Guidelines For Case Selection, Continuance and Dismissal for Speech-Language Services Within Intermediate Unit 1

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Voice

Definition - Voice

A voice disorder exists when the vocal characteristics of pitch, intensity, quality, or resonance interfere with communication, draw unfavorable attention, adversely affect the speaker or listener, and/or are inappropriate to the age and/or sex of the individual.

ASHA (1993a, p.40) indicates that "a voice disorder is characterized by the abnormal production and/or absence of vocal quality, pitch, loudness, resonance, or duration, which is inappropriate for an individual's age and/or sex."

Voice disorders are classified according to their etiology or symptoms. The etiology is its cause, which is either organic or functional. Organic disorders have a known physical cause with a related medical history. Functional disorders do not have a physical cause but may result in physical changes. They may be caused by 'faulty usage' or behavioral histories. The features of voice are identified as pitch, quality, loudness, nasal resonance and oral resonance.

Classifying the voice disorders by vocal behaviors or symptoms provides the SLP with useful information. Some examples of functional and organic disorders are:

• Functional Disorders
  • Contact ulcers
  • Phonation breaks
  • Pitch breaks
  • Traumatic laryngitis
  • Vocal nodules
  • Vocal polyps
• Organic Disorders
  • Cancer
  • Laryngectomy
  • Pubertal changes
  • Vocal fold paralysis

Eligibility/Entry Criteria

A student may be eligible for services as a student who is speech-language impaired in the area of voice when any of the following adversely effect educational performance:

• The formal evaluation reveals voice deviations in pitch, resonance, nasality, intensity, range or rate.
• Formal/informal assessment results reveal voice that is not adequate for success in the regular education curriculum as verified by members of the educational team.

Additional considerations:

Boone and McFarlane (1988) suggest that "Patients with voice quality and resonance problems generally require some medical evaluation of the ears, nose, and throat as part of the total voice evaluation...A laryngeal examination must be made before a patient can begin voice therapy for problems related to quality or resonance...Voice therapy efforts should be deferred until a medical examination (which would include laryngoscopy) is concluded, because there are occasional laryngeal contraindicated. However, the presence of a medical condition (e.g., vocal nodules) does not necessitate the provision of voice therapy as a disability requiring special education - nor does a prescription for voice therapy from a physician.

A voice impairment does not exist, thus making the student not eligible for services, when vocal characteristics:

• Are the result of temporary physical factors such as: allergies, colds, abnormal tonsils or adenoids, short term vocal abuse or misuse.
• Are the result of regional, dialectic or cultural differences.
• Do not interfere with educational performance.

Assessment

To complete a thorough assessment of voice, it is important to collect a representative sample of the student's speech in a variety of settings. This can be done informally or by using a formal assessment procedure such as the Boone Voice Program for Children. Regardless of the assessment procedure used it is important to assess the following areas:

• Pitch
• Intensity
• Quality
• Resonance
• Effect on Communication
• Effect on Educational Performance

Assessment Procedures

• Collect data obtained during the pre-referral process
• Obtain classroom teacher input
• Obtain parent input
• Conduct a classroom observation (observe student in structured and unstructured situations in the school environment)
• Review student's school records and/or reports from other agencies
• Interview student to determine self-perception of communication abilities
• Complete an oral-peripheral examination
• Obtain medical report from an otolaryngologist
• Collect a representative sample of the student's speech
• Analyze voice, pitch, intensity and quality
• Document how the student's voice impairment adversely affects the student's educational performance in the general education classroom or the learning environment.
• Complete the Voice Severity Rating Scale

Dismissal/Exit Criteria

The criteria for exit from services for speech and language impairments should be discussed with IEP team members at the beginning of intervention.

A student will be recommended for dismissal when any of the following occur:

1. Voice goals on the IEP have been accomplished and specially designed instruction is no longer warranted.
2. Voice deficits no longer interfere with the student's ability to perform in the educational setting.
3. Voice deficits no longer interfere with the student's ability to establish and maintain appropriate social/emotional development.
4. The student has other associated and/or handicapping conditions that prevent continued improvement.
5. There is a lack of progress documented over time by charting, therapy data, and/or teacher/parent input or consultation.
6. The student demonstrates a lack of motivation, consistent incompletion of assignments or inappropriate behaviors that are not conducive to therapy, such as:
   1. Not being cooperative
   2. Chronic absenteeism
   3. Verbally or physically disruptive in therapy
7. Withdrawal is requested by the parent/guardian. This must be obtained in writing and agreed to by the educational team.

Additional considerations:

When attempting trial therapy for vocal abuse and no improvement is seen within three to six months, the immediate supervisor should be contacted. At that time, a referral for a laryngeal examination should be discussed. Continuation of therapy would be contingent upon the results of the examination.

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