Elsevier

Journal of Voice

Volume 27, Issue 6, November 2013, Pages 787.e11-787.e18
Journal of Voice

Clinical and Acoustic Vocal Profile in Children With Attention Deficit Hyperactivity Disorder

https://doi.org/10.1016/j.jvoice.2013.06.013Get rights and content

Summary

Purpose

The objective of this study was to evaluate the presence of etiologic factors, symptoms, and vocal acoustic alterations related to vocal hyperfunction in children with attention deficit hyperactivity disorder (ADHD).

Method

In 23 children with ADHD and 28 control children, vocal acoustic exploration was performed to analyze the F0, jitter %, and voice turbulence index for the sustained vowels /a/ and /i/ and the average tone and intensity and tonal modulation in tests of continuous speech. The children's parents completed a specific questionnaire aimed at detecting etiologic factors and vocal symptoms.

Results

Children with ADHD displayed more vocal symptoms (hoarseness, neck strain, and shortness of breath while talking) and more etiologic factors (they shouted more, spoke louder and faster, and became angry more easily) than did children in the Control group. Likewise, children in the ADHD group exhibited a greater % jitter and a lower average intensity in the continuous speech tests.

Conclusions

These results indicate that children with ADHD display greater vocal hyperfunction as compared with children in the Control group and suggest a higher risk of developing dysphonia. The results of this study could be useful for designing vocal programs focusing on vocal education and hygiene to prevent and decrease vocal risks and on promoting vocal health in children with ADHD.

Introduction

Attention deficit hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder.1 According to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) (DSM-IV-TR) of the American Psychiatric Association ADHD is a chronic neurobiologic disorder of multifactorial origin, characterized by an impaired ability to regulate activity (hyperactivity), inhibit behavior (impulsiveness), and maintain attention to a task (inattention). It is estimated that between 3% and 7% of school-aged children have ADHD.2 In Spain, the prevalence is 4.57% in children aged between 6 and 11 years.3 Boys exhibit ADHD more often than do girls,4 with the boy/girl ratio varying from 5/1 to 3/1 during childhood.5

The chronicity of the disorder implies a major public health problem because there are other associated illnesses. The comorbidity of ADHD is well known. The repercussions in the child's familial, social, and academic context require considerable assistance and educational care and entail a substantial economic cost.6

From a psychiatric point of view, it is estimated that 60% of children with ADHD have other impairments. Between 20% and 25% children display anxiety, 20% have behavioral disorders and 15–25% have mood disorders.7 Regarding language, speech delays are observed in 35%, learning disorders in 20–30%, and expressive language disorders in 10–54%. Pragmatic language disorders are of special interest because they further limit the social interactions of these children. Children with ADHD are known to have difficulties in understanding communicative intent and the nonverbal indicators of their interlocutors (eg, changes in intonation and voice volume). They often poorly measure their own emotional behavior during conversations.8, 9 It has been reported that this communicative conflict has important socioemotional implications10 and could add to other vocally abusive behaviors, such as high-pitched talking or shouting to obtain attention.

The hyperkinetic voice use can produce excessive laryngeal and extralaryngeal muscle tension during voice emission, which can trigger vocal hyperfunction.11, 12, 13

Vocal hyperfunction has been defined as “conditions of abuse and/or misuse of the vocal mechanisms due to excessive and/or imbalanced muscular forces.”14 It has an estimated prevalence of 10–40% of cases of vocal dysfunction15 and is often associated with psychological and personality factors.16 It has been observed that children with ADHD are very likely to exhibit characteristics of vocal hyperfunction, including talkativeness.17 Early detection and control of abusive vocal behaviors is of great clinical interest because it prevents vocal hyperfunction and phonotrauma, which have been associated with laryngeal injuries such as edema, nodules, and polyps.18, 19

Current literature primarily includes studies dealing with learning and psychiatric alterations among children with ADHD. Few publications have focused on the vocal characteristics and voice disorders that these children may exhibit. Therefore, the objective of the present study was to evaluate the vocal characteristics of children with ADHD for detection of vocal hyperfunction and, in particular, vocal etiologic factors that may generate vocal symptoms and acoustic changes in voice. The results could be useful for designing vocal programs focusing on vocal education and hygiene to prevent and decrease vocal risks and on promoting vocal health.

Section snippets

Subjects

The study examined 51 children, 35 boys and 16 girls, aged 6–15 years. The children were classified into two groups: an ADHD group and a Control group.

The ADHD group consisted of 23 cases (20 boys and 3 girls) with an average age of 10.48 years (range: 6–14 years). Within the ADHD group, two cases had hyperactivity (8.70%), two cases had attention deficit (8.70%), and 19 cases were diagnosed with the combined type (82.60%). The Control group included 28 cases (15 boys and 13 girls) with an

Higher frequency of vocal symptoms in the ADHD group compared with the control group

Table 1 shows the number of ADHD and control cases according to the frequency of symptoms reported on the questionnaire. The ADHD group had a higher frequency of vocal symptoms for each of the three studied variables.

Based on a frequency scale with a minimum value of 0 and a maximum value of 4, the study of these variables generated the following results.

All the vocal symptoms indicated by the parents of the children with ADHD reached average values above level 1. Tension in the neck while

Vocal symptoms and etiologic variables

The exploration of the vocal symptoms in our study, as perceived by parents (Hoarseness, Tension in the neck while talking, and Breathlessness while talking), is remarkable, for the relatively low frequency with which these symptoms appeared in both groups of children. Although the parents of children in the ADHD group observed significantly more vocal symptoms than did the parents of the Control group children, they observed those symptoms only occasionally, resulting in a value slightly above

Conclusion

In summary, our results suggest that children with ADHD probably make up a high-risk group for the development of voice disorders. They presented more frequent etiologic risk factors, shouting, excessive loudness, increased talking speed, and so forth. These hyperfunctional habits reflect in their voice quality, which perceived by their parents, specially hoarseness. These finding, enforced by the evidence of a less periodic larynx vibration, detected in acoustic analysis, turns to be

References (41)

  • R. Barkley et al.

    Attention-Deficit Hyperactivity Disorder. A Clinical Workbook (3rd edition)

    (2006)
  • W.E. Pelham et al.

    The economic impact of attention-deficit/hyperactivity disorder in children and adolescents

    J Pediatr Psychol

    (2007)
  • A.S. Rowland et al.

    The epidemiology of attention-deficit/hyperactivity disorder (ADHD): a public health view

    Ment Retard Dev Disabil Res Rev

    (2002)
  • T.J. Spencer

    ADHD and comorbility in childhood

    J Clin Psychiatry

    (2006)
  • T.J. Spencer et al.

    Attention deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities and neurobiology

    J Pediatr Psychol

    (2007)
  • J. Vaquerizo-Madrid et al.

    El lenguaje en el trastorno por déficit de atención con hiperactividad: competencias narrativas

    Rev Neurol

    (2005)
  • J. Hirschberg et al.

    Voice disorders in children

    Int J Pediatr Otorhinolaryngol

    (1995)
  • N. Roy

    Assessment and treatment of musculoskeletal tension in hyperfunctional voice disorders

    Am J Speech Lang Pathol

    (2008)
  • R.E. Hillman et al.

    Objective assessment of vocal hyperfunction: an experimental framework and initial results

    J Speech Hear Res

    (1989)
  • N. Roy

    Functional dysphonia

    Curr Opin Otolaryngol Head Neck Surg

    (2003)
  • Cited by (13)

    • Vocal Characteristics of School-Aged Children With and Without Attention Deficit Hyperactivity Disorder

      2019, Journal of Voice
      Citation Excerpt :

      Voice therapy remains the primary preventative treatment measure to date for children with laryngeal injuries.25,26,47 Previous studies have reported variability in the prevalence rates of VFN in school-aged children with ADHD and thus merit further investigation.10,12,15,16,18,21 As a result, the following research question is posed: What are the vocal characteristics of school-aged children with ADHD?

    • A review of our experience in phonosurgery in children

      2017, Acta Otorrinolaringologica Espanola
    • Attention deficit hyperactivity disorder symptoms in children with vocal fold nodules

      2016, International Journal of Pediatric Otorhinolaryngology
      Citation Excerpt :

      These findings support that preexisting certain behavioral characteristics might predispose some children toward voice misuse and contribute to the development of VNs. Garcia-Real et al. have reported that children with ADHD displayed more vocal symptoms (hoarseness, neck strain, and shortness of breath while talking) and predisposing factors (shouting, excessive loudness, increased talking speed, and becoming angry easily) for developing dysphonia than the control group [9]. Hamdan et al. have found that children with ADHD were louder and had more hoarseness, breathiness, and straining than controls [10].

    • Vocal Hyperfunction in Parents of Children with Attention Deficit Hyperactivity Disorder

      2016, Journal of Voice
      Citation Excerpt :

      As such, parents have little free time to improve their relationship with their children.27–29 Several of the effects of ADHD in the voices of these children have been studied.30,31 However, there are few studies on the vocal characteristics of parents of children with ADHD.

    View all citing articles on Scopus
    View full text