Child Sexual Abuse of Elite Athletes: Prevalence, Perceptions, and Mental Health.

Despite a series of high-profile media reports of sexual abuse in sport over the past few years, little research has been done to explore the scope of the problem in the United States. The current article reports on prevalence of child sexual assault in elite athletes in the United States. Using a retrospective web survey, adults answered questions on their experiences in sport. Of the 473 elite athletes surveyed, 3.8% (n = 18) reported being sexual assaulted as a minor in the sporting context. Of those reporting assault, most (61%) reported being abused by an adult authority figure (usually a coach) and 44% reported being assaulted by a peer. Abused athletes were significantly more likely to report having been diagnosed with a mental disorder (Fisher's exact test; p < .001). The findings can be utilized to improve prevention and child protection measures and other safeguarding initiatives in sport.

Daily Phonotrauma Index: An Objective Indicator of Large Differences in Self-Reported Vocal Status in the Daily Life of Females With Phonotraumatic Vocal Hyperfunction.

PURPOSE: The purpose of this study is to evaluate if the Daily Phonotrauma Index (DPI) can quantitatively discriminate large differences in overall vocal status in the daily life of patients with phonotraumatic vocal hyperfunction (PVH). METHOD: For 1-4 weeks, 23 females with PVH wore an ambulatory voice monitor and answered three vocal status questions (i.e., difficulty producing soft, high-pitched phonation; discomfort; and fatigue) at the beginning, at 5-hr intervals, and the end of each day. DPI values were obtained for each patient's time periods of worst and best self-rated vocal status, and data for the group were analyzed for significant changes using a linear mixed-effects regression model. RESULTS: The DPI was significantly lower during periods self-rated as "best vocal status" compared to during periods self-rated as "worst vocal status" (mean difference in DPI = 0.53) with a medium-to-large effect size (Cohen's d = -0.68). CONCLUSIONS: In a group of patients with phonotraumatic lesions, the DPI indicated lower potential for phonotrauma during time periods of better vocal status compared to time periods of worse vocal status. Assuming that a large portion of variance in vocal status for patients with PVH is associated with the extent to which voicing is phonotraumatic, these results support the validity of obtaining estimates of DPI for much shorter time periods (i.e., an estimate every 2 min of voicing) than previous studies (i.e., a single estimate for the entire day or week). Future work can investigate the DPI's use for in-clinic assessment/treatment and ambulatory biofeedback and can gain further insights into phonatory mechanisms that underlie DPI via comparisons with other physiologically relevant measures and computational vocal fold modeling.

Ambulatory Voice Biofeedback: Acquisition and Retention of Modified Daily Voice Use in Patients With Phonotraumatic Vocal Hyperfunction.

PURPOSE: Voice ambulatory biofeedback (VAB) has potential to improve carryover of therapeutic voice use into daily life. Previous work in vocally healthy participants demonstrated that motor learning inspired variations to VAB produced expected differences in acquisition and retention of modified daily voice use. This proof-of-concept study was designed to evaluate whether these VAB variations have the same desired effects on acquisition and retention in patients with phonotraumatic vocal hyperfunction (PVH). METHOD: Seventeen female patients with PVH wore an ambulatory voice monitor for 6 days: three baseline days, one biofeedback day, one short-term retention day, and one long-term retention day. Short- and long-term retention were 1- and 7-days postbiofeedback, respectively. Patients were block-randomized to receive one of three types of VAB: 100%, 25%, and Summary. Performance was measured in terms of adherence time below a subject-specific vocal intensity threshold. RESULTS: All three types of VAB produced a biofeedback effect with 13 out of 17 patients displaying an increase in adherence time compared to baseline days. Additionally, multiple patients from each VAB group increased their adherence time during short- and/or long-term retention monitoring compared to baseline. CONCLUSIONS: These findings show that VAB can be associated with acquisition and retention of desired voice use in patients with PVH. Specifically, all three feedback types improved multiple patients' performance and retention for up to 1 week after biofeedback removal. Future work can investigate the impact of incorporating VAB into voice therapy.

Amount and Characteristics of Speaking and Singing Voice Use in Vocally Healthy Female College Student Singers During a Typical Week.

OBJECTIVES: Singers, college students, and females are groups known to be at an elevated risk of developing functional/hyperfunctional voice disorders; therefore, female college students majoring in vocal performance may be at an even higher risk. To mitigate this risk, it would be helpful to know the "safe limits" for voice use that would help maintain vocal health in this vulnerable group, but there is a paucity of high-quality objective information upon which to base such limits. This study employed weeklong ambulatory voice monitoring in a large group of vocally healthy female college student singers to begin providing the types of objective data that could be used to help develop improved vocal health guidelines. METHODS: Participants included 64 vocally healthy females currently enrolled in a vocal performance or similar program at a college or university. An ambulatory voice monitor recorded neck-surface acceleration throughout a typical week. A singing classifier was applied to the data to separate singing from speech. Weeklong vocal dose measures and distributional characteristics for standard voice measures were computed separately for singing and speech, and for both types of phonation combined. RESULTS: Participants spent 6.2% of the total monitoring time speaking and 2.1% singing (with total phonation time being 8.4%). Singing had a higher fo mode, more pitch variability, higher average sound pressure level (SPL), negatively skewed SPL distributions, lower average CPP, and higher H1-H2 values than speaking. CONCLUSIONS: These results provide a basis for beginning to establish vocal health guidelines for female students enrolled in college-level vocal performance programs and for future studies of the types of voice disorders that are common in this group. Results also demonstrate the potential value that ambulatory voice monitoring may have in helping to objectively identify vocal behaviors that could contribute to voice problems in this population.

Relationships Among Personality, Daily Speaking Voice Use, and Phonotrauma in Adult Female Singers.

PURPOSE: This study sought to determine whether personality traits related to extraversion and impulsivity are more strongly associated with singers with nodules compared to vocally healthy singers and to understand the relationship between personality and the types of daily speaking voice use. METHOD: Weeklong ambulatory voice recordings and personality inventories were obtained for 47 female singers with nodules and 47 vocally healthy female singers. Paired t tests investigated trait differences between groups. Relationships between traits and weeklong speaking voice measures (vocal dose, sound pressure level [SPL], neck surface acceleration magnitude [NSAM], fundamental frequency, cepstral peak prominence [CPP], and the ratio of the first two harmonic magnitudes [H 1 -H 2]) were examined using pairwise Pearson r coefficients. Multiple regressions were performed to estimate voice parameters that correlated with two or more traits. RESULTS: Singers with nodules scored higher on the Social Potency scale (reflecting a tendency toward social dominance) and lower on the Control scale (reflecting impulsivity) compared to the vocally healthy singers. In vocally healthy singers, vocal dose measures were positively correlated with a combination of Wellbeing (i.e., happiness) and Social Potency, mean SPL was positively correlated with Wellbeing, SPL variability was positively correlated with Social Potency and negatively with Harm Avoidance, and CPP mean was positively correlated with Wellbeing. Singers with nodules had a negative correlation between NSAM skewness and Social Potency. Both groups had negative correlations between H 1 -H 2 mean and Social Potency and Social Closeness. CONCLUSIONS: Singers with nodules are more socially dominant and impulsive than vocally healthy singers. Personality traits are related to daily speaking voice use, particularly in vocally healthy singers. Individuals with higher levels of traits related to happiness and social dominance and lower Harm Avoidance tended to speak more, with higher laryngeal forces, with more SPL variability, and with more pressed glottal closure, which could increase risk of phonotrauma.

Psychometric Analysis of an Ecological Vocal Effort Scale in Individuals With and Without Vocal Hyperfunction During Activities of Daily Living.

Objective The purpose of this study was to examine the psychometric properties of an ecological vocal effort scale linked to a voicing task. Method Thirty-eight patients with nodules, 18 patients with muscle tension dysphonia, and 45 vocally healthy control individuals participated in a week of ambulatory voice monitoring. A global vocal status question was asked hourly throughout the day. Participants produced a vowel-consonant-vowel syllable string and rated the vocal effort needed to produce the task on a visual analog scale. Test-retest reliability was calculated for a subset using the intraclass correlation coefficient, ICC(A, 1). Construct validity was assessed by (a) comparing the weeklong vocal effort ratings between the patient and control groups and (b) comparing weeklong vocal effort ratings before and after voice rehabilitation in a subset of 25 patients. Cohen's d, the standard error of measurement (SEM), and the minimal detectable change (MDC) assessed sensitivity. The minimal clinically important difference (MCID) assessed responsiveness. Results Test-retest reliability was excellent, ICC(A, 1) = .96. Weeklong mean effort was statistically higher in the patients than in controls (d = 1.62) and lower after voice rehabilitation (d = 1.75), supporting construct validity and sensitivity. SEM was 4.14, MDC was 11.47, and MCID was 9.74. Since the MCID was within the error of the measure, we must rely upon the MDC to detect real changes in ecological vocal effort. Conclusion The ecological vocal effort scale offers a reliable, valid, and sensitive method of monitoring vocal effort changes during the daily life of individuals with and without vocal hyperfunction.

Analysis of the Written Policies of the 32 U.S. Archdioceses on the Prevention of Child Sexual Abuse.

The Catholic Church in the U.S. has been under concerted public pressure to improve its child protection policies. However, development of these policies has largely been left to the discretion of local dioceses with little central oversight. To determine the scope of current abuse prevention policies, we analyzed all 32 U.S. archdioceses' policies and practices for developing a safe environment and preventing child sexual abuse. Using a tool developed from a list of unique components selected from the policies of all 32 archdioceses, we compared policies and procedures across archdioceses. On a group level, we found policies to be inadequate. The average score for archdioceses in the general area of prevention was 40.7 (SD = 9.3) out of 102 possible points (40% of possible points) with few prevention policies conforming to basic best practices that would be expected of a youth-serving organization. The variation and inconsistencies across archdioceses reveal the need for the Catholic Church to establish more uniform standards for preventing sexual abuse. These standards should be grounded in evidence-based practices and expert guidance. We also discuss some key areas which warrant immediate attention in future policy-making.

Changes in the Daily Phonotrauma Index Following the Use of Voice Therapy as the Sole Treatment for Phonotraumatic Vocal Hyperfunction in Females.

Purpose The aim of this study was to use the Daily Phonotrauma Index (DPI) to quantify group-based changes in the daily voice use of patients with phonotraumatic vocal hyperfunction (PVH) after receiving voice therapy as the sole treatment. This is part of an ongoing effort to validate an updated theoretical framework for PVH. Method A custom-designed ambulatory voice monitor was used to collect 1 week of pre- and posttreatment data from 52 female patients with PVH. Normative weeklong data were also obtained from 52 matched controls. Each week was represented by the DPI, which is a combination of neck-surface acceleration magnitude skewness and the standard deviation of the difference between the first and second harmonic magnitudes. Results Compared to pretreatment, the DPI statistically decreased towards normal in the patient group after treatment (Cohen's d = -0.25). The posttreatment patient group's DPI was still significantly higher than the control group (d = 0.68). Conclusions The DPI showed the pattern of improved ambulatory voice use in a group of patients with PVH following voice therapy that was predicted by the updated theoretical framework. Per the prediction, voice therapy was associated with a decreased potential for phonotrauma in daily voice use, but the posttreatment patient group data were still significantly different from the normative control group data. This posttreatment difference is interpreted as reflecting the impact on voice use of the persistence of phonotrauma-induced structural changes to the vocal folds. Further validation of the DPI is needed to better understand its potential clinical use.

Differences in Daily Voice Use Measures Between Female Patients With Nonphonotraumatic Vocal Hyperfunction and Matched Controls.

Purpose The purpose of this study was to obtain a more comprehensive understanding of the pathophysiology and impact on daily voice use of nonphonotraumatic vocal hyperfunction (NPVH). Method An ambulatory voice monitor collected 1 week of data from 36 patients with NPVH and 36 vocally healthy matched controls. A subset of 11 patients with NPVH were monitored after voice therapy. Daily voice use measures included neck-skin acceleration magnitude, fundamental frequency (f o), cepstral peak prominence (CPP), and the difference between the first and second harmonic magnitudes (H1-H2). Additional comparisons included 118 patients with phonotraumatic vocal hyperfunction (PVH) and 89 additional vocally healthy controls. Results The NPVH group, compared to the matched control group, exhibited increased f o (Cohen's d = 0.6), reduced CPP (d = -0.9), and less positive H1-H2 skewness (d = -1.1). Classifiers used CPP mean and H1-H2 mode to maximally differentiate the NPVH and matched control groups (area under the receiver operating characteristic curve of 0.78). Classifiers performed well on unseen data: the logit decreased in patients with NPVH after therapy; ≥ 85% of the control and PVH groups were identified as "normal" or "not NPVH," respectively. Conclusions The NPVH group's daily voice use is less periodic (CPP), is higher pitched (f o), and has less abrupt vocal fold closure (H1-H2 skew) compared to the matched control group. The combination of CPP mean and H1-H2 mode appears to reflect a pathophysiological continuum in NPVH patients of inefficient phonation with minimal potential for phonotrauma. Further validation of the classification model is needed to better understand potential clinical uses. Supplemental Material https://doi.org/10.23641/asha.14390771.

Differences Between Female Singers With Phonotrauma and Vocally Healthy Matched Controls in Singing and Speaking Voice Use During 1 Week of Ambulatory Monitoring.

Purpose Previous ambulatory voice monitoring studies have included many singers and have combined speech and singing in the analyses. This study applied a singing classifier to the ambulatory recordings of singers with phonotrauma and healthy controls to determine if analyzing speech and singing separately would reveal voice use differences that could provide new insights into the etiology and pathophysiology of phonotrauma in this at-risk population. Method Forty-two female singers with phonotrauma (vocal fold nodules or polyps) and 42 healthy matched controls were monitored using an ambulatory voice monitor. Weeklong statistics (average, standard deviation, skewness, kurtosis) for sound pressure level (SPL), fundamental frequency, cepstral peak prominence, the magnitude ratio of the first two harmonics (H1-H2 ), and three vocal dose measures were computed from the neck surface acceleration signal and separated into singing and speech using a singing classifier. Results Mixed analysis of variance models found expected differences between singing and speech in each voice parameter, except SPL kurtosis. SPL skewness, SPL kurtosis, and all H1-H2 distributional parameters differentiated patients and controls when singing and speech were combined. Interaction effects were found in H1-H2 kurtosis and all vocal dose measures. Patients had significantly higher vocal doses in speech compared to controls. Conclusions Consistent with prior work, the pathophysiology of phonotrauma in singers is characterized by more abrupt/complete glottal closure (decreased mean and variation for H1-H2 ) and increased laryngeal forces (negatively skewed SPL distribution) during phonation. Application of a singing classifier to weeklong data revealed that singers with phonotrauma spent more time speaking on a weekly basis, but not more time singing, compared to controls. Results are used as a basis for hypothesizing about the role of speaking voice in the etiology of phonotraumatic vocal hyperfunction in singers.

Changes in a Daily Phonotrauma Index After Laryngeal Surgery and Voice Therapy: Implications for the Role of Daily Voice Use in the Etiology and Pathophysiology of Phonotraumatic Vocal Hyperfunction.

Purpose This study attempts to gain insights into the role of daily voice use in the etiology and pathophysiology of phonotraumatic vocal hyperfunction (PVH) by applying a logistic regression-based daily phonotrauma index (DPI) to predict group-based improvements in patients with PVH after laryngeal surgery and/or postsurgical voice therapy. Method A custom-designed ambulatory voice monitor was used to collect 1 week of pre- and postsurgery data from 27 female patients with PVH; 13 of these patients were also monitored after postsurgical voice therapy. Normative weeklong data were obtained from 27 matched controls. Each week was represented by the DPI, standard deviation of the difference between the first and second harmonic amplitudes (H1-H2). Results Compared to pretreatment, the DPI significantly decreased in the patient group after surgery (Cohen's d effect size = -0.86) and voice therapy (d = -1.06). The patient group DPI only normalized after voice therapy. Conclusions The DPI produced the expected pattern of improved ambulatory voice use across laryngeal surgery and postsurgical voice therapy in a group of patients with PVH. The results were interpreted as providing new objective information about the role of daily voice use in the etiology and pathophysiology of PVH. The DPI is viewed as an estimate of potential vocal fold trauma that relies on combining the long-term distributional characteristics of two parameters representing the magnitude of phonatory forces (neck-surface acceleration magnitude) and vocal fold closure dynamics (H1-H2). Further validation of the DPI is needed to better understand its potential clinical use.

Ambulatory monitoring of Lombard-related vocal characteristics in vocally healthy female speakers.

Speakers typically modify their voice in the presence of increased background noise levels, exhibiting the classic Lombard effect. Lombard-related characteristics during everyday activities were recorded from 17 vocally healthy women who wore an acoustic noise dosimeter and ambulatory voice monitor. The linear relationship between vocal sound pressure level and environmental noise level exhibited an average slope of 0.54 dB/dB and value of 72.8 dB SPL at 50 dBA when correlation coefficients were greater than 0.4. These results, coupled with analyses of spectral and cepstral vocal function measures, provide normative ambulatory Lombard characteristics for comparison with patients with voice-use related disorders.

Differences in Weeklong Ambulatory Vocal Behavior Between Female Patients With Phonotraumatic Lesions and Matched Controls.

Purpose Previous work using ambulatory voice recordings has shown no differences in average vocal behavior between patients with phonotraumatic vocal hyperfunction and matched controls. This study used larger groups to replicate these results and expanded the analysis to include distributional characteristics of ambulatory voice use and measures indicative of glottal closure. Method Subjects included 180 adult women: 90 diagnosed with vocal fold nodules or polyps and 90 age-, sex-, and occupation-matched controls with no history of voice disorders. Weeklong summary statistics (average, variability, skewness, kurtosis) of voice use were computed from neck-surface acceleration recorded using an ambulatory voice monitor. Voice measures included estimates of sound pressure level (SPL), fundamental frequency (f o), cepstral peak prominence, and the difference between the first and second harmonic magnitudes (H1-H2). Results Statistical comparisons resulted in medium-large differences (Cohen's d ≥ 0.5) between groups for SPL skewness, f o variability, and H1-H2 variability. Two logistic regressions (theory-based and stepwise) found SPL skewness and H1-H2 variability to classify patients and controls based on their weekly voice data, with an area under the receiver operating characteristic curve of 0.85 and 0.82 on training and test sets, respectively. Conclusion Compared to controls, the weekly voice use of patients with phonotraumatic vocal hyperfunction reflected higher SPL tendencies (negatively skewed SPL) with more abrupt glottal closure (reduced H1-H2 variability, especially toward higher values). Further work could examine posttreatment data (e.g., after surgery and/or therapy) to determine the extent to which these differences are associated with the etiology and pathophysiology of phonotraumatic vocal fold lesions.

Automatic speech and singing classification in ambulatory recordings for normal and disordered voices.

Ambulatory voice monitoring is a promising tool for investigating phonotraumatic vocal hyperfunction (PVH), associated with the development of vocal fold lesions. Since many patients with PVH are professional vocalists, a classifier was developed to better understand phonatory mechanisms during speech and singing. Twenty singers with PVH and 20 matched healthy controls were monitored with a neck-surface accelerometer-based ambulatory voice monitor. An expert-labeled ground truth data set was used to train a logistic regression on 15 subject-pairs with fundamental frequency and autocorrelation peak amplitude as input features. Overall classification accuracy of 94.2% was achieved on the held-out test set.