Chronic Hoarseness in American Indian School-aged Children

Volume 11, No. 2 - Winter 1999
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This study was launched to verify observations made of the American Indian population, who appeared to demonstrate a high incidence of chronic hoarseness. Although hoarseness is common, the literature describes this group of people as being soft spoken. Thus the number of voice disorders is typically underestimated as the result of the lack of identification and referral from parents and teachers. If these individuals were better equipped to identify suspected cases of hoarseness, proper treatment by a speech-language pathologist or referral to other disciplines, such as an ear, nose, and throat doctor, could be made. Early identification and treatment by a speech-language pathologist is the key to voice management. If this is not pursued, long lasting hoarseness and/or the need for surgical management of potentially vocal nodules may be needed.

Hoarseness, which occurs in 5 percent to 20 percent of school-aged children, is the most common reason for voice referral (Baynes, 1966; Shearer, 1972; Yairi, Yairi, Horton, Currin, and Bulian, 1974). Chronic hoarseness typically affects children aged 6 to 10 and lasts for periods of one month or longer. Jackson (1959) described hoarseness as sounding rough, grating, harsh, discordant, and lower in pitch than is normally expected. The studies investigating voice disorders have primarily been concerned with the general population, rather than making socioeconomic, geographic, or ethnic differentiations. Health issues and cultural experiences vary among these groups. As these factors may affect voice characteristics, there is a need for additional research in this area.

Bayles and Harris (1982) have indicated the need for further investigation of communication disorders within the American Indian population. A limited amount of data is available on American Indians on voice disorders. Since the literature indicates that American Indians tend to have a higher prevalence of speech, language, and hearing disorders, it would seem that vocal quality of this population needs further investigation.

Hoarseness in the general population

First, it is necessary to illustrate the incidence rates of hoarseness within the general population. Yairi et al. (1974) focused on the incidence of hoarseness in first through sixth graders over a one-year period. During an initial screening it was discovered that 13.3 percent demonstrated a hoarse vocal quality. Three months later the same group was screened and found to demonstrate a 12.9 percent incidence of hoarseness. Males displayed a hoarse quality 17 percent of the time in contrast to females whose quality was hoarse only 10 percent of the time. Comparisons among grades revealed that the majority of hoarseness occurred in first grade students. As for ethnic distribution, a 21 percent incidence rate was discovered in African-American students, which was 9 percent higher than demonstrated in other groups (Caucasian, Hispanic American).

Researchers stress the importance of  including a complete voice assessment when other primary communication disorders exist so that therapy or proper medical treatment may be provided (Filter and Poyner, 1982; Powell, Filter, and Williams, 1989; Yairi et al. 1974). Ruscello, St. Louis, and Mason (1991) discussed a study that Shriber and his associates conducted. Their results indicated that half of the participants displayed vocal deviations in addition to a phonological disorder. The speech and voice skills of children in residual (mild to moderate phonological impairments) and delayed (severe phonological impairments) groups were investigated. Within the residual group, of the 75 percent who had vocal deviations, 67 percent were hoarse. Within the delayed group, 75 percent were identified as having poor vocal quality, with 56 percent demonstrating hoarseness.

Casper, Abramson, and Forman-Franco (1981) studied the incidence of hoarseness in 96 summer camp subjects. Their initial and final speech samples indicated occurrence rates of 18 percent and 53 percent, respectively. It was concluded that as a result of swelling, which disturbed vocal fold closure, the children made compensatory efforts to ensure complete vocal fold contact by increasing the force necessary for laryngeal muscle contraction.

Etiological factors related to hoarseness are also important to consider. Sederholm, McAllister, Dalkvist, and Sundberg (1995) identified the most common causes of hoarseness to be psychological factors, organic diseases, vocal abuse, and familial influence. The authors studied eight third grade male subjects with hoarseness. In order to determine factors associated with chronic hoarseness, they conducted the following examinations: audiometric, laryngoscopic, and perceptual. In addition, questionnaires were distributed to parents and teachers, requesting information on personality traits, medical background, development, and social relations. The investigation revealed that gender and personality traits were highly correlated with chronic hoarseness. Questionnaire data indicated that the subjects tended to be more extroverted, although emotional stability seemed to be less developed. They were also described as immature, loud-voiced, active participants in large groups, and lacking concentration. There was no medical basis established in relation to the occurrence of chronic hoarseness (Sederholm et al., 1995).

Many researchers recognized that although common colds may be responsible for hoarseness, vocal abuse was also a factor to consider (Filter and Poynor, 1982; Shearer, 1972). Some of the problems related to vocal abuse included nodules and polyps. Benjamin and Croxson (1987) noted that between 38 percent and 78 percent of the time, vocal nodules were the greatest factor leading to chronic hoarseness. Maragos (1990) also explored the realm of factors associated with the etiology of hoarseness. A variety of infectious diseases caused by bacteria, viruses, or fungi can influence the onset of acute laryngitis in association with swelling of the surrounding areas.

American Indian communication styles

The communicative style of the American Indian population must be considered. Verbal expression of American Indian school-aged children is described as being soft, low, and lacking in intonational variation. It is important to keep in mind that this population considers silence to be an attribute. It is not uncommon for the American Indian child to be quiet in the presence of authority figures since they are encouraged to be listeners rather than talkers. Typically, American Indians do not communicate unless the message is purposeful and well thought out. These characteristics are utilized to show respect for others (Pitton, 1993).

To further illustrate the general communicative style of American Indians, Fiordo (1985) made some observations. He found many differences when comparing classroom speeches of American Indians and the general population. American Indians tended to utilize a soft-spoken voice that at times affected articulation precision and pronunciation, whereas the general population tended to be more outspoken. The slower speech rate commonly used by the American Indian group was considered more pleasing to the listener, while in contrast, the general population spoke at a faster rate.

Fiordo (1985) stated, “Native speakers tend to limit their vocal variety more than non-Native speakers, while pausing more effectively and maintaining a soothing vocal quality throughout” (p. 40). He reported that when effective, the soft-spoken way of the American Indian group seemed patient and gentle; however, when the message was not effective, it was perceived as shy and timid. It was also noted that when effective, the general population’s message seemed to be strong and confident. Yet, it was determined to be aggressive and unreceptive in other situations. The general population is perceived to be louder, faster, articulate, varied in intonation, and less agreeable (Fiordo, 1985).

American Indian children are likely to inherit the communicative style of authority figures in their culture. In contrast to the general population, American Indians use disciplinary methods that lack extensive use of harsh verbal and physical actions (Bearcrane, Dodd, Nelson, and Ostwald, 1990; California State Department of Education, 1992). Koelsch, Trumbull-Estrin, and Farr (1995) stated, “Much of the cultural learning takes place through demonstration and quiet, self-guided practice, rather than through explicit instruction via language” (p. 14). Communicative behavior is emphasized through nonverbal messages and thus detected by keen observation. Small talk is discouraged since the American Indian culture respects the act of speech by making contacts meaningful and stressing the emotional factors (California State Department of Education, 1992).

It is not uncommon for American Indian caregivers to discourage their infants from crying. As they mature, children are encouraged to be silent bystanders during exchanges of communication.. In contrast to Anglo mothers who verbally interact with their infants, American Indian mothers often remain silent, relying on eye contact alone. It was found that the mothers of these two cultures perceived active speech patterns differently. American Indian mothers felt that this type of speech behavior was self-centered and lacked courtesy and discipline. On the other hand, Anglo mothers felt that the child was actively learning and developing preferred behaviors. Passivity and observation allow the American Indian child to learn customs and rituals through demonstration rather than verbal instruction (Harris, 1985).

Causes of Indian voice disorders

Health and developmental issues within the American Indian population may contribute to the incidence of voice disorders. Berman’s (1976) report on the Standing Rock Sioux indicated that of 763 students screened, 10.4 percent needed speech or language treatment. Harris (1986) listed communication disorders as one of the most prevalent disabilities among American Indian children. Harris (1986) proposed that possibly 5 percent to 15 percent more American Indian children display communication disorders than the general population. It has also been documented that speech impairments were the largest class of disabilities within tribal Headstart programs.

Johnson (1991) presented information from 1987 studies conducted by the Bureau of Indian Affairs (BIA) and the U.S. Department of Education, Office of Civil Rights. These studies discovered that speech impairments affected 5.74 percent of American Indian children, versus 2.9 percent of children in the general population. An example of speech disorders occurring at a higher incidence was cleft lips, which occur in one of every 400 American Indians. In contrast, the general population exhibits cleft lip rates of one per every 700 infants. Bayles and Harris (1982) presented BIA survey results that listed 33 percent of American Indian children in BIA schools as having impairments. Of those students, 19 percent suffered from speech difficulties, 13 percent from hearing loss, and 1.0 percent from deafness.

A study conducted on the Papago Indian tribe in Arizona (Bayles and Harris, 1982) focused on the voice, fluency, and language abilities of 583 children. Ten percent of the students displayed language delays, 5 percent showed articulation disorders, and 0.6 percent were disfluent. Additionally, one child displayed a voice problem, and two failed a hearing screening. Scores derived from the language testing suggested that those students were over one year behind the general population in their English comprehension abilities.

Within the American Indian population, otitis media was noted as the leading disorder. Toubbeh (1985) listed data from a 1981 reported conducted by the Indian Health Service (IH S). This report indicated that 4,574 individuals were diagnosed with otitis media and other ear diseases, thus placing service needs in this area as the highest for the International Classification of Disease diagnoses. Toubbeh (1985) reported occurrences of otitis media to be 4 to 13 times greater in American Indians when compared to the general population. Johnson (1991) noted that in the 1987 studies conducted by the BIA and U.S. Department of Education, hearing disorders were reported to be as much as 20 percent to 30 percent greater in children of the American Indian population when compared with the general population. The National Institute of Handicapped Research (NIHR) reported deafness occurring at rates of 2.7 percent for American Indians compared with .90 percent for the general population; additional hearing problems reached 15.9 percent in the American Indian population and only 5.3 percent in the general population (Toubbeh, 1985).

The amount of information available on the topic of hoarseness in the American Indian population is limited. Therefore, based on these literature findings, it is evident that further research is needed.

Methodology of study

Permission forms were sent to 180 parents of students in the first, third, and fifth grades from both the Fort Berthold and the Turtle Mountain Reservations located in North Dakota. Thirty-four subjects from the Turtle Mountain Elementary School and 37 subjects from Edwin Loe Elementary School participated in this study. There were 28 males (39 percent) and 43 females (61 percent).

Students were screened using a tool that specified hoarseness severity on a five- point scale. This condition was evaluated based on the child’s performance on the following (1) counting from 1 to 10; (2) prolonging selected vowels for a five second period; (3) a one minute connected speech sample, and (4) a one minute reading sample or repetition of a nursery rhyme.

The screening tool incorporated a five- point scale that ranged from a score of one for normal voices to five for severely disordered voices. Students who received a rating of two or higher were re-evaluated four weeks from the initial screening date. If the score of two or higher persisted in this follow-up, the student was identified as exhibiting chronic hoarseness (Wilson, 1987).

Results of study

Overall, American Indian students demonstrated a 32 percent incidence rate of chronic hoarseness in contrast to the general population at 5 percent to 20 percent. It was discovered that gender differences existed. Forty-three percent of males and 26 percent of females displayed some degree of hoarseness. Additionally, grade differences were noted. Forty-three percent of first graders, 38 percent of third graders, and 17 percent of fifth graders were chronically hoarse. Figure 1 describes the number of Fort Berthold and Turtle Mountain students who displayed chronic hoarseness ratings of two or higher during the follow-up screening.

Figure 2 displays the number of students from each reservation who demonstrated chronic hoarseness ratings of two or higher during the follow-up screening. This figure represents the consistency between the two reservations. Since similar test results were collected from each reservation, it further solidifies the possibility that chronic hoarseness is a common trend among the American Indian population.

FIGURE 1Figure 1. The incidence of chronic hoarseness in Fort Berthold and Turtle Mountain students broken down by grade and gender.

FIGURE 2Figure 2. The incidence of chronic hoarseness in Turtle Mountain and Fort Berthold students broken down by grade and reservation.

Mean and standard deviation scores were calculated for each grade level as seen in Table 1. These mean scores indicate that based on a five-point scale, the majority of students identified as being chronically hoarse were in the mild range.

TABLE 1Table 1: Mean and standard deviation scores

These data support the hypothesis that of the students who participated in this study, a higher incidence of chronic hoarseness was found when compared to general population studies. The percentage of students identified in this study as being chronically hoarse was considerably higher than past reports of the general population. Grade and gender trends displayed in this study were similar to previous research conducted in the general population.

In contrast to inconsistent reports of chronic hoarseness displayed in the general population, the two reservations studied revealed similar results. While a high incidence did exist, the majority of those identified did not demonstrate a severity level that would qualify them for speech services in a public school setting. Although this may be true, these students, as would most, could benefit from voice education. It is highly recommended that speech-language pathologists in the school setting educate faculty members so that they can aid in proper identification of hoarseness and discourage vocally abusive behaviors noted in the classroom.


The author can only speculate as to which causal factors may be involved with these results, as there are many possibilities. One possibility is the health- related problems experienced by the American Indian population. As noted in the literature, more frequent occurrences of otitis media, cleft palate, and other infections such as upper respiratory, may be related to voice disorders. Although these health problems may be short term, they can initiate and add to the vocal quality associated with a hoarse voice, which can persist for extended periods of time unless treated. Also, cultural influences may play a role in learned voice behaviors. This is demonstrated by chronic hoarseness that is observed across generations of families. Another possibility is that a biological predisposition to chronic hoarseness exists. This would imply that the composition of the vocal folds might be different, thus placing this group at a higher risk for hoarseness.

Further research is need for the following reasons. First, in order to determine if American Indian students as a group demonstrate a higher incidence of chronic hoarseness, it would be beneficial to conduct studies in various geographical locations with large populations of American Indians. This would also take any tribal differences into consideration. Second, this study used subjective methods of measuring vocal quality. To confirm the findings of this study, objective means of collecting data, through instrumentation assessment should be employed. This would encourage various disciplines to be involved in the evaluation process as suggested by the literature. Last, a control group was not utilized in this study. Therefore it would be beneficial to gather voice samples from the general population within the region studied in order to determine if the incidence of chronic hoarseness is a geographical rather than a cultural difference.

Bridget Francisco earned her master’s degree in speech-language pathology from Minot State University in North Dakota. She is currently working toward a doctorate from the University of Southern California. Dr. John Torgerson is a professor emeritus at Minot State.


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