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Characteristics and Professional Use of Voice in Street Children in Aracaju, Brazil
Characteristics and Professional Use of Voice in Street Children in Aracaju, Brazil *Neuza Josina Sales, †Ricardo Queiroz Gurgel, ‡Maria Ineˆs Rebelo Gonc¸alves, §Edı´lson Cunha, §Valeria Maria Prado Barreto, kJoa˜o Carlos Todt Neto, and *Jeferson Sampaio D’Avila, *yxkSergipe and zSa˜o Paulo, Brazil
Summary: The objective of the study was to evaluate voice characteristics of children engaged in street selling, which involves an essentially professional use of voice in this population. A controlled cross-sectional study was carried out. A randomly chosen sample of 200 school children with a history of street selling assisted by public social services and 400 school children without this experience was selected. Seven- to 10-year-old children of both sexes were studied. Both groups were interviewed and given vocal assessment (auditory-perceptual assessment and spectrographic acoustic measures) and otorhinolaryngological evaluation (physical and videonasolaryngoscopic examination). Children with abnormal results in both groups were compared using c2 (Chi-squared test). The significance level was established at 5% (P < 0.05). Voice problems were detected more frequently in working children (106–53%) than in regular school children (90–22.5%). The control group achieved better school performance as more children in this group attend school regularly than street children, although age-for-grade deficit was similar. The control group had more access to medical visits (80–40%) and treatment with a doctor (34–17%). Language assessment has shown that the control group had more dysphonia (73–37%) and myofunctional orofacial disorders (20–10%). Street children had more normal voice but had more nasal disorders and greater glottal closure than the school control group. Voice disorders were present in both groups, but less frequently in street children. Although subject to inadequate living conditions, street children had better voice quality than the control group. An explanation could be that by adapting their voice professionally for selling goods in the streets, they developed adequate resilience to their difficult living conditions. Key Words: School children–Street children–Voice characteristics–Dysphonia–Professional voice. INTRODUCTION Social groups make use of speech in their interpersonal relations within familiar, social, leisure, and work settings.1 Living and working conditions may interfere and change the professional use of speech, quality of voice, and quality of health in specific groups.2–4 The voice is unique for each individual and can be modified dynamically by anatomical and physiological factors, as well as by the psychological and sociocultural environment as well as each individual’s particularity.5,6 Dysphonia is the expression of unhealthy voice comportment and allows disturbances to be identified and addressed. Most studies point to a wide variation on dysphonia incidence in school children, varying from 0.12% to 78%.6–10 In Brazil and other developing countries, children in early living contact with the streets is a common situation, and it is found that more than 150 million children live and work in the streets of these countries.11,12 Street child labor brings potential physical and psychological damage to the children during their vulnerable period where immaturity of the organs and the psychological structure prevails.13,14
Accepted for publication December 9, 2008. From the *Department of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil; yDepartment of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil; zDepartment of Speech-Language Pathology, Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil; xDepartment of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil; and the kDepartment of Otorhinolaryngological, Sa˜o Lucas Hospital, Aracaju, Sergipe, Brazil. Address correspondence and reprint requests to Ricardo Queiroz Gurgel, Av Beira Mar 2016/402, Bairro 13 de Julho, Aracaju, Sergipe 49025 040, Brazil. E-mail: ricardoqg@ infonet.com.br Journal of Voice, Vol. 24, No. 4, pp. 435-440 0892-1997/$36.00 Ó 2010 The Voice Foundation doi:10.1016/j.jvoice.2008.12.007
In Aracaju, Northeast Brazil, the estimated number of street children was calculated to be over 1500 in 2004.15,16 There are some studies evaluating the causal and maintaining factors for, and psychological and biological interference of, street-living situation on the development of children and adolescents.14,17–19 Otherwise, studies linking street-living situation and quality of voice could not be found, and the evaluation of the impact of voice quality on health condition is not well studied. This study aims to evaluate the voice quality and characteristics of a group of children with street-selling experience as opposed to a group of children without this experience. METHODS A cross-sectional controlled study was undertaken with 7– 10-year-old children of both sexes, with voice disorder identified during voice screening. This age range was selected because they were at school age and before puberty, where the physiological changes that occur would interfere with voice characteristics. Both groups, at the time of data collection, lived with their families and attended school regularly, but in one group, there was a clear history of child labor20 in street selling and no such history in the other. The former street children group was assisted by the Child Labour Elimination Programme (Programa de Erradicac¸a˜o do Trabalho Infantil [PETI]),21 during the year 2005, when data were collected. From the 600 children assisted in this program, we chose 200 randomly to constitute the study group (street children). The control group was selected from city public schools located in the same area where street children live, matched by age and sex in a 2:1 basis. Both groups attend public schools of Aracaju, the capital city of Sergipe state, in Northeast Brazil. Aracaju has a population of 520 303, and is considered
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to have better social indicators within the capital cities in the region.12 Initially, all children were submitted to an interview and individual vocal screening with a speech-language pathologist. The ones identified as having a voice disorder were assessed using the GRBAS Scale22 to evaluate the auditory perception, voice type, and deviation classification. In a normal conversation, /e/ vowel during sustained emission was evaluated and classified according to GRBAS protocol, where ‘‘G’’ indicates grade of dysphonia level, ‘‘R’’ indicates roughness, ‘‘B’’ represents breathiness (air sensation on voice), ‘‘A’’ indicates asthenia (voice weakness), and ‘‘S’’ represents strain (larynx constriction). The level of severity was recorded using a 4-point scale, where ‘‘0’’ was normal, ‘‘1’’ was mild deviation;‘‘2’’ was moderate deviation, and ‘‘3’’ was severe deviation. During normal conversation, other communication disorders, such as myofunctional orofacial, speech and hearing disorders could be evaluated. A clinical and videonasolaryngoscopic examination during otolaryngological evaluation was performed according to previous techniques23,24 using breathing (inspiration and expiration) to evaluate median posterior glottal closure and glottal emission of /e/, and /i/. Examination was carried on with the child sitting on the parent’s lap after local anesthesia of left nasal passage. Laryngeal images and voice characteristics were recorded in a video home system (VHS) tape for later evaluation. Differences between group categories were evaluated using chisquared test (c2), considering P < 0.05 as significant.25 Ethics Committee of Federal University of Sergipe approved the study (protocol number: 11/2004), and all parents of students signed written consent for their children to participate. RESULTS During the screening for voice disorders, street children had a significantly higher proportion of voice problems identified (53% as opposed to 22.5%) than controls (Table 1). After screening, group composition changed, with street children having similar sex distribution (males, 49%; females, 51%) and average age of 9 years, but in the control group, males predominated (73.3 3 27.7%) and the average age was 8.4 years (not significant). Most street children (88%) were enrolled at PETI for 1–2 years but still worked during the other period of the day (60%) and weekends (66%). School performance was different in the two groups. The control group attended school everyday (42%), which ex-
TABLE 1. Voice Disorders Detected During Screening Absent
Present
Total
Groups
N (%)
N (%)
N (%)
Street children Control group Total
94 (47) 310 (77.5) 404 (67.3)
106 (53) 90 (22.5) 196 (31.7)
200 (100) 400 (100) 600 (100)
P < 0.0001.
TABLE 2. School Performance in Street Children and Control Group in Aracaju
Variables
Street Children
Control Group
Total
n (%)
n (%)
n (%)
c2
102 (52) 94 (48) 196 (100)
0.76 (ns)
78 (40) 118 (60) 196 (100)
1.98 (ns)
50 (64) 19 (24) 9 (12) 78 (100)
5.03 (ns)
Age-for-grade deficit Yes 58 (30) 44 (22) No 48 (24) 46 (24) Total 106 (54) 90 (46) Deficit because of retention Yes 47 (24) 31 (16) No 59 (30) 59 (30) Total 106 (54) 90 (46) Number of years lost 1 26 (33) 24 (31) 2 13 (16) 6 (8) >2 8 (11) 1 (1) Total 47 (60) 31 (40) School attendance 1–2 d 4 (2) 2 (1) 3–4 d 61 (32) 9 (5) Daily 33 (18) 79 (42) Total 98 (52) 90 (48) Enjoy school Yes 73 (37) 90 (46) No 33 (17) 0 Total 106 (54) 90 (46)
6 (3) 70 (37) 112 (60) 188 (100)
57.95*
163 (83) 33 (17) 196 (100)
33.7*
Abbreviation: ns, not significant. * P < 0.001.
ceeded that by street children (18%) (P < 0.001), but school age-for-grade deficit was similar for both groups (Table 2). All the control group students referred enjoyed attending school, whereas only 73 out of 106 street children enjoyed attending school (P < 0.001). Otorhinolaryngological evaluation outcome was significantly different within the two groups. The street children group had a higher proportion (P < 0.05) of nasal disorders (34 3 23%) and posterior medium triangular glottal closure (20 3 16%), but the control group had significantly (P < 0.001) more palatal tonsil hypertrophy (12 3 9%). Other disorders, including those of nose, larynx, and hearing, were not different in the two groups (Table 3). When evaluated using GRBAS Scale, the street children had more normal (20%) or mild degree (21%) than the control group (P < 0.01). The latter presented a significantly higher proportion of moderate roughness (38%), mild to moderate breathiness (34%), and moderate strain voice (37%) when compared with the street children group (Table 4). Communication and hearing disorders were significantly different within the two groups. The control group presented significantly more dysphonia (37 3 34%) and myofunctional orofacial disorders (10 3 6%). There were no differences between the groups on speech disorders and hearing impairment (Table 5).
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TABLE 3. Vocal Tract Disorders in Street Children and Control Students in Aracaju
Involved Segment Otologic disorders Yes No Total Nasal disorders Yes No Total Pharyngeal disorders Yes No Total Palatal tonsil hypertrophy Yes No Total Pharyngeal tonsil hypertrophy Yes No Total Posterior medioglottal closure Yes No Total Laryngeal constriction Yes No Total Laryngeal nodules Yes No Total Laryngitis Yes No Total Laryngeal edema Yes No Total Gastroesophageal reflux Yes No Total Vocal fold cyst Yes No Total
Street Children
Control Group
Total
n (%)
n (%)
n (%)
c2
7 (4) 96 (64) 103 (68)
5 (4) 42 (28) 47 (32)
12 (8) 138 (92) 150 (100)
0.64 (ns)
52 (34) 51 (34) 103 (68)
34 (23) 13 (9) 47 (32)
86 (57) 64 (43) 150 (100)
6.3*
70 (46) 33 (22) 103 (68)
33 (22) 14 (10) 47 (32)
103 (69) 47 (31 150 (100)
0.07 (ns)
14 (9) 89 (59) 103 (68)
18 (12) 29 (20) 47 (32)
32 (21) 118 (79) 150 (100)
69 (46) 34 (22) 103 (68)
31 (21) 16 (11) 47 (32)
100 (67) 50 (33) 150 (100)
0.02 (ns)
30 (20) 73 (48) 103 (68)
23 (16) 24 (16) 47 (32)
53 (36) 9 (6) 150 (100)
5.54*
10 (6) 93 (22) 103 (68)
8 (5) 39 (27) 47 (32)
18 (11) 132 (89) 150 (100)
1.63 (ns)
41 (27) 62 (41) 103 (68)
20 (14) 27 (18) 47 (32)
61 (40) 89 (60) 150 (100)
0.10 (ns)
12 (8) 91 (60) 103 (68)
2 (2) 45 (30) 47 (32)
14 (10) 136 (90) 150 (100)
2.08 (ns)
5 (3) 98 (65) 103 (68)
6 (4) 41 (28) 47 (32)
11 (7) 139 (93) 150 (100)
2.97 (ns)
9 (6) 94 (62) 103 (68)
2 (2) 45 (30) 47 (32)
11 (8) 139 (92) 150 (100)
0.95 (ns)
10 (6) 93 (62) 103 (68)
5 (4) 42 (28) 47 (32)
15 (10) 135 (90) 150 (100)
0.03 (ns)
11.74y
Abbreviation: ns, not significant. * P < 0.05. y P < 0.001.
DISCUSSION Till date, children living and/or working in the streets is a common situation in Brazil,12 and in Sergipe, an estimated
1500 children live in the streets.15,16 These children are exposed to a high level of stress, including physical (accidents and aggressions, transmissible diseases) and psychological
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TABLE 4. Voice Assessment Using GRBAS Scale Street Children Variables
n (%)
(G) Grade 0 40 (20) 1 41 (21) 2 25 (13) Total 106 (54) (R) Roughness level 0 40 (20) 1 38 (19) 2 28 (15) Total 106 (54) (B) Breathiness level 0 54 (27) 1 27 (14) 2 25 (13) Total 106 (54) (A) Asthenic level 0 103 (52.5) 1 2 (1) 2 1 (0.5) Total 106 (54) (S) Strain level 0 39 (20) 1 34 (17) 2 33 (17) Total 106 (54)
Control Group
TABLE 5. Speech-Language Pathologist Diagnosis
Total 2
n (%)
n (%)
14 (7) 40 (20) 36 (19) 90 (46)
54 (27) 81 (41) 61 (32) 196 (100)
13.29*
16 (8) 37 (19) 37 (19) 90 (46)
56 (28) 75 (38) 65 (34) 196 (100)
10.31*
23 (12) 32 (16) 35 (18) 90 (46)
77 (39) 59 (30) 60 (31) 196 (100)
13.35*
90 (46) 0 0 90 (46)
193(98.5) 2 (1) 1 (0.5) 196 (100)
2.58 (ns)
18 (9) 30 (15) 42 (22) 90 (46)
57 (29) 64 (32) 75 (39) 196 (100)
7.81y
c
Abbreviation: ns, not significant. Significant Ps are in bold. Roughness refers to hoarseness and roughness of the voice. * P < 0.01. y P < 0.05.
(sexual exploitation and abuse) stress. There is a daily, widespread tension, which may negatively interfere with speech expression. The group of street children assessed in this study continues to work in the streets selling goods and delivering personal services to costumers despite being enrolled in aid programs and living with their parents. Although they are vulnerable to different kinds of aggressions, they develop skills and create emotional, economical, and social links to help them cope with the situation.13,14 Our study group attends PETI activities in the other day period when they are not at school. There, they develop social activities, sports, and arts, contributing to reduce their vocal tension and facilitating socioeducational inclusion and improving self-esteem, besides limiting their stay in the streets. This does not seem to be enough to protect the voice quality as they presented more vocal disorders than control school children. Worse access to health facilities seems to explain this finding.15 Their families received income supplementation, and it would be anticipated that these children did not go to the streets. This expectation is not always confirmed and
Functional Disorders Dysphonia Yes No Total Myofunctional orofacial disorders Yes No Total Speech disorders Yes No Total Hearing functional impairment Yes No Total
Street Children
Control Group
Total
n (%)
n (%)
n (%)
c2
67 (34) 39 (20) 106 (54)
73 (37) 17 (9) 90 (46)
140 (71) 7.64* 56 (29) 196 (100)
11 (6) 95 (48) 106 (54)
20 (10) 70 (36) 90 (46)
31 (16) 5.12y 165 (84) 106 (100)
2 (1) 104 (53) 106 (54)
1 (0.5) 3 (1.5) 0.19 (ns) 89 (45.5) 193 (98.5) 90 (46) 196 (100)
0 106 (54) 106 (54)
0 90 (46) 90 (46)
0 — 196 (100) 196 (100)
Abbreviation: ns, not significant. * P < 0.01. y P < 0.05.
many children keep working, making school grade/age discrepancy higher than that in controls. In Joa˜o Pessoa (800 km from Aracaju), similar results26 were found, including grade/age discrepancy. This phenomenon is common in Brazilian public schools12 demanding continuous investment to guarantee better quality in public education. Several studies show that voice and speech skills may be adapted to the context and to the subject of communication,2,27 but an intense daily and long-term vocal demand may promote hyperfunction on vocal muscles leading to vocal fatigue and speech and vocal tract disorders. In our study, both groups had vocal impairments, but the control group presented significantly worse quality of voice than the street children group. We speculate that the members of this group develop protective mechanisms to their vocal health in a demonstration of resilience to the street situation. This phenomenon has been shown in other situations.17,19 To facilitate approach to costumers and to be successful in their working activities, street children educate and protect their voices, making them more intimate and seductive, rather than invasive, weak, and infantile, in a specific professional configuration adapted to their street labor. Similar adaptive strategies were found elsewhere.13,14 Here the members of the street children group use their voices professionally as sellers to complement family income, characterizing professional use of voice. Voice is, hence, an
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Use of Voice in Street Children
indispensable tool for the professional activity,28 particularly, in case of street child labor. Our street children group justifies its necessity to work to complement family income and considers its activity as regular and mandatory. This seems to be a professional activity despite knowing that vocal expressivity results from sociocultural and educational background of each group.29 The two groups had similar incidents of hearing disorders, vocal fold cyst/nodules, larynx constriction, and gastroesophageal reflux. The street children group presented more nasal disorders associated with medium glottal closure and less tonsil enlargement than the control group. Nasal findings may be because of street exposure, whereas glottal closure is a compensatory mechanism. Tonsil enlargement may explain, in part, the greater incidence of dysphonia in the control group.6,23,24 Although the street group had more vocal disorders detected in the initial screening, they had more normal or mild degrees of evaluations than the control group using GRBAS Scale. These children probably present a different vocal comportment by adapting their speech to the seller activity they perform in the streets. They have a dual experience of adult (professional activity) and child (students) lives and seem to cope well with this as previously reported for street children in other situations.13,14 The control group had increased prevalence of dysphonia and more compromised social and physiological vocal expressivity. This group has limited stimulus to develop its expressivity, as it does not have access to supplementary activities and social support, such as the PETI group. They have access only to classroom activities and few social and familiar supports, and no vocal care. This group showed a larger proportion of hearing and speech disorders, including dysphonia and myofunctional orofacial disorders. Severe hearing and speech impairment was not detected in any group. In another study,30 which used questionnaires given by speech therapists to children who suffered aggressions, a larger proportion of voice development delay was found. In Aracaju, street children admitted to the PETI still work in the streets, although they were supposed to quit this activity when admitted to this program. Street life is usually associated with violence and drug involvement (including glue aspiration), but our children have denied involving in drugs. This seems to be true as they have better voice quality when compared with controls. This study allowed us to evaluate voice quality of children with two different backgrounds where the school and social support program seem to play different roles. Speech therapy and otorhinolaryngological evaluation identified differences between the groups, and the better performance of street children in this evaluation seems to be related to the professional use of voice. The PETI program seems to be important in enabling its participants to adapt, but is not enough to avoid their street exposure. The professional use of voice is a new way to show their resilience to poverty and aggressive environment, and resulted in a better voice quality when compared with regular students. Our group did not examine drug use, which probably would in-
terfere with this performance. In our opinion, it would be more important to improve PETI and other social programs to actually eliminate the street-living situation and child labor in our society. Acknowledgments The authors thank Aracaju city Education Secretary and Social Issues Secretary. They have no competing interests to declare. REFERENCES 1. Penteado RZ, Bicudo-Pereira IMT. Avaliac¸a˜o do impacto da voz na qualidade de vida de professores. Rev Soc Bras de Fonoaud. 2003;8:19-28. 2. Roy N, Merrill RM, Thibeautls S, et al. Voice disorders in teachers and the general population: effects on work performance, attendance and future career choices. J Speech Lang Hear Res. 2004;44:542-552. 3. Grillo MHMM, Penteado RZ. The impact of voice on the quality of life of elementary school teachers. Pro´-Fono Rev de Atual Cient. 2005;17: 321-330. 4. Connor NP, Cohen SB, Theis SM, et al. Attitudes of children with dysphonia. J Voice. 2007;22:197-209. 5. Wertzner HF, Schreiber S, Amaro L. Analysis of the fundamental frequency, jitter, shimmer and vocal intensity in phonological disordered children. Rev Bras Otorrinolaringol. 2005;71:582-588. 6. Jotz GP, Cervantes O, Settani FAP, et al. Acoustic measures for the detection of hoarseness in children. Arq Int Otorrinolaringol/Int Arch Otorhinolaryngol. 2006;10:14-20. 7. Vasilenko Iu S. Vocal problems in children and adolescents. Vestn Otornolaringol. 2005;6:46-48. 8. Carding PN, Roulstone S, Northstone K, et al. The prevalence of childhood dysphonia: a cross-sectional study. J Voice. 2006;20:623-630. 9. Mckinnon DH, Mcleod S, Reilly S. The prevalence of stuttering, voice, and speech-sound disorders in primary school students in Australia. Lang Speech Hear Serv Sch. 2007;38:5-15. 10. Duff MC, Proctor A, Yari E. Prevalence of voice disorders in African American and European American preschoolers. J Voice. 2004;18: 348-353. 11. Scalon TJ, Tomkins A, Lynch MA, et al. Street children in Latin America. BMJ. 1998;316:1596-1600. 12. IBGE. Instituto Brasileiro de Geografia e Estatı´stica. Censo Demogra´fico 2007. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatı´stica, 2007. Available at http://www.ibge.gov.br. Accessed April 22, 2008. 13. Le Roux J, Smith CS. Psychological characteristics of South African street children. Adolescence. 1998;33:891-899. 14. Huang CC, Barreda P, Mendoza V, et al. A comparative analyses of abandoned street children and formerly abandoned street children in La Paz, Bolı´via. Arch Dis Child. 2004;89:821-826. 15. Abdegalil S, Gurgel RQ, Theobalds S, et al. Household and family characteristics of street children in Aracaju, Brazil. Arch Dis Child. 2004;89: 817-820. 16. Gurgel RQ, Castaneda DFN, Gill G, et al. Capture—recapture to estimate the number of street children in a city of Brazil. Arch Dis Child. 2004;89: 222-224. 17. Flores E, Cicchetti D, Rogosch FA. Predictors of resilience in maltreated and nonmaltreated Latini children. Dev Psychol. 2005;4:338-351. 18. Gardner TW, Dishion TJ, Connell AM. Adolescent self-regulation as resilience: resistance to antisocial behavior within the deviante peer context. J Abnorm Child Psychol. 2008;36:273-284. 19. Rew L, Taylor-Seehafer M, Thomas NY, et al. Correlates of resilience in homeless adolescent. J Nurs Scholarsh. 2001;33:33-40. 20. UNICEF (United Nations Children’s Fund). LatinAmerica Seminar on Community Alternatives for Street Children, Brazilia, 1984:12–15. 21. Brasil. Ministe´rio do desenvolvimento social e combate a fome. Programa de Erradicac¸a˜o do Trabalho Infantil. Available at http://www.mds.gov.br/ programas/rede-suas/protec¸a˜o-social-especial/programa-de-errad.-do-trabinfantil-PETI. Accessed May 4, 2008.
440 22. Fex S. Perceptual evaluation. J Voice. 1992;6:155-158. 23. D’Avila J, Naves AB, Chagas L, et al. Adenoidectomia: Novos Princı´pios. Estudo Interdisciplinar. Rev Bras Otorrinolaringol. 1999;66: 511-516. 24. D’Avila JS, Sennes JU, Tsuji DH. Estudo comparativo da microvascularizac¸a˜o das pregas vocais humanas acometidas por cisto e reac¸a˜o nodular contra-lateral sob endoscopia rı´gida. Rev Bras Otorrinolaringol. 2003;69: 166-173. 25. Zar JH. Biostatistical Analysis. New Jersey: Prentice Hall; 1996. Vol. 3: 662. 26. Maciel C, Brito S, Camino L. Caracterizac¸a˜o dos meninos em situac¸a˜o de rua de Joa˜o Pessoa. Psicol Reflex Crı´t. 1997;10:315-334.
Journal of Voice, Vol. 24, No. 4, 2010 27. Behlau M, Hogikyan ND, Gasparini G. Quality of life and voice: study of a Brazilian population using the voice-related quality of life measure. Folia Phoniatr et Logop. 2007;59:286-296. 28. Koufman JA, Isacson G. Voice Disorders. Philadelphia: WB Saunders; 1991. 29. Behlau M, Feijo´ D, Madazio G, Rehder MI, Azevedo R, Ferreira AE. Voz profissional: aspectos gerais e atuac¸a˜o fonoaudiolo´gica. In: Behlau M, eds. Revinter Voz: O livro do especialista. Rio de Janeiro 2005: 2:287–372. 30. Noguchi MS, Assis SG, Malaquias JV. Occurrence of child abuse: knowledge and possibility of action of speech-language pathologists. Pro´-Fono Rev Atua Cient. 2006;18:41-48.
Summary: The objective of the study was to evaluate voice characteristics of children engaged in street selling, which involves an essentially professional use of voice in this population. A controlled cross-sectional study was carried out. A randomly chosen sample of 200 school children with a history of street selling assisted by public social services and 400 school children without this experience was selected. Seven- to 10-year-old children of both sexes were studied. Both groups were interviewed and given vocal assessment (auditory-perceptual assessment and spectrographic acoustic measures) and otorhinolaryngological evaluation (physical and videonasolaryngoscopic examination). Children with abnormal results in both groups were compared using c2 (Chi-squared test). The significance level was established at 5% (P < 0.05). Voice problems were detected more frequently in working children (106–53%) than in regular school children (90–22.5%). The control group achieved better school performance as more children in this group attend school regularly than street children, although age-for-grade deficit was similar. The control group had more access to medical visits (80–40%) and treatment with a doctor (34–17%). Language assessment has shown that the control group had more dysphonia (73–37%) and myofunctional orofacial disorders (20–10%). Street children had more normal voice but had more nasal disorders and greater glottal closure than the school control group. Voice disorders were present in both groups, but less frequently in street children. Although subject to inadequate living conditions, street children had better voice quality than the control group. An explanation could be that by adapting their voice professionally for selling goods in the streets, they developed adequate resilience to their difficult living conditions. Key Words: School children–Street children–Voice characteristics–Dysphonia–Professional voice. INTRODUCTION Social groups make use of speech in their interpersonal relations within familiar, social, leisure, and work settings.1 Living and working conditions may interfere and change the professional use of speech, quality of voice, and quality of health in specific groups.2–4 The voice is unique for each individual and can be modified dynamically by anatomical and physiological factors, as well as by the psychological and sociocultural environment as well as each individual’s particularity.5,6 Dysphonia is the expression of unhealthy voice comportment and allows disturbances to be identified and addressed. Most studies point to a wide variation on dysphonia incidence in school children, varying from 0.12% to 78%.6–10 In Brazil and other developing countries, children in early living contact with the streets is a common situation, and it is found that more than 150 million children live and work in the streets of these countries.11,12 Street child labor brings potential physical and psychological damage to the children during their vulnerable period where immaturity of the organs and the psychological structure prevails.13,14
Accepted for publication December 9, 2008. From the *Department of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil; yDepartment of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil; zDepartment of Speech-Language Pathology, Federal University of Sa˜o Paulo, Sa˜o Paulo, Brazil; xDepartment of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil; and the kDepartment of Otorhinolaryngological, Sa˜o Lucas Hospital, Aracaju, Sergipe, Brazil. Address correspondence and reprint requests to Ricardo Queiroz Gurgel, Av Beira Mar 2016/402, Bairro 13 de Julho, Aracaju, Sergipe 49025 040, Brazil. E-mail: ricardoqg@ infonet.com.br Journal of Voice, Vol. 24, No. 4, pp. 435-440 0892-1997/$36.00 Ó 2010 The Voice Foundation doi:10.1016/j.jvoice.2008.12.007
In Aracaju, Northeast Brazil, the estimated number of street children was calculated to be over 1500 in 2004.15,16 There are some studies evaluating the causal and maintaining factors for, and psychological and biological interference of, street-living situation on the development of children and adolescents.14,17–19 Otherwise, studies linking street-living situation and quality of voice could not be found, and the evaluation of the impact of voice quality on health condition is not well studied. This study aims to evaluate the voice quality and characteristics of a group of children with street-selling experience as opposed to a group of children without this experience. METHODS A cross-sectional controlled study was undertaken with 7– 10-year-old children of both sexes, with voice disorder identified during voice screening. This age range was selected because they were at school age and before puberty, where the physiological changes that occur would interfere with voice characteristics. Both groups, at the time of data collection, lived with their families and attended school regularly, but in one group, there was a clear history of child labor20 in street selling and no such history in the other. The former street children group was assisted by the Child Labour Elimination Programme (Programa de Erradicac¸a˜o do Trabalho Infantil [PETI]),21 during the year 2005, when data were collected. From the 600 children assisted in this program, we chose 200 randomly to constitute the study group (street children). The control group was selected from city public schools located in the same area where street children live, matched by age and sex in a 2:1 basis. Both groups attend public schools of Aracaju, the capital city of Sergipe state, in Northeast Brazil. Aracaju has a population of 520 303, and is considered
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Journal of Voice, Vol. 24, No. 4, 2010
to have better social indicators within the capital cities in the region.12 Initially, all children were submitted to an interview and individual vocal screening with a speech-language pathologist. The ones identified as having a voice disorder were assessed using the GRBAS Scale22 to evaluate the auditory perception, voice type, and deviation classification. In a normal conversation, /e/ vowel during sustained emission was evaluated and classified according to GRBAS protocol, where ‘‘G’’ indicates grade of dysphonia level, ‘‘R’’ indicates roughness, ‘‘B’’ represents breathiness (air sensation on voice), ‘‘A’’ indicates asthenia (voice weakness), and ‘‘S’’ represents strain (larynx constriction). The level of severity was recorded using a 4-point scale, where ‘‘0’’ was normal, ‘‘1’’ was mild deviation;‘‘2’’ was moderate deviation, and ‘‘3’’ was severe deviation. During normal conversation, other communication disorders, such as myofunctional orofacial, speech and hearing disorders could be evaluated. A clinical and videonasolaryngoscopic examination during otolaryngological evaluation was performed according to previous techniques23,24 using breathing (inspiration and expiration) to evaluate median posterior glottal closure and glottal emission of /e/, and /i/. Examination was carried on with the child sitting on the parent’s lap after local anesthesia of left nasal passage. Laryngeal images and voice characteristics were recorded in a video home system (VHS) tape for later evaluation. Differences between group categories were evaluated using chisquared test (c2), considering P < 0.05 as significant.25 Ethics Committee of Federal University of Sergipe approved the study (protocol number: 11/2004), and all parents of students signed written consent for their children to participate. RESULTS During the screening for voice disorders, street children had a significantly higher proportion of voice problems identified (53% as opposed to 22.5%) than controls (Table 1). After screening, group composition changed, with street children having similar sex distribution (males, 49%; females, 51%) and average age of 9 years, but in the control group, males predominated (73.3 3 27.7%) and the average age was 8.4 years (not significant). Most street children (88%) were enrolled at PETI for 1–2 years but still worked during the other period of the day (60%) and weekends (66%). School performance was different in the two groups. The control group attended school everyday (42%), which ex-
TABLE 1. Voice Disorders Detected During Screening Absent
Present
Total
Groups
N (%)
N (%)
N (%)
Street children Control group Total
94 (47) 310 (77.5) 404 (67.3)
106 (53) 90 (22.5) 196 (31.7)
200 (100) 400 (100) 600 (100)
P < 0.0001.
TABLE 2. School Performance in Street Children and Control Group in Aracaju
Variables
Street Children
Control Group
Total
n (%)
n (%)
n (%)
c2
102 (52) 94 (48) 196 (100)
0.76 (ns)
78 (40) 118 (60) 196 (100)
1.98 (ns)
50 (64) 19 (24) 9 (12) 78 (100)
5.03 (ns)
Age-for-grade deficit Yes 58 (30) 44 (22) No 48 (24) 46 (24) Total 106 (54) 90 (46) Deficit because of retention Yes 47 (24) 31 (16) No 59 (30) 59 (30) Total 106 (54) 90 (46) Number of years lost 1 26 (33) 24 (31) 2 13 (16) 6 (8) >2 8 (11) 1 (1) Total 47 (60) 31 (40) School attendance 1–2 d 4 (2) 2 (1) 3–4 d 61 (32) 9 (5) Daily 33 (18) 79 (42) Total 98 (52) 90 (48) Enjoy school Yes 73 (37) 90 (46) No 33 (17) 0 Total 106 (54) 90 (46)
6 (3) 70 (37) 112 (60) 188 (100)
57.95*
163 (83) 33 (17) 196 (100)
33.7*
Abbreviation: ns, not significant. * P < 0.001.
ceeded that by street children (18%) (P < 0.001), but school age-for-grade deficit was similar for both groups (Table 2). All the control group students referred enjoyed attending school, whereas only 73 out of 106 street children enjoyed attending school (P < 0.001). Otorhinolaryngological evaluation outcome was significantly different within the two groups. The street children group had a higher proportion (P < 0.05) of nasal disorders (34 3 23%) and posterior medium triangular glottal closure (20 3 16%), but the control group had significantly (P < 0.001) more palatal tonsil hypertrophy (12 3 9%). Other disorders, including those of nose, larynx, and hearing, were not different in the two groups (Table 3). When evaluated using GRBAS Scale, the street children had more normal (20%) or mild degree (21%) than the control group (P < 0.01). The latter presented a significantly higher proportion of moderate roughness (38%), mild to moderate breathiness (34%), and moderate strain voice (37%) when compared with the street children group (Table 4). Communication and hearing disorders were significantly different within the two groups. The control group presented significantly more dysphonia (37 3 34%) and myofunctional orofacial disorders (10 3 6%). There were no differences between the groups on speech disorders and hearing impairment (Table 5).
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TABLE 3. Vocal Tract Disorders in Street Children and Control Students in Aracaju
Involved Segment Otologic disorders Yes No Total Nasal disorders Yes No Total Pharyngeal disorders Yes No Total Palatal tonsil hypertrophy Yes No Total Pharyngeal tonsil hypertrophy Yes No Total Posterior medioglottal closure Yes No Total Laryngeal constriction Yes No Total Laryngeal nodules Yes No Total Laryngitis Yes No Total Laryngeal edema Yes No Total Gastroesophageal reflux Yes No Total Vocal fold cyst Yes No Total
Street Children
Control Group
Total
n (%)
n (%)
n (%)
c2
7 (4) 96 (64) 103 (68)
5 (4) 42 (28) 47 (32)
12 (8) 138 (92) 150 (100)
0.64 (ns)
52 (34) 51 (34) 103 (68)
34 (23) 13 (9) 47 (32)
86 (57) 64 (43) 150 (100)
6.3*
70 (46) 33 (22) 103 (68)
33 (22) 14 (10) 47 (32)
103 (69) 47 (31 150 (100)
0.07 (ns)
14 (9) 89 (59) 103 (68)
18 (12) 29 (20) 47 (32)
32 (21) 118 (79) 150 (100)
69 (46) 34 (22) 103 (68)
31 (21) 16 (11) 47 (32)
100 (67) 50 (33) 150 (100)
0.02 (ns)
30 (20) 73 (48) 103 (68)
23 (16) 24 (16) 47 (32)
53 (36) 9 (6) 150 (100)
5.54*
10 (6) 93 (22) 103 (68)
8 (5) 39 (27) 47 (32)
18 (11) 132 (89) 150 (100)
1.63 (ns)
41 (27) 62 (41) 103 (68)
20 (14) 27 (18) 47 (32)
61 (40) 89 (60) 150 (100)
0.10 (ns)
12 (8) 91 (60) 103 (68)
2 (2) 45 (30) 47 (32)
14 (10) 136 (90) 150 (100)
2.08 (ns)
5 (3) 98 (65) 103 (68)
6 (4) 41 (28) 47 (32)
11 (7) 139 (93) 150 (100)
2.97 (ns)
9 (6) 94 (62) 103 (68)
2 (2) 45 (30) 47 (32)
11 (8) 139 (92) 150 (100)
0.95 (ns)
10 (6) 93 (62) 103 (68)
5 (4) 42 (28) 47 (32)
15 (10) 135 (90) 150 (100)
0.03 (ns)
11.74y
Abbreviation: ns, not significant. * P < 0.05. y P < 0.001.
DISCUSSION Till date, children living and/or working in the streets is a common situation in Brazil,12 and in Sergipe, an estimated
1500 children live in the streets.15,16 These children are exposed to a high level of stress, including physical (accidents and aggressions, transmissible diseases) and psychological
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TABLE 4. Voice Assessment Using GRBAS Scale Street Children Variables
n (%)
(G) Grade 0 40 (20) 1 41 (21) 2 25 (13) Total 106 (54) (R) Roughness level 0 40 (20) 1 38 (19) 2 28 (15) Total 106 (54) (B) Breathiness level 0 54 (27) 1 27 (14) 2 25 (13) Total 106 (54) (A) Asthenic level 0 103 (52.5) 1 2 (1) 2 1 (0.5) Total 106 (54) (S) Strain level 0 39 (20) 1 34 (17) 2 33 (17) Total 106 (54)
Control Group
TABLE 5. Speech-Language Pathologist Diagnosis
Total 2
n (%)
n (%)
14 (7) 40 (20) 36 (19) 90 (46)
54 (27) 81 (41) 61 (32) 196 (100)
13.29*
16 (8) 37 (19) 37 (19) 90 (46)
56 (28) 75 (38) 65 (34) 196 (100)
10.31*
23 (12) 32 (16) 35 (18) 90 (46)
77 (39) 59 (30) 60 (31) 196 (100)
13.35*
90 (46) 0 0 90 (46)
193(98.5) 2 (1) 1 (0.5) 196 (100)
2.58 (ns)
18 (9) 30 (15) 42 (22) 90 (46)
57 (29) 64 (32) 75 (39) 196 (100)
7.81y
c
Abbreviation: ns, not significant. Significant Ps are in bold. Roughness refers to hoarseness and roughness of the voice. * P < 0.01. y P < 0.05.
(sexual exploitation and abuse) stress. There is a daily, widespread tension, which may negatively interfere with speech expression. The group of street children assessed in this study continues to work in the streets selling goods and delivering personal services to costumers despite being enrolled in aid programs and living with their parents. Although they are vulnerable to different kinds of aggressions, they develop skills and create emotional, economical, and social links to help them cope with the situation.13,14 Our study group attends PETI activities in the other day period when they are not at school. There, they develop social activities, sports, and arts, contributing to reduce their vocal tension and facilitating socioeducational inclusion and improving self-esteem, besides limiting their stay in the streets. This does not seem to be enough to protect the voice quality as they presented more vocal disorders than control school children. Worse access to health facilities seems to explain this finding.15 Their families received income supplementation, and it would be anticipated that these children did not go to the streets. This expectation is not always confirmed and
Functional Disorders Dysphonia Yes No Total Myofunctional orofacial disorders Yes No Total Speech disorders Yes No Total Hearing functional impairment Yes No Total
Street Children
Control Group
Total
n (%)
n (%)
n (%)
c2
67 (34) 39 (20) 106 (54)
73 (37) 17 (9) 90 (46)
140 (71) 7.64* 56 (29) 196 (100)
11 (6) 95 (48) 106 (54)
20 (10) 70 (36) 90 (46)
31 (16) 5.12y 165 (84) 106 (100)
2 (1) 104 (53) 106 (54)
1 (0.5) 3 (1.5) 0.19 (ns) 89 (45.5) 193 (98.5) 90 (46) 196 (100)
0 106 (54) 106 (54)
0 90 (46) 90 (46)
0 — 196 (100) 196 (100)
Abbreviation: ns, not significant. * P < 0.01. y P < 0.05.
many children keep working, making school grade/age discrepancy higher than that in controls. In Joa˜o Pessoa (800 km from Aracaju), similar results26 were found, including grade/age discrepancy. This phenomenon is common in Brazilian public schools12 demanding continuous investment to guarantee better quality in public education. Several studies show that voice and speech skills may be adapted to the context and to the subject of communication,2,27 but an intense daily and long-term vocal demand may promote hyperfunction on vocal muscles leading to vocal fatigue and speech and vocal tract disorders. In our study, both groups had vocal impairments, but the control group presented significantly worse quality of voice than the street children group. We speculate that the members of this group develop protective mechanisms to their vocal health in a demonstration of resilience to the street situation. This phenomenon has been shown in other situations.17,19 To facilitate approach to costumers and to be successful in their working activities, street children educate and protect their voices, making them more intimate and seductive, rather than invasive, weak, and infantile, in a specific professional configuration adapted to their street labor. Similar adaptive strategies were found elsewhere.13,14 Here the members of the street children group use their voices professionally as sellers to complement family income, characterizing professional use of voice. Voice is, hence, an
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Use of Voice in Street Children
indispensable tool for the professional activity,28 particularly, in case of street child labor. Our street children group justifies its necessity to work to complement family income and considers its activity as regular and mandatory. This seems to be a professional activity despite knowing that vocal expressivity results from sociocultural and educational background of each group.29 The two groups had similar incidents of hearing disorders, vocal fold cyst/nodules, larynx constriction, and gastroesophageal reflux. The street children group presented more nasal disorders associated with medium glottal closure and less tonsil enlargement than the control group. Nasal findings may be because of street exposure, whereas glottal closure is a compensatory mechanism. Tonsil enlargement may explain, in part, the greater incidence of dysphonia in the control group.6,23,24 Although the street group had more vocal disorders detected in the initial screening, they had more normal or mild degrees of evaluations than the control group using GRBAS Scale. These children probably present a different vocal comportment by adapting their speech to the seller activity they perform in the streets. They have a dual experience of adult (professional activity) and child (students) lives and seem to cope well with this as previously reported for street children in other situations.13,14 The control group had increased prevalence of dysphonia and more compromised social and physiological vocal expressivity. This group has limited stimulus to develop its expressivity, as it does not have access to supplementary activities and social support, such as the PETI group. They have access only to classroom activities and few social and familiar supports, and no vocal care. This group showed a larger proportion of hearing and speech disorders, including dysphonia and myofunctional orofacial disorders. Severe hearing and speech impairment was not detected in any group. In another study,30 which used questionnaires given by speech therapists to children who suffered aggressions, a larger proportion of voice development delay was found. In Aracaju, street children admitted to the PETI still work in the streets, although they were supposed to quit this activity when admitted to this program. Street life is usually associated with violence and drug involvement (including glue aspiration), but our children have denied involving in drugs. This seems to be true as they have better voice quality when compared with controls. This study allowed us to evaluate voice quality of children with two different backgrounds where the school and social support program seem to play different roles. Speech therapy and otorhinolaryngological evaluation identified differences between the groups, and the better performance of street children in this evaluation seems to be related to the professional use of voice. The PETI program seems to be important in enabling its participants to adapt, but is not enough to avoid their street exposure. The professional use of voice is a new way to show their resilience to poverty and aggressive environment, and resulted in a better voice quality when compared with regular students. Our group did not examine drug use, which probably would in-
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