International Journal of Pediatric Otorhinolaryngology (2007) 71, 77—82
Pediatric Voice Handicap Index (pVHI): A new tool for evaluating pediatric dysphonia Karen B. Zur a,*, Stephanie Cotton b, Lisa Kelchner b, Susan Baker b,c, Barbara Weinrich b,c, Linda Lee b a
Division of Otolaryngology, Head & Neck Surgery, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, 34th Street & Civic Center Boulevard, 1 Wood, Philadelphia, PA 19104, United States b Department of Speech Pathology and Otolaryngology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229, United States c Department of Speech Pathology and Audiology, Miami University, 2 Bachelor Hall, Oxford, OH 45056, United States Received 4 May 2006; received in revised form 6 September 2006; accepted 8 September 2006
KEYWORDS Voice; Quality of life; Pediatric Voice Handicap Index; Dysphonia
Summary Purpose: The Voice Handicap Index (VHI) is widely used and accepted into adult clinical practice. The present study was initiated to adapt the VHI to the pediatric population and to validate it in the form of a parental proxy. Methods: The initial modification of the adult VHI involved changing the language of the statements to reflect a parent’s responses about their child and eliminating questions that would not relate to children. It was administered in conjunction with 10 open-ended questions regarding the impact of the child’s voice quality on overall communication, development, education, social and family life. The pVHI was then modified in content and language, and the final 23-item parental proxy product was used for the validation process. The modified pVHI was administered to two groups of patients following IRB approval from Cincinnati Children’s Hospital Medical Center. Results: Normative data was obtained from 45 parents of healthy children. The group consisted of 21 males, age ranges 3—12 years old. The mean scores of the total pVHI and its subscales are: functional (F) 1.47, physical (P) 0.20, emotional (E) 0.18 and total (T) 1.84. The test group consisted of 33 guardians of children presenting for a voice evaluation pre- or post-laryngotracheal reconstruction. This group differed greatly from the control group on each subscale and total score. The mean scores of the
* Corresponding author. Tel.: +1 215 590 3440; fax: +1 215 590 3986. E-mail address: [email protected]
(K.B. Zur). 0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2006.09.004
K.B. Zur et al. airway group were as follows: F 13.94, P 15.48, E 12.15 and T 41.58. Test—retest reliability of the total pVHI score was measured using Pearson’s correlation coefficient. The scores were 0.95, 0.77, 0.79 and 0.82, respectively. A correlation matrix for pVHI subscore and total score showed significance, with results similar to those reported for the original adult VHI. Conclusions: The aim of the present study was to modify the VHI to serve a similar role in the evaluation of the effects of dysphonia on the pediatric population. The statistical results reveal a high correlation between the VHI and the pVHI. The pVHI provides a high internal consistency and test—retest reliability. This tool will be utilized to follow a child’s development following surgical, medical and behavioral interventions. # 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction The traditional endoscopic imaging tools used to evaluate the pediatric larynx provide extensive information about vocal fold and supraglottic pathology. Although these instruments allow for physiologic evaluation of the causes of a voice disorder or dysphonia, they do not provide information regarding their impact on a child’s life. Healthrelated quality of life can be defined as the ‘‘subjective and objective impact of dysfunction associated with illness or injury, medical treatment, and health care policy’’ . Numerous health-related quality of life instruments have been developed to measure the effect of the illness and disability on children’s activities of daily living. These instruments focus on general concepts related to physical abilities, growth and development, general health perception , autonomy and cognition abilities . However, there is currently no single instrument that accurately describes the unique issues facing young children presenting with a voice disorder. Development of a more detailed instrument would assist in quantifying the impact of a voice disturbance on the child’s social, emotional, and functional well-being. Several commonly used voice-related quality of life measurements exist and are validated for the adult population. These include the voice handicap index (VHI) , voice outcome survey (VOS) , and voice-related quality of life . The VHI is an adult self-assessment that is considered reliable and valid  and is widely used in clinical practice. It consists of 30 statements and is scored on a Likert scale ranging from 0 to 4. The objective of the VHI is to provide a measurement of the severity of a voice disorder in three domains: emotional, physical, and functional. It provides the individual’s perception of the severity of his/her voice and its impact on the daily life, and is used to follow progress pre- and post-therapy. To date, the pediatric voice outcome survey (PVOS) is the only voice survey that is validated for use in the pediatric population . The PVOS
is a four-item parental proxy questionnaire aiming to determine voice-related quality of life. The parent is asked to rate the child’s speaking voice, strain, limitation in social environment and limitations in a noisy environment. Although the PVOS is short and easy to complete, several key areas are not addressed. In particular there is little probing of more specific domains that can affect the daily function and development of the child. Clinical reports suggest that voice disorders can negatively impact a child’s education and lifestyle . An instrument that can assess the social, emotional, and academic impact of the voice disorders on children is an important component of a comprehensive voice evaluation. The purpose of the present study was to adapt the current VHI to the pediatric population in the form of a parent proxy. Validation of the tool on children with and without known voice disorder was accomplished.
2. Methods 2.1. pVHI development The initial modification of the adult VHI, a 30-item survey, involved changing the language of the statements to reflect a parent’s responses about his or her child and eliminating questions that would not relate to a pediatric patient. Approval for use and modification was obtained from the copyright office of the American Speech, Language, and Hearing Association. The pVHI was administered in conjunction with 10 open-ended questions regarding the impact of the child’s voice quality on his or her overall communication, development, education, social and family life (Appendix A). The parent’s responses were tabulated, and the frequency of issues and concerns was noted. The pVHI was then modified in content and language, and the final 23-item parental proxy product was used for the validation process. The pVHI subscales still focus on the functional, physical
Pediatric Voice Handicap Index (pVHI) and emotional impacts of the voice disorders on the child’s daily activity. Furthermore, a visual analog scale (VAS, 100 mm long) of parental judgment of the overall voice severity was included (Appendix B). The modified pVHI was administered to two groups of patients. IRB approval was obtained for administration of the pVHI and data analysis.
2.2. Test—retest reliability Ten parents of patients undergoing airway reconstruction at the Cincinnati Children’s Hospital Medical Center were randomly selected to serve as subjects for the test—retest reliability evaluation. These 10 parents were asked to fill out a second survey within a week of the original office visit, without their child having undergone intervening surgical, medical or behavioral treatment. All surveys were returned within 3 weeks.
79 Table 1 A comparison of the mean scores obtained for the control group and the dysphonic group of airway patients Scale
Functional Physical Emotional
1.47 0.20 0.18
13.94 15.48 12.15
The values reflect the pVHI subscales, total scores and overall severity (as calculated from the visual analog scale (VAS)). a A diverse group of dysphonic airway patients.
control group on each subscale and on the total scores. The mean scores obtained for the control group were 1.47 (functional), 0.20 (physical), 0.18 (emotional) and 1.84 (total). The mean scores obtained for the diverse group of dysphonic airway patients were 13.94 (functional), 15.48 (physical), 12.15 (emotional) and 41.58 (total). The mean VAS severity score in the airway population was 52.91 (out of a total of 100).
3.1. pVHI development
3.2. Test—retest reliability
3.1.1. Control group Normative data was obtained from 45 parents of children with no present or past history of a voice disorder, hearing loss, or related disability that affected the child’s voice or speech. The group consisted of 21 males and 24 females, age ranges 3—12 years old. Parents of children who were younger than 3 years of age were not included. Participants were selected from parents whose children attended area schools, religious organizations, and recreational facilities.
Test—retest reliability of the total pVHI score and the subscales was measured using Pearson’s correlation coefficient (Fig. 1). The test—retest stability was confirmed for the functional (r = 0.95), physical (r = 0.77), emotional (r = 0.79) and total (r = 0.82) components. Each of these correlations was highly significant ( p < 0.01). The VAS of overall severity had the lowest test—retest reliability score (r = 0.71, p = 0.02). Paired t-tests on the test—retest data showed no significant difference — no evidence that the mean scores changed — for any pVHI scale or the VAS ( p > 0.1).
3.1.2. Dysphonia group This group consisted of 33 parents or legal guardians of children from the treatment seeking population presenting for laryngotracheal reconstruction and/ or voice evaluation following reconstruction at the Cincinnati Children’s Hospital Medical Center (CCHMC) Department of Otolaryngology. All children had the diagnosis of subglottic stenosis secondary to prolonged intubation. Excluded were surveys of children younger than 3 years of age or those who lacked functional voicing capabilities (e.g. secondary to severe laryngotracheal stenosis, neurological, pulmonary, systemic disease/disorder). The age range was 4—21 years (mean = 11). The mean scores of the total pVHI and its subscales for the control group are shown in Table 1. The dysphonia group differed greatly from the
Fig. 1 Test—retest reliability of the total pVHI score and the subscales was measured using Pearson’s correlation coefficient. The test—retest stability was confirmed for the functional (0.95), physical (0.77), emotional (0.79) and total (0.82) components. The VAS (visual analog scale) of overall severity had the lowest test—retest reliability score (0.71).
Fig. 2 A correlation matrix for pVHI subscore and total score. The functional and emotional subsets had the highest correlation of 0.86. These correlations are similar to those reported by Jacobson et al.  for the adult VHI.
A correlation matrix for pVHI subscore and total score was analyzed, showing the magnitude of correlation between the pVHI subsets. The correlation between the function, emotional and physical scores among the dysphonic airway patients was moderate with scores ranging from 0.59 to 0.86. The functional and emotional subsets had the highest correlation of 0.86. The lowest correlation was between the functional and physical subsets. These correlations are similar to those reported by Jacobson et al.  for the adult VHI (Fig. 2). The relationship of the overall voice severity and total pVHI score was examined. The visual analog scale (VAS) overall severity of voice reported by the parent had a moderate correlation with the total pVHI score (r = 0.66). There was a moderate-high stability of VAS test—retest (r = 0.71).
4. Conclusions The aim of the present study was to modify the commonly used VHI to serve a similar role in the evaluation of the effects of dysphonia on the pediatric population. The statistical results reveal that the adult VHI and pVHI scores are highly comparable (Fig. 2). We found that the pVHI provided a high internal consistency and test—retest reliability. This tool will be utilized to follow the emotional, physical and functional aspects of a child’s development following surgical, medical and behavioral interventions. The limitations of this study are its small sample size, which is inherent to the selective population of dysphonic patients evaluated at Cincinnati Children’s Hospital Medical Center. Furthermore, the validation process was focused on the children undergoing evaluation or post-operative follow-up of laryngotracheal stenosis and reconstruction. Exclusion of the results of other types of dysphonic
K.B. Zur et al. patients (those due to vocal fold paralysis, psychogenic origin, papillomatosis, and benign lesions) was necessary in this particular study due to the limited amount of patients with these pathologies seen in our specialized Voice Center. Further analysis of dysphonia in children with these other pathologies is underway. Preliminary data from seven non-airway children with dysphonia revealed that the pVHI scores of these few patients with benign vocal fold pathologies were lower than the airway group of patients. The age distribution was 4—13 years (mean = 9). The mean scores obtained for this small and diverse group were 27.9 (total pVHI), 8 (functional), 14 (physical) and 6 (emotional). The pVHI stands to become an important tool that should be incorporated into the comprehensive evaluation of any pediatric dysphonia patient. Results can be used to expand our current knowledge regarding the effects of a pediatric voice disorder on a child’s social, emotional and educational well being as well as empower treatment advocacy.
Acknowledgment The authors are indebted to Roger R. Marsh, Ph.D. (Children’s Hospital of Philadelphia) for the statistical analysis of the data.
Appendix A. Pediatric voice clinic: parent questionnaire The following is a list of questions regarding the impact of your child’s voice quality on his/her overall communication, development, education, social and family life. Any input or insight you have will be a great help to the CCHMC voice team: 1. Please describe your child’s voice: 2. Please describe how your child’s voice effects his/her overall ability to communicate within the home: 3. Please describe how your child’s voice effects his/her ability to communicate in social situations (play, recess, with friends): 4. Please describe how your child’s voice effects his/her ability to communicate in educational settings: 5. Are you satisfied with the support your child receives from his/her school regarding voice and communication? 6. If your child has a tracheotomy tube, are you satisfied with the level of support and care you receive from the schools?
Pediatric Voice Handicap Index (pVHI) 7. Please describe the physical effort (e.g. gets tired, strains) your child experiences when using his/her voice: 8. Do you feel like your child’s voice has an impact on his/her general well-being and development? If yes, how?
81 9. Please describe any concerns your child has about his/her voice (e.g. sometimes embarrassed, sometimes avoids communication, never has a concern): 10. Other comments? Thank you
Appendix B. Pediatric voice handicap index
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