1. Pediatric Voice Useful References LSHSS issues dedicated to voice disorders July 1996 October 2004

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

3. Laryngomalacia  Soft larynx  Collapse of laryngeal structures during breathing  Partial airway obstruction  Stridor  Often resolves w/o intervention

4. Other more common anomalies Vocal fold paralysisSubglottic stenosis

5. Congenital Laryngeal Web

6. Less common congenital anomalies Laryngeal clefts

7. Laryngeal cleft

8. Less common congenital anomalies Laryngeal cysts

9. 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

13. 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

14. 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

15. 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

16. 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

17. Hooper (2004)

18. As with adults, accurate diagnosis is critical for appropriate decision making

19. Approaches to Treatment  Prevention  Therapy Indirect Direct

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

21. 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)

22. 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

23. 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

24. 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)

25. 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)

26. Is voice therapy for children efficacious?  Limited outcomes research  Studies that suggest treatment effects lack strong controls (e.g. Mori (1999))

27. Puberphonia  What is it?  Identification  What can be done about it?