- Original Article
- Open Access
Behavioral characteristics and parenting styles in chronic habitual hyperfunctional childhood dysphonia
The Egyptian Journal of Otolaryngology volume 38, Article number: 136 (2022)
This study aimed to understand the association of child behavior and parenting practices with chronic habitual hyperfunctional childhood dysphonia (CHCD) for a better understanding of the nature of the psychological background of the problem. The study involved 52 Egyptian children aged 4 to 14 years old of both genders; the case group included 26 children diagnosed with (CHCD) based on auditory perceptual assessment using the modified GRBAS scale and laryngeal examination using an indirect laryngoscope, and the control group included 26 healthy children of the same age and gender. All of the children in the study had their histories were taken (demographic data, child vocal behavior history, and family vocal behavior history), the social class determined, SDQ for child behavior, and APQ for parenting practices.
The findings revealed that children with CHCD were more likely to engage in unhealthy vocal behavior and engage in street/sports activities. At the SDQ, children with CHCD had significantly higher emotional, conduct, and total difficulty scores. The degree of dysphonia was associated with prosocial behavior and emotional symptoms. The two groups’ parenting practices did not significantly differ from one another.
According to our research, CHCD is associated with several behavior problems, such as emotional symptom and conduct issues, but not with parenting practices.
Hyperfunctional dysphonia is caused by voice abuse and misuse, as well as improper breathing during phonation and excessive tonus of the neck muscles . Voice abuse refer to any action or circumstance that stresses or harms the vocal folds. This could involve loud speech, cleaning the throat frequently, coughing, breathing irritants, smoking, yelling, or screaming . Voice misuse refer to inappropriate voice use, such as speaking too loudly or with abnormally high or low pitch . Persistent hyperfunctional dysphonia can result in edematous lesions and soft nodules on the vocal folds, which can eventually lead to fibrosis and become hard vocal fold nodules .
The development of VFNs has been linked to “phonotraumatic” activities such as yelling, screaming, and speaking loudly for long periods of time, all of which have been linked to histological changes edema, hyalinization, and fibrosis . These behaviors are the result of a mix of anatomical, physiological, social, emotional, or environmental factors, and they can be seen as forms of interaction, aggression, impulsivity, leadership, or a desire to fit in with a group . VFNs, for example, have been linked to a slew of social, emotional, and behavioral issues .
Children, unlike adults, are often oblivious of the qualities of their vocal actions and are less capable of determining whether or not those behaviors are suitable . As a result, parents play an important role in monitoring and addressing their children’s vocal misbehaviors and abusive actions. Parenting is characterized as a complicated activity that includes a number of distinct behaviors that interact to influence child outcomes both individually and collectively . Several studies have discovered a statistically significant link between parenting and developmental outcomes such as performance, accomplishment methods, self-regulated learning, achievement objectives, self-efficacy, and children’s well-being [9,10,11,12,13]. This raises the issue of the involvement of parents in the development and maintenance of childhood hyper functional dysphonia. So, the goal of this study was to better understand the relationship between child behavior and parenting practices and chronic habitual hyper function childhood dysphonia in order to have a deeper understanding of the nature of the problem’s psychological basis.
The current research was a case–control study with an analytical component. From May 2019 to May 2020, the study was conducted on 52 Egyptian children aged (4–14) of both genders. The case group included 26 children diagnosed with (CHCD) according to auditory perceptual assessment (APA) and laryngeal examination by indirect laryngoscope, and the control group included 26 children with healthy voices according to APA, matched for age and gender; they were chosen among the siblings of children who had visited the phoniatric outpatient clinic. Regarding exclusion criteria, children with known hearing problems or evident intellectual disability, chronic upper or lower respiratory tract diseases, known neurological or psychiatric disorders, and other organic voice disorders were excluded from both groups. Documentation of auditory perceptual assessment (APA) for both groups included the following variables according to the modified GRBAS scale: grade and character (quality), pitch, register, register break, loudness, glottal attack, and associated laryngeal functions . The case group was subjected to laryngeal examination by indirect laryngoscope: a 70° rigid laryngoscope (Karl Storz) was used in conjunction with a camera (LEMKE MC 204) to do a thorough evaluation of the supraglottic, glottis, and infraglottic areas.
After ensuring confidentiality, each participant’s parent gave informed consent to participate in the study. Patients had the right to withdraw from the study at any moment during the study without incurring any penalties. The study protocol was approved by the institutional research board (IRB): MS.19.05.642.
The Statistical Package for Social Science (SPSS) Version was used to gather, tabulate, and statistically analyze data on an IBM-compatible personal computer . The qualitative data was presented as number (No) and percent (%), while quantitative data was given as mean and standard error.
Chi-square test was used to test association between categorical variables. It was replaced by Fisher exact test if the expected cell count was less than 5 in four-cell tables, while it was replaced by Monte Carlo test if the expected cell count was less than 5 in more than four-cell tables. The independent sample t-test was used to compare two normally distributed continuous variables in 2 independent groups, while the Mann–Whitney U test (z) was used to compare two non-normally distributed continuous variables in two independent groups. The one-way analysis of variance (ANOVA) is used to determine if the means of two or more independent (unrelated) groups differ statistically. To compare non-normally distributed continuous variables in more than two groups, the Kruskal–Wallis H test was utilized. P-values more than 0.05 were judged non-significant, whereas P-values less than 0.05 were considered significant.
The results of the current study were classified into the following.
Descriptive comparative statistics between the studied groups
1. Demographic data and socioeconomic status:
Table 1 demonstrated that there was no significant difference in age or gender between the two groups. However, the socioeconomic status of the case group was noticeably less than that of the control group.
2. Comparison of vocal behavior and history items between studied groups:
Table 2 demonstrated that there were significant differences between the two groups as regards child vocal behavior and playing in street/sports, while other parameters showed no significant differences.
3. Comparison of behavioral problems scores between studied groups:
Table 3 showed that there was a significant increase in emotional symptom score and conduct problems score in the case group compared to the control group. There was no significant differences in other parameters.
4. Parenting practices score
Table 4 showed that there were no significant differences as regards all parameters of positive and negative parenting.
Descriptive statistics of the case groups
1. Duration of dysphonia and results of indirect laryngoscope:
Table 5 showed that the duration of dysphonia was a median of 18 months; 100% of the children had bilateral broad nodules.
2. Auditory perceptual assessment (APA) of patient’s voice of the case group:
Table 6 showed that all of the children had dysphonia with strained and leaky characters with low pitch and reduced loudness.
1. Association between grade of dysphonia and behavioral characteristics in the case group:
Table 7 summarized the associations between dysphonia grade and other parameters in the case group. The grade of dysphonia had a significant association with the Emotional Symptoms Score and the Prosocial Behavior Score.
2. Association between grade of dysphonia and parenting practices in the case group:
Table 8 summarized the associations between dysphonia grade and parenting practices. There was no significant association as regards all parameters of positive and negative parenting.
The comparison between the case group and the control group revealed that children’s vocal behavior was significantly different between both. This is in line with the notion that repeated micro trauma caused by vocal abuse or misuse triggers an inflammatory response that results in VFNs . These practices are harmful to the layers of the vocal folds, particularly the mucosa of the vocal folds, and prevent the vocal folds from functioning properly .
The validated Arabic version of the SDQ was used in this study to examine behavior indicators and social skills. The case group’s SDQ parent report scored higher on the emotional, conduct, hyperactive/inattention, and peer problem subscales but scored lower on the prosocial behavior subscale than the control group’s parent report.
Emotional symptoms include headaches, stomachaches, nausea, anxieties, feeling upset, feeling frustrated, and crying as detailed by Kollbrunner and Seifert  who mapped the relationship between voice and emotional symptoms and concluded that emotional conflicts in childhood can lead to functional vocal problems. Ribeiro et al.  noted that the increased scores for anxiety/depression and somatic complaints observed in the adolescent group with voice complaints can be attributed to the fact that the voice disorder potentiated the insecurities and emotional conflicts that are common during this developmental stage.
Conduct problems refer to aggressive behavior that can take many forms (e.g., physical, proactive, reactive, relational) (anger, temper tantrums, fights, cheating, and lying attitudes). This can be explained by the theory that people with voice problems have more externalizing problems considering that vocally aggressive behaviors like screaming and shouting are usually associated with the etiology of childhood dysphonia itself .
The results in the current study are consistent with the observations of Lima and Behlau  who found that children and adolescents with CHCD scored higher on emotional symptoms and conduct problems domains using the SDQ both self-report and parent-report versions, according to Mahmoud et al.  who used the child behavior checklist to find significant differences in withdrawal/depression, somatic complaints, social problems, rule-breaking, and aggressive behavior between children with dysphonia and children without dysphonia (CBCL).
These results are in some ways consistent with the findings of the following researchers: The Children’s Behavior Questionnaire (CBQ) was employed in Egger et al.  investigation which indicated a strong significance in the scales of irritation/frustration, sadness, sensitivity, and discomfort. Angelillo et al.  relied on clinical neuropsychiatric examination and found that 83% had aggression and hyperactivity attitudes. Green  used Walker Problem Behavior Identification Checklist (WPBIC) ratings to compare the behavior characteristics of children with CHCD and vocally normal school-age children and discovered that the children with CHCD had significantly higher ratings in aggression, distractibility, and disturbed peer relations. Wilson  noted that children with CHCD are more vocally aggressive, hypochondriacal, and prone to repressed physical aggressiveness. According to Nemec , children with CHCD were more aggressive and immature than their vocally normal counterparts. They interacted with their social, educational, and familial environments aggressively.
Wilson and Lamb , who used the Rorschach test, and Roy et al. , who used the (CBCL), both failed to identify significant behavioral differences between children with CHCD and vocally normal children.
It is also important to highlight the association between CHCD severity and SDQ scores. The grade of dysphonia was found to have a significant association with the emotional problems score and prosocial behavior scores in this study. Prosocial behavior is related to social skills or competencies. Children who are socially competent exhibit adaptive behaviors toward their peers their age . This coincides with Lima and Behlau  who suggested the highest occurrence of vocal symptoms does not reduce their prosocial behavior but can be a risk factor for the development of emotional/behavioral problems.
Regarding hyperactive/inattentive symptoms, it was not able to confirm reports assuming that there is a strong association between ADHD symptoms and CHCD in our study, which is consistent with Maia et al. [38. ], who did not detect the positive link established by other authors.
Lima and Behlau  and Reis-Rego et al. , both of whom used the SDQ, found a strong correlation between the higher hyperactivity/inattention scores and the presence of CHCD. The difference between our results and those of the two studies could be explained by the large size sample and the male dominance, as Leache et al.  found that males were more than twice as likely to be diagnosed with ADHD as females.
Other studies examining the association between ADHD and CHCD used the same diagnostic method as the DSM-IV but used different sample selection criteria reducing the strength of the evidence obtained in the comparison between them . For example, Erdur et al.  suggest associations between CHCD and hyperactivity and oppositional behavior in children using Conners’ Parent Rating Scale-Revised: Short Form (CPRS-RS), which was used to compare the symptoms of ADHD in children with VFNs and normal children. D’Alatri et al.  also compared the symptoms of ADHD in children with CHCD with children without CHCD, concluding that ADHD is a possible risk factor for the development of CHCD. Hamden et al.  examined APA between children with ADHD and children without ADHD, finding that children with ADHD have more hoarseness, breathiness, strain, and loudness than children without ADHD.
It is important to notice that the assessment of the child’s behavior in this study is based on the mother’s own rating. The mother has extended time and better acquaintance with the child so she can give us an image of the child’s behavior that not minded by his/her CHCD problem; however, the bias of the mother’s opinion cannot be excluded. Generally, the disparities in findings may be due to differences in the methodologies and tools employed to assess them. According to Maia et al.’s systemic review study , there is no typical behavioral profile in children with CHCD, the integrative review of the behavioral characteristics of dysphonic children does not establish a profile, and the cause-and-effect relationship has not been established.
This study assessed parenting using the Alabama Parenting Practice Questionnaire . The APQ was developed to examine the five parenting dimensions that have been related to behavior problems among adolescents: involvement, positive parenting, poor monitoring/supervision, inconsistent discipline, and corporal punishment .
Up to our knowledge, no studies investigated the relationship between parenting and CHCD, despite the fact that there have been plenty of studies looking into parenting and behavior problems of children.
Positive parenting scales, parental involvement, and poor supervision were all lower in the current study case group, whereas inconsistent discipline and incorporeal punishment were greater, with no statistically significant difference between the two groups. Also, dysphonic children scored higher on the emotional and conduct scale, although there was no definite correlation between behavior and parenting in this study. As a result, we may compare this conclusion to studies that examined at the association between parenting and behavioral problems.
This data is similar to that reported by Barry et al. , who found no significant correlation between parenting reports of poor or positive parenting practices and any indicators of conduct problems.
This finding is in line with the data reported by Fathima and Jaya  who compared two groups of children, the first of which included mothers of boys from the normal population and the second group included the mothers of boys who have been clinically diagnosed with ADHD and co-morbid disruptive behavioral problems (ODD/CD) by a psychologist/psychiatrist. Except for the use of corporal punishment by mothers of children with behavioral disorders, their data show no link between child behavioral problems and parenting practices.
In this study, neither Frick et al. , who assumed that both negative and positive parenting practices were most clearly associated with child conduct problems, nor Dallaire et al. , who reported that both positive and negative parenting practices were related to child internalizing problems, could be agreed upon.
The similarities in parenting practices observed between the two studied groups could be attributed to similarities in parenting practices between lower and middle socioeconomic classes, as Morelli et al.  stated that people with similar lifestyles, based on sociodemographic status, have similar views on parenting practices. Furthermore, because parents tend to reflect a good image of their parenting, this study depended on parent-report, which may not be reliable. In addition, relying on one parent (usually the mother) does not have a complete picture of the practices to which the child has been exposed.
Abuse and misuse of voice were found to be a predictor of CHCD in this study. Children with CHCD are more likely to abuse, misuse, and engage in activities that include phonotraumatic behavior, such as street/sports play. Children with CHCD had a higher score on the emotional symptoms scale, which included headaches, stomachaches, nausea, anxieties, upset, feeling downhearted, and crying. Furthermore, the conduct problems score refers to aggressive behavior. The degree of dysphonia is linked to emotional symptoms and prosocial behavior, both of which are related to social skills or social competency. There is no association between parenting practices and CHCD.
Behavioral problems and parenting practices among CHCD should be assessed using child-report rather than parent-report in future studies. Behavioral problems in CHCD should also be studied by age group (preschool age and school age) and gender.
Availability of data and materials
Available (the datasets used and/or analyzed during the current study are available from the corresponding author).
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This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the institutional research board of the Mansoura University (IRB) MS.19.05.642. Date: 12 June 2019. The parents of the children signed a written consent form.
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Ibrahim, A.S.M.S., Amer, A.M., Tobar, S.S. et al. Behavioral characteristics and parenting styles in chronic habitual hyperfunctional childhood dysphonia. Egypt J Otolaryngol 38, 136 (2022). https://doi.org/10.1186/s43163-022-00324-9
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