within ASHA, the category of “specialization in voice” was determined by self-identification in response to question 15, “I consider myself to be a voice specialist.”
Assessment and treatment techniques listed were based on those used in the Australian study (MacBean et al., 2014) as well as discussion with U.S. SLPs evaluating and treating voice. Specific perceptual assessment techniques listed on the survey included the Consensus Auditory Perceptual Evaluation of Voice (Kempster, Gerratt, Verdolini Abbott, Barkmeier-Kraemer, & Hillman, 2009), the GRBAS scale of perceptual voice quality (Hirano, 1981; Isshiki, Okamura, Tanabe, & Morimoto, 1969), and the Oates Perceptual Voice Profile (Oates & Russell, 1998), as well as audio voice recordings and informal listener judgment without a formal scale. QOL measures listed on the survey were the Voice Handicap Index (VHI; Jacobson et al., 1997), Pediatric Voice Handicap Index (pVHI; Zur et al., 2007), Voice Symptom Scale (Deary, Wilson, Carding, & MacKenzie, 2003), Voice Outcome Survey (Gliklich, Glovsky, & Montgomery, 1999), Pediatric Voice Outcome Survey (Hartnick, 2002), Voice-Related Quality of Life (Hogikyan & Sethuraman, 1999), Pediatric Voice-Related Quality of Life (Boseley, Cunningham, Volk, & Hartnick, 2006), Voice Activity and Participation Profile (Ma & Yiu, 2001), and Therapy Outcome Measures (Enderby & John, 1999).
Direct and indirect voice therapy techniques listed on the survey were vocal hygiene and education, chant talk, Froeschels's (1952)  chewing technique, Voicecraft techniques (http://www.voicecraft.com.au/), glottal attack changes, open-mouth approaches, yawn–sigh, Adventures in Voice (http://visionsinvoice.com/), accent method (Bassiouny, 1998), confidential voice, resonant voice (Verdolini, Druker, Palmer, & Samawi, 1998), Estill voice techniques (https://www.estillvoice.com/), semioccluded vocal tract exercises (Titze, 2006), and vocal function exercises (Stemple, Lee, D'Amico, & Pickup, 1994).
Respondents were asked for the U.S. state and county in which they provided SLP services (e.g., Wisconsin, Dane). These geographical locations of service were classified according to the rural–urban continuum codes (RUCCs) published by the United States Department of Agriculture (2013) . RUCCs categorize locations according to a 9-point scale detailed in Table 1.
Table 1. Rural–urban continuum codes (United States Department of Agriculture, 2013).
Rural–urban continuum codes (United States Department of Agriculture, 2013).×
Metro counties 1 Counties in metropolitan areas with population of ≥ 1 million
2 Counties in metropolitan areas of 250,000 to 1 million
3 Counties in metropolitan areas of fewer than 250,000
Nonmetro counties 4 Urban population of 20,000 or more adjacent to a metropolitan area
5 Urban population of 20,000 or more not adjacent to a metropolitan area
6 Urban population of 2,500 to 19,999 adjacent to a metropolitan area
7 Urban population of 2,500 to 19,999 not adjacent to a metropolitan area
8 Completely rural or less than 2,500 urban population adjacent to a metropolitan area
9 Completely rural or less than 2,500 urban population not adjacent to a metropolitan area
Table 1. Rural–urban continuum codes (United States Department of Agriculture, 2013).
Rural–urban continuum codes (United States Department of Agriculture, 2013).×
Metro counties 1 Counties in metropolitan areas with population of ≥ 1 million
2 Counties in metropolitan areas of 250,000 to 1 million
3 Counties in metropolitan areas of fewer than 250,000
Nonmetro counties 4 Urban population of 20,000 or more adjacent to a metropolitan area
5 Urban population of 20,000 or more not adjacent to a metropolitan area
6 Urban population of 2,500 to 19,999 adjacent to a metropolitan area
7 Urban population of 2,500 to 19,999 not adjacent to a metropolitan area
8 Completely rural or less than 2,500 urban population adjacent to a metropolitan area
9 Completely rural or less than 2,500 urban population not adjacent to a metropolitan area
×
Two-by-two cross-tabulation analyses (chi-squared and Fisher's exact for cell counts < 5; SPSS Statistics 22, IBM, Armonk, NY) were used to investigate the influence of clinician specialty (self-identified as voice specialist vs. nonspecialist) and workplace type on management approaches (used alone or in combination vs. never; used 50% or more of the time vs. never or rarely) and sources of clinical information (used vs. not used). Any workplace types with fewer than five SLPs were excluded from cross-tabulation analysis (greater than five data points are necessary for completion of a chi-square). Responses with multiple workplace types identified were also excluded in order to remove confounding variables, but these participants were not excluded from other analyses. A total of 19 responses were excluded from this analysis. P values < .05 were deemed significant. Open-ended questions allowing for more elaboration were included in the survey in order to better understand participants' answers and to supplement the more structured responses.
Results
Complete survey responses were obtained from 100 SLPs (89 women, 11 men) currently providing service for pediatric vocal health across 34 U.S. states in a range of health and educational settings. Although there may be overlap between some of these settings, participants were asked to select the one where they see the most children with voice disorders. RUCCs 1 (metropolitan population ≥ 1 million) through 6 (urban population of 2,500 to 19,999 adjacent to a metro area) were represented, with 93% of respondents providing services within metropolitan areas. SLPs ranged from newly certified to having 42 years of experience in the profession (M = 16.44, SD = 12.10 years); 51 to 64 years (36%) was the most frequent age category represented. Demographics of respondents are detailed in Table 2.
Table 2. Demographics of respondents.
Demographics of respondents.×
Variable n
Workplace type
 School 10
 Birth-to-three program 1
 Hospital 32
 Skilled nursing facility 1
 Outpatient clinic 32
 Private practice 27
 University clinic 16
RUCC
 1 54
 2 26
 3 13
 4 2
 5 1
 6 1
 7 0
 8 0
 9 0
Age (years)
 20–30 16
 31–40 29
 41–50 17
 51–64 36
 ≥65 2
Note. RUCC = rural–urban continuum code.
Note. RUCC = rural–urban continuum code.×
Table 2. Demographics of respondents.
Demographics of respondents.×
Variable n
Workplace type
 School 10
 Birth-to-three program 1
 Hospital 32
 Skilled nursing facility 1
 Outpatient clinic 32
 Private practice 27
 University clinic 16
RUCC
 1 54
 2 26
 3 13
 4 2
 5 1
 6 1
 7 0
 8 0
 9 0
Age (years)
 20–30 16
 31–40 29
 41–50 17
 51–64 36
 ≥65 2
Note. RUCC = rural–urban continuum code.
Note. RUCC = rural–urban continuum code.×
×
All SLPs reported completing a master's qualification; 11 also had a PhD. All SLPs received graduate training within the United States (across 32 states), with the exception of one respondent trained in Canada. With the exception of three SLPs (one evaluation, two intervention), all SLPs both assessed and provided intervention for pediatric voice clients. On average, SLPs indicated pediatric voice disorders to compose 17.82% of their total caseload (SD = 18.99, range = 1%–100%); 35.24% consisted of assessment (SD = 29.23, range = 0%–100%), 38.74% consisted of treatment (SD = 30.82, range = 0%–100%), and 8.71% consisted of nonclient specific education, service, and/or outreach (SD = 16.23, range = 0%–100%).
Ninety-five percent (n = 95) of the respondents felt confident in the management of pediatric vocal health, with 77% (n = 77) of SLPs self-identifying as voice specialists. SLPs reported gaining clinical information regarding the management of pediatric vocal health from multiple sources, including reading journal articles (n = 94, 94%), attending professional development events and conferences (n = 94, 94%), referring to previous notes from lectures and conferences (n = 85, 85%), colleagues and expert opinion (n = 87, 87%), textbooks (n = 71, 71%), voice interest groups (n = 64, 64%), and the Internet (n = 45, 45%). Professional development events were identified as the most frequent source of information (n = 45, 45%), followed by journals and textbooks (n = 27, 27%), colleague and expert opinion (n = 22, 22%), voice interest groups (n = 3, 3%), and the Internet (n = 2, 2%).
All 99 SLPs who assessed voice as a component of their pediatric voice caseload considered assessment of a child for his or her vocal health to be important, with 89.9% (n = 89) indicating it to be either very important (n = 36, 36.36%) or essential (n = 53, 53.54%). SLPs used a range of instrumental, perceptual, and QOL measures in the assessment of pediatric vocal health (see Figures 1 and 2). More than 80% of SLPs included perceptual measures of vocal quality (n = 85), evaluation of body movement and positioning (n = 84), and ability to modify voice to a model (n = 82) in every case, whereas the majority of SLPs reported never using electroglottography (n = 88), using high-speed endoscopy (n = 75), or performing videostroboscopy (n = 55). VHI (n = 58) and pVHI (n = 55) were the most frequently used QOL scales, and the majority of SLPs reported using the Consensus Auditory Perceptual Evaluation of Voice (n = 74), audio recordings (n = 92), and informal clinical judgments (n = 86) for perceptual evaluation.
Figure 1.

Assessments for voice evaluation: frequency of use by speech-language pathologists (SLPs; n = 99). ENT = ear, nose, and throat specialist.

 Assessments for voice evaluation: frequency of use by speech-language pathologists (SLPs; n = 99). ENT = ear, nose, and throat specialist.
Figure 1.

Assessments for voice evaluation: frequency of use by speech-language pathologists (SLPs; n = 99). ENT = ear, nose, and throat specialist.

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Figure 2.

Assessments at evaluation: percentage of speech-language pathologists (n = 100) using approach alone or in combination. CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; PVP = Pediatric Voice Profile; QOL = quality of life; VHI = Voice Handicap Index; pVHI = Pediatric Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; VAPP = Voice Activity and Participation Profile; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; TOMS = Therapy Outcome Measures.

 Assessments at evaluation: percentage of speech-language pathologists (n = 100) using approach alone or in combination. CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; PVP = Pediatric Voice Profile; QOL = quality of life; VHI = Voice Handicap Index; pVHI = Pediatric Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; VAPP = Voice Activity and Participation Profile; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; TOMS = Therapy Outcome Measures.
Figure 2.

Assessments at evaluation: percentage of speech-language pathologists (n = 100) using approach alone or in combination. CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; PVP = Pediatric Voice Profile; QOL = quality of life; VHI = Voice Handicap Index; pVHI = Pediatric Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; VAPP = Voice Activity and Participation Profile; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; TOMS = Therapy Outcome Measures.

×
Most SLPs (n = 71, 72.4%) indicated once a week service delivery to be standard, whereas twice a week (n = 12, 12.2%), every 2 weeks (n = 10, 10.2%), and intensive voice therapy blocks were less common (n = 3, 3.1%). All SLPs (n = 98) reported the use of direct therapy approaches to be typical within their practice, whereas one quarter (n = 25, 25.5%) of SLPs also indicated using a “wait and see” or no-treatment approach with children when appropriate. Indirect approaches (e.g., vocal hygiene, voice minimization) were reported by all but a few SLPs (n = 92, 93.9%), with just over half (n = 54, 55.1%) indicating use of a combination of surgery and therapy and a quarter (n = 26, 26.5%) typically referring for surgery alone (e.g., treatment for nodules). Direct approaches were reportedly used in combination rather than alone. Resonant voice (n = 91, 90.8%) was the most frequently used approach, and accent method (n = 15, 15.3%) was the least commonly used approach (see Figure 3).
Figure 3.

Intervention: percentage of speech-language pathologists (n = 98) using approach alone versus in combination. SOVT = semioccluded vocal tract exercises; VFE = vocal function exercises.

 Intervention: percentage of speech-language pathologists (n = 98) using approach alone versus in combination. SOVT = semioccluded vocal tract exercises; VFE = vocal function exercises.
Figure 3.

Intervention: percentage of speech-language pathologists (n = 98) using approach alone versus in combination. SOVT = semioccluded vocal tract exercises; VFE = vocal function exercises.

×
The majority of SLPs (n = 75, 76.5%) reported using biofeedback during intervention for pediatric voice disorders. Qualitative responses included low- and high-technology options for providing information on overall voice quality (audio recordings, n = 16, 21%; video recordings, n = 7, 9%) and function (laryngeal visualization, n = 11, 15%) in addition to specific features of pitch, loudness, and resonance—Visi-Pitch (Pentax Medical, Montvale, NJ), n = 44, 59%; sound pressure level meters, n = 12, 16%; Computer Speech Lab games (Pentax Medical), n = 8, 11%; Sona-Speech II (Pentax Medical), n = 6, 8%; real-time spectrograms, n = 5, 7%; piano keyboard, n = 3, 4%; nasometer (Pentax Medical), n = 2, 3%; Multidimensional Voice Program, n = 1, 1%; electroglottography, n = 1, 1%; tuning device, n = 1, 1%; visual feedback on airflow, n = 1, 1%—and tools to assist in monitoring practice and progress; for example, VocaLog (Griffin Laboratories, Temecula, CA), n = 1, 1%; wrist counter, n = 1, 1%; charts and calendars, n = 1, 1%. In addition, 16% of SLPs (n = 12) reported using apps on personal devices, including tablets and mobile phones, as a key biofeedback tool. Those SLPs not using biofeedback reported being restricted in access to funding for equipment and training (n = 15, 65%), saw little value in using biofeedback with pediatric cases (n = 7, 30%), or did not provide a reason (n = 5, 21%).
When asked to describe in an open-ended manner the most effective voice therapy for children, respondents focused on the importance of a flexible, person-centered approach, the involvement of parents and other significant caregivers such as teachers, and specific consideration of the child's age and etiology of voice problems. Most of the SLPs listed multiple answers to this question, suggesting that most do not feel that there is one most effective approach. Twenty-nine respondents specifically mentioned the need to use a combination of approaches, including both direct and indirect therapy, making this the most commonly identified theme. Fifteen respondents mentioned the need for an individualized or patient-centered approach. Parent involvement was listed as the most effective component of voice therapy by 11 respondents, and direct voice therapy without specific type was listed by nine respondents. Resonant voice therapy was specifically mentioned by 11 people, whereas eight specified a set program by name (Buzzy Child or Adventures in Voice). Education of the child and caregivers on aspects of vocal hygiene was listed as effective by 14 respondents. Other participants mentioned medical or surgical management as appropriate, breathing, vocal function exercises, nerve stimulation, cognitive behavioral therapy, and biofeedback.
Formal discharge (e.g., taking outcome measures and recommending cessation of therapy) was reported to occur on average in 68.63% of cases (SD = 23.37), with self-discharge (e.g., the client cancels the next appointment and does not rebook) occurring on average in one quarter of pediatric cases (M = 24.85%, SD = 23.33). Assessments used at discharge were predominantly reported to be perceptual ratings of voice quality, review of pre/post voice recordings, perceived ability of the client to modify voice to a model, and patient self-perception. Formal QOL scales were included by many, of which the pVHI (2% alone, 49% in combination) and VHI (3% alone, 39% in combination) were the most frequently reported (see Figures 4 and 5). Acoustic analysis (n = 65, 65%) and review of ENT videostroboscopy (n = 31, 31%) were the most frequently reported instrumental measures (50% or more of cases), whereas electroglottographic assessment was rarely used (n = 4, 4%).
Figure 4.

Assessments prior to discharge: percentage of speech-language pathologists (n = 100) using approach alone versus in combination. pVHI = Pediatric Voice Handicap Index; VHI = Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; VAPP = Voice Activity and Participation Profile; TOMS = Therapy Outcome Measures.

 Assessments prior to discharge: percentage of speech-language pathologists (n = 100) using approach alone versus in combination. pVHI = Pediatric Voice Handicap Index; VHI = Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; VAPP = Voice Activity and Participation Profile; TOMS = Therapy Outcome Measures.
Figure 4.

Assessments prior to discharge: percentage of speech-language pathologists (n = 100) using approach alone versus in combination. pVHI = Pediatric Voice Handicap Index; VHI = Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; VAPP = Voice Activity and Participation Profile; TOMS = Therapy Outcome Measures.

×
Figure 5.

Assessments prior to discharge: frequency of use by speech-language pathologists (SLPs; n = 100). ENT = ear, nose, and throat specialist; EGG = electroglottography.

 Assessments prior to discharge: frequency of use by speech-language pathologists (SLPs; n = 100). ENT = ear, nose, and throat specialist; EGG = electroglottography.
Figure 5.

Assessments prior to discharge: frequency of use by speech-language pathologists (SLPs; n = 100). ENT = ear, nose, and throat specialist; EGG = electroglottography.

×
Questions seeking participant views on involvement of medical specialists in vocal health management were included in both the assessment and therapy sections of the survey to ensure coverage of those SLPs who may not personally assess voice but provide therapy (and vice versa). When a child had not been referred by an otolaryngologist (ENT), just over half (n = 52, 52.5%) of SLPs considered referral to an ENT to be essential prior to completing the evaluation, with the remainder rating it as desirable (n = 31, 31.3%) or case dependent (n = 15, 15.2%). Fewer SLPs indicated ENT review to be essential (n = 46, 46.9%) prior to commencing therapy, with one in six not requiring it at all (n = 17, 17.3%) and 36% (n = 35) considering it to be case dependent. Of the respondents considering an ENT referral essential, 17 (32%) worked in an outpatient clinic, 14 (27%) worked in a hospital, 13 (25%) worked in private practice, nine (17%) worked in schools, one (0.2%) worked in a birth-to-three program, one worked in a skilled nursing facility, and one worked in home health. SLPs supporting involvement of ENT review in every case cited reasons including using ENT diagnosis to guide management approach (therapy, surgery), ensuring no contraindications and exclusion of pathology; providing an accurate measure of vocal structure and function; compliance with legal, ethical, and insurance requirements and workplace policy; medical provider as primary source of referrals; emphasis in SLP training received; and a personal preference for a multidisciplinary approach. On the other hand, employer policies were also listed as restricting involvement of medical professionals, particularly in the case of school district employees, where requiring medical review prior to service was considered by SLPs to be against policy. Other reasons surrounding ENT involvement on a case-by-case basis included a preference to trial therapy first; a view that the child may not tolerate ENT assessment (which may in turn reduce trust in the clinician–client relationship); the client being referred by another physician (e.g., pulmonologist, pediatrician); a behavioral intervention unlikely to do harm; limited benefit from ENT assessment due to restricted communication between providers; a combination of good case history and observation of client's speech being considered sufficient; an ENT being needed only if presentation suggests pathology; and limited access to ENT resources, particularly pediatric specialists. Three respondents indicated that a pulmonologist or other specialist might be involved in the patient's care, specifically in the case of paradoxical vocal fold motion, in which case they did not believe an ENT evaluation was indicated. Eleven responses stated that an ENT evaluation could be completed after the SLP evaluation if it was not feasible to see the physician first or at the same appointment; some of these advocated for the SLP-first approach, as the physician could then review the videostroboscopy without duplication of efforts.
SLPs identifying as voice specialists were found to differ in practice patterns from nonspecialists across select case management variables and sources of clinical information (see Table 3). Compared with nonspecialists, self-identified voice specialists (a) considered assessment of voice in children to be of greater importance—94.70% versus 73.91% very important or essential, χ2(1, N = 99) = 10.608, p = .014; (b) more frequently performed stroboscopy, 47% versus 13%, p = .003, acoustic analyses, 82% versus 39%, χ2(1, N = 99) = 15.685, p < .001, and voice recordings, 96% versus 78%, p = .016; and (c) included GRBAS perceptual ratings—45% versus 22%, χ2(1, N = 99) = 3.911, p = .048—and the pediatric-specific QOL measure (pVHI)—63% versus 30%, χ2(1, N = 99) = 7.634, p = .006—more frequently during evaluation. Likewise, statistically significant differences in intervention on the basis of specialty were found to be more frequent use of specific approaches alone or in combination, including the following: chant talk, 71% versus 45%, χ2(1, N = 99) = 4.934, p = .026; resonant voice, 96% versus 73%, p = .004; semioccluded vocal tract exercises, 96% versus 68%, p = .001; vocal function exercises, 91% versus 68%, χ2(1, N = 99) = 7.121, p = .008; and biofeedback, 83% versus 55%, χ2(1, N = 99) = 7.634, p = .006 (see Table 1). Once a week intervention was the most frequent service delivery model for both groups, but only voice specialists indicated the use of a once every 2 weeks (fortnightly) approach, 13.15% versus 0.00%, χ2(1, N = 99) = 10.896, p = .028. Prior to discharge, voice specialist SLPs were less likely to use the Voice Symptom Scale (Deary et al., 2003; 2% vs. 17%, p = .024) than their nonspecialist colleagues and reported more frequent use of acoustic analysis—70% versus 48%, χ2(1, N = 99) = 3.873, p = .049—and instrumental assessments in general: 79% versus 56%, χ2(1, N = 99) = 4.743, p = .029.
Table 3. Practice patterns: voice specialist versus nonspecialist speech-language pathologists (SLPs).
Practice patterns: voice specialist versus nonspecialist speech-language pathologists (SLPs).×
Variable Voice specialist
Nonspecialist
χ2 p
n % n %
Assessment (item 24; n = 99)
 SLP stroboscopy 50% or more 36 47.37 3 13.04 .003
Never/rarely 40 52.63 20 86.96
 Acoustic analysis 50% or more 62 81.58 9 39.13 15.685 <.001
Never/rarely 14 18.42 14 60.87
 GRBAS Alone/in combination 34 44.74 5 21.74 3.911 .048
Never used 42 55.26 18 78.26
 Voice recordings Alone/in combination 73 96.05 18 78.26 .016
Never used 3 3.95 5 21.74
 pVHI Alone/in combination 48 63.16 7 30.43 7.657 .006
Never used 28 36.84 16 69.57
Treatment (item 35; n = 98)
 Chant talk Alone/in combination 54 71.05 10 45.45 4.934 .026
Never used 22 28.95 12 54.55
 Resonant voice Alone/in combination 73 96.05 16 72.73 .004
Never used 3 3.95 6 27.27
 Semioccluded vocal tract Alone/in combination 73 96.05 15 68.18 .001
Never used 3 3.95 7 31.82
 Vocal function exercises Alone/in combination 69 90.79 15 68.18 7.121 .008
Never used 7 9.21 7 31.82
 Biofeedback Used 63 82.89 12 54.55 7.634 .006
Not used 13 17.11 10 45.45
Discharge (item 43; n = 100)
 VoiSS Alone/in combination 2 2.60 4 17.39 .024
Never used 75 97.40 19 82.61
 Instrumental assessments Alone/in combination 61 79.22 13 56.52 4.743 .029
Never used 16 20.78 10 43.48
 Acoustic analysis 50% or more 54 70.13 11 47.83 3.873 .049
Never/rarely 23 29.87 12 52.17
Sources of clinical information (item 16; n = 100)
 Voice interest groups Used 57 74.03 7 30.43 14.606 <.001
Not used 20 25.97 16 69.57
 Journal articles Used 76 98.70 18 78.26 13.120 <.001
Not used 1 1.30 5 21.74
Note. Fisher's exact test used when cell count < 5. pVHI = Pediatric Voice Handicap Index; VoiSS = Voice Symptom Scale.
Note. Fisher's exact test used when cell count < 5. pVHI = Pediatric Voice Handicap Index; VoiSS = Voice Symptom Scale.×
Table 3. Practice patterns: voice specialist versus nonspecialist speech-language pathologists (SLPs).
Practice patterns: voice specialist versus nonspecialist speech-language pathologists (SLPs).×
Variable Voice specialist
Nonspecialist
χ2 p
n % n %
Assessment (item 24; n = 99)
 SLP stroboscopy 50% or more 36 47.37 3 13.04 .003
Never/rarely 40 52.63 20 86.96
 Acoustic analysis 50% or more 62 81.58 9 39.13 15.685 <.001
Never/rarely 14 18.42 14 60.87
 GRBAS Alone/in combination 34 44.74 5 21.74 3.911 .048
Never used 42 55.26 18 78.26
 Voice recordings Alone/in combination 73 96.05 18 78.26 .016
Never used 3 3.95 5 21.74
 pVHI Alone/in combination 48 63.16 7 30.43 7.657 .006
Never used 28 36.84 16 69.57
Treatment (item 35; n = 98)
 Chant talk Alone/in combination 54 71.05 10 45.45 4.934 .026
Never used 22 28.95 12 54.55
 Resonant voice Alone/in combination 73 96.05 16 72.73 .004
Never used 3 3.95 6 27.27
 Semioccluded vocal tract Alone/in combination 73 96.05 15 68.18 .001
Never used 3 3.95 7 31.82
 Vocal function exercises Alone/in combination 69 90.79 15 68.18 7.121 .008
Never used 7 9.21 7 31.82
 Biofeedback Used 63 82.89 12 54.55 7.634 .006
Not used 13 17.11 10 45.45
Discharge (item 43; n = 100)
 VoiSS Alone/in combination 2 2.60 4 17.39 .024
Never used 75 97.40 19 82.61
 Instrumental assessments Alone/in combination 61 79.22 13 56.52 4.743 .029
Never used 16 20.78 10 43.48
 Acoustic analysis 50% or more 54 70.13 11 47.83 3.873 .049
Never/rarely 23 29.87 12 52.17
Sources of clinical information (item 16; n = 100)
 Voice interest groups Used 57 74.03 7 30.43 14.606 <.001
Not used 20 25.97 16 69.57
 Journal articles Used 76 98.70 18 78.26 13.120 <.001
Not used 1 1.30 5 21.74
Note. Fisher's exact test used when cell count < 5. pVHI = Pediatric Voice Handicap Index; VoiSS = Voice Symptom Scale.
Note. Fisher's exact test used when cell count < 5. pVHI = Pediatric Voice Handicap Index; VoiSS = Voice Symptom Scale.×
×
Statistical analysis of the influence of workplace type on practice patterns was determined for 81 SLPs (19 responses were excluded due to identification of multiple settings) currently providing services in schools, hospitals, outpatient clinics, private practice, and university clinics. (Skilled nursing facilities, home health, and birth-to-three programs were excluded due to fewer than five SLP respondents in each type of setting.) Geographical location was not found to influence approach, likely due to few participants (n = 5) providing services within nonmetropolitan areas (RUCC codes 4–6). Statistically significant differences were found between service providers in different workplace types (see Table 4), with the most frequent differences found in the comparison of school-based SLPs (n = 9) with non-school-based SLPs (n = 72; combined hospital, outpatient clinics, private practice, and university clinics). Ten case management variables (four assessment, one treatment, three discharge, and two sources of information) reached significance. It is notable that school-based SLPs identified most often as nonvoice specialists (n = 6, 67%), representing a significant difference (p < .01) from other workplaces, where the majority of SLPs considered voice to be a specialty.
Table 4. Practice patterns: workplace type.
Practice patterns: workplace type.×
Variable School
Hospital
Outpatient clinic
Private practice
University clinic
n % n % n % n % n %
Assessment (item 24; n = 80)
 SLP stroboscopy 50% or more 0 0.00* 8 47.06 8 36.36 7 33.33 9 81.82**
Never/rarely 9 100.00 9 52.94 16 72.73 14 66.67 2 18.18
 ENT stroboscopy 50% or more 0 0.00* 12 70.59** 7 31.82 9 42.86 3 27.27
Never/rarely 9 100.00 5 29.41 15 68.18 12 57.14 8 72.73
 Aerodynamics 50% or more 1 11.11 9 52.94 4 18.18 7 33.33 7 63.64*
Never/rarely 8 88.89 8 47.06 18 81.82 14 66.67 4 36.36
 CAPE-V Alone/combination 4 44.44* 17 100.00** 17 77.27 14 66.67 10 90.91
Never used 5 55.56 0 0.00 5 22.73 7 33.33 1 9.09
 VRQOL Alone/combination 2 22.22 4 23.53 3 13.64 1 4.76* 7 63.64**
Never used 7 77.78 13 76.47 19 86.36 20 95.24 4 36.36
 Acoustics 50% or more 3 33.33* 13 76.47 14 63.64 16 76.19 10 90.91
Never/rarely 6 66.67 4 23.53 8 36.36 5 23.81 1 9.09
 Voice recordings Alone/combination 8 88.89 17 100.00 18 81.82* 20 95.24 11 100.00
Never used 1 11.11 0 0.00 4 18.18 1 4.76 0 0.00
Treatment (item 35; n = 79)
 Resonant voice Alone/combination 4 50.00** 17 100.00 21 95.45 20 95.24 11 100.00
Never used 4 50.00 0 0.00 1 4.55 1 4.76 0 0.00
 Confidential voice Alone/combination 4 50.00 7 41.18* 13 59.09 17 80.95 9 81.82
Never used 4 50.00 10 58.82 9 40.91 4 19.05 2 18.18
Discharge (item 43; n = 81)
 VoiSS Alone/combination 3 33.33** 1 5.56 0 0.00 0 0.00 0 0.00
Never used 6 66.67 17 94.44 22 100.00 21 100.00 11 100.00
 VRQOL Alone/combination 2 22.22 2 11.11 3 13.64 0 0.00* 5 45.45**
Never used 7 77.78 16 88.89 19 86.36 21 100.00 6 54.55
 Pre/post recordings Alone/combination 7 77.78 17 94.44 16 72.73* 21 100.00 11 100.00
Never used 2 22.22 1 5.56 6 27.27 0 0.00 0 0.00
 SLP stroboscopy 50% or more 1 11.11 6 33.33 5 22.73 4 19.05 9 81.82**
Never/rarely 8 88.89 12 66.67 17 77.27 17 80.95 2 18.18
 Acoustics 50% or more 2 22.22** 14 77.78 12 54.55 14 66.67 10 90.91
Never/rarely 7 77.78 4 22.22 10 45.45 7 33.33 1 9.09
 Self-perception 50% or more 9 100.00 17 94.44 20 90.91 16 76.19* 10 90.91
Never/rarely 0 0.00 1 5.56 2 9.09 5 23.81 1 9.09
 Instrumental assessments Alone/combination 4 44.44* 14 77.78 15 68.18 16 76.19 11 100.00
Never used 5 55.56 3 16.67 7 31.82 5 23.81 0 0.00
 ENT stroboscopy 50% or more 1 11.11 9 50.00* 17 77.27 7 33.33 10 90.91
Never/rarely 8 88.89 9 50.00 5 22.73 14 66.67 1 9.09
 Clinician judgment Alone/combination 9 100.00 17 94.44 18 81.82* 20 95.24 11 100.00
Never used 0 0.00 1 5.56 4 18.18 1 4.76 0 0.00
Sources of clinical information (item 16; n = 81)
 Notes (e.g., lectures, conferences) Yes 5 55.56* 17 94.44 16 72.73 18 85.71 11 100.00
No 4 44.44 1 5.56 6 27.27 3 14.29 0 0.00
 Voice interest groups Yes 1 11.11** 11 61.11 1 4.55 17 80.95 8 72.73
No 8 88.89 7 38.89 21 95.45 4 19.05 3 27.27
Clinical specialty (item 15; n = 81)
 Voice specialist Yes 3 33.33** 15 83.33 17 77.27 19 90.48 9 81.82
No 6 66.67 3 16.67 5 22.73 2 9.52 2 18.18
Note. Fisher's exact test used for statistical analysis; 2 × 2 cross-tabulations. SLP = speech-language pathologist; ENT = ear, nose, and throat specialist; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; VRQOL = Voice-Related Quality of Life; VoiSS = Voice Symptom Scale.
Note. Fisher's exact test used for statistical analysis; 2 × 2 cross-tabulations. SLP = speech-language pathologist; ENT = ear, nose, and throat specialist; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; VRQOL = Voice-Related Quality of Life; VoiSS = Voice Symptom Scale.×
* p < .05.
p < .05.×
** p < .01.
p < .01.×
Table 4. Practice patterns: workplace type.
Practice patterns: workplace type.×
Variable School
Hospital
Outpatient clinic
Private practice
University clinic
n % n % n % n % n %
Assessment (item 24; n = 80)
 SLP stroboscopy 50% or more 0 0.00* 8 47.06 8 36.36 7 33.33 9 81.82**
Never/rarely 9 100.00 9 52.94 16 72.73 14 66.67 2 18.18
 ENT stroboscopy 50% or more 0 0.00* 12 70.59** 7 31.82 9 42.86 3 27.27
Never/rarely 9 100.00 5 29.41 15 68.18 12 57.14 8 72.73
 Aerodynamics 50% or more 1 11.11 9 52.94 4 18.18 7 33.33 7 63.64*
Never/rarely 8 88.89 8 47.06 18 81.82 14 66.67 4 36.36
 CAPE-V Alone/combination 4 44.44* 17 100.00** 17 77.27 14 66.67 10 90.91
Never used 5 55.56 0 0.00 5 22.73 7 33.33 1 9.09
 VRQOL Alone/combination 2 22.22 4 23.53 3 13.64 1 4.76* 7 63.64**
Never used 7 77.78 13 76.47 19 86.36 20 95.24 4 36.36
 Acoustics 50% or more 3 33.33* 13 76.47 14 63.64 16 76.19 10 90.91
Never/rarely 6 66.67 4 23.53 8 36.36 5 23.81 1 9.09
 Voice recordings Alone/combination 8 88.89 17 100.00 18 81.82* 20 95.24 11 100.00
Never used 1 11.11 0 0.00 4 18.18 1 4.76 0 0.00
Treatment (item 35; n = 79)
 Resonant voice Alone/combination 4 50.00** 17 100.00 21 95.45 20 95.24 11 100.00
Never used 4 50.00 0 0.00 1 4.55 1 4.76 0 0.00
 Confidential voice Alone/combination 4 50.00 7 41.18* 13 59.09 17 80.95 9 81.82
Never used 4 50.00 10 58.82 9 40.91 4 19.05 2 18.18
Discharge (item 43; n = 81)
 VoiSS Alone/combination 3 33.33** 1 5.56 0 0.00 0 0.00 0 0.00
Never used 6 66.67 17 94.44 22 100.00 21 100.00 11 100.00
 VRQOL Alone/combination 2 22.22 2 11.11 3 13.64 0 0.00* 5 45.45**
Never used 7 77.78 16 88.89 19 86.36 21 100.00 6 54.55
 Pre/post recordings Alone/combination 7 77.78 17 94.44 16 72.73* 21 100.00 11 100.00
Never used 2 22.22 1 5.56 6 27.27 0 0.00 0 0.00
 SLP stroboscopy 50% or more 1 11.11 6 33.33 5 22.73 4 19.05 9 81.82**
Never/rarely 8 88.89 12 66.67 17 77.27 17 80.95 2 18.18
 Acoustics 50% or more 2 22.22** 14 77.78 12 54.55 14 66.67 10 90.91
Never/rarely 7 77.78 4 22.22 10 45.45 7 33.33 1 9.09
 Self-perception 50% or more 9 100.00 17 94.44 20 90.91 16 76.19* 10 90.91
Never/rarely 0 0.00 1 5.56 2 9.09 5 23.81 1 9.09
 Instrumental assessments Alone/combination 4 44.44* 14 77.78 15 68.18 16 76.19 11 100.00
Never used 5 55.56 3 16.67 7 31.82 5 23.81 0 0.00
 ENT stroboscopy 50% or more 1 11.11 9 50.00* 17 77.27 7 33.33 10 90.91
Never/rarely 8 88.89 9 50.00 5 22.73 14 66.67 1 9.09
 Clinician judgment Alone/combination 9 100.00 17 94.44 18 81.82* 20 95.24 11 100.00
Never used 0 0.00 1 5.56 4 18.18 1 4.76 0 0.00
Sources of clinical information (item 16; n = 81)
 Notes (e.g., lectures, conferences) Yes 5 55.56* 17 94.44 16 72.73 18 85.71 11 100.00
No 4 44.44 1 5.56 6 27.27 3 14.29 0 0.00
 Voice interest groups Yes 1 11.11** 11 61.11 1 4.55 17 80.95 8 72.73
No 8 88.89 7 38.89 21 95.45 4 19.05 3 27.27
Clinical specialty (item 15; n = 81)
 Voice specialist Yes 3 33.33** 15 83.33 17 77.27 19 90.48 9 81.82
No 6 66.67 3 16.67 5 22.73 2 9.52 2 18.18
Note. Fisher's exact test used for statistical analysis; 2 × 2 cross-tabulations. SLP = speech-language pathologist; ENT = ear, nose, and throat specialist; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; VRQOL = Voice-Related Quality of Life; VoiSS = Voice Symptom Scale.
Note. Fisher's exact test used for statistical analysis; 2 × 2 cross-tabulations. SLP = speech-language pathologist; ENT = ear, nose, and throat specialist; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; VRQOL = Voice-Related Quality of Life; VoiSS = Voice Symptom Scale.×
* p < .05.
p < .05.×
** p < .01.
p < .01.×
×
Discussion
Unlike other areas of SLP practice (speech, language, swallowing), ASHA (2004)  preferred practice patterns for voice (voice disorders, laryngeal speech, and/or laryngeal disorder affecting respiration) apply across the life span, with no separate guidance for pediatric versus adult caseloads. Expected outcomes of a voice assessment include identification and description of underlying strengths and deficits affecting respiration and communication, effects of the voice on the individual's daily life, and contextual factors serving as barriers and facilitators to successful communication, with a voice disorder defined as “the abnormal production and/or absences of vocal quality, pitch, loudness, resonance, and/or duration, which is inappropriate for an individual's age and/or sex” (ASHA, 1993). ASHA supports the use of standardized, nonstandardized, perceptual, and instrumental methods of evaluation in order to document perceptual, acoustic, physiological, behavioral, emotional, and functional aspects of voice production, stipulating, however, that “all patients/clients with voice disorders are examined by a physician, preferably in a discipline appropriate to the presenting complaint” (ASHA, 2004). Augmenting the ASHA guidelines, the recent clinical practice guidelines for hoarseness (dysphonia; Schwartz et al., 2009) recommend visualization of the larynx to be performed in all patients with unresolved hoarseness of a maximum of 3 months or sooner in those with suspected serious etiologies. SLPs in the current study generally reported practice in line with evaluation recommendations, using a combination of perceptual and instrumental measures to document voice. However, half did not require otolaryngology consultation, and measurement tended to focus on vocal structure and function to a greater extent than activity, participation, and QOL.
There were several similarities, as well as some striking differences, between the results of this study and those performed in Australia. Signorelli et al. (2011)  reported similar findings to ours in the use of a combination of voice therapy techniques: 89% reported use of a combination of indirect and direct therapy in the treatment of acute vocal fold nodules, and 87% reported the same in the treatment of chronic vocal fold nodules. MacBean et al. (2014)  found that 92% used direct therapy, 84% used indirect therapy, 42% reported a combination of surgery and therapy, and 34% reported a “wait and see” approach. This compares with 100% of SLPs in this study reporting use of direct therapy, 93.9% using indirect voice therapy, 50% reporting a combination of surgery and therapy, and 25% reporting a “wait and see” approach. Specific therapy techniques varied somewhat, but vocal hygiene was the most frequently used therapy approach in all three surveys. Voicecraft was the most heavily used direct therapy approach reported by Signorelli et al. (2011), whereas MacBean et al. (2014)  found that resonant voice was the most frequently reported, similar to the current study.
The broader literature surrounding the evaluation of voice disorders supports a multidisciplinary approach, noting the importance of examination of structure and function of the larynx and respiratory system to guide appropriate management. The respondents supported a multidisciplinary approach but identified barriers to this. Some stated that they felt children's poor tolerance of ENT assessments outweighed the relative benefits of laryngeal visualization and reported the view that behavioral therapy is unlikely to do harm. Concern surrounding endoscopic examination of the larynx in children may stem from reported requirements of highly invasive procedures requiring anesthesia in those presenting with hoarseness (e.g., universal protocols of direct laryngoscopy, rigid bronchoscopy with bronchoalveolar lavage, and oesophagoscopy with biopsy; Mandell et al., 2004). Recent publications in the area, however, suggest that transnasal fiberoptic laryngoscopy or rigid laryngostroboscopy is likely tolerated by most children when performed with appropriate equipment by clinicians with suitable skill (Connelly et al., 2009; Schwartz et al., 2009) and may not be necessary in those children with intermittent dysphonia who respond to a 2-month trial of voice therapy (Connelly et al., 2009). It is important to note that documentation of laryngeal pathologies and a medical diagnosis is possible only through medical involvement (ASHA, 1998), and although serious underlying conditions are not common in children, voice change may be the first symptom of a potentially life-threatening condition (e.g., laryngeal papilloma, congenital heart disease, hydrocephalus, or tumors; Schwartz et al., 2009). It is of particular concern, then, that a proportion of the respondents in the current study cited workplace restrictions (e.g., limited access to ENT resources, school districts not able to require a medical visit prior to beginning therapy) as the major reason behind not requiring ENT review, raising ethical and potentially legal dilemmas for clinicians (Leeper, 1992).
Frequent use of approaches such as ability to modify voice to a model, perceptual evaluation of vocal quality, and acoustic analysis points to considered examination of vocal function. A much higher percentage of U.S. SLPs than Australian SLPs reported the use of visualization and instrumental assessment in evaluation. The majority of SLPs demonstrated effort to gain insight into voice-related impact on well-being through inclusion of at least one QOL measure during evaluation, similarly to MacBean et al. (2014) . However, not all SLPs reported repeating QOL measures prior to discharge, and instruments used by clinicians encompassed a spectrum of published and self-derived approaches, only a proportion of which were specific to the pediatric population. Discharge assessment more frequently involved ability to modify to model, body movement and position, perceptual assessment of voice quality, and patient self-perception. Participants indicated a self-discharge rate (as opposed to formal, clinician-driven discharge) of 24.8%. This contrasts with the reported self-discharge or dropout rate in adults undergoing voice therapy of 64.6% (Hapner, Portone-Maira, & Johns, 2009).
Determining the impact of voice disorders on daily living and well-being is less well defined in pediatrics than in adult clients (Carroll, Mudd, & Zur, 2013). Multiple scales are available for clinical use; however, these generally rely on parent proxy as a direct adaptation of adult instruments (Johnson, Brehm, Weinrich, Meinzen-Derr, & de Alarcon, 2011). Concerns have been raised surrounding the validity of such an approach, with the view that children experience different consequences and demands on voice than adult clients (Carroll et al., 2013), requiring specifically developed scales. In addition, patient-derived voice-related QOL measures have been shown to differ from the clinician's evaluation of voice, with no current consensus on a single outcome measure for voice intervention in this population (Johnson et al., 2011). Potential exists, then, to further advance client care through more comprehensive examination of functioning in terms of activity, participation, and well-being, with current practice in this area providing impetus for further research into valid measures of voice-related QOL in children.
Clinicians indicated a preference for individualized intervention, preferring to tailor a combination of direct (e.g., semioccluded vocal tract, vocal function exercises, yawn–sigh) and indirect (vocal hygiene, relaxation, breathing) therapy approaches, depending on the child and etiology of voice disorder, in collaboration with parents and other significant caregivers (e.g., teachers). This combination of approaches, although in line with person-centered care approaches advocated by the International Classification of Functioning, Disability and Health (World Health Organization, 2001; fundamental to ASHA's preferred practice patterns), raises the issue of evidence-based practice—in particular, whether the individual techniques themselves are valid and the impact of piecing together elements of different approaches in formulating individualized care. Although intervention for voice therapy is considered both effective and efficient in addressing voice disturbances in both adults and children (ASHA, 2005), the evidence surrounding control or preventative measures (e.g., hydration, avoidance of irritants) was recently reported to be of insufficient scope and quality for a recommendation to be made for routine inclusion in management (Schwartz et al., 2009). Direct voice therapy has been shown to be effective in improving perceptual and instrumental measures of voice quality in children (Tezcaner, Karatayli Ozgursoy, Sati, & Dursun, 2009; Trani, Ghidini, Bergamini, & Presutti, 2007; Valadez et al., 2012). Specific direct therapy techniques (e.g., vocal function exercises, resonant therapy, and semioccluded vocal tract exercises) have been reported to offer superior results compared with indirect approaches (Roy, 2012). However, uncertainty remains surrounding the “active ingredient” and optimum dosage of direct therapies for individual cases (Roy, 2012).
The rate of self-identification as a voice specialist was high in comparison with the MacBean et al. (2014)  study, in which only 16.6% of respondents identified themselves as voice specialists. It is interesting to note that 92% reported confidence in treating voice disorders. This is much higher than the 43.75% in the survey by MacBean et al. (2104)  and in stark contrast with the survey of school-based SLPs in Nebraska (Teten et al., 2015), in which the mean self-rated competency levels on 24 of 25 items were less than “moderately competent.”
Degree of expertise in the management of pediatric dysphonia (voice specialist vs. nonspecialist) did appear to affect clinical choices among SLPs, as did workplace setting. To a large extent, these findings are not unexpected, with frequency of use of instrumental techniques, for example, likely associated with availability of instrumentation in university and hospital settings and degree of specialty training. Acceptance of the child with a voice disorder on the school caseload has been reported to be problematic for more than 20 years (Leeper, 1992), with calls for greater appreciation of the academic and social implications of childhood dysphonia and continued research (Hooper, 2004). Responses to open-ended questions did identify barriers to assessment and treatment of voice disorders in schools, including lack of equipment and inability to refer to an ENT. Specific focus on the identification of barriers and facilitators across stages of clinical management, as perceived by key stakeholders, may be of assistance in promoting best practice for school-based SLPs, with particular reference to ethical and legal requirements of SLP practice within this setting.
Interpretation of these results should be made with a clear understanding of the possible confounds, including participants and survey methodology. Participants were diverse in terms of clinical experience and workplace setting, aiding the generalizability of the results to SLPs in the United States. However, it must be noted that within the sample, few SLPs provided services in nonmetropolitan areas, and school-based SLPs were relatively less well represented than those in health care settings. Recruitment procedures were directed toward all SLPs currently servicing voice within their pediatric caseload. Even so, 77% of respondents identified as specialists in voice, suggesting that clinicians with a special interest in voice may have been more likely to respond to the survey. For those clinicians providing service to few clients with voice disorders, these results may overestimate their use of assessment and treatment approaches. The survey itself was online (potentially affecting the type of respondent), was lengthy (only complete responses were used), and contained set options for response, which, although encouraging recall of a range of techniques, may have influenced results. The methods of distribution (e-mail, ASHA groups, social media) were designed to reach a high number of SLPs. Despite this, response rate was low in comparison with similar studies. For example, Allen et al. (1991)  received responses from 32 SLPs in the state of Maine alone (a 46% response rate), Signorelli et al. (2011)  had 63 respondents in Australia, and MacBean et al. (2014)  had 49 complete responses. Previous surveys have been shorter in length, ranging from 11 questions (Allen et al., 1991) to 25 questions (Teten et al., 2015), and the length of the survey may have negatively affected completion. The limited number of responses is a limitation of the study, as it may not be reflective of the SLP population of the United States as a whole. The anonymous nature of the survey encouraged accurate reporting; however, it is possible that self-report bias was present to some degree. The scope of the project—examining pediatric voice disorders in general and not focusing on a specific disorder as previous studies have done—may have served to draw a wider range of answers. For example, the qualitative responses of some participants discuss evaluation and treatment of paradoxical vocal fold motion, for which evaluation and therapy are different than for nodules or other benign vocal fold lesions causing hoarseness. Future studies would benefit from focusing on one specific disorder or subset of disorders or from sections within the same survey addressing different disorders.
Through documentation of current practice patterns of SLPs in pediatric dysphonia, future research, advocacy, and education can be better directed toward areas of need and isolate areas most likely to result in maximum impact. Differences in approaches between workplace settings, for example, warrant further investigation, particularly school-based SLPs compared with those in health care settings. In line with holistic, client-centered care ideals, attention toward accurate examination of QOL and well-being factors is required, as is further research evidence of voice therapy approaches.
This investigation provides vital insight into the current practice of SLPs in the management of pediatric vocal health, highlights the influence of intrinsic and extrinsic factors on practice, and identifies targets for ongoing quality improvement. In general, the reported approaches mirror literature recommendations, with clinicians favoring multidisciplinary collaboration and use of a combination of perceptual, instrumental, and QOL measures to shape individualized intervention approaches. Substantial numbers of SLPs, however, report practice contrary to existing guidelines, particularly regarding the involvement of medical specialists. To ensure that SLPs are best able to support children in successful communication and optimize overall functioning, further research, education, and advocacy targeted toward those areas most likely to result in maximum impact on SLP practice and improvements in client care are required. This may include increased continuing education focused on voice evaluation and treatment in children, more research on the aspects of a voice evaluation most necessary to determine appropriate treatment, and strategies to improve collaboration between school-based and medically based SLPs and otolaryngologists, especially outside of specialized voice clinics.
Acknowledgments
This work was funded by the Diane M. Bless Endowed Chair in Otolaryngology–Head and Neck Surgery. The authors acknowledge statistical assistance from Glen Leverson, Department of Surgery, University of Wisconsin–Madison.
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Trani, M., Ghidini, A., Bergamini, G., & Presutti, L. (2007). Voice therapy in pediatric functional dysphonia: A prospective study. International Journal of Pediatric Otorhinolaryngology, 71, 379–384. https://doi.org/10.1016/j.ijporl.2006.11.002 [Article] [PubMed]
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Appendix
Survey
1. I am ASHA certified to practice as an SLP in the United States.
○ Yes (1)
○ No (2)
2. Within the past 6 months, I have provided services for voice as part of my pediatric caseload within the United States through either direct contact (assessment/treatment) or nonclient specific education.
○ Yes (1)
○ No (2): Thank you for your interest, but we are not able to take your response at this time.
3. What percentage of your caseload relates to pediatric voice disorders? Please enter a percentage value between 1 and 100. _______________________
4. Within your pediatric voice caseload, what percentage relates to (please enter a percentage value between 1 and 100):
• Assessment (1) ____________
• Treatment (2) ____________
• Education/service/outreach (3) ____________
5. My gender is:
○ Male (1)
○ Female (2)
6. My age bracket is:
○ 20–30 years old (1)
○ 31–40 years old (2)
○ 41–50 years old (3)
○ 51–64 years old (4)
○ 65+ years old (5)
7. My speech pathology qualifications include (you may select more than one response):
□ Bachelor's degree (1)
□ Master's degree (2)
□ PhD (3)
8. I completed my speech pathology training in:
○ United States (1)
○ Europe (2)
○ Canada (3)
○ Australia (4)
○ New Zealand (5)
○ South Africa (6)
○ United Kingdom (7)
○ Ireland (8)
○ Other: (9) ____________________
9. If you completed your speech pathology education in America, please indicate the state and university where you received this training:
○ Alabama (AL) (1)
○ Alaska (AK) (2)
○ Arizona (AZ) (3)
○ Arkansas (AR) (4)
○ California (CA) (5)
○ Colorado (CO) (6)
○ Connecticut (CT) (7)
○ Delaware (DE) (8)
○ Florida (FL) (9)
○ Georgia (GA) (10)
○ Hawaii (HI) (11)
○ Idaho (ID) (12)
○ Illinois (IL) (13)
○ Indiana (IN) (14)
○ Iowa (IA) (15)
○ Kansas (KS) (16)
○ Kentucky (KY) (17)
○ Louisiana (LA) (18)
○ Maine (ME) (19)
○ Maryland (MD) (20)
○ Massachusetts (MA) (21)
○ Michigan (MI) (22)
○ Minnesota (MN) (23)
○ Mississippi (MS) (24)
○ Missouri (MO) (25)
○ Montana (MT) (26)
○ Nebraska (NE) (27)
○ Nevada (NV) (28)
○ New Hampshire (NH) (29)
○ New Jersey (NJ) (30)
○ New Mexico (NM) (31)
○ New York (NY) (32)
○ North Carolina (NC) (33)
○ North Dakota (ND) (34)
○ Ohio (OH) (35)
○ Oklahoma (OK) (36)
○ Oregon (OR) (37)
○ Pennsylvania (PA) (38)
○ Rhode Island (RI) (39)
○ South Carolina (SC) (40)
○ South Dakota (SD) (41)
○ Tennessee (TN) (42)
○ Texas (TX) (43)
○ Utah (UT) (44)
○ Vermont (VT) (45)
○ Virginia (VA) (46)
○ Washington (WA) (47)
○ West Virginia (WV) (48)
○ Wisconsin (WI) (49)
○ Wyoming (WY) (50)
○ Washington, DC (51)
10. Please write the name of the institution where you received this training:
_____________________________________________________
11. I was certified as a CCC-SLP in (year): _______________
12. I currently work in:
Note. If you working in more than one area specified, please choose the employment option where you see the most children.
□ School (1)
□ Birth-to-three program (2)
□ Hospital (3)
□ Skilled nursing facility (4)
□ Outpatient clinic (5)
□ Private practice (6)
□ University clinic (7)
□ Home health (8)
□ Other (9) ____________________
13. I provide speech pathology services in:
State (e.g., Wisconsin) (1) _______________________
County (e.g., Dane) (2) ___________________________
14. I feel confident managing the assessment and treatment of pediatric voice disorders.
○ Yes (1)
○ No (2)
15. I consider myself to be a voice specialist.
○ Yes (1)
○ No (2)
16. Please specify which sources you use to attain clinical information about the management of vocal health in children:
□ Journal articles (1)
□ Textbooks (2)
□ The Internet (3)
□ Notes from lectures, conferences, and so on (4)
□ Colleagues and expert opinions (5)
□ Attending workshops, training seminars, professional development events, and conferences (6)
□ Voice interest groups (7)
□ Other: (8) ____________________
17. Please specify which source you most frequently use to attain clinical information about the management of pediatric vocal health.
○ Journal articles and textbooks (1)
○ Internet resources (e.g., websites, YouTube videos) (2)
○ Colleagues and expert opinion (3)
○ Professional development events (e.g., workshops, conferences) (4)
○ Voice interest groups (5)
○ Other: (6) ____________________
18. Do you currently provide education regarding pediatric vocal health (not client specific)? Please indicate all that apply.
□ No (1)
□ Yes, written information to service providers (e.g., schools, performing arts training) (2)
□ Yes, in-person seminars at service providers (e.g., schools, performing arts training) (3)
□ Yes, in-services with your organization (4)
□ Other; please provide detail in box (5) ____________________
19. What percentage of your pediatric voice caseload is providing education/service/outreach regarding voice disorders (not client specific)? Please enter a percentage value between 0 and 100. _______________
20. I assess voice as a part of my pediatric voice caseload.
○ Yes (1)
○ No (2): Go to question 29.
21. What percentage of your pediatric voice caseload is assessment only? Please enter a percentage value between 0 and 100. _____________________
22. How important do you consider the need to assess a child for his or her vocal health?
○ Not important (1)
○ Slightly important (2)
○ Moderately important (3)
○ Very important (4)
○ Essential (5)
○ Other: (6) ____________________
23. What is your reason for this choice?
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
24. How often do you use the following assessment procedures with a child for his or her voice problems?
Never (1) Rarely (2) About 50% of the time (3) Often (4) All of the time (5)
Videostroboscopy (SLP performed) (1)
Videostroboscopy (review of ENT video) (2)
High-speed laryngoscopy (3)
Instrumental aerodynamic assessment (4)
Instrumental acoustic assessment (5)
Electroglottographic assessment (6)
Patient self-perception assessment (7)
Perceptual assessment of voice quality (8)
Observation of patient's body movement and position (9)
Observation of patient's ability to modify voice production in response to direction and/or modeling (10)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.__________________________________ (11)
Never (1) Rarely (2) About 50% of the time (3) Often (4) All of the time (5)
Videostroboscopy (SLP performed) (1)
Videostroboscopy (review of ENT video) (2)
High-speed laryngoscopy (3)
Instrumental aerodynamic assessment (4)
Instrumental acoustic assessment (5)
Electroglottographic assessment (6)
Patient self-perception assessment (7)
Perceptual assessment of voice quality (8)
Observation of patient's body movement and position (9)
Observation of patient's ability to modify voice production in response to direction and/or modeling (10)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.__________________________________ (11)
×
25. How do you use the following perceptual assessment techniques in the management of an individual child with a voice disorder?
I use this technique alone (1) I use this combined with other techniques (2) I don't use this technique (3)
Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) (1)
GRBAS Scale for Auditory-Perceptual Evaluation (2)
Oates Perceptual Voice Profile (3)
Audio voice recordings (no formal rating scale) (4)
Informal listener judgment (i.e., not using a published rating scale) (5)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.___________________________________ (6)
I use this technique alone (1) I use this combined with other techniques (2) I don't use this technique (3)
Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) (1)
GRBAS Scale for Auditory-Perceptual Evaluation (2)
Oates Perceptual Voice Profile (3)
Audio voice recordings (no formal rating scale) (4)
Informal listener judgment (i.e., not using a published rating scale) (5)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.___________________________________ (6)
×
26. How do you use the following patient perception of quality of life scales in the management of an individual child with a voice disorder?
I use this measure alone (1) I use this combined with other measures (2) I don't use this measure (3)
Voice Handicap Index (VHI) (1)
Pediatric Voice Handicap Index (pVHI) (2)
Voice Symptom Scale (VoiSS) (3)
Voice Outcome Survey (VOS) (4)
Pediatric Voice Outcome Survey (pVOS) (5)
Voice-Related Quality of Life (V-RQOL) (6)
Pediatric Voice-Related Quality of Life (pV-RQOL) (7)
Voice Activity and Participation Profile (VAPP) (8)
Therapy Outcome Measures (TOMS) (9)
Other: Please list and briefly describe any quality of life measures that you use that were not listed above.________________________________ (10)
I use this measure alone (1) I use this combined with other measures (2) I don't use this measure (3)
Voice Handicap Index (VHI) (1)
Pediatric Voice Handicap Index (pVHI) (2)
Voice Symptom Scale (VoiSS) (3)
Voice Outcome Survey (VOS) (4)
Pediatric Voice Outcome Survey (pVOS) (5)
Voice-Related Quality of Life (V-RQOL) (6)
Pediatric Voice-Related Quality of Life (pV-RQOL) (7)
Voice Activity and Participation Profile (VAPP) (8)
Therapy Outcome Measures (TOMS) (9)
Other: Please list and briefly describe any quality of life measures that you use that were not listed above.________________________________ (10)
×
Other: ____________________________________
27. If the patient has not been referred by an otolaryngologist (ENT), how important do you consider an ENT referral before completing your assessment of the child's voice?
○ Essential (1)
○ Desirable (2)
○ Case dependent (3)
○ Not required (4)
28. What are your reasons for this choice?
_______________________________________________________
_______________________________________________________
_______________________________________________________
29. I provide therapy as a part of my pediatric voice caseload.
○ Yes (1)
○ No (2): Go to question 41.
30. What percentage of your pediatric voice caseload is therapy only (i.e., time spent doing voice therapy with children that does not include assessment)? Please enter a percentage value between 1 and 100. __________________________
31. What is your usual frequency of voice therapy with children?
○ Once a week (1)
○ Twice a week (2)
○ Every 2 weeks (3)
○ Intensives (e.g., over school break/vacation) (4)
○ Other: (5) ____________________
32. Please specify which management approaches you typically use for a child with a voice disorder. Select yes or no for each option.
Yes (1) No (2)
No treatment or wait and see (1)
Indirect voice therapy (e.g., vocal hygiene, voice minimization) (2)
Direct voice therapy (e.g., yawn–sigh, yell well, resonant voice therapy) (3)
Refer for surgery (e.g., treatment for nodules) (4)
A combination of voice therapy and surgery (e.g., treatment of nodules) (5)
A set therapy program (e.g., Adventures in Voice) (6)
Other: Please specify other methods of treatment _________________________ (7)
Yes (1) No (2)
No treatment or wait and see (1)
Indirect voice therapy (e.g., vocal hygiene, voice minimization) (2)
Direct voice therapy (e.g., yawn–sigh, yell well, resonant voice therapy) (3)
Refer for surgery (e.g., treatment for nodules) (4)
A combination of voice therapy and surgery (e.g., treatment of nodules) (5)
A set therapy program (e.g., Adventures in Voice) (6)
Other: Please specify other methods of treatment _________________________ (7)
×
33. What do you believe is the most effective treatment for childhood voice disorders?
_______________________________________________________
_______________________________________________________
_______________________________________________________
34. What is your reason for this choice?
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
35. Please specify which indirect and direct voice techniques you use to treat an individual child with a voice disorder.
I use this technique alone (1) I use this combined with other techniques (2) I don't use this technique (3)
Vocal hygiene and education programs (1)
Chant talk (2)
Froeschels's chewing technique (3)
Voicecraft techniques (e.g., giggle, sob, yell well) (4)
Glottal attack changes (5)
Open-mouth approaches (6)
Yawn–sigh (7)
Set program (e.g., Adventures in Voice) (8)
Accent method (9)
Confidential voice (10)
Resonant voice (11)
Estill voice techniques (e.g., retraction, silent giggle, twang) (12)
Semioccluded vocal tract exercises (e.g., lip trills, humming, straw phonation) (13)
Vocal function exercises (14)
Other: Please list and briefly describe any therapy techniques you use that were not listed above._______________________________ (15)
I use this technique alone (1) I use this combined with other techniques (2) I don't use this technique (3)
Vocal hygiene and education programs (1)
Chant talk (2)
Froeschels's chewing technique (3)
Voicecraft techniques (e.g., giggle, sob, yell well) (4)
Glottal attack changes (5)
Open-mouth approaches (6)
Yawn–sigh (7)
Set program (e.g., Adventures in Voice) (8)
Accent method (9)
Confidential voice (10)
Resonant voice (11)
Estill voice techniques (e.g., retraction, silent giggle, twang) (12)
Semioccluded vocal tract exercises (e.g., lip trills, humming, straw phonation) (13)
Vocal function exercises (14)
Other: Please list and briefly describe any therapy techniques you use that were not listed above._______________________________ (15)
×
36. Do you use instrumental tools to provide biofeedback during sessions?
○ Yes (1)
○ No (2): Go to question 39.
37. Please describe which instrumental tools you use (e.g., Visi-Pitch, organizing trials on scope with ENT for therapy techniques):
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
38. What is your reason for this choice?
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
39. Do you require otolaryngology (ENT) review prior to commencing therapy?
○ Yes (1)
○ No (2)
○ Dependent on case (3)
40. What is your reason for this choice?
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
41. What percentage of patients do you formally discharge (e.g., take outcome measures, recommend cessation of therapy)? Please enter a percentage value between 1 and 100. _____________________________
42. What percentage of your patients typically self-discharge (e.g., cancel next appointment and do not rebook)? Please enter a percentage value between 1 and 100. _____________________________
43. Do you use the following outcome measures prior to discharging a child with a voice disorder?
I use this measure alone (1) I use this combined with other measures (2) I don't use this technique (3)
Voice Handicap Index (VHI) (1)
Pediatric Voice Handicap Index (pVHI) (2)
Voice Symptom Scale (VoiSS) (3)
Voice Outcome Survey (VOS) (4)
Pediatric Voice Outcome Survey (pVOS) (5)
Voice-Related Quality of Life (V-RQOL) (6)
Pediatric Voice-Related Quality of Life (pV-RQOL) (7)
Voice Activity and Participation Profile (VAPP) (8)
Therapy Outcome Measures (TOMS) (9)
Pre/post recording comparison (10)
Clinician judgment (11)
Review of ENT assessment (12)
Instrumental assessment (13)
Other: Please list and briefly describe any outcome measures that you use that were not listed above. ________________________ (14)
I use this measure alone (1) I use this combined with other measures (2) I don't use this technique (3)
Voice Handicap Index (VHI) (1)
Pediatric Voice Handicap Index (pVHI) (2)
Voice Symptom Scale (VoiSS) (3)
Voice Outcome Survey (VOS) (4)
Pediatric Voice Outcome Survey (pVOS) (5)
Voice-Related Quality of Life (V-RQOL) (6)
Pediatric Voice-Related Quality of Life (pV-RQOL) (7)
Voice Activity and Participation Profile (VAPP) (8)
Therapy Outcome Measures (TOMS) (9)
Pre/post recording comparison (10)
Clinician judgment (11)
Review of ENT assessment (12)
Instrumental assessment (13)
Other: Please list and briefly describe any outcome measures that you use that were not listed above. ________________________ (14)
×
44. How often do you perform the following assessments with a child for his or her voice problems at the time of discharge?
Never (1) Rarely (2) About 50% of the time (3) Often (4) All of the time (5)
Videostroboscopy (SLP performed) (1)
Videostroboscopy (review of ENT video) (2)
High-speed laryngoscopy (3)
Instrumental aerodynamic assessment (4)
Instrumental acoustic assessment (5)
Electroglottographic assessment (6)
Patient self-perception assessment (7)
Perceptual assessment of voice quality (8)
Observation of patient's body movement and position (9)
Observation of patient's ability to modify voice production in response to direction and/or modeling (10)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.__________________________________________ (11)
Never (1) Rarely (2) About 50% of the time (3) Often (4) All of the time (5)
Videostroboscopy (SLP performed) (1)
Videostroboscopy (review of ENT video) (2)
High-speed laryngoscopy (3)
Instrumental aerodynamic assessment (4)
Instrumental acoustic assessment (5)
Electroglottographic assessment (6)
Patient self-perception assessment (7)
Perceptual assessment of voice quality (8)
Observation of patient's body movement and position (9)
Observation of patient's ability to modify voice production in response to direction and/or modeling (10)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.__________________________________________ (11)
×
45. Are there any additional comments you would like to make regarding how you decide on which management approach to use for pediatric vocal health?
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
The survey presented in this Appendix appears courtesy of the authors.
Figure 1.

Assessments for voice evaluation: frequency of use by speech-language pathologists (SLPs; n = 99). ENT = ear, nose, and throat specialist.

 Assessments for voice evaluation: frequency of use by speech-language pathologists (SLPs; n = 99). ENT = ear, nose, and throat specialist.
Figure 1.

Assessments for voice evaluation: frequency of use by speech-language pathologists (SLPs; n = 99). ENT = ear, nose, and throat specialist.

×
Figure 2.

Assessments at evaluation: percentage of speech-language pathologists (n = 100) using approach alone or in combination. CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; PVP = Pediatric Voice Profile; QOL = quality of life; VHI = Voice Handicap Index; pVHI = Pediatric Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; VAPP = Voice Activity and Participation Profile; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; TOMS = Therapy Outcome Measures.

 Assessments at evaluation: percentage of speech-language pathologists (n = 100) using approach alone or in combination. CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; PVP = Pediatric Voice Profile; QOL = quality of life; VHI = Voice Handicap Index; pVHI = Pediatric Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; VAPP = Voice Activity and Participation Profile; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; TOMS = Therapy Outcome Measures.
Figure 2.

Assessments at evaluation: percentage of speech-language pathologists (n = 100) using approach alone or in combination. CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; PVP = Pediatric Voice Profile; QOL = quality of life; VHI = Voice Handicap Index; pVHI = Pediatric Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; VAPP = Voice Activity and Participation Profile; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; TOMS = Therapy Outcome Measures.

×
Figure 3.

Intervention: percentage of speech-language pathologists (n = 98) using approach alone versus in combination. SOVT = semioccluded vocal tract exercises; VFE = vocal function exercises.

 Intervention: percentage of speech-language pathologists (n = 98) using approach alone versus in combination. SOVT = semioccluded vocal tract exercises; VFE = vocal function exercises.
Figure 3.

Intervention: percentage of speech-language pathologists (n = 98) using approach alone versus in combination. SOVT = semioccluded vocal tract exercises; VFE = vocal function exercises.

×
Figure 4.

Assessments prior to discharge: percentage of speech-language pathologists (n = 100) using approach alone versus in combination. pVHI = Pediatric Voice Handicap Index; VHI = Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; VAPP = Voice Activity and Participation Profile; TOMS = Therapy Outcome Measures.

 Assessments prior to discharge: percentage of speech-language pathologists (n = 100) using approach alone versus in combination. pVHI = Pediatric Voice Handicap Index; VHI = Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; VAPP = Voice Activity and Participation Profile; TOMS = Therapy Outcome Measures.
Figure 4.

Assessments prior to discharge: percentage of speech-language pathologists (n = 100) using approach alone versus in combination. pVHI = Pediatric Voice Handicap Index; VHI = Voice Handicap Index; pvRQOL = Pediatric Voice-Related Quality of Life; VRQOL = Voice-Related Quality of Life; pVOS = Pediatric Voice Outcome Survey; VOS = Voice Outcome Survey; VoiSS = Voice Symptom Scale; VAPP = Voice Activity and Participation Profile; TOMS = Therapy Outcome Measures.

×
Figure 5.

Assessments prior to discharge: frequency of use by speech-language pathologists (SLPs; n = 100). ENT = ear, nose, and throat specialist; EGG = electroglottography.

 Assessments prior to discharge: frequency of use by speech-language pathologists (SLPs; n = 100). ENT = ear, nose, and throat specialist; EGG = electroglottography.
Figure 5.

Assessments prior to discharge: frequency of use by speech-language pathologists (SLPs; n = 100). ENT = ear, nose, and throat specialist; EGG = electroglottography.

×
Table 1. Rural–urban continuum codes (United States Department of Agriculture, 2013).
Rural–urban continuum codes (United States Department of Agriculture, 2013).×
Metro counties 1 Counties in metropolitan areas with population of ≥ 1 million
2 Counties in metropolitan areas of 250,000 to 1 million
3 Counties in metropolitan areas of fewer than 250,000
Nonmetro counties 4 Urban population of 20,000 or more adjacent to a metropolitan area
5 Urban population of 20,000 or more not adjacent to a metropolitan area
6 Urban population of 2,500 to 19,999 adjacent to a metropolitan area
7 Urban population of 2,500 to 19,999 not adjacent to a metropolitan area
8 Completely rural or less than 2,500 urban population adjacent to a metropolitan area
9 Completely rural or less than 2,500 urban population not adjacent to a metropolitan area
Table 1. Rural–urban continuum codes (United States Department of Agriculture, 2013).
Rural–urban continuum codes (United States Department of Agriculture, 2013).×
Metro counties 1 Counties in metropolitan areas with population of ≥ 1 million
2 Counties in metropolitan areas of 250,000 to 1 million
3 Counties in metropolitan areas of fewer than 250,000
Nonmetro counties 4 Urban population of 20,000 or more adjacent to a metropolitan area
5 Urban population of 20,000 or more not adjacent to a metropolitan area
6 Urban population of 2,500 to 19,999 adjacent to a metropolitan area
7 Urban population of 2,500 to 19,999 not adjacent to a metropolitan area
8 Completely rural or less than 2,500 urban population adjacent to a metropolitan area
9 Completely rural or less than 2,500 urban population not adjacent to a metropolitan area
×
Table 2. Demographics of respondents.
Demographics of respondents.×
Variable n
Workplace type
 School 10
 Birth-to-three program 1
 Hospital 32
 Skilled nursing facility 1
 Outpatient clinic 32
 Private practice 27
 University clinic 16
RUCC
 1 54
 2 26
 3 13
 4 2
 5 1
 6 1
 7 0
 8 0
 9 0
Age (years)
 20–30 16
 31–40 29
 41–50 17
 51–64 36
 ≥65 2
Note. RUCC = rural–urban continuum code.
Note. RUCC = rural–urban continuum code.×
Table 2. Demographics of respondents.
Demographics of respondents.×
Variable n
Workplace type
 School 10
 Birth-to-three program 1
 Hospital 32
 Skilled nursing facility 1
 Outpatient clinic 32
 Private practice 27
 University clinic 16
RUCC
 1 54
 2 26
 3 13
 4 2
 5 1
 6 1
 7 0
 8 0
 9 0
Age (years)
 20–30 16
 31–40 29
 41–50 17
 51–64 36
 ≥65 2
Note. RUCC = rural–urban continuum code.
Note. RUCC = rural–urban continuum code.×
×
Table 3. Practice patterns: voice specialist versus nonspecialist speech-language pathologists (SLPs).
Practice patterns: voice specialist versus nonspecialist speech-language pathologists (SLPs).×
Variable Voice specialist
Nonspecialist
χ2 p
n % n %
Assessment (item 24; n = 99)
 SLP stroboscopy 50% or more 36 47.37 3 13.04 .003
Never/rarely 40 52.63 20 86.96
 Acoustic analysis 50% or more 62 81.58 9 39.13 15.685 <.001
Never/rarely 14 18.42 14 60.87
 GRBAS Alone/in combination 34 44.74 5 21.74 3.911 .048
Never used 42 55.26 18 78.26
 Voice recordings Alone/in combination 73 96.05 18 78.26 .016
Never used 3 3.95 5 21.74
 pVHI Alone/in combination 48 63.16 7 30.43 7.657 .006
Never used 28 36.84 16 69.57
Treatment (item 35; n = 98)
 Chant talk Alone/in combination 54 71.05 10 45.45 4.934 .026
Never used 22 28.95 12 54.55
 Resonant voice Alone/in combination 73 96.05 16 72.73 .004
Never used 3 3.95 6 27.27
 Semioccluded vocal tract Alone/in combination 73 96.05 15 68.18 .001
Never used 3 3.95 7 31.82
 Vocal function exercises Alone/in combination 69 90.79 15 68.18 7.121 .008
Never used 7 9.21 7 31.82
 Biofeedback Used 63 82.89 12 54.55 7.634 .006
Not used 13 17.11 10 45.45
Discharge (item 43; n = 100)
 VoiSS Alone/in combination 2 2.60 4 17.39 .024
Never used 75 97.40 19 82.61
 Instrumental assessments Alone/in combination 61 79.22 13 56.52 4.743 .029
Never used 16 20.78 10 43.48
 Acoustic analysis 50% or more 54 70.13 11 47.83 3.873 .049
Never/rarely 23 29.87 12 52.17
Sources of clinical information (item 16; n = 100)
 Voice interest groups Used 57 74.03 7 30.43 14.606 <.001
Not used 20 25.97 16 69.57
 Journal articles Used 76 98.70 18 78.26 13.120 <.001
Not used 1 1.30 5 21.74
Note. Fisher's exact test used when cell count < 5. pVHI = Pediatric Voice Handicap Index; VoiSS = Voice Symptom Scale.
Note. Fisher's exact test used when cell count < 5. pVHI = Pediatric Voice Handicap Index; VoiSS = Voice Symptom Scale.×
Table 3. Practice patterns: voice specialist versus nonspecialist speech-language pathologists (SLPs).
Practice patterns: voice specialist versus nonspecialist speech-language pathologists (SLPs).×
Variable Voice specialist
Nonspecialist
χ2 p
n % n %
Assessment (item 24; n = 99)
 SLP stroboscopy 50% or more 36 47.37 3 13.04 .003
Never/rarely 40 52.63 20 86.96
 Acoustic analysis 50% or more 62 81.58 9 39.13 15.685 <.001
Never/rarely 14 18.42 14 60.87
 GRBAS Alone/in combination 34 44.74 5 21.74 3.911 .048
Never used 42 55.26 18 78.26
 Voice recordings Alone/in combination 73 96.05 18 78.26 .016
Never used 3 3.95 5 21.74
 pVHI Alone/in combination 48 63.16 7 30.43 7.657 .006
Never used 28 36.84 16 69.57
Treatment (item 35; n = 98)
 Chant talk Alone/in combination 54 71.05 10 45.45 4.934 .026
Never used 22 28.95 12 54.55
 Resonant voice Alone/in combination 73 96.05 16 72.73 .004
Never used 3 3.95 6 27.27
 Semioccluded vocal tract Alone/in combination 73 96.05 15 68.18 .001
Never used 3 3.95 7 31.82
 Vocal function exercises Alone/in combination 69 90.79 15 68.18 7.121 .008
Never used 7 9.21 7 31.82
 Biofeedback Used 63 82.89 12 54.55 7.634 .006
Not used 13 17.11 10 45.45
Discharge (item 43; n = 100)
 VoiSS Alone/in combination 2 2.60 4 17.39 .024
Never used 75 97.40 19 82.61
 Instrumental assessments Alone/in combination 61 79.22 13 56.52 4.743 .029
Never used 16 20.78 10 43.48
 Acoustic analysis 50% or more 54 70.13 11 47.83 3.873 .049
Never/rarely 23 29.87 12 52.17
Sources of clinical information (item 16; n = 100)
 Voice interest groups Used 57 74.03 7 30.43 14.606 <.001
Not used 20 25.97 16 69.57
 Journal articles Used 76 98.70 18 78.26 13.120 <.001
Not used 1 1.30 5 21.74
Note. Fisher's exact test used when cell count < 5. pVHI = Pediatric Voice Handicap Index; VoiSS = Voice Symptom Scale.
Note. Fisher's exact test used when cell count < 5. pVHI = Pediatric Voice Handicap Index; VoiSS = Voice Symptom Scale.×
×
Table 4. Practice patterns: workplace type.
Practice patterns: workplace type.×
Variable School
Hospital
Outpatient clinic
Private practice
University clinic
n % n % n % n % n %
Assessment (item 24; n = 80)
 SLP stroboscopy 50% or more 0 0.00* 8 47.06 8 36.36 7 33.33 9 81.82**
Never/rarely 9 100.00 9 52.94 16 72.73 14 66.67 2 18.18
 ENT stroboscopy 50% or more 0 0.00* 12 70.59** 7 31.82 9 42.86 3 27.27
Never/rarely 9 100.00 5 29.41 15 68.18 12 57.14 8 72.73
 Aerodynamics 50% or more 1 11.11 9 52.94 4 18.18 7 33.33 7 63.64*
Never/rarely 8 88.89 8 47.06 18 81.82 14 66.67 4 36.36
 CAPE-V Alone/combination 4 44.44* 17 100.00** 17 77.27 14 66.67 10 90.91
Never used 5 55.56 0 0.00 5 22.73 7 33.33 1 9.09
 VRQOL Alone/combination 2 22.22 4 23.53 3 13.64 1 4.76* 7 63.64**
Never used 7 77.78 13 76.47 19 86.36 20 95.24 4 36.36
 Acoustics 50% or more 3 33.33* 13 76.47 14 63.64 16 76.19 10 90.91
Never/rarely 6 66.67 4 23.53 8 36.36 5 23.81 1 9.09
 Voice recordings Alone/combination 8 88.89 17 100.00 18 81.82* 20 95.24 11 100.00
Never used 1 11.11 0 0.00 4 18.18 1 4.76 0 0.00
Treatment (item 35; n = 79)
 Resonant voice Alone/combination 4 50.00** 17 100.00 21 95.45 20 95.24 11 100.00
Never used 4 50.00 0 0.00 1 4.55 1 4.76 0 0.00
 Confidential voice Alone/combination 4 50.00 7 41.18* 13 59.09 17 80.95 9 81.82
Never used 4 50.00 10 58.82 9 40.91 4 19.05 2 18.18
Discharge (item 43; n = 81)
 VoiSS Alone/combination 3 33.33** 1 5.56 0 0.00 0 0.00 0 0.00
Never used 6 66.67 17 94.44 22 100.00 21 100.00 11 100.00
 VRQOL Alone/combination 2 22.22 2 11.11 3 13.64 0 0.00* 5 45.45**
Never used 7 77.78 16 88.89 19 86.36 21 100.00 6 54.55
 Pre/post recordings Alone/combination 7 77.78 17 94.44 16 72.73* 21 100.00 11 100.00
Never used 2 22.22 1 5.56 6 27.27 0 0.00 0 0.00
 SLP stroboscopy 50% or more 1 11.11 6 33.33 5 22.73 4 19.05 9 81.82**
Never/rarely 8 88.89 12 66.67 17 77.27 17 80.95 2 18.18
 Acoustics 50% or more 2 22.22** 14 77.78 12 54.55 14 66.67 10 90.91
Never/rarely 7 77.78 4 22.22 10 45.45 7 33.33 1 9.09
 Self-perception 50% or more 9 100.00 17 94.44 20 90.91 16 76.19* 10 90.91
Never/rarely 0 0.00 1 5.56 2 9.09 5 23.81 1 9.09
 Instrumental assessments Alone/combination 4 44.44* 14 77.78 15 68.18 16 76.19 11 100.00
Never used 5 55.56 3 16.67 7 31.82 5 23.81 0 0.00
 ENT stroboscopy 50% or more 1 11.11 9 50.00* 17 77.27 7 33.33 10 90.91
Never/rarely 8 88.89 9 50.00 5 22.73 14 66.67 1 9.09
 Clinician judgment Alone/combination 9 100.00 17 94.44 18 81.82* 20 95.24 11 100.00
Never used 0 0.00 1 5.56 4 18.18 1 4.76 0 0.00
Sources of clinical information (item 16; n = 81)
 Notes (e.g., lectures, conferences) Yes 5 55.56* 17 94.44 16 72.73 18 85.71 11 100.00
No 4 44.44 1 5.56 6 27.27 3 14.29 0 0.00
 Voice interest groups Yes 1 11.11** 11 61.11 1 4.55 17 80.95 8 72.73
No 8 88.89 7 38.89 21 95.45 4 19.05 3 27.27
Clinical specialty (item 15; n = 81)
 Voice specialist Yes 3 33.33** 15 83.33 17 77.27 19 90.48 9 81.82
No 6 66.67 3 16.67 5 22.73 2 9.52 2 18.18
Note. Fisher's exact test used for statistical analysis; 2 × 2 cross-tabulations. SLP = speech-language pathologist; ENT = ear, nose, and throat specialist; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; VRQOL = Voice-Related Quality of Life; VoiSS = Voice Symptom Scale.
Note. Fisher's exact test used for statistical analysis; 2 × 2 cross-tabulations. SLP = speech-language pathologist; ENT = ear, nose, and throat specialist; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; VRQOL = Voice-Related Quality of Life; VoiSS = Voice Symptom Scale.×
* p < .05.
p < .05.×
** p < .01.
p < .01.×
Table 4. Practice patterns: workplace type.
Practice patterns: workplace type.×
Variable School
Hospital
Outpatient clinic
Private practice
University clinic
n % n % n % n % n %
Assessment (item 24; n = 80)
 SLP stroboscopy 50% or more 0 0.00* 8 47.06 8 36.36 7 33.33 9 81.82**
Never/rarely 9 100.00 9 52.94 16 72.73 14 66.67 2 18.18
 ENT stroboscopy 50% or more 0 0.00* 12 70.59** 7 31.82 9 42.86 3 27.27
Never/rarely 9 100.00 5 29.41 15 68.18 12 57.14 8 72.73
 Aerodynamics 50% or more 1 11.11 9 52.94 4 18.18 7 33.33 7 63.64*
Never/rarely 8 88.89 8 47.06 18 81.82 14 66.67 4 36.36
 CAPE-V Alone/combination 4 44.44* 17 100.00** 17 77.27 14 66.67 10 90.91
Never used 5 55.56 0 0.00 5 22.73 7 33.33 1 9.09
 VRQOL Alone/combination 2 22.22 4 23.53 3 13.64 1 4.76* 7 63.64**
Never used 7 77.78 13 76.47 19 86.36 20 95.24 4 36.36
 Acoustics 50% or more 3 33.33* 13 76.47 14 63.64 16 76.19 10 90.91
Never/rarely 6 66.67 4 23.53 8 36.36 5 23.81 1 9.09
 Voice recordings Alone/combination 8 88.89 17 100.00 18 81.82* 20 95.24 11 100.00
Never used 1 11.11 0 0.00 4 18.18 1 4.76 0 0.00
Treatment (item 35; n = 79)
 Resonant voice Alone/combination 4 50.00** 17 100.00 21 95.45 20 95.24 11 100.00
Never used 4 50.00 0 0.00 1 4.55 1 4.76 0 0.00
 Confidential voice Alone/combination 4 50.00 7 41.18* 13 59.09 17 80.95 9 81.82
Never used 4 50.00 10 58.82 9 40.91 4 19.05 2 18.18
Discharge (item 43; n = 81)
 VoiSS Alone/combination 3 33.33** 1 5.56 0 0.00 0 0.00 0 0.00
Never used 6 66.67 17 94.44 22 100.00 21 100.00 11 100.00
 VRQOL Alone/combination 2 22.22 2 11.11 3 13.64 0 0.00* 5 45.45**
Never used 7 77.78 16 88.89 19 86.36 21 100.00 6 54.55
 Pre/post recordings Alone/combination 7 77.78 17 94.44 16 72.73* 21 100.00 11 100.00
Never used 2 22.22 1 5.56 6 27.27 0 0.00 0 0.00
 SLP stroboscopy 50% or more 1 11.11 6 33.33 5 22.73 4 19.05 9 81.82**
Never/rarely 8 88.89 12 66.67 17 77.27 17 80.95 2 18.18
 Acoustics 50% or more 2 22.22** 14 77.78 12 54.55 14 66.67 10 90.91
Never/rarely 7 77.78 4 22.22 10 45.45 7 33.33 1 9.09
 Self-perception 50% or more 9 100.00 17 94.44 20 90.91 16 76.19* 10 90.91
Never/rarely 0 0.00 1 5.56 2 9.09 5 23.81 1 9.09
 Instrumental assessments Alone/combination 4 44.44* 14 77.78 15 68.18 16 76.19 11 100.00
Never used 5 55.56 3 16.67 7 31.82 5 23.81 0 0.00
 ENT stroboscopy 50% or more 1 11.11 9 50.00* 17 77.27 7 33.33 10 90.91
Never/rarely 8 88.89 9 50.00 5 22.73 14 66.67 1 9.09
 Clinician judgment Alone/combination 9 100.00 17 94.44 18 81.82* 20 95.24 11 100.00
Never used 0 0.00 1 5.56 4 18.18 1 4.76 0 0.00
Sources of clinical information (item 16; n = 81)
 Notes (e.g., lectures, conferences) Yes 5 55.56* 17 94.44 16 72.73 18 85.71 11 100.00
No 4 44.44 1 5.56 6 27.27 3 14.29 0 0.00
 Voice interest groups Yes 1 11.11** 11 61.11 1 4.55 17 80.95 8 72.73
No 8 88.89 7 38.89 21 95.45 4 19.05 3 27.27
Clinical specialty (item 15; n = 81)
 Voice specialist Yes 3 33.33** 15 83.33 17 77.27 19 90.48 9 81.82
No 6 66.67 3 16.67 5 22.73 2 9.52 2 18.18
Note. Fisher's exact test used for statistical analysis; 2 × 2 cross-tabulations. SLP = speech-language pathologist; ENT = ear, nose, and throat specialist; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; VRQOL = Voice-Related Quality of Life; VoiSS = Voice Symptom Scale.
Note. Fisher's exact test used for statistical analysis; 2 × 2 cross-tabulations. SLP = speech-language pathologist; ENT = ear, nose, and throat specialist; CAPE-V = Consensus Auditory Perceptual Evaluation of Voice; VRQOL = Voice-Related Quality of Life; VoiSS = Voice Symptom Scale.×
* p < .05.
p < .05.×
** p < .01.
p < .01.×
×
Never (1) Rarely (2) About 50% of the time (3) Often (4) All of the time (5)
Videostroboscopy (SLP performed) (1)
Videostroboscopy (review of ENT video) (2)
High-speed laryngoscopy (3)
Instrumental aerodynamic assessment (4)
Instrumental acoustic assessment (5)
Electroglottographic assessment (6)
Patient self-perception assessment (7)
Perceptual assessment of voice quality (8)
Observation of patient's body movement and position (9)
Observation of patient's ability to modify voice production in response to direction and/or modeling (10)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.__________________________________ (11)
Never (1) Rarely (2) About 50% of the time (3) Often (4) All of the time (5)
Videostroboscopy (SLP performed) (1)
Videostroboscopy (review of ENT video) (2)
High-speed laryngoscopy (3)
Instrumental aerodynamic assessment (4)
Instrumental acoustic assessment (5)
Electroglottographic assessment (6)
Patient self-perception assessment (7)
Perceptual assessment of voice quality (8)
Observation of patient's body movement and position (9)
Observation of patient's ability to modify voice production in response to direction and/or modeling (10)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.__________________________________ (11)
×
I use this technique alone (1) I use this combined with other techniques (2) I don't use this technique (3)
Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) (1)
GRBAS Scale for Auditory-Perceptual Evaluation (2)
Oates Perceptual Voice Profile (3)
Audio voice recordings (no formal rating scale) (4)
Informal listener judgment (i.e., not using a published rating scale) (5)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.___________________________________ (6)
I use this technique alone (1) I use this combined with other techniques (2) I don't use this technique (3)
Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) (1)
GRBAS Scale for Auditory-Perceptual Evaluation (2)
Oates Perceptual Voice Profile (3)
Audio voice recordings (no formal rating scale) (4)
Informal listener judgment (i.e., not using a published rating scale) (5)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.___________________________________ (6)
×
I use this measure alone (1) I use this combined with other measures (2) I don't use this measure (3)
Voice Handicap Index (VHI) (1)
Pediatric Voice Handicap Index (pVHI) (2)
Voice Symptom Scale (VoiSS) (3)
Voice Outcome Survey (VOS) (4)
Pediatric Voice Outcome Survey (pVOS) (5)
Voice-Related Quality of Life (V-RQOL) (6)
Pediatric Voice-Related Quality of Life (pV-RQOL) (7)
Voice Activity and Participation Profile (VAPP) (8)
Therapy Outcome Measures (TOMS) (9)
Other: Please list and briefly describe any quality of life measures that you use that were not listed above.________________________________ (10)
I use this measure alone (1) I use this combined with other measures (2) I don't use this measure (3)
Voice Handicap Index (VHI) (1)
Pediatric Voice Handicap Index (pVHI) (2)
Voice Symptom Scale (VoiSS) (3)
Voice Outcome Survey (VOS) (4)
Pediatric Voice Outcome Survey (pVOS) (5)
Voice-Related Quality of Life (V-RQOL) (6)
Pediatric Voice-Related Quality of Life (pV-RQOL) (7)
Voice Activity and Participation Profile (VAPP) (8)
Therapy Outcome Measures (TOMS) (9)
Other: Please list and briefly describe any quality of life measures that you use that were not listed above.________________________________ (10)
×
Yes (1) No (2)
No treatment or wait and see (1)
Indirect voice therapy (e.g., vocal hygiene, voice minimization) (2)
Direct voice therapy (e.g., yawn–sigh, yell well, resonant voice therapy) (3)
Refer for surgery (e.g., treatment for nodules) (4)
A combination of voice therapy and surgery (e.g., treatment of nodules) (5)
A set therapy program (e.g., Adventures in Voice) (6)
Other: Please specify other methods of treatment _________________________ (7)
Yes (1) No (2)
No treatment or wait and see (1)
Indirect voice therapy (e.g., vocal hygiene, voice minimization) (2)
Direct voice therapy (e.g., yawn–sigh, yell well, resonant voice therapy) (3)
Refer for surgery (e.g., treatment for nodules) (4)
A combination of voice therapy and surgery (e.g., treatment of nodules) (5)
A set therapy program (e.g., Adventures in Voice) (6)
Other: Please specify other methods of treatment _________________________ (7)
×
I use this technique alone (1) I use this combined with other techniques (2) I don't use this technique (3)
Vocal hygiene and education programs (1)
Chant talk (2)
Froeschels's chewing technique (3)
Voicecraft techniques (e.g., giggle, sob, yell well) (4)
Glottal attack changes (5)
Open-mouth approaches (6)
Yawn–sigh (7)
Set program (e.g., Adventures in Voice) (8)
Accent method (9)
Confidential voice (10)
Resonant voice (11)
Estill voice techniques (e.g., retraction, silent giggle, twang) (12)
Semioccluded vocal tract exercises (e.g., lip trills, humming, straw phonation) (13)
Vocal function exercises (14)
Other: Please list and briefly describe any therapy techniques you use that were not listed above._______________________________ (15)
I use this technique alone (1) I use this combined with other techniques (2) I don't use this technique (3)
Vocal hygiene and education programs (1)
Chant talk (2)
Froeschels's chewing technique (3)
Voicecraft techniques (e.g., giggle, sob, yell well) (4)
Glottal attack changes (5)
Open-mouth approaches (6)
Yawn–sigh (7)
Set program (e.g., Adventures in Voice) (8)
Accent method (9)
Confidential voice (10)
Resonant voice (11)
Estill voice techniques (e.g., retraction, silent giggle, twang) (12)
Semioccluded vocal tract exercises (e.g., lip trills, humming, straw phonation) (13)
Vocal function exercises (14)
Other: Please list and briefly describe any therapy techniques you use that were not listed above._______________________________ (15)
×
I use this measure alone (1) I use this combined with other measures (2) I don't use this technique (3)
Voice Handicap Index (VHI) (1)
Pediatric Voice Handicap Index (pVHI) (2)
Voice Symptom Scale (VoiSS) (3)
Voice Outcome Survey (VOS) (4)
Pediatric Voice Outcome Survey (pVOS) (5)
Voice-Related Quality of Life (V-RQOL) (6)
Pediatric Voice-Related Quality of Life (pV-RQOL) (7)
Voice Activity and Participation Profile (VAPP) (8)
Therapy Outcome Measures (TOMS) (9)
Pre/post recording comparison (10)
Clinician judgment (11)
Review of ENT assessment (12)
Instrumental assessment (13)
Other: Please list and briefly describe any outcome measures that you use that were not listed above. ________________________ (14)
I use this measure alone (1) I use this combined with other measures (2) I don't use this technique (3)
Voice Handicap Index (VHI) (1)
Pediatric Voice Handicap Index (pVHI) (2)
Voice Symptom Scale (VoiSS) (3)
Voice Outcome Survey (VOS) (4)
Pediatric Voice Outcome Survey (pVOS) (5)
Voice-Related Quality of Life (V-RQOL) (6)
Pediatric Voice-Related Quality of Life (pV-RQOL) (7)
Voice Activity and Participation Profile (VAPP) (8)
Therapy Outcome Measures (TOMS) (9)
Pre/post recording comparison (10)
Clinician judgment (11)
Review of ENT assessment (12)
Instrumental assessment (13)
Other: Please list and briefly describe any outcome measures that you use that were not listed above. ________________________ (14)
×
Never (1) Rarely (2) About 50% of the time (3) Often (4) All of the time (5)
Videostroboscopy (SLP performed) (1)
Videostroboscopy (review of ENT video) (2)
High-speed laryngoscopy (3)
Instrumental aerodynamic assessment (4)
Instrumental acoustic assessment (5)
Electroglottographic assessment (6)
Patient self-perception assessment (7)
Perceptual assessment of voice quality (8)
Observation of patient's body movement and position (9)
Observation of patient's ability to modify voice production in response to direction and/or modeling (10)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.__________________________________________ (11)
Never (1) Rarely (2) About 50% of the time (3) Often (4) All of the time (5)
Videostroboscopy (SLP performed) (1)
Videostroboscopy (review of ENT video) (2)
High-speed laryngoscopy (3)
Instrumental aerodynamic assessment (4)
Instrumental acoustic assessment (5)
Electroglottographic assessment (6)
Patient self-perception assessment (7)
Perceptual assessment of voice quality (8)
Observation of patient's body movement and position (9)
Observation of patient's ability to modify voice production in response to direction and/or modeling (10)
Other: Please list and briefly describe any assessment techniques that you use that were not listed above.__________________________________________ (11)
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