VOICE DISORDERS IN DOWN SYNDROME

ARTHUR L. PENTZ
Oklahoma State University
Stillwater, OK
MICHAEL J. MORAN
Auburn University
Auburn, AL

Dowrr SYNDROME CHiLDREN have numerous characteristics which set them apart
from other children. There are the overt physical stigmata which may include
unique eye shape and appearance; malformations of the lobules of the ears; hyper-
extendable joints; shortened or unusually curved fingers; and shortened, broad,
malproportioned hands. A second problem which almost invariably accompanies
the syndrome is some degree of mental retardation.
Another disorder which is often present in many Down Syndrome children
is some disruption in the oral communicative processes. Karlin and Strazulla
(1952) and Schlanger and Gottsleben (1957) noted that, among other communi-
cative abnormalities, a large number of Down Syndrome children have voice prob-
lems. Numerous terms, including &dquo;husky; &dquo;monotonous; &dquo;gutteral; &dquo;low-pitched;
and &dquo;raucous&dquo; were used to describe the vocal quality disorder exhibited by many
of these children. Several other investigators have confirmed these impressions
of abnormal voice quality. (Montague & Hollien, 1973; Moran & Gilbert, 1978;
1982; Pentz & Gilbert, 1983; Moran, 1986; Moran, LaBarge, & Haynes, in press)
At one time, the voice quality of children with Down Syndrome did not
command much attention. In light of the other problems associated with this
syndrome, voice quality was considered to be a minor factor, especially when
the child was in an institutional setting. As more of these children function in
less restrictive settings and encounter people less familiar with the syndrome,
the unusual voice quality of Down Syndrome becomes more of a stigmatizing
factor.
A report by Moran, LaBarge, and Haynes (in press) presented a rather vivid
illustration of this negative effect of voice quality. Pictures of Down Syndrome
children were presented to observers along with a sustained vowel sample. In
one situation, observers were presented with pictures of Down Syndrome children

paired with sustained vowel samples produced by those children. In another

situation, listeners were presented with the same pictures of Down Syndrome
children paired with sustained vowel samples from non-Syndrome children. The
speakers were rated using a 12-item semantic differential. The Down Syndrome

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speakers were consistently rated lower on ten of the twelve items when the photos .

were accompanied by the individual’s own vocal sample.

FUNDAMENTAL FREQUENCY
A considerable amount of research into vocal quality differences in Down Syn-
drome children has been directed toward their speaking fundamental frequen-
cies. The overall perception of a &dquo;lowered pitch&dquo; seems to imply that perhaps the
average frequency is lower in Down Syndrome than in non-Down Syndrome chil-
dren. A study of five- and six-year-old Down Syndrome children by Weinberg
and Zlatin (1970) revealed that individuals in that age group had speaking fun-
damental frequencies which were, on the average, somewhat higher than those
of their carefully matched non-Syndrome counterparts. Studies by Michel and
Carney (1964), Hollien and Copeland (1965), Novak (1972), Montaque, Brown,
and Hollien (1974), and Pentz and Gilbert (1983) also failed to substantiate the
notion of a lowered fundamental frequency in Down Syndrome children in their
later preadolescent years.
The paradoxical relationship between perceived pitch and fundamental fre-
quency reported in children with Down Syndrome apparently continues into adult- ’

hood. In studies involving adults, Moran and Gilbert (1978; 1982) reported that
Down Syndrome speakers exhibited significantly higher speaking fundamental
frequencies than a matched group of non-Syndrome speakers. Pcrceptually, how-
ever, the Down Syndrome speakers were judged by listeners to have a lower pitch
than the control group. Moran and Gilbert (1982) reported a moderate correla-
tion between pitch and fundamental frequency for female Down Syndrome
speakers (r .75), but a very low correlation for male speakers (r
=
.16). =

Thus, it would appear that early preadolescent (five and six-year-old) Down
Syndrome children have average speaking fundamental frequencies which are
somewhat higher than normal. Later preadolescent Down Syndrome children
appear to have fundamental frequencies similar to those of their non-Syndrome
counterparts. How the frequencies of Down Syndrome and non-Down Syndrome
adolescents compare is unclear. However, according to Moran and Gilbert (1978; ,

1982), adults appear to have speaking fundamental frequencies which are higher
than those for normal adults at comparable age levels.
Hence, the clinician who is eager to begin voice therapy needs to be very cau-
tious about setting therapeutic goals which target a change in speaking fundamental
frequency. Previous research would seem to indicate that a lowered speaking fun-
damental frequency is not a common dimension of the vocalizations of Down
Syndrome speakers. _

FUNDAMENTAL FREQUENCY RANGE

Several investigators have also studied the fundamental frequency ranges of Down

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Syndrome individuals in an attempt to determine whether restricted fundamental
frequency ranges might contribute to the acoustic bases of their unique vocal
quality. However, neither Michel and Carney (1964), Hollien and Copeland (1965),
nor Pentz and Gilbert (1983) reported evidence to support the hypothesis that

fundamental frequency ranges of Down Syndrome individuals were different from

those of similar non-Syndrome speakers.
Once again, the clinician who may target the fundamental frequency range
as a vocal parameter which requires change should be cautious. Restricted fun-
damental frequency range is not a common dimension of the vocalizations of
Down Syndrome speakers.
.

The clinician who suspects that either speaking fundamental frequencies or

fundamental frequency ranges may be aberrant should determine empirically
what the present patterns are for a given individual before setting related goals.
A tape-recorded speech sample using appropriate materials should be analyzed
at an adequately equipped facility. Those data should then be contrasted with
other similar data from normal talkers of similar ages. In individuals where ther-
apeutic intervention in fundamental frequency or frcquency range appears ap-
propriate, the initial taped measures should serve as a baseline, and periodic
recordings throughout therapy could be used to chart progress and change.

FREQUENCY PERTURBATIONS (Jitter)

While research tends to discount any contribution of lowered average speaking
fundamental frequency or restricted fundamental frequency range, there are other
vocal fold movement dimensions which are often unusual in speakers with poor
vocal quality or vocal fold maladies.
When the vocal folds open and close rapidly in the process of phonation, they
do so with a fair degree of regularity. Lieberman (1961; 1963) discussed the rela-
tive consistency of vocal fold cycles in normal talkers, and the increased irregularity
of successive vocal fold cycles in speakers with vocal fold difficulties and poor voice
quality. The successive cycle-to-cycle changes in the periods of vocal fold vibra- ’

tions is often referred to as jitter.

Pentz and Gilbert (1983) contrasted the magnitudes of vocal fold cycle-to-cycle
frequency changes in a group of seven- to ten-year-old Down Syndrome speakers
and a similar group of normal talkers. The data indicated that the Down Syn-
drome speakers had significantly larger frequency perturbations or jitter factors
than did the non-Down Syndrome group.
Moran and Gilbert (1982) reported that perturbation factors among adult Down
Syndrome speakers were generally between one and six percent. Three of the
sixteen subjects (one female and two males) demonstrated perturbation factors
greater than ten percent. Perturbation was significantly correlated with perceived
hoarseness among the female Down Syndrome speakers, but not among the males.

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 AMPLITUDE PERTURBATIONS .

Another dimension of the vocal fold vibrational cycles also appears to suffer from
increased irregularity in many people with vocal quality differences. The ampli-
tude of each vocal fold’s vibration is fairly consistent in normal talkers. That is,
in a string of single cycles in vocal signal, each adjacent cycle exhibits a relatively
small difference with respect to the ones before it or following it.
Cycle-to-cycle amplitude changes, or shimmer, have been studied by a number
of investigators. Wendahl (1966), Koike (1969), and Kitajima and could (1976)
have studied the presence and effects of large cycle-to-cycle amplitude changes
in persons with abnormal voice quality. Generally, perceptual studies would in-
dicate that such differences can be equated with the identification of a voice quality
as being &dquo;harsh&dquo; or &dquo;rough’L’ Since those terms are often used to describe the vocal

quality of Down Syndrome speakers, Pentz and Gilbert )1983) sought to estab-
lish the presence of abnormal amplitude perturbations in such individuals. That
comparison revealed abnormally large amounts of cycle-to-cycle amplitude changes ’

in seven- to ten-year-old Down Syndrome speakers.

The reasons for these larger than normal cycle-to-cycle frequency and ampli-
tude changes in some Down Syndrome speakers is not fully understood. Laryn-
geal examinations, along with stroboscopic analyses of the actions of the vocal .

folds, is needed to provide more information about the problem. However, one
characteristic which may contribute to the problem is that many Down Syndrome
individuals have an overall reduction in muscle tone (Benda, 1969). Such a
deficiency may be reflected in a weakened vocal mechanism which may not be
capable of maintaining as consistent an amount of vocal fold tension as one with
better developed muscle tone might be. Such inconsistencies may be manifested
in more irregular vocal sound wave periods and amplitudes.
.

Deficient muscle tone may also have some implications for the respiratory system
as well. Such a weakened drive system, while mostly adequate for biological needs,

may not be so capable of maintaining the consistent air supply at the more or
less steady pressure required if the vocal folds are to be forced apart and closed
at similar speeds and magnitudes each time.

SPECTRAL NOISE
Many times speakers who are perceived as having an abnormal voice quality ,
demonstrate the presence of unusually large amounts of spectral noise in their
vocalizations. In most speakers, the vocal folds close tightly and are then forced
open by subglottal air pressure. When this closure is weak for some reason, or
less complete because of vocal fold patholcgy, there is abnormal or turbulent airflow
which usually results in excessive amounts of spectral noise in vocal sound.
This excessive turbulent airflow might be perceived by some as &dquo;breathiness&dquo;
in vocal quality. However, Wilson (1972) probably better described it as the pro-

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 cess of &dquo;airloss’: This airloss
impacts upon the spectra of the vocal sound signal.
According Isshiki,
to Yanagihara, and Morimoto (1966), turbulent airflow often
results in large amounts of spectral noise in the speech sounds (spectral noise
being the aperiodic component of the vocal sound).
On a sonogram made from a speech sample of a speaker with normal vocal
quality, there will be very small amounts of varying intensities of gray across
the entire frequency span of the spectrogram. However, on a sonogram of a speech
sample containing an abundance of airloss, there will tend to be copious amounts
of gray shading in the background areas of that chart. That gray background
may even obscure the acoustic clarity of various phonemes, especially with re-
spect to the higher vowel formants.
Obviously, the same muscle tone deficiencies which can contribute to cycle-
to-cycle frequency and amplitude aberrations can impact upon the nature and
motion of either individual vocal fold. A weakened or fluctuating intrinsic vocal
fold tension which does not support precise movement and adequate strength
of closure would tend to permit excessive airloss and turbulent airflow which adds
to the periodicity of the speech sound.
Moran and Gilbert (1982) reported that increased noise-to-harmonic compo-
nent ratios were noted among 56 percent of the adult Down Syndrome speakers
in their study. Noise-to-harmonic component ratio was significantly correlated
with perceived breathiness for both male and female speakers, and also perceived
hoarseness in female speakers.

FORMANT AMPLITUDE
As airloss occurs, it appears that the regularity with which the various segments
of each vocal fold moves is also affected. Note that this is not the same kind of
periodicity with which the folds abduct or adduct. Weakened or deficient vocal
fold closure seems to reduce the precision and clarity with which the harmonic
components of a vocal fold’s undulating motion occur. According to Isshiki et
al. (1966), that malady also increases the number and magnitude of aperiodic
movements that occur. Thus, the harmonic or periodic component of voice upon
which relative formant amplitude depends is reduced in intensity. Also, since
there is a decrease in the harmonic components, there is a relative increase in
the abundance of non-harmonic components. The interformant regions are
marked with increases in energy levels. So, not only are formants masked by
the interformant energy levels, but they are, in themselves, reduced in intensity
Pentz (1987) reported that, in contrast to a similar group of non-Down Syndrome
children, later preadolescent Down Syndrome children had significant reductions
in their formant amplitude levels, and that their vowel formants were less dis-
tinct and often obscured by non-formant sound energy.
.

Obviously, the same weakened or fluctuating mechanism which may impact

upon the amount of turbulent airflow through the folds can also contribute to

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 a reduction in the smooth undulating motion of each vocal fold and would also
tend to reduce the relative amplitude of the harmonics of the vocal sound source.
However, some other problems might also impact upon the vocal signal.

ORAL AND NASAL RESONANCE

It has been suggested that resonance characteristics also contribute to the unique
voice quality of Down Syndrome children. Montague and Hollien (1973) reported
that Down Syndrome children exhibit a greater degree and severity of hyperna-
sality than do non-Down Syndrome children. Novak (1972) indicated that Down
Syndrome children demonstrate some fusion or blending of vowel formants and
suggested this oral resonance difference contributed to the perceived voice quality.
Moran (1986) reported that judges listening to prolonged vowels only were able
to distinguish adult Down Syndrome speakers from non-retarded speakers with
hoarse voices. This finding was consistent with the reports of Montague and Hollien
(1973) and Novak (1972) which indicated that resonance factors contributed to
the unusual voice quality of Down Syndrome speakers. The adult Down Syn-
drome speakers evaluated by Moran (1986), however, did not demonstrate the
formant fusion reported by Novak (1972). The vowel formants for the adult Down
Syndrome speakers evaluated by Moran (1986) were similar to those of non-
retarded adults.
Benda (1969) and Levinson, Friedman, and Stamps (1955) reported that many
Down Syndrome individuals had reduced physical development in the oral and
nasal regions. Also, many were reported to have disproportionately large tongues.
First of all, a reduction in the overall size of the vocal tract would probably have
an increased damping effect on the vocal signal as it is passed through the system.

The eHects of that increase on the sound spectra at the lips would probably be
marked by a reduction in intensity levels of the spectral components.
Hoivever, the exact way in which the individual components might be altered
is not easily predicted. Often times a disproportionately large tongue in a rela-
tively underdeveloped vocal cavity further constricts the oral channel, driving
an unusually large amount of sound energy into the nasal chambers. The nature

of the tissues contained in that region and the size of that large, side chamber
cause a damping of formant amplitudes as evidenced by the nature of the spectra
of nasal sounds.
Thus the formant amplitudes of a signal which seemingly had lowered levels
of periodic components to start out with, arc even further reduced. The term
&dquo;nasal&dquo; which is also used to describe the speech of many Down Syndrome indi-
viduals, may stem from the perception of a vocal quality which results from an
unusually large amount of sound energy being directed out through the nasal
resonance cavity.

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 ’

IMPLICATIONS AND SUMMARY

The vocal sound quality of Down Syndrome individuals is often described as

hoarse, breathy, nasal, harsh, and raucous. These perceptions are not accurate
descriptions of the underlying acoustic differences manifested in the vocaliza-
tions of Down Syndrome speakers. However, the widespread recognition of vocal
quality differences would seem to be at least somewhat substantiated by aberrant
acoustic characteristics. Some of these acoustic differences may be physiologi-
cally or anatomically based, and must be properly assessed and treated. But,
from the therapeutic standpoint, the clinician must not feel professionally helpless.
There are numerous things for the clinician to consider. First, the therapeutic
priority which vocal quality might receive will vary from child to child. On the
one hand, the individual with severe phonologic and language delays and dis-
orders often requires that a bulk of the therapeutic effort be directed at those
problems. On the other hand, another child may have very mild communicative
problems in the latter areas or perhaps no evident phonologic or language deficits,
and also exhibit a poor vocal quality. The amount of therapeutic attention directed
at the voicc quality disorder may be substantial. Unfortunately, the options are
seldom that clear cut.
Regardless of coexisting communicative problems, the poor vocal quality and
patterns which are often present should not be ignored. Many Down Syndrome
children are very capable of learning and habituating good vocal habits. Plus,
many are already seen regularly for multidimensional communicative therapy
into which some vocal therapy goals can be integrated. Their inclusion need not
disrupt or interfere with other therapeutic aims. Nor does their inclusion neces-
sarily indicate that vocal quality differences are the primary communicative
problem, although in some cases they might be.
.
It is our clinical observation that many Down Syndrome individuals use poor
rate, inflection, and intensity patterns, and use a poor oral resonance balance.
More often than not, if rate needs adjustment, it needs to be slowed. Many times
such an adjustment if reflected in greater phonologic accuracy. Also, a more ap-
propriate balance of oral and nasal sound can be achieved in spite of some of
the physical and anatomic limitations of the mechanism. Simply using a wider
mouth opening during speech will sometimes improve the oral-nasal resonance
balance. Better exploitation of more fitting inflection and intensity patterns can
be acquired. Adjustments in all these domains can be accomplished by many
Down Syndrome speakers, and such successes can have..a marked effect upon
overall communicative effectiveness.
A final concern lies in the problem of vocal abuse. It is our clinical impression
that many Down Syndrome children engage in an abundance of vocally abusive
behaviors. Consistently elevated and inappropriate loudness is often a habit with

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 many of these youngsters. Sudden and hard phonational onsets are often persis-
tent problems, and frequent yells are noticed.
These abusive habits are often, in themselves, enough to cause vocal fold dis-
tress. However, such poor vocal habits in Down Syndrome children may further

compound an already poor vocal quality. Fortunately, many can be taught to

successfully reduce abusive behaviors. Fewer such behaviors can be a feasible
goal, the achievement of which can have a markedly positive effect on the preser-
vation and maintainence of the best possible vocal quality.
The poor vocal quality which is often present as a dimension of Down Syn-
drome children’s speech may be attributed to the interaction of a variety of acoustic
’

parameters, physical parameters, and poor vocal habits. However, voice quality
should not be ignored. In spite of what appear to be anatomic and physical limi-
tations, many Down Syndrome children are capable of learning how to habit-
uate good, effective vocal habits. Often these children receive speech and lan-
guage therapy into which some vocal therapy goals could be easily integrated.
Their inclusion does not necessarily need to interfere with those other aims of
therapy.
Down Syndrome children need to habituate the best possible vocal quality within
the limits of their vocal mechanism. Many will have limited success due to struc-
tural and physical factors, and may not achieve the improvement which might
be expected of others without such limits. However, even small amounts of success
can have noticeable effects.

Address Correstbondente to:

Michael J. Moran, Ph.D.
Department of Communication Disorders
1199 Haley Center
Auburn University
Auburn, AL 36849

Acknowlegmenl
Portions of this paper were presented at a Miniseminar during the 1987 annual meeting
of the American Speech-Language-Hearing Association in New Orleans, LA.

About the Authors

Arthur L. Pentz received a Ph.D. From Pennsylvania State University in 1981. He is
currently Associate Professor of Speech Pathology and Audiology at Oklahoma State
University. His research interests are in the areas of speech science and voice disorders.
Michael J. Moran received a Ph.D. from Pennsylvania State University in 1980. He is
currently Associate Professor of Communication Disorders at Auburn University. His
research interests are in articulation and voice.

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