Posts tagged #researchtues

Diagnoses Are Changed...There Must Be Something in the Water

It's Research Tuesday again! There may be "Something in the Water" for Carrie Underwood for her to be changed, and the same is true for the diagnosis of many voice disorders following videostroboscopic evaluation. In this recent article in the Laryngoscope, Seth Cohen (no not the one from the OC), Nelson Roy, Mark Courey and others take a look at how important Videolaryngostroboscopy (VLS) is as an evaluation tool. They did this retrospectively for patients from 2004-2008, who had been evaluated by an otolaryngologist and then had a specialty voice evaluation with a VLS component within 90 days. Findings? Half of the patients had a change in diagnosis following a VLS. HALF! That's insane. I love examining vocal folds with my strobe light and rigid endoscope, and now I love it even more. If this examination can correctly identify disorders that would have been misdiagnosed otherwise, I'll shout it from the mountain tops! Strobes matter!

Think about the otolaryngologist. He sees 20-30 patients per day, and voice complaints usually result in a quick look with a flexible endoscope through the nose. This is to determine if there is something scary or not, and to determine the depth of evaluation necessity. The ENT will then usually refer the patient to a voice specialist for a videostroboscopic examination, or do it himself if he has the training, technology and time. He makes the best call he can for the technology and time he has, and when he knows the patient will benefit from further analysis, he refers. This is efficient.

What makes a videostroboscopy so much more comprehensive?

  1. It can be recorded and reviewed multiple times to educate the patient and to share with other care providers.
  2. It is magnified greater than a flexible endoscope, so you see the laryngeal vestibule in greater detail.
  3. The strobe light allows the vocal folds to be seen in motion. This helps us evaluate the vocal folds in five ways, as well as for color and structure.

This saves us money, it saves the patient money, and it saves insurance companies money. In this study, 83% of 125 individuals who had the diagnosis of acute laryngitis had their diagnosis changed to something different. This was not the only initial diagnosis, but it showed the biggest change. Difference in diagnosis means that there were differences in treatment patterns as well. This means that PPI's were only used when necessary, surgery wasn't performed if it wasn't necessary and voice therapy may have helped in many cases. I like the otolaryngologists I work closely with because they are very conservative when they treat. We provide voice therapy and wait and watch. Vocal folds are so delicate and unnecessary surgery could make a voice quality worse than what the person was complaining of. Each case is different, but many times voice therapy can make a huge difference and even help avoid surgery.

So what was being over diagnosed? Acute laryngitis and vocal fold paresis had a higher chance of being changed as a diagnosis than chronic laryngitis. Cancer and nonspecific dysphonia had less of a chance than chronic laryngitis. The article also states that ENT's are less comfortable with diagnosing specific voice disorders unless they are very visual in presentation, so even more reason for our specialty to shine. Get out there, stay educated on interpreting and strobe, people!

Source: Change in diagnosis and treatment following specialty voice evaluation: A national database analysis. Cohen, Seth; Kim, Jaewhan; Roy, Nelson; Wilk, Amber; Thomas, Steven, & Courey, Mark. Laryngoscope, 13 Feb 2015, doi: 10.1002/lary.25192

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Shine Bright Like a Voice Analysis

Why does a voice sound disordered? Does it sound harsh? Does it sound breathy? Does it sound too high pitched? We can hear a voice and perceptually tell that it sounds unnatural. How do we prove this? There are perceptual scales, like the CAPE-V and the GRBAS, and I use the Vanderbilt FITQ scale. (It's a rating scale for Frequency, Intensity, Timing and Quality on a 0-3 rating.) There are self-perception measures like the Vocal Handicap Index and the Reflux Symptom Index. Unfortunately, we can't just say someone sounds dysphonic and expect the service to be covered. Insurance companies tend to prefer hard numbers and measurable data. The perceptual scales are measurable, however they are subject to intra and inter rater reliability issues because on any given day each of us hears things differently.

Many clinicians utilize acoustic measures like Jitter and Shimmer, as well as noise-to-harmonic ratio when they gather data. Jitter is displacement in frequency periods or pitch variations, and shimmer is changes in intensity or amplitude. Noise-to-harmonic ratio is simply comparing the relationship of good sounds to bad ones, and if the noise outweighs the harmonies, then there is dysphonia. These measures are limited because they require the person to sustain a vowel to capture data, and that can be difficult for some voice patients. While it is important to measure sustained vowel productions, but it is vital to measure the voice in connected speech as well. There are reasons for this: 1) Adductor spasmodic dysphonia sounds relatively normal during a sustained "ahh" but is very apparent during connected speech. 2) Sustained vowels are not as multidimensional as speech. Speech contains rapid voice onsets, offsets, inflections, stress, pauses, voiced and non voiced sounds.

What if we could somehow combine how we measure both connected speech and prolonged vowels? Youri Maryn, Marc De Bodt and Nelson Roy developed a protocol that is multifaceted, like a diamond. The voice has many layers and dimensions, so shouldn't it be analyzed the same way? It's called the Acoustic Voice Quality Index. It takes into consideration 6 parameters:  shimmer local, shimmer local dB, harmonics-to-noise ratio, general slope of spectrum, tilt of regression line through the spectrum and smoothed cepstral peak prominence. If these are unfamiliar terms, that's okay. Just know that the sound signal is being analyzed in different ways and tested to determine if the numbers accurately reflect what is heard perceptually. The testers in this article are making sure that if a voice quality sounds disordered, the numbers consistently reflect this when compared with numbers from a normal sounding voice. 

Cepstral peak prominence is an emerging measure for acoustic analysis. (Cepstrum is spectrum with the letters rearranged, but it the calculations to find it are a bit more involved.) The more periodic a sound signal is, the more you will see a prominent cepstral peak, so we are looking for a low number to represent a dysphonic voice. The great thing about cepstral peak is that it is the only acoustic metric that shows dysphonia in sustained vowel productions and connected speech. Jitter, Shimmer and NHR are limited to the former.

Simply by using PRAAT, a free program, you can easily obtain data in a non-invasive way. Maryn et al 2010 says that there are other similar models of voice data analysis, but none utilize continuous speech and sustained vowels to determine how severe a person's dysphonia is. Maryn and team cross-validated the AVQI in 2009 with 251 subjects. This 2010 study looked at 72 voice samples, as well as 33 other samples to determine the AVQI's responsiveness to change. Acoustic measures were taken using James Hillenbrand's "SpeechTool" (another free program) and PRAAT.

AVQI was developed specifically to be widely available to those providing voice therapy with limited budgets. It's super nice to have CSL software from Kay Pentax, but for the vast majority of clinicians in hospitals, private practices, schools and clinics, budgets are tight. PRAAT can be downloaded on Mac or PC, so it is easily accessible. If you were like me, you might have been collecting data with PRAAT and SpeechTool, but with this measure you can streamline your data collection and use only one program. This saves you time and money, as well as provides you with better data. Excellent... The script necessary to complete calculations can be found in the appendix data for Maryn 2014.

So why the AVQI? Maryn and Weenink found that listeners rate sustained vowels more severely than connected speech when there is dysphonia present. I can vouch for this because my patients usually can only hear a target production in isolated sustained vowels, not in connected speech when I demonstrate both. The AVQI has also been tested across multiple languages, like Dutch and German. Studies have found that despite language differences, the measure remains reliable and valid.

The 2014 article cautions for clinicians to make sure they are accounting for environmental noise in the room as well as mobile phone interference. Recommendations are for a head-mounted condenser microphone with XLR connection as well as an external mixer soundcard to improve the quality of the audio signal and to keep it the same across patients. Remember to tilt the microphone away from the mouth and record voice sounds with a sampling frequency of at least 26kHz.

Using the AVQI has allowed me to streamline my evaluations by a few minutes, as well as show a picture representation of the voice to my patients. Visual is always good. Minutes of each day all are precious because they add up, so I hope you will read up on this available and easy-to-use option for acoustic measurements.

-ATVC

Resources: The Acoustic Voice Quality Index: Toward improved treatment outcomes assessment in voice disorders Youri Maryn, Marc De Bodt, Nelson Roy. Journal of Communication Disorders 43 (2010) 161–174

Objective Dysphonia Measures in the Program Praat: Smoothed Cepstral Peak Prominence and Acoustic Voice Quality Index. Marin, Youri & Weenink, David. J Voice. 2015 Jan;29(1):35-43. doi: 10.1016/j.jvoice.2014.06.015. Epub 2014 Dec 9.

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Acquire The Fire: Why Do We Care About Motor Learning Theory?

#Researchtues

Featuring Integrated Implicit-Explicit Learning Approach to Voice Therapy by Cari M. Tellis

I wonder to myself all the time how I would train another SLP to be like me. Would I be good at it? Thank goodness I had skilled and patient mentors, because voice therapy is a difficult bear! And the skills you acquire should set a fire in you to save the world, one voice client at a time. You have to listen closely and train yourself to command poor productions as well as target ones. I wonder too, how did I obtain all of my skills at discriminatory listening and skilled productions? Which learning type was I? I wanted to spare you the hairy read of this very thought provoking article, and try to give you the quick and dirty. I had time to peruse this article thoroughly, so here is the scoop.

Don't freak out just yet. I had flashbacks to graduate school cognitive therapy classes and I almost began to have a melt down. Let's begin with Implicit Learning. This is what you pick up on in your unconscious learning abilities. Easy, right? You can think of it as how a child learns communication skills as he or she grows and develops. Babies, Implicit babies. Children demonstrate new receptive and expressive communication skills in new ways literally every day and they did not sit through a powerpoint presentation to do so. Plenty of studies have looked at Implicit Learning and say that skills learned implicitly mean that a person has no conscious memory of learning the skill.

Continue to breathe, do not freak out. Let's discuss Explicit Theory now. This is learning tasks or information after detailed instruction. You must easily be able to demonstrate this newly acquired skill on command. This can be done because you had someone telling you the most optimal way to achieve that target production or skill. Explicit teaching is thought to streamline you to the best possible outcome. Think of every CEU you have ever earned. Now, all of that information was most likely learned explicitly through whatever forum you decided to obtain it from...be it online, classroom instruction, one-on-one training, whatever. Explicit learning is usually the mode of choice for left brained individuals, and this is because it appeals to the organized and supported way to learn new information.

So now that we have defined Implicit and Explicit, there is one more potentially complicated term pair that might get your knickers in a twist: Top-down and bottom-up. Okay, the flashbacks are here again. Bottom-up is where you begin with implicit learning and scaffold to explicit learning. Top-down is the exact opposite. This article suggests that combining both, regardless of which is first, can support all learning avenues and give you the best outcome.

So why do we care about how a person learns new information? Because voice therapy attrition rates (fancy word for drop out) are climbing. With 30% of adults reporting voice issues, 65% of them drop out of voice therapy prior to achieving some sort of positive result. Is this because we as voice therapists aren't appealing to each person's learning type right off the bat? It's worth looking into how well you can identify a person's preferred skill acquisition type because your therapy can then propel the client on the most efficient path.

You don't want to overwhelm or confuse clients in the therapy room. Yes, you know your stuff, but they don't care. They just want to get better. So where do you start? Your run-of-the-mill voice therapy sessions utilize auditory-perceptual, implicit learning to get the job done. This is when you produce a target sound, the one you want the client to mimic, and they produce it exactly. Why do we do this? We hope that eventually after practice and repeating-repeating-repeating, the client will generalize because all toddlers walk eventually. Implicit babies, remember?

This is all well and good, but what about when the client is home and discharged from therapy. Can he or she conjure up the targets again? How will the client know if the targets are correct targets? This is where the importance of explicit learning comes into play. Explicit teaching needs to be completed by a therapist who is well versed in anatomy and how the anatomy functions properly and in error. We can only see so much of our speech mechanism (tongue, lips, teeth etc.) and we are left to depend on feeling, visualizing and hearing the rest. So we create metaphors for our clients. Kittie Verdolini cautions to be careful of over doing the metaphors in the therapy room because although they may facilitate, they may confuse.

So Misericordia University and its Voice Science Laboratory have come up with this 5 step process to combine the best of both learning processes for voice therapy purposes. This is because they feel that your brain works better if you are presented with easy and difficult tasks from day one. This should promote generalization outside the therapy room and cut down on in-therapy frustration.

Step 1 is to teach basic auditory perceptual cues to get the client to produce sounds. Have the client ahh like you, then ask the client assess the production. Based on the answers and production accuracy, you can then decide what the client is stimulable for and use that to guide your therapy technique choices. (Oh, and this is implicitby the way.)

Step 2 is teaching anatomy and physiology for my favorite part of the body. The laryngeal mechanism and how it works can be taught two ways, depending on your learner. Part-whole and whole-Part. (Don't hyperventilate, no flashbacks please.) The part-whole peeps learn specific ahhs, oohs, eeehs, forward resonance, back resonance, etc. and then prefer to piece together how they add up to a target voice quality. The whole-part peeps prefer achieving the desired quality before those specifics are even discussed. Decide which your client is, then go. And don't worry, experts and novice voice clinicians both obtain a similar outcomes for patients when helping them while relying on perceptual measures only. Trust you ears and eyes people. (Step 2 is explicit, in case you were testing yourself, you overachiever you.)

Step 3 is adding gestures. Yes, like your voice teacher did with rainbow phrasing and your own personal arm rainbow. Yes, like you do with your little ones while teaching "sh" and running your hand up your arm. Yes, like you do when describing an exquisite Italian meatball dish your grandmother used to whip up. (Lip pucker optional.) Research shows that using gestures offloads the cognitive mechanism. Maybe the Italians are on to something...

Step 4 is, surprise, letting your clients do the work with your guidance. "Deliberate practice is important to skill learning and improves performance and reduces the potential for practicing improper voice productions." Help your clients generalize by giving them a firm base of implicitly and explicitly learned skills to pull from. Guide their practice so they can generalize in a variety of contexts.

Step 5 is nurturing fully capable clients. They have used top-down, bottom-up, part-whole, whole-part, implicit, explicit, however and whatever. They can troubleshoot their own productions and hopefully help themselves in the future because of the expert knowledge and skills you have given them.

Help decrease attrition! Acquire the fire! This study pulls from much hard work and it is right here at your fingertips to take to the streets....or therapy room...hey, you might givevoice therapy on the streets...I don't know. Anyway, happy Research Tuesday!

-ATVC

 

 

 

References:

Integrated Implicit-Explicit Learning Approach to Voice Therapy. SIG 3 Perspectives on Voice and Voice Disorders, November 2014, Vol. 24, 111-118. doi:10.1044/vvd24.3.111

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Voice Rx: Birth Control, Tylenol and Breath Support?

I was listening to a podcast from NATS (National Association of Teachers of Singing) this week and was surprised when I heard that Dr. Robert Sataloff was being interviewed. He is a special physician because he has his Doctor of Musical Arts in Vocal Performance from Combs College of Music in addition to being an otolaryngologist and a musician, which peaked my interest immediately. I am sure that others know of him already, but this was news to me and it made me excited. I couldn't wait to hear the questions that the NATS group had for him.

This chat was on the subject of performing arts medicine and care of the professional voice. The first question raised was in regards to PMS. I immediately thought back to voice changes that Moya Andrews talked about around "that time of the month" in one of her books. The doctor said to consider avoiding any diuretics or water-shedding pills when you are about to start your period. Why? Because during the pre-menstrual time, the vocal folds are swollen, like other muscles in your body, with a protein-bound edema fluid which will not be expelled by a diuretic. The only thing that taking these pills would do is strip the essential epithelial lubrication on your vocal folds and make them more susceptible to damage from overuse and misuse. The swelling remains until the woman's period has finished. His recommendation for the few days prior to your period beginning? Stay hydrated. I'm thinking, yeah....let's add more fluid to the mix....Mucinex will not compensate for the benefits of hydration, but it might help you thin secretions when they are too thick. You should avoid any bloating pills if you are a professional voice user. He also recommends in some extreme cases that birth control pills can help with avoiding that fluid overload altogether by hormone regulation.

Next he addressed pain killers. Ibuprofen and aspirin were discussed in detail in regards to the effects on the voice, but the consensus was that Tylenol or any acetaminophen was usually safe for the vocal performer. Ibuprofen (Advil and Motrin) thins your blood and puts you at risk for vocal fold bleeding for only about 24 hours. For the time the drug is still in your system, you should be careful not to strain or overuse your voice. Aspirin, he warned, is even more dangerous to the professional voice because its effects last 7-10 days after just popping one pill. It interferes with platelet function, so it increases the bleeding risk for a person. He also says that if your blood vessels are already dilated and delicate (ie you are about to begin a period or are sick with laryngitis or a cold) and then you consume ibuprofen or aspirin, you are at very high risk for hemorrhage of the vocal folds. Old types of birth control pills with high doses of hormones used to cause some consumers to lose part of the upper vocal register and when pills were ceased, the voice returned to normal. New BC pills, though lacking formal studies, don't seem to be having that dramatic of an effect on the voice because they contain much lower amounts of hormones. He warns women to be wary of birth control pills containing androgens (male hormones), as they may lower the pitch of the voice.

He discussed vocal fry with one listener. This is the way a Kardashian speaks, with a low, guttural creak at the end of almost every utterance. We categorize our voices within 3 registers or physiological frequency ranges: modal (normal)-- falsetto (high)-- and fry (lower). For modal register, the vocal fold vibratory cycle contains vocal folds spending an equal amount of time open as they spend closed. Falsetto produces sound with the vocal folds barely touching or not at all. Vocal fry is different. Vocal Fry produces sound with a very long vocal fold contact time. Here, the majority of the sound production time is spent with closed vocal folds. It is this constant contact in combination with the pressing that causes the vocal fold damage and makes this a vocally abusive behavior. Most of the time, Dr. Sataloff says, people are using poor breath support when they utilize the fry register. I know I find myself doing it when I'm lying in bed on the phone or when I'm tired.

When a person presses, he or she is squeezing the muscles of the larynx to make sound instead of letting the breath do the work. He reminds us that most of the time, using vocal fry is abusive to the vocal folds.

He also discussed the importance of diaphragmatic breathing and body awareness to treat MTD or Muscle Tension Dysphonia. He encouraged relaxation awareness to improve outcomes for professional voice users and even gave a "shout out" to Speech-Language Pathologists and singing voice specialists and our important role in treating this disorder in speakers and singers.

This was a nice breath of fresh air about voice and medicine and I am thankful this was shared on a twitter account I follow.

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

A Cure for Stage Fright? Can Blood Pressure Medication Help or Hurt?

In honor of #ResearchTuesday, I have chosen to blog about a study I was given to peruse this past week about a double-blind controlled trial about how stage fright affects the voice. Stage fright is an issue for many performers and public speakers, and has varying degrees of intensity. The study wanted to explore quantifying these effects of stage fright stress on the human voice.

In previous studies, fundamental frequency (your voice's pitch) is the constant here, as it is documented to increase with stress. Conflicting evidence on vocal intensity (loudness) and speaking rate exists, so I guess for some individuals experiencing stage fright, you might get louder with a faster rate of speech or quieter and slower....or a combination....My mind begins to wander back to middle school presentations I had to give. I stood there at the front of the class, shaking and flushed in the face. I can't remember what my voice did, so I'm was interested in the outcome of this study.

Some folks don't like the shaky, sweaty palms, nausea or diarrhea that stage fright brings upon a person...I wonder why? So, they take beta-adrenergic blockers. This is your basic medication to lower the blood pressure by blocking adrenaline and slowing the heart beat, but side effects are a danger.

So this study took individuals and induced stress upon them by putting them in a room with 200 IEP goals to formulate in 1 hour's time. No, I'm kidding. They used cold pressor testing, then gave one group a placebo and one group medication and tested Fo (fundamental frequency), voice onset time, speaking rate, jitter (cycle-to-cycle differences in frequency or pitch), shimmer (cycle-to-cycle differences in amplitude or loudness), and a few other measures. Cold pressor testing is your hand in ice water for one whole minute (aka how one tries to prepare for the pain of child labor...ha. Just keep breathing and imaging yourself on a sunny beach...)

Findings were an increase in blood pressure more in female participants than in male, but both the placebo group and the medication group showed an increase. Jitter increased following medication for stage fright, and speaking rate increased with no medication following the cold water test. I am pretty sure I would have the same reaction if you made me hold my hand in an ice cold glass of water. "Please let me take my hand out now thank you very much yadayadayada....." It would be like truth serum.

It was interesting to me that the researchers hypothesized that the voice parameters measured would all increase in a person with stage fright. They thought the changes in the lungs from the body's reaction to the cold water test would increase the airflow in the throat and therefore increase the vocal fold vibratory speed (making the person's pitch increase). They found that without medication to combat the stress, a person's pitch increased.  

Unfortunately, the only statistically significant finding from this study was that jitter increased after receiving medication for the stress. This means that there is no reason to pop some blood pressure meds before your huge opera debut or that presentation you have to give this week to keep your voice from going all wonky. In fact, this study actually suggests that professional voice users should avoid any medication of this type before singing or speaking because it might be counterproductive, as it increases the noise in your voice.

I guess we will all have to just rely on practice, practice and more practice to keep the "jitters" away during any performance or speaking engagement. Fake it 'till you make it, and by then you will have performed so many times, the stage fright should only come from a ghost light...

-ATVC

 

References:

Beta-Adrenergic Blockade and Voice: A Double-Blind, Placebo-Controlled Trial. Giddens, Cheryl L.; Baron, Kirk W.; Clark, Keith F.; Warde, William D. Journal of Voice , Volume 24 , Issue 4 , 477 - 489.

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.