International Journal of Pediatric Otorhinolaryngology (2007) 71, 77—82

www.elsevier.com/locate/ijporl

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 Summary
Voice;
Quality of life; Purpose: The Voice Handicap Index (VHI) is widely used and accepted into adult
Pediatric Voice clinical practice. The present study was initiated to adapt the VHI to the pediatric
Handicap Index; population and to validate it in the form of a parental proxy.
Dysphonia 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: zur@email.chop.edu (K.B. Zur).

0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2006.09.004
78 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 coeffi-
cient. 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 is a four-item parental proxy questionnaire aiming

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 dis-
order or dysphonia, they do not provide information
regarding their impact on a child’s life. Health-
related quality of life can be defined as the ‘‘sub-
jective and objective impact of dysfunction asso-
ciated with illness or injury, medical treatment, and
health care policy’’ [1]. 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 instru-
ments focus on general concepts related to physical
abilities, growth and development, general health
perception [2], autonomy and cognition abilities
[3]. 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 distur-
bance on the child’s social, emotional, and func-
tional 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) [4], voice outcome survey (VOS) [5], and
voice-related quality of life [6]. The VHI is an adult
self-assessment that is considered reliable and valid
[4] 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 [7]. The PVOS
to determine voice-related quality of life. The par-
ent is asked to rate the child’s speaking voice,
strain, limitation in social environment and limita-
tions 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 [8]. An
instrument that can assess the social, emotional,
and academic impact of the voice disorders on
children is an important component of a compre-
hensive 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 state-
ments 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 commu-
nication, 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) 79

and emotional impacts of the voice disorders on the Table 1 A comparison of the mean scores obtained for
child’s daily activity. Furthermore, a visual analog the control group and the dysphonic group of airway
scale (VAS, 100 mm long) of parental judgment patients
of the overall voice severity was included Scale Control Airway a
(Appendix B). Functional 1.47 13.94
The modified pVHI was administered to two Physical 0.20 15.48
groups of patients. IRB approval was obtained for Emotional 0.18 12.15
administration of the pVHI and data analysis.
Total 1.84 41.58
VAS 52.91
2.2. Test—retest reliability
The values reflect the pVHI subscales, total scores and overall
severity (as calculated from the visual analog scale (VAS)).
Ten parents of patients undergoing airway recon- a
A diverse group of dysphonic airway patients.
struction at the Cincinnati Children’s Hospital Med-
ical Center were randomly selected to serve as
subjects for the test—retest reliability evaluation. control group on each subscale and on the total
These 10 parents were asked to fill out a second scores. The mean scores obtained for the control
survey within a week of the original office visit, group were 1.47 (functional), 0.20 (physical), 0.18
without their child having undergone intervening (emotional) and 1.84 (total). The mean scores
surgical, medical or behavioral treatment. All sur- obtained for the diverse group of dysphonic airway
veys were returned within 3 weeks. 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
3. Results (out of a total of 100).

3.1. pVHI development 3.2. Test—retest reliability

3.1.1. Control group Test—retest reliability of the total pVHI score and
Normative data was obtained from 45 parents of the subscales was measured using Pearson’s correla-
children with no present or past history of a voice tion coefficient (Fig. 1). The test—retest stability
disorder, hearing loss, or related disability that was confirmed for the functional (r = 0.95), physical
affected the child’s voice or speech. The group (r = 0.77), emotional (r = 0.79) and total (r = 0.82)
consisted of 21 males and 24 females, age ranges components. Each of these correlations was highly
3—12 years old. Parents of children who were significant ( p < 0.01). The VAS of overall severity
younger than 3 years of age were not included. had the lowest test—retest reliability score
Participants were selected from parents whose chil- (r = 0.71, p = 0.02). Paired t-tests on the test—ret-
dren attended area schools, religious organizations, est data showed no significant difference — no
and recreational facilities. 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 laryngotra-
Fig. 1 Test—retest reliability of the total pVHI score and
cheal stenosis, neurological, pulmonary, systemic
the subscales was measured using Pearson’s correlation
disease/disorder). The age range was 4—21 years coefficient. The test—retest stability was confirmed for
(mean = 11). the functional (0.95), physical (0.77), emotional (0.79)
The mean scores of the total pVHI and its sub- and total (0.82) components. The VAS (visual analog scale)
scales for the control group are shown in Table 1. of overall severity had the lowest test—retest reliability
The dysphonia group differed greatly from the score (0.71).
80
Fig. 2 A correlation matrix for pVHI subscore and total
score. The functional and emotional subsets had the high-
est correlation of 0.86. These correlations are similar to
those reported by Jacobson et al. [4] for the adult VHI.
A correlation matrix for pVHI subscore and total
score was analyzed, showing the magnitude of cor-
relation 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 high-
est correlation of 0.86. The lowest correlation was
between the functional and physical subsets. These
correlations are similar to those reported by Jacob-
son et al. [4] 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 pedia-
tric 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 devel-
opment 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 Chil-
dren’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, psycho-
genic 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-air-
way 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 eva-
luation 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 statis-
tical 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 over-
all 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 situa-
tions (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) 81

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 develop-
ment? If yes, how?
9. Please describe any concerns your child has
about his/her voice (e.g. sometimes embar-
rassed, sometimes avoids communication,
never has a concern):
10. Other comments?
Thank you

Appendix B. Pediatric voice handicap index

82
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