The word ‘voice’ can often be used to mean many different things; the general concept of someone talking, a singing voice, or having your ‘voice’ or opinions heard. In speech and language therapy, what we mean by ‘voice’ is the sound that is produced in our throat that we use for speech or singing. Every person’s voice is unique to them in terms of its tone, loudness and pitch (highness or lowness) and we are able to identify close friends and family by their voices alone. Through our accent, tone of voice and voice quality we can communicate our identity, including our personality, mood and emotions.

We can think of language as the words, phrases and sentences that we understand and use. Speech is the physical production of sounds that make up those words and sentences. Voice is the sound that we produce in our throat to be able to make words and speech sounds – it is the difference between what is said (speech and language) and how it is said (voice).

In this two-part blog series, I will explain how we produce voice and the difficulties that we can experience. Part 1 focuses on the difficulties that children can experience with their voices and how to support these. Part 2 will focus on the adult voice and what we can all do to keep our voices healthy.

So, first we are going to think about how voice is produced. When we are speaking, air moves from our lungs through two small structures in our throat, called the vocal folds. When we are breathing (and not speaking) the vocal folds are open and air passes easily between them. We can produce quiet sounds, with no voice, when the vocal folds are apart, such as when we are whispering. With the vocal folds closed, the air causes them to vibrate as it moves through them, resulting in a noisy sound or voice being produced. We then modify this noise as it moves through our throat and mouth by moving different articulators (tongue, lips, palate) to change the airflow and produce different speech sounds.

Diagram to show how we produce voice

Our voice develops and changes as we grow. As babies we play around with making different sounds – crying, screaming, shrieking, babbling – to develop our voice and the range of sounds that we are able to produce. As we get older, the tone and quality of our voice changes as our mouths and throats grow, including the size of the vocal folds. Rapid growth takes place during puberty, particularly for young men, which results in the voice becoming deeper.

The vocal folds are very small; approximately 6-8mm long at birth, growing to an adult length of between 8-16mm. We need to take care of them to ensure that they remain healthy and working correctly. Everyone has experienced a time when their voice was hoarse; after shouting and cheering too much for a favourite sports team, singing on a night out, or when we have a cold or throat infection. These difficulties usually last for a short period of time, with our voice then returning to normal. When these difficulties last for a longer period of time, this is a voice disorder

A voice disorder is when the quality, loudness and pitch of a person’s voice are not normal for them, and this occurs over a prolonged period of time. For example, a young child could present with a hoarse voice quality that is very deep and more commonly heard in an older man. A child’s voice quality may change over time so that they sound very different to ‘normal’. Other children may have had difficulties from when they were very young, meaning that to school staff working with them, this is how they have always sounded. A child with a voice disorder might sound a bit rougher or breathier than usual. Their voice could be difficult to get started, might break, squeak unexpectedly or hurt when they speak or sing. This may change during the course of the day, often with the voice sounding better at the beginning of the day and becoming worse by the end of the day after use.

The most common cause of voice disorder in children is vocal misuse; bouts of screaming, shouting and overuse of the voice. This is because the vocal folds are coming together with too much force, which can cause irritation and swelling. As all children frequently shout, scream and sing, with most not developing a voice disorder, it is not the actions themselves that cause the difficulty but the fact that they are being completed excessively or with too much tension. For most children, these difficulties disappear on their own, but for some, these unhelpful patterns of talking become entrenched and they need support to develop healthy patterns of using their voice. Voice disorders can also be caused by physical or neurological difficulties and, less commonly, can occur as a result of psychological difficulties.

Having a voice disorder makes it difficult for children to communicate effectively as their voice may tire easily and be unreliable, or they may have difficulty projecting their voice to be heard. This can make them lose self confidence and can result in poor self-esteem as voice is so personal and reflects who we are as an individual. If you notice that a child you are working with is having voice difficulties, there are some things that you can do to help:

  • Encourage good drinking habits – the vocal folds are covered in mucus and it is important to keep them well hydrated so that they can continue working properly. Make sure that children drink plenty of water and it is beneficial for children to have access to a water bottle at school, so that they can drink regularly. Fizzy drinks or tea and coffee contain caffeine which can dry out the vocal folds, making them work less effectively.
  • Support them to avoid shouting – screaming, shouting or talking very loudly for prolonged periods of time can affect the vocal folds. Reward charts with pictures to represent different volumes or ways of using the voice can support children to identify what you mean when you say ‘talk more quietly/gently’ e.g. using pictures of noisy and quiet animals. These need to be used at school and at home to support the child to change their talking habits. You can make the child aware of when they are speaking loudly (using their ‘tiger’ voice) and praise them when you hear them doing their ‘gentle voice’.
  • Reduce general noise level – children with voice disorders find it difficult to make themselves heard, particularly when there is background noise, so it is important that you reduce the general noise level to support them with this. Speaking over noise means that children need to increase their volume and put in more effort to make themselves heard, which can put increased strain on their voice.
  • Support them to avoid whispering – whispering for prolonged periods of time pushes the vocal folds apart and causes increased strain.
  • Reduce throat clearing – repeated coughing or throat clearing bang the vocal folds together and can increase irritation and swelling. Encourage children to try taking small sips of water, blowing out air and sniffing, as these can all help the vocal folds to move apart, and to feel less tight and irritated.
  • Ask them to get closer – encourage children to get closer to the person that they are talking to, rather than shouting from a distance, for example at home where they may be shouting to family members in a different room. Support other children (and adults) to try and speak one at a time, so that the child doesn’t need to speak loudly to compete to be heard.
  • Encourage time for voice rest – it can be beneficial to identify times during the day for completing quiet tasks that do not involve talking, for example reading or relaxation exercises.

If you are concerned about a child’s voice quality and they have had difficulties for more than three weeks, it is important that you discuss your concerns with the child’s parents and encourage them to speak to their GP. A referral to Speech and Language Therapy and/or ENT may be needed for assessment and treatment. In a rare number of cases, a voice disorder may be an indication of something more serious, therefore it is important that persistent voice difficulties are investigated fully, to enable children to receive the treatment and support that they need.

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