Multidimensional Voice Profiles in Pediatric Professional Voice Users: Objective and Subjective Comparisons between Hifz Students and Normophonic Peers

Abstract

Objective: Hifz students, who undergo intensive Qur’an memorization training from childhood, are considered “pediatric professional voice users” due to their prolonged daily recitation and high vocal demands. Such training involves repetitive, loud, and melodic voice use, which may predispose them to early voice disorders. This study aimed to compare the multidimensional voice characteristics of Hifz students, who undergo intensive Qur’an memorization training, with age-matched normophonic peers.

Material and Methods: A total of 124 Turkish-speaking children (62 Hifz, 62 controls; aged 11–14 years) were assessed using the Turkish Children’s Voice Handicap Index–10 (TR-CVHI-10), GRBAS scale, aerodynamic measure (maximum phonation time, /s/ and /z/ durations, s/z ratio), and acoustic analyses (fundamental frequency, jitter, shimmer, harmonic-to-noise ratio, cepstral peak prominence smoothed).

Results: Hifz students reported significantly higher TR-CVHI-10 scores (p<0.001). They exhibited elevated s/z ratios (p<0.01), whereas the maximum phonation time did not differ. Acoustically, Hifz students showed lower fundamental frequency (p<0.05), higher perturbation (jitter and shimmer; both p<0.01), and reduced harmonic-to-noise ratio and cepstral peak prominence (p<0.01). GRBAS ratings indicated predominantly mild-to-moderate dysphonia.

Conclusion: Hifz students demonstrated an elevated risk profile for voice disorders, with adverse self-perceptual, acoustic, aerodynamic, and perceptual indicators. Integrating voice hygiene and structured training into Hifz curricula is recommended to support vocal health.

Keywords

• Hifz students
• pediatric voice
• professional voice use
• acoustic voice analysis
• voice disorders
• child

References

1. Pinheiro AP. Behind a voice there is a speaker: Why vocal emotion research needs to become 'Personal'. Affect Sci 2025;6(3):562-74.
2. Guldner S, Lavan N, Lally C, Wittmann L, Nees F, Flor H, et al. Human talkers change their voices to elicit specific trait percepts. Psychon Bull Rev 2024;31(1):209-22.
3. Al-Khleifat K. The effects of vocal training on the cognitive and emotional development of young children. Scientific Bulletin of Mukachevo State University Series “Pedagogy and Psychology”. 2025;11(1):113-24.
4. Connor NP, Cohen SB, Theis SM, Thibeault SL, Heatley DG, Bless DM. Attitudes of children with dysphonia. J Voice 2008;22(2):197-209.
5. Krohling LL, Pereira de Paula KM, Behlau MS. Behavior, social competence, and voice disorders in childhood and adolescence. J Voice 2016;30(6):677-83.
6. Brinkman RJ, Hage JJ. Andreas Vesalius' 500th Anniversary: Initial integral understanding of voice production. J Voice 2017;31(1):124 e11- e19.
7. Amberger P. Voice disorder in children : what can be done ? Rev Med Suisse 2020;16(717):2348-50.
8. Fujiki RB, Thibeault SL. Voice disorder prevalence and vocal health characteristics in children. JAMA Otolaryngol Head Neck Surg 2024;150(8):677-87.

9. Kılıç MA, Okur E, Yildirim I, Güzelsoy S. The prevalence of vocal fold nodules in school age children. Int J Pediatr Otorhinolaryngol 2004;68(4):409-12.
10. Mohammadzadeh A, Sandoughdar N. Prevalence of voice disorders in iranian primary school students. J Voice 2017;31(2):263 e13- e18.
11. Szkielkowska A, Miaskiewicz B, Gos E, Skarzynski PH, Swierniak W. Voice disorders in children starting school education. Otolaryngol Pol 2020;74(6):16-20.
12. Tuzuner A, Demirci S, Oguz H, Ozcan KM. Pediatric vocal fold nodule etiology: What are its usual causes in children? J Voice 2017;31(4):506 e19- e23.
13. Swain SK, Nahak B, Sahoo L, Munjal S, Sahu MC. Pediatric dysphonia - A Review. Indian Journal of Child Health 2019;6(1):1-5.
14. Mudd P, Noelke C. Vocal fold nodules in children. Curr Opin Otolaryngol Head Neck Surg 2018;26(6):426-30.
15. Karali FS, Azizli E, Tadihan-Ozkan E, Eskioglu EI, Sari A, Resuloglu A. Voice therapy efficacy in pediatric professional voice users with vocal fold nodules: A preliminary study. J Voice 2025;39(2):567e1-6.
16. Dzulkifli MA, Solihu AKH. Methods of Qur’ānic memorisation (Ḥifẓ): Implications for learning performance. Intellectual Discourse 2018;26(2):931-47.
17. Hilmi M, Nasir MA, Saparudin S, Dahlan F, Saharudin S. Tahfiẓ Al-Qur'an as brand image of modern Islamic education in lombok. QALAMUNA: Jurnal Pendidikan, Sosial, dan Agama 2023;15(2):483-96.
18. Bhutto S. Traditional and Modern Methods Used for Memorization of Quran in Turkey. Ma’arif Research Journal 2015;10:91-100.
19. Sataloff RT. Professional Voice: The Science and Art of Clinical Care. 4th ed. San Diego, CA: Plural Publishing; 2017.
20. Carroll L, Barson P, Rosenberg A, Zur KB. Dysphonic Children: Performers vs. Non-Performers. J Voice 2026.
21. Crossley EJ, Hutchison L, Aymat A, Gibbins N, Awad R. Dysphonia in pediatric professional voice users: Is it just nodules? J Voice 2023.
22. Tunc Songur E, Esen Aydinli F, Sari A, Demirci AN, Incebay O. A comparison of voice disorder types and voice-related handicap levels among Islamic clergy and other professional voice users in Turkiye. J Relig Health 2025;64(4):2697-711.
23. Buyukatalay ZC, Gokmen MF, Yildirim S, Dursun G. Voice disorders in Islamic religious officials: Is it any different than those of the teachers, another well-known professional voice users? J Voice 2020;34(5):738-42.
24. Sarıca S. Prevalence and risk factors for voice problems in imams. Turkish Journal of Family Medicine and Primary Care 2018;12(4):275-80.
25. Abou-Elsaad T, Baz H, Afsah O, Abo-Elsoud H. Validation and adaptation of the singing voice handicap index for egyptian singing voice. J Voice 2017;31(1):130 e1- e6.
26. Buckley KL, Carey LB. Systems Approaches to occupational vocal health: Considerations for community faith leaders. J Relig Health 2022;61(2):1183-206.
27. Jayakumar T, Yasin HAM, Benoy JJ. Prevalence of voice problems and associated risk factors among tamil-speaking imams. J Voice 2025;39(3):846 e25- e33.
28. Ricci-Maccarini A, De Maio V, Murry T, Schindler A. Development and validation of the children's voice handicap index-10 (CVHI-10). J Voice 2013;27(2):258 e23- 8.
29. Tadihan Ozkan E, Tuzuner A, Ciyiltepe M, Balo E, Ozcelik Korkmaz M, Cagli A. Reliability and validity of the Turkish children's voice handicap index-10 (TR-CVHI-10). Int J Pediatr Otorhinolaryngol 2017;96:131-4.
30. Hirano M. Clinical examination of voice: Springer-Verlag; 1981.
31. Duffy JR. Motor speech disorders: Substrates, differential diagnosis, and management. 4th ed: Mosby; 2019.
32. Ferrand CT. Diagnosis and evaluation of voice disorders. Voice disorders: Scope of theory and practice. 2nd ed. New York: Pearson Education; 2019. p. 99-160.
33. Gianlorenço AC, Costa V, Fabris-Moraes W, Teixeira PEP, Gonzalez P, Pacheco-Barrios K, et al. Associations of Voice Metrics with Postural Function in Parkinson’s Disease. Life 2025;15(1):27.
34. Kılıç MA. Objektif ses analizi. In: Özüdoğru EN, editor. Ses Bozukluklarına Güncel Yaklaşım. 1st ed. Ankara: Türkiye Klinikleri; 2019. p. 33-9.
35. Cortés Ponce JR, Garza Montelongo L, Juárez Silva JE, Trevino González JL. Smoothed Cepstral Peak Prominence: A Comparison Between Dysphonic and Non-dysphonic Mexican Adults Employing the Praat Software. Cureus 2024;16(10):e72292.
36. Esen Aydinli F, Ozcebe E, Incebay O. Use of cepstral analysis for differentiating dysphonic from normal voices in children. Int J Pediatr Otorhinolaryngol 2019;116:107-13.
37. Brockmann M, Drinnan MJ, Storck C, Carding PN. Reliable jitter and shimmer measurements in voice clinics: the relevance of vowel, gender, vocal intensity, and fundamental frequency effects in a typical clinical task. J Voice 2011;25(1):44-53.
38. Murton O, Hillman R, Mehta D. Cepstral Peak Prominence Values for Clinical Voice Evaluation. Am J Speech Lang Pathol 2020;29(3):1596-607.
39. Iwarsson J, Hollen Nielsen R, Næs J. Mean fundamental frequency in connected speech and sustained vowel with and without a sentence-frame. Logoped Phoniatr Vocol 2020;45(2):91-6.
40. Solomon NP, Garlitz SJ, Milbrath RL. Respiratory and laryngeal contributions to maximum phonation duration. J Voice 2000;14(3):331-40.
41. Eckel FC, Boone DR. The S/Z ratio as an indicator of laryngeal pathology. J Speech Hear Disord 1981;46(2):147-9.
42. Köse A. Materyaller ve vaka örnekleriyle kekemelik terapisi [Stuttering therapy with materials and case examples]. 2nd ed: Nobel Academic Publishing; 2025.
43. Incebay O, Kose A, Esen Aydinli F, Ozcebe E. The Effects of Age and Gender on Laryngeal Aerodynamics in the Children Population J Voice. 2020;34(2):300 e27- e46.
44. López-Martín E, Ardura D. The effect size in scientific publication. Educación XX1: Revista de la Facultad de Educación 2023;26(1):9-17.
45. Sezin RK, Yasar O, Erensoy I. Effectiveness of a Voice Training Program for Religious Officials in Turkey. J Relig Health 2024;63(6):4657-71.
46. Clarós P, Porebska I, Clarós-Pujol A, Pujol C, Clarós A, López-Muñoz F, et al. Association Between the Development of Pediatric Voice Disorders and Singing in Children's Choir. JAMA Otolaryngol Head Neck Surg 2019;145(5):445-51.
47. Ozmen S, Yesilyurt M, Yelken K. Muslim Religious Officials Have Less Voice Training and Higher Rate of Voice Disorder Than Christian Religious Officials. J Voice. 2025.
48. Yanushevskaya I, Kenny C. Cepstral Peak Prominence: Normative Values for Clinical Voice Assessment-A Systematic Review and Meta-analysis. J Voice 2025.
49. Mendes Tavares EL, Brasolotto AG, Rodrigues SA, Benito Pessin AB, Garcia Martins RH. Maximum phonation time and s/z ratio in a large child cohort. J Voice 2012;26(5):675.e1-4.
50. Naeem I, Mubeen R, Shah SAH, Obaid S, Saqulain G. Maximum Phonation Time of School-Aged Children in Pakistan: A Normative Study : Maximum Phonation Time of School-Aged Children. Pakistan Journal of Health Sciences 2024;5(02):13-8.