Section 5

Voice Assessment of Protocols

Child Case History

Interview Protocol

Orofacial Examination and Hearing Screening

Vocal Abuse and Misuse Assessment Protocol

Child Voice Evaluation Protocol

Resonance and Velopharyngeal Function Assessment Protocol

Voice Stimulability Assessment Protocol

Voice Assessment Report

The protocols on this section may be individualized and printed out as a group and used for a
complete voice assessment. Also, one or more protocols may be selectively printed out and used
as needed. In assessing children with multiple disorders of communication, the clinician may
combine these voice protocols with other protocols (e.g., speech assessment protocols, language
assessment protocols, or fluency assessment protocols).
Note to the clinician: Individualize each protocol as you see fit before printing them for
clinical use. Please delete any extraneous comments or notes found in each of the protocols.

Child Case History

Have the parents or other caregivers fill out the case history form given in Section 1 (Common
Assessment Protocols). Let the case history form guide your interview.

Interview Protocol
Name__________________ DOB __________ Date __________ Clinician ____________
Preparation
Review the interview guidelines presented in Chapter 1.
Make sure the setting is comfortable with adequate seating and lighting.
Record the interview whenever possible.
Find out if the parent is comfortable having the child in the same room during the
interview. If so, have something for the child to do (toys, books, etc.). If not, make
arrangements for someone else to supervise the child during the interview.
Whenever possible, review the case history ahead of time, noting areas you want to
review or obtain more information in.
Introduction
Introduce yourself. Briefly review your plan for the day and how long you expect it
to take.
Example: Hello Mr. /Mrs. [parents name]. My name is [clinicians name]
and I am the speech pathologist who will be assessing [childs name]
today. I would like to start by reviewing the case history and asking
you a few questions. Once we are finished talking, I will work with
[childs name]. Todays assessment should take about [estimate the
amount of time you plan to spend].
Interview Questions
What is your primary concern regarding your childs voice?
Can you describe the problem?
When did you first notice that your childs voice was different?
How did the problem progress from there?
Has it gotten better or worse?
Have you seen your family doctor about your concerns?
Did your family doctor refer you to an ear, nose, and throat specialist?
What did the doctor(s) tell you?
Is it hard for people to understand your child? Approximately what percent of his [her]
speech do you understand? How do you respond when you cant understand?
How does your child react when others dont understand him [her]?
Are there times when your childs voice is better or worse? For example, is it better in
the morning than in the evening or visa-versa?
Has your child ever lost his [her] voice completely? How long did it last?
Do you feel that your childs voice problem is affecting his [her] social interactions?
Do you feel that your childs voice problem is affecting his [her] school performance?

Has anyone else in your family ever experienced a voice problem?

Is anyone in your family hard of hearing?
Is there anyone living in the home who smokes? Is your child exposed to second hand
smoke outside the home?
Are there any other children living in the home? How many? Ages?
Does your child attend day care, preschool, school? Where?
How does your child interact with other children?
Does your child participate in sports? Which ones? How often?
Is your child involved in drama?
Is your child involved in debate club or public speaking?
Is your child in a choir or singing group?
Do you have a pet? How does your child interact with the pet?
Does your child have asthma?
Has your child seen any other specialists for this problem? If so, who and when? What
were their recommendations? How have you followed up on this?
Does your child have reflux (GERD or LPR)? [provide a brief explanation of these
problems, as needed]
Has your child seen any other specialists for this problem? If so, who and when? What
were their recommendations? How have you followed up on this?
Does your child experience frequent or chronic allergies or colds?
Has your child had a history of ear infections?
Has your child ever had a hearing test? If yes, when and where? What were the results?
Has your child seen any other specialists for this problem? If so, who and when? What
were the recommendations? How have you followed up on this?
Has your child received speech or voice therapy before? If yes, when and where? What
did they work on in therapy? Can you describe the types of activities that were used?
How did your child respond? Do you feel the therapy was helpful? Why or why not?
Is your child currently on any medications?
Review the Vocal Abuse and Misuse Inventory with the parent and identify any behaviors
that might be contributing to the cause or maintenance of the voice problem.
Review the case history and follow up with any additional questions you need clarification
on. Fill in any blanks in the medical, developmental, social, and educational histories.
Closing the Interview
Summarize the major points that you gathered from the interview, allowing the parent or
caregiver to interrupt or correct information, as needed. Close the interview with the
following:
Do you have any questions for me at this point?
Thank you very much for you input. The information has been very helpful.
Now, I will work with [childs name]. Once we are finished, I will sit down to share my
findings with you.

Orofacial Examination and Hearing Screening

Complete the Orofacial Examination and Hearing Screening Protocol given in Section 2
(Common Assessment Protocols). Use this protocol along with the Instructions for
Conducting the Orofacial Examination: Observations and Implications, also found in
Section 2.
If preliminary findings during the orofacial examination reveal the possibility of
velopharyngeal inadequacy or incompetence, then use the Resonance and
Velopharyngeal Function Assessment Protocol included in this section.

Vocal Abuse and Misuse Assessment Protocol

Name___________________ DOB __________ Date __________ Clinician ______________
Instructions: Use the rating scale below to rate each area on the inventory as it applies to
your child. Please use the lined area for any additional comments.
0 = never
1 = occasionally
2 = frequently
3 = always
yelling, screaming: _____________________________________________________
arguing with siblings and friends: _________________________________________
excessive talking: ______________________________________________________
talking at an inappropriate pitch level: ______________________________________
talking at an inappropriate loudness level: ___________________________________
athletic activities that involve yelling or loud talking: __________________________
_____________________________________________________________________
cheerleading activities: __________________________________________________
vocalizing toy or animal noises: ___________________________________________
using the telephone: ____________________________________________________
talking in the car: ______________________________________________________
talking in a noisy environment: ___________________________________________
talking in a smoky environment: __________________________________________
singing: ______________________________________________________________
participation in plays, debate club or public speaking: _________________________
_____________________________________________________________________
grunting during exercise or lifting: _________________________________________
crying: _______________________________________________________________
frequent or excessive coughing: ___________________________________________
frequent or excessive throat clearing: _______________________________________
breathing through the mouth: _____________________________________________
talking at an inappropriate pitch level: ______________________________________
exposure to environmental irritants: ________________________________________
exposure to second-hand smoke: __________________________________________
upper respiratory infections: ______________________________________________
asthma attacks: ________________________________________________________
Dietary considerations:
dairy products: ________________________________________________________
caffeine products (coffee, tea, soft drinks): __________________________________
____________________________________________________________________
mint products (gum, mints, candy): ________________________________________
tomato-based products: __________________________________________________
citrus products: ________________________________________________________
spicy foods: __________________________________________________________

Child Voice Evaluation Protocol

Name_________________ DOB _________ Date _________ Clinician ______________
Physician: _________________________________
Findings:

Description of the Problem (Summarize findings from Case History and Interview)

Description of Home and School Environments

Medical and Developmental History

Birth and Development:
Surgeries / Injuries / Accidents:
Current Medications:
allergies

asthma

chronic colds

other:

GERD or LPR

Inventory of Vocal Abuse and Misuse

Instructions: Use the rating scale below to rate each area on the inventory.
0 = never
1 = occasionally
2 = frequently
3 = always
yelling, screaming
excessive talking

arguing with siblings and friends

talking at an inappropriate loudness level

cheerleading activities
using the telephone
talking in a noisy environment
talking in the car
crying
grunting during exercise or lifting
frequent or excessive throat clearing
exposure to environmental irritants
Other:

vocalizing toy or animal noises

athletic activities that involve yelling
talking in a smoky environment
singing
participation in plays or public speaking
frequent or excessive coughing
breathing through the mouth
exposure to second-hand smoke

Dietary considerations:
dairy products
citrus products
spicy foods

tomato-based products
caffeine products (coffee, tea, soft drinks)
mint products (gum, mints, candy)

Instructions: Use the childs spontaneous speech sample and reading sample (if the child
is able to read) to note the following:
Breathing and Breath Support (circle all that apply)
Clavicular

Thoracic

Diaphragmatic-Abdominal

Inadequate Breath Support

Irregular Breathing Rhythm

Mouth Breather

Vocal Quality (circle all that apply)

Breathy

Hoarse

Harsh

Glottal Fry

Glottal Attacks

Phonation Breaks

Pitch Breaks

Monotone

Voice Onset

Voice Termination

Strained-Strangled

Whisper Aphonia

Other:

Resonance (circle all that apply)

Hypernasality

Hyponasality

Assimilation Nasality

Nasal Emission

Note: If resonance is a concern, attach the Resonance and Velopharyngeal Function Assessment protocol.

Pitch (circle all that apply)

Age/sex appropriate
Variable
Other:

Too High
Diplophonia

Too Low

Monopitch

Habitual Pitch = ________Hz.

Loudness (circle all that apply)

Appropriate

Too Loud

Inadequate Loudness

Variable

Loudness Decay

Average Loudness Level = _________dB.

Other:
Laryngeal Tension (mark all that apply)
Child complains of pain in the laryngeal area
Pain upon laryngeal palpation
The laryngeal position in the neck is very rigid: the clinician is not able to gently
wiggle it back and forth.
Other:
Maximum Phonation Time: /a/ = ________ seconds
s/z Ratio:

/s/ =

seconds

/z/ = ________ seconds

seconds

________ seconds

seconds

________ seconds

s/z ratio = ________ (longest /s/) ________ (longest /z/) = ____________

Other Clinical Tasks (circle tasks that were administered and note the results)
Assess nasal patency
Words per Breath
Highest Pitch (falsetto with /i/)
Lowest Pitch (glottal fry)
Pitch Range
Loudness Range
Vocal Endurance (count vigorously from 1 100)
Testing for Hard Glottal Attacks (count from 80 - 89)
Attach protocol for the Resonance and Velopharyngeal Function Assessment, as
needed.

Stimulability (circle tasks that were administered and note the results) A separate protocol for
stimulability assessment is available and can be attached, as needed.
Coughing, throat clearing, and laughing
Inhalation Phonation
Glottal Fry
Yawn-sigh
Tone Focus
Explore the pitch range, listening for improved vocal quality
Summary

Recommendations
Vocal quality appears to be within normal limits, therefore therapy is not
recommended at this time.
Recommend evaluation and laryngoscopy by an ENT to rule out or confirm the
presence of vocal pathology.
Recommend a full audiologic evaluation.
Voice therapy is recommended for the following goals:

Other:

Resonance and Velopharyngeal Function Assessment Protocol

Name___________________ DOB __________ Date __________ Clinician ______________
Hypernasality
1.

Alternate nose holding technique

have the child say /u/ -or- alternate /a/-/i/-/a/-/i/

alternate between occluding and releasing the childs nostrils

Results:

the childs voice changed (suspect hypernasality)

the childs voice did not change (hypernasality is not indicated)

2.

Non-nasal words and phrases

have the child recite non-nasal words and phrases (below) (Boone, 1993)
o

This horse eats grass.

I saw the teacher at church.

Sister Suzie sat by a thistle.

Results:
3.

excessive nasal pressure is felt, or a nasal snort is heard (suspect

hypernasality)

Maybe-baby (Boone & McFarlane, 1988)

have the child recite maybe-baby-maybe-baby. . . .

Results:

it sounds like maybe-maybe-maybe. . . . (suspect hypernasality)

it sounds like baby-baby-baby-baby. . . . (suspect hyponasality)

4.

Count from 60 to 100 (adapted from Mason & Grandstaff, 1971)

have the client count from 60 to 100 while the clinician listens for the following:
o

60 to 69 = listen for VPI and nasal emission secondary to frequent /s/

productions

70 to 79 = listen for assimilation nasality secondary to the recurring /n/

o
phoneme
o

80 to 89 = listen for normal or near normal resonance and articulation

90 to 99 = listen for substitutions of /d/ for /n/ which would indicate

hyponasality

Results:

nasal emission / VPI

assimilation nasality

hyponasality

normal resonance

Nasal Emission
1.

Counting from 60 to 79 (see Hypernasality task #4)

2.

Production of pressure consonants

have the child recite phrases loaded with pressure consonants, such as those listed
later (See Assimilation Nasality and VPI, task #5)
Result:

production of these phrases resulted in increased nasal emission

Hyponasality
1.

Maybe-baby-maybe-baby (see Hypernasality task #3)

2.

Count from 90 to 99 (see Hypernasality task #4)

3.

Humming
Result:

4.

impaired humming (suggests hyponasality)

Nasally loaded words and phrases (Boone, 1993)

have the child produce phrases that are loaded with nasals as you occlude and
release their nose (see list in Assimilation Nasality, task #4)

Result:

the occluded and unoccluded productions sound the same (hyponasality is

present)

Assimilation Nasality and Velopharyngeal Insufficiency

1.

Count from 60 to 80 (see Hypernasality task #4)

2.

Suzy-suzy-suzy-suzy. . . . This task can be used to determine if the childs

hypernasality is the result of a physical etiology or if it is functional

have the child recite suzy-suzy-suzy. . . as you occlude their nares

suddenly release the nares

Results:

3.

the child immediately reverts back to their hypernasal pattern (it is likely the
result of a physical, organic etiology such as VPI)
the child has one or more normal productions before reverting to the
hypernasal pattern (it is likely functional)

Modified tongue anchor procedure (Fox & Johns, 1970)

Tell the child to puff up your cheeks like this and model the behavior. Practice
until the child is able to do it.
Tell the child to stick out the tongue. Hold the tongue tip with a piece of sterile gauze.
While you are holding the tongue, tell the child to puff up his or her cheeks again.
At the same time, occlude the childs nares.
Tell the child to continue holding the air in his or her mouth. Release the nose.
As the nostrils are released, listen for nasal emission.

Results:

nasal emission occurs (the velopharyngeal seal is considered inadequate)

no nasal emission occurs (the velopharyngeal seal is considered adequate)

4.

Repeat this procedure several times to verify your observations.

For assimilation nasality recite phrases that have a combination of nasal and non-nasal
sounds

have the child recite the words, phrases, and sentences; the combination of nasal
and nonnasal sounds in these phrases will exaggerate the presence of assimilation nasality,
making it easier to identify:
Words

Phrases

Sentences

knees

another night

Mike wants more noodles.

now

no more

Mommy made lemon jam.

money

more money

Jenny made me mad.

moon

man on the moon

No more singing tonight.

my

Mickey Mouse

Make noise with a drum.

Result:
5.

assimilation nasality is present

no assimilation nasality noted

pressure consonants

Have the child produce words, phrases, and sentences that contain pressure
consonants ( /p/, /b/, /t/, /d/, /k/, /g/, /s/, /z/, /f/, /v/, //, //, //, //, //, and //)
that stress a weak velopharyngeal system and reveal hypernasality or nasal
emission:

Result:

Words

Phrases

Sentences

pepper

black pepper

Pass the pepper.

baby

baby bib

The baby bib is blue.

tickle

teddy bear

Tickle the teddy bear.

daddy

daddy digging

Daddy dug a deep ditch.

cake

birthday cake

Dont kick the birthday cake.

goat

big goat

Give the goat a big hug.

feather

soft feather

Find a soft feather.

vest

blue vest

The blue vest is size five.

Suzie

Suzie sews

Suzie sews zippers.

shoe

dishwasher

The shoe is in the dishwasher.

cheese

cheese sandwich

Chew the cheese sandwich.

third

third bath

Her third bath was on Thursday.

they

their father

They saw their father the other day.

hypernasality or nasal emission noted (possible VPI)

Voice Stimulability Assessment Protocol

Name___________________ DOB __________ Date __________ Clinician ______________
Use the boxes to indicate whether a task was successful. For Part I, mark with a + if
phonation is produced and a if phonation is not produced. For Part II, mark with a + if the
quality of phonation is improved and a if the quality of phonation is not improved.

I. Tasks Used to Evoke Phonation in a Potentially Aphonic Patient

1.

Nonspeech acts are sometimes useful in helping children with functional aphonia
find
their voice. Have the child do the following tasks.
coughing
throat clearing
laughing
If you marked a + for any of the tasks, try shaping that phonation into a hum or vowel
production as a precursor to producing words, phrases, and conversational speech.
Results of attempting to shape nonspeech acts into speech sounds:

2.

Inhalation phonation: Have the child produce inhalation phonation if you

suspect
aphonia or ventricular phonation.
Demonstrate this technique for the child and ask the child to:
o Phonate a high-pitched humming sound as you inhale
o Try to match that phonation as you exhale
o Repeat, but as you exhale glide your pitch down to a lower level
o Repeat [until an acceptable pitch is produced on exhalation]

3.

Shape the exhaled hum phonation into words, phrases, and conversational speech
Glottal fry: Glottal fry, produced in a relaxed manner at a low pitch with very

little
airflow or subglottic air pressure, is a useful stimulation technique for improving a
hyperfunctional voice and it is sometimes successful in evoking voice in a child who
is aphonic. Glottal fry can be attempted using both inhalation and exhalation. The
desired outcome is the production of a slow series of individual pops.

Demonstrate the technique for the child and ask the child to:
o Let out about half of your air, then say /i/ softly

o Cue the child to lower the pitch or slow down the airflow, as needed
o Encourage a wider mouth opening, then shape various vowel sounds as the child
is producing /i/ with glottal fry

II. Tasks Used to Assess Stimulability for the Production of a More Relaxed
Phonation with Improved Vocal Quality in a Child with Dysphonia
1.

Glottal fry: (previous section)

2.

Inhalation phonation: (earlier section)

3.

Yawn-sigh: The yawn-sigh is an excellent technique for minimizing laryngeal

tension and is a useful stimulability technique with children who have a
hyperfunctional voice disorder.

Explain to the child that when the mouth is opened wide during a yawn, it is very
relaxing, and that the sigh at the end of the yawn will be the best voice
Demonstrate the technique for the child
Have the child practice producing large, relaxed, open mouth yawns that extend
into a sigh

Improved vocal quality during the sigh is a good prognostic indicator and may be
helpful in shaping h-words or open mouth vowels.
4.

Tone focus: Tone focus may be useful as a stimulability technique for children
who have vocal hyperfunction or who have a voice that sounds as if it is being
produced too low, deep down in the throat. It may help the child to resonate a little
higher up, thus taking the focus off the laryngeal area.

Have the child hum and feel with their fingers for vibration around their nose
and eyes. This area is called the facial mask.
Once the child can feel the vibration during humming, slowly shape various
vowel sounds while maintaining the vibration (resonation in the facial mask).
Try shaping from vowel sounds into words.

If vocal quality improves, this is a good prognostic indicator for using tone focus in
therapy.
5.

Explore the pitch range, listening for improved vocal quality: Explore the pitch
range to find out if a slight elevation or lowering of pitch improves vocal quality in
a child who speaks in an inappropriate pitch.

Voice Assessment Report

Use the Assessment Report Outline given in Section 1 (Common Assessment Protocols).
Expand the voice section to include all relevant information gathered through the case
history, interview, assessment procedures, and reports from other professionals.
Remember that the confidential information in this report should not be shared with
anyone other than the childs parents or legal guardians unless a written Permission to
Release Information has been obtained.