Voice issues can be difficult to detect in anyone, especially children. You might sense that something sounds “off” with your child’s voice. Maybe their voice sounds rough, or raspy, or strained, or breathy.

First of all, what is a voice disorder?

According to the American Speech-Language-Hearing Association (ASHA), a voice disorder occurs when voice quality, pitch and loudness differ or are inappropriate for an individual’s age, gender, cultural background or geographic location.

Sometimes an older child can sense their voice is different and even though other people may not notice it, it’s impacting their self-esteem at school and with their friends. That can be considered a voice disorder, too.

It might be harder to tell in our little ones, so what should we look for?

Some signs and symptoms that you might be able to perceive in your own child include:

• rough or raspy vocal quality
• breathy vocal quality
• strained vocal quality (tense or harsh)
• abnormal pitch (too high, too low, breaks, decreased range)
• abnormal loudness/volume (too high, too low, decreased range, unsteady volume)
• running out of breath quickly when talking
• frequent coughing or throat clearing
• excessive throat tension/pain/tenderness

There are different causes for voice disorders ranging from structural to functional. What does that mean?

Voice disorders caused by an underlying structural issue can include paralyzed vocal cord(s), blisters or callouses on the cords or damage to the nerve in the brain that controls our voice.

Functional voice disorders are more common and are caused by abuse, misuse, and overuse of the vocal cords.

If your child screams a lot and they have a raspy voice, it could be from vocal cord abuse. That might sound a little confusing – my child is “abusing” his voice?

The tissue of the vocal cords is fragile, so if they come together too forcefully as they do with coughing, throat clearing, and screaming, they can become irritated. With repeated injury, it can cause callouses (nodules) to form on the vocal cords. This will prevent the vocal cords from closing all the way, allowing more air to come through which makes that raspy or breathy quality. In more severe cases, bleeding can occur on one of the vocal cords.

Other things that may possibly be hurting your child’s voice:

• Too much caffeine
• Not drinking enough water
•  Whispering
• Making funny noises
• Smoking or being around smoke
• Uncontrolled allergies or reflux

If your child isn’t using their voice properly, what can you do to help? 

The no. 1 recommendation is good vocal hygiene. Encourage your child to:

• Drink plenty of water
• Avoid clearing their throat and coughing. Instead: swallow hard or take small sips of water
• Talk in a normal voice; don’t whisper or yell
• Limit caffeine intake
•  Talk with their doctor about managing allergies and reflux
• Have quiet periods when they can rest their voice

What if those do not help? Talk to your doctor about speech therapy.

Speech Therapy

As speech therapists, we can help your child learn to use their voice in a healthier way. We teach that this starts at the power source: the breath.

Children can modify how they use their voice through a variety of strategies, such as breathing techniques, stretches to decrease tension in the neck and exercises for proper breath control that will create a strong, healthy voice.

If your child is experiencing any of these symptoms, reach out to their primary physician to discuss a potential referral to an ENT (otolaryngologist) for further diagnostic testing.

We only have one voice and we want to protect it.

All children learn to babble and talk at different times. Before you know it, they can read their favorite book or tell you what they want for their birthday. But, when they can't tell you what they want to eat for breakfast or the daycare teacher can't understand what they say, parents need somewhere to turn.

At Cook Children's Rehabilitation Services, our speech language pathologists (SLPs) are highly skilled and experienced in children's communication development. They work with parents to help empower their children to achieve their goals.

We have about 40 SLPs who serve our patients in our medical center and outpatient clinics. They have expertise in:

• Feeding/dysphagia
• Speech/language skills
• Augmentative and alternative communication
• Hearing loss
• Autism
• Traumatic brain injury and so much more!

As we celebrate Better Speech and Hearing Month this May, Jonathan Suarez, Rehabilitation Services clinic lead, and Suzanne Bonifert, Rehabilitation Services manager, provide answers to commonly asked questions about speech and hearing.

What can I do to get my child to speak more?

Model words for your child, even if he/she doesn’t repeat them. For example, if he/she vocalizes and points to juice, you can say, “juice” or “you want juice.” That way the child is hearing the words even though he/she cannot say them yet.

It’s also good to use comments (i.e. “You want juice.”), rather than questions (i.e. “What do you want?”). Doing so can be less stressful for kids, especially those having some challenges learning to talk.

We also recommend talking to your pediatrician about a referral to see a SLP for an evaluation. The SLP can help you identify your child’s strengths and challenges and may recommend therapy to help give your child a boost!

Is it OK to speak more than one language to my child throughout the day?

Yes, yes and yes! Every child is different and the amount of time they spend using each language can vary, depending on exposure in school, at home or during extracurricular activities.

Sometimes a child may understand multiple languages but will only use one. Keep practicing each language!

Some children may “code switch,” or use both languages when they speak. This is not a disorder. The child is learning how to use the rules of both languages.

How do I know when to be concerned about my child’s communication or when to see a speech therapist?

By the time your child is 12 months old, he/she should be able to speak two to three words. By the time he/she is 2 years old, he/she should be able to speak at least 200 words. By age 3, he/she should be able to speak 900 words.

Trust your gut. If you feel there is a concern, you can ask your pediatrician for a speech therapy referral and have your child evaluated.

Once the evaluation is complete, an SLP can provide information to help with your child’s communication.

Here are links to two helpful speech and language milestone charts:

• Speech and Language Milestone Chart, LD Online
• Speech and Language Developmental Milestones, National Institute on Deafness and Other Communication Disorders

Is there something I could have done as a parent to prevent my child’s speech delay?

No. We often hear parents say, “We never had to worry about my older children talking.” But there is nothing you could have done to prevent your child’s speech delay. In most cases, there are steps you can take now to help your child’s language skills grow.

Since your child has a language delay, we need to be intentional in the language we are using with them.

How long will my child need to be in speech therapy to gain the skills they need to communicate?

Progress can vary from child to child. Our goal is to improve the child’s language while also teaching the parent or caregiver some interaction and language strategies to elicit communication.

What can a speech therapist do with a toddler who cannot sit still?

We can teach language in a variety of ways! Activities involving movement are great for keeping children interested. Sometimes, children are having so much fun that they do not realize they are actually doing a language activity!

Instead of sitting at a table for activities, you could:

• Stand up and sing songs using motions and actions
• Play hide-and-seek
• Play chase while running, jumping or skipping
• Read a book while acting each part out

To learn more about the Cook Children’s speech therapy program, please visit our website. 

But do they feel welcome at your table?

Don't despair, however. A diagnosis of dyslexia doesn't mean your child will struggle to read the rest of his or her life. Help that can train your child to adapt is available.

Though the root cause of dyslexia is still under investigation, we do know that it is a neurological learning disability and can run in families. Children with dyslexia process words differently than other children do, and as a result, have difficulty mastering language skills.

"Many children with dyslexia are undiagnosed," said DeeDee Hernandez, MS, CCC-SLP, a speech language pathologist and certified dyslexia tutor with Cook Children's Rehabilitation Services Northeast Clinic. "Parents should be on the lookout for signs that could indicate the child has dyslexia, especially if the learning disability runs in the family.

Know the signs

Young children with dyslexia may have trouble rhyming, recognizing letters, learning their sounds, pronouncing words and learning sequences – such as the days of the week or letters of the alphabet.

Signs in school-age children include trouble with spelling, gripping a pencil, mastering handwriting, learning new skills, comprehending math and following a sequence of directions or putting letters in order.

Teenagers with untreated dyslexia may struggle with learning a foreign language, managing their time, reading aloud or at an age-appropriate level, memorizing things and grasping the concept of jokes and plays on words.

Because dyslexia is a neurological disorder and not a visual problem, special glasses and exercises have not been shown to be effective.

However, speech language pathologists such as Hernandez help children with dyslexia learn the pivotal building blocks of language. She recommends parents seek specially trained professionals for help with dyslexia.

For more information

With rehabilitation locations in Fort Worth, Hurst and Mansfield, Cook Children’s provides specialized support for children in need of audiology, occupational therapy, physical therapy and speech therapy. To make an appointment, talk to your primary care pediatrician or call 682-885-3898.

That question makes me cringe. Not because of the question itself. I understand it. As parents, we all want what’s best for our children. I’m not afraid of the question or looking to evade it. It’s just who is making the choice on what’s “normal.” I use the opportunity to talk to parents. To reframe what may be thought of as normal, go over their concerns and provide perspective.

Here are some basic guidelines that I give to parents on how a child should be developmentally from 1 to 6 years old. Every child is different and this is only a starting point. If you have you concerns, please talk with your pediatrician for a referral to a speech/language pathologist.

• 12 months old - Children usually can say 1-21 words on their own, actively listen, wave bye-bye, look around when asked, "Where is __?" and use real and toy objects to act out common actions, e.g., feeding, cleaning, etc.
• 24 months old - Speak 145-150 words, combine 2-3 words, produce plural - s and - ing words, enjoy nursery rhymes, finger play and songs and put 2-3 actions in symbolic play.
• 30 months old - Say 360-600 words, speak in simple sentences, have his or her speech understood by family members, listen to real stories and start role playing in life experiences, such as going to the doctor.
• 36 months old - Say so many words you can't count them, have his or her speech understood by more than half the people your child meets, use "I, me, my and you" correctly. Answer what, where, when and who questions and retell familiar stories. At this age, children should be asking questions, not learning to read yet, but enjoying books and making friends. 
• 4 years old - Your child should start playing with words and making up stories. Most children at this age will be playing with friends and pretending to be a superhero, a cowboy, a parent or an animal. Children may begin using voices as characters and creating their own costumes and props.
• 5 years old - Most children at this age have started school. They can sit and listen for a whole story. They will start using words such as "know, understand and think." They will talk to ask questions, to explain things and to imagine.
• 6 years old - At this age, most children begin to speak more like grownups, especially at school. They can be polite when talking and know when adults don't understand what they have said. Often times, children will be able to change what they originally said to be better understood. Children at this age should be able to use all of their speech sounds and begin reading.

You know your child better than anyone and of course there will be times when your child just won't pay attention or doesn't feel like reading. But these general guidelines should be taken into account as an overall view of your child's development. I hope this helps give a better understanding of what we observe as speech patholigsts at Cook Children's.

*The vocabulary ranges used in this blog are based on MacArthur-Bates CDI.

About the author

Carol Edley, M.S., CCC-SLP, is a speech/language pathologist at Cook Children's. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury.

That question makes me cringe. Not because of the question itself. I understand it. As parents, we all want what’s best for our children. I’m not afraid of the question or looking to evade it. It’s just who is making the choice on what’s “normal.” I use the opportunity to talk to parents. To reframe what may be thought of as normal, go over their concerns and provide perspective.

Here are some basic guidelines that I give to parents on how a child should be developmentally from 1 to 6 years old. Every child is different and this is only a starting point. If you have you concerns, please talk with your pediatrician  for a referral to a speech/language pathologist.

• 12 months old - Children usually can say 1-21 words on their own, actively listen, wave bye-bye, look around when asked, "Where is __?" and use real and toy objects to act out common actions, e.g., feeding, cleaning, etc.
• 24 months old - Speak 145-150 words, combine 2-3 words, produce plural - s and - ing words, enjoy nursery rhymes, finger play and songs and put 2-3 actions in symbolic play.
• 30 months old - Say 360-600 words, speak in simple sentences, have his or her speech understood by family members, listen to real stories and start role playing in life experiences, such as going to the doctor.
• 36 months old - Say so many words you can't count them, have his or her speech understood by more than half the people your child meets, use "I, me, my and you" correctly. Answer what, where, when and who questions and retell familiar stories. At this age, children should be asking questions, not learning to read yet, but enjoying books and making friends.
• 4 years old - Your child should start playing with words and making up stories. Most children at this age will be playing with friends and pretending to be a superhero, a cowboy, a parent or an animal. Children may begin using voices as characters and creating their own costumes and props.
• 5 years old - Most children at this age have started school. They can sit and listen for a whole story. They will start using words such as "know, understand and think." They will talk to ask questions, to explain things and to imagine.
• 6 years old - At this age, most children begin to speak more like grownups, especially at school. They can be polite when talking and know when adults don't understand what they have said. Often times, children will be able to change what they originally said to be better understood. Children at this age should be able to use all of their speech sounds and begin reading.

You know your child better than anyone and of course there will be times when your child just won't pay attention or doesn't feel like reading. But these general guidelines should be taken into account as an overall view of your child's development. I hope this helps give a better understanding of what we observe as speech patholigsts at Cook Children's.

*The vocabulary ranges used in this blog are based on MacArthur-Bates CDI.

About the author

Carol Edley, M.S., CCC-SLP, is a speech/language pathologist at Cook Children's. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury.