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. 

Have you ever gotten to a point in doing something so much that you feel like you just need to take a break?

No … I’m not talking about marriage. I’m talking more like working out. You know what I mean. You get to the point where you’re doing like 2 or 3 hundred pushups in a row. Who am I kidding? I’ve never done that many pushups. But I have tried having a trainer before. I remember getting to a point in the training where I felt like I could basically take over. As I did the exercises, I knew when my form was off and I knew what exercises I needed to improve on.

Speech therapy can be the same way. So many times, we want therapy to continue year after year after year. I get it. It’s hard to let go of something you know is helping your child. But breaks are sometimes not only needed, but beneficial.

Often, when working out you come to some sort of plateau. You feel like no matter what you do, you aren’t improving. Well, that’s when you can go back to the trainer, who will help you make adjustments and keep the improvement going. Speech language pathologists (SLP) are really knowledgeable and can help adjust your child’s plan of care so your child continues toward attaining his or her true potential.

Let’s first address the purpose of therapy. Your speech language pathologist’s goals should be:

1.Work with you to figure out the needs of your child and how their speech and language difficulties are affecting their day to day life and learning.

2.Come up with a treatment plan that allows for your child to improve in the areas you and the SLP feel are important.

3.Teach you strategies you can use to work on the things your child has trouble with as well as discuss activities that can be done outside of therapy.

4.Teach you to be your child’s speech therapist at home!!

As a clinician, I feel No. 4 is most important. Most kids get therapy maybe 1-2 times a week for about 30-60 minutes. Most parents feel that isn’t enough.

I AGREE!!!

Just imagine if you could learn everything the therapist was teaching and the strategies to teach the concepts. Your child would be getting therapy basically at all waking hours. All of a sudden your interactions change. For example, you know that when your child has difficulty understanding a direction, you can assist them by using the “breakdown” strategy.

This is where you maybe break the direction up into pieces. For instance “Dominic, go to your room and get the ball.”

Well little Dominic may just look at you with a confused face. Kind of like the face my wife says I have when she asks me to do something. But that’s neither here nor there. By “breaking down” the direction, you may first say “Dominic, go to your room.” Then, when that is complete you say “Get the ball.” This allows him to fully understand the direction. Similarly, you may use a strategy that would make it easier to produce a sound, such as providing a tactile or visual cue.

Let’s say little Mia has difficulty producing the “B” sound. We may point to our lips to get her to realize that we need our lips to make lip sounds. Now that is awesome. When children apply what they have learned in therapy, it is wonderful because we want children to improve; BUT when parents apply what they have learned, it is magical. Questions to ask your therapist could include:

1.What are the goals for my child?

2.What strategies are you using to assist my child and teach them the concept? Can you teach them to me and help me do them correctly?

3.What can I do at home to help with generalization of the skill?

Every child is different so each plan of care may differ in how long therapy lasts. At some point though, through ongoing discussions with the clinician there should be an ending point. You get to now apply what you and your child have learned in therapy.

Keep in mind that this isn’t the end-all-be-all. In most cases, I recommend a re-evaluation in 6 months to ensure that there is continued improvement or even to adjust the plan of care. As a therapist, I understand there still may be concerns. I want, however, my parents to feel empowered by the knowledge they now possess. My goal is that the parent leaves my therapy session understanding our objectives and strategies.

Bob Keeshan made a good point when he said “Parents are the ultimate role models for children. Every word, movement and action has an effect. No other person or outside force has a greater influence on a child than the parent.”

Aye, aye captain.

Whether it’s bottle feeding or breastfeeding, you may have some questions or concerns – things that many other parents have also questioned! If not, or maybe you’re just not sure, speak to your pediatrician about a possible feeding evaluation by a speech-language pathologist (SLP). Build or re-build that bond. There’s lots that can be done to help and it will have lasting effects! Let’s take a look at three of the most common problems moms have and suggestions on what can be done about them.

1. Problem: Baby won’t stay latched during breastfeeding or falls asleep.

The best intervention for saving breastfeeding is the earliest intervention. Getting help from a lactation counselor or consultant before you feel like throwing in the towel will help to alleviate some of the frustration you and baby may be experiencing. Don’t wait - below are some resources you can contact. The WHO’s (World Health Organization) stance is breastfeeding serves a nutritional purpose for children until they’re at least 2 years of age! So keep it up, Mama!

2. Problem: My baby coughs, chokes, and is simply a messy eater.

If a baby is coughing, choking or losing milk from around the bottle when feeding, stop what you’re doing and find a nipple that may flow a little slower. Despite their very new presence in the world, babies are usually very good communicators if we’re really “listening”! They may be telling you that the milk is coming faster than they can swallow it. This might be a really easy fix. However, make sure your feedings are not taking too long and baby is getting enough. If you’re unsure, ask for help.

3. Problem: My baby spits up more than what I feel is normal.

Dr. Smith just wrote a very informative and thorough blog about gastroesophageal reflux and how it impacts feeding. Take a look at what he has to say about it and compare it to what you are seeing in your child. While the majority of cases of reflux resolve on their own around 6 months, as SLPs, we do see infants and children whose eating habits have been severely affected by it. Make sure to make notes about your baby’s behavior and discuss them with your pediatrician!

Learn more from the Tarrant County Breastfeeding Coalition

She loves to use her baby talk with Dominic. As both a speech-language pathologist and a father, I’m conflicted. The sparkle in his eye and wonderful smile just make you melt anytime she says “O doe ma chikyweekys” or any other baby talk. It’s great, I get it, BUT we have to throw in some real words. Who will ever understand him if he says “chikyweekys.” Again, what is that?!?! (I’m just giving my wife a hard time, hopefully she doesn’t read this!)

You may have heard the term motherese and wondered what it was. Baby talk and motherese sound similar, but if you really pay attention there is a difference. Baby talk is the changing of your voice from high to low, but with nonsense words. Hence, “O doe ma chikyweekys” is a great example. But motherese, or parentese, is a bit more sophisticated and much more preferred by me as a speech therapist and as a male/father:

Parentese is:

• Varying your intonation using a sing-songy voice
• Slowing your rate of speech down
• Using short simple phrases with REAL words
• Having FUN

So if you were showing a baby a puppy for instance, you may want to try it like this: “Oh looook at the puuuuppy. Isn’t it a preeeetty puuuuppy!” As the individual using parentese, you would make sure to put some inflection (raise your voice in a fun loving way) on a few of the important words in the sentence. In this case, you could consider the important words to be “look,” “puppy” (both times) and “pretty.”

Let’s say you were playing hide-n-seek and tickle time with your baby, you could do something like this:

“Where’s my baaaaby? Where’s my baaaaby boy? Oh, I seeee him? ... tickle, tickle.” The important words in this case may be “baby” (both times) and “see.”

Some parents find that using parentese is hard or even embarrassing. I don’t blame them. When I started as a speech therapist, I thought it was awkward and very unnatural. As I used it more, I noticed a huge difference in my interactions with the little kids I was treating. They actually listened to me.

What happens if you don’t use parentese? Does the name Ben Stein mean anything to anyone? “Bueller? Bueller?” He’s that guy. He’s the one in the Clear Eye commercials using a monotone voice. The next time you play with your child, I want you to try a little experiment. While playing, talk in a monotone, Ben Stein-like voice, keeping your pitch the same throughout. Although Mr. Stein can get our attention for those commercials, you will see how quickly you lose your child’s attention.

Just like anything else, talking in parentese takes some practice, but from a child’s perspective hearing parentese is exciting and interesting. As a therapist and as a parent, I need my child’s attention if I want to teach them anything. I have seen how using parentese works in a therapeutic setting and now, with my son Dominic, I’ve seen first-hand how it works at home as well. Using my sing-songy voice, it may sound a little like this ...

Our interactions may sound silly to others, but when Dominic and I are in the moment it’s just plain good old-fashioned fun. I believe Rob Olson said it best when he said “My childhood may be over, but that doesn’t mean playtime is."

About the author

Jonathan Suarez is a speech 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. 

Evaluation, treatment and home programming are available for children with:

• Feeding and swallowing disorders
• Articulation, voice, resonance, and fluency disorders
• Receptive and expressive language disorders
• Aural rehabilitation/ auditory verbal therapy for hearing loss or cochlear implant
• Evaluation for augmentative communication devices

About 3 percent of kids suffer from severe selective eating, to the extent that they can't eat out at a restaurant, said lead researcher Nancy Zucker, an eating disorders specialist at Duke University Medical Center in Durham, N.C.

Severely selective eaters are more than twice as likely to be diagnosed with depression or social anxiety, when compared with kids who'll eat anything, according to findings published online Aug. 3 in the journal Pediatrics.

Alaina Everett, a Cook Children’s licensed psychologist in Denton, says severe picky eating can be treated from a psychological/behavioral perspective as well as through oral-motor and sensory therapies and trying new foods for children who have severe selective eating can be terrifying.

“The fear is only intensified when parents make threats or express anger and frustration,” Everett said. “In our psychology department we emphasize the belief that kids do well if they can. Likewise they will eat well if they can. But there are obstacles that get in the way. Whether the original issue is a sensory processing disorder, oral-motor weakness or a gastrointestinal problem, all these kids have one thing in common, anxiety.”

From a psychological standpoint, these kids have had unpleasant experiences with food and the lingering trauma may be real. This is especially true for well-meaning moms who hide veggies in their kids’ favorite foods. If you have a seriously picky eater, Everett says this strategy will back-fire big time.

So how much anxiety can meal time actually cause?

“It is not uncommon in my practice to see children cry, scream, hide under the table, and quite literally shake at the sight of a novel food or when asked to join me at the table,” said Amanda Fyfe, a speech-language pathologist at Cook Children's in Arlington and Mansfield. “The anxiety severe picky eaters cope with is real and it can be intense. These kiddos often have months or years of negative food experiences fueling this fear, and unraveling it takes real work on everyone’s part. “

Fyfe says severely picky eaters:

• Have a significantly limited food repertoires (think 10 foods). These foods are probably similar in some way, although figuring out the rhyme or reason to what your little guy will or won’t eat can be mind boggling. It may be that his safe foods are the same color or have the same texture.
• Frustrate us with behavior that makes mealtime at home a catastrophe and eating out unheard of. He may refuse to eat with your family or cry and scream at the sight of the casserole you’ve so lovingly prepared.
• Refuse foods based on ALL sensory properties, including appearance, smell, texture, and taste. A picky eater may not even tolerate an offensive food on his plate. The sight of a non-preferred food may cause gagging, retching, and vomiting. Eating is more than simply chewing and swallowing. Interacting with, smelling, touching, and tasting are ALL important steps in the eating process. And disruption can occur at any step.
• May struggle to meet nutritional demands

“A child will not eat the broccoli and pork chops if you wait him out. He just won’t,” Fyfe said. “In fact, he may grow more and more rigid in his food selection because he IS hungry and grumpy. If a food or experience causes a child stress, discomfort, or pain, he will avoid it, plain and simple.”

Fyfe says these children are hypersensitive to foods in ways most of us might not even consider when planning our meals. Foods have to pass many tests before deemed acceptable for consumption, believe it or not, and severely picky eaters really put their meals to the test.

The first and possibly the most important test his dinner must pass? What it looks like. Children are acutely aware of the color of the food and may question why the color, shape, or size changes from bite to bite or from meal to meal. In addition, they might become overwhelmed by the smell of a particularly pungent food (think roasted broccoli, guys) and lose all ability to even consider tasting it. The texture of yogurt or pudding may cause a gag with incredible force. All of these reactions to food can lead to increased behavior disruption and meal time chaos.

“They can taste everything,” Everett said. “Zucchini pasta does not fool anyone and they are likely to stop eating pasta altogether. Presenting motivators like extra video game time can help, but it doesn’t solve the underlying anxiety. The scenario will just repeat itself when the next new food is presented.”

If your child shows signs of extreme picky eating, you will need some help. Talk to your child’s pediatrician about scheduling a feeding evaluation with a speech-language pathologist to determine the origin of the feeding woes and develop strategies to improve the eating experience for the entire family. A child psychologist may also be used if necessary.

http://www.npr.org/sections/health-shots/2015/08/03/428016725/could-your-childs-picky-eating-be-a-sign-of-depression

https://childhealthanddevelopment.files.wordpress.com/2012/03/kaytoomey.pdf

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. 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. Click here to find the closest Cook Children's Rehabilition Services near you.

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.