Research Article| Volume 27, ISSUE 5, P579-588, September 2013

Download started.


Functional Hoarseness in Children: Short-Term Play Therapy With Family Dynamic Counseling as Therapy of Choice

  • Jürg Kollbrunner
    Address correspondence and reprint requests to Jürg Kollbrunner, Division of Phoniatrics, Department of Otorhinolaryngology, Head Neck Surgery, Inselspital, Freiburgstrasse, CH-3010 Bern, Switzerland.
    Division of Phoniatrics, Department of Otorhinolaryngology, Head Neck Surgery, Inselspital, Bern, Switzerland
    Search for articles by this author
  • Eberhard Seifert
    Department of Otorhinolaryngology, University Hospital Berne, Bern, Switzerland
    Search for articles by this author


      Children with nonorganic voice disorders (NVDs) are treated mainly using direct voice therapy techniques such as the accent method or glottal attack changes and indirect methods such as vocal hygiene and voice education. However, both approaches tackle only the symptoms and not etiological factors in the family dynamics and therefore often enjoy little success. The aim of the “Bernese Brief Dynamic Intervention” (BBDI) for children with NVD was to extend the effectiveness of pediatric voice therapies with a psychosomatic concept combining short-term play therapy with the child and family dynamic counseling of the parents. This study compares the therapeutic changes in three groups where different procedures were used, before intervention and 1 year afterward: counseling of parents (one to two consultations; n = 24), Brief Dynamic Intervention on the lines of the BBDI (three to five play therapy sessions with the child plus two to four sessions with the parents; n = 20), and traditional voice therapy (n = 22). A Voice Questionnaire for Parents developed by us with 59 questions to be answered on a four-point Likert scale was used to measure the change. According to the parents' assessment, a significant improvement in voice quality was achieved in all three methods. Counseling of parents (A) appears to have led parents to give their child more latitude, for example, they stopped nagging the child or demanding that he/she should behave strictly by the rules. After BBDI (B), the mothers were more responsive to their children's wishes and the children were more relaxed and their speech became livelier. At home, they called out to them less often at a distance, which probably improved parent-child dialog. Traditional voice therapy (C) seems to have had a positive effect on the children's social competence. BBDI seems to have the deepest, widest, and therefore probably the most enduring therapeutic effect on children with NVD.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Voice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Connor N.P.
        • Cohen S.B.
        • Theis S.M.
        • Thibeault S.L.
        • Heatley D.G.
        • Bless D.M.
        Attitudes of children with dysphonia.
        J Voice. 2008; 22: 197-209
        • Schwartz S.R.
        • Cohen S.M.
        • Dailey S.H.
        • et al.
        Clinical practice guideline: hoarseness (dysphonia).
        Otolaryngol Head Neck Surg. 2009; 141: S1-S31
        • Fuchs M.
        • Meuret S.
        • Stuhrmann N.C.
        • Schade G.
        Stimmstörungen bei Kindern und Jugendlichen.
        HNO. 2009; 57 ([In German]): 603-614
        • Verduyckt I.
        • Remacle M.
        • Jamart J.
        • Benderitter C.
        • Morsomme D.
        Voice-related complaints in the pediatric population.
        J Voice. 2011; 25: 373-380
        • Duff M.C.
        • Proctor A.
        • Yairi E.
        Prevalence of voice disorders in African American and European American preschoolers.
        J Voice. 2004; 18: 348-353
        • Nicollas R.
        • Giovanni A.
        • Triglia J.-M.
        Les dysphonies de l'enfant.
        Arch Pédiatr. 2008; 15 ([In French]): 1133-1138
        • Mortensen M.
        • Schaberg M.
        • Woo P.
        Diagnostic contributions of videolaryngostroboscopy in the pediatric population.
        Arch Otolaryngol Head Neck Surg. 2010; 136: 75-79
        • Dejonckere P.H.
        Pathogenesis of voice disorders in childhood.
        Acta Otorhinolaryngol Belg. 1984; 38: 307-314
        • McMurray J.S.
        Disorders of phonation in children.
        Pediatr Clin North Am. 2003; 50: 363-380
        • Connelly A.
        • Clement W.A.
        • Kubba H.
        Management of dysphonia in children.
        J Laryngol Otol. 2009; 123: 642-647
        • Ulis J.M.
        • Yanagisawa E.
        What's new in differential diagnosis and treatment of hoarseness?.
        Curr Opin Otolaryngol Head Neck Surg. 2009; 17: 209-215
        • Wohl D.L.
        Nonsurgical management of pediatric vocal fold nodules.
        Arch Otolaryngol Head Neck Surg. 2005; 131: 68-70
        • Lee E.K.
        • Son Y.l.
        Muscle tension dysphonia in children: voice characteristics and outcome of voice therapy.
        Int J Pediatr Otorhinolaryngol. 2005; 69: 911-917
        • Roy N.
        • Holt K.I.
        • Redmond S.
        • Muntz H.
        Behavioral characteristics of children with vocal fold nodules.
        J Voice. 2007; 21: 157-168
        • Tezcaner C.Z.
        • Ozgursoy S.K.
        • Sati I.
        • Dursun G.
        Changes after voice therapy in objective and subjective voice measurements of pediatric patients with vocal nodules.
        Eur Arch Otorhinolaryngol. 2009; 266: 1923-1927
        • Trani M.
        • Ghidini A.
        • Bergamini G.
        • Presutti L.
        Voice therapy in pediatric functional dysphonia: a prospective study.
        Int J Pediatr Otorhinolaryngol. 2007; 71: 379-384
        • Van Houtte E.
        • Van Lierde K.
        • Claeys S.
        Pathophysiology and treatment of muscle tension dysphonia: a review of the current knowledge.
        J Voice. 2011; 25: 202-207
        • Schindler A.
        • Capaccio P.
        • Maruzzi P.
        • Ginocchio D.
        • Bottero A.
        • Otraviani F.
        Preliminary considerations on the application of the voice handicap index to paediatric dysphonia.
        Acta Otorhinolaryngol Ital. 2007; 27: 22-26
        • Hartnick C.J.
        Validation of a pediatric voice quality-of-life instrument: the pediatric voice outcome survey.
        Arch Otolaryngol Head Neck Surg. 2002; 128: 919-922
        • Zur K.B.
        • Cotton S.
        • Kelchner L.
        • Baker S.
        • Weinrich B.
        • Lee L.
        Pediatric Voice Handicap Index (pVHI): a new tool for evaluating pediatric dysphonia.
        Int J Pediatr Otorhinolaryngol. 2007; 71: 77-82
        • Merati A.I.
        • Keppel K.
        • Braun N.M.
        • Blumin J.H.
        • Kerschner J.E.
        Pediatric Voice-Related-Quality of Life: findings in healthy children and in common laryngeal disorders.
        Ann Otol Rhinol Laryngol. 2008; 117: 259-262
        • Verduyckt I.
        • Morsomme D.
        • Remacle M.
        Validation and standardization of the Pediatric Voice Symptom Questionnaire: a double-form questionnaire for dysphonic children and their parents.
        J Voice. 2012; 26: e129-e139
        • Patel R.R.
        • Bless D.M.
        • Thibeault S.L.
        Boot camp: a novel intensive approach to voice therapy.
        J Voice. 2011; 25: 562-569
        • Mori K.
        Vocal fold nodules in children: preferable therapy.
        Int J Pediatr Otorhinolaryngol. 1999; 49: S303-S306
        • Kollbrunner J.
        Funktionelle Dysphonien bei Kindern. Ein psycho- und familiendynamischer Therapieansatz.
        Schulz-Kirchner, Idstein, Germany2006 ([In German])
        • Toohill R.J.
        The psychosomatic aspects of children with vocal nodules.
        Arch Otolaryngol. 1975; 101: 591-595
        • Carding P.N.
        • Roulstone S.
        • Northstone K.
        • ALSPAC Study Team
        The prevalence of childhood dysphonia: a cross-sectional study.
        J Voice. 2006; 20: 623-630
        • Beushausen U.
        Therapeutische Entscheidungsfindung in der Sprachtherapie. Grundlagen und 14 Fallbeispiele.
        Urban & Fischer/Elsevier, München, Germany2009 ([In German])
        • Signorelli M.E.
        • Madill C.J.
        • McCabe P.
        The management of vocal fold nodules in children: a national survey of speech-language pathologists.
        Int J Speech Lang Pathol. 2011; 13: 227-238
        • Nienkerke-Springer A.
        • McAllister A.
        • Sundberg J.
        Effects of family therapy on children's voices.
        J Voice. 2005; 19: 103-113
        • Hamdan A.L.
        • Deeb R.
        • Sibai A.
        • Rameh C.
        • Rifai H.
        • Fayyad J.
        Vocal characteristics in children with attention deficit hyperactivity disorder.
        J Voice. 2009; 23: 190-194
        • Baker J.
        The role of psychogenic and psychosocial factors in the development of functional voice disorders.
        Int J Speech Lang Pathol. 2008; 10: 210-230
        • O'Hara J.
        • Miller T.
        • Carding P.
        • Wilson J.
        • Deary V.
        Relationship between fatigue, perfectionism, and functional dysphonia.
        Otolaryngol Head Neck Surg. 2011; 144: 921-926
        • Deary V.
        • Miller T.
        Reconsidering the role of psychosocial factors in functional dysphonia.
        Curr Opin Otolaryngol Head Neck Surg. 2011; 19: 150-154
        • House A.O.
        • Andrews H.B.
        Life events and difficulties preceding the onset of functional dysphonia.
        J Psychosom Res. 1988; 32: 311-319
        • Daniilidou P.
        • Carding P.
        • Wilson J.
        • Drinnan M.
        • Deary V.
        Cognitive behavioral therapy for functional dysphonia: a pilot study.
        Ann Otol Rhinol Laryngol. 2007; 116: 717-722
        • Kollbrunner J.
        • Menet A.-D.
        • Seifert E.
        Psychogenic aphonia: no fixation even after a lengthy period of aphonia.
        Swiss Med Wkly. 2010; 140: 12-17
        • Nienkerke-Springer A.
        Die Kinderstimme - Ein systemischer Förderansatz.
        Luchterhand, Neuwied, Germany2000 ([In German])
        • Rubin J.S.
        • Greenberg M.
        Psychogenic voice disorders in performers: a psychodynamic model.
        J Voice. 2002; 16: 544-548
        • Axline V.M.
        Kinder-Spieltherapie im nicht-direktiven Verfahren.
        Ernst Reinhard, München, Germany1997 ([In German])
        • Krucker W.
        Spielen als Therapie – ein szenisch-analytischer Ansatz zur Kinderpsychotherapie.
        Pfeiffer, München, Germany1997 ([In German])
        • Goetze H.
        Handbuch der personenzentrierten Spieltherapie.
        Hogrefe, Göttingen, Germany2002 ([In German])
        • Kurz F.
        Zur Sprache kommen. Psychoanalytisch orientierte Sprachtherapie mit Kindern.
        Ernst Reinhard, München, Germany1993 ([In German])
        • Schneider B.
        • Wendler J.
        • Seidner W.
        The relevance of stroboscopy in functional dysphonias.
        Folia Phoniatr Logop. 2002; 54: 44-54
        • Santos M.A.
        • Moura J.M.
        • Duprat A.C.
        • Costa H.O.
        • de Azevedo B.B.
        The interference of voice change on structural vocal cords lesions.
        Braz J Otorhinolaryngol. 2007; 73: 226-230
        • De Bodt M.S.
        • Ketelslagers K.
        • Peeters T.
        • et al.
        Evolution of vocal fold nodules from childhood to adolescence.
        J Voice. 2007; 21: 151-156
        • Abresch J.
        Stimmstörung als Krisenvertonung. Über biographische Einflüsse auf die Gewordenheit unserer Stimme und über die Entstehung funktioneller Stimmstörungen.
        Integr Ther. 1988; 1 ([In German]): 40-62
        • Mans E.J.
        Psychotherapeutische Behandlung von Patienten mit funktionellen Stimmstörungen.
        Folia Phoniatr Logop. 1994; 46 ([In German]): 1-8
        • Fuchs M.
        Alters- und entwicklungsentsprechende Diagnostik und Therapie von Stimmstörungen bei Kindern und Jugendlichen (Teil 2).
        Laryngorhinootologie. 2008; 87 ([In German]): 86-91
        • Muck O.
        Heilungen von schwerer funktioneller Aphonie.
        MMW. 1916; 63 ([In German]): 441
        • Angelillo N.
        • Di Costanzo B.
        • Angelillo M.
        • Costa G.
        • Barillari M.R.
        • Barillari U.
        Epidemiological study on vocal disorders in paediatric age.
        J Prev Med Hyg. 2008; 49: 1-5