Introduction:
Puberphonia is a disorder predominant on
post-pubescent male (without known organic cause),
who exhibit higher register than other male of the same
age group. This disorder has also been observed in
females, where the manifestation is very less, as females
generally have higher register voice. This condition in
female is known as "Juvenile Resonance Disorder" or
"Little Girls’ Voice".
The high voice may be produced at the top of
the chest register or in falsetto; this high voice is
sometimes called mutational falsetto. It may be
associated with mild dysphonia and increased, effortful
phonation. Vocal instability is often marked with
extensive frequency swing.
Vocal impairment in male is generally of higher
pitch i.e. above 200Hz, and sometimes observable with
downward pitch breaks. Downward pitch break
reveals the natural lower pitch level, which may be close
to 110-125 Hz.
o Aerodynamic characteristics:
Possibly elevated then average airflow, if
breathy voice accompanies higher pitch.
o Acoustic characteristics:
Elevated in young men and women during or
after pubertal changes.
Psychosocial impact on puberphonic and effectiveness of voice therapy: A case report
1
B. Bhattarai1
, A. Shrestha2
, Sunil Kumar Shah3
1
Audiologist and Speech Therapist, Dept. of ENT, 2
Lecturer, Dept. of ENT, 3
Lecturer, Dept of Psychiatry
Abstract: Puberphonia is a rare disorder, in which the patient manifests higher register voice than others
of their same age group. Manifestation is less in women than men. The prevalence is 1 in 900,000. Apart
from impact on voice of patient, puberphonia also has impact on the psycho-social aspect. Different
treatment modalities have been put forward in the past, many of which lack validity and EBP. Voice
therapy has proven to be the most effective in the management of puberphonia.
Voice Handicap Index (VHI) is a tool for assessing the perceived handicap by the patient. VHI has 3
parts and overall score of 120 and individual subset has score of 40 each.
Result: Patient who received voice therapy obtained better score on the overall scale as well as on each
subsets of the VHI.
Conclusion: The study concludes that the voice therapy not only improves the voice quality of the patient,
but also improves the quality of life of the patient. The impact of voice disorder (puberphonia) is most
prominent on the emotional section.
Keywords: Puberphonia, voice therapy, VHI.
Correspondences: Mr. Bibek Bhattarai
E-mail: bibeck.bhattarai@gmail.com
Case Report Journal of College of Medical Sciences-Nepal, 2010, Vol. 6, No. 1, 57-62
57
Prevalence of puberphonia is not well established.
In one study by Banerjee (in Press), it was estimated
that the prevalence of puberphonia, in India is about 1
in 900,000, which was supported by other studies1
.
Juvenile Resonance Disorder is very rare as female
generally have higher pitched voice2
.
The normal course of disorder is high pitched, prepubescent
voice, possibly accompanying downward
pitch break (in males) persisting after puberty.
Negative social reactions commonly occur,
affecting overall social and vocational goals.
Impact of voice disorder:
The impact of voice disorder varies greatly from
person to person. Occupation, environment, family
members and overall personality are all the variables
that can affect the way voice disorder affects a specific
person. In general, people with puberphonia tend to
encounter problems that include psychological,
emotional, social and professional related difficulty 3
.
Recently there has been increased interest in the HRQOL,
and a research conducted by Wilson et. al. has
emphasized the importance of including QOL measure
in an otolaryngologic and voice assessment4
.
Voice Handicap Index:
It was developed and validated by Jacobson,
Johnson, Grgnalski, Silbergleit and Beginner in 1997.
Initially it was developed to fill the requirement of
patient’s outcome with emphasis on patient’s physical,
emotional and functional changes as the treatment
progresses. First version of VHI had 85 items, which
was then reduced to form 30 item scale as VHI-30,
which is the most popular scale used in both clinics
and research 5
.
Each sub-section of VHI is weighs a score of 40,
which gives total of 120. A VHI score 0 to 30
represents low scores indicating that there is a minimal
amount of handicap associated with the voice disorder.
A score of 31 to 60 denotes a moderate amount of
handicap due to voice problem. A VHI score from 60
to 120 represents significant and serious amount of
handicap due to voice problem and are often seen in
patient with new onset vocal fold paralysis or severe
vocal fold scarring6
.
Rosen et. al. (2000) reported that Voice Handicap
Index as a useful instrument to monitor the treatment
efficacy for wide range of voice disorders 7 & 8. VHI is
also used to assess the effect voice disorder has on
patients’ daily living 5
. The overall VHI score, as well
as the percentage change between VHI scores preto
post-intervention, and scores on the individual
subscales of VHI can be important for assessing
treatment option and treatment outcome 7
.
Pathophysiology:
In infants, the laryngo-tracheal complex lies at
a higher level. It descends rapidly during puberty in
males. The larynx becomes larger & unstable. Also
the brain is more accustomed to infant voice. The boy
may hence continue to use a high pitched voice or it
may break into higher and lower pitches. Other causes
can be strong feminine identification, desire to maintain
the childhood soprano singing voice 9
.
Objective:
To understand the psycho-social impact on
puberphonics before and after treatment (voice
therapy). Also to demonstrate the efficacy of voice
therapy on puberphonic, in conjunction with manual
digital manipulation of muscles of larynx.
Journal of College of Medical Sciences-Nepal, 2010, Vol. 6, No. 1
58
Rationale:
Apart from impact on voice of the
puberphonic, this disorder also has impact on social
and psychological level. The case history generally
concerns about the level of psychological impact of
the patient, but research has not yet addressed the
change in the psycho-social behavior of the patient after
the success of voice therapy.
There have been researches on the efficacy of
voice therapy for puberphonics, which has shown to
be effective both in term of validity and Evidence Based
Practice (EBP). This study is conducted to see the
outcome in context of Nepal, as there is lack of
awareness about the disorder and also the treatment
outcome of it as well.
It has also been noted that the patient with voice
disorder (especially puberphonic) has a tendency to
be left out not due to how other people behave, instead
due to the inferiority of oneself. Hence this study also
takes on to see the outcome of voice therapy on that
aspect. For which the emotional aspect of VHI will be
used extensively, both before and after therapy.
Also there has been very little research, as only 8
researches (as shown on pub-med search) have been
published so far since 1983. And also the available
studies lack validity10.
Methodology:
20 year male attending voice therapy at college of
medical sciences was selected for the preliminary study
after medical and voice evaluation. Patient was asked
to fill out the questionnaire of VHI before the treatment
and after the successful restoration of voice
(acceptable). Therapy was carried out at 2 sessions
per week for 2 months. The evaluation will be based
on the 3 parameters of VHI as Physical, Functional
and Emotional. The overall score will be compared to
see the changes in perceived impact of disorder. The
score on emotional section will be considered for
psychosocial changes after the treatment.
Treatment included:
; Digital manipulation of muscles of larynx.
; Pitch modulation.
o Sliding o Twang
o Rising o Prill
o Siren o Humming
; Pitch stabilization
; Other vegetative exercises as
o Breathing exercise
ƒ Abdominal breathing
; Counseling
Review of literature:
In a study by Murry and Rosen, the VHI was
used to assess changes in the degree of handicap
patients experience following voice treatment in which
it was demonstrated that patients from different
diagnostic groups (unilateral vocal cord paralysis,
muscle tension dysphonia, and vocal cord polyp or
vocal cord cyst) showed decrease in average VHI
score following treatment. The study suggests that while
the absolute score on VHI is important, the percentage
of change between the pre-treatment and posttreatment
score is the more critical measure when
assessing treatment outcome7
.
VHI has been proven to be a valuable tool in
assessing self perceived handicap in a diverse
population of voice patients. It has also proved to be
effective in the evaluation of treatment outcome in wide
range of voice disorders 8
.
B. Bhattarai et al. Psychosocial impact on puberphonic and effectiveness of voice therapy: A case report
59
Result:
The scores when compared to the pre and post
therapy showed marked differences on the overall
score as well as on the individual subsets of VHI. The
score before therapy was 94 (out of 120) on overall
score and on each subsets it was as follows; emotional
35 (out of 40), functional 26 (out of 40) and on physical
section 33 (out of 40). Overall rating of patients’ voice
within the period of 2 weeks was Poor.
The scores after the completion of the therapy were
6 on the overall score. On the subsection it was as
follows; emotional 0 (out of 40), functional 1 (out of
40) and on physical section 5 (out of 40). The overall
rating of voice in the period of 2 week was very good.
Discussion:
The higher scores on the overall and each
subsection of the VHI conclusively prove that voice
disorder affects the person’s psycho-social life as well
as his quality of life. The study also opened the door to
other aspect of viewing puberphonic as; the maximum
impact is seen on the emotional aspect of the VHI,
which imposes that the management should aim more
at the emotional aspect of the patient.
Change in the scores from pre to post therapy
indicates that voice therapy is the effective tool for
management of puberphonics, which is supported by
the studies form past 10 & 11.
Earlier researches have equivocally stated the
benefit as well as shortcoming of voice therapy for
dysphonics, as MacKenzie et. al11 has concluded, in a
longitudinal study, that voice therapy improves voice;
but no improvement on QOL. Other studies as Rosen
et. al. (1995 and 2005) indicated that there is
improvement of QOL based on HR-QOL scales.
This study also supports the findings of earlier
researches, wherein the focus has been only on
puberphonics, rather than on broader spectrum as
dysphonics. We have tried to explore primarily the
psychosocial impact on puberphonic and secondarily
efficacy of voice therapy. Though there have not been
much researches on the psychosocial impact, there has
been research on the efficacy of voice therapy 10.
Review of literature shows that different techniques
has been used in treatment of puberphonia, as surgical
and laryngoscope procedure, both of which has poor
validity/ EPB 1 & 12. On the other hand, voice therapy
has shown good validity and EBP10 & 13.
As the prevalence of case is less, it is difficult to assess
the incidence and treatment outcome10.
Conclusion and Future Directions:
The study concludes that the voice therapy is the
most effective im management of puberphonia which
is supported by earlier studies as well10 & 13, and with
successful completion of voice therapy, the patients’
psychosocial level also gets improved; which in turn
improves the quality of life. Also the VHI is handy tool
for assessment as well as monitoring the progress of
the therapy, which is perceived by the patient himself.
Since this is the pilot study, it lacks the number of patients
for generalizing the results, so the study can be carried
out with greater population.
Acknowledgement:
We would like to thank our H.O.D Dr. N.S.
Reddy for allowing us to carry out this study at the
department. Also we would like to thank the patient
for their participation in the study.
Journal of College of Medical Sciences-Nepal, 2010, Vol. 6, No. 1
60
References:
1. Pau H, Murty G.E. (2001). First case of surgically
corrected puberphonia. The Journal of Laryngology
& Otology, 115, 60-1.
2. Hedge M.N. (2001). Introduction to communicative
disorders, 3rd Ed. Austin, Tx: Pro-Ed.
3. Scott S., Wilson J.A., Robinson K., et al Patient reported
problems associated with dysphonia. Clinical
Otolaryngology 1997; 22:37-40.
4. Wilson J., Deary I., Millar A. et al The quality of life
impact of dysphonia. Clinics of Otolaryngology, 27(3),
179-82.
5. Jacobson B., Johnson A., Grywalski C., et al The Voice
Handicap Index (VHI): Development and Validation.
American Journal of Speech-Language Pathology,
6(3), 66-9.
6. Hedge M., Achala C., Bhat S. (2009). Voice Handicap
index- A comparison of Clinician’s Ratings and Self
Rating by Individuals with dysphonia. JAIISH, 28, 25-
30.
7. Rosen C.A., Murry T., Zinn A. et al. Voice Handicap
Index change following treatment of voice disorder.
Journal of voice, 14(4), 619-23.
8. Beginner M., Ahuja A.S., Gardner G.,.Assessing
outcomes for dysphonic patients. Jourmal of Voice, 12
(4), 540-50.
9. Stemple J.C., Glaze L.E., Klaben B.G. (2000). Clinical
Voice Pathology: Theory and Management, 3rd Ed.
Clifton Park, NY: Delmar Cengage Learning.
10. Dagli M., Sati I., Acar A., et al.(2008) Mutational
Falsetto: Intervention outcomes in 45 patients. The
journal of Laryngology & Otology, 122, 277-81.
11. MacKenzie K., Millar A., Wilson J.A., et al. Is voice
therapy an effective treatment for dysphonia? A
randomized controlled trial. British Medical Journal,
323, 1-6.
12. Vaidya S. Vyas G. (2006). Puberphonia: A Novel
approach to treatment. Indian Journal of
Otolaryngology and Head and Neck surgery, 58.
13. Lim J.Y., Lim S.E., Choi S.H., et al Clinical
characteristic & voice analysis of patients with
mutational dysphonia: Clinical significance of
diplophonia and closed quotients. Journal of voice,
21, 12.
B. Bhattarai et al. Psychosocial impact on puberphonic and effectiveness of voice therapy: A case report
61
Voice Handicap Index:
Part-I: Functional
1. My voice makes it difficult for people to hear me. 0 1 2 3 4
2. People have difficulty understanding me in a noise room. 0 1 2 3 4
3. My family has difficulty hearing me when I call them throughout the house. 0 1 2 3 4
4. I use the phone less often than I would like to. 0 1 2 3 4
5. I tend to avoid groups of people because of my voice. 0 1 2 3 4
6. I speak with friend, neighbors, or relatives less often because of my voice. 0 1 2 3 4
7. People ask me to repeat myself when speaking face to face. 0 1 2 3 4
8. My voice difficulties restrict personal and social life. 0 1 2 3 4
9. I feel left out of conversations because of my voice problem. 0 1 2 3 4
10. My voice problem causes me to lose income. 0 1 2 3 4
Part-II: Physical
1. I run out of air when I talk. 0 1 2 3 4
2. The sound of my voice varies throughout the day. 0 1 2 3 4
3. People as, "What is wrong with your voice?" 0 1 2 3 4
4. My voice sounds creaky and dry. 0 1 2 3 4
5. I feel as though I have to strain to produce voice. 0 1 2 3 4
6. The clarity of my voice is unpredictable. 0 1 2 3 4
7. I try to change my voice to sound different. 0 1 2 3 4
8. I use a great deal of effort to speak. 0 1 2 3 4
9. My voice sounds worse in the evening. 0 1 2 3 4
10. My voice "gives out" on me in the middle of speaking. 0 1 2 3 4
Part-III: Emotional
1. I am tensed when talking to others because of my voice. 0 1 2 3 4
2. People seem irritated with my voice. 0 1 2 3 4
3. I find that other people don’t understand my voice problem. 0 1 2 3 4
4. My voice problem upsets me. 0 1 2 3 4
5. I am less outgoing because of my voice problem. 0 1 2 3 4
6. My voice makes me feel handicapped. 0 1 2 3 4
7. I feel annoyed when people ask me to repeat. 0 1 2 3 4
8. I feel embarrassed when people ask me to repeat. 0 1 2 3 4
9. My voice makes me feel incompetent. 0 1 2 3 4
10. I am ashamed of my voice problem. 0 1 2 3 4
The overall quality of my voice during last 2 weeks has been (please circle):
Poor Fair Good Very good Excellent
Journal of College of Medical Sciences-Nepal, 2010, Vol. 6, No. 1
62
Treating Voice Disorders
Treating Voice Disorders in the
School-Based Setting: Working
Within the Framework of IDEA
Bari Hoffman Ruddy
University of Central Florida, Orlando
Christine M. Sapienza
University of Florida, Gainesville
LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 35 • 327–332 • October 2004 © American Speech-Language-Hearing Association 327
0161–1461/04/3504–0327
ABSTRACT: The role of the speech-language pathologist
(SLP) has developed considerably over the last 10 years
given the medical and technological advances in lifesustaining
procedures. Over time, children born with
congenital, surgical, or “medically fragile” conditions have
become mainstreamed into regular school-based settings,
thus extending the traditional role of the SLP and
multidisciplinary team. Understanding the impact of these
voice disorders on the child’s educational performance has
been a struggle for many clinicians because the eligibility
decisions for students in school-based settings must be
made within the framework of federal legislation and
regulations governing the provision of services for students
with disabilities. This article discusses how to identify
children with voice disorders under the Individuals With
Disabilities Education Act (IDEA) definition, the role of
the SLP in assigning priority in various voice management
scenarios, and how models of therapy can be
incorporated in the school-based setting.
KEY WORDS: child, voice disorder, IDEA, treatment,
education
LSHSS
T
Clinical Forum
he role of the speech-language pathologist
(SLP) in treating children with voice
disorders has developed considerably over
the last 10 years. Technological advances have sustained
the life of the medically fragile child and have allowed
congenital conditions to be diagnosed before a child is
born. Over time, medically fragile children with these
conditions become mainstreamed into regular school-based
settings, thus extending the traditional role of the SLP and
multidisciplinary team in the academic setting.
Given these advances, many school-based clinicians are
expected to assess and treat more children with voice and
other upper airway disorders. Many clinicians have expressed
apprehension and fear in treating this population because
their graduate-level education has been minimal and their
clinical exposure has been limited or nonexistent. Therefore,
their lack of confidence in treating this population may lead
to nonidentification and nontreatment of these disorders.
Many clinicians have also reported uncertainty as to what
types of voice disorders are educationally relevant to treat in
the school-based setting. Several clinicians and county
directors who were interviewed and surveyed before the
2002 American Speech-Language-Hearing Association
(ASHA) Schools Conference held in June, 2002, in Nashville,
Tennessee, reported that eligibility decisions under the
definition of IDEA are left to interpretation, thereby causing
further confusion and inconsistency for the school-based
clinician. For example, some of the questions that have been
raised include: What types of voice disorders are educationally
relevant to treat? Are all voice disorders that occur in
the school-age child educationally relevant to treat? Can
voice difficulty in the school-based setting actually limit
academic goals and achievement? In order to answer these
questions and understand the role of the school-based SLP,
knowledge about certain legislative acts is necessary.
IDEA DEFINITION
Eligibility decisions for students in school-based
settings must be made within the framework of the federal
328 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 35 • 327–332 • October 2004
legislation and regulations governing the provision of
services for students with disabilities. The Individuals With
Disabilities Education Act (IDEA) Amendments of 1997
(P.L. 105-17) provide parameters for services that are
provided in an educational setting. The final Part B section
of the document states that a child is only eligible for
services if the impairment “adversely impacts educational
performance.” IDEA final Part B regulations define the
categories of disabilities that qualify a school-age child with
a voice disorder for services under the law. These categories
include physical development, communication development,
social or emotional development, and adaptive development.
However, students with voice disorders may fail to receive
therapeutic services due to the misperception that their
disability will not adversely affect academic performance or
achievement, or a misunderstanding of IDEA.
The phrase “adversely affects educational performance”
has never been defined in the federal regulations. However,
the Department of Education and the Office of Special
Education Programs (OSEP) have issued a number of
policy letters interpreting this phrase. In a letter of interpretation,
the OSEP clarified the term educational performance,
as used in IDEA,
to include effect upon academic and nonacademic areas.
Furthermore, if the presence of a speech-language impairment
has been established by a SLP through appropriate appraisal
procedures, the receipt of services is not conditional upon
academic performance. A child who is achieving at grade level
can still qualify as having a speech-language disability
(Andrews, 2002, p. 593).
This letter of interpretation from OSEP suggests that a
vocal impairment can include disorders or difficulties with
the production of voice, misperception of one’s voice, and/
or misperception by others. Students with voice problems
can face many difficulties that have the potential to affect
academic and social–emotional aspects of life. Because oral
communication is basic to all classroom learning and is the
major vehicle of instruction and interaction between
students and teachers, children who experience changes in
voice production or vocal behavior will generally require
intervention to offset potential academic difficulties
(Andrews, 2002).
IMPACT OF VOICE DISORDERS
ON EDUCATION
A voice disorder can include deviant vocal behavior
related to the pitch, loudness, and/or overall quality of a
child’s voice. However, the frequency and consistency of
deviant vocal behavior must be considered. Some of the
common voice disorders seen in school-age children may
occur from functional, organic, or neurologic processes.
Some of the common functional disorders occurring from
behaviors of misuse, overuse, or abuse include vocal fold
edema, vascularity, nodules, and/or polyps. Fluency or
articulation disorders may also result in secondary
functional voice problems due to the increased phonatory
effort. Organic voice disorders can be congenital, or
acquired, and may include papilloma, laryngeal pharyngeal
reflux (LPR), granuloma, or contact ulcers. Some neuromuscular
disorders with a secondary voice component
include cerebral palsy, muscular dystrophy, or other disease
processes affecting speech motor control.
Structural changes to the upper airway (congenital or
acquired) can also impair laryngeal function. Congenital
conditions include laryngeal anomalies, such as stenosis,
laryngeal malacia, clefts, laryngoceles, webs, and cysts.
Disorders of the central nervous system include hydrocephalus,
encephalocele, and Arnold-Chiari syndrome; disorders
of the cardiovascular system may include cardiomegaly or
abnormal vessels. Acquired disorders include trauma from
birth injury or postsurgical correction of cardiovascular,
esophageal, or cranial anomalies; tumor compression; and
infection, such as whooping cough, polio, syphilis, or
tetanus (Friedberg, 1983; Gray, Smith, & Schneider, 1996).
The challenge for clinicians is to understand how the
underlying pathophysiology of these disease processes
affects vocal function and the child’s behavior in order to
provide effective therapeutic interventions.
Children with voice disorders can be negatively affected
in a variety of ways. For example, children may attempt to
conceal atypical vocal production or feelings of inferiority
about their voices. This in turn may seriously limit their
classroom participation, giving them fewer opportunities to
practice and receive feedback. Andrews (2002) stated that
school-age children’s preoccupation with concealing deviant
vocal behaviors might interfere with concentration during
academic activities and/or cause peer reaction or embarrassment.
Social–emotional implications may include children
becoming withdrawn and reticent, or vocally aggressive and
defiant, in situations where the child is attempting to
compensate for his or her vocal disability. These problems
can become progressively worse without intervention and can
seriously impact learning. Additionally, children who use a
limited number of vocal strategies (i.e., whining, crying, or
talking loudly and incessantly) as a way to solve interpersonal
problems may be at risk for being evaluated in
negative ways by educators. This may indirectly affect how
they are viewed in all aspects of their educational process.
For the adolescent population, academic content emphasizes
school-to-career activities. The school-to-career
program connects academic learning to practical application.
Many of these career-related activities demand
efficient vocal communication skills for interviewing,
employment opportunities, internships, apprenticeships, or
mentorships in order to create a strong relationship between
the student and the worksite. The adolescent with voice
difficulty may have fewer opportunities (or none at all) to
participate in these educational routines. Furthermore,
adolescents with voice problems may have difficulty
modifying maladaptive habits and inappropriate compensations
later in life as they transition into college and careerrelated
activities. Some of the adverse effects of voice
impairment on a child’s educational performance can
include the following:
• difficulty being heard or communicating in educational
environments inside or outside of the classroom
setting
Ruddy • Sapienza: Treating Voice Disorders in the School-Based Setting 329
• limited participation in public speaking activities
• fear of participating in oral reading activities
• limited participation in classroom discussions with
peer groups
• fear of conversing in interpersonal interactions (i.e.,
raising hand to request to go to the bathroom)
• limited participation in regular physical education
routines due to compromised physiologic aspects of
the laryngeal anatomy
• limited participation in music education (vocal and
instrumental) due to a compromised upper airway
• reluctance to participate in activities, such as school
plays, cheerleading, and debate
• limited participation in secondary education coop
activities, requiring the student to take nonvocal jobs
only
• reluctance to participate in interview activities,
thereby limiting access to employment and certain
educational opportunities
• negative attention from peers, teachers, and other
school personnel
• hindrance of academic goals of other classroom
students (i.e., a child’s voice quality may be distracting
to other classmates who may focus on the
abnormal voice quality instead of on the content of
the message)
In the care of voice, the benefits of a multidisciplinary
team approach are numerous. Below is a description of the
IDEA criteria for a multidisciplinary team, as well as a
description of their function.
IDEA: THE MULTIDISCIPLINARY TEAM
According to IDEA, a multidisciplinary team must decide
eligibility for special education services. Members of the
team include the child’s parents, at least one regular
education teacher (if the child will be participating in regular
education), at least one special education teacher or special
education provider, a representative of the school, and an
individual who can interpret the instructional implications of
evaluation results. An ad hoc member of the team may also
include the otolaryngologist and/or voice pathologist.
Each member serves an important role on the multidisciplinary
team. For example, the role of the classroom
teacher is to identify children who are at risk and to have
an understanding of the consequences of vocal difficulty on
a student’s educational performance. In addition, the
classroom teacher works in collaboration with the SLP by
providing consistency between the therapy room and the
classroom for generalization into the child’s more natural
setting (i.e., voice production in the classroom with peers,
on the playground, and in the lunchroom). Classroom
teachers are also able to facilitate and support the child’s
efforts to maintain good vocal habits throughout the school
day versus the portion of time that the child is receiving
direct services.
Because voice therapy relies on home programming for
carryover to the child’s real world, the compliance and
motivation of parents, siblings, friends, and other family
members is critical to the success of the treatment. Occasionally,
the child may face teasing or ridicule from
siblings or peers because of the need to practice various
vocal exercises or the need to restrict the use of his or her
voice. Therefore, the inclusion of family members and
friends in the child’s vocal rehabilitation program is a key
factor in generating support for the child in the therapy
process when he or she leaves the therapeutic setting.
Without this support, the child may feel alone or misunderstood.
SLPs can help by counseling the parent, sending
home checklists, and corresponding via phone or face-toface
conferences to facilitate home carryover. Another role
of the parent is to assist the SLP in identifying vocal abuse
problems that are occurring in the home or in extracurricular
settings. Such activities may include loud peer or family
involvement, smoky environments, vocal manipulations
(i.e., crying to get what they want), and possible allergens.
The role of the SLP in the school-based setting is vast.
The SLP becomes an advocate for the child and a motivator
for the entire team. The SLP is typically the only oncampus
link between the physician and the parent. As such,
the SLP acts as the leader for dissemination of information
between all team members. Most importantly, the role of
the SLP is to become an educator for campus staff and
teachers. The SLP may do so by providing inservice
wokshops, demonstrations, checklists, and/or pamphlets.
Resources such as the Quick Screen for Voice instrument
found in this issue should be included in this process (Lee,
Stemple, Glaze, & Kelchner, 2004). In turn, teachers and
staff can help identify children who are at risk and make
appropriate referrals in a timely manner.
In many settings, once school-based personnel identify a
child as having a “potential voice problem,” it is the school
SLP who often becomes the primary advocate for the child’s
laryngeal examination. The justification for persistence in
this recommendation is clear-cut. For example, there are
times when dysphonia in a child may seem consistent with a
hyperfunctional disorder, but in fact it may be a perceptual
representation of other organic pathology (e.g., papillomatosis,
submucosal cysts, gastrointestinal or laryngeal-pharyngeal
reflux, webbing, stenosis, paralysis) Medicinal, rather
than solely behavioral, treatment is needed for these
laryngeal conditions (Glaze, 1996). Moreover, an understanding
of the primary pathology may lead to better
insight regarding the secondary laryngeal and respiratory
compensations that a child may exhibit.
There is also a need for the SLP to “suspect a correct
diagnosis” (Glaze, 1996) whenever the child’s vocal
behaviors and verbal affect do not match the profile of
“vocal abuse/misuse” or other patterns associated with a
particular disease process. For example, Glaze discussed an
unusual case that was described by a clinician regarding a
child with presumed nodules, when the child actually had
suffered a fractured larynx during an incident of stranger
abuse. Because the child’s affect was very reticent, quiet,
and withdrawn, the clinician was alerted to the mismatch
between typical hyperfunctional voice activity and her
330 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 35 • 327–332 • October 2004
client’s vocal behaviors. Another example described by a
referring otolaryngologist (J. Lehman, personal communication,
September 14, 1999) revealed that a child had been
treated in the school-based setting for presumed vocal
nodules due to the perceived hoarse voice quality, strained
production, and inadequate respiratory dynamics. The child
had been receiving speech therapy in the elementary school
for 31
/2 years before a diagnosis of anterior webbing was
made. These scenarios provide a firm justification for
insisting that all children with presumed voice disorders
must receive a medical diagnosis (preferably by an otolaryngologist)
before initiating any therapeutic services
(ASHA, 1992, 1998). Furthermore, there are certain
laryngeal pathologies for which voice therapy would not be
appropriate and would, in fact, be strongly contraindicated
(i.e., papillomatosis, stenosis). For these conditions, the
delay of an accurate diagnosis could be potentially life
threatening (Boone & McFarlane, 2000).
TRIAGE SCENARIOS
Scenario 1
Triage is a general term that refers to a system of
assigning priority. When a child is referred to the schoolbased
SLP, the typical triage scenario involves an abbreviated
screening of the child’s vocal quality. If the screening
reveals moderate to severe changes in voice quality, the
SLP will then meet (district/state) criteria by referring the
child to a physician for a laryngeal examination (preferably
an otolaryngologist). Once the diagnosis is established, the
physician will provide treatment recommendations. If
behavioral voice therapy is indicated, the child is referred
back to the school-based SLP and an individualized
education plan (IEP) is developed so the child can receive
services as stipulated under IDEA.
The goals of voice therapy (included in IEPs) should
reflect the nature of the voice impairment. For example, if
a child is diagnosed with vocal fold nodules, then the goals
for therapy may include the following:
• building awareness of factors relating to this voice
problem (i.e., vocal overuse, misuse or abuse)
• discriminating between healthy versus vocally abusive
behaviors
• applying laryngeal relaxation strategies for optimal
use of the vocal mechanism
• using appropriate pitch, loudness, and rate in spontaneous
conversation
• using appropriate voice quality in everyday speaking/
spontaneous conversation
The objectives of each goal should be individually
tailored for the child based on his or her symptom profile.
Example objectives for goal #1 (building awareness of
factors relating to the voice problem) may include (a)
awareness of normal anatomy of the vocal mechanism, (b)
awareness of causes of voice problems and how they affect
the vocal folds, and (c) identification of physical behaviors
that contribute to inappropriate voice. These objectives may
be facilitated through a combination of activities, such as
constructing the vocal mechanism with clay; drawing or
painting the anatomical landmarks; using anatomy coloring
books, video demonstration, observation, and/or question
and answer sessions.
In order to document improvement, a goal must have
criteria that are measurable. An example for goal #2
(discriminating between healthy and vocally abusive
behaviors) might be that the child will discriminate
between healthy and abusive voice production 80% of the
time. The clinician may have the child listen to audio
samples of him- or herself or others and rate each
production. Clinicians may also consider having the
classroom teacher or parent involved in data collection
while the child is engaged in voice production in a more
natural setting. The clinician may facilitate this by
providing checklists of appropriate vocal behaviors or
progress charts to the teacher and parent to fill out for a
specified activity (i.e., classroom discussion, oral reading,
engaging with siblings in the home). The SLP can collect
and review these data sheets and make adjustments to the
therapeutic plan based on the child’s compliance in these
different settings.
Other scenarios clinicians may encounter are more
complex. Some of the situations described below may
further extend the role of the SLP in order to provide an
effective diagnostic and therapeutic process. Provided in
each scenario are suggestions of ways to advocate for
each child’s needs, even when the situation is less than
optimal.
Scenario 2
In this scenario, the child is referred to the SLP by the
classroom teacher for perceived hoarseness and vocal
difficulty. The SLP administers a standard voice screening
as per district/county guidelines; however, a further
evaluation is not warranted because the child’s screening
did not yield a score that would qualify the child for
further evaluation based on the district/county guidelines
for speech and language services. Clinicians may question
how far the role of the SLP extends. Could the child’s
“mild” voice difficulty worsen without treatment? Should
the SLP refer the child for private services because he or
she does not qualify for services in the schools?
The role of the SLP here would include correspondence
with the parents, providing them with a checklist of
behavioral indicators in case the condition progresses.
Certainly, the child’s condition could worsen over time,
particularly if behavioral management is not completed and
the parent is unaware of how to modify the child’s environment.
The SLP may elect to educate the parents on vocal
health and hygiene and organize a home therapy program.
The SLP should also provide the parents with resources
available in their community if the parents wish to seek
services on their own outside of the school setting.
Although the child is not eligible for services under IDEA
in this scenario, the SLP’s time consulting with the parent
is considered part of the standard workload (ASHA, 2002).
Ruddy • Sapienza: Treating Voice Disorders in the School-Based Setting 331
Scenario 3
In this scenario, the classroom teacher refers the child to
the SLP. The SLP administers a standard voice screening.
Based on the results of the screening, the child is referred
to a physician for a laryngeal examination. After a period
of time, the SLP learns that the child was never examined
by a physician due to noncompliance by the parent and/or
no financial support. Clinicians may be concerned about
how the child’s needs get addressed under IDEA.
In several counties or school districts, Scenario 3 has
been successfully addressed through free community-based
clinics organized by the school-based SLP (Leeper, 1992).
These clinics involve a physician (preferably an otolaryngologist)
and an SLP/voice pathologist specializing in
voice care outside of the school-based setting who is
particularly knowledgeable with the distinguishing features
of pediatric laryngeal structure and function. The physician
and SLP/voice pathologist would volunteer their time
and services for this activity. The clinic could be held at
the school (if space is available) or in a medical office.
The child presents for the laryngeal examination with both
the parent and the school-based SLP. A brief review of the
child’s past medical and developmental history is discussed
and a symptom profile is established. The otolaryngologist
would perform an indirect (or preferably endoscopic)
laryngeal examination for the children who were
identified as being at risk. Once the diagnosis is established,
the SLP/voice pathologist would conduct a short
consultation with the child, parent, and school SLP
suggesting treatment strategies appropriate for the current
condition. The school-based SLP would now be able to
develop the IEP and implement therapeutic services under
the guidelines of IDEA.
Scenario 4
In this scenario, a child is referred to the SLP by the
classroom teacher due to abnormal voice quality. Following
a standard screening, the child is referred to a
physician for a laryngeal exam. The physician’s report is
negative for laryngeal pathology but agrees that the child
has a “functional” dysphonia. What is the role of the
SLP? Will the child need therapeutic services or just
outgrow the behavior?
Scenario 4 may present some challenges to the schoolbased
SLP, primarily because school district/state guidelines
may vary regarding the management of “functional” cases.
If district/state guidelines do not permit the SLP to initiate
therapy, one possible solution is to counsel the classroom
teacher on therapeutic strategies that may be helpful in
eliminating deviant or “functional” behavior. Another
strategy would be to determine if the child is stimulable for
any normal voice production. If the child is stimulable, then
the SLP may elect to provide the parent and/or classroom
teacher with strategies to facilitate the therapeutic process.
Last, the school-based SLP may consider the potential for
another underlying cause for the resulting voice quality and
make appropriate referrals to medical professionals to share
in the evaluation and care of this child.
Scenario 5
The classroom teacher refers a child to the SLP. The
child’s voice screening from the SLP warrants a referral to
the otolaryngologist due to presumed hyperfunction. The
otolaryngologist finds organic pathology (or severe structural
abnormality). The otolaryngologist recommends that
the child receive voice therapy and refers him or her back
to the school-based SLP. However, the SLP feels uncertain
about the type of voice therapy that is appropriate for this
child and is uncomfortable initiating treatment. How does
the child receive the services that he or she requires?
It may be helpful to identify a “voice specialist” within
the school district who can consult on these difficult-to-treat
cases. Inservice workshops that are presented in a “grand
rounds” style may also be helpful so that ideas for treatment
can be discussed or demonstrations of new treatment
techniques can be practiced in a forgiving environment.
SERVICE DELIVERY OPTIONS
There are several service delivery options that are
effective under the IDEA guidelines. It is important for
clinicians to remember that the typical therapy model that
is followed for children with articulation or language-based
deficits may not be an effective model for children with
voice disorders. Therapeutic models should be tailored to
fit the academic and therapeutic needs of each child.
However, children with voice disorders typically represent a
small group of the general population of children receiving
speech and language services in the schools. Therefore,
clinicians may experience difficulty finding the best group,
time, or service delivery model for a child with a voice
disorder. General questions and concerns that clinicians
may face include the following: Which therapy group
would the child fit in best? What treatment activities would
fit with the other disorders being treated in the same
group? How long do I keep the child in therapy or on the
caseload? How do I collect the appropriate data to reflect
progress? Some of the IDEA options for service delivery to
address these issues can include the following:
• Classroom pullout. The child leaves the regular
education classroom to receive voice therapy in a oneon-one
or small-group environment. The therapeutic
activities may include identification of vocal behaviors,
education on vocal health/hygiene, or practicing
vocal exercises.
• Classroom-based service delivery. The SLP works
with the child in the classroom or recreational
environment for a designated period of time. The
clinician may incorporate voice therapy during smallgroup
“centers” (i.e. reading group) with peer interaction
or observe vocal behavior of the child during
physical education activities, providing timely
feedback and cues.
• Collaborative method. The SLP works in collaboration
with other service delivery team members (i.e.,
occupational therapist or physical therapist),
332 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 35 • 327–332 • October 2004
incorporating voice therapy strategies during other
therapeutic services.
• Consultative method. The child and clinician meet one
time per month to monitor progress or reestablish
appropriate use of therapeutic techniques.
• Individual therapy sessions. The clinician and child
meet one-on-one to establish therapeutic techniques in
an intensive manner.
• Small-group sessions. These sessions ideally would be
conducted with other children with voice disorders.
The frequency of visits can vary from one time per week,
every other week, one time per month, or any combination
of these options. In addition, some unique intervention
models could be integrated into service delivery options.
Some of these models include implementing classroom
lessons for the entire class that involve vocal health and
prevention strategies; creating science and health projects
associated with voice; providing materials that parents can
use to teach vocal awareness at home to the entire family;
implementing voice treatment programs with small groups,
in peer dyads, or one-on-one; and collaborative voice
therapy programs with music, drama, or physical education
teachers (Andrews, 2002). Clinicians may continue to
explore other collaborative therapeutic programs within the
school-based community in order to facilitate a therapeutic
plan that is unique to the child’s individual needs.
SUMMARY
Understanding the impact of voice disorders on the
educational performance of children continues to be a
struggle for many clinicians. This article describes some of
the factors that may affect eligibility criteria and defines
the role of the SLP and multidisciplinary team working
within the framework of IDEA. In addition, triaging
scenarios are provided as practical models of intervention
and have described some unique ways to advocate for each
child’s needs, even when the scenario is less than optimal.
If left untreated, any voice disorder has the potential to
result in more severe structural abnormalities and have a
significant impact on academic performance and learning.
REFERENCES
American Speech-Language-Hearing Association. (1992). Vocal
tract visualization and imaging. Asha, 34(Suppl. 7), 37–40.
American Speech-Language-Hearing Association. (1998, April).
The role of the otolaryngologist and speech-language pathologist
in the performance and interpretation of strobovideolaryngoscopy.
Asha, 40(Suppl. 18), 32.
American Speech-Language-Hearing Association. (2002). A
workload analysis approach for establishing speech-language
caseload standards in schools: Guidelines. ASHA Desk Reference,
3, 409–418.
Andrews, M. (2002). Voice treatment for children and adolescents.
San Diego, CA: Singular.
Boone, D., & McFarlane, S. (2000). The voice and voice therapy
(6th ed.). Boston: Allyn & Bacon.
Friedberg, J. (1983). Hoarseness. In C. Bluestone & E. Sylvan
(Eds.), Pediatric otolaryngology: Volume 2 (pp. 1181–1189).
Philadelphia: W.B. Saunders.
Glaze, L. (1996). Treatment of voice hyperfunction in the preadolescent.
Language, Speech, and Hearing Services in Schools,
27, 244–250.
Gray, S. D., Smith, M. E., & Schneider, H. (1996). Voice
disorders in children. Pediatric Clinics of North America, 43(6),
1357–1384.
Lee, L., Stemple, J., Glaze, L., & Kelchner, L. (2004). Quick
Screen for Voice and supplementary documents for identifying
pediatric voice disorders. Language, Speech, and Hearing
Services in Schools, 35, 308–319.
Leeper, L. (1992). Diagnostic examination of children with voice
disorders: A low-cost solution. Language, Speech, and Hearing
Services in Schools, 23, 353–360.
Individuals with Disabilities Education Act Amendments of 1997,
Pub. L. No. 105-17, 20 U.S.C., 1400 et seq.
Received March 5, 2003
Accepted January 8, 2004
DOI: 10.1044/0161-1461(2004/032)
Contact author: Bari Hoffman Ruddy, PhD, P.O. Box 162215,
Orlando, FL 32816. E-mail: bhruddy@mail.ucf.edu
Posted by m, On 09:49
Puberphonia Conservative approach A reviewBalasubramanian ThiagarajanStanley Medical College
Abstract:
Puberphonia is persistence of adolescent voice after puberty in the absence of organic cause. This common condition is seen in males. These patients have a high pitched voice. This article at-tempts to review published literature on this topic with specific focus on conservative management. This condition is also considered to be a psycho-genic voice disorder. Conservative management has met with excellent success. Conservative man-agement modalities for this condition ranges from voice therapy to laryngeal manipulation
Introduction:
The persistence of adolescent voice even after pu-berty in the absence of organic cause is known as Puberphonia1. This condition is commonly seen in males. This is uncommon in females because laryngeal growth spurt occurs commonly only in males. According to Banerjee the incidence of Puberphonia in India is about 1 in 900,000 pop-ulation 2. In females this condition is known as “Juvenile Resonance Disorder” or a “Little Girl’s Voice”. This condition is characterised by vocal instability with extensive frequency swing.
Pathophysiology:
In infants the laryngotracheal complex lies at a higher level. It gradually descends. During puberty in males this descent is rapid, the larynx becoming larger and unstable and on top of it the brain is more accustomed to infant voice.
The boy may hence continue to use a high pitched voice or it may break into higher and lower pitch-es 3.
Etiology: include
1. Emotional stress
2. Delayed development of secondary sexual characters
3. Psychogenic
4. Hero worship of older boy or sibling
5. Excessive maternal protection
6. Non fusion of thyroid laminae
7. Increased laryngeal muscle tension causing laryngeal elevation
Complaints:
1. Unusual high pitched voice persisting beyond puberty
2. Hoarseness of voice
3. Breathy voice
4. Inability to shout
5. Vocal fatigue
The typical fundamental frequency of adult male voice ranges between 85-180 Hz and that of a typical adult female is about 165-255 Hz 4. In Puberphonia the boy continues to use a higher pitch which stresses the laryngeal mus-culature.Examination of these patients should include a complete physical examination including a geni-tal examination also. Secondary sexual charac-ters should be assessed, hypogonadism should be ruled out. A complete psychological profile of the patient in question should be built to rule out psychological causes. If psychological causes could be identified they treating it should take precedence over other modalities. These patients speak in a double voice, both in high pitch and low pitch.The impact of this voice disorder varies from person to person. This depends on the follow-ing variables
1. Occupation
2. Environment
3. Family members
4. Personality
Goals of treatment of Puberphonia:
1. The patient should be taught to phonate at a low pitch
2. The patient should be taught to fully utilise the Phonatory and Respiratory musculature
5. Vocal fatigue
5. Vocal fatigue
5. Vocal fatigue
Puberphonia is persistence of adolescent voice after puberty in the absence of organic cause. This common condition is seen in males. These patients have a high pitched voice. This article at-tempts to review published literature on this topic with specific focus on conservative management. This condition is also considered to be a psycho-genic voice disorder. Conservative management has met with excellent success. Conservative man-agement modalities for this condition ranges from voice therapy to laryngeal manipulation
Introduction:
The persistence of adolescent voice even after pu-berty in the absence of organic cause is known as Puberphonia1. This condition is commonly seen in males. This is uncommon in females because laryngeal growth spurt occurs commonly only in males. According to Banerjee the incidence of Puberphonia in India is about 1 in 900,000 pop-ulation 2. In females this condition is known as “Juvenile Resonance Disorder” or a “Little Girl’s Voice”. This condition is characterised by vocal instability with extensive frequency swing.
Pathophysiology:
In infants the laryngotracheal complex lies at a higher level. It gradually descends. During puberty in males this descent is rapid, the larynx becoming larger and unstable and on top of it the brain is more accustomed to infant voice.
The boy may hence continue to use a high pitched voice or it may break into higher and lower pitch-es 3.
Etiology: include
1. Emotional stress
2. Delayed development of secondary sexual characters
3. Psychogenic
4. Hero worship of older boy or sibling
5. Excessive maternal protection
6. Non fusion of thyroid laminae
7. Increased laryngeal muscle tension causing laryngeal elevation
Complaints:
1. Unusual high pitched voice persisting beyond puberty
2. Hoarseness of voice
3. Breathy voice
4. Inability to shout
5. Vocal fatigue
The typical fundamental frequency of adult male voice ranges between 85-180 Hz and that of a typical adult female is about 165-255 Hz 4. In Puberphonia the boy continues to use a higher pitch which stresses the laryngeal mus-culature.Examination of these patients should include a complete physical examination including a geni-tal examination also. Secondary sexual charac-ters should be assessed, hypogonadism should be ruled out. A complete psychological profile of the patient in question should be built to rule out psychological causes. If psychological causes could be identified they treating it should take precedence over other modalities. These patients speak in a double voice, both in high pitch and low pitch.The impact of this voice disorder varies from person to person. This depends on the follow-ing variables
1. Occupation
2. Environment
3. Family members
4. Personality
Goals of treatment of Puberphonia:
1. The patient should be taught to phonate at a low pitch
2. The patient should be taught to fully utilise the Phonatory and Respiratory musculature
5. Vocal fatigue
5. Vocal fatigue
5. Vocal fatigue
Posted by m, On 09:36
Subscribe to:
Comments (Atom)