LSHSS

Clinical Forum

Quick Screen for Voice and

Supplementary Documents for
Identifying Pediatric Voice Disorders
Linda Lee
University of Cincinnati, OH
Joseph C. Stemple
Blaine Block Institute for Voice Analysis and Rehabilitation, Dayton, OH
Leslie Glaze
University of Minnesota, Minneapolis
Lisa N. Kelchner
University of Cincinnati, OH

V oice is the product of a combination of

physiologic activities, including respiration,
phonation, and resonance. A voice disorder is
present when a person’s quality, pitch, and loudness differ
from those of a person’s of similar age, gender, cultural
background, and geographic location, or when an individual
indicates that his or her voice is not sufficient to meet
daily needs, even if it is not perceived as deviant by others
(Colton & Casper, 1996; Stemple, Glaze, & Klaben, 2000).
The incidence of voice disorders in children is often
estimated at between 6% and 9% (Boyle, 2000; Hirschberg
ABSTRACT: Three documents are provided to help the et al., 1995). However, other sources identify ranges of 2%
speech-language pathologist (SLP) identify children with to 23% (Deal, McClain, & Sudderth, 1976; Silverman &
voice disorders and educate family members. The first is Zimmer, 1975). In one study, 38% of elementary school-aged
a quickly administered screening test that covers multiple children were identified as having chronic hoarseness
aspects of voice, respiration, and resonance. It was tested (Leeper, 1992). Unfortunately, it is estimated that the vast
on 3,000 children in kindergarten and first and fifth
majority of children with voice disorders are never seen by a
grades, and on 47 preschoolers. The second document is
speech-language pathologist (SLP; Kahane & Mayo, 1989),
a checklist of functional indicators of voice disorders that
could be given to parents, teachers, or other caregivers and children with voice disorders only make up between 2%
to increase their attention to potential causes of voice and 4% of an SLP’s caseload (Davis & Harris, 1992).
problems and to provide the SLP with information Few studies have identified the type of laryngeal
pertinent to identification. The final document is a pathologies that are most common to children. Dobres, Lee,
brochure with basic information about voice disorders Stemple, Kretschmer, and Kummer (1990) described the
and the need for medical examination. It may be used to occurrence of laryngeal pathologies and their distribution
help the SLP educate parents, particularly about the need across age, gender, and race in a pediatric sample. Data
for laryngeal examination for children who have been were collected on 731 patients seeking evaluation or
identified as having a voice problem.
treatment at a children’s hospital otolaryngology clinic. The
most frequent laryngeal pathologies were subglottic
KEY WORDS: voice disorders, screening voice, voice
assessment, pediatric voice disorders stenosis, vocal nodules, laryngomalacia, functional dyspho-
nia, and vocal fold paralysis. For the total sample, these

308 LL , S,PEECH
ANGUAGE
ANGUAGE SPEECH , AND
, AND HEARING
HEARING SERVICES
SERVICES IN S CHOOLS
IN S CHOOLS • Vol. 35 •• 308–319
Vol. 35 • October
• 308–319 • American
2004 © October Speech-Language-Hearing
2004 Association
0161–1461/04/3504–0308
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 pathologies were much more common in males than in Additionally, a checklist of functional indicators of voice
females, with the youngest patients (less than 6 years old) disorders in children and adolescents that could be given to
identified as having the most pathologies. The distribution parents, teachers, or other caregivers may increase their
of pathologies within the races sampled (Caucasian, African attention to potential causes of voice problems and provide
American, and Asian) was similar to that found throughout the SLP with information pertinent to identification. Finally,
the total sample. a brochure with basic information about voice disorders and
Although it has been argued by some that treating voice the need for medical examination may help the SLP
disorders in children is unnecessary or even potentially educate parents. These needs are addressed in the present
harmful (Batza, 1970; Sander, 1989), others have argued document.
for the opposite opinion (Kahane & Mayo, 1989; Miller &
Madison, 1984). Indeed, Andrews (1991) suggested that
unlike some other developmental disorders, maturation
alone does not significantly affect vocal symptoms. QUICK SCREEN FOR VOICE
Habitual patterns of poor voice use do not, as some have
suggested, disappear at puberty. In other words, children do A screening tool entitled Quick Screen for Voice (see
not outgrow voice disorders. Appendix A) was developed by the second author (JS). It
The identification and management of pediatric voice provides more thorough delineation of tasks and measures
disorders is important for the child’s educational and than the more open-ended requests for observation of voice
psychosocial development, as well as physical and emo- quality that are currently available on speech and language
tional health. The underlying cause of any dysphonia must screening tests. The tool may be used for speakers of all
be determined because voice disorders that share the same ages, from preschool through adult.
quality deviations may have vastly different behavioral, Respiration, phonation, resonance, and vocal flexibility
medical, or psychosocial etiologies (see review in Stemple are the hallmarks of healthy and acceptable voice production,
et al., 2000). and all are included in this test. These subsystems of voice
The majority of children with voice problems are production are assessed separately. Lists of perceptual
identified by individuals other than the school SLP (Davis characteristics that are commonly associated with disorders
& Harris, 1992). Typically, the teacher, nurse, or a family of that subsystem are contained in each section. Definitions
member notices that a child has developed an abnormal of each perceptual characteristic are provided in Appendix B.
voice quality and makes the initial contact with the SLP. The protocol is designed to be administered in 5 to 10
These referral sources lack training in making perceptual min. Administration time is reduced when the child’s voice
quality judgments, so they may miss more subtle problems is judged to be normal. When abnormal signs are found in
that need professional attention. Depending on the task, any subsection, the test form provides appropriate language
teachers may or may not be accurate in identifying children for vocal behaviors that the SLP may not observe or
with voice deviations (see review in Davis & Harris, 1992), identify without it. These identifiers can then be used when
and many parents may assume that the child will outgrow reporting findings and generating individualized educational
the disorder. Perceptual voice quality evaluation can be plan (IEP) goals, if a management program is necessary.
difficult even for the SLP (Kreiman, Gerratt, Kempster,
Erman, & Berke, 1993; Kreiman, Gerratt, Precoda, & Directions and Scoring
Berke, 1992), so depending on untrained persons to identify
these children is less than ideal. The Quick Screen for Voice should be administered in a
One common method of identifying childhood communi- quiet area that is free of distractions. The tester should be
cation disorders is through mass screening. Unfortunately, seated close to the individual.
voice has received scant attention in most speech and Perceptual characteristics of the voice are judged by
language screening tools. For example, the Fluharty-2 listening to the individual speak. Therefore, the examiner
Preschool Speech and Language Screening Test (Fluharty, should engage the individual in topics, such as family or
2001) has one line for clinician response to voice quality friends, hobbies or other interests, favorite holidays or
(“sounded normal; recheck may be necessary”). Similarly, vacations, favorite classes in school, and so on. To assist
one line for description of the voice is allotted on the elicitation of spontaneous speech, the individual may be
Speech-Ease Screening Inventory (Pigott et al., 1985). asked to tell a story about pictures that are sufficiently
These conventional one-line summaries fail to address the detailed to allow a 2–3 min description or elicited sample.
voice comprehensively; that is, they do not assess the three Recited passages, counting, or other natural samples of
subsystems of respiration, phonation, and resonance. Voice continuous speech may also be used.
problems are typically reduced to a generic description of The examiner responds to a checklist of observations that
quality deviation and may easily be overlooked because of are made during the spontaneous speech and other voicing
such minimal opportunity for evaluation. tasks. The speaker fails the screening test if one or more
Identification of children with voice disorders could be disorders in production are found in any section. In such
facilitated with several documents. A screening tool cases, the individual would be scheduled to be screened
covering multiple aspects of voice, respiration, and reso- again, have a more comprehensive voice evaluation, or be
nance could replace the more general voice evaluation referred to a physician with a request that the child be
statements that are provided on current screening tools. examined by an otolaryngologist or other specialist.

Lee et al.: Quick Screen for Voice 309

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 Field Tests and Subsequent Revisions Table 1. Results of administration of the Quick Screen for
Voice to 3,000 students, half in kindergarten and first grade
and half in fifth grade. The total percentage failed, percentage
The screening tool was used during two formal mass by subcategories of the test, and percentage after Delphi
speech and language screenings with preschool and school- adjustment are presented. Individual percentages do not add
age children, and more informally with adult graduate up to the total percentage because it is possible that a child
students taking a voice disorders class. The primary purpose could have more than one item checked in each area.
of using the tool in these situations was to determine its ease
and clarity of use, whether or not it contained complete lists
of observations under each category, and confirmation of the After After Delphi
Delphi adjustment
criterion for passing or failing.
adjustment for false
Screening of kindergarten and first and fifth grade Percentage for false positives and
students. The Quick Screen for Voice was used as part of a failing positives false negatives
comprehensive speech, language, and hearing screening of
3,000 elementary school children in 53 school districts
Grades K and 1
throughout Ohio. Half of the children were in regular Total 34.5 23.3 19.7
kindergarten and first grade; half were in fifth grade. The Respiration 17.4 11.3 9.6
school districts were chosen because they represented a wide Phonation 10.2 8.0 7.1
variety of urban, rural, and suburban locations; average Resonance 3.3 3.9 2.0
Range/flexibility 29.1 17.0 15.3
family income; percentage of minority population; and
district expenditure per pupil. Students receiving part-time Grade 5
special education services were included. Students receiving Total 20.9 18.1 14.1
full-time special education in segregated classes or separate Respiration 6.6 5.9 4.0
Phonation 7.5 6.5 5.6
buildings were omitted from the sample. Seven university
Resonance 1.8 2.1 1.1
departments participated. The screening tests were adminis- Range/flexibility 13.8 11.3 9.4
tered by trained graduate students under the supervision of
licensed and certified SLPs. The students practiced adminis-
tering the tests before conducting the screening. students failing the test. False negatives were calculated as
The percentage of students failing the total screening a ratio of the number of students with a voice disorder who
test and each subcategory is contained in Table 1. Some were incorrectly classified as having passed the test, over
individuals who fail screening tests will be found by more the total number of students passing the test. Because the
intensive diagnostic tests not to have a communication actual number of false positives and false negatives was
disorder (i.e., a false positive). Conversely, some students not known, the numbers used in the ratios were based on
with a communication disorder may pass a screening, expert panel predictions. The panel first adjusted the
although the incidence of these false negatives is expected observed scores for false positives, and then made an
to be low if examiners are trained and tests are properly additional adjustment for both false positives and false
administered. The actual number of false positives and false negatives, combined. These percentages are contained in
negatives resulting from the mass screening is not known. Table 1.
Therefore, the percentage of students failing the screening The percentage of actual failures (34.5% for kindergar-
was adjusted by factors that would correct for both false ten and first grade; 20.9% for fifth grade) was higher than
positives and false negatives by using the Delphi technique most previous reports in the literature (Boyle, 2000; Deal
(Linstone & Turoff, 1975; Rothwell & Kazanas, 1997; et al., 1976; Hirschberg et al., 1995; Silverman & Zimmer,
Woudenberg, 1991). This procedure involves a series of 1975). The percentage of children failing the present voice
steps to elicit and refine the perspectives of a group of screening was consistent with the results of the concurrent
people who are experts in the field. The first step was speech and language screenings, which were also consid-
selection of the panel (in this case, a group of individuals ered high (16.9%, 3.2%, and 1.2% of kindergarten and first
in academic and clinical settings with extensive knowledge graders, and 13.5%, 2.6%, and 1.1% of fifth graders failed
about similar tests and their outcomes). The second step language, articulation, and fluency, respectively). Overall,
was to survey the panel members to obtain their predictions 39.2% of kindergarten and first graders and 29.5% of fifth
of test outcome based on their knowledge about the current graders failed all language, articulation, fluency, voice, and
literature. The estimates were analyzed using descriptive hearing screening, even after Delphi adjustment for false
statistics such as mean and median. If the estimates were positives.
close to each other, the values were used. If the estimates It should be noted that the highest percentages of failures
were not close, the results were cycled back to the panel on the Quick Screen for Voice were in the category of vocal
members, who were asked to reconsider their answers. range and flexibility. On the version of the tool used in the
Respondents who were relatively far off from the average mass screening, habitual pitch, pitch inflection, loudness
figures were asked to explain why they kept their original effectiveness, and loudness variability were based on
response, if they decided to do so. clinician judgment of these parameters during conversational
False positives were calculated as a ratio of the number speech. The authors suspected that the failure rate on this
of students without a voice disorder who were incorrectly subtest may have been inflated because of difficulty with
classified as having failed the test, over the total number of judging these particular parameters during conversation,

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 especially because the parameters were not defined. is to screen only certain grades each year. Some evidence
Therefore, specific tasks to demonstrate pitch and loudness exists that teachers can be a reliable referral source if they
were substituted for the more subjective judgments. are asked to make a gross dichotomous judgment (refer/do
Habitual pitch and loudness are determined by having the not refer) and if they are encouraged to overrefer if in
child count from 1 to 10, repeat, but stop at “three” and doubt (Davis & Harris, 1992).
hold out the /i:/. A maximum phonation time (MPT) task The Functional Indicators Checklist (Appendix C) is an
was also added to this section. The changes in the tool may informal probe that is designed to detect evidence of
lower the percentage of failures on this subtest. consistent voice differences that can represent a potential
Screening of preschool children. The second revision of voice disorder resulting from underlying medical, voice use,
the Quick Screen for Voice followed screening of 47 or emotional factors. The checklist uses symptoms or
children (25 boys; 22 girls; ages 3–6 years) in a Head Start situational-based judgments that are identifiable to parents,
program at Arlitt preschool in Cincinnati, Ohio. None of teachers, and other caregivers of children and adolescents.
the children who participated in this screening had been The specific probe items are nonstandardized, and there is
previously diagnosed with a voice disorder. Four trained no critical number of positive signs that suggest a need for
graduate students completed the testing. further referral. Rather, the “yes/no” format is intended to
Results revealed that 19% (9 out of 47) of the partici- summarize an inventory of impressions about the speaker’s
pants failed the initial screening. Six were boys; three were ability to use effective voice in the “real world.”
girls. Subjects failed because of abnormalities in the areas of The checklist items were derived from the authors’
respiration (n = 1), phonation (n = 4), and resonance (n = experience with common case history questions that are
4). No abnormalities were found in the category of nonver- useful in signaling a potential threat to voice quality. The
bal vocal range and flexibility. The 4 subjects who failed the probes are intended to “operationalize” specific judgments
initial screening because of resonance disturbance passed the of voice production and quality. For example, rather than
second screening. The examiners had noted signs of a cough querying abstract constructs related to voice loudness or
and nasal congestion upon initial examination, and these endurance, a representative functional indicator was
problems apparently resolved before the second test. The selected and was related directly to academic interference,
remaining 5 subjects retained the characteristics found on the which is a key qualification standard for service in the
initial screening and failed the second screening. schools (e.g., “Can’t be heard easily in the classroom when
In order to determine intrajudge reliability, one examiner there is background noise”). Because information is sought
gave the test a second time to 5 subjects who passed the about vocal competence, as well as overall speaker confi-
screening test and the 4 subjects who failed the phonation dence in the functional communicative environment, probe
section. The second test was administered a week following items were included to assess the emotional impact of
the first, and the results of the initial test were not avail- voice differences (e.g., “Doesn’t like the sound of his/her
able to her. Interjudge agreement was measured by having own voice” or “Is teased for the sound of his/her voice”).
two of the graduate students independently test 5 subjects The Functional Indicator Checklist is a quick and easy
who failed any portion of the screening test and 6 subjects supplement that may cross-validate the other Quick Screen
who passed it. Both intrajudge reliability and interjudge judgments made for voice production. For example, the item
agreement were excellent (100% for each measure). Finally, “Voice sounds worse after shouting, singing, or playing
all subjects who failed the initial screening were tested outside” will provide the screener with information about
again 5 months later. No intervention was provided between variability and potential voice use factors that may support
screening tests. The 5 subjects who failed the second audio-perceptual judgments of vocal instability. Although the
screening also failed the third. checklist is meant to be a supportive adjunct to the Quick
Final version of the tool. Clinicians participating in Screen, it may also be used as a follow-up survey.
both the preschool and school-age screenings provided Finally, the Functional Indicators Checklist can lend
feedback to the authors about their experiences with the support to any future treatment plans if the real world ties
screening tool. Suggestions for improving directions, ease to communication needs are sufficiently meaningful to
of use, and lists of observations under each category were children and adults. A child may certainly not care about
incorporated into subsequent revisions, all of which were the pitch, loudness, or quality of his or her vocal signal,
considered minor. The clinicians agreed with the pass/fail but may respond more willingly to goals that are designed
criterion provided a second screening was considered for to create a voice that is loud enough to call a play on the
any child who demonstrated signs of illness, such as baseball field, or answer a question from the back of the
congestion resulting from an upper respiratory infection. class, or doesn’t hurt or sound “scratchy” at the end of the
day. These and other functional voice connections can
inform the treatment process and provide direct applications
FUNCTIONAL INDICATORS OF VOICE to generalization and treatment outcome measures.
DISORDERS IN CHILDREN
AND ADOLESCENTS
The identification of children with voice disorders in the
YOUR CHILD’S VOICE
schools does not rely on annual screening of every child. “Your Child’s Voice” (see Appendix D) is a document
Although policies differ across districts, the usual practice that was developed to help SLPs educate the parent of a

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 child who has been identified with a voice disorder. It was multiple and/or traumatic intubations, routine deep
developed in response to comments to the authors by a suctioning, and/or tracheotomy. Furthermore, coexisting
number of otolaryngologists that parents had only a vague conditions of severe gastroesophageal reflux, pulmonary
sense of why they were instructed to bring their child for compromise, multiple medications, and/or chronic dysph-
evaluation. SLPs have limited time to provide information agia may result in altered laryngeal and subsequent
to parents, and parents tend to retain more of the informa- phonatory function.
tion if it is supplemented in writing. Lack of parental Laryngeal/phonatory sequelae may coexist with multiple
follow-up on the SLP’s request for laryngeal examination and/or chronic medical conditions, or in some instances,
by a physician is a primary concern of school-based laryngeal injury may be the only remnant of a previously
clinicians (Leeper, 1992). The American Speech-Language- medically fragile child’s history (for more information, see
Hearing Association Preferred Practice Patterns for the Woodnorth, 2004). Whenever vocal symptoms are present
Profession of Speech-Language Pathology (1997) states: (e.g., voice sounds weak or strained, uses a lot of effort to
talk, complains of vocal fatigue) in students with a
All patients/clients with voice disorders must be examined by a
physician, preferably in a discipline appropriate to the complicated medical history, the SLP should consider
presenting complaint. The physician’s examination may occur requesting a further laryngeal/voice evaluation. Occasion-
before or after the voice evaluation by the speech-language ally, the vocal symptoms indicate a previously undetected
pathologist. (Section 12.7) laryngeal pathology, such as vocal fold paralysis or
“Your Child’s Voice” provides some basic information laryngeal joint fixation. Etiologies underlying vocal fold
about how voice is produced; how a voice disorder might paralysis are neurological and may result from disorders of
affect a child’s education; and common causes of voice the central nervous system or cranial nerve ten (vagus).
disorders, including voice misuse, medical problems, and Laryngeal joint fixation occurs when the regular position of
personality-related issues. This is followed by an explana- a cricoarytenoid joint is dislocated secondary to some type
tion of purpose and procedures of the voice evaluations of trauma. In either case, if the immobile vocal fold
conducted by the otolaryngologist and SLP. The importance remains in a close to midline position, voice symptoms
of medical examination is emphasized, and some sugges- may be minimal. However, an immobile vocal fold may
tions are provided for circumstances where the otolaryngol- migrate from its original resting position, resulting in a
ogy examination is not covered by insurance. A section change to voice quality. These vocal symptoms may worsen
about various types of management is provided, along with through elementary and teenage years as the larynx grows.
resources for more information. It is suggested that the SLP Increasingly, the relationship between medically fragile
conclude the document with some information specific to infant conditions and later success in primary and second-
the voice problem of the child in question. ary education is being studied. Most investigations focus on
The Functional Indicators Checklist and “Your Child’s the correlation between early health difficulties and later
Voice” documents have not been tested formally. However, speech, language, intellectual, and academic performance.
they have been used by many SLPs who attended previous There are those that specifically examine early pulmonary
presentations by the authors. Informal feedback has been compromise with later pulmonary function, which in turn
very positive. can influence phonatory function (Doyle et al., 2001;
Gross, Iannuzzi, Kveslis, & Anbar, 1998; Lewis et al.,
2002). However, few studies have investigated chronic
laryngeal impairment and associated voice disorders in the
ADDITIONAL CONSIDERATIONS: medically fragile child.
ETIOLOGIES WITH LOWER INCIDENCE
Etiologies with lower incidence than those due to vocal
misuse or abuse may also be identified through the use of CONCLUSION
the Quick Screen for Voice and the Functional Indicators
Checklist. There are increasing numbers of children in The literature suggests that the vast majority of children
special and regular education who have extensive medical with voice disorders are never evaluated by an SLP
problems that may result in voice disorders or laryngeal (Kahane & Mayo, 1989). To rectify this situation, SLPs
pathologies. With advancements in the field of neonatology, must be prepared to use their knowledge, listening training,
the numbers of medically fragile babies now surviving and and interpersonal skills to intervene. Educating the class-
being served by the public school system are increasing. room teacher and families about indicators that put children
For example, the number of premature babies born in the at risk for laryngeal pathologies may make those with the
United States has increased significantly over the past 20 closest child contact more reliable referral sources. If
years according to recent reports. Currently, close to 12% screening is warranted, the SLP may find the Quick Screen
(460,000) of babies born annually are premature (defined as for Voice preferable to the more typical one-line response
< 37 weeks gestation) (Barrett, 2002). These children may to voice quality deviation, because it encompasses all
be at higher risk for developmental, learning, and academic aspects of voice production (respiration, phonation, reso-
special needs; however, they are also more likely to have nance, and vocal range and flexibility). The descriptors for
required multiple medical procedures in infancy that can vocal behaviors used in the test may also be helpful when
result in injury to the larynx. Such procedures can include reporting findings or writing IEP goals. Finally, the

312 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 35 • 308–319 • October 2004

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 obstacle of receiving medical clearance for therapy typi- Hirschberg, J., Dejonckere, P., Hirano, M., Mori, K., Schultz-
cally requires educating the parent and, occasionally, the Coulon, H., & Vrticka, K. (1995). Symposium: Voice disorders
primary care physician. “Your Child’s Voice” can be used in children. International Journal of Pediatric Otorhinolaryngol-
as a supplement to the parent conference. ogy, 32(Suppl.), 109–125.
Although voice disorders have a lower incidence than Kahane, J., & Mayo, R. (1989). The need for aggressive pursuit
many other types of communication disorders, all SLPs of healthy childhood voices. Language, Speech, and Hearing
recognize their responsibility to use their knowledge, Services in Schools, 20, 102–107.
listening training, and interpersonal skills to identify and Kent, R. D., Kent, J. F., & Rosenbek, J. C. (1987). Maximum
manage these children. The authors hope that the docu- performance tests of speech production. Journal of Speech and
ments provided here will improve clinician intervention Hearing Disorders, 52, 367–387.
while reducing the time demands inherent in an increas- Kreiman, J., Gerratt, B. R., Kempster, G. B., Erman, A., &
ingly complex profession. Berke, G. S. (1993). Perceptual evaluation of voice quality:
Review, tutorial, and a framework for future research. Journal of
Speech and Hearing Research, 36, 21–40.
Kreiman, J., Gerratt, B. R., Precoda, K., & Berke, G. S.
ACKNOWLEDGMENTS (1992). Individual differences in voice quality perception.
Journal of Speech and Hearing Research, 35, 512–520.
The authors would like to thank Chase Striby, MA, for Leeper, L. H. (1992). Diagnostic examination of children with
coordinating administration of the Quick Screen for Voice for the voice disorders: A low cost solution. Language, Speech, and
preschool children and Ann Glaser, MS, for her input from the Hearing Services in Schools, 23, 353–360.
statewide elementary school screening.
Lewis, B. A., Singer, L. T., Fulton, S., Salvatore, A., Short, E.
J., Klein, N., et al. (2002). Speech and language outcomes of
children with bronchopulmonary dysplasia. Journal of Communi-
cation Disorders, 35, 393–406.
REFERENCES
Linstone, H., & Turoff, M. (1975). The Delphi method: Tech-
American Speech-Language-Hearing Association. (1997). niques and applications. Reading, MA: Addison-Wesley.
Preferred practice patterns for the profession of speech-language Miller, S., & Madison, C. (1984). Public school voice clinics, part
pathology. Rockville, MD: Author. II: Diagnosis and recommendations—A 10-year review.
Andrews, M. (1991). Voice therapy for children. San Diego, CA: Language, Speech, and Hearing Services in Schools, 15, 58–64.
Singular. Pigott, T., Barry, J., Hughes, B., Eastin, D., Titus, P., Stensel,
Barrett, J. (2002). Environmental links to early deliveries. H., et al. (1985). Speech-Ease Screening Inventory (K–1).
Environmental Health Perspectives, 110, 78–79. Austin, TX: Pro-Ed.
Batza, E. (1970). Vocal cord nodules in children: Pathogenesis, Rothwell, W. J., & Kazanas, H. C. (1997). Mastering the
clinical manifestations, therapy. Clinical Pediatrics, 9, 14–16. instructional design process: A systematic approach. San
Francisco: Jossey-Bass.
Boyle, B. (2000). Voice disorders in school children. Support for
Learning, 15, 71–75. Sander, E. (1989). Arguments against the pursuit of aggressive
voice therapy for children. Language, Speech, and Hearing
Colton, R., & Casper, J. K. (1996). Understanding voice Services in Schools, 20, 94–101.
problems (2nd ed). Baltimore: Williams & Wilkins.
Silverman, E., & Zimmer, C. (1975). Incidence of chronic
Davis, C. N., & Harris, T. B. (1992). Teacher’s ability to
hoarseness among school-age children. Journal of Speech and
accurately identify disordered voices. Language, Speech, and Hearing Disorders, 40, 211–215.
Hearing Services in Schools, 23, 136–140.
Stemple, J. C., Glaze, L. E., & Klaben, B. G. (2000). Clinical
Deal, R., McClain, B., & Sudderth, J. (1976). Identification,
voice pathology: Theory and management. San Diego, CA:
evaluation, therapy, and follow-up for children with vocal Singular.
nodules in a public school setting. Journal of Speech and
Hearing Disorders, 41, 390–397. Woodnorth, G. H. (2004). Assessing and managing medically
fragile children: Tracheostomy and ventilatory support. Lan-
Dobres, R., Lee, L., Stemple, J., Kretschmer, L., & Kummer, A. guage, Speech, and Hearing Services in Schools, 35, 363–372.
(1990). Description of laryngeal pathologies in children
evaluated by otolaryngologists. Journal of Speech and Hearing Woudenberg, G. (1991). An evaluation of Delphi. Technological
Disorders, 55, 526–532. Forecasting and Social Change, 40, 131–150.
Doyle, L. W., Cheung, M. M., Ford, G. W., Olinsky, A., Davis,
N. M., & Callanan, C. (2001). Birth weight <1501 g and Received August 16, 2003
respiratory health at age 14. Archives of Disease in Childhood, Accepted September 15, 2003
84, 40–44.
DOI: 10.1044/0161-1461(2004/030)
Fluharty, N. B. (2001). Fluharty-2 Preschool Speech and
Language Screening Test. Austin, TX: Pro-Ed. Contact author: Linda Lee, PhD, Professor and Graduate
Gross, S. J., Iannuzzi, D. M., Kveslis, D. A., & Anbar, A. D. Program Director, University of Cincinnati, Department of
(1998). Effect of pre-term birth on pulmonary function at school Communication Sciences and Disorders, 202 Goodman Avenue,
age: A prospective controlled study. Journal of Pediatrics, French East Building G-65, Cincinnati, OH 45267-0394. E-mail:
133(2), 188–192. [email protected]

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 APPENDIX A. QUICK SCREEN FOR VOICE

Name: _______________________________________________________________________________________________________________

Birth Date: ______________________________ Screening Date: _________________________________________________ Age: ________

Speech-Language Screening Date: _____________________________ Passed Failed

If failed, describe communication status:___________________________________________________________________________________

Hearing Screening Date: _____________________________ Passed Failed

If failed, describe hearing status:_________________________________________________________________________________________

Pertinent medical and social history: _______________________________________________________________________________________

______________________________________________________________________________________________________________________

Directions: The Quick Screen for Voice should be conducted in a quiet area. Elicit verbal activities, such as spontaneous conversation,
picture description, imitated sentences, recited passages, counting, and other natural samples of voice and speech, or perform the tasks
requested. The screening test is failed if one or more disorders in production are found in any area, indicating that a more thorough
evaluation is needed.

Mark all observations that apply, as the individual produces connected speech:

Respiration

_____ Inhalatory stridor or expiratory wheeze _____ Limited breath support for speech
_____ Infrequent breaths; talking too long on one breath _____ Reduced loudness or vocal weakness

_____ Normal respiration for speech

Phonation

_____ Rough or hoarse quality _____ Breathy quality

_____ Vocal strain and effort _____ Aphonia
_____ Persistent glottal fry _____ Hard glottal attacks
_____ Conversational pitch is too high or too low _____ Conversational voice is too loud or too soft
_____ Conversational voice is limited in pitch or loudness variability

_____ Normal voice quality

Resonance

_____ Hyponasality (observed during humming, nasal _____ Nasal turbulence or audible nasal emission (observed
consonant contexts: Mommy makes me muffins; during pressure consonant contexts: Counting from
Man on the moon; Many men make money, etc.). 60 to 69; Popeye plays baseball; Give Kate the cake;
_____ Consistent mouth breathing Buy Bobby a puppy, Take a ticket to Daddy, etc.).
_____ Hypernasality (observed during vowel and oral consonants) _____ Juvenile resonance characteristics

_____ Normal resonance

Nonverbal Vocal Range and Flexibility

Model the series of nonverbal tasks that are described on the test form. Multiple trials are allowed. Visual cues such as hand gestures,
moving a toy car across the table (for maximum phonation time) or up and down a hill (for pitch range), etc. may be used to supplement the
auditory model.

1. Habitual pitch and loudness task: “Count from 1 to 10. Repeat, but stop at ‘three’ and hold out the /i:/.”

_____ Abnormal pitch and/or loudness

_____ Normal pitch and loudness

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 2. Maximum phonation time (MPT) task: “Take your biggest breath and hold out an /a:/ as long as possible.”
Record time with a secondhand.

_____ Number of seconds /a/ was sustained.

Age (years) Normal Mean in Seconds (Range)*
_____ MPT less than: 3 7 (3–11)
4 9 (5–15)
5 10 (5–16)
6–7 13 (5–20)
8–9 16 (5–29)
10–12 20 (9–39) Males
16 (5–28) Females
13–17 23 (9–43) Males
20 (9–34) Females
18+ 28 (9–-62) Males
22 (6–61) Females

Note. MPT values are related to age and height; multiple attempts also influence results.
*Data summarized from Kent, Kent, & Rosenbek (1987)

_____ MPT within normal limits

3. Pitch range task: “Make your voice go from low to high like this (demonstrate upward pitch glide on the word ‘whoop’). Now go
down from your highest to low (demonstrate rapid downward pitch glide like a bomb falling).” Or, model and elicit a fire siren
sound.

_____ Little pitch variation

_____ Voice breaks in pitch glides up or down

_____ Acceptable pitch range and flexibility

Other Comments or Observations

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

From Quick Screen for Voice by L. Lee, J. C. Stemple, & L. Glaze, in press, Gainesville, FL: Communicare Publishing.
Copyright 2003 by Communicare. Reprinted with permission.

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 APPENDIX B. DEFINITIONS OF THE VARIABLES USED IN THE QUICK SCREEN FOR VOICE

Respiration Resonance
Inhalatory stridor or expiratory wheeze: Sound heard on inhalation Hyponasality: Reduction in nasal resonance during the production
or exhalation, indicating an obstruction at some point in the airway of nasal consonants /m, n, N/, reflecting blockage in the nasophar-
that creates airflow turbulence ynx or the entrance to the nasal cavity

Limited breath support for speech: Failure to create a sufficient Consistent mouth breathing: Open-mouth posture; the need to
amount of air to support connected utterances; frequent need to breathe through the mouth because of possible nasal airway
replenish the breath supply; typically, failure to inspire beyond the obstruction
tidal breathing range
Nasal turbulence or audible nasal emission: Also called nasal
Infrequent breaths; talking too long on one breath: Failure to rustle, nasal turbulence is frication heard as air pressure is forced
replenish breath often, or failing to take sufficient breaths so that through a partially opened velopharyngeal valve; audible nasal
utterances extend beyond end-tidal breathing into the expiratory emission, also called nasal air escape, is inappropriate airflow
reserve through the nose during speech, typically occurring on high
pressure consonants because of velopharyngeal dysfunction; either
Reduced loudness or vocal weakness: Soft voice, or one that characteristic may be a consonant-specific learned behavior
sounds fatigued, possibly due to diminished respiratory support
Hypernasality: Sound entering the nasal cavity during production
of vowels or liquid consonants due to velopharyngeal dysfunction,
Phonation resulting in excessive acoustic nasal resonance

Rough or hoarse quality: Quality deviation of the voice reflecting Juvenile resonance characteristics: Child-like quality to the voice;
aperiodic vibration of the vocal folds during phonation often accompanied by high pitch and abnormal tongue posture,
giving the voice an immature sound, usually seen in teenage girls
Breathy quality: Quality deviation of the voice reflecting a larger and women
than normal glottal opening, allowing excessive airflow through the
vocal folds during phonation
Nonverbal Vocal Range and Flexibility
Vocal strain and effort: Tension, strain, and/or effort needed to
speak; this may include difficulty initiating or maintaining Habitual pitch and loudness task: Relative to the speaker’s age and
phonation, and may also include supporting evidence of visible sex, the appropriateness of pitch or loudness during a sustained
neck or jaw tension vowel is noted

Aphonia: Absence of voicing, which may be intermittent or Maximum phonation time task: The length of maximum phonation
constant; may occur as voice “cutting out” or whisper, and can be time is noted; norms are provided by age category to help the
accompanied by apparent strain, tension, or effort examiner decide whether or not MPT is within normal limits

Persistent glottal fry: Rough, low-pitched, tense voice quality that Pitch range task: Ability to vary the pitch of the voice, and the
often occurs at the end of sentences, reflecting tightly approxi- presence of voice breaks during the gliding activity, are noted; the
mated vocal folds with flaccid edges vibrating at a low fundamen- pitch range increases with age from approximately one-half octave
tal frequency for preschool children to over two octaves for adults

Hard glottal attacks: A manner of initiating voicing characterized

by rapid and complete adduction of the vocal folds prior to the
initiation of phonation

Conversational pitch is too high or too low: Relative to the

speaker’s age and sex, the voice is maintained at an inappropriate
average fundamental frequency

Conversational voice is too loud or too soft: Relative to the

speaker’s age and sex, the voice is maintained at an inappropriate
average intensity

Conversational voice is limited in pitch or loudness variability:

The voice lacks normal variations in fundamental frequency or
intensity, leading to reduction in pitch or loudness variations;
monopitch or monoloudness may be considered the extremes

From Quick Screen for Voice by L. Lee, J. C. Stemple, & L. Glaze, in press, Gainesville, FL: Communicare Publishing.
Copyright 2003 by Communicare. Reprinted with permission.

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 APPENDIX C. FUNCTIONAL INDICATORS OF VOICE DISORDERS IN CHILDREN AND
ADOLESCENTS

Please check all that apply to this child:

_____ Coughs, clears throat, or chokes frequently

_____ Has difficulty breathing or swallowing
_____ Complains of a sore throat often
_____ Voice sounds rough, hoarse, breathy, weak or strained
_____ Loses his/her voice every time s/he has a cold
_____ Always sounds “stuffed up,” like during a cold; or sounds like s/he is talking “through the nose”
_____ Voice sounds worse at different times of the day (morning, after school, evening)
_____ Sounds different from his/her friends of the same age and sex
_____ Voice sounds worse after shouting, singing, playing outside, or talking for a long time
_____ Uses a lot of effort to talk; or complains of vocal fatigue
_____ Yells, screams, or cries frequently
_____ Likes to sing and perform often; participates in acting and/or singing groups
_____ Participates in sports activities or cheerleading activities that require yelling and calling
_____ Has difficulty being understood by unfamiliar listeners
_____ Can’t be heard easily in the classroom or when there is background noise
_____ Talks more loudly than others in the family or classroom
_____ Voice problem is interfering with his/her performance at school
_____ Doesn’t like the sound of his/her voice; or is teased for the sound of his/her voice
_____ Attends many loud social events (parties, concerts, sports games)
_____ Seems tired or unhappy a lot of the time
_____ Is facing difficult changes, such as death, divorce, financial problems
_____ Does not express his/her feelings to anyone
_____ Lives with a family that uses loud voices frequently
_____ Smokes, or is exposed to smoke at home or at a job
_____ Uses alcohol
_____ Eats “junk food” frequently; or complains of heartburn or sour taste in the mouth
_____ Drinks beverages that contain caffeine; or drinks little water
_____ Has allergies, respiratory disease, or frequent upper respiratory infections
_____ Has hearing loss or frequent ear infections
_____ Takes prescription medications (please list)
_____ Has a history of injuries to the head, neck, or throat (please describe)
_____ Has had surgeries (please describe)
_____ Was intubated at birth or later (please describe)
_____ Has a chronic illness or disease (please describe)

My primary concern about this child’s voice is (please describe):

From Functional Indicators of Voice Disorders in Children and Adolescents by L. Lee, J. C. Stemple, & L. Glaze, in press, Gainesville FL,
Communicare Publishing. Copyright 2003 by Communicare. Reprinted with permission.

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 APPENDIX D. YOUR CHILD’S VOICE

Your child has been identified as having a voice disorder, meaning How Might a Voice Disorder
that his/her voice sounds different from that of other children of
the same age and sex. The purpose of this pamphlet is to provide Affect a Child’s Education?
you with information about the cause, diagnosis, and management
of voice disorders. The effects of a voice disorder may decrease the child’s ability to
interact effectively in the classroom setting. Speech may be
difficult to hear or understand, and the child may be less likely to
How Is Voice Produced? participate in daily educational activities, such as volunteering
answers or reading aloud. A childhood voice disorder may also
Figure 1 contains the primary structures in the vocal tract. The decrease the potential for developing a normal adult voice.
larynx is a system of cartilages, muscles, and ligaments in the
neck (pharynx). It sits on top of trachea, the passageway to the
lungs. The passageway to the stomach is behind the larynx and What Are Common Causes
trachea. The larynx is covered when we swallow, so food does not of a Voice Disorder?
enter the trachea.
Laryngeal pathologies are changes in the larynx and vocal folds
The larynx contains thin membranes, called vocal folds. The vocal that are associated with voice disorders. Many factors contribute to
folds sit in an open position during breathing. When a person the development of laryngeal pathologies, including voice misuse,
wants to speak, muscles close the folds, and air from the lungs medical problems, and personality-related issues. Each of these
causes them to vibrate. The sound the vocal folds make then is described below.
resonates through the mouth (or nose, for some sounds) and speech
is created. The combination of breathing, vibrating the vocal folds, Voice Misuse
and shaping or resonating the vibration creates the distinct sound The majority of laryngeal pathologies are due to the way a child
you recognize as your child’s voice. A problem with any part of misuses the voice. Children often engage in loud talking, scream-
the voicing process may lead to a voice disorder. ing, or shouting, such as at sports events. They may enjoy making
vocal noises during play, imitating motorcycles, action figures or
monsters. Habits such as these may harm young voices. Excessive
coughing or throat clearing may also damage the vocal folds.
Figure 1. The vocal tract. Sometimes children learn to speak in an incorrect manner, such as
using a very low pitch level. Or, the child may be so eager to
communicate that he/she does not pause for enough breaths to
support the voice.

The vocal folds are covered by a thin layer of mucous membrane,

somewhat similar to the lining of the cheek. If a child drinks
caffeinated soft drinks and little water, this membrane can become
dry. Other sources of dryness may be exposure to smoke, dust, or
dehumidified air.

The examples presented are habits that may cause irritation to the
vocal folds. Constant irritation may lead to vocal fold changes,
such as swelling (edema), redness, or callous-like growths called
vocal nodules.

Medical Causes
Some children develop voice disorders because of a medical
problem. An infant may be born with structural defects of the
larynx. Neurologic problems, such as vocal fold paralysis, can occur.
Chronic upper respiratory or other viral infections, allergies, and
gastrointestinal disorders are other examples of medical problems
that may lead to laryngeal pathologies. The larynx may be damaged
during an accident or surgery. Finally, some medications have side
effects that may contribute to changes in vocal fold vibration.

A resonance problem is a special category of voice disorders

related to how the sound travels through the oral and nasal cavities
after it leaves the larynx. The hard palate separates the two
cavities, and the soft palate acts like a valve to open or close the
nasal area. The sound should resonate in the oral cavity for all
vowels and consonants except m, n, or ng, which resonate in the
nasal cavity. A resonance imbalance occurs when the sound takes
the wrong path, or when the sound is distorted due to a problem
encountered as it travels through the cavity. For example, if a child
sounds like he/she has a cold (hyponasality), it may be due to a
blockage somewhere between the nose and mouth. Enlarged
adenoids are one common cause of hyponasality. If sound is heard
coming through the nose when it should not be present

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 (hypernasality or nasal turbulence), there may be an incomplete specific insurance, you are encouraged to discuss this issue with
closure of the soft palate. Children born with a cleft palate are the provider-relations representative. Should your insurance be one
among those who may develop resonance problems. of the few that does not cover this examination, you may negotiate
a reasonable payment plan with most otolaryngology offices. The
Personality-Related Causes speech-language pathologist at your child’s school may also
The larynx is very sensitive to emotions. Therefore, a child’s voice provide information about funding sources.
disorder may be due to the way he or she feels, physically and
emotionally. For example, a child experiencing overall tension
because of anxiety encountered in school or at home may also How Will My Child’s Voice
tense the muscles that control the voice, and this can lead to a
voice disorder. Occasionally, difficulties in the child’s life may
Disorder Be Corrected?
become so severe that he/she may unconsciously develop a voice
disorder in an attempt to avoid the stressful situation. Other types Methods of correcting your child’s voice disorder depend entirely
of voice disorders are related to personality development or upon the cause. Treatment may be managed through voice therapy
hormonal changes during puberty. provided by a speech-language pathologist, medical management
provided by an otolaryngologist, or a combination of the two.

Because the cause of a voice disorder cannot be determined by the

How Will I Know the Cause characteristics of the voice, the speech-language pathologist in
of My Child’s Voice Disorder? your child’s school cannot conduct voice therapy until a physician
provides a medical diagnosis. Parents know their child’s vocal
It is important to note that no one can tell the cause of a voice habits and are sometimes convinced the problem is due to misuse.
disorder by the way a child sounds. A child with a vocal nodule As an example, they may feel the voice disorder will simply go
caused by yelling and screaming can have the same voice away if the child stops screaming. Unfortunately, the most vocally-
characteristics as the child with a laryngeal pathology due to a abusive child may have a coexisting medical condition requiring
medical problem. In order to determine the cause of your child’s medical management. For the child’s protection, the American
voice problem, the vocal folds must be examined. Speech-Language-Hearing Association’s Preferred Practice
Patterns (1997) require medical examination prior to voice
therapy.
Who Will Examine My Child,
Most voice problems due to misuse or abuse can be eliminated
and How Will It Be Done? through voice therapy. The child learns to eliminate the causes of
the voice problem and ways to change the manner of speaking.
Although some primary-care physicians will examine the vocal
Vocal exercises or other activities may be combined with learning
folds, most refer the child to an Ear, Nose and Throat specialist
healthy vocal habits to eliminate the problem and prevent future
(ENT). Another name for an ENT is an otolaryngologist. The
recurrence.
otolaryngologist will determine the presence and cause of any
laryngeal pathology.
Medically-caused voice problems are typically managed through
medication or surgery. Sometimes voice therapy is needed after
The otolaryngologist may view the vocal folds by one of several
medical intervention.
methods. Some physicians place a small mirror in the child’s
mouth to visualize the folds. Others use a small flexible scope
The speech-language pathologist, working closely with you and
inserted into the child’s nose. This procedure is called
other individuals in the child’s life, often manages personality-
nasendoscopy, and it can also be used to examine a child with a
related voice problems. Sometimes a psychologist or classroom
resonance problem. A third method, called videostroboscopy,
teacher is included in the therapy process.
involves placing a small video-scope in the child’s mouth. When
attached to a special instrument called a stroboscope, the vocal
folds can be viewed during their vibration. Both nasendoscopy and
videostroboscopy provide a view of the vocal folds or other
Where Can I Find More
structures on a television monitor. Information About Voice Disorders?
None of the procedures used to examine the child with a voice Many resources exist to provide information about voice disorders.
disorder is harmful, and children tolerate them well. Sprays may The speech-language pathologist at your child’s school and the
be used to temporarily numb the nose or back of the throat to otolaryngologist will have suggestions specific to your child’s
eliminate any mild discomfort. voice disorder. Textbooks about voice disorders are available
through university or medical libraries.
Some otolaryngologists work in collaboration with speech-
language pathologists who specialize in voice disorders. The The American Speech and Hearing Association is a national
speech-language pathologist (SLP) will determine the effect of the organization serving all individuals with communication disorders.
laryngeal pathology on voice production. The SLP in your child’s For information, call 1-800-498-2071, or use the address http://
school may have already conducted a voice evaluation. www.asha.org on the Internet.

What if the Otolaryngologist’s The Following Information

Exam Is Not Covered by My Is Specific to My Child
Insurance, or I Cannot Afford It?
Most private insurance, managed care plans, and Medicaid cover
the costs of diagnostic procedures. To determine coverage of your

From Your Child’s Voice by L. Lee, J. C. Stemple, & L. Glaze, in press, Gainesville FL: Communicare Publishing.
Copyright 2003 by Communicare. Reprinted with permission.

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