Acceptance and commitment therapy and systematic voice training effects on children voice function recurrence and anxiety

Abstract

BACKGROUND

Children with vocal nodules often experience persistent hoarseness and anxiety, creating a vicious cycle that impairs recovery and increases recurrence. Standard voice training lacks psychological intervention. This study hypothesizes that adding acceptance and commitment therapy (ACT) to systematic voice training improves voice function, reduces anxiety, and lowers recurrence.

AIM

To investigate the effect of ACT combined with systematic voice training on children with voice disorders.

METHODS

A randomized controlled trial enrolled 120 children with vocal nodules (6-12 years) at a tertiary hospital, randomized into two groups (n = 60 each). The control group received 8-week systematic voice training; the observation group added ACT. Outcomes included pediatric voice handicap index, vocal fatigue, vocal fold function, anxiety, and 6-month recurrence. Data were analyzed via t-tests and χ² tests.

RESULTS

After the intervention, the observation group showed significantly lower scores in pediatric voice handicap index (28.46 ± 6.15 vs 42.63 ± 7.28), vocal fatigue (2.35 ± 0.82 vs 4.52 ± 1.05), and Scale for Children’s Anxiety Disorders compared to the control group. Furthermore, the improvement in vocal fold vibration symmetry and mucosal wave integrity under videostroboscopy was more pronounced in the observation group (all P < 0.05). During the follow-up period, the recurrence rate of hoarseness in the observation group was 5.00%, significantly lower than the 18.33% in the control group (P < 0.05).

CONCLUSION

Combined intervention improves voice function, alleviates anxiety, and reduces hoarseness recurrence in children with vocal nodules.

Key Words: Acceptance and commitment therapy; Systematic voice training; Voice disorders; Recurrence rate; Anxiety

Core Tip: Combining acceptance and commitment therapy with systematic voice training significantly improves voice function, reduces anxiety, and lowers the recurrence rate of hoarseness in children with vocal fold nodules compared to voice training alone. The integrated approach addresses both physiological and psychological factors, enhancing treatment adherence and long-term outcomes.

INTRODUCTION

As a core communication tool, vocal function is essential for social interaction, emotional expression, and physical and mental development. Vocal dysfunction impairs daily communication and learning and may trigger psychological and behavioral issues from social limitations, harming both physical and mental health[1,2]. Children have delicate laryngeal mucosa, immature vocal folds, and poor self-regulation, making them prone to vocal misuse and dysfunction. In recent years, the incidence of voice disorders in children has been increasing year by year. It has become one of the common clinical diseases in pediatrics and otolaryngology, and has attracted widespread attention from the medical community and all walks of life.

Among the many causes of voice disorders in children, vocal cord nodules are one of the most important causes of hoarseness, and their occurrence is often closely related to excessive and improper use of the voice, such as prolonged crying, loud shouting, frequent singing, and habitual speaking loudly in noisy environments[3]. Clinical studies have shown that the core clinical manifestation of children with vocal cord nodules is persistent hoarseness, which may be accompanied by uncomfortable symptoms such as vocal fatigue, foreign body sensation in the throat, and irritating cough. In severe cases, abnormal vocal cord vibration may occur, affecting the sound quality and volume of the voice, and adversely affecting the child’s language development process. In addition to physical discomfort, vocal cord nodules can also have a significant impact on the psychological state of children[4,5]. Because symptoms such as hoarseness affect language expression, children with the disease may encounter misunderstandings, ridicule, or avoidance in social situations such as classroom speeches and interactions with classmates, which may lead to negative emotions such as low self-esteem and anxiety[6]. This psychological abnormality will not only reduce the quality of life of children, but may also further hinder the recovery of voice function. Therefore, when intervening for children with voice disorders, it is not only necessary to pay attention to the improvement of the physiological functions of their voices, but also to pay attention to the adjustment of their psychological state to achieve coordinated physiological and psychological intervention.

At present, clinical intervention for voice disorders such as vocal cord nodules in children is mainly based on systematic voice training. This method uses breathing training, vocal control training, resonance training and other standardized methods to help children correct their bad voice habits, improve the vibration function of their vocal cords, and thereby alleviate the symptoms of hoarseness. However, standard voice training is limited: It targets only physiological function and ignores psychological factors, failing to break the anxiety-vocal misuse cycle; on the other hand, due to children’s limited cognitive level, compliance with training is easily affected by emotions, and simple voice training often cannot guarantee long-term intervention effects, resulting in the recurrence of hoarseness in some children after treatment. Therefore, there is an urgent need to optimize existing intervention programs.

Acceptance and commitment therapy (ACT), as one of the core representatives of the third generation of cognitive behavioral therapy, takes “acceptance of emotions and commitment to action” as its core concept. It helps individuals accept their own negative emotions and uncomfortable experiences through six core techniques of acceptance, cognitive dissociation, focus on the present, self-awareness, value clarification, and commitment to action, instead of escaping or fighting, and then guides individuals to take positive actions in the direction of their own values[7,8]. Compared with traditional cognitive behavioral therapy, ACT pays more attention to the acceptance of emotional experiences and behavioral changes, without the need to deliberately correct negative cognitions, and is more suitable for children whose cognitive levels are not yet fully mature[9]. In recent years, ACT has been widely used in the intervention of children with anxiety disorders, attention deficit hyperactivity disorder, chronic pain and other diseases, and has achieved precise clinical results. Its advantages in improving children’s negative emotions and improving behavioral compliance have been clinically confirmed.

Few studies have evaluated combined ACT and voice training for pediatric voice disorders, limiting evidence for optimized interventions. Notably, anxiety and vocal dysfunction in children show a certain bidirectional relationship. Anxiety can trigger physiological reactions such as increased throat muscle tension and shortness of breath, which can aggravate hoarseness and cause vocal fatigue. Conversely, persistent hoarseness can impair social communication, leading to peer teasing, social withdrawal, and increased anxiety. This bidirectional cycle exacerbates voice abuse and delays recovery, highlighting the need to address voice symptoms and anxiety simultaneously. Therefore, the purpose of this study was to explore the effect of ACT combined with systematic voice training on functional improvement, recurrence rate and anxiety state in children with voice disorders. By combining ACT with systematic voice training, improves training compliance, thereby reducing the recurrence rate, achieving dual improvements in physiological functions and psychological status, and providing a scientific basis for clinical development of more efficient and comprehensive intervention programs for children with voice disorders, which has important clinical significance and application value.

MATERIALS AND METHODS

Research object

Total 120 children with vocal cord nodules admitted to Anhui Provincial Children’s Hospital from November 2023 to November 2025 were selected as the research subjects.

Inclusion criteria: (1) Vocal cord nodules were diagnosed by electronic laryngoscopy and met the clinical diagnostic criteria for children’s vocal cord nodules; (2) There are clear symptoms of hoarseness, and the duration is ≥ 8 weeks; (3) Aged 6-12 years old, able to cooperate in completing voice function assessment and intervention training; and (4) The guardian of the child gave informed consent and signed an informed consent form.

Exclusion criteria: (1) Combined with other organic lesions of the larynx (such as vocal cord polyps, laryngeal tumors, etc.); (2) There are hearing impairment, language development delay, mental retardation and other diseases that affect communication and training; (3) Previous voice training or psychological intervention treatment; (4) Combined with severe heart, liver, kidney and other organ dysfunction or mental system disease; and (5) Lost to follow-up during the follow-up period or refused to cooperate in completing the follow-up evaluation.

This study has been approved through the expedited review process of the Medical Ethics Committee of Anhui Provincial Children’s Hospital.

Grouping method

A random number table method was used to divide 120 children into an observation group and a control group, with 60 cases in each group. A dedicated person will use statistical software to generate a random number sequence, and the children will be assigned to two groups based on the random numbers. In order to ensure the randomness and balance of the grouping, a baseline comparison was made on the gender, age, disease duration, severity of voice disorder and other general information of the two groups of children to ensure that the differences between the groups were not statistically significant (P > 0.05) and were comparable.

Interventions

Both groups of children received an 8-week intervention treatment. During the intervention period, a dedicated person would follow up regularly to supervise the implementation of the training, answer the questions of the children and guardians in a timely manner, and ensure the standardized implementation of the intervention plan.

Control group: Receive routine systematic voice training, the specific contents include: (1) Breathing training: Instruct the children to perform abdominal breathing training, using the rhythm of “inhale for 4 seconds – hold breath for 2 seconds-exhale for 6 seconds”, 3 times a day, 15 minutes each time, and help the children to Master the correct breathing method to provide sufficient airflow support for vocalization; (2) Vocal control training: Conduct basic vocal training through “beating” and “humming” to guide children to control the intensity and frequency of vocalization and avoid excessive vocalization, twice a day, each time 10 minutes; (3) Resonance training: Resonance adjustment training is carried out with the help of vowel sounds (a, o, e, i, u), guiding the children to focus the sound on the nasal cavity, oral cavity and other resonance cavities to improve the sound quality of the voice, twice a day, 10 minutes each time; and (4) Guidance on voice habits: Explain to children and their guardians the dangers of inappropriate voice use, and formulate personalized voice usage norms, such as avoiding loud crying and shouting, controlling the duration of daily talking, reducing conversations in noisy environments, etc., and the guardians will assist in supervising the implementation.

Observation group: On the basis of the conventional systematic voice training in the control group, ACT intervention was added, which was implemented by professionally trained psychotherapists. The specific intervention plan was designed based on the six core technologies of ACT, using a combination of individual intervention and family collaborative intervention, once a week, 40 minutes each time, for a total of 8 times. The specific content is as follows: (1) The first time to second time (acceptance and cognitive dissociation): Use gamification to introduce the relationship between emotions and voice to children, guide children to accept their own negative emotions such as anxiety and low self-esteem caused by hoarseness, and avoid confrontational emotions, use the “emotion label” game to help children achieve cognitive dissociation, separate themselves from negative emotions, and reduce the impact of emotions on vocal behavior; (2) The third time to fourth time (focus on the present moment and self-awareness): Instruct the children to perform mindfulness breathing training, focus on breathing to perceive the current state, and improve the awareness of their own vocal behavior and emotional changes, use the “Voice Diary” to allow the children to record their daily vocal usage and emotional state, and enhance their awareness of self-monitoring; (3) The fifth time to sixth time (value clarification and commitment action): Through interviews and interactive games, help children clarify the importance of good voice function for learning and social interaction, and clarify their own value goals, work with children and guardians to formulate a personalized voice behavior change plan, clarify daily training tasks and voice usage norms, and encourage children to take positive actions toward value goals; and (4) The seventh time to eighth time (consolidation and strengthening): Review the progress and deficiencies during the intervention process, strengthen the positive behaviors of the children, adjust the action plan according to the problems that arise during the intervention process, guide the guardians on how to continue to support and encourage the children in daily life, and consolidate the intervention effect.

Evaluation indicators and methods

The relevant indicators of the two groups of children were evaluated before the intervention (T0) and 8 weeks after the intervention (T1). After the intervention, the children were followed up for 6 months to record the recurrence of hoarseness.

Assessment of voice function: (1) Pediatric voice handicap index (pVHI)[10]: The children’s version of the Voice Handicap Index Questionnaire is used to evaluate the impact of voice disorder on the quality of life of children. The questionnaire contains 3 dimensions: Functional, physiological, and emotional, with a total of 25 items. Each item is scored on a 5-point scale from 0 to 4, with a total score of 0 to 100. The higher the score, the more serious the voice disorder is. The child’s guardian assisted in filling out the questionnaire; and (2) Vocal fatigue degree: Use the visual analogue scale (VAS) to evaluate the degree of vocal fatigue. Let the children mark their vocal fatigue degree on a scale of 0-10 points. 0 is no fatigue and 10 is extreme fatigue. The higher the score, the more serious the vocal fatigue is.

Vocal fold function assessment: To evaluate the improvement of hoarseness, use dynamic voice microscopy to evaluate the symmetry of vocal fold vibration and the integrity of mucosal waves. Operated by professional otolaryngologists, the children’s vocal cord vibration symmetry [divided into three levels: (1) Symmetrical; (2) Basically symmetrical; and (3) Asymmetrical] and mucosal wave integrity [divided into three levels: (1) Complete; (2) Basically complete; and (3) Incomplete] before and after the intervention were recorded. Quantitative scoring was performed based on the grading standards. The higher the score, the more significant the improvement in vocal cord function.

Assessment of anxiety state the screening: Scale for Children’s Anxiety Disorders (SCARED) is used to assess children’s anxiety. This scale includes 5 dimensions: (1) Somatization/panic; (2) Generalized anxiety; (3) Separation anxiety; (4) Social phobia; and (5) School phobia, with a total of 41 items. Each item is scored on a three-point scale from 0 to 2, with a total score of 0-82 points. The higher the score, the more serious the anxiety[11]. Children complete the scale with the assistance of their guardians.

Recurrence rate statistics: After the intervention, the children were followed up for 6 months through outpatient follow-up, telephone follow-up, etc., and the recurrence of hoarseness was recorded during the period. Recurrence was defined as the disappearance of hoarseness symptoms after intervention, the recurrence of persistent hoarseness during follow-up, and the recurrence or aggravation of vocal cord nodules confirmed by electronic laryngoscopy. Recurrence rate = number of recurrence cases/total number of cases × 100%.

Statistical analysis

SPSS26.0 statistical software was used to analyze and process the research data. Measurement data that conform to normal distribution are expressed as mean ± SD. Paired t-test is used for comparison before and after intervention within the group, and independent samples t-test is used for comparison between groups. Count data are expressed as n (%), and χ² test is used for comparison between groups. Rank sum test is used for grade data (vocal fold vibration symmetry, mucosal wave integrity score). P < 0.05 was considered as a statistically significant difference.

RESULTS

Comparison of general information of the two groups of children

The gender and average age of the two groups of children were 8.62 ± 1.35 years old vs 8.58 ± 1.41 years old; the duration of the disease was 4.31 ± 1.24 weeks vs 4.27 ± 1.29 weeks. There was no statistical difference in general information such as average pVHI score (62.35 ± 8.42 vs 61.98 ± 8.53) before intervention and was comparable (Table 1).

Table 1 Baseline characteristics of participants, mean ± SD/n (%).

Variable	Observation group (n = 60)	Control group (n = 60)	P value
Male	32 (53.33)	33 (55.00)	0.857
Age (years)	8.62 ± 1.35	8.58 ± 1.41	0.872
Disease duration (weeks)	4.31 ± 1.24	4.27 ± 1.29	0.859
Pre-intervention pVHI score	62.35 ± 8.42	61.98 ± 8.53	0.813

pVHI: Pediatric voice handicap index.

Comparison of voice function indicators between the two groups of children before and after intervention

Before the intervention (T0), there was no statistically significant difference in the pVHI scores and vocal fatigue VAS scores of the two groups of children; after 8 weeks of intervention (T1), the pVHI scores and vocal fatigue VAS scores of the two groups of children were significantly lower than before the intervention (both P < 0.05), and the above scores of the observation group (28.46 ± 6.15, 2.35 ± 0.82) were significantly lower than those of the control group (42.63 ± 7.28, 4.52 ± 1.05) (P both < 0.05; Table 2).

Table 2 Comparison of pediatric voice handicap index scores and vocal fatigue visual analogue scale scores of two groups of children before and after intervention (points), mean ± SD.

Group	Time node	pVHI score (points)	Vocal fatigue VAS score (points)
Observation group (n = 60)	Before intervention	62.35 ± 8.42	7.21 ± 1.35
	After intervention	28.46 ± 6.15a, b	2.35 ± 0.82a, b
Control group (n = 60)	Before intervention	61.98 ± 8.53	7.18 ± 1.42
	After intervention	42.63 ± 7.28a	4.52 ± 1.05a

^aP < 0.05, compared with this group before intervention.

^bP < 0.05, compared with the control group after intervention.

pVHI: Pediatric voice handicap index; VAS: Visual analogue scale.

Comparison of improvement in hoarseness between the two groups of children before and after intervention

Before the intervention, there was no statistically significant difference in the vocal cord vibration symmetry and mucosal wave integrity scores of the two groups of children under dynamic voice microscopy; after the intervention, both groups improved significantly in vibration symmetry (observation: 2.76 ± 0.42; control: 2.15 ± 0.45) and mucosal wave integrity (observation: 2.81 ± 0.38; control: 2.08 ± 0.41). The observation group showed greater improvements (All P < 0.05), indicating that the observation group had better improvement in hoarseness (Table 3).

Table 3 Comparison of vocal cord vibration symmetry and mucosal wave integrity scores between the two groups of children before and after intervention (points), mean ± SD.

Group	Time node	Vocal fold vibration symmetry score (points)	Mucosal wave integrity score (points)
Observation group (n = 60)	Before intervention	1.23 ± 0.35	1.18 ± 0.32
	After intervention	2.76 ± 0.42a, b	2.81 ± 0.38a, b
Control group (n = 60)	Before intervention	1.21 ± 0.38	1.15 ± 0.34
	After intervention	2.15 ± 0.45a	2.08 ± 0.41a

^aP < 0.05, compared with this group before intervention.

^bP < 0.05, compared with the control group after intervention.

Scoring criteria: (1) 1 point: Asymmetrical/incomplete; (2) 2 points: Basically symmetrical/basically complete; and (3) 3 points: Symmetrical/complete.

Comparison of anxiety status of two groups of children before and after intervention

Before the intervention, there was no statistically significant difference in the SCARED total score and each dimension score of the two groups of children; after the intervention, both groups had reduced total SCARED scores (observation: 18.42 ± 5.18; control: 26.73 ± 6.45) and subscale scores. The observation group had lower postintervention anxiety scores (All P < 0.05; Table 4).

Table 4 Comparison of Scale for Children’s Anxiety Disorders scores between the two groups of children before and after intervention (points), mean ± SD.

Group	Time node	Vocal fold vibration symmetry score (points)	Mucosal wave integrity score (points)
Observation group (n = 60)	Before intervention	1.23 ± 0.35	1.18 ± 0.32
	After intervention	2.76 ± 0.42a, b	2.81 ± 0.38a, b
Control group (n = 60)	Before intervention	1.21 ± 0.38	1.15 ± 0.34
	After intervention	2.15 ± 0.45a	2.08 ± 0.41a

^aP < 0.05, compared with this group before intervention.

^bP < 0.05, compared with the control group after intervention.

Comparison of hoarse recurrence rates between the two groups of children during follow-up

After the intervention, the two groups of children were followed up for 6 months. Among the 60 children in the observation group, 3 children had recurrence of hoarseness, with a recurrence rate of 5.00%; among the 60 children in the control group, 11 children had recurrence of hoarseness, with a recurrence rate of 18.33%. The recurrence rate of hoarseness in the observation group was significantly lower than that in the control group, and the difference was statistically significant (χ² = 5.926, P = 0.015).

DISCUSSION

Pediatric vocal nodules are a common otolaryngological condition driven by poor vocal habits, with psychological factors often overlooked[12]. This study uses a composite intervention model to explore the impact of ACT combined with systemic voice training on children’s voice function, anxiety state and recurrence rate. The results show that the composite intervention model is effective and provides new ideas and basis for clinical intervention in children with voice disorders.

Systemic voice training is a basic intervention method for children with voice disorders. Its core value is to help children correct bad voice habits and improve vocal cord vibration function through standardized breathing, vocalization and resonance training, thereby alleviating hoarseness symptoms[13,14]. In this study, after 8 weeks of systematic voice training for children in the control group, their pVHI scores, vocal fatigue VAS scores, and vocal cord vibration-related indicators were significantly improved compared with those before the intervention, confirming the effectiveness of this intervention method. But at the same time, the recurrence rate of the control group during the 6-month follow-up was still 18.33%, and the improvement in anxiety state was limited. This result is similar to the results of the former study[15]. This is mainly due to poor compliance with voice hygiene, persistent overuse of the voice, and unresolved psychological distress related to social anxiety and low self-esteem, suggesting that although simple physiological intervention is effective in improving short-term symptoms, it does not target the psychological driving factors of adverse vocal behaviors and is difficult to achieve stable long-term effects. The intervention plan needs to be further optimized. In contrast, the relapse rate in the ACT combination treatment group was significantly reduced to 5.00%, demonstrating the correlation between integrated psychological intervention and anxiety-driven voice misuse cycles and reduced risk of relapse.

After the observation group combined ACT intervention on the basis of systematic voice training, the improvement effect of various evaluation indicators and long-term prognosis were better than those of the control group. The core reason is that ACT makes up for the shortcomings of simple voice training in the psychological intervention level. Psychologically, hoarseness-related social distress causes anxiety, which triggers vocal misuse and creates a vicious cycle[16]. ACT uses acceptance and cognitive defusion to help children acknowledge negative emotions, separate self from emotions, and reduce anxiety-driven vocal misuse[17-19]; at the same time, through mindfulness breathing training, it improves children’s awareness of their own vocal behavior and emotional changes, and uses value to clarify the importance of good voice function, thereby stimulating their inner motivation to actively standardize their voice use[20]. This kind of psychological intervention not only significantly reduced the children’s SCARED score, but also improved their compliance with voice training and ensured the effective implementation of the physiological intervention plan.

From the perspective of voice function improvement and recurrence prevention mechanisms, systematic voice training focuses on the immediate improvement of vocal cord vibration function, while ACT uses a family collaborative intervention model to guide guardians to continue to supervise and support children in daily life, helping them transform the correct voice habits learned in training into normal behaviors, and avoiding the rebound of bad voice habits after the intervention. Reduced anxiety also lessens mood-related vocal overuse and vocal fold injury, lowering hoarseness recurrence. In this study, the recurrence rate of 5.00% in the observation group was significantly lower than the 18.33% in the control group, which fully proved the advantages of the composite intervention model in consolidating long-term efficacy.

The results of this study are consistent with the conclusions of the application of ACT in disease intervention in children and adolescents in recent years[21]. Existing studies have shown that ACT can improve treatment compliance by improving children’s psychological state in the intervention of children with asthma, chronic pain and other diseases, thereby optimizing clinical efficacy[22-24]. This study applied ACT to the field of children’s voice disorders, expanding its clinical application scope and confirming the unique value of this therapy in the simultaneous treatment of body and mind. Compared with traditional cognitive behavioral therapy, ACT adopts a game-based intervention form, which is more in line with children’s cognitive characteristics and acceptance habits, avoids complex cognitive correction processes, and improves children’s cooperation with the intervention. This is also an important reason for its remarkable application effects in children[25].

At the same time, this study also has certain limitations. First, the sample size is limited to a single center, and there may be selection bias. Subsequent multi-center, large-sample studies need to be carried out to verify the universality of the conclusions; second, the follow-up time is only 6 months, and the stability of the long-term efficacy still requires longer follow-up observation; third, the correlation between the specific intervention dose of ACT and the efficacy is not discussed. The intervention program can be further optimized in the future to clarify the personalized ACT intervention parameters for children of different ages.

CONCLUSION

ACT combined with systematic voice training can effectively improve the voice function of children with voice disorders, relieve their anxiety, and significantly reduce the recurrence rate of hoarseness. The intervention effect is definite and the long-term efficacy is stable. This composite intervention model achieves an organic combination of physiological intervention and psychological adjustment, meets the pathogenesis and intervention needs of children’s voice disorders, and has important clinical promotion value. In the future, clinical intervention plans can be further optimized and personalized intervention strategies can be developed based on the age and severity of the disease to improve the accuracy and effectiveness of the intervention.