Voice production is the result of vibration of the vocal folds, which then is modified by the resonating chambers of the pharynx, oral, and nasal cavities. Phonotrauma, also known as vocal abuse, is defined as trauma to the laryngeal mechanism (vocal folds) as the result of vocal behaviors that include yelling, screaming, throat-clearing, and sound produced during play (e.g., superhero, animal, or baby sounds). Vocal fold nodules often occur as a result of this trauma. Rehabilitation of children with phonotraumatic voice use involves much more than simply eliminating the traumatic behaviors; indirect and direct treatment can be helpful in assisting children and families to minimize trauma to the vocal folds.

When parents bring their child to a speech-language pathologist with concerns about a "hoarse voice," they may be seeking a quick, easy solution. What parents don't realize is that changing the culture of the home is critical to success. Some parents perceive that their child's voice is normal for that child and "similar" to the vocal habits of other children of the same age (Saniga, 1993). Changing the culture in the home may mean parents helping their children change vocal habits as well as changing their response to the child's vocal habits. Guiding the family and child through this transition may seem like finding one's way through a corn maze, never sure of the exit in relation to one's current position. Similarly, this "maze effect" may confuse the clinician with minimal experience in treating voice disorders. But options are available for clinicians and families.

Redefining and Managing Phonotrauma

It is useful to clarify the terms "phonotrauma" and "vocal abuse." The term "abuse" may imply negative acts of mistreating, insulting, or harming the child. A parent's misunderstanding of the term "vocal abuse" can result in hostility toward the speech-language pathologist and hinder the child's progress. Some families confuse vocal abuse with verbal abuse. I recall one parent who, upon hearing the term "vocal abuse," became defensive, believing that she was being accused of "verbally abusing" her son. The term "abuse" also suggests that the behavior is intentional. While the actions of the child (yelling, making play sounds, etc.) may be intentional, the resulting trauma to the vocal folds is not. Additionally, the expression may suggest that the child may have an "abusive personality." Use of terms such as "phonotrauma" (Verdolini, 2006), "vocal fold shock," and "enthusiastic voice user" still make the point, but do not carry the negative connotations.

Management of voice disorders includes behavior management, vocal hygiene, and direct intervention. A treatment approach to each of these includes the following activities:

• Behavior management
• Educate student, parent/guardian/significant others (including teachers)
• Identify and eliminate vocal traumatic behaviors
• Utilize carryover into the natural environment
• Vocal hygiene
• Improve hydration
• Decrease signal/noise ratio
• Promote appropriate diet to avoid exacerbating reflux
• Direct Voice Therapy
• Use front-focus strategy

Education

Educating the child and others in his or her life helps keep everyone on the same page. Accomplishing this first goal as a clinician without alienating parents and the child can be a challenge. After describing the development of vocal fold nodules to the child and family, showing the vocal folds in motion is beneficial. Even if stroboscopy is not available, videos and other information can be accessed on Web sites such as the Greater Baltimore Medical Center's.

Identify Behaviors

Many families have their own patterns of phonotrauma, and may reject the SLP's description. Verifying that many of the vocal behaviors are typical, but modifiable, is the second goal in educating families.

Identifying phonotraumic behaviors can be challenging, especially if the parent is unaware of them. To help raise awareness, put yourself in the parent's shoes. My own past experience of my babysitter's comment that my preschooler "whined" was a shock. What, my son a whiner? I never heard him whine. But when I set aside some time just to listen, I was mortified by the accuracy of her statement. Offering the parent a similar scenario invites them to do the same at home.

Identification by the Family

Consider strategies that can help parents identify their child's behaviors. For example, set aside 30 minutes each day to listen only for one suggested behavior, supplied by either the parent or the SLP. Count instances of that behavior during those 30 minutes, ignoring other phonotrauma behaviors. It may be too overwhelming to count them all. As the week progresses, the parent may monitor additional behaviors, perhaps one noticed while counting another behavior.

Identification by the Child

Assisting the child in identifying the child's own vocal behaviors can be even more challenging. One strategy is to ask the child to seek out and identify specific behaviors in cartoon characters, TV characters, unfamiliar persons such as those observed at the shopping mall or park, or other family members. Then, ask the child to identify similarities.

Once parents have an idea of the degree of phonotrauma in their child—and most likely in other family members—the challenge is to decrease and eliminate them. Positive reinforcement is more effective than criticism (Verdolini & Hersan, 2006). I often offer parents a scenario that summarizes the process of replacing old vocal habits with new behavior. Think of the child running down the hallway at school; when a teacher spots the child, the teacher stops the child and has the child retrace the run with a walk.

A similar event can occur at home. For example, the child yells for the parent from his or her bedroom to the kitchen regarding a lack of clean socks (after all, having no clean socks is surely an emergency).

Discuss with the parents how to change this situation. Consider this scenario:

• Parents empties out the sock drawer to create a communication need (child needs to communicate that he or she has no socks).
• Practice having the child walk to the parent to communicate the need for clean socks.
• Reinforce this new behavior with a tangible or verbal reward.
• As this behavior increases, continue verbal reinforcements. After the behavior is established, fade out verbal reinforcements, as appropriate.

Hydration and Vocal Intensity

SLPs communicate the need for water for good vocal hygiene, but do we tell children and their families the reason for hydration? Providing a rationale for this behavior should help families realize the importance of incorporating this behavior to their daily routines (Verdolini-Marston, Sandage, & Titze, 1994).

Clinicians can explain to parents that:

• Dehydration requires increased subglottic air pressure to initiate vocal fold vibration, resulting in hyperfunction, including increased tension and strain
• Well-hydrated vocal folds decrease the probability of edematous tissue reaction
• Decreased subglottic air pressure translates into decreased tension and strain, aiming toward more balanced function
• Well-hydrated vocal folds translate into increased ease of voicing

The use of earplugs might be considered to help the child reduce his or her vocal intensity. Jónsdottir et al. (2001) found that use of earplugs resulted in lower vocal intensity during classroom reading.

Direct Voice Treatment

Both vocal-function exercises and resonant voice treatment offer strategies to relearn more appropriate voice production (Stemple et al., 2000). Although the techniques differ, they share the common element of "front focus" and can be used together for maximal effect. More information on these techniques can be obtained from seminars and articles (see references online).

Research supports the effectiveness of treatment techniques using a semi-occluded oral tract, such as in the front-focus technique. Titze (2006) found that the use of a semi-occlusion such as in the front of the vocal tract (at the lips) heightens source (vocal) tract interaction resulting in reduction of tension. The intent of front-focus voice production is to produce voice with normal intensity with less mechanical trauma to tissue.

Titze suggested a theoretical hierarchy of resistance in the degree of semi-occlusion, starting at the lips:

• Highly resistant (small-diameter) stirring straw
• Less resistant (larger-diameter) drinking straw
• Bilabial or labiodental voiced fricatives
• Lip or tongue trill
• Nasal consonants
• Vowels /u/ and /i/

Engage Teachers

Children are with teachers for six hours a day during the school year. Many teachers have an interest in the child's voice difficulty but may not know how to help.

Suggestions for teachers include:

• Music/choir teacher: This instructor's training in use of the voice is a real bonus to the treatment program. Vocal warm-ups have some similarities to vocal function exercises as well as to resonant voice treatment. Consider requesting that the child participate in the vocal warm-up section of the class and lip sync the rest (ASHA, 2005).
• Science teacher: Offer to show a video of vocal fold vibration. If human anatomy is the subject, request that the development of vocal fold nodules, as well as good vocal hygiene, be discussed.
• Art teacher: Suggest an art project, such as banners to hang in classrooms to dampen noise.
• All teachers: Discuss allowing child to bring water bottle to class. Have a prewritten letter supporting the need for increased hydration for the child.

Treatment of voice disorders associated with phonotrauma and hyperfunction need not be a mystery. Educate yourself formally and confer with SLPs with expertise in voice. The information and training is available for the SLP and family alike.