JSLHR

Article

Listeners Attitudes Toward Children With Voice Problems

Estella P.-M. Maa and Camille H.-Y. Yua

Purpose: To investigate the attitudes of school teachers toward children with voice problems in a Chinese population. Method: Three groups of listeners participated in this study: primary school teachers, speech-language pathology students, and general university students. The participants were required to make attitude judgments on 12 voice samples using a semantic differential scale with 22 bipolar adjective pairs. The voice samples were collected from 6 children with healthy voices and 6 children with dysphonia. The 22 bipolar adjective pairs were intended to cover nonspeech characteristics about the childs personality, social characteristics, and physical appearance. Results: The mean attitude ratings received by children with dysphonic voice were significantly lower (i.e., less favorable) than those received by children with healthy voices in all of

the 22 adjective pairs (all ps < .002). The attitude ratings made by the 3 groups of listeners were not significantly different from one another ( ps > .05). Conclusion: To our knowledge, this is the first study in which the authors examine listeners perception toward children with voice problems in the Chinese population. The results suggest that voice problems in children warrant attention, and their effects on the child should not be underestimated. The findings also highlight the importance of early identification and intervention for children with voice problems. Key Words: pediatric voice disorders, negative stereotype, listeners perception, personality, physical appearance, social characteristics

oice problems in children are common. High prevalence figures of voice disorders have been reported in pediatric populations, with rates ranging from at least 6% (McNamara & Perry, 1994) to 11.6% (Carding, Roulstone, Northstone, & the ALSPAC Study Team, 2006) and up to 23.4% (Silverman & Zimmer, 1975). Voice problems in children can lead to substantial adverse impacts on their quality of life in physical, functional, and emotional domains (Boseley, Cunningham, Volk, & Hartnick, 2006; Connor et al., 2008; Hartnick, 2002; Hartnick, Volk, & Cunningham, 2003; Zur et al., 2007). For example, children with voice problems may encounter difficulties in raising their voice and being heard in noisy environments such as playgrounds. They may feel frustrated because of their voice problems. Moreover, attitude research demonstrates that deviant voice quality can lead to listeners false estimates of the childs intelligence, personality traits, and other attributes not related to speech such as physical appearance and
a Voice Research Laboratory, University of Hong Kong, Hong Kong, SAR, Peoples Republic of China

Correspondence to Estella P.-M. Ma: estella.ma@hku.hk Editor: Jody Kreiman Associate Editor: Bruce Gerratt Received September 1, 2011 Revision received April 20, 2012 Accepted January 7, 2013 DOI: 10.1044/1092-4388(2013/11-0242)

social characteristics. When compared with peers who are vocally healthy, children with voice problems have been labeled with a negative stereotype by adults (Ruscello, Lass, & Podbesek, 1988), adolescents (Lass, Ruscello, Bradshaw, & Blankenship, 1991), and their age peers (Lass, Ruscello, Stout, & Hoffman, 1991). Semantic differential scaling is a commonly used technique for attitude measurement and has been used in research on attitudes toward individuals with communication disorders such as lisping (Silverman, 1976), dysarthria (Ruscello, Lass, Hansen, & Blankenship, 1992), and stuttering (Franck, Jackson, Pimentel, & Greenwood, 2003). The semantic differential method was originally developed by Thurstone in the late 1920s (1928) and was further adapted by Osgood, Suci, and Tannenbaum (1957). The theoretical basis of this rating method is that ones attitude can be described in terms of direction and magnitude through the use of bipolar adjective pairs. Osgood et al. (1957) found three semantic categories of evaluative (e.g., goodbad), potency (e.g., hardsoft), and activity (e.g., activepassive) for describing attitude. It has been shown that the scale is a reliable and valid measurement of attitude. It is easy to administer and easy to score (Heise, 1970). Ruscello et al. (1988) examined the attitudes of university students toward a group of children with dysphonia ages 711 years. The university students were required to listen to voice samples of eight children with dysphonic voices and eight children with healthy voices. For each voice sample, the listeners were required to make judgment on a

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seven-point semantic differential scale with 24 adjective pairs covering semantic categories of evaluative, potency, and activity. As expected, children with voice disorders were rated more negatively for most (22 of 24) adjective pairs than their age- and gender-matched peers who were vocally healthy. Children with voice disorders were rated as less active, less clean, and less honest than peers who were vocally healthy. Similar findings were reported in two subsequent studies with age peers and adolescents as listeners. Lass, Ruscello, Stout, et al. (1991) investigated the attitudes of age peers toward children with and without voice disorders, using the same pool of voice samples as that used by Ruscello et al. (1988). Twenty elementary school students of similar age as the child speakers (who did not know the speakers) served as listeners. They were asked to judge the personality and physical appearance of the speakers using a seven-point semantic differential scale with 22 bipolar adjective pairs. Results revealed that children with voice disorders were perceived more negatively than those with healthy voices in half of the adjective pairs describing personality traits (e.g., interestingboring) and physical appearance (e.g., cleandirty). In the same year, Lass, Ruscello, Bradshaw, et al. (1991) examined the attitudes of adolescents toward children with and without voice disorders. Nineteen adolescents were recruited from a middle school as listeners. The authors used the same pool of voice samples and bipolar adjective pairs as used in the study by Lass, Ruscello, Stout, et al. (1991). Results indicated that children with voice disorders were rated more negatively in nine of the 22 adjective pairs. They were rated as less clean, less interesting, and less strong than children who were vocally healthy. The three studies reviewed above commonly report that deviant voice qualities can generate negative perception toward children with voice problems. However, in each of these studies, only one group of listeners was recruited. None of these studies had a control group of listeners for comparison. Therefore, a conclusion cannot be drawn as to whether listeners of different backgrounds would perceive voice problems differently. School teachers have close relationships and frequent daily interactions with children. They play an important role in a childs whole-person development of academic, social, and psychological well-being. Knowing how teachers perceive children with voice problems has clinical and educational implications because teachers perceptions can affect childrens experience in school. Connor et al. (2008) conducted a qualitative study among children with chronic dysphonia to examine their perceived impacts of the voice problems on their lives. Some children reported scenarios indicating that they received undue attention in class by substitute teachers who did not understand their voice conditions. Furthermore, teachers perceptions can influence their expectation of the childs academic development (Lass et al., 1992). In other area of communication disorders, it has been shown that students physical attractiveness can influence teachers prediction accuracy of students intellectual ability. For example, children with cleft lip and palate who have relatively severe facial disfigurement (i.e., physically less attractive) received less accurate ratings from teachers on their intellectual ability than did children with relatively typical facial appearance

(i.e., physically more attractive; Richman, 1978). To date, there is a scarcity of information on teachers perceptions of children with voice problems. Moreover, most of the previous studies on listeners perception toward children with voice disorders were carried out in western cultures with English-speaking listeners. Given that voice problems in children are a worldwide problem, it is necessary to conduct similar attitude-related research in other cultural groups to enrich our current knowledge of the impacts of voice problems on a child. Previous studies have reported that Chinese people tend to have a lower degree of acceptance of individuals with speech disorders. In these studies, the authors assert that Chinese people believe that individuals with speech disorders could improve their speech if they tried hard (Bebout & Arthur, 1992; Chan, McPherson, & Whitehill, 2006). In this study, our aim was to investigate school teachers perceptions of children with voice problems in a Chinese population. This study was an extension of the previous study conducted by Ruscello et al. (1988) to a different cultural group with different groups of listeners. Three groups of listeners were recruited: primary school teachers, speech-language pathology students, and general university students. It was hypothesized that primary school teachers would judge children with voice problems negatively. Speech-language pathology students served as a comparison group. It was expected that with the professional training of this group of listeners, they would judge children with voice problems more neutrally in terms of the adjectives used in the rating scale. General university students were included as a control group. We obtained ethical approval from the Human Research Ethics Committee of Nonclinical Faculties at the University of Hong Kong.

Method
Participants
Speakers. Twelve children (six with healthy voices and six with chronic voice problems) were selected from a cohort of students who participated in a voice recording session. Their ages ranged from 7.5 to 11.0 years (Mage = 9.37 years, SD = 1.49). All children with dysphonia had voice problems that existed over the previous 4 weeks as reported by their parents. The control group that comprised six children with healthy voices was individually matched with children in the dysphonic group according to gender and age (1 year). All of the child participants were native Cantonese speakers. According to the class teacher and parent reports, none of the children had a history of hearing impairment and communication disorders such as articulation, reading, and language disorders. This criterion was set to rule out any communicative features (e.g., speech errors and fluency problem) that might also influence listeners perceptions (Franck et al., 2003; Silverman, 1976). Each speaker was also judged perceptually by the second author, who is a final-year speech-language pathology student, as having healthy speech fluency and articulation. Listeners. Forty-five listeners participated in this study. They came from three different groups: 15 primary

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school teachers (three men and 12 women; Mage = 25 years, SD = 3.04, range = 2130 years), 15 speech-language pathology students (six men and nine women; Mage = 21.9 years, SD = 1.16, range = 2024 years), and 15 general university students (eight men and seven women; Mage = 21.9 years, SD = 1.92, range = 1825 years). All of the listeners passed a hearing screening test of 25 dB at hearing threshold levels of octave frequencies between 0.5 kHz and 8.0 kHz. All of them were native Cantonese speakers. The teachers were recruited on a voluntary basis from the social circle of the second author. None of the teachers who participated taught any of the children whose voices were recorded. The speech-language pathology students were recruited from the Division of Speech and Hearing Sciences at the University of Hong Kong. These students were in either their penultimate year or final year, and they had already successfully completed the coursework on voice disorders.

Grade 2 textbooks, and only one character (0.8%) was covered by Grade 3 textbooks. Therefore, the characters used in the passage were considered to be familiar to children in early grades.

Preparation of Listening Samples

Selection of voice samples. The first author, who has more than 10 years of experience in managing caseloads of patients with voice disorders, first screened the cohort of voice-recorded samples. From the cohort, six samples of dysphonic voice were selected, with two samples representing each category of mild, moderate, and severe dysphonia. To facilitate comparison between voice-disordered and vocally healthy groups, we selected an equal number (six) of vocally healthy samples. While screening the voice samples, we noticed that some children misread a few characters. Most children could read the first paragraph without any reading errors. Therefore, for each speaker, among the three trials of passage recorded, we edited out the trial with the first paragraph that did not have any reading errors, and we used it as the voice sample for rating. Rating of voice samples. The 12 voice samples were then rated by a panel of three experienced speech-language pathologists (SLPs). All of them had at least 10 years of experience in assessing and treating children with speech and voice disorders on a daily basis. They were asked to rate the voice samples as normal, mildly, moderately, or severely impaired. Their judgment results are listed in Table 1. The three SLPs agreed on over 50% of the voice samples (seven of 12), and 100% agreement was obtained within one rating point. Disagreements were resolved by consensus. Six of the children were considered to have healthy voices, and the other six were considered to have disordered speech. Of the six children with disordered speech, two of them were rated

Materials
Recording of voice samples. Voice samples were recorded from students studying at a local primary school in Hong Kong. Parents of the children were first provided with an information sheet describing the nature and purpose of the study. Children of parents who gave written informed consent were then invited to attend a voice recording session. Voice samples were recorded in a quiet corner at the school. Throughout the recording, the background noise of the recording environment was kept below 50 dBA, measured by a sound-level meter (TES-1350A, Taiwan). The children were required to sit upright during the recording. The voices were captured by using a headset microphone (AKG Acoustics C420, Vienna, Austria) through an external sound card (M-AUDIO). The microphone was kept 8 cm away from the childs left mouth corner and with a depression angle of 45. All of the children were required to read aloud the Cantonese passage North Wind and the Sun using the same habitual pitch, loudness, and rate as used in daily conversation. They were allowed to become familiar with the text by practice-reading the passage aloud before actual recording. Three trials of the passage reading were recorded. Reading material. The North Wind and the Sun passage (International Phonetic Association, 1999) had 132 Chinese characters that were divided into four paragraphs. This passage was chosen because it was more representative of the individuals vocal qualities as used in daily continuous speech than sustained vowel prolongation and spoken phrases (Yiu, Worrall, Longland, & Mitchell, 2000). In addition, this passage is a popular story that is introduced in kindergarten classrooms in Hong Kong; therefore, it is familiar to the children. To ensure that the text was of age-appropriate reading level for school-age children, we compared all characters in the passage against the Hong Kong Corpus of Primary School Chinese (HKCPSC; Leung & Lee, 2002). The corpus comprised Chinese characters extracted from textbooks and workbooks used by local primary schools from Grades 1 to 6 in Hong Kong. Among the 132 characters in the passage, 120 characters (90.9%) were covered by Grade 1 textbooks, 11 characters (8.3%) were covered by

Table 1. Severity ratings by the three speech-language pathologists (SLPs). Severity rating Voice sample Dysphonic 1a 2 3a 4a 5 6a Normal 7 8a 9 10a 11 12a
a

SLP 1

SLP 2

SLP 3

Mild Mild Moderate Moderate Severe Severe Normal Normal Normal Normal Normal Normal

Mild Mild Moderate Moderate Moderate Severe Normal Normal Normal Normal Normal Normal

Mild Moderate Moderate Moderate Severe Severe Mild Normal Mild Normal Mild Normal

The severity level agreed upon by the three SLPs.

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as mildly dysphonic, two were rated as moderately dysphonic, and two were rated as severely dysphonic. Apart from voice severity levels, we also asked the three SLPs to rate each voice sample on reading fluency, speech rate, and speech naturalness, using a nine-point equal-appearing interval scale. The results showed that there were no significant differences between the group with voice disorders and the vocally healthy group for all three speech parameters (naturalness, 7.81 [dysphonic] vs. 8.19 [normal]; MannWhitney U = 505.0, p = .09; fluency, 7.53 [dysphonic] vs. 7.89 [normal]; MannWhitney U = 528.0, p = .16; speech rate, 5.33 [dysphonic] vs. 4.86 [normal]; MannWhitney U = 507.5; p = .09). The speech rates of the 12 samples (the paragraph that listeners were asked to judge) were also calculated. In this study, speech rate was taken as speaking rate, which was measured in syllables per minute (i.e., the total number of syllables read aloud divided by the total speaking time in minutes). The mean speech rate of all child speakers was 170.22 syllables per minute (SD = 25.6, range = 141.50210.33 syllables per minute). Such range of speech rate was within the normal limits as suggested by Lallh and Rochet (2000). The mean speech rates of the group with voice disorders and the vocally healthy group were similar to each other and were not significantly different (171.34 syllables per minute [dysphonic] vs. 169.10 syllables per minute [normal]; MannWhitney U = 15.0, p = .63). The amplitude of the waveforms of all voice samples was standardized using Adobe Audition 3.0. A silent period of 2 s was given before the onset and after the offset of each sample. To assess the intralistener reliability in the attitude rating process, we duplicated the 12 voice samples and randomized the 24 voice samples in the order of presentation. No consecutive voice samples were the same. Scale for attitude measurement. Listener attitudes toward the speakers were ascertained through use of a 22-item semantic differential scale anchored with bipolar adjectives. The adjectives were selected from the adjective pairs with high factor loading in the areas of evaluation, potency, and activity (Osgood et al., 1957) and also were adapted from previous studies in the literature on listeners perception toward individuals with voice disorders (see, e.g., Lallh & Rochet, 2000). Because the adjective pairs were presented in English in the previous studies, they were first translated into written Chinese by an undergraduate student majoring in translation. Another undergraduate student who was also majoring in translation was asked to translate the adjectives back into English. We performed this procedure to enhance and ensure the accuracy of the translations. A final version of the adjective pairs was further tried with a focus group of 10 final-year speech-language pathology students. The focus group was told that the adjectives were used to describe a childs personality, physical appearance, and social characteristics. They were asked to think of a child they knew by using the adjective pairs and to comment on the clarity of the adjectives. All participants in the focus group expressed that the adjectives used were clear and without any ambiguity. A horizontal 10-cm visual analog scale (VAS) was used for attitude rating. The left end represented negative

attribute (e.g., nervous), and the right end represented positive attribute (e.g., calm). To minimize the potential bias when the listeners gave the ratings on each adjective pair, we randomly selected 13 of the 22 adjective pairs and reversed them in direction of presentation. For these 13 pairs, the left end of the VAS represented positive attribute, and the right end of the VAS represented negative attribute. Listeners were instructed that they could mark anywhere along the line. They were also told that the middle point of the line referred to a neutral response for the adjective pair. Listeners were asked to complete rating for all adjectives. For each adjective pair, the attitude rating was measured as the distance in cm (up to 1 decimal place) from the negative end to where the listener made a cross on the line. The attitude rating score for each pair ranged from 0 to 10. A high rating indicated that the child was perceived positively by the listener, and a low rating indicated that the child was perceived negatively.

Procedure
Listening sessions were held individually in a quiet room with background noise level of about 40 dBA. The voice samples were presented to listeners over headphones (HD 280pro, Sennheiser) at a comfortable intensity level. Listeners were allowed to adjust the loudness level themselves at the beginning of the judgment session. They were also briefed by the researcher about the procedures of the study and the use of the VAS for attitude rating. At the beginning of the judgment session, two additional voice samples were given to listeners for practice. These two voice samples were not included in the experimental voice samples. Therefore, the listeners were required to listen and rate the 26 voice samples using the 22 adjective pairs on a 10-cm long VAS. These individuals could listen to each voice sample only three times. They could take breaks during the rating sessions as needed. However, they were not allowed to access previously rated samples.

Results
Intralistener Reliability
We used intraclass correlation coefficients (ICCs; two-way, mixed-model) to determine intralistener reliability. The ICCs for attitude ratings of the three listener groups were .84 for primary school teachers, .85 for general university students, and .89 for speech-language pathology students.

Attitude Scores for Children With Healthy Voices and Children With Dysphonic Voices
Table 2 lists the mean attitude scores and SDs by listener group and voice condition. A one-way mixed-model analysis of variance (ANOVA) was conducted with one within-subject factor (voice condition: normal or dysphonic) and one between-subject factor (listener type: primary school teachers, speech-language pathology students, or general university students). To ensure that the assumptions of ANOVA were met, we carried out KolmogorovSmirnov tests for

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Table 2. Mean attitude scores by listener group and voice condition. Vocally healthy voices Listener group Primary school teachers SLP students General university students All listeners M 6.37 6.71 6.46 6.51 (SD) (1.50) (1.56) (1.41) (1.49)

Dysphonic voices M 5.33 5.42 5.30 5.35 (SD) (1.39) (1.54) (1.32) (1.42)

All voices M 5.85 6.06 5.88 5.93 (SD) (1.53) (1.68) (1.48) (1.57)

children with healthy voices and children with voice problems on 22 bipolar adjective pairs. Results revealed that the mean attitude ratings received by children with voice problems were significantly lower than those received by children with healthy voice in all 22 adjective pairs (all ps < .002). The top three adjective pairs with the largest difference in mean attitude ratings between vocally healthy children and children with dysphonia were unsure versus confident (mean difference = 1.81), nervous versus calm (mean difference = 1.72), and sick versus healthy (mean difference = 1.66).

normal distribution of the data and Levenes test for homogeneity of variances. Results revealed that the attitude scores showed acceptable normality of distribution (Kolmogorov Smirnov tests of normality, p = .20) and homogeneity of variance (Levenes tests of equality of error variances, p > .05). Mauchlys test of sphericity for within-subject factor voice condition was not significant (p > .05); the assumption of compound symmetry was met. The results of the ANOVA revealed nonsignificant differences between the listener groups, F(2, 267) = 1.12, p = .33, partial h2 = .008. We found significant main effects for voice conditions, F(1, 267) = 88.18, p = .0001, partial h2 = .25. The Listener Group Voice Condition interaction was not significant, F(2, 267) = 0.35, p = .71, partial h2 = .003. Independent t tests were further carried out on each adjective pair as follow-up tests. The alpha level was adjusted to .002, using Bonferroni adjustment to avoid Type I error. Table 3 lists the means and SDs of all listeners toward
Table 3. Mean attitude scores on each adjective pair. Children with healthy voices Adjective pair Unintelligentintelligent* Unsureconfident* Nervouscalm* Rigidflexible* Loudquiet* Dishonesthonest* Aggravatingsoothing* Boringinteresting* Unreliablereliable* Incompetentcompetent* Uncooperativecooperative* Unfriendlyfriendly* Passiveactive* Meannice* Cruelkind* Unapproachableapproachable* Unpleasantpleasant* Repellingattracting* Uglybeautiful* Weakstrong* Dirtyclean* Sickhealthy* M 6.63 6.81 6.63 6.04 5.88 6.42 6.77 5.91 6.68 6.60 7.31 7.31 6.05 6.46 6.40 6.54 6.53 6.28 6.10 5.50 6.89 7.36 (SD) (2.55) (2.47) (2.58) (2.86) (2.60) (2.32) (2.41) (2.45) (2.33) (2.34) (2.23) (1.91) (2.64) (2.21) (2.14) (2.19) (2.16) (2.10) (2.09) (2.18) (2.10) (2.07) Children with dysphonia M 5.38 5.00 4.91 5.03 5.08 5.51 5.47 4.99 5.30 5.06 6.01 6.02 5.13 5.65 5.53 5.36 5.75 5.35 5.16 4.70 5.59 5.70 (SD) (2.59) (2.93) (2.64) (2.79) (2.65) (2.30) (2.32) (2.54) (2.47) (2.33) (2.47) (2.23) (2.59) (2.15) (2.11) (2.45) (2.25) (2.00) (2.09) (2.15) (2.09) (2.53)

Discussion
In this study, we set out to investigate listeners first impressions of children with voice problems in nonspeech characteristics of personality traits, social characteristics, and physical appearance. Three groups of listeners were recruited, including primary school teachers, speech-language pathology students, and general university students. The first major finding was that the attitude scores made by the three groups of listeners were similar and were not significantly different from one another. The three groups of listeners unanimously perceived children with dysphonia more negatively than children with healthy voices. In addition, authors of previous studies have reported teachers negative perceptions toward children with communication disordersnamely, stuttering (Lass et al., 1992) and speech sound disorders (Overby, Carrell, & Bernthal, 2007). The results of the present study suggest that voice disorders can also adversely influence school teachers judgments of the childs nonspeech characteristics. Given their level of professional training, one would expect speech-language pathology students to be less biased (or more neutral) in their perceptions toward children with voice disorders. We were surprised to find that their mean attitude ratings were similar to those obtained in the other two listener groups. There are two possible explanations for this finding. The first possible explanation is that listeners perceptions toward communication disability (e.g., voice disorders) are rather persistent. Such perception does not vary much with the amount of knowledge about the disorders. The findings support the notion that changing ones negative attitudes toward individuals with communication disorders simply by educating one with more knowledge about the disorder is not sufficient (Lallh & Rochet, 2000). Other experiences such as role-playing and direct interactions with the individual are more likely to facilitate changing ones negative stereotyping (Anthony, 1972; Ibrahim & Herr, 1982). Alternatively, it might be possible that the attitude ratings made by this group of listeners were biased by their professional knowledge. The listeners might have mapped the dysphonic voice to a typical hyperfunctional case scenario, which is associated with poor vocal hygiene and with behavioral problems, leading to the negative perceptions (Green, 1989). Another major finding of this study was that deviant voice qualities can lead to listeners negative estimation of the childs nonspeech characteristics. The results corroborate the well-documented negative stereotyping in individuals with voice problems (Altenberg & Ferrand, 2006; Blood,

*Difference in all adjective pairs was significant at the .002 level; maximum attitude score for each adjective pair = 10.

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Mahan, & Hyman, 1979; Lass, Ruscello, Bradshaw, et al., 1991; Lass, Ruscello, Stout, et al., 1991; Ruscello et al., 1988). Apparently, such vocal stereotyping can exist in both adults and children with voice disorders. The vocal stereotype might be explained by the halo effect, which states that the negative impression about a specific disability can be generalized to other attributes not related to the disability (Livneh, 1982). In our study, children with dysphonia were perceived more negatively on attributes unrelated to voice namely, intelligence and personality traits. Such negatively biased judgments also generalized to attributes that were relatively less predictable, such as physical appearance and social characteristics. The unfavorable perceptions may affect the interpersonal relationship between the listeners and children and how readily the listeners accept these children socially. In the present study, the attitude score toward vocally healthy children ranged from 5.50 to 7.36 on a 10-cm-long VAS (see Table 3). Although such attitude scores were not particularly positive, they were comparable to those reported in previous studies (Lass, Ruscello, Bradshaw, et al., 1991; Lass, Ruscello, Stout, et al., 1991; Ruscello et al., 1988). In those reports, the attitude scores were rated on a seven-point scale. The scores for vocally healthy children ranged from 4.00 to 5.56 (Ruscello et al., 1988), from 3.85 to 5.10 (Lass, Ruscello, Bradshaw, et al., 1991), and from 3.45 to 5.07 (Lass, Ruscello, Stout, et al., 1991).

Limitations and Directions for Future Research

There are several limitations in the present study that should be considered when interpreting the results. The first limitation relates to the possible interactions between voice quality, speech parameters, and attitude ratings. In the study, we attempted to ensure that voice samples of the two groups (voice disorders and controls) were similar in terms of speech naturalness, fluency, and rate. However, at this time, we cannot address whether there existed any possible interactions between vocal quality, speech parameters, and ratings with individual voice sample. Future research using the same speaker simulating different severity levels of vocal quality while standardizing other speech parameters (e.g., speech rate and speech prosody) would be interesting as a gauge against which to compare the results of the present study. Another limitation relates to the small number of voice samples (healthy and disordered) used in this study. The use of a larger number of samples with voice disorder preferably, with more samples for each severity level of voice impairmentis warranted. This would allow us to examine whether attitude scores vary as a function of voice impairment severity. In a previous study with adult speakers, the authors reported that listeners attitude ratings became more negative as the severity of voice impairment increased (see, e.g., Altenberg & Ferrand, 2006). Whether a similar relationship between attitude ratings and voice impairment severity also applies to the child population needs to be validated. Such information would be useful when prioritizing children for receiving voice therapy. In a future study, researchers could

also examine whether there exists a gender difference in attitude ratings, by having a larger sample with an equal ratio of female-to-male listeners in each group. In this study, the level of dysphonic severity was judged perceptually by a panel of three SLPs. Perceptual voice evaluation was used because it has been commonly regarded as the gold standard of clinical assessment (Kreiman, Gerratt, Kempster, Erman, & Berke, 1993). Nevertheless, future studies should include more measurements of the childrens voice status and more description of the types of laryngeal pathologies that underlie these childrens dysphonia. Finally, it should be noted that listeners attitudes can be influenced by cultural and social values. Chinese listeners tend to have a less positive attitude toward individuals with communication disorders. Altenberg and Ferrand (2006) found that CantoneseEnglish bilingual speakers were significantly different from English monolingual speakers in their perceptions toward adults with voice disorders. These bilingual speakers rated severely disordered voice samples significantly more negatively than did the English monolingual listeners. Similar cultural differences in attitudes toward children with communication disordersnamely, cleft lip and palatehave also been reported (Chan et al., 2006). Cross-cultural comparison of the listeners attitudes toward children with voice disorders in Western cultures would enrich our current understanding of the impacts of voice problems on a child. This provides insights into the clinical management of children of different cultures who have voice disorders.

Clinical Implications and Conclusions

Several clinical implications have arisen from this study. First, school teachers should be aware of their potential negative stereotype associated with deviant voice qualities in their students. The phenomenon of vocal stereotyping should be addressed as early as during their preservice training or in professional development courses for teachers. Second, for SLPs, these findings highlight the importance of the early identification of children who are developing voice problems and the provision of early intervention services for them. Finally, the present results have education implications for the Chinese population. In Chinese society, parents place a considerable emphasis on academic achievements (Li & Chung, 2009). Our findings suggest that having a healthy voice is another aspect to which parents need to pay attention. Because of the negative stereotype, children with voice problems may be disadvantaged in school tasks and assessments that require verbal presentation. In summary, this study represents the first systematic study to examine school teachers perceptions toward children with voice disordersspecifically, in the Chinese population. Through our findings, we urge readers to recognize that voice problems in children warrant attention, and their impacts on the child should not be underestimated. These results, together with future studies, would improve the clinical management of children with voice problems.

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Acknowledgment
A preliminary version of this article was presented at the 8th Pan-European Voice Conference, Dresden, Germany, August 2008.

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