Pediatric VoiceUseful References

LSHSS issues dedicated to voice disorders

July 1996

October 2004

Pediatric voice disorders Brief survey of congenital problems Anatomical differences in children Occurrence of voice disorders in children Therapy considerations

Laryngomalacia Soft larynx Collapse of laryngeal

structures during breathing

Partial airway obstruction

Stridor Often resolves w/o

intervention

Other more common anomalies

Vocal fold paralysis Subglottic stenosis

Congenital Laryngeal Web

Less common congenital anomalies

Laryngeal clefts

Laryngeal cleft

Less common congenital anomalies

Laryngeal cysts

Pediatric larynx: Anatomical differences

Size Newborn 2.5-3.0 mm Adult female: 11-15 mm Adult male: 17-21 mm

Shorter membranous portion of vocal fold Lack of full layered structure Location in neck

Occurrence of voice disorders in children Occurrence data ranges from 6-23% of school

age children Adolescents may exceed general occurrence

estimates Good epidemiological studies clearly

stratified by age/group needs to be done

Types of voice problems typically reported in children

“Functional” voice problems Misuse/abuse related Presence of vocal nodules

Reflux related voice problems Paradoxical vocal fold motion Unidentified congenital problems

Do children get voice services in schools? Voice problems constitute 2-4 % of school

SLP caseload Only about 1-4 % of dysphonic children

receive Tx (McNamara & Perry, 1994; Clark, 2003)

SLPs with larger caseloads more likely to provide voice services

Why are school SLPs reluctant to take voice disordered students onto caseloads?

Perceived lack of severity or priority of problem

Lack of experience Difficulty getting a laryngoscopic evaluation Concern about meeting service requirements

– see Ruddy and Sapienza (2004) for discussion

Hooper (2004)

As with adults, accurate diagnosis is critical for

appropriate decision making

Approaches to Treatment Prevention Therapy

Indirect Direct

“Children” are a large and varied group Preschoolers School age children (pre-adolescent) Adolescents

Role of Prevention 59 %* of school SLPs believe prevention is

an efficient way to deliver voice treatment 19 %* of schools SLPs perform such

practices

Prevention can be incorporated into the regular academic curriculum talk to the science/health teacher

*McNamara and Perry (1994)

Therapy Considerations Underlying treatment rationale for adults also

applies to children However, implementing the strategies need to

be tailored to the child Awareness and education are very important

Therapy Considerations Computer-based speech & voice programs are

quite appealing to children Many real-time feedback programs are freely

available for clinicians to download Good link to investigate

http://www.phon.ucl.ac.uk/resource/software.php

Therapy “phases” particularly important for children General awareness of vocal behaviors Specific awareness of behaviors to change Direct voice therapy or voice production

activities Generalization and carryover activities

(Andrews & Summers, 2002)

Therapy Considerations

“… These include the following:• parent/family involvement• teacher involvement in the school-age child• a component of child/family lifestyle education or vocal hygiene education• psychodynamic and interpersonal factors and related behavioral intervention or discussion• the incorporation of vocal behavior into good language and communication behavior• the use of age-appropriate activities if direct voice therapy is recommended” (Cooper, 2004)

Is voice therapy for children efficacious? Limited outcomes research Studies that suggest treatment effects lack

strong controls (e.g. Mori (1999))

Puberphonia What is it? Identification What can be done about it?