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CHAPTER 1:
Vocal health and awareness
Welcome
Sing Up is delighted to present you with Inside the voice, an authoritative handbook for the spoken and
singing voice. Produced for classroom teachers and other professional voice users, this accessible and
engaging resource tells you everything you need to know about how your voice works and how you can look
after it. It also gives information about children’s voices, alongside insights into warm-up theory and tips for
improving vocal technique. The content is rigorously backed up by evidence-based research and has been
vetted by an academic panel at the top of their fields.
Each of the six chapters are written as standalone documents, meaning you can pick the bits that are most
useful to you. If you want to get the most of what the resource has to offer though, we recommend you
read all six! There is also a handy glossary, where you can find definitions of the more technical terms used
elsewhere in the resource.
We hope you enjoy Inside the voice, and that it gives you and your pupils all you need to keep your
voices healthy.

Contents
1. Vocal health and awareness
2. How the voice works
3. Voice care in and out of the classroom
4. Voice development over the lifespan
5. Improving singing technique
6. Warm-up theory & practice
7. Glossary & further reading

The authors
Stuart Barr M.Phil, M.A.(Cantab), PGAdvDip(RCM), HonARAM, is a consultant singing coach and conductor
working with choirs, West End performers and pop artists at the highest level. He was President of the British
Voice Association 2009-2010, is a judge for BBC Choir of the Year, and regularly presents on the workings of
the voice at conferences.

Jenevora Williams PhD ARCM, is a singing teacher and voice researcher. She is singing consultant for the
National Youth Choir and has taught at the Royal College of Music, as well as in universities and at the major
UK cathedrals. In her busy private practice, she works with people ranging from professionals to students.
She was recently awarded a PhD for research on the vocal health and development of choristers, and the
Van Lawrence Prize for her contribution to the field of voice research.

Inside the voice team

Editor: Henry Bird
Resource team: Celi Barberia, Louise Cleverdon, Beth Millett
Advisory panel: Professor Graham Welch (Chair of Music Education, Institute of Education);
Dr Declan Costello (Consultant Ear Nose & Throat Surgeon, Queen Elizabeth Hospital, Birmingham and
55 Harley Street, London)
Design by: Frances Matthews; Illustrations by: Harry Venning
© 2011 Stuart Barr and Jenevora Williams

INSIDE THE VOICE www.singup.org 2

Inside the voice
Chapter 1: Vocal health
and awareness
In this chapter:
The surprising scale of poor vocal health among teachers and
children is examined. Don’t worry though – understanding the voice
and its use in teaching will help to minimise the problems.

Why good vocal health is important 4

A look at why it’s important that we all take care of our voices

The scale of teachers’ vocal ill-health 4

We outline how primary school teachers are particularly susceptible to
problems with their voices

Voice problems in children 7

An insight into the problems found in children’s voices

Prevention is better than cure 7

How the other chapters of Inside the voice will help prevent voice problems before
they occur

INSIDE THE VOICE www.singup.org 3

 CHAPTER 1

Why good vocal health is important

The voice is our primary communication tool. It expresses our commands, needs, desires and emotions.
Despite this, we tend to take it for granted unless it goes wrong. Voice problems reduce our ability to
communicate, which can lower our self-esteem and limit the extent to which we achieve our goals in life.
Our voices are like mirrors that reflect our health, age, emotion and mood. All of us, at some time, suffer
from ill-health that affects our voices. The cause of voice loss can be as simple as the common cold, but it
can also come from problems in the way we use our voices, or from issues relating to lifestyle. It can also be
caused as an indirect result of anxiety levels. These factors may only be partly within our control, but being
aware of the facts can help us lessen symptoms, shorten recovery time or avoid problems altogether.
In 2010, a teacher in Hillingdon was awarded £150,000 in compensation after suffering permanent vocal
damage through having to raise her voice over playground noise next to her classroom. Repeated requests
for help from management were not followed through and she eventually had to stop teaching.
This is probably a worst case scenario, but even in less extreme cases taking time off work through vocal
ill-health is disruptive to teaching and costly to schools. Teachers’ voice problems don’t just impact upon their
own lives; they also negatively affect classroom outcomes, as studies demonstrate. Children’s voices are
susceptible to health issues too, and awareness among teachers can help mitigate this.
The good news is that most voice use is excellent. Much of this guide is about helping teachers and voice
leaders maintain this excellence in all circumstances, allowing them to head off small problems before they
become big ones.
Before examining how the voice works in Chapter 2, and how to look after it in Chapter 3, the rest of this
chapter looks at how many teachers and children are affected by vocal health problems.

The scale of teachers’ vocal ill-health

There are four key indicators that demonstrate the extent to which teachers suffer poor vocal health:

zz voice problems in teachers compared to those in other occupations

zz the proportion of Voice Clinic patients being teachers
zz the rate of reported voice problems among teachers
zz the impact of voice problems on teaching outcomes.

The studies outlined in the following pages are a snapshot of some of the research currently being
undertaken in this area. If you’d like to find out more about the studies, see the endnotes on p8.
Any way you look at the problem, it’s clear is that the issue is a substantial one.

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 CHAPTER 1

Voice problems in teachers versus Diagram 1: Voice problems in teachers versus

other occupations other occupations
School teachers, all levels
Research overwhelmingly reports that teachers
are far more susceptible to voice problems than Other occupations
those in other occupations. In one study, teachers
were almost 30 times more likely to develop voice
problems and five times more likely to miss work as
a result (see Diagram 1).1
32%
Teachers versus other occupations 20%
in NHS Voice Clinics
The picture from the point of view of NHS Voice 4%
Clinics is even more telling, with one study reporting 1%
that teachers made up 12% of the patients (see
Diagram 2).2 With teachers only making up 1.5% of
Ever had a voice Missed work due to
society, the occupational health message is stark: problem? a voice problem?
being a teacher makes you nine times as likely to
be a Voice Clinic patient than the average adult.
Diagram 2: Proportion of NHS Voice Clinic
The rate of teachers’ voice patients who are teachers
Proportion of voice
problems in primary schools clinic patients who
are teachers
A study has revealed that over two-thirds of
UK primary teachers have at some time had a Proportion of
teachers in society
voice problem, of whom nearly a quarter missed
work as a result (see Diagram 3).3 The results
for all schools (independent and state, and at all
levels) showed that it was primary teachers who
12%
reported the most problems.
Reasons for primary teachers being worst
affected may include larger class size, the nature
1.5%
of primary teaching, and the gender balance of
the teaching profession (see p7).

Diagram 3a: Have you ever experienced Diagram 3b: If you experienced voice problems, did you:
voice problems that you feel could have
been caused by your job?
1. visit GP?

2. visit Voice Clinic?

NO 3. take time off work? 47%

4. use over-the-
32% counter medication? 37% 39%
YES 5. do nothing?
24%
68%
12%
(All responses from
primary school teachers)
1 2 3 4 5

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 CHAPTER 1

Impact of voice problems on teaching outcomes

The impact of voice-related teacher absence, in terms of additional costs and disruption to teaching, is
obvious. However, a hidden and potentially more important aspect is the negative effect on classroom
outcomes when pupils have a teacher with a voice problem. One study reports a significant reduction in
pupils’ learning ability from dysphonic teachers (ie. those suffering from vocal ill-health).4 The suggestion is
that dysphonic teachers’ voices can result in children directing more resources to processing what’s being
said, thereby reducing their capacity for comprehension.

How vocal ill-health happens

There are several reasons behind vocal ill-health:
zz Organic illness, which can range from the common cold and other respiratory viruses, through to
growths such as cysts and cancerous growths. Other causes include acid reflux and allergies.
zz High vocal loading, which includes the amount of use, the level of use and emotional stress.
zz Poor technique, such as constricting posture, bad vocal habits and inefficient voicing.
zz Irritants, including atmospheric pollutants such as dust, chemical fumes and smoke.
Solutions to all these issues can be found in Chapter 3.

Why teachers are particularly

susceptible to vocal illness
The factors above can affect all voice users, but it’s the level
of vocal loading (possibly compounding the other factors)
that causes most vocal ill-health in teaching.
Vocal loading is a measure of stress on the voice. It is
increased by amount of use (hours of voicing per day),
level of use (how loud the voice has to be) and emotional
stress. Teachers can have an unusually high degree of all
these factors!
When you look at the levels of vocal loading in teaching,
and the importance of healthy voice use, one would hope that teachers are well prepared as part of their
training. As studies prove, this is absolutely not the case. When asked whether they had voice care included
in their training, only 12.7% of teachers replied that they had, despite 94% saying that they thought voice care
should be a compulsory part of teacher training (see Diagram 4).5
This is an enormous missed opportunity, and until it is redressed, we have to try to help teachers in the
workplace to become aware of how they use their voices.

No
Diagram 4a: Was voice Yes 1%
care included in your
13%
teacher training?
Don’t know
5%
No Yes
87% 94%
Diagram 4b: Should voice
care be a compulsory part
of primary school teacher
training?
(All responses from
primary school teachers)

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 CHAPTER 1

In-built gender imbalance

An inescapable fact is that gender differences disadvantage women
when it comes to voice problems. Post-puberty, men’s larynxes grow
more than women’s, which results in women having:
zz shorter vocal folds (historically known as vocal cords), giving a
higher speaking pitch and meaning they beat together nearly twice
as many times each second
zz thinner vocal folds, giving a lower acoustic output for a
given effort.
This means that women’s vocal folds have to work faster and harder,
increasing the likelihood of inflammation or injury. This is borne out
by the fact that most NHS Voice Clinic patients are female. With the
primary school teaching profession also being predominantly female,
it follows that primary school staff are affected so much more
than others.

Voice problems in children

Voice disorders are also surprisingly common among school-aged children. Up to 20% of children have what
would clinically be defined as voice disorders, although most of these cases are never referred for clinical
treatment. Voice disorders are more common in boys than girls, probably for social and cultural reasons.
Many problems get better without treatment as the child grows and use and function develop. However,
when children have voice problems that persist, it can affect many aspects of their life, as they may be less
able to project their voice socially, in sports or when singing or acting. This can negatively impact on self-
esteem and overall development.
If children have voice problems, poor singing technique is rarely the cause. It is nearly always as a result
of high vocal loading elsewhere, or of high levels of anxiety in the child. It is crucial to help children establish
good habits of voice use when speaking, singing or shouting; it is of limited use to give a child good singing
technique if it is not also applied on the football field! The good vocal habits that we want to encourage
are linked to a general awareness of voice use. For example, children can learn how to notice when their
voices are beginning to tire from over-use. They can also be aware of having a balanced posture and good
breathing technique, as these principles have a positive impact on all forms of voice use.

Prevention is better than cure

There is so much that can be done to help prevent problems before they occur, and stop minor issues
becoming bigger ones. Awareness, both of our own voices and those of our pupils’, is the first step.

We hope that this first chapter has given you a good insight into the scale of the problem of poor vocal
health among teachers, and into why it’s important that we all look after our voices. Read on to Chapter 2 for
an outline of how the voice works, from being powered by the respiratory system, to the source of the sound
in the larynx, to the sound being filtered by the upper vocal tract. Chapter 3 will give you practical voice care
tips, as well as more detail on voice problems. Chapter 4 outlines how children’s voices develop, and how
adults’ voices age. Chapters 5 and 6 give you tips for improving singing technique and for warming up your
voice. Finally, the glossary provides definitions of all the vocal health-related terms used in this guide.

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 CHAPTER 1

Summary
zz Teachers are much more likely to suffer vocal ill-health than the public at large.
zz The scale of the problem is greatest among primary school teachers.
zz Female voices are more susceptible to problems than male voices.
zz Voice care has, historically, been almost non-existent in teacher training.
zz Vocal ill-health happens because of organic illness, high vocal loading, poor technique or irritants.
zz Children’s voices also suffer from problems.
zz Much can be done to prevent problems; awareness is the first step.

1. E. Smith, J. Lemke, M. Taylor, H. Kirchner, H. Hoffman, Frequency of voice problems among teachers and other occupations, 1998,
Journal of Voice, Volume 12, Issue 4, pp.480-488.
2. Voice Care Network survey (2003) of over 3000 voice clinic patients.
3. Association of Teachers & Lecturers’ Survey of 490 teachers, 2008.
4. Rogerson J, Dodd B. Is there an effect of dysphonic teachers’ voices on children’s processing of spoken language? Journal of Voice
2005; 19:1, 47-60.
5. Association of Teachers & Lecturers’ Survey of 490 teachers, 2008.

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