Personality, Psychological Factors, and Behavioral Tendencies in Children With Vocal Nodules: A Systematic Review I *Jeong Min Lee, *Nelson Roy, and † Maria Dietrich, *Salt Lake City, Utah, and yColumbia, Missouri Abstract: Objectives. This systematic review examined the evidence linking vocal nodule development in chil- dren to personality traits, psychological factors, and associated behavioral tendencies. Methods. Four electronic databases—PubMed, Scopus, ScienceDirect, EBSCO Host—as well as the reference lists from articles (including online sources) were searched. After screening for relevance, eight comparative, case-control studies were identified that met inclusion criteria. The quality of each study was evaluated by two raters using a modified, standardized checklist. Results. Four studies were rated as “good quality” and four were “fair”. The questionnaires used to measure personality or psychological factors varied widely among the studies, and the results linking personality disposi- tions (and associated behavioral inclinations) to vocal nodule development in children were mixed. Conclusions. Fair to good quality evidence exists to suggest that psychological factors or personality traits related to extraversion and impulsivity (and their related behavioral inclinations) might predispose children to vocal nodules and deserve further attention. Clinical implications, limitations of the current systematic review, and recommendations for future research are also discussed. Keywords: Vocal nodulesChildrenPersonality traitsPsychological factorsSystematic review. INTRODUCTION Vocal fold nodules (VNs) are bilateral, symmetrical, cal- lous-like lesions occurring on the mid-membranous vocal folds—the site of maximum tissue collision and shearing forces during phonation. 1,2 Thus, their development is often attributed to chronic, repetitive intense vocal activity including prolonged loud talking, yelling, screaming and singing. 3 VNs represent the most common cause of dyspho- nia in children and reported prevalence rates vary from 1% to 14%. 410 In children, VNs occur more frequently among prepubescent boys as compared with girls, with a ratio of 3:1, and a peak age of onset of 510 years. 11 The dysphonia associated with VNs in children (1) places a significant bur- den on social communication, 12 (2) engenders negative attri- butions by teachers and listeners, 13 and (3) reduces quality of life due to adverse physical sensations (effort and discom- fort) during voice production and negative socioemotional effects (anger, frustration, embarrassment). 14,15 Voice therapy often aims to eliminate the proximal cause (s) of VNs (ie, repetitive phonotrauma), but the lesions in some children are resistant to therapy and/or tend to recur. 1619 In general, voice therapy for VNs demands con- siderable self-regulation including deliberate and sustained reduction or elimination of intense phonotraumatic behav- iors. However, specific behavioral characteristics may pre- dispose some children toward extreme and potentially phonotraumatic voice use, thereby contributing secondarily to VN formation. Thus, improved understanding of psycho- behavioral factors that (1) predispose to the development and maintenance of VNs and (2) possibly mediate voice therapy failure is important for both clinical and theoretical reasons. To this end, valuable insights may be gained by examin- ing the literature related to adults wherein VNs are the most common cause of dysphonia among women. 20,21 Although phonotraumatic vocal behaviors such as extended loud talk- ing have been attributed to specific occupations, 22 an expanding literature suggests a role for personality traits or psychological factors in the development of VNs. 2328 For instance, high levels of extraversion, anxiety, stress, emo- tional maladjustment, and reduced self-concept have been reported in women with VNs. 17,20,2931 In an attempt to explain how individual differences in personality contribute to the development of VNs in women, Roy and Bless 32 developed the “Trait Theory”. The Trait Theory incorporates the “Big Three” personality superfactors which include Extraversion versus Introversion (High E versus Low E), Neuroticism versus Stability (High N versus Low N), and Constraint versus Disinhibition (High CON versus Low CON). 33 Roy and Bless 32 proposed that the combination of elevated Extraversion and Neuroti- cism (ie, High E and N) predisposes some women to develop VNs in part because of sustained vocal “excesses” related to their personality. Roy and Bless 32 reasoned that women with VNs would score high on indices of Extraver- sion (sociability, dominance) and Neuroticism (emotional/ stress reactivity, aggressiveness), and low on measures of Constraint (reflecting impulsivity). They postulated that this combination of traits might ultimately manifest in pho- notraumatic vocal patterns, thus contributing to the devel- opment and maintenance of VNs. For instance, it was argued that persistent loud voice use, which elevates the risk I Financial Disclosure Statement: The authors have no financial relationships rele- vant to this article to disclose. Conflict of Interest Statement: The authors have no conflicts of interest to disclose. From the *Department of Communication Sciences and Disorders, The University of Utah, Salt Lake City, Utah; and the yDepartment of Communication Science and Disorders, University of Missouri, Columbia, Missouri. Address correspondence and reprint requests to Jeong Min Lee Department of Communication Sciences and Disorders, 390 South 1530 East, Suite 1201, BEH SCI- Salt Lake City, Utah 84112. E-mail: jeongmin.lee@utah.edu Journal of Voice, Vol. &&, No. &&, pp. 118 0892-1997 © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvoice.2018.07.016 ARTICLE IN PRESS