Associations Between Social Determinants of Health, Mental Effort, and Frustration for Voice Therapy

Early life adversity and related social determinants of health (SDOHs) are risk factors for trauma, learning and regulation difficulties, and poor adult health outcomes, such as functional voice disorders (FVDs). It is unknown if learning new voice techniques is confounded by a history of adverse experiences. The purpose of this study was to investigate the relationship between SDOHs and cognitive effort in voice therapy.

Patients referred for voice therapy at the Emory Voice Center in Atlanta, GA were recruited to participate in a non-experimental prospective study using an event-based ecological momentary assessment (EMA) methodology. At therapy initiation, patients completed the Trauma Symptoms of Discrimination Scale (TSDS), the Adverse Childhood Experiences (ACEs) questionnaire, and the Voice Handicap Index-10 (VHI-10). To assess mental effort and frustration for voice therapy, the NASA Task Load Index (NASA-TLX) was administered following each therapy session. Statistical tests were applied to examine differences in ratings among races and voice disorder diagnosis. Pairwise comparisons and generalized estimating equations were used to determine correlations between different outcome measures.

Twenty-seven participants (89% female, 60% white) completed the study. No significant differences in baseline perceptions of voice handicap, mental effort, frustration, trauma symptoms, or early adversity were observed among different groups. Elevated and clinically significant TSDS scores (M=46.18, SD=23.82) were observed among patients with FVDs. Statistically significant and positive correlations were observed between TSDS and mental effort and frustration scores (r=0.51, adjusted p=0.0296). Participants' mental-effort scores decreased significantly after therapy visits when considering the effects of confounders, but frustration scores did not.

Results indicate that patients reporting more trauma symptoms were also more likely to report greater cognitive effort and frustration during voice therapy than those reporting fewer trauma symptoms. While mental effort decreased from session to session during therapy, frustration did not. Findings underscore the need for the universal practice of trauma-informed care that includes equipping patients with resources that encourage positive emotions and resilience for the purpose of sustaining mental effort throughout the course of voice therapy.