Voice Disorder Prevalence and Vocal Health Characteristics in Children

Key Points

Questions

What is the prevalence of voice problems in school-aged children across the US, and what factors constitute risk for voice disorders?

Findings

In this survey study of 1154 caregivers of children aged 4 to 12 years, the prevalence of voice problems was 6.7%, and lifetime prevalence was 12%. Risk factors for voice problems included voice use patterns (ie, frequent talking, coughing, throat clearing, crying/yelling, and vocal strain), being male, poor speech intelligibility, larger household composition, online gaming, and secondhand smoke exposure.

Meaning

The results of this survey study suggest that pediatric voice complaints are common and can limit quality of life.

Abstract

Importance

Voice disorders impede communication and limit quality of life for many children. However, research demonstrating the prevalence of pediatric voice problems and associated voice use patterns is scarce. This investigation examined the prevalence of voice problems and vocal health characteristics of school-aged children.

Objective

To examine the prevalence of voice problems in school-aged children throughout the US with reference to lifestyle, demographic characteristics, and voice use patterns.

Design, Setting, and Participants

This study used a cross-sectional design to survey a probability sample of caregivers of children aged 4 to 12 years living throughout the US in 2023.

Main Outcomes and Measures

Caregivers were surveyed regarding their children’s voice use, voice symptoms, voice problems, extracurricular activities, and demographic information. Caregivers also competed the Pediatric Voice-Related Quality of Life questionnaire. The Fisher exact test, χ² tests, and logistic regression were used to compare children with and without voice problems.

Results

Overall, 6293 panelists were invited to complete screening questions for the survey, and 1789 individuals were screened for eligibility between March and April 2023. Of these, 1175 parents (65.7%) completed the survey. Twenty-one (1.8%) were excluded for a combination of either high refusal rates (n = 16), speeding (n = 2), or straight lining (n = 12). The final number of participants included in analysis was 1154 caregivers of children aged 4 to 12 years (559 female children [48.4%]; 595 male children [51.6%]; mean [SD] age, 8.02 [2.49] years). The prevalence of voice problems in children was 6.7% (n = 78), and the lifetime prevalence was 12% (n = 138). Benign vocal fold lesions was the most common diagnosis underlying voice complaints, and other causes included respiratory illness, allergies, autism-related voice issues, and other neurological conditions. Risk factors for pediatric voice problems included being male (odds ratio [OR], 1.47; 95% CI, 1.0-2.1), having more than 4 individuals living in the household (OR, 2.30; 95% CI, 1.2-4.4), poor speech intelligibility (OR, 2.26; 95% CI, 1.2-4.3), maternal history of voice problems (OR, 4.54; 95% CI, 1.2-16.4), participating in online gaming (OR, 1.56; 95% CI, 1.0-2.3), and secondhand smoke exposure (OR, 1.7; 95% CI, 1.1-2.6). Voice use–related risk factors included frequent talking, coughing, throat clearing, tantrums/crying, and vocal strain. Voice problems were associated with substantially detracted quality of life as measured by the Pediatric Voice-Related Quality of Life questionnaire, limited social/extracurricular interactions, increased school absences, and negative attention from adults.

Conclusions

The results of this survey study suggest that pediatric voice problems are relatively common and detract from quality of life. Specific environmental and behaviorial factors are associated with increased risk for voice disorders.

This survey study examines the prevalence of voice problems in school-aged children throughout the US with reference to lifestyle, demographic characteristics, and voice use patterns.

Introduction

Healthy vocal function allows children to communicate their needs,¹ share their ideas, and express their emotions.^2,3 Vocal health characteristics can be quantified through numerous parameters, including voice quality, pitch, loudness, resonance, pitch range, and measures of endurance and effort.⁴ When parents perceive that their children are experiencing voice-related problems, clinicians often compare these parameters with normative data.^5,6,7 Unfortunately, to our knowledge, there are limited data describing normal pediatric voice use patterns, voice symptoms, or risk factors for dysphonia. This lack of information prevents clinicians from offering evidence-based recommendations and interventions for children and their parents.

The effects of voice disorders are wide reaching.^8,9,10,11 Children with dysphonia are perceived more negatively by other children and adults than their normophonic peers.^12,13,14,15 Additionally, voice disorders may be associated with psychosocial difficulties and altered self-esteem,^16,17 as well as teacher perceptions of a child’s maturity level.¹⁸ Preliminary studies examining the prevalence of dysphonia in children estimate that between 6% and 11% of children are affected,^{19,20,21,22,23} with estimates differing across clinician assessment and parent report.^21,22 For example, a large-scale investigation from the UK reported that 11% of parents endorsed dysphonia in their 8-year-old children, while 6% of children received a diagnosis of dysphonia by clinicians.²² Research has often been limited to specific age groups or geographical locations or has not probed specific voice symptoms and their underlying etiologies.^20,22 As such, our understanding of pediatric voice disorder prevalence is limited.

To understand voice disorder prevalence, it is crucial to understand the association between voice use and voice symptomology.²⁴ For adults, researchers have characterized typical voice use patterns as well as the ways in which these patterns are associated with risk for vocal pathology.^25,26 For example, phonating in poor acoustic environments,²⁷ background noise,^28,29 or at increased intensity^30,31,32 have all been documented to induce vocal fatigue symptoms in adults.³³ However, it is unclear how these patterns affect children. Children participate in numerous social, athletic, extracurricular, and academic activities,³⁴ many of which are associated with specific vocal demands.³⁵ Additionally, children often phonate in suboptimal acoustic environments, such as playgrounds and crowded or noisy rooms,^36,37 and may not carefully regulate vocal volume or behavior in general.³⁸ Normative data regarding voice use patterns and symptoms in children are needed to identify risk factors for dysphonia.

Although young children often experience voice problems,^16,39 they may lack the awareness or ability to report these symptoms on their own. As such, pediatric-focused patient-reported measures of voice have been designed for parents to serve as proxies for their children.^40,41,42 Evidence suggests that parents can effectively report their children’s voice complaints,⁴³ particularly when young children have difficulty reporting their own voice use patterns. Parent report is an important method of assessing dysphonia risk factors and prevalence in young children.

Research documenting the specific voice use patterns, voice symptoms, and risk factors for dysphonia is essential to effectively manage voice problems in children. To prevent geographic, cultural, or environmental confounding, it is important that such data come from a population sample that is representative of the US. The prevalence of pediatric voice disorders should ideally be studied on a national level. As such, this study examined the voice characteristics of school-aged children throughout the US. Demographic characteristics, voice use patterns, extracurricular and academic activities, voice symptoms, and voice disorder prevalence were surveyed through parents serving as proxies for their children. The association of vocal function with quality of life was also probed.

Methods

Serving as proxies for their children, parents of children aged 4 to 12 years were surveyed concerning voice use, voice symptoms, voice-related quality of life, environmental factors, extracurricular involvement, and demographic information. The survey was adapted from previous large-scale investigations of voice disorder prevalence in adults to allow for comparisons across populations.^24,25 To identify a sample representative of the US population, this survey was distributed to the AmeriSpeak Panel at the National Opinion Research Center. Study procedures were approved by all relevant institutional review boards. All participants provided written informed consent before survey completion.

Participants and Recruitment

Participants were legal guardians of a child aged 4 to 12 years who lived within their immediate household. If a respondent had more than 1 child within this age range, they completed the survey on behalf of the child who most recently had a birthday. Participants spoke and read English. Child demographic characteristics matched those of the US pediatric population. Age, sex, race and ethnicity, and parent’s highest education level were considered. Where recruitment matching the US population was not possible, data were statistically weighted (eTable in Supplement 1). To ensure accurate data, participants were removed for speeding (completing the survey in less than one-third of the median survey duration), high refusal rates (skipping or refusing ≥50% of questions), or straight lining (choosing the same answer for eligible grid item questions).

Survey

To facilitate comparisons with previously published epidemiological investigations of voice problems in adult populations, the survey was adapted from past work^24,25,26 and the 2012 National Health Interview Survey.^19,20 Participants also completed the Pediatric Voice-Related Quality-of-Life Survey (Ped-VRQOL).⁴⁰ Questions taken from the National Health Interview Study probed for the presence of voice symptoms, as well as the nature, duration (number of days), and influence of these symptoms during the previous year. Voice-related health care use and age of symptom onset were probed, as well as parent use of the internet for health care–related information. In keeping with past studies, a voice disorder was defined as “any time your child’s voice does not work, perform, or sound as you feel it normally should so that it interferes with communication.” A voice problem was considered to be chronic if it lasted longer than 4 weeks (yes/no). Participants were also asked if their child’s voice problem was current (yes/no). If respondents endorsed a voice problem in their child, voice-related diagnoses were collected via caregiver report. The Box presents items probed by the survey.

Box. Factors Probed Using the Study Instrument.

Demographic

• Caregiver age, child’s age

• Child’s sex on birth certificate, caregiver sex

• Child’s gender identity

• Caregiver relationship to child

• Child’s year in school

• Child’s average letter grade

• Child’s ethnicity

• Number of individuals living in the home

• Position in family (oldest, youngest, middle child, only child)

• Recreational/social activities (yes/no)

  • Average number of hours per week

• Extracurricular activities (yes/no)

  • Average number of hours per week

• Number of times a week child sings (<3 times, 3-5 times, 6-10 times, >10 times)

Voice symptoms (all questions posed about the child)

• Frequency of the following symptoms and source of those symptoms (class, home, extracurricular activities)

  • Hoarseness

  • Voice tires or changes quality

  • Trouble speaking/singing softly

  • Difficulty projecting

  • Loss of singing range

  • Discomfort using voice

  • Monotone voice

  • Effort to talk

  • Chronic dryness of throat

  • Wet, gurgly voice quality

  • Chronic sore throat

  • Frequently clear throat

  • Bitter or acidic taste

  • Wobbly or shaky voice

  • Breathy voice

• Days of school missed due to a voice problem

• Whether voice problems had caused any of the following:

  • Inability to sing

  • Inability to participate in extracurricular activities

  • Negative comments from teachers and other adults

  • Limitations or inability to do certain tasks

• Family history of voice problems (yes/no)

  • Which family member

• Whether their voice had interfered with their normal social activities or school during the previous 2 wk

• Whether they strained to produce their voice

• Frequency of the following:

  • Secondhand smoke exposure

  • Carbonated beverages

  • Caffeinated beverages

• Speech intelligibility (percentage of the time adults can understand the child)

Voice use (all questions posed about the child)

• Frequency of the following at school, home, and during extracurricular activities (5-point Likert scale)

• Talking quietly

• Talking loudly

• Singing

• Laughing

• Shouting/yelling/cheering

• Throat clearing

• Coughing

• Frequency of crying, screaming, or tantrums

Statistical Analysis

Descriptive statistics were calculated for all variables. Fisher exact tests and χ² tests (depending on variable type) were used to compare the characteristics of those with a history of voice problems (past or present) and those who had never experienced voice issues. These analyses also compared children with current and past voice problems, as well as those with acute (<4 weeks) and chronic (>4 weeks) complaints. When significant associations were observed, logistic regression and odds ratios (ORs) were calculated to characterize risk for voice disorders. Before regression, factors were condensed where possible. For determining statistical significance, α was set at .01 to protect against type 1 errors. Statistical analyses were performed using SAS (version 26; SAS Institute).

Results

Overall, 6293 panelists were invited to complete screening questions for the survey, and 1789 individuals were screened for eligibility between March and April 2023. Of these, 1175 parents (65.7%) completed the survey. Twenty-one (1.8%) were excluded for a combination of either high refusal rates (n = 16), speeding (n = 2), or straight lining (n = 12). The final number of participants included in analysis was 1154. Caregiver relationships to children are presented in Table 1.

Table 1. Participant Demographic Characteristics, Extracurricular Activities, and Social Activities.

Characteristic	No (%)
Year in school
Preschool	132 (11.4)
Kindergarten	132 (11.4)
First grade	133 (11.4)
Second grade	156 (13.5)
Third grade	120 (10.4)
Fourth grade	130 (11.3)
Fifth grade	141 (12.4)
Sixth grade	143 (12.4)
Not currently enrolled	61 (5.3)
Not reported	6 (0.5)
Position in the family
First-born child	438 (37.9)
Middle child	199 (17.2)
Youngest child	290 (25.1)
Only child	227 (19.7)
Extracurricular activities
Basketball	180 (15.6)
Academic club	47 (4.1)
Baseball/softball	159 (13.8)
Cheerleading	42 (3.6)
Chess	8 (0.6)
Choir	39 (3.4)
Community theater	8 (0.7)
Dance	82 (7.1)
Debate/mock trial	1 (0.1)
Drama	19 (1.7)
Drill team	1 (0.1)
Football	57 (6.6)
Gymnastics	58 (5.0)
Hockey	6 (0.5)
Ice skating	4 (0.3)
Junior ROTC	10 (0.8)
Lacrosse	10 (0.8)
Musical ensemble	37 (3.2)
Martial arts	43 (3.7)
Musical theater	22 (1.9)
Piano	30 (2.5)
Poetry out loud	3 (0.2)
Singing lessons	11 (0.9)
Scouting	32 (2.7)
Skiing	4 (0.3)
Soccer	230 (20.0)
Student government	13 (1.1)
Swimming	180 (15.6)
Tennis	21 (1.8)
Track and field	34 (2.9)
Volleyball	39 (3.4)
Wrestling	9 (0.7)
Yearbook	2 (0.1)
4H club	4 (0.3)
How often does the child sing?
<3 Times a week	404 (35.0)
3-5 Times a week	342 (29.6)
6-10 Times a week	156 (13.6)
>10 Times a week	238 (20.6)
Siblings in the home
Mean (SD)	1.8 (1.1)
Tantrum frequency
<3 Times a week	860 (74.5)
3-5 Times a week	188 (16.3)
6-10 Times a week	42 (3.6)
>10 Times a week	37 (3.2)
Not reported	27 (2.3)
Types of events attended
Athletics	362 (31.3)
Religious groups	286 (24.8)
Performing arts	133 (11.5)
Live music	118 (10.2)
Gaming	237 (20.5)
Karaoke	24 (2.0)
Marching band	9 (0.8)
Other	58 (5.0)
Mean grade
A (child excels)	487 (42.2)
B (greater than average)	331 (28.7)
C (average)	228 (19.7)
D (child struggles)	55 (4.8)
E/F (not passing)	2 (0.2)
Rather not say	49 (4.3)
Guardian completing survey
Mother	728 (63.1)
Father	339 (29.3)
Grandmother	37 (3.2)
Grandfather	14 (1.2)
Other	35 (3.1)
Weekly hours in extracurricular activities
Mean (SD)	13.0 (8.2)
How often can adults understand what your child is saying?
<50% of the Time	61 (5.3)
50%-60% of the Time	38 (3.3)
61%-70% of the Time	53 (4.6)
71%-80% of the Time	67 (5.8)
81%-90% of the Time	141 (12.2)
91%-100% of the Time	779 (67.5)
Not reported	15 (1.3)
Exposure to secondhand smoke
Never	933 (80.9)
Occasionally	166 (14.4)
Monthly	6 (0.5)
Weekly	11 (0.9)
Daily	35 (3.0)
Not reported	3 (0.2)
Voice interference with normal social activities or school
Not at all	936 (81.1)
Slightly	92 (8.0)
Moderately	69 (6.0)
Quite a bit	22 (1.9)
Extremely	23 (2.0)
Not reported	12 (1.0)
Does your child strain to speak because of their voice?
Not at all	1023 (88.7)
Slightly	62 (5.4)
Moderately	32 (2.8)
Quite a bit	25 (2.1)
Extremely	2 (0.2)
Not reported	9 (0.8)
Age of guardian completing survey, y
18-24	36 (4.0)
25-34	375 (32.5)
35-44	506 (43.8)
45-54	169 (14.6)
55-64	39 (3.4)
65-74	20 (1.7)
Ethnicity
Asian	29 (2.5)
Black	163 (14.1)
Hispanic	13 (1.1)
White	674 (58.4)
Multiracial	218 (18.9)
Other	57 (5.0)
Family history of voice disorder
Child’s sister	2 (0.1)
Child’s mother	15 (1.2)
Child’s father	26 (2.2)
None	994 (86.1)
Child’s brother	14 (1.2)
Child’s cousin	12 (1.0)
Child’s grandmother	7 (0.6)
Child’s aunt	2 (0.1)
Child’s uncle	4 (0.3)
Unknown	92 (7.9)
Child’s grandfather	6 (0.5)
Distant relative	4 (0.3)
No. of days with voice problems
26-30	24 (2.1)
7-12	50 (4.3)
13-20	25 (2.1)
1-6	196 (17.0)
21-25	4 (0.3)
31-60	7 (0.6)
Unknown	156 (13.5)
91-180	3 (0.2)
271-365	26 (2.3)
61-90	3 (0.2)
None	646 (56)

Abbreviations: 4H, Head, Heart, Hands, and Health; NA, not applicable; ROTC, Reserve Officers' Training Corps.

Demographic Characteristics

Regarding sex, 559 children (48.4%) were female and 595 (51.6%) were male. Regarding gender, 554 (48.0%) identified as cis-female, 594 (51.5%) as cis-male, 4 (0.4%) as nonbinary, and 1 (0.1%) as transfemale. The mean (SD) age was 8.02 (2.49) years. A total of 179 participants (15.5%) lived in the Northeast, 243 (21.1%) the Midwest, 457 (39.6%) the South, and 276 (23.9%) the Western US. The mean (SD) number of siblings living in the home was 1.82 (1.1), ranging from 10 to none. Table 1 presents the distribution of race and ethnicity, child’s year in school, letter grade average, household makeup, recreational activities, extracurricular activities, and singing frequency.

Voice Use

Table 2 presents the frequency of vocal behaviors at school, home, and extracurricular/social activities. A total of 860 parents (74.5%) indicated that their child screamed or threw tantrums fewer than 3 times a week, 188 (16.3%) reported 3 to 5 times a week, 42 (3.6%) reported 6 to 10 times a week, and 37 (3.2%) indicated more than 10 times a week.

Table 2. Voice Use Patterns Among Children Across Home, School, and Social/Extracurricular Activities.

Voice behavior	No. (%)
	Never	Rarely	Sometimes	Often	All the time	Not reported
Voice use at class/school
Talk	56 (4.8)	31 (2.7)	157 (13.6)	362 (31.4)	542 (46.9)	7 (0.6)
Talk quietly	106 (9.2)	159 (13.8)	524 (45.4)	237 (20.5)	117 (10.)	11 (0.9)
Talk loudly	77 (6.7)	126 (10.9)	444 (38.5)	326 (28.2)	172 (14.9)	9 (0.8)
Sing	141 (12.2)	212 (18.4)	448 (38.8)	252 (21.8)	90 (7.8)	11 (1.0)
Shout/yell/cheer	84 (7.3)	193 (16.7)	438 (38.0)	310 (26.9)	116 (10.1)	12 (1.1)
Clear throat	262 (22.7)	443 (38.4)	306 (26.5)	79 (6.9)	49 (4.3)	14 (1.2)
Laugh	35 (3.0)	36 (3.1)	183 (15.8)	561 (48.6)	329 (28.5)	10 (0.9)
Cough	97 (8.4)	491 (42.5)	457 (39.6)	83 (7.2)	12 (1.0)	14 (1.2)
Voice use at home
Talk	37 (3.2)	16 (1.4)	109 (9.4)	343 (29.7)	633 (54.8)	16 (1.4)
Talk quietly	81 (7.0)	246 (21.3)	488 (42.3)	168 (14.6)	151 (13.1)	20 (1.7)
Talk loudly	44 (3.8)	104 (9.0)	347 (30.1)	407 (35.2)	231 (20.0)	22 (1.9)
Sing	91 (7.9)	157 (13.6)	438 (37.9)	290 (25.1)	161 (14.0)	18 (1.5)
Shout/yell/cheer	60 (5.2)	135 (11.7)	433 (37.6)	326 (28.2)	181 (15.7)	18 (1.5)
Clear throat	231 (20.0)	458 (39.7)	312 (27.0)	71 (6.2)	56 (4.8)	26 (2.2)
Laugh	34 (3.0)	23 (2.0)	167 (14.5)	521 (45.2)	338 (33.6)	20 (1.7)
Cough	101 (8.7)	505 (43.8)	391 (33.9)	98 (8.5)	33 (2.9)	26 (2.2)
Voice use at extracurricular/social activities
Talk	83 (7.2)	57 (5.0)	288 (25.0)	345 (29.9)	347 (30.0)	34 (2.9)
Talk quietly	108 (9.4)	212 (18.4)	505 (43.8)	191 (16.5)	89 (7.7)	49 (4.2)
Talk loudly	84 (7.2)	157 (13.6)	436 (37.7)	278 (24.1)	147 (12.7)	53 (4.6)
Sing	224 (19.4)	274 (23.8)	376 (32.6)	149 (12.9)	92 (7.9)	38 (3.3)
Shout/yell/cheer	105 (9.1)	188 (16.3)	451 (39.1)	238 (20.7)	123 (10.6)	49 (4.3)
Clear throat	299 (25.9)	429 (37.2)	297 (25.7)	47 (4.0)	45 (3.9)	37 (3.2)
Laugh	67 (5.8)	55 (4.8)	355 (30.8)	407 (35.3)	228 (19.8)	40 (3.5)
Cough	213 (18.5)	483 (41.9)	329 (28.5)	61 (5.3)	21 (1.8)	47 (4.0)

Voice Disorder Prevalence

Overall, 138 respondents (12.0%) reported that their child experienced a voice problem that was consistent with the study definition at some point. Onset occurred at the following ages: 0 to 2 years (79 [57.3%]), 3 to 4 years (31 [22.7%]), 5 to 6 years (18 [13.3%]), and 7 to 8 years (4 [2.9%]), and 5 (3.4%) were unsure when onset occurred. Of these, 112 (80.6%; 9.7% of the total study population) indicated that their child had experienced a chronic voice problem lasting longer than 4 weeks. Of the 138 participants who reported their child had experienced a voice problem, 89 (64.4%; 7.7% of the study population) indicated that this problem occurred within the previous 12 months, and 78 (56.2%; 6.7% of the study population) indicated that their child’s voice problem was current. A total of 108 (78%) indicated that symptom onset occurred gradually, and 30 (21.7%) indicated that symptom onset was sudden. Eighty-four (61%) indicated that their child experienced the voice problem continuously, while 53 (38.5%) indicated the voice problem was off and on.

Voice Symptoms

Table 3 presents the frequency of voice symptoms and symptom sources. Table 1 presents the number of days children experienced a voice problem. Forty respondents (3%) indicated that a voice problem had caused their child to experience limitations or an inability to perform certain tasks. Sixty-three (5%) indicated that a voice problem caused their child to miss 1 to 3 days of school, and 35 (3%) missed more than 3 days of school. Thirty-three (2.8%) indicated that their child’s voice problem caused an inability to sing, and 28 (2.4%) reported a voice-related inability to participate in extracurricular activities. Additionally, 42 (3.6%) reported that their child’s voice was associated with negative comments from teachers or adults. Table 1 presents rates of voice interference with social and extracurricular activities.

Table 3. Frequency and Source of Voice Symptoms.

Symptom	Frequency, No. (%)								Source, No. (%)a
	No, never	Yes, daily	Yes, weekly	Yes, monthly	Yes, several times a year	Yes, yearly	Yes, less than once per y	Not reported	Class/school	Home	Extracurricular/social activities	Unknown/not reported
Hoarseness	850 (73.6)	11 (0.9)	28 (2.4)	9 (0.8)	56 (4.9)	44 (3.8)	145 (12.6)	11 (0.9)	127 (43.3)	135 (46.2)	83 (28.4)	20 (6.9)
Voice tires or changes quality	974 (84.4)	14 (1.2)	24 (2.0)	11 (0.9)	31 (2.6)	30 (2.6)	47 (4.1)	24 (2.1)	66 (42.3)	76 (49)	51 (32.5)	16 (10.5)
Trouble speaking/singing softly	972 (84.2)	46 (4.0)	27 (2.4)	13 (1.2)	37 (3.2)	15 (1.3)	22 (1.9)	21 (1.8)	68 (42.2)	93 (57.8)	40 (24.8)	12 (7.2)
Difficulty projecting	976 (84.5)	33 (2.9)	25 (2.1)	24 (2.1)	33 (2.9)	9 (0.8)	25 (2.1)	29 (2.5)	64 (42.6)	68 (45.5)	40 (26.7)	15 (10.1)
Loss of singing range	1052 (91.1)	15 (1.3)	13 (1.1)	9 (0.7)	9 (0.7)	17 (1.5)	16 (1.4)	24 (2.1)	34 (43.4)	25 (31.8)	21 (26.8)	7 (8.9)
Discomfort using voice	1001 (86.7)	23 (2.0)	36 (3.2)	6 (0.6)	22 (1.9)	24 (2.1)	30 (2.6)	12 (1.0)	77 (54.4)	64 (45.3)	30 (21.3)	10 (6.8)
Monotone voice	1033 (89.5)	31 (2.7)	14 (1.2)	14 (1.2)	20 (1.7)	7 (0.6)	13 (1.1)	22 (1.9)	42 (42.5)	53 (53.1)	32 (32.6)	2 (2.5)
Effort to talk	987 (85.5)	42 (3.6)	16 (1.4)	22 (1.9)	21 (1.8)	14 (1.2)	28 (2.4)	24 (2.0)	71 (49.3)	79 (55.3)	45 (31.2)	11 (7.3)
Chronic dryness of throat	1011 (87.6)	15 (1.3)	11 (1.0)	5 (0.5)	37 (3.2)	28 (2.4)	21 (1.8)	25 (2.2)	53 (44.7)	70 (59.9)	30 (25.2)	6 (5.2)
Wet, gurgly voice quality	1027 (89.0)	18 (1.6)	9 (0.8)	7 (0.6)	16 (1.0)	20 (1.7)	15 (1.3)	42 (3.6)	28 (33.1)	57 (67.6)	20 (23.6)	5 (5.8)
Chronic sore throat	963 (83.4)	7 (0.6)	9 (0.7)	18 (1.6)	44 (3.8)	45 (3.9)	55 (4.8)	13 (1.1)	102 (57.3)	83 (46.7)	47 (26.2)	11 (6.0)
Frequently clear throat	884 (76.6)	65 (5.6)	29 (2.5)	43 (3.7)	55 (4.8)	30 (2.6)	23 (2.0)	25 (2.2)	102 (41.7)	150 (61.3)	55 (22.6)	13 (5.4)
Bitter or acidic taste	1064 (92.2)	5 (0.4)	12 (1.0)	10 (0.8)	24 (2.1)	12 (1.0)	9 (0.8)	18 (1.5)	18 (25.0)	51 (70.6)	16 (21.4)	2 (2.5)
Wobbly or shaky voice	1054 (91.3)	10 (0.9)	16 (1.4)	20 (1.7)	17 (1.5)	4 (0.3)	11 (0.9)	24 (2.0)	33 (42.8)	33 (42.8)	24 (31.8)	9 (11.3)
Breathy voice	1046 (90.6)	22 (1.9)	14 (1.2)	12 (1.0)	18 (1.5)	16 (1.4)	4 (0.3)	23 (2.0)	44 (51.9)	43 (50.0)	25 (28.7)	4 (4.6)

^a Calculated as a percentage of participants reporting that symptom.

Peds VRQOL

The mean (SD) Peds VRQOL score was 17.8 (14.3). Children with a history of a voice problems presented with significantly higher scores than those who had never experienced a voice complaint (Cohen d = 0.32; voice problem: mean [SD], 21.8 [13.1]; none: mean [SD], 17.3 [14.4]). Additionally, children with current voice problems scored significantly higher than those with past problems only (Cohen d = 0.48; current: mean [SD], 24.5 [13.9]; past: mean [SD], 18.4 [11.1]). No significant differences were observed between those with chronic and acute voice problems.

Treatment

Of the 138 respondents whose child experienced a voice problem, 106 (76.7%) reported that they had sought help for their child’s voice problem. Of these, 14 (13.3%) indicated that they had seen a speech-language pathologist (SLP); 74 (69.4%) had seen an ear, nose, and throat physician; and 71 (66.5%) had seen a primary care physician. Seventy-three respondents (68%) who sought help for a voice problem reported that their child had undergone voice therapy, and 67 (92.7%) of those respondents indicated that voice therapy was helpful. Of the 106 respondents who sought treatment, 49 (46.2%) indicated that they had been given a reason for their voice problem. The distribution of diagnoses among those who had seen a medical clinician was as follows (respondents could choose more than 1): 1 (<3%) colds/strep throat, 27 (55%) vocal fold nodules or polyps, 1 (<3%) voice use (yelling, talking, singing), 1 (<3%) acid reflux, 2 (3%) allergies, 4 (7%) autism-related voice issues, or 16 (32%) other neurological causes.

Health-Related Information From the Internet

During the previous 12 months, 139 parents (12%) indicated that they sought health-related information regarding their child on the internet. Fifty-four (4.7%) indicated that they sought information on voice disorders online. Of those who sought information online, 76 (54%) indicated that this information was written by medical professionals, and 45 (32%) indicated this information was very helpful, 92 (66.1%) somewhat helpful, or 2 (1.2%) not helpful.

Risk Factors for Voice Problems

Table 4 presents bivariate factors associated with increased voice problem prevalence. Male individuals were 47% more likely to report voice problems than female individuals (OR, 1.47; 95% CI, 1.0-2.1). Additionally, children living in a household with more than 4 individuals were twice as likely to report a voice problem compared with those from smaller families (OR, 2.30; 95% CI, 1.2-4.4). Poor speech intelligibility (OR, 2.26; 95% CI, 1.2-4.3) and maternal history of voice problems (OR, 4.54; 95% CI, 1.2-16.4) were also associated with increased prevalence of voice problems. The average letter grade earned in school was also associated with voice disorder prevalence, as voice complaints were most common in students who received Ds (15 [28%]) and decreased as grades improved (A = 44 [8%], B = 45 [13%], C = 30 [15%]). Other factors associated with increased voice problems were online gaming, karaoke, and secondhand smoke exposure.

Table 4. Association of Bivariate Factors and Voice Symptoms With Increased Prevalence of Voice Problems.

Variable	Endorsed variable		Denied variable		OR (95% CI)
	No.	Voice problem, %	No.	Voice problem, %
Extracurriculars and hobbies (yes vs no)
Basketball	12	6.7	131	13.4	0.5 (0.3-0.9)
Soccer	22	8.5	121	13.5	0.6 (0.4-1.0)
Karaoke	4	28.5	139	12.2	2.9 (0.9-9.)
Online gaming	36	16.8	107	11.4	1.6 (1.0-2.3)
Demographic factors (yes vs no)
Male (vs female)	86	14.4	57	10.2	1.5 (1.0-2.1)
>4 Individuals living in home	10	59.7	133	35.0	2.3 (1.2-4.4)
Understood <50% of the time	21	47.7	122	11.1	2.3 (1.2-4.3)
Mother with voice problem	10	66.0	11	30.5	4.5 (1.2-16.4)
Environmental factors (yes vs no)
Secondhand smoke exposure	13	18.1	108	11.3	1.7 (1.1-2.6)
Voice use (yes vs no)
Tantrums (crying, screaming)	28	58.2	113	10.9	1.7 (0.7-4.2)
Vocal strain	48	50.5	94	8.9	10.3 (6.5-16.3)
Symptoms (daily vs never)
Hoarseness	25	24.5	95	11.2	2.6 (1.5-4.2)
Voice tires or changes quality	36	49.3	97	9.7	9.0 (5.4-14.9)
Difficulty with soft voice	49	46.6	79	7.9	10.1 (6.4-15.8)
Difficulty projecting	47	47.9	81	8.1	10.5 (6.6-16.5)
Loss of singing range	14	42.4	117	10.9	6.0 (2.9-12.2)
Discomfort using voice	27	42.8	101	9.9	6.8 (3.9-11.7)
Monotone voice	26	45.6	111	10.4	7.2 (4.1-12.5)
Effort to talk	57	64.7	71	7.0	24.4 (14.7-40.1)
Chronic dryness of throat	23	31.9	108	10.5	4.0 (2.3-6.7)
Chronic sore throat	30	37.5	105	10.8	5.0 (3.0-8.1)
Frequently clear throat	42	22.7	90	10.0	2.6 (1.7-3.9)
Bitter or acidic taste	20	50.0	118	10.9	8.2 (5.2-15.6)
Wobbly or shaky voice	20	47.6	114	10.6	7.6 (4.0-14.4)
Breathy voice	21	39.6	113	10.6	5.5 (3.1-9.8)

Abbreviation: OR, odds ratio.

More frequent talking was associated with increased prevalence of voice problems (never = 4 [9%], rarely = 7 [36%], sometimes = 29 [23%], often = 34 [8%], all the time = 67 [11%]). The same was true for frequency of coughing (never = 11 [12%], rarely = 44 [8%], sometimes = 66 [14%], often = 18 [25%], all the time = 3 [23%]), throat clearing (never = 28 [11%], rarely = 44 [9%], sometimes = 49 [16%], often = 12 [17%], all the time = 8 [23%]), and shouting/yelling/cheering (never = 5 [6%], rarely = 15 [8%], sometimes = 58 [12%], often = 45 [15%], all the time = 19 [18%]). Tantrums and vocal strain were also associated with increased voice problems (Table 4).

Children with voice problems were 15 times as likely to report an inability to do certain vocal tasks (ie, sing, do extracurricular activities; OR, 15.7; 95% CI, 8.3-29.8; voice problems = 29 [64%]; none = 16 [35%]) and were 6 times as likely to report an inability to participate in social or extracurricular activities (OR, 6.05; 95% CI, 2.7-13.2; voice problems = 12 [44%], none = 15 [55%]). Children with voice problems were also 4 times as likely to report an inability to sing (OR, 4.52; 95% CI, 2.1-9.4; voice problems = 12 [37%], none = 20 [62%]) and 3 times as likely to have missed more than 3 days of school (OR, 3.10; 95% CI, 1.1-8.2; voice problems = 6 [30%], none = 14 [70%]). They were also more than 11 times as likely to have received negative comments from a teacher or other adult regarding their voice (OR, 11.5; 95% CI, 6.1-21.9; voice problems = 25 [58%], none = 18 [41%]).

Current vs Past and Chronic vs Acute Voice Problems

Children with current voice problems were 10 times as likely to present with vocal strain compared with those with past problems (OR, 0.3; 95% CI, 6.5-16.3; current = 3 [72%], past = 13 [27%]). Children with current voice problems were also 87% more likely to report monotone voice quality at home (OR, 1.87; 95% CI, 0.7-4.7; current = 16 [88%], past = 2 [11%]). Children with chronic voice problems were 14% more likely to report hoarseness at school than those with acute problems (OR, 1.14; 95% CI, 1.0-1.5; current = 14 [58%], past = 10 [41%]).

Discussion

This survey study investigated the prevalence of voice problems and voice use patterns in children throughout the US. Childrens’ demographic characteristics, extracurricular activities, vocal health characteristics, and symptoms were considered. The current prevalence of voice problems in children was 6.7%. The lifetime prevalence of voice problems (12%) was about half that reported in young adults.^25,26 This might be expected considering that children had less life experience than previously studied adults.^24,25,44 Eighty percent of reported voice problems were chronic (>4 weeks duration). In more than half of cases, benign vocal fold lesions had been identified as the underlying etiology. Other causes included respiratory illness, allergies, autism-related voice issues, and other neurological conditions. Risk factors for pediatric voice problems included being male, larger household makeup, poor intelligibility, maternal history of voice problems, online gaming, and secondhand smoke exposure. Voice use–related risk factors included frequent talking, coughing, throat clearing, tantrums/crying, and vocal strain.

Some of the risk factors identified in this study support past work.²² Male individuals and children living in homes of more than 4 individuals were 47% and more than twice as likely, respectively, to report a voice problem compared with children who did not fall into these categories.²² Past studies suggest that voice use patterns likely contribute to the propensity for voice problems in pediatric male individuals,^18,45 as increased hyaluronic acid, collagen distribution, and size (which protect adult male larynges) are not yet developed.^46,47,48 Similarly, communicating in larger households likely involves louder phonation in greater levels of background noise, factors known to be detrimentally associated with vocal function over short periods.^31,49,50 This may explain why a previous investigation from Finland suggested that children with older siblings are at increased risk for voice problems.¹⁸ In the current study, it was household size rather than position in the family that was associated with increased prevalence of voice problems. This variation in findings likely represents geographical differences between studies.

Additionally, children with a maternal history of voice problems were more than 4 times as likely to experience a voice problem compared with those with no such family history. This supports past work suggesting that a family history of voice problems is associated with increased voice disorder risk in children.⁵¹ It is possible that genetic factors are associated with a person’s propensity for voice problems,⁵² as genes govern the cellular response of the larynx to the microenvironment, mechanical stress, and injury.⁵³

Increased talking was associated with higher levels of voice problems. Benign vocal fold lesions were the most common etiology of voice complaints in the study population, and talkative personalities have been associated with these pathologies.^54,55,56 Additionally, benign lesions are twice as common in pediatric male individuals compared with female individuals.⁵⁶ Coughing, throat clearing, and tantrum throwing were also associated with voice problems, possibly because these behaviors involve high-impact laryngeal oscillation.⁵⁷ Research suggests that as many as 22% of children with chronic cough present with dysphonia.⁵⁸ Additionally, children involved in online gaming were 56% more likely to present with voice problems. This form of play frequently involves extended periods of loud vocalization over the internet,⁵⁹ a form of communication documented to increase vocal effort.⁶⁰

Children exposed to secondhand smoke were 70% more likely to present with voice problems. Secondhand smoke has been tied to laryngeal pathology in adults,⁶¹ as cigarette smoke damages vocal fold mucosa on a cellular level.^62,63,64 Specifically, cigarette vapor induces vocal fold injury and disrupts typical cellular immunological response.^65,66 These data suggest that children are also vulnerable to the effects of secondhand smoke. This supports past work tying pediatric secondhand smoke exposure to adverse growth outcomes,⁶⁷ sleep disturbances,^68,69 and poorer cognitive function.⁷⁰

Children with poorer speech intelligibility were more than twice as likely to report voice problems. It is possible that dysphonia contributed to poor speech intelligibility, as past studies suggest that voice quality is tied to speech intelligibility in adults.^71,72 Poor speech intelligibility could also be associated with poorer academic performance, which might partially explain why children with failing grades experienced higher levels of voice problems. Negative adult perceptions of children with dysphonia may have also contributed to poorer academic performance,¹³ particularly as teacher-student relationships in kindergarten have been shown to be associated with academic performance through eighth grade.⁷³ Our findings suggest that vocal function and academic performance are associated. Future work should determine if school-based voice services may mitigate these problems.

Strengths and Limitations

There are considerations that should be remembered when interpreting the current data. First, the current study considered parent report of voice problems rather than clinician assessments. Dysphonia etiology was collected to ensure accuracy; however, future work should examine findings from voice evaluations. Additionally, although measures were taken to mitigate recall bias, this risk can never be entirely eliminated. Lastly, many of the risk factors identified in this study will require further study to understand if a causal relationship exists.

Considering that 12% of children in the current study had already experienced a voice complaint and 80% of these problems were chronic, it is clear that effective voice-related medical care is crucial for this population.^39,74,75,76 This is particularly important given that voice problems were associated with limited social/extracurricular interactions, increased school absences, and negative attention from adults.^13,77 Additionally, Peds-VRQOL scores were substantially higher for children with voice problems, suggesting that dysphonia was negatively associated with quality of life.

Conclusions

In this survey study, the current prevalence of voice problems was 6.7% and lifetime prevalence was 12%. Eighty percent of voice problems lasted longer than 4 weeks. In 55% of cases, the underlying diagnosis was benign vocal fold lesions, with other causes, including respiratory illness, allergies, and other neurological conditions. Risk factors for pediatric voice problems included being male, a larger household makeup, poor speech intelligibility, maternal history of voice problems, online gaming, and secondhand smoke exposure. Voice use–related risk factors included frequent talking, coughing, throat clearing, tantrums/crying, and vocal strain. Peds-VRQOL scores were substantially higher for children with voice problems, suggesting that dysphonia was detrimental to quality of life. These findings illustrate the manner in which voice problems present in children and emphasize the need for efficient and efficacious treatment of these conditions in children.

Supplement 1.

eTable. Demographics for the United States pediatric population and the weighted and unweighted data sets

Supplement 2.

Data sharing statement