Abstract
Adventures in Voice (AIV), developed by Katherine Verdolini Abbott, is a form of RVT formulated specifically for children 4 to 11 years of age with voice problems due to voice use. Using the foundational theories of RVT, AIV presents activities in a manner that corresponds with the learning styles of children. Using play and exploration-based learning, AIV teaches children how to properly care for their voices and use anterior-focused vibrations while speaking. While limited data is available regarding the AIV resonant voice program for children, research has demonstrated the effectiveness of its precursor, RVT, with the adult population. According to Stemple, Glaze, and Klaben (2010), the basic training premise of RVT is the training of the client’s attention to sensory stimuli such as what he hears or feels while producing voice. The goal of RVT is to achieve the strongest, “easiest” voice possible while limiting the adduction and force of the vocal folds (Stemple, Glaze, & Klaben, 2010). AIV is based on the same biomechanical and behavioral ideologies as RVT but is formatted in a more child-friendly manner and based on active and engaged learning (Verdolini Abbott, 2011).
AIV therapy takes the form of a trip around the world. Consisting of eight lands, the child and his adventure guide (aka, clinician) go on a journey to the Land of Healthy Voices. Along the way, the child learns several “super powers,” which assist him in his journey, such as basic voice care, loudness identification, and body language. In addition, the child is provided with an AIV passport, which is stamped on the achievement of each of the targeted skills. At the beginning of each session, the child rates his voice on a scale from 0 to 10, with 0 representing no voice and 10 representing an easy voice. On the conclusion of the session, the child is provided homework activities and rating sheets so he can rate his vocal quality daily.
The first land, titled Get Ready for the Journey, provides the child with background knowledge regarding his vocal mechanism and how it functions. Through hands-on activities, the child learns about the relationship between the respiratory system and laryngeal mechanism, as well as how the vocal folds adduct, abduct, contract, and elongate to produce sound. Subsequently, the clinician and the child tell or read an injury and healing story (this is included within the patient manual). The purpose of the story is to explain to the child that sometimes we can hurt ourselves unintentionally. Verdolini Abbott (2011) stressed the importance of emphasizing to the child that he did not mean to hurt his voice, but sometimes it just happens and that he should not feel ashamed. Subsequently, the child is instructed about vocal hygiene and educated on ways in which he can protect and care for his voice. The next portion of the first land targets the child’s differentiation between “hurting” and “feel good sounds” and loudness levels, including no voice, quiet voice, inside voice, and outside voice. Last, the child is taught how to communicate using body language, rather than voice, to engage in vocal rest.
Easy Vibrations, the second land in AIV, teaches the child about gross body sensations and vibrations. Initially, all of the vibrations are externally focused on the child’s extremities, but they are gradually orientated toward the vocal tract. Subsequently, the child naturally experiments with producing oral vibrations through the use of several tools such as straws, plastic spoons, kazoos, and vibrating toothbrushes. The child is educated on how easy vibrations are healing and is taught how to rate oral vibrations as either easy or hard, or weaker or stronger. Last, the child is introduced to using easy vibrations in a functional context by saying, “nnnoooo,” for no and, “mmhmm” for yes in daily communication.
The third land, Land of Chants, begins by reviewing the production of natural vibrations introduced in the previous land. Once the child becomes proficient at producing the natural vibrations, the vibrations are extended into chants. Initially, the chants are simply words that are high frequency in nasal sounds, but as the child becomes more adept at the skill, the chants are extended into nursery rhymes and other similar verses. The final tasks of this land focus on pull-out or rescue and recovery. The child is taught to identify a tense versus an easy voice, both in the clinician’s and his productions. Next, he is instructed on how to return to using easy vibrations when he reverts back to using a tense or strained voice.
Land of Calls, the fourth land in AIV, once again begins with a review of the production of easy vibrations; however, as the name implies, the main focus of the fourth land is teaching the child how to produce a loud safe voice by abducting rather than adducting the vocal folds. This practice is initially taught by having the child hum through a straw into a cup of water while progressively getting louder. If he begins to become louder by adducting the vocal folds, fewer (if any), bubbles are produced; however, if the child is producing a louder voice by abducting the vocal folds, he will continue to be able to easily blow bubbles in the water. Like the previous lands, time is spent not only on the production of easy vibrations, but also on the perception of them. As the child becomes more consistent in producing the easy vibrations, these skills are extended into more complex speech chants.
The fifth land in AIV is the Land of Safe, Loud Voice. Like the previous three lands, this land begins by reviewing the principles of easy vibrations. Subsequently, the child is taught to extend the use of a loud, safe voice into loud game activities such as basketball. As children can often become louder and strain their voices during play, the purpose of this land is to teach them how to safely use their voices in a functional context such as play.
The sixth land, the Land of Noise, extends on the skills learned in the previous lands by teaching the child how to produce and sustain easy vibrations while engaging in communication in background noise. The child is taught that although it may be impossible to hear easy vibrations in background noise, it is still possible for him to feel when he is producing easy vibrations. Initially, these tasks begin in the therapy room using masking noises; however, as the child becomes more successful in sustaining easy vibrations in that context, he is taught how to use easy vibrations while communicating in a functional context, like a school cafeteria.
The Land of Freedom, the seventh land in AIV, focuses on teaching the child how to use a free voice, rather than a stuck voice, when in emotionally infused situations. The clinician and the child can practice alternating between a free and stuck voice while telling jokes in the session. Furthermore, they can practice and model voices under different emotional contexts while playing a form of emotions charade. Last, these activities are extended into a more functional context by including the child’s family members or peers into the exercises.
The last and final land in AIV is The Land of Healthy Voices. This land focuses on helping the child self-monitor his productions while engaged in functional, real-life activities. Verdolini Abbott suggests beginning initially by playing active or frustrating games with the child. After the child is determined to be proficient at self-monitoring his vocal productions, the clinician and the child discuss how to care for one’s voice in the event of an illness like an upper respiratory infection. Together, they compile a Voice Super Power Tool Kit, which consists of reminders and strategies for maintaining a healthy voice. The final session concludes with discharge instructions and any follow-up recommendations.
AIV is one of the primary direct voice therapy programs developed for children. While evidence-based research is not available regarding its efficacy at this time, significant research supports its precursor, RVT. Currently, the National Institute on Deafness and Other Communication Disorders (NIDCD) is funding a multicenter randomized clinical trial of AIV. Data and results are expected to be available within the next 5 years.