Parents influence their child’s performance in many ways. (Original illustration by Joey Phyland)
Young Singers in the Professional Entertainment Industry
With the global success of television talent shows such as The Voice, Idol, and Got Talent and the explosion of social media in recent times, the performing child as ‘star’ has become increasingly more celebrated [5]. Similarly, in the music theatre genre, many of the shows introduced this century such as Billy Elliot, Matilda, and School of Rock feature children as central to the plot and can even involve a larger number of children than adults in the cast. Along with evergreen shows such as Oliver! and Annie, these professional productions now abound worldwide, and audiences embrace the child as a key performer in the story-telling. Perhaps as a direct reflection of the increased prevalence of children performing in these various contexts, we have also witnessed a boom of commercial enterprises such as talent training and performing arts schools focusing on both the child and adolescent performer.
Although it is beyond the scope of this chapter to muse on the potential benefits and downsides of children working in the entertainment industry, it is important to recognise there can be psychosocial, logistic, and developmental implications. Workplace regulations and child employment laws vary enormously across and within countries [6, 7], but performer children may work long shift hours, be highly scheduled, become dependent on external validation, suffer fatigue, experience performance anxiety, and also miss out on childhood and educational experiences for production seasons that can last for months and even years. Of course, on the other hand, children can thrive in this environment, develop a stronger sense of self-esteem and social inclusion, and be well rewarded financially and psychologically for their hard work and talents. When clinically assessing and managing these children’s voices, it is prudent to consider these performance-related factors and their potential impact on the vocal apparatus.
Other Singing Contexts
Young choirs, glee clubs, and student musical productions also abound in schools and in local community as part of our contemporary culture. For some children, singing is a compulsory school activity, whereas others may seek involvement and performance opportunities in school or external contexts such as cathedral and worship choirs, community theatre, busking, concerts, cultural events, and the like. They may sing with specific or mixed age groups and genders, with several different groups in school and with outside organisations, and with repertoire that may or may not be age-appropriate or easily achievable in terms of their vocal range, pitch, loudness, and style. In our experience, young singers may try to emulate adult voice characteristics or be placed or maintain singing within a vocal range or voice category that does not reflect their potentially changing tessitura (e.g. a transitioning boy soprano continuing to sing treble when undergoing mutation). The child singing in the school concert or musical production may be regularly instructed to sing louder or required to ‘binge’ sing during technical week, without adequate preparation for vocal fitness. For some, the vocal load can be extreme, and the vocal techniques adopted to achieve the vocal demands may be maladaptive and potentially injurious to vocal health. For other children, their natural singing capabilities and competencies are extended by positive vocal experiences along with increasing maturity – it is these children that perhaps achieve greater singing success for reasons other than simply ‘survival of the fittest’.
Influence of Singing on Vocal Development and Health
Relative to the fully developed adult voice, there is surprisingly little known about the effects of singing on the developing larynx. Although several studies have demonstrated the positive effects of regular singing and individual voice training on vocal efficiency and health among children [8–11], whether this translates to a reduction in risk of voice disorders has also not been previously well investigated. Of the few studies available, most relate to children engaged in choral singing. Rather than espousing the positive benefits of choral singing, several authors suggest child choristers experience more symptoms of voice problems than non-singers or soloists, particularly if undertrained, due to factors associated with choral singing such as increased vocal load, reduced auditory feedback, and possible competitive effects causing vocal strain or misuse [10–13]. Whether these are only short-term or have a cumulative negative effect is not established. More recently, however, Clarós et al. [14] reported on 1544 children (half of whom were singers) and found the opposite – children singing in a choir were significantly less likely to be diagnosed with voice problems [14]. Whether this is also the case with soloists and young singers within other genres such as musicals and other contexts requires further investigation.
The manner or style of singing may also influence the nature and amount of impact sustained by vocal fold tissue and effects on neuromuscular function and should be an important consideration in the estimation of the vocal load demands among singers. Along with the duration of voicing, singing activity can vary enormously in terms of loudness and pitch parameters and also in other vibratory characteristics such as glottic closure durations and patterns, phonatory onsets, and aerodynamic aspects which all contribute to their vocal load [15–18]. In the young performer, the potential long-term effects are not known of the current tendency in popular music for children to sing in a predominantly modal register up to high frequencies or to regularly use a ‘belt-like’ vocal posture. Such laryngeal postures typically involve high vocal intensities and subglottic pressures, increased glottic closure times, high vocal effort, and hence heavy vocal load [15]. Since the vocal folds of children are structurally smaller, they are arguably experiencing greater vocal tissue load than the adult singing equivalents when singing the same repertoire. Whether these vocal choices may influence the short-term and long-term health of the not yet fully developed instrument has not been established. It is also not clear whether there are age-related differences in the ability of the vocal fold lamina propria and muscles to withstand or recover from heavy vocal load [19–21]. For a more comprehensive explanation of vocal fold structure and morphology in children and the potential impact of heavy vocal load, the reader is directed to Chaps. 8 and 9.
There are inherent difficulties in establishing whether singing in childhood poses a risk to vocal health since there are so many potential confounders. By nature, children who sing are more likely to be gregarious [22], and therefore it is difficult to ascertain whether their personality and potentially associated heavy speaking voice load are influencing overall vocal health. Another issue is that paediatric singers may be overrepresented in treatment-seeking clinical settings compared to non-singing children due to differences in the importance attached to their voice and with their vocal needs. As previously mentioned, however, there is an overall need for an increased understanding of the potential physiologic and functional impact of sustained vocal load on children’s vocal fold development. The perceived trend towards more young people aspiring to be performers also provides a wealth of opportunities for increasing our understanding of the impact of performance (and training) load on the developing larynx and potential for injury and the development of pathology.
Influences of Vocal Health on the Singing Experience
Good vocal health will obviously contribute to optimal singing competence and capability and therefore successful singing experiences. There are also other potential benefits of this, in that children who sing are more likely to have a positive self-concept and sense of being socially included [23]. Conversely, it would seem logical that children with compromised vocal function or voice disorders may be less likely to engage in singing or to enjoy the singing experience which may lead to negative consequences such as frustration, lower self-esteem, and reduced social participation. Both these arguments provide a strong rationale for maximising vocal health in children in order to provide the option of singing participation and optimal performance.
Influences on Singing Voice Health
Differences in vocal function and vocal health of children according to age, gender, voice use patterns, training, and various medical factors have been well described elsewhere in this textbook, but it is of interest to further explore these variables in relation to their singing voice relevance.
Age and Gender
The age of a child will influence the expected pitch and loudness ranges, voice quality, and resonance characteristics of the singing voice as these dynamics are mostly dictated by the size, shape, and nature of the vocal tract structure and the development of increasing neuromuscular control. Physical changes occur throughout the respiratory, laryngeal, and resonatory systems so there are differences across developmental stage in power, source, and filter aspects of vocal function. Specifically, with advancing age, there are increases in breathing capacity, changes in vocal fold structure, increases in neck length and width and relative descent of the larynx, and subsequent enlargement of the vocal tract and resonatory system. There is also growth of the paranasal sinuses and nasal turbinates with atrophy of the tonsils and the adenoids, thereby creating more resonance space. When singing through childhood, it is therefore important to a child’s optimal vocal health that the repertoire and vocal demands are commensurate with the developmental stage and capabilities of the child in terms of respiration, voice, and resonance [4, 24–28].
Prior to puberty, the singing voices of boys and girls are similar in terms of their pitch range and vocal qualities, in keeping with the vocal tract structures being relatively the same shape and size [24]. Differences between the genders across childhood in singing activity have been suggested, however, with boys being less likely than girls to participate in singing activities, especially at school [28]. This may no longer be the case perhaps due to social and cultural shifts, and indeed gender representation in the childhood entertainment industry would now seem relatively even.
The onset of adolescent voice change particularly for males can be dramatic and rapid or a gradual and relatively undetected process. Neither age nor the onset of puberty seems to be the best indicator of the advent of voice changes [4], but the mean average onset is suggested to occur between 10 and 12 years [29, 30], and the peak of pubertal voice changes around 12–14 years of age in both females and males [29–38]. The Cooksey six-stage classification of pubescent voice change is based on singing range and tessitura and can be useful in tracking singing alterations across puberty [12, 29–38]. Some male singers can pass through all these musical stages of adolescent voice change in 12 months, but it is also possible for this process to be much slower and to last several years. Singing dynamics will be affected by both the hormonal and psychological influences of puberty, and it is sometimes difficult to tease out the relative contribution of each to the pubescent singer’s vocal profile. It is also worth noting that, in our experience, it is not only the voice quality and pitch that change but often there are subtle resonance changes too that yield a richer timbre and signal adolescence is nigh.
The prediction as to when a boy’s voice is likely to start breaking is therefore not an exact science, but some sense of the timing of this is desired when casting young male singers in music theatre productions. Some seasons of the shows featuring prepubescent male roles, such as the roles of Bruce in Matilda, Billy and Michael in Billy Elliot, and Oliver and Artful Dodger in Oliver!, may span over 2 years from audition to end of the contract. Producers and creatives invest much in these performers and understandably wish to avoid cast changes but, in addition to changes in physical attributes (such as height and weight), declining ability to achieve the vocal demands of the role due to puberty invariably leads to compromised performances or a cessation of the pubescent child playing these roles. In our experience, young male performers are often acutely aware of their vulnerability and can become highly anxious about any voice issues in case they are symptomatic of mutation. We have also noticed, although typically in a less obvious way, that the prepubescent female singer can similarly alter for some weeks or months around the time of the menarche, becoming lower in modal pitch and variable in quality, more prone to vocal fatigue and fluctuating vocal fold oedema.
There is some conjecture within the scientific literature that singers may differ from non-singing children in their ability to control and extend some aspects of their singing dynamics, such as vocal quality, pitch, and loudness ranges, and thereby exceed age-related physical constraints [4, 12, 30, 31]. This is attributed to singing training, singing experience, and perhaps inherently superior singing competency or talent [9, 23]. Although purely anecdotal, it is our experience that, although children’s vocal folds can be very resilient and can demonstrate improved efficient voicing for singing, repeated overextension beyond their comfortable physical limits in singing can be problematic for a child’s short-term vocal health. Whether this is potentially injurious to long-term vocal health has not been ascertained, but common sense suggests that clinicians and vocal pedagogues should be strong proponents of children singing efficiently within their current comfortable range and adapting repertoire accordingly.
The Team Approach
The concept of team management within all aspects of performance medicine has been increasingly favoured [39] and is particularly cogent for young performers. Our experience working together over the past 26 years in a Voice Clinic with a strong singer focus has reinforced the value of a team approach, with each member offering specific and complementary expertise to optimise patient care. An expert understanding of singers’ needs, performance, and vocal demands and of vocal pedagogy is required within the team composition, in addition to the usual clinical skillset described in Chap. 2.
In our experience, there can be additional complexities and frequently emotionally-laden stakes associated with the vocal care of the child performer that distinguish them from non-singing children. Managing both the singer and parental concerns can be challenging, and there is often an imperative to meet performance expectations and requirements above other priorities, including medical recommendations. Parents may be unintentionally providing an array of alternative remedies that are confounding recovery or adding medical complexity with multiple visits to various specialists. In addition, the children themselves may be reluctant participants in the treatment-seeking process and highly anxious about the potential ramifications of vocal care advice. For example, a recommendation for a reduction in vocal load may be the difference between performing or not. Similarly, the suggestion to sing in the alto rather than treble group in the choir may jeopardise the potential for any involvement, for solo opportunities or reduce singing satisfaction.
We have also seen countless young singers who are concerned they may have vocal nodules (colloquially coined ‘nodes’) and can even seem somewhat comparatively relieved when they are diagnosed with another pathology. In popular culture, vocal nodules have become associated with catastrophic performance consequences, as best described in the clip Chloe tells The Bellas that she has nodes from the much celebrated movie Pitch Perfect. When asked to explain her diagnosed ‘nodes’, Chloe responds, ‘They sit on your windpipe and crush your dreams’ (http://pitchperfectmovie.com). This concords with our experience that a diagnosis of nodules is commonly perceived as a dire outcome for young singers, despite the findings that children’s voices can fluctuate significantly and also that well-established nodules among paediatric singers of both genders and in post-pubescent males are extremely rare. Such potential preconceptions and the extra layers of importance attached to vocal health for this population highlight the necessity for a considered and sensitive team approach to the clinical assessment and management of the young singer. There is also a frequent need for the team to de-catastrophize the clinical findings for both the child and parent/s and to be cognisant of the recent vocal load of the young singer, in order to account for acute rather than chronic issues, and not ‘over-call’ pathology. The overall message must be one of vocal survival and success, and indeed, in our experience, with appropriately targeted care, there is almost never a need to stop a child from singing, unless recovering from sickness or surgery, and from pursuing their performance goals.
Speech Pathologist Approach
Assessment
Special considerations in the assessment of the singing child
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