JSLHR

Article

Intensive Voice Treatment (LSVT LOUD)

for Children With Spastic Cerebral
Palsy and Dysarthria
Cynthia Marie Foxa and Carol Ann Boliekb

Purpose: The purpose of this study was to examine the effects of

an intensive voice treatment (Lee Silverman Voice Treatment,
commonly known as LSVT LOUD) for children with spastic
cerebral palsy (CP) and dysarthria.
Method: A nonconcurrent multiple baseline single-subject design
with replication across 5 children with spastic CP was used.
Auditoryperceptual analysis of speech, acoustic measures of
vocal functioning, and perceptual ratings by parents of participants
were obtained at baseline, posttreatment, and 6-week follow-up
recording sessions.
Results: Listeners consistently preferred the speech samples taken
immediately posttreatment over those taken during the baseline
phase for most perceptual characteristics rated in this study.
Changes in acoustic measures of vocal functioning were not

peech disorders have been reported to occur in children with spastic cerebral palsy (CP; Workinger &
Kent, 1991); however, reliable prevalence figures
have not been documented (Pennington, Miller, & Robson,
2009). The most common perceptual characteristics
include consistent hypernasality, breathy voice quality,
monotonous speech, reduced loudness, and uncontrolled
rate and rhythm of voice (Workinger & Kent, 1991). Disordered respiration characterized by short vowel durations, shallow inspirations, and forced expirations also
has been reported (Clement & Twitchell, 1959; Solomon
& Charron, 1998). In addition, disordered articulation has
a

National Center for Voice and Speech, Denver, CO

University of Alberta, Edmonton, Alberta, Canada
Correspondence to Cynthia Marie Fox:
cynthia.fox@lsvtglobal.com
Editor: Anne Smith
Associate Editor: Jessica Huber
Received August 24, 2010
Revision received March 4, 2011
Accepted October 19, 2011
DOI: 10.1044/1092-4388(2011/10-0235)
b

930

consistent across participants and occurred more frequently for

maximum performance tasks as opposed to speech. Although
parents of the treated participants reported an improved perception
of vocal loudness immediately following treatment, maintenance
of changes at 6-week follow-up varied across the participants. No
changes were observed in the 5th participant, who did not receive
treatment.
Conclusions: These findings provide some preliminary observations
that the children with spastic CP in this study not only tolerated
intensive voice treatment but also showed improvement on select
aspects of vocal functioning. These outcomes warrant further
research through Phase 2 treatment studies.
Key Words: cerebral palsy, voice treatment, LSVT LOUD

been described in these children (Clement & Twitchell,

1959; Hixon & Hardy, 1964). There are limited efficacy
data on speech treatment for children with CP; hence,
there is a great need for research in this area (Pennington
et al., 2009).
Advances in clinical neurorehabilitation have documented key elements of motor learning and principles
that drive activity-dependent neuroplasticity (i.e., modifications in the central nervous system in response to
physical activity), such as intensive treatment, repetitive active practice, and sensory feedback associated
with movement. These elements may have merit in the
context of successful treatment paradigms for adults
and children with neurological disease or impairments
(Garvey, Giannetti, Alter, & Lum, 2007; Kleim &
Jones, 2008; Kleim Jones, & Schallert, 2003; Maas
et al., 2008). Moreover, there is a growing focus in speech
Disclosure Statement
Cynthia Marie Fox receives lecture honoraria and has ownership interest
in the for-profit company LSVT Global, Inc. She is in full compliance with
Federal Statute 42 C.F.R., Part 50, Subpart F (see http://grants.nih.gov/
grants/compliance/42_CFR_50_Subpart_F.htm) and the University of
ColoradoBoulder Policy on Conflict of Interest and Commitment.

Journal of Speech, Language, and Hearing Research Vol. 55 930945 June 2012 D American Speech-Language-Hearing Association

treatment research to translate principles of both motor

learning and activity-dependent neuroplasticity into
protocols for treatment of motor speech disorders in children and adults (Ludlow et al., 2008; Maas et al., 2008).
Previous studies have documented that children
with CP are capable of intensive treatment regimes
and that initial fatigue may be due to deconditioning
effects that often decrease over time (Bower, McLellan,
Arney, & Campbell, 1996; Schindl, Forstner, Kern, &
Hesse, 2000). Research also has shown that the use of
task-specific, repetitive practice and active practice
along with increased numbers of practice trials results
in marked improvements in gait (Damiano, Kelly, &
Vaughan, 1995; Schindl et al., 2000), grip force production (Valvano & Newell, 1998), and anticipatory grip
force precision (Gordon & Duff, 1999) in children with
CP. In addition, enhanced sensory input and active attention to sensory feedback during practice may facilitate
neuroplastic changes of cortical sensorimotor maps,
which is thought to foster internal representations for
movement important for carryover and maintenance of
the new target behavior, such as reaching (HaddersAlgra, 2000; Hadders-Algra, van der Fits, Stremmelaar,
& Touwen, 1999; Lenz & Byl, 1999).
Current speech treatment methods for children
with CP and dysarthria are varied but typically use a
systems approach to address respiration, phonation,
articulation, and resonance (Pennington et al., 2009).
Recently reviewed observational studies of speech interventions for children with dysarthria indicated that
teaching slow, loud speech may be associated with improvements in speech intelligibility, voice quality, and
clarity (Pennington et al., 2009). For example, Pennington,
Miller, Robson, and Steen (2010) reported on 16 children
with CP and dysarthria who received intensive treatment consisting of three 35- to 40-min sessions a week
for 6 weeks, focusing on controlling breath support, phonation, and rate. Improvements were documented in
single-word and connected speech intelligibility for
both familiar and unfamiliar listeners.
A model of speech treatment, known as LSVT LOUD
(Lee Silverman Voice Treatment), has been developed
for individuals with Parkinsons disease (PD) and has
documented efficacy for that population (Ramig et al.,
2001). The training mode of LSVT LOUD is consistent
with principles that drive activity-dependent neuroplasticity and motor learning (Fox et al., 2006). LSVT LOUD
incorporates enhancement of the voice source, consistent
with improving the carrier in the classic engineering concept of signal transmission (Titze, 1993) and using vocal
loudness as a trigger for distributed effects across the
speech production system (Dromey & Ramig, 1988; Sapir,
Spielman, Ramig, Story, & Fox, 2007). The extent to which
the effects of LSVT LOUD are specific to hypokinetic
dysarthria is not clear. However, positive outcomes in

acoustic measures (e.g., vocal sound pressure level [SPL])

and listener perceptions (e.g., articulatory precision) have
been reported postLSVT LOUD from single-subject
and case studies of adults with spastic and ataxic types
of dysarthria (Sapir et al., 2001, 2003).
The idea of targeting vocal loudness or respiratory
phonatory effort in treatment of dysarthria is not new.
Establishing a respiratoryphonatory foundation before
addressing other speech subsystems is consistent with
approaches recommended for treating motor speech disorders that (a) create a single-motor organizing theme,
(b) have a maximum impact on other aspects of speech
production, and (c) increase effort across the speech
mechanism (Duffy, 1995; Rosenbek & LaPointe, 1985;
Yorkston, Beukelman, & Bell, 1988). Moreover, it has
been recommended that treating respiratoryphonatory
support for speech should occur first or at least co-occur
with any focused articulation treatment in children
with motor speech disorders (Strand, 1995). The unique
aspect of LSVT LOUD is the singular target of training
healthy vocal loudness (respiratoryphonatory effort) to
the exclusion of targeting rate, articulation, and resonance.
The singular training target of healthy vocal loudness may be desirable for children with spastic CP.
These children have disordered voice characteristics,
which may be due to muscle weakness or incoordination
of respiratory and laryngeal subsystems (Ansel & Kent,
1992; Workinger & Kent, 1991). The single focus on vocal
loudness limits cognitive demands associated with
treatment, which may be important for children with
low-average to below-average cognitive functioning. Finally, the target vocal loudness trained in LSVT LOUD
is elicited through modeling behavior (e.g., do what I
do), which minimizes explicit verbal instructions and
may allow the childs system to implicitly self-organize
in order to achieve the goal (Schmidt & Fitzpatrick,
1996). Further, LSVT LOUD addresses criticisms of
previous behavioral treatment studies in children with
CP, for example, that (a) treatment was not delivered
in a standardized manner, (b) dosages of treatment
were not discrete, and (c) techniques were often combined (Butler & Darrah, 2001). LSVT LOUD minimizes
these issues through a protocol of specific daily exercises prescribed for the entire treatment regime, a finite
period of treatment, and a single treatment focus on
vocal loudness.
The purpose of this Phase 1 treatment study was to
examine any therapeutic effects of delivering LSVT
LOUD in children with spastic CP and dysarthria
(Robey & Schultz, 1998). The specific questions related
to this purpose are as follows: (a) Do listeners prefer
posttreatment over baseline speech samples of children
with CP on a number of perceptual characteristics of
voice and speech; (b) will intensive voice treatment affect
the vocal motor system of children with spastic CP and

Fox & Boliek: Intensive Voice Treatment for Children With CP

931

dysarthria as evidenced by changes in acoustic measures of voice; (c) do parents perceive changes in perceptual voice and speech characteristics after intensive
voice treatment; and (d) do treatment effects, if any,
last over time?

Participants

determined by an otolaryngologist; (d) ability to follow

directions for the study tasks; and (e) stable medications,
if applicable. Children with severe velopharyngeal
incompetence, structural disorders of the speech mechanism, or a concomitant speech disorder (e.g., stuttering)
were excluded. The medical diagnosis of spastic CP was
confirmed by review of medical records. The characteristics and severity of dysarthria were determined by consensus of two certified speech-language pathologists
from audio and video samples of participants with CP.

Five children between the ages of 5 and 7 years with

a medical diagnosis of predominantly spastic CP were
recruited. Characteristics of each participant are detailed in Table 1. Additional selection criteria included
(a) dysarthria; (b) hearing that was within normal limits
or aided to normal limits; (c) no vocal fold pathology as

A yoked group of typically developing, sex- and agematched children was recruited to participate in this
study. This allowed for a direct comparison between performance of participants with CP and their matched peers,
because data were collected using the same tasks and
methodology. The typically developing peers had no

Method

Table 1. Participant characteristics.

Participant
Descriptor

P1

P2

P3

P4

P5

Age (years;months)

7;10

5;10

6;1

7;7

6;7

Gender

Male

Female

Male

Male

Female

Diagnosis

Spastic quadriparesis
due to CP; secondary
seizure disorder

Spastic quadriparesis
due to CP

Parent-reported
speech and
voice concerns

Breathy, quiet voice

with weak breath
support, did not
have confidence
with speaking (e.g.,
intimidated by
other kids)

Improving breath
Weak breath control,
control, improving
soft speech, choppy
clarity of speech,
speech (i.e., took a
maintaining loudness
lot of breaths to finish
and clarity at end
a sentence)
of sentences

Observed speech
and voice
signs (2 SLPs)

Variable loudness,
Reduced loudness,
inconsistent breathymonotone, intermittent
harsh voice quality,
hypernasality, intermittent
inconsistent slow
harshness, imprecise
rate, whispered at
consonants, variable
end of sentences,
slow rate (task dependent),
mild articulatory
prosodic abnormalities
imprecision

Dysarthria type
Overall dysarthria
severity
Study condition
Age (years;months),
gender-matched
control

Spastic quadriparesis
secondary to CP

Spastic quadriparesis
secondary to CP

Spastic quadriparesis
secondary to CP

Breath control; quiet,

whispered voice;
short utterances

Take a full tidal

breath, not always
having enough
breath, stopping
in the middle of
sentences to get a
breath, breathing
coordination

Variable loudness;
Minimal voicing,
Variable loudness,
variable pitch;
reduced loudness to
irregular articulatory
inconsistent strained
aphonic, monotone,
breakdowns, variable
voice quality,
imprecise articulation,
rate, strained voice
especially at end
spoke only 12 word
quality with occasional
of sentences; mild,
phrases
voice stoppages,
imprecise articulation
intermittent glottal fry

Spastic

Spastic

Mixed spastic/ataxic

Spastic

Spastic

Moderate

Mildmoderate

Moderate

Marked

Moderate

Condition A
4 BASE/2 weeks

Condition C
5 BASE/5 weeks

Condition B
5 BASE/3 weeks

Condition A
4 BASE/3 weeks

Condition D
4 BASE/3 weeks

7;6 Male

6;2 Female

6;1 Male

7;1 Male

7;0 Female

Note.

P1 (P2, etc.) = Participant 1 (2, etc.); CP = cerebral palsy; SLP = speech-language pathologist; BASE = baseline.

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Journal of Speech, Language, and Hearing Research Vol. 55 930945 June 2012

known neurological disease or condition and no history

of speech or voice disorders. Their ages and pairings with
participants with CP are listed in Table 1.

Design
This study used a nonconcurrent multiple baseline
design with replication across subjects (Barlow & Hersen,
1984; Watson & Workman, 1981). In this design, the
treatment variable (intensive treatment) was applied
sequentially to the same behavior (vocal output) across
different but matched subjects sharing the same environmental conditions. In a nonconcurrent design, the
length of the baseline phase is varied (some short and
some longer) and predetermined (Watson & Workman,
1981). When participants became available, they were
randomly assigned to one of the predetermined baseline
conditions. This provided flexibility for conducting the
research within real-world constraints while maintaining the internal validity achieved with a concurrent design (i.e., controlling for history or maturation variables;
Watson & Workman, 1981).

Procedures
Participant Selection
A telephone screening questionnaire was completed
with parents of potential participants followed by a faceto-face screening session with the child. All the parents
signed a consent form, and children signed an assent
document agreeing to participate. This study received
approval from the University of Arizona Institutional
Review Board. The screening session included (a) a brief
voice and speech screening, (b) an assessment of abilities to follow directions related to the study tasks, and
(c) a hearing screening (500 Hz, 1000 Hz, 2000 Hz, and
4000 Hz at 25 dB HL). In addition, a laryngeal examination was conducted by an otolaryngologist to ensure that
no laryngeal pathology (e.g., vocal nodules or paralysis)
existed. All five participants completed the entire study.

Study Conditions
Participants were randomly assigned to one of four
study conditions with varying durations of baseline
phases according to the nonconcurrent study design. A
minimum of four baseline recordings were planned
across Conditions A (2-week baseline), B (3-week baseline),
and C (4-week baseline). Participant assignment to study
conditions and the actual number of recording sessions
are summarized in Table 1. These conditions all included
16 treatment sessions (4 sessions a week for 4 consecutive weeks), two recording sessions 1 week immediately
following treatment (POST), and two recording sessions
6 weeks after the conclusion of treatment (FUP). Condition D matched Condition A except no treatment was de-

livered. Treatment was administered to the participant

in Condition D following the final FUP recording session. The inclusion of an untreated participant with
CP was to document potential maturational changes
that may occur during the study period and affect interpretation of the results (Stiller, Marcoux, & Olson, 2003).

Recording Sessions
Equipment and setup. Data collection procedures
were identical for all baseline (BASE), posttreatment
(POST), and follow-up (FUP) recording sessions. Duration of recording sessions ranged from 30 min to 1 hr.
Data were collected in an Industrial Acoustics Company
sound-treated booth, and all sessions were videotaped.
Four of the participants were comfortably seated in
their own wheelchairs. One participant sat in an adaptive
chair. Audio recordings were made with the participant
wearing a small omni-directional condenser microphone
(Audio-Technica, Model AT 803b) taped to his or her forehead and secured with a soft, elastic cloth headband. The
distance from the corner of the childs mouth to his or her
forehead was measured for placement of the microphone
at each recording session. This allowed for a constant
mouth-to-microphone distance of 4 in. within and across
recording sessions. Microphone signals were recorded
onto a digital audiotape (DAT) recorder (Panasonic Digital Audio Tape Deck, Model SV-3500). Calibration signals
were recorded at the beginning and end of each session by
securing the omni-directional condenser microphone and
sound level meter (SLM) microphone to a Styrofoam head
at a distance of 4 in. from the mouth of the head, mimicking
the setup on the child. A tone generator (KORG Auto Chromatic Tuner, AT-12) was placed in the same plane as the
Styrofoam heads mouth. The generated tone (960.5 Hz)
was recorded to the DAT, and the exact sound pressure
level (dB SPL) reading from the SLM was recorded.
Data were collected by four graduate students and
the first author, who were well trained in the experimental protocol. The investigator who delivered treatment
(the first author) did not collect POST or FUP data. All
attempts to keep the student data collectors blinded to
the purpose of the study were made; however, there
were occasions when the participants revealed aspects
of the treatment they received. All data collectors were
trained to keep the same demeanor and instructions regardless of the participants comments.
Voice and speech tasks. The protocol included two
maximum performance tasks, including a sustained
vowel and maximal frequency range for vowels, as well
as a sentence repetition task (Kent & Kent, 2000; Kent,
Kent, & Rosenbek, 1987; Rvachew, Hodge, & Ohberg,
2005). For the maximal performance tasks, instructions
were Take a deep breath and say ah for as long as you
can, and Take a deep breath and say ah as high / low as

Fox & Boliek: Intensive Voice Treatment for Children With CP

933

you can. The data collectors were careful to use specific

instructions that encouraged maximum performance for
duration and frequency range but never gave any specific
instructions or cues related to vocal loudness. Multiple
repetitions of each task (average of six trials) were elicited
during each recording session to ensure that maximum
performance was captured (Kent et al., 1987). The speech
task involved repeating the sentences Buy Bobby a
puppy, The potato stew is in the pot, and The blue
spot is on the key three times at each recording session. The instructions were as follows: I am going to
say some sentences. After I say the sentence, I will
point to you and I want you to repeat what I say. Data
collectors were careful to model the sentences consistently across sessions and without exaggerated loudness, articulation, or pitch inflection. These sentences
were not trained during the treatment phase of the
study. The order of presentation of maximum performance and sentence repetition tasks was randomized
across all recording sessions.
Parent rating forms. A visual analog scale (Kempster,
1984; Schiffman, Reynolds, & Young, 1981) was filled out
by one of the participants parents at BASE, POST, and
FUP sessions. This scale obtained ratings on 10 variables related to voice (loud, nasal, hoarse/scratchy,
monotone, breathy, strained), speech (speaks so others
can understand), and spoken communication (talks
when playing with other kids, starts talking with other
kids, frustrated when talking). The scale required the
parent to place a vertical slash through a solid horizontal
line (15.2 cm) that represented a continuum ranging
from continuous presence of a characteristic, Voice is always loud enough, to complete absence of a characteristic, Voice is never loud enough. Parents were instructed
to make their ratings based on perceptions of their childs
speech most of the time versus their perception on the
day of the recording session.

Intensive Voice Treatment

LSVT LOUD treatment consisted of 16 individual
1-hr treatment sessions delivered on 4 consecutive days
each week for 4 consecutive weeks. Homework and carryover exercises were assigned every day during the month
of treatment. All treatment was delivered by an expert LSVT LOUD clinician (the first author). All treatment sessions were conducted in the participants
home. The first half of each treatment session consisted
of three daily tasks: (a) maximum duration sustained
vowels, (b) maximum frequency range, and (c) repetition
of 10 functional phrases (generated by the participant
and his or her family) five times each. The second half
of treatment sessions was spent on a speech hierarchy
progressing in difficulty from single words to conversational speech. In the case where a child had reduced verbal output (one- to four-word phrases), the progression

934

went from structured to less structured tasks (e.g., naming pictures to playing games requiring spontaneous
speech output). All exercises included a minimum of
15 repetitions of each training task while incorporating
sensory augmentation, such as cueing increased vocal
effort and loudness, and sensory awareness by asking
the children, Did you feel your voice? Did you hear
how you sounded? Children practiced one homework
session on treatment days (lasting 510 min) and two
homework sessions on nontreatment days (lasting 10
15 min). Daily carryover exercises were specific assignments to use the new target voice with someone in
the childs daily living environmentfor example, Say
good morning to the bus driver using your loud voice.
The impact of the carryover assignment was discussed
in the next treatment session (e.g., Did the bus driver understand you yesterday?). Family members assisted
the child in completing homework and carryover assignments. All participants and family members were
encouraged to continue homework routines at the conclusion of treatment.

Participation of Typically
Developing Peers
The typically developing peers participated in two
recording sessions in 1 weeks time, completing the
same tasks as the participants with CP. These children
did not participate in the laryngeal examination or the
treatment phase of this study.

Analysis
AuditoryPerceptual Data (Listener Task)
A group of seven certified speech-language pathologists who had extensive experience in the areas of motor
speech disorders and voice served as judges in a paired
comparison listening task. Three repetitions of the sentences Buy Bobby a puppy, The blue spot is on the
key, or The potato stew is in the pot from the final
BASE, POST, and FUP recording sessions were included
for speech samples. These final sessions were chosen to
ensure that each child would have the greatest familiarity with the task across the study phases. Speech samples
containing three repetitions of each of the sentences were
constructed for BASE, POST, and FUP sessions. The
order of presentation of speech samples was randomized
across study phases (e.g., BASE vs. POST or FUP vs.
BASE).
Listening task. Paired speech samples were presented to listeners via a computer and external speakers.
They rated which sample they preferred for the following variables: (a) overall loudness, (b) loudness variability,
(c) overall pitch, (d) pitch variability, (e) overall voice quality, and (f ) articulatory precision. Listeners marked on a

Journal of Speech, Language, and Hearing Research Vol. 55 930945 June 2012

rating form which sample they preferred, Sample A,

Sample B, or no preference. A listening CD was created
for each participant. Practice speech samples, consisting
of two randomly selected pairs for that child, were provided, during which the listener could adjust the volume
control on the speakers to a loudness level that was comfortable. Once the volume control was set for a given
participant, it did not change at any time during the listening task for that participant. Listeners were allowed
to replay the samples as many times as they wanted
prior to making their decision and were given the option
to provide comments about why they chose one speech
sample over another. The listening task took approximately 2 hr to complete. The number of times a speech
sample was preferred from the BASE session, POST session, or FUP session or there was no preference (NP)
was tabulated.
Statistical analysis. Auditoryperceptual data were
analyzed using two chi-square tests on the categorical
assignment of preference for each participant. The first
chi-square test assessed the categorical assignment of
preference for BASE versus POST versus NP. The second chi-square assessed the categorical assignment of
preference for BASE versus FUP versus NP. Differences
in the proportional distribution of preference for three
preference categories were examined for each participant, based on an a priori probability model of equal likelihood of all three categories.

Acoustic Data
Data preparation and digitizing procedures. All
acoustic data were reviewed, and problematic samples,
such as clipped signals (approximately 1015 samples
across all participants and sessions) and faulty microphone signals (one recording session for two participants), were excluded. Data from the DAT tapes were
digitized at 22.05 kHz with the commercial software program Praat (Boersma & Weenick, 2002). Each sample of
a sustained vowel, high vowel, low vowel, or sentence
repetition was saved in an individual .wav file. The calibration tone for each recording session was analyzed for
dB SPL. The value of the calibration tone from Praat was
subtracted from the recorded SLM value, creating a correction factor. The correction factor was applied to all
dB SPL values produced by Praat, providing calibrated
dB SPL at 4 in. across all participants and recording
sessions.
Measurements. Vowel samples (longest, highest,
lowest) from each session were displayed using Praat.
Both the acoustic waveform and spectrogram, including
intensity (dB SPL) and pitch (F0 in hertz) contours, were
displayed for analysis. All acoustic measures were derived from standard Praat algorithms. The following
measures were made for sustained vowel phonation:

(a) maximum vowel duration (s) from the first to the

last glottal pulse, (b) mean dB SPL (and SDs) from the
first to the last glottal pulse, and (c) harmonics-to-noise
ratio (HNR) selected from the middle 0.30-s segment of
each vowel. For the highest and lowest vowel phonations, the acoustic waveform and pitch contours were
inspected for any variations in voicing that interfered
with the pitch tracking analysis, such as glottal fry. Aberrant segments were cut, and the F0 range was derived
(maximum F0 minimum F0) from the remaining pitch
contour. Each digitized sentence repetition was filtered
through a customized analysis program (Mathworks,
code written by B. Story, 2002) that removed pauses
and voiceless consonants. The acoustic waveforms, intensity contour (dB SPL), and pitch contour (Hz) of the
filtered files were displayed using Praat. Pitch contours
were inspected for any variations in voicing that interfered with the pitch tracking analysis, and aberrant segments were cut. The remaining voiced segment of the
sentences was analyzed for mean (with SD) dB SPL
and F0 range (maximum F0 minimum F0) at each recording session.
Using the measures described above, we identified
and graphed for visual analysis the following values
from each recording session: (a) the duration of the
single longest sustained vowel (s), (b) the maximum
F0 range (Hz) from the single highest and lowest vowels,
(c) the mean (and SD) dB SPL of the three longest
vowels, (d) the mean (and SD) HNR of the three longest
vowels, (e) mean (and SD) dB SPL of nine sentence repetitions, and (f) mean F0 range of nine sentence repetitions. The three longest duration vowels from each
recording session were chosen for dB SPL and HNR of
sustained phonation analysis to capture variability in
trial-to-trial performance, versus only including the single best performance of the task (longest duration).
Grand means (and SDs) also were calculated for each
participant across BASE, POST, and FUP sessions.
These data were used to compare performance of each
participant with CP to mean (and SD) data of his or
her yoked typically developing peer.
Visual analysis. Visual inspection was completed by
three independent judges who did not have any contact
with the children in the study. A total of 30 data graphs
(six graphs per participant) of acoustic variables were visually analyzed for trend and overlapping data points
(Barlow & Hersen, 1984). On the few occasions when
there was disagreement between judges, the majority
ruled (two of three).
Statistical analysis. Statistical analysis was applied
according to the following rules: (a) if there was clear
visual evidence of no treatment effect, defined as no variability in baseline data, no visual trends, and overlapping data points across all study phases, then no statistic
was applied; (b) if there was clear visual evidence of a

Fox & Boliek: Intensive Voice Treatment for Children With CP

935

treatment effect, defined as a visual trend with no overlapping data points between study phases, statistics
were used to confirm the effect; and (c) if there was unclear
evidence of a treatment effect, defined as a visual trend
with overlapping data points, or no visual trend with
variable baseline data, statistics were applied to ascertain whether there was a possible treatment effect not
evident through visual inspection of the graphed data.
We began our statistical analysis by checking for serial
dependency in the data by running a lag-1 auto-correlation
(Pearson) on neighboring data points in the baseline.
If there was no significant auto-correlation, then we
averaged data in each phase and conducted a one-way,
repeated-measures analysis of variance (ANOVA). Least
significant differences were used for post hoc comparisons. If baseline data were significantly correlated,
then a split-middle binomial probabilities test was applied (Siegel, 1956). A lenient post hoc analysis and
p value of <.05 for significance was chosen, allowing liberal tolerances for Type I errors, consistent with Phase 1
treatment research goals (Robey & Schultz, 1998). Effect
size calculations were derived using a modified Cohens
d statistic (Busk & Serlin, 1992), as suggested by Beeson
and Robey (2006) for use with single-subject research
designs. For comparison of participants with CP with
their typically developing peers, a difference in mean beyond 2 SDs was considered significant.

Parent Rating Forms

Standard procedures for analysis of visual analog
scales were used (Boeckstyns & Backer, 1989). The total
distance of the line (15.2 cm) representing the continuum
of presence or absence of a characteristic was measured.
The distance of the slash on the line from right end of the
continuum was measured and calculated into a percentage based on the total distance of the line (Fox & Ramig,
1997). This percentage represents the parents perceived
presence of a particular characteristic in the child with CP
most of the time. Difference scores from BASE to POST
and BASE to FUP were calculated. Given that there was
only a single data point at BASE, POST, and FUP for
parent ratings, statistical analyses were not applied.

Reliability
Auditory Perceptual Analysis
We determined intrarater reliability for the seven
listeners by repeating 30% of the paired speech samples
per participant in the listening task. Intrarater reliability across listeners ranged from 74% to 89%.

Mean difference scores (MDs) and Pearson product

moment correlations (r) were calculated. Intermeasurer
reliability scores were as follows: duration, MD = 0.005 s,
r = .99; F0 range, MD = 28.5 Hz, r = .99; dB SPL of sustained phonation, MD = 0.03 dB SPL, r = .99; HNR of
sustained phonation, MD = 0.01 dB SPL, r = .94; dB
SPL of sentences, MD = 0.08 dB SPL, r = .99; F0 range
of sentences, MD = 6.03 Hz, r = .90. These values represent good intermeasurer reliability.

Visual Analysis
We determined intrarater reliability for the three
judges who visually examined data by randomly selecting 10 of the 30 graphs for repeated analysis. The
intrarater reliability ranged from 98% to 100%. We determined interrater reliability by comparing agreements among the three raters. Interrater reliability
was 94.7%.

Parent Ratings
We determined intrarater reliability of parent perceptual ratings by repeating a visual analog scale at
one additional BASE, POST, or FUP recording. Intrarater reliability was available for all participants parents except Participant 1 (P1). Mean difference scores
(MDs) and Pearson productmoment correlations (r)
were calculated. Intrarater reliability fell in the following ranges: MD = 7.00%0.47% (0%100% scale),
r = .68.90.

Results
Auditoryperceptual data and chi-square analyses
are displayed in Table 2. The number of preference
choices per BASE, POST, FUP, or NP (3 Sentence
Pairs 7 Listeners = 21 total choices per perceptual variable) and the accompanying statistic are listed. All
acoustic data are displayed in Table 3. Effect size (ES)
was commensurate with observed direction of change
and statistical significance in all but one case (P1, dB
SPL for sustained phonation). Judgments regarding
magnitude of the ES were not made due to the Phase 1
nature of the study (Beeson & Robey, 2006). Difference
scores across study phases of parent perceptual ratings
(expressed in percentages) are displayed in Table 4. Positive and negative values reflect perceptions of improvement or deterioration, respectively.

Data for P1
Listener Ratings

Acoustic Analysis
We calculated measurement reliability by having
20% of the data reanalyzed by a second measurer.

936

Chi-square analysis revealed statistically significant

preferences for the POST over BASE samples across all
perceptual variables except loudness variability. These

Journal of Speech, Language, and Hearing Research Vol. 55 930945 June 2012

Table 2. Summary analysis for auditoryperceptual data.

BASEPOST

BASEFUP

BASE

POST

NP

c2

BASE

FUP

NP

c2

Overall loudness
Loudness variability
Overall pitch
Pitch variability
Overall voice quality
Articulatory precision

2
2
0
0
2
1

14*
11
13*
13*
14*
19*

5
8
8
8
5
1

.004
.050
.002
.002
.004
.000

11.14
6.0
12.28
12.28
11.14
30.86

9
9
8
11*
11
8

2
2
1
1
2
4

10
10
12*
9
8
9

.066
.066
.012
.018
.050
.368

5.43
5.43
8.86
8.0
6.0
2.0

Overall loudness
Loudness variability
Overall pitch
Pitch variability
Overall voice quality
Articulatory precision

1
2
3
2
1
0

12*
11*
6
10*
9*
4

1
1
5
2
4
10*

.000
.002
.607
.010
.030
.004

15.39
13.0
1.0
9.14
7.0
10.86

4
8
3
4
3
0*

14*
13*
10
13*
14*
11

3
0
8
4
4
10

.005
.002
.156
.021
.005
.005

10.57
12.27
3.71
7.71
10.57
10.57

Overall loudness
Loudness variability
Overall pitch
Pitch variability
Overall voice quality
Articulatory precision

2
2
0
1
1
0

14*
14*
8
11*
12*
14*

5
5
13*
9
8
7

.004
.004
.002
.018
.012
.001

11.14
11.14
12.29
8.0
8.86
14.0

10
3
1
0*
1
5

8
13*
5
11
13*
7

3
5
15*
10
7
9

.156
.018
.001
.005
.006
.565

3.71
8.0
14.86
10.57
10.29
1.14

Overall loudness
Loudness variability
Overall pitch
Pitch variability
Overall voice quality
Articulatory precision

1
0
0
0
0
0

19*
18*
13*
11*
20*
14*

1
3
8
10
1
7

.000
.0001
.002
.005
.0001
.0009

30.86
26.57
12.29
10.57
36.28
14.0

0
0
2
2
2
1*

16*
17*
6
7
17*
11

5
4
13*
12*
2
9

.000
.000
.012
.028
.000
.018

19.14
22.57
8.86
7.14
21.42
8.0

Overall loudness
Loudness variability
Overall pitch
Pitch variability
Overall voice quality
Articulatory precision

1
1
1
1
3
1

3
4
3
6
5
3

17*
16*
17*
14*
13*
17*

.000
.000
.000
.002
.018
.000

21.74
18.0
21.71
12.29
8.00
21.74

4
5
3
4
3
6

4
5
6
6
8
3

13*
11
12*
11
10
12*

.021
.180
.050
.156
.156
.050

7.71
3.43
6.0
3.71
3.71
6.0

Variable
P1

P2

P3

P4

P5

Note. For each perceptual variable, there were a total of 21 choices (3 Sentence Pairs 7 Listeners) for each comparison BASE to POST
and BASE to FUP (with the exception of P2 for POST). The values represent the number of listeners who preferred either a BASE, POST, FUP,
or NP speech sample. Boldfaced and asterisked values indicate the preference (BASE, POST, FUP, or NP) that was statistically significant.
P4 repeated only single words versus the entire sentence in this task. POST = posttreatment; FUP = follow-up; NP = no preference.

preferences were not maintained at FUP. Listener comments for preference of POST samples included louder,
more variable, pitch more stable, natural, less
strain, decreased nasal emissions, more crisp, and
less effort. Comments for preference of BASE samples
included more consistent loudness, louder, and less
gurgle.

difference was found included maximum F0 range

from BASE to POST and maximum duration ah from
BASE to FUP. P1 was 2 SDs below the mean values of his
matched typically developing peer at BASE, POST, and
FUP for all variables except dB SPL and F0 range of sentence repetition at all phases.

Parent Ratings
Acoustic Analysis
The measures for which a visual treatment effect
was observable and for which a statistically significant

Perceptual variables with the greatest percentage

increase from BASE to POST included always loud
enough (44%) and never breathy voice (31%). These

Fox & Boliek: Intensive Voice Treatment for Children With CP

937

Table 3. Summary analysis for acoustic data.

Grand means
Variable

BASEPOST

BASE

POST

FUP

TP

Visual

Max performance ah
Duration (s)
Max performance
F0 range (Hz)
Sustained phonation
dB SPL of 3 longest ahs
Sustained phonation
HNR of 3 longest ahs
Sentence repetition
dB SPL
Sentence repetition
F0 range (Hz)

2.4
(1.0)
200
(42)
87.4
(4.9)
22.1
(2.3)
75.0
(1.6)
62
(7)

3.5
(1.0)
436
(139)
87.4
(2.9)
22.9
(0.7)
76.4
(1.3)
76
(3)

4.4
(0.5)
301
(45)
87.4
(7.2)
24.1
(0.8)
76.0
(0.74)
66
(16)

16.1
(2.8)
884
(234)
96.5
(1.3)
26.3
(0.1)
74.9
(3.6)
96.1
(49)

Max performance ah
Duration (s)
Max performance
F0 range (Hz)
Sustained phonation
dB SPL of 3 longest ahs
Sustained phonation
HNR of 3 longest ahs
Sentence repetition
dB SPL
Sentence repetition
F0 range (Hz)

1.8
(0.6)
289
(215)
86.3
(1.5)
22.0
(2.3)
73.0
(1.9)
109
(16)

5.7
(0.4)
724
(147)
94.6
(1.1)
22.0
(2.8)
82.0
(0.4)
131
(23)

7.0
(1.4)
1097

11.4
(0.6)
2242
(61)
95.3
(2.3)
27.9
(1.6)
78.6
(0.4)
180
(29)

Max performance ah
Duration (s)
Max performance
F0 range (Hz)
Sustained phonation
dB SPL of 3 longest ahs
Sustained phonation
HNR of 3 longest ahs
Sentence repetition
dB SPL
Sentence repetition
F0 Range (Hz)

5.3
(0.8)
796
(127)
82.4
(2.7)
19.2
(4.9)
80.4
(2.9)
118
(18)

6.8
(0.6)
633
(112)
84.2
(2.8)
21.7
(0.5)
79.3
(2.9)
128
(32)

13.4

Max performance ah
Duration (s)
Max performance
F0 range (Hz)
Sustained phonation
dB SPL of 3 longest ahs
Sustained phonation
HNR of 3 longest ahs
Sentence repetition
dB SPL
Sentence repetition
F0 range (Hz)

1.0
(0.7)
137
(34)
83.1
(10.1)
15.6
(4.4)
70.4
(4.4)
34
(18)

1.2
(0.2)
211
(21)
87.5
(2.5)
19.3
(2.0)
75.0
(0.7)
42
(9)

STAT

BASEFUP
ES

Visual

STAT

ES

p < .12a

1.1

p < .035a

2.0

p < .01a

5.6

p < .17a

2.4

p < .0001b

0.0

p < .0001b

0.0

N/A

0.3

N/A

0.8

N/A

0.9

N/A

0.6

N/A

2.0

N/A

0.6

p < .001a

6.5

p < .0001a

5.2

p < .0001b

2.0

p < .0001b

3.8

p < .0001a

5.5

p < .0001a

8.7

p < .87a

0.0

p < .451a

0.9

p < .005a

4.7

p < .002a

5.5

p < .23a

1.4

p < .003a

7.3

p < .05a

1.9

p < .001a

10.1

p < .14a

1.3

p < .07a

1.6

N/A

0.7

N/A

1.8

N/A

0.5

N/A

0.8

p < .861a

0.4

p < .626a

0.4

N/A

0.6

N/A

0.9

N/A

0.3

N/A

0.7

p < .0001b

2.2

p < .0001b

1.4

N/A

0.4

N/A

0.6

p < .17a

0.8

p < .03a

2.0

p < .001b

1.1

p < .001b

1.5

N/A

0.4

N/A

1.0

P1

P2

99.4
(1.0)
24.0
(1.3)
83.5
(4.4)
225
(26)

P3

1005
87.2
23.3
82.9
134

15.7
(1.0)
2853
(48)
93.9
(2.6)
26.4
(4.0)
74.4
(3.7)
107
(38)

P4
1.5
(0.4)
185
(18)
89.4
(1.4)
24.5
(0.7)
76.8
52

16.9
(0.1)
1638
(1099)
94.3
(0.5)
26.8
(0.5)
75.7
(0.6)
118
(6)

(Continued on the following page)

938

Journal of Speech, Language, and Hearing Research Vol. 55 930945 June 2012

Table 3 Continued . Summary analysis for acoustic data.

Grand means
Variable

BASEPOST

BASEFUP

BASE

POST

FUP

TP

Visual

STAT

ES

Visual

STAT

ES

6.7
(1.4)
860
(146)
95.1
(1.4)
22.6
(4.7)
78.9
(2.4)
132
(38)

7.4
(1.3)
519
(81)
91.2
(5.04)
22.9
(0.5)
78.5
(1.9)
106
(8)

7.3
(0.8)
719
(69)
95.3
(4.2)
21.7
(2.47)
78.4
(2.5)
96
(141)

15.8
(5.3)
1066
(110)
99.7
(3.6)
28.9
(0.2)
86.9
(0.1)
165
(0.7)

N/A

0.5

N/A

0.4

p < .02a

2.3

p < .24a

0.1

p < .20a

2.8

p < .95a

0.1

N/A

0.1

N/A

0.2

N/A

0.2

N/A

0.2

N/A

0.7

N/A

0.9

P5
Max performance ah
Duration (s)
Max performance
F0 range (Hz)
Sustained phonation
dB SPL of 3 longest ahs
Sustained phonation
HNR of 3 longest ahs
Sentence repetition
dB SPL
Sentence repetition
F0 range (Hz)

Note. Mean data across BASE, POST, FUP, and TP are presented with SDs in parentheses. Effect sizes were calculated using a Cohens (1988) d statistic
modified by Busk and Serlin (1992). Direction of arrows and triangles reflects direction of change (up indicating improvements, down indicating
worsening). TP = typically developing peer; Visual = summary of the visual trend analysis; STAT = results of the statistical analysis, if applied; r or 4 = visual
trends with nonoverlapping data points; j or , = visual trends with overlapping data points; = no visual trend in the data, including instances of variable
baseline data; HNR = harmonics-to-noise ratio; N/A = statistics not applied.
a

p value derived through analysis of variance. bp value derived through split-middle binomial probability test.

comments for preference of POST or FUP samples included louder, more variable, not strained, less
monotone, more precise, and less hoarse. Comments when a BASE sample was preferred over FUP
included not yelling, which referred to her FUP repetition of Buy Bobby a puppy.

percentage increases from BASE to FUP were not maintained at 5% and 2%, respectively.

Data for P2
Listener Ratings
Chi-square analysis revealed statistically significant
preferences for both POST over BASE and FUP over
BASE samples for overall loudness, loudness variability, pitch variability, and overall voice quality. Listener

Acoustic Analysis
The measures that had a visual treatment effect and
also were statistically significant included maximum

Table 4. Parents perceptual ratings of their childs voice, speech, and communication most of the time.
Difference scores in parent perceptual ratings
P1

P2

P3

P4

Perceptual characteristic

BP

BF

BP

BF

BP

BF

BP

Always loud enough

Never nasal voice
Never hoarse, scratchy voice
Never monotone
Never breathy voice
Never strained voice
Always speaks so others can understand
Always talks when playing with kids
Always starts talking with other kids
Never frustrated when talking

44
8
20
5
31
17
18
18
23
23

5
2
22
7
2
19
10
71
72
10

39
11
1
32
39
7
20
3
7
3

40
13
2
38
39
5
24
5
5
5

33
4
6
3
22
28
13
17
14
26

23
1
2
15
12
19
0
2
2
13

32
18
31
6
1
2
9
0
22
25

P5
BF

BP

BF

8
14
26
1
6
2
30
11
10
2

Note. B P is the difference score in percentage rating from BASE to POST; B F is the difference score in percentage rating from BASE to FUP.
Positive values reflect improved perceptions; negative values reflect worsening perceptions.

Fox & Boliek: Intensive Voice Treatment for Children With CP

939

duration ah, maximum F0 range, dB SPL of sustained

phonation, dB SPL of sentence repetition from BASE to
POST and BASE to FUP, and F0 range for sentence repetition from BASE to FUP. P2 was 2 SDs below the mean
value of her matched typically developing peer for all
variables at BASE, POST, and FUP except dB SPL of
sustained phonation, and F0 range of sentence repetition at POST and FUP. She was 2 SDs above the mean
value for dB SPL of sentence repetition.

Parent Ratings
Perceptual variables with the greatest percentage
increase from BASE to POST included always loud
enough (39%) and never breathy voice (39%). These
percentage increases from BASE to FUP were maintained at 40% and 39%, respectively.

Data for P3
Listener Ratings
Chi-square analysis revealed statistically significant preferences for the POST over BASE samples for
all variables except overall pitch. Preference for loudness
variability and overall voice quality were maintained at
FUP. Listener comments for preference of POST or FUP
samples included more precise, louder, consistent
loudness, less breathy, less strain and strangle,
and clearer voice quality.

Acoustic Analysis
The measure that had a visual treatment effect,
which also was statistically significant, was maximum
sustained ah from BASE to FUP. P3 was 2 SDs
below the mean value of his matched typically developing peer for all variables at BASE, POST, and FUP,
except for HNR of sustained phonation and dB SPL
and F0 range of sentence repetition at all study phases.

Parent Ratings
Perceptual variables with the greatest percentage
increase from BASE to POST included always loud
enough (33%) and never strained voice (28%). These
percentage increases from BASE to FUP were somewhat
maintained at 23% and 19%, respectively.

Data for P4
P4 was unable to repeat entire sentences; therefore,
he repeated the last word of each sentence (puppy,
pot, key) during the sentence repetition task. There
are no data for sentence repetition at BASE 2 due to P4s
unwillingness to perform the task and at FUP 2 due to
microphone failure.

940

Listener Ratings
Chi-square analysis revealed statistically significant preferences for the POST over BASE single-word
repetition samples across all six perceptual variables
rated. Preference for overall loudness, loudness variability, and overall voice quality were maintained at FUP.
Listener comments for preference of POST or FUP samples included louder, more variable, less breathy,
less pressed, easier for child to produce, more precise, and more natural pitch.

Acoustic Analysis
The measures that had a visual treatment effect and
also were statistically significant included maximum
F0 range from BASE to POST and maximum F0 range,
HNR of sustained phonation, and dB SPL of his singleword repetition from BASE to FUP. P4 was two SDs
below the mean value of his matched typically developing peer for all variables at BASE, POST, and FUP, except for maximum F0 range at all phases and dB SPL of
sentences at POST and FUP.

Parent Perceptual Ratings

The perceptual variable with the greatest percentage increase from BASE to POST was for always loud
enough (33%). The second largest percentage change
was in a negative direction reflecting an increase in the
perception of a hoarse, scratchy voice (31%). Data for
FUP measures from the same parent who completed the
BASE and POST ratings were not available.

Data for P5
P5 was an untreated comparison participant in this
study. Therefore, the study phases of POST and FUP
were actually additional BASE recordings following
1 month and an additional 6 weeks of no treatment.

Listener Ratings
Chi-square analysis revealed statistically significant preferences for the NP category for all variables
rated from BASE to POST and for overall loudness, overall pitch, and articulatory precision at the FUP session.

Acoustic Analysis
The measure that had a visual treatment effect and
also was statistically significant was a decreasing performance for maximum F0 range from BASE to POST.
P5 was 2 SDs below the mean value of her matched typically developing peer for all variables at BASE, POST,
and FUP except maximum duration at all phases, maximum F0 range at BASE, and dB SPL of sustained phonation at BASE and FUP.

Journal of Speech, Language, and Hearing Research Vol. 55 930945 June 2012

Parent Ratings
The perceptual variable with the greatest percentage increase from BASE to POST was for never hoarse,
scratchy voice (26%). The next largest percentage
change was a decrease (worsening) for the perception
of always speaks so others can understand (30%).
Data for FUP measures from the same parent who completed the BASE and POST ratings were not available.

Discussion
This Phase 1 treatment study examined the effects
of an intensive voice treatment in children with spastic
CP and dysarthria. A nonconcurrent single-subject multiple baseline design with replication across participants
was used. Listeners preferred POST speech samples for
loudness, pitch variability, and voice quality over BASE
speech samples in all four treated participants. Treated
participants made a significant gain in at least one acoustic
measure during maximum performance tasks; improvements were not as frequently observed for speech. All
parents rated an improved percentage for always loud
enough from BASE to POST. Maintenance of these perceptual and acoustic changes at FUP varied across participants and are detailed below. The untreated participant
did not make improvements over the course of the study.
The implications of these findings and directions for future research are discussed below.

Listener Preferences
Listeners preferred POST over BASE speech samples from the sentence repetition task for most of the perceptual variables rated, including five of six for P1, four
of six for P2, five of six for P3, and six of six for singleword repetitions for P4. These listener ratings support
an immediate therapeutic effect of the intervention.
However, these findings should be interpreted with caution
for a number of reasons. First, a lenient p value, which is
consistent with Phase 1 treatment research goals, increased the potential for Type 1 error (treatment effect
identified when none exists). Second, perceptual variables rated in this study were not specifically defined
for the listeners. Although loudness, pitch, voice quality,
and articulatory precision are standard perceptions, listeners may have interpreted these variables differently.
Third, the intrarater reliability for some of the listeners
was borderline acceptable. Finally, the model for sentence
repetition was provided by verbal output from data collectors. Although these data collectors were well trained on
presentation style of the sentences, we cannot eliminate
the possibility that differences in models may have affected the participants speech. Future research using
prerecorded samples, perhaps with animated characters

to engage children (e.g., Test of Childrens Speech by

Hodge, Daniels, & Gotzke, 2006) would standardize
this task presentation.

Acoustic Measures
Overall there were minimal changes in acoustic
measures across study phases, with the exception of P2.
In addition, most participants with CP were still 2 SDs
below the mean performance of their typically developing peers for maximum performance tasks after treatment. These findings are consistent with those of Wit,
Maassen, Gabreels, and Thoonen (1993), who reported
that children with spastic CP were significantly reduced
in their performance envelope compared with typically
developing peers. These findings also are different
from the pattern of results found in adults with PD who
nearly always have large and significant changes in maximum performance tasks, which are trained targets in
LSVT LOUD (Sapir, Ramig, & Fox, 2011). This was
most likely related to the different etiology of the dysarthria in PD versus CP. In PD, the soft voice is often due to
deficits in scaling amplitude of motor output and sensory
perception of normal loudness (Sapir et al., 2011). Targeting vocal loudness in people with PD may cue or access a relatively intact motor system that is capable of
scaling up output to produce normal vocal loudness. In
CP, the soft voice is related to generalized weakness of
respiratory and laryngeal systems, coupled with a lack
of coordination between the respiratory and laryngeal
subsystems (Ansel & Kent, 1992; Workinger & Kent,
1991). Thus, unlike in PD, there may be inherent neuromuscular limitations in CP that impact gains on tasks
targeting the maximum performance envelope.
The acoustic variables measured for sentence repetition (mean vocal SPL and F0 range) may not have been
adequate to capture what the listeners perceived in
speech, when they preferred POST speech samples.
Selecting different or additional acoustic measures in future studies may better capture potential changes in vocal
motor functioning that underlie the listener-perceived
changes. For example, including the entire speech envelope in vocal SPL analysis for sentences versus a focus on
the voiced segments may capture the whispered elements of some participants speech at the end of sentences.
Although the acoustic measures did not document significant changes for most participants, written comments
from listeners often indicated that children spoke with
less effort, less strain and strangle, or less of a
struggle. These perceptions of decreased effort and
strain are not reflected in measures of vocal SPL or F0
range and may have been the basis of listener preference
of POST samples.
Using multiple strategies to detect change in singlesubject designs may provide the best interpretation of

Fox & Boliek: Intensive Voice Treatment for Children With CP

941

data. For example, P1 revealed no visual trend, no mean

differences, and no effect size for dB SPL of sustained
phonation, yet the split-middle technique revealed a statistically significant difference. In this case, the statistical detection of a true change is suspect. Conversely,
P2 exhibited a visual trend, a statistically significant
difference, and a relatively large effect size for POST and
FUP duration of sustained phonation. In this case, a true
change is likely. The interpretation of effect size in this
study is limited. The ability to interpret effect sizes in
single-subject designs requires averaging them across
studies in order to establish meaningful effect size magnitudes for specific variables of interest for a given treatment approach (Beeson & Robey, 2006). Including effect
size calculations in the current study will contribute to
interpretation of outcomes from future studies.

Changes in Parent Ratings

Qualitative information from parent ratings identified improvement on some perceptual variables, which
may indicate a possible impact in the participants
daily living, outside of the laboratory setting. Parent ratings corroborated many of the listener perceptions of improvement immediately posttreatment. Although the
parent ratings must be interpreted with caution, given
the lack of replication, moderate intrarater reliability,
and descriptive level of analysis, they are a step in the
direction of assessing external validity of the findings.
Future work should continue to address the perceived
impact of treatment on family, friends, and teachers in
the environment.

Did Treatment Effects Last?

Maintenance of listener preferences at FUP varied
across participants. Listeners did not perceive P1 to
have maintained any of the improvements in perceptual
characteristics from BASE to FUP, but listeners perceived P2 to have maintained all of the improvements
from BASE to FUP, P3 to have maintained two of the
five improvements from BASE to FUP, and P4 to have
maintained three of the six improvements from BASE
to FUP. Perceptions of improvement that were maintained included those most closely related to the treatment target of voice (e.g., overall loudness, loudness
variability, and overall voice quality). All acoustics measures showed maintenance or improvement of skill from
BASE to FUP with the exception of F0 range for P1. Parent perceptual ratings at FUP were not maintained at
POST levels for P1, but they were maintained for P2
and somewhat maintained for P3. FUP data were not
available from the parents of P4.
The maintenance of treatment effects may have
depended on multiple factors, such as acceptance of the

942

treatment techniques and family support. Although we

did not systematically log home practice in the 6-week
interval between POST and FUP, parents reported on
their childs progress. P2s parent indicated that she frequently reminded herself to use her loud /strong voice
and she did so regularly in daily communication. P3s
mother reported that if she could not understand her
son, cueing him to repeat with his strong voice was a
helpful strategy. P4 had four older siblings who constantly cued him to use his big voice. For P1, changes
in speech were not maintained according to listener and
parent ratings. The parent reported that P1 was unwilling to practice on his own or with family members.

General Comments on Treatment

Mode and Target
The intensive treatment protocol consistent with select principles of motor learning and activity-dependent
neuroplasticity was well tolerated by all participants, with
100% compliance during the treatment phase. These findings are similar to those of Schindl et al. (2000) for an
intensive gait-training program and Pennington et al.
(2010) for intensive speech therapy for children with
CP. According to parent report, physical fatigue occurred
in most participants at the start of treatment; however,
over time they reported that fatigue diminished. P1s
parent even reported in later treatment sessions that
he was energized and performed better on other
tasks, such as physical therapy, when they occurred on
the same day. Repeated active-practice trials in therapy
were also well tolerated by participants with CP. Most of
the treatment sessions were completed without breaks
for rest.
The treatment target of vocal loudness was highly
salient to the participants. At BASE, all parents reported
concerns about their childs vocal loudness, citing soft
speech, breathy, quiet voice, maintaining loudness
at end of sentences, and whispered voice. At the
same time, the speech-language pathologists reported
that some of these children also had occurrences of
harsh voice quality and strained voice quality. We
speculate that the poor voice quality that occurred
prior to treatment may have been the result of compensatory strategies to overcome generalized weakness of
respiratory and laryngeal musculature (Ansel & Kent,
1992). With treatment, the need for compensatory behaviors may have been diminished at POST and replaced
with improved vocal strategies as indicated by listener
comments of less strain [or pressed or strangled] for
all four treated participants. This is similar to findings in
individuals with PD after treatment with LSVT LOUD
(Countryman, Hicks, Ramig, & Smith, 1997). To confirm
these speculations, further study is needed in children
with CP and dysarthria. Severity of dysarthria also

Journal of Speech, Language, and Hearing Research Vol. 55 930945 June 2012

may play a role in treatment success. The child with CP

who demonstrated the greatest improvements across
all acoustic measures in this study (P2) had the mildest
rating of dysarthria. P3 differed slightly from the other
participants in that he was described as having spastic
ataxic dysarthria characterized by variable loudness.
For this participant, listeners preferred POST and
FUP speech samples on the measure of loudness variability, which is consistent with reported improved control over variable loudness post-LSVT in an adult with
ataxic dysarthria (Sapir et al., 2003). For P4, the parents
rated increased hoarseness at POST. This may be
explained by the fact that, after therapy, P4 was voicing
versus whispering, which may have made parents more
aware of vocal quality. Increased hoarseness was not
reported by listener perceptions of improved voice quality on single-word repetitions at POST and FUP or with
reported HNR values.

Study Limitations and Future Directions

The single-subject design used for this study precludes generalization of these results to the population
of children with spastic CP. The liberal tolerance of
Type I errors may have overestimated some of the treatment outcomes. Adding a spontaneous speech task with
a peer or parent interaction in a naturalistic environment would have been desirable. The inclusion of systematic monitoring of homework practice sessions would
have been helpful for the interpretation of skills maintenance. Furthermore, there is a need for including ratings
of speech intelligibility at a single-word and connected
speech level (Pennington et al., 2010).
Future studies may investigate additional acoustic
parameters of voice and speech. Examining potential
physiological changes that may accompany treatment
will provide insight into the mechanism of change. In
addition, examination of alternative treatment targets
(e.g., oromotor exercises or articulation) administered
in a parallel mode and intensity will help delineate key
elements of treatment success. Future studies are also
required to determine duration of treatment effects
(e.g., more than 6 weeks) and to delineate the most effective dosage. Finally, studies that engage a larger
number of children with spastic CP are required to determine generalizability of treatment outcomes for this
population.

Summary
Improving speech in children with CP is challenging. Many of these children have a range of medical problems, multiple speech mechanism disorders, and
cognitive deficits, all of which may limit the magnitude
and long-term effects of treatment outcomes. This Phase 1

treatment study (Robey & Schultz, 1998) examined a

standardized treatment approach (LSVT LOUD) in children with spastic CP and dysarthria. Findings provide
some preliminary support for intensive voice treatment
to improve select aspects of vocal functioning in the children with spastic CP and dysarthria who participated in
this study. Future Phase 2 treatment research studies
are warranted.

Acknowledgments
This work was supported, in part, by National Multipurpose Research and Training Center Grant DC-01409 from
the National Institute of Deafness and Other Communication
Disorders and by the Final Project Fund from the Graduate
College at the University of Arizona. This article is based on a
doctoral dissertation completed by Cynthia Marie Fox at the
University of Arizona under the direction of Carol Ann Boliek
and Jeannette Hoit. We thank Jeannette Hoit, Brad Story,
Leslie Tolbert, Becky Farley, and Lorraine Ramig for their
expert advice. Special thanks go to the children and families
who participated in this study.

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