Voice disorders are a generally classified into subgroups, reflecting individual aetiology and presentation. For example, vocal nodules are classified as an organic voice disorder, indicating changes to the tissue. Puberphonia is classified as a psychogenic voice disorder. Although there has been some recent discussion as to whether this is an appropriate descriptor, it remains that clients with puberphonia present with no structural changes to the voice mechanism. In other words, we can’t ‘see’ the cause of puberphonia. For those unfamiliar with the term, puberphonia refers to the persistence of an adolescent voice even after other physical changes associated with puberty have occurred.
During my recent trip to Vietnam, I was surprised to learn that anecdotally, puberphonia was one of the more common presentations seen at the ENT hospital speech pathology clinic. Following vocal nodules and paralysis, the speech pathologists reported that Puberphonia was one of their most frequent caseloads. Most cases are young men in their twenties. Some come to therapy soon after they become concerned about their voice, but many do not seek assistance for years. The SP team hypothesise that this is either due to a lack of awareness that something can be done, an inability to afford treatment (in some hospitals in Vietnam, the cost of therapy is around $3 a session) or feelings of embarrassment in seeking out help.
What does puberphonia sound like?
When a patient with puberphonia comes to the clinic, we observe and assess a number of elements of the voice. In typical cases, the predominant feature is a high pitch, falsetto like voice that is generally considered inappropriate for their age. In addition to the higher pitch, a patient may experience breathy vocal quality, hoarseness, unpredictable pitch breaks and a monotonous tone. Clients report that while there is no pain or discomfort associated with this voice, the psychosocial effects are significant. One young man reported: “When I answer the phone, people think it’s a girl and it can be difficult at work, meeting new people and customers”.
Working with speech pathology students as a clinical educator, it can be difficult to convey to voice therapy students the need to consider the effects of voice difficulties beyond the anatomy of the larynx. The effect of many voice disorders flow into every aspect of a person’s life (just ask a teacher who developed nodules). Often, it is other people’s reactions to voice changes that impact how the person perceives their own voice. As much as we like to think we don’t judge, we automatically make judgements of people based on the sound of their voice. Our voice can reflect our emotions moment to moment (Stemple, Glaze & Gerdeman, 2000). If a colleague has a hoarse voice one morning, we assume they are unwell. If someone’s voice quivers and wavers, it suggests they may be upset. If a twenty-something year old male starts talking in a high pitched falsetto voice, our first impressions may be (however unintentionally) altered. For those of us who’ve never had a voice disorder: imagine feeling supremely confident and skilled within yourself, only to have your voice not reflect what you are feeling – and having people judge you according to that which they can see or hear.
“Why does my voice sound like this?”
One young man we treated in Vietnam began his session by asking, “Why does my voice sound like this?” It’s a common but concurrently interesting question. Causes of Puberphonia are likely to be multifaceted with ideas of aetiology including; emotional stress, embarrassment associated with the new voice secondary to changes connected with puberty, or a desire to maintain a younger ‘old’ voice. As mentioned earlier, aetiology of Puberphonia is currently under discussion, with some clinicians suggesting that there may be a functional element – muscle incoordination with no known cause – affecting the voice. Specifically, researchers feel that the cause may be due to an attempt to control unstable pitch and increased tension and contraction of the muscles of the larynx causing it to elevate (Colton & Casper, 1996).
Can the voice change?
Therapy for puberphonia taps in key motor learning principles. Like other body functions, the voice has the capacity to adapt and change in response to experience (experience being disease, therapy, aging etc). Muscles are able to get stronger or adapt for the tasks for which they are trained. This is the basic principle of neuroplasticity. If motor learning occurs in the right way, it can lead to positive changes.
The basic facets of therapy for puberphonia include, but are not necessarily limited to:
- Education regarding voice function and laryngeal anatomy
- Finding the patients natural pitch in the ‘new’ voice (there are a variety of strategies to do this)
- Building patient confidence in their voice in a safe environment
- Generalising the new voice into everyday scenarios
Voice therapy can be an effective treatment option for puberphonia which improves the quality of life of a person with puberphonia. As we frequently hear from patients, puberphonia is a disorder that has an effect well beyond just voice. It can affect a person’s self-confidence which may have a flow-on affect into the social and occupational aspects of a person’s life. Fortunately, therapy is available to assist in achieving a patient’s goals regarding their voice.
Contact us for results focused speech therapy
This article was written by our speech pathologist Jenna Butterworth who is a Speech Pathology Australia member.
If you have questions about puberphonia or communication, contact your local doctor who will arrange for you to see a speech pathologist.
Colton, R.H., & Casper, J.K. (1996). Understanding voice problems: A physiological perspective for diagnosis and treatment (2nd ed.). USA: Lippincott Williams & Wilkins.
Stemple, J.C.,Glaze L.E. & Klaben, B.G. (2000) Clinical Voice Pathology: Theory and Management. San Diego, California: Singular Publishing Group
Ludlow, C.L., Joit, Jeannette, H., Kent, R., Ramig, L.O., Shrivastav, R., Strand, E., Yorkston, K., Sapienza, C. (2008). Translating principles of neuroplasticity into research on speech motor control recovery and rehabilitation. Journal of Speech, Language and Hearing Research (51)1, 240-258.
Translating Principles of Neural Plasticity into Research on Speech Motor Control Recovery and Rehabilitation
Vrushali, D. & Prasun, M. (2012). Voice therapy outcome in puberphonia. Journal of Laryngology & Voice (2)1, 26