Tinnitus in Children and Teenagers - Practice Guidance - DRAFT VERSION FOR PUBLIC CONSULTATION
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Tinnitus in
Children and
Teenagers
Practice Guidance
DRAFT VERSION
FOR PUBLIC
CONSULTATION
June 2014
Draft version for public consultation - June 2014
Foreword
1 The James Lind Alliance Tinnitus Priority Setting Partnership was set up at the instigation of the British Tinnitus
2 Association. Its aim was to identify the top ten research uncertainties for tinnitus. In 2011 and 2012, the Partnership
3 carried out an extensive, nationwide consultation of tinnitus patients and clinicians and at the 2012 British Society of
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Audiology annual conference, an appeal to address these top ten research priorities was launched. One of the top
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6 ten questions is: “what is the optimal set of guidelines for assessing children with tinnitus?”
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8 It was hoped that the identification of research priorities would be a catalyst for more research and encourage funders
9 and researchers alike to rise to the challenge of addressing the selected priorities. These guidelines are a response to
10 that challenge. The development of these guidelines was undertaken through the British Society of Audiology by a
11 working party of national specialists in paediatric tinnitus. The project was kindly supported by the British Tinnitus
12 Association.
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14 This document presents Practice Guidance by the British Society of Audiology (BSA). This Practice Guidance
15 represents, to the best knowledge of the BSA, the evidence-base and consensus on good practice, given the stated
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methodology and scope of the document and at the time of publication.
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Although care has been taken in preparing the information supplied by the BSA, the BSA does not and cannot
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20 guarantee the interpretation and application of it. The BSA cannot be held responsible for any errors or omissions,
21 and the BSA accepts no liability whatsoever for any loss or damage howsoever arising. This document supersedes
22 any previous recommended procedure by the BSA and stands until superseded or withdrawn by the BSA.
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26 Ms Rosie Kentish
27 Consultant Clinical Psychologist
28 Royal National Throat Nose and Ear Hospital, University College London Hospital NHS Foundation Trust
29 Chair of the Paediatric Tinnitus Working Group
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Draft version for public consultation - June 2014
Contents
1 Foreword! 2
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3
Contents! 3
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5 Terminology & Abbreviations! 4
6 Executive Summary! 5
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8 1! Introduction & Overview! 6
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2! Tinnitus in Children - Implications for Clinical Practice! 9
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11 3! Assessment of Tinnitus in Children! 11
12 History taking 11
13 Clinical examination 14
14 Audiological assessment 14
15 Specialist tests 15
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17 Red flags and onwards referral 15
18 4! Management Strategies! 16
19 Explanation, advice and information giving 16
20 Tinnitus management strategies 16
21 Sound enrichment: hearing aids and other devices 18
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23 Psychological approaches to tinnitus 19
24 Tinnitus management in the classroom 20
25 5! Development of a Paediatric Tinnitus Service! 22
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Appendices! 23
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29 1 Service provision 23
30 2 Evidence Base 24
31 3 Child-Friendly Interview Techniques 26
32 4 Key Elements of the Clinical Assessment 27
33 5 Signs of Tinnitus Distress 27
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35 6 Psychological Associations with Tinnitus 28
36 7 Formal Assessment Measures 29
37 8 Tinnitus in the Classroom: Information Booklet 31
38 9 Hearing Protection 33
39 10 Further Resources 34
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42 References! 35
43 Authors! ! 39
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Draft version for public consultation - June 2014
Terminology Abbreviations
1 Child ADHD PTA
2 The term ‘child’ is used throughout Attention Deficit Hyperactivity Pure Tone Audiogram/Audiometry
3 this document to include children up Disorder
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to the age of 16 years. SENCO
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APD Special Educational Needs
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Healthcare Professional Auditory Processing Disorder Co-ordinator
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8 This term has been used generically
9 to refer to doctors, audiologists, and ASD VAS
10 other allied healthcare professionals Autistic Spectrum Disorder Visual Analogue Scale
11 such as hearing therapists, teachers
12 of the deaf, nurses, counsellors, AVM
13 Audiovestibular Medicine
psychologists, psychiatrists and any
14
15 other professionals that may be
AVP
16 involved in the child’s care.
Audiovestibular Physician
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18 Parents
BSA
19 This includes mothers, fathers, carers
20 British Society of Audiology
and other adults with responsibility for
21 caring for a child or young person,
22 BTA
including for example, those with
23 British Tinnitus Association
responsibilities for looked after
24
25 children and young offenders. CBT
26 Cognitive Behavioural Therapy
27 Red Flags
28 Red flags are used as indicators for ENT
29 onward referral to another specialty Ear, Nose and Throat
30 as appropriate.
31 GP
32 Management General Practitioner
33 This term has been used to refer to
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both assessment and treatment. IEP
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36 Individual Educational Plan
Tinnitus Distress
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38 This term distress is used to cover the IHP
39 range of negative emotions that Individual Hearing Profile
40 children and parents may feel as a
41 consequence of their tinnitus, such as LDLs
42 annoyance, anger, fear, worry, anxiety. Loudness Discomfort Levels
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Executive Summary
1 • Tinnitus is a common experience in • The focus of management should • These guidelines acknowledge that
2 childhood. be on the child and not the ear or hyperacusis often co-exists with
3 tinnitus. A holistic approach (child, tinnitus, but hyperacusis requires
4 • The evidence base on paediatric family and school) is required to different assessment and
5 tinnitus is scarce. In view of this, the
6 meet the needs of children who management methods and
underlying principles of managing present with tinnitus. therefore is not covered here.
7
8 adult tinnitus are applied to the
9 management of children with • Where tinnitus impact and distress • These guidelines have been
10 tinnitus. However the aetiology, is found to be minimal, simple developed and promoted as a
11 presentation and management of information counselling will result of public and professional
12 the child’s tinnitus need to respect frequently be sufficient, and this consultation exercises.
13 the child’s age, cognitive and may prevent tinnitus distress from
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linguistic ability and individual developing.
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16 circumstances. The evidence base
for the management of childhood • Skills for the management of
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18 anxiety and pain is relevant to children with mild to moderate
19 aspects of the tinnitus profile of distress should be available within
20 children. most paediatric audiology services.
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22 • These guidelines offer a pragmatic • Children with severe distress and/or
23 approach to the management of complex presentations should be
24 managed within regional centres of
children with tinnitus at all levels of
25 excellence (Transforming services
26 severity for children up to 16 years.
for children with hearing difficulty
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28 • In general, in hearing appointments and their families: a good practice
29 other than routine ENT audiometry guide services) where specialist
30 and school screening, children skills in paediatric tinnitus
31 should routinely be asked whether assessment and therapy are
32 they ‘hear noises in their ears or available. The exact members and
33 head’ and if they do, whether they roles of this team will vary
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are bothered by them. The vast according to the service.
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36 majority of children are untroubled
37 by these noises and a simple • Children should be managed in an
38 explanation and reassurance are all appropriate paediatric setting by
39 that is required. Further assessment health care professionals with
40 will be required for the minority of appropriate paediatric skills and
41 knowledge of legislation relevant to
children that report tinnitus distress,
42 the paediatric population.
43 or impact.
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45 • Whenever possible, healthcare
46 professionals should involve young
47 children in the assessment and
48 management of their symptoms and
49 should not rely upon information
50 provided by parents alone.
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1
Introduction & Overview
Do children experience tinnitus? Whilst the experience of tinnitus is
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Aims of the A commonly held view is that tinnitus common, most children with tinnitus
only occurs in adults, relates to an are not bothered by it, and a simple
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guidelines ageing auditory system, and occurs explanation and reassurance are all
5 Tinnitus in children is a neglected very rarely in children. A number of that is required. Only a small number
6 area, from both a clinical and a research studies internationally have of children will require further
7 research perspective. To date, looked at the prevalence of tinnitus in management to help with distress or
8 research provides information about children (see appendix 2). Although impact upon their lives.
9 prevalence and co-morbidity of of variable quality, findings overall
indicate that some form of tinnitus Is tinnitus in children a clinical
10 tinnitus in children, but very little, if
11 anything, about managing non- experience is fairly common in concern?
12 distressing tinnitus in a children's children (Sheyte 2010) and There is some debate as to whether
13 clinic or effective therapies for furthermore it may even be on the tinnitus in children is a significant
14 alleviating the distress it can cause. increase (Juul 2012). Tinnitus clinical concern. Referral numbers
15 Given the lack of an evidence base, appears to be twice as common in for children with tinnitus are reported
16 many views about tinnitus in children children with hearing loss compared to be low (Baguley 2013a),
17 are held largely on the basis of to children with normal hearing suggesting that children do not
18 common belief or personal opinion. (Graham 1987; Raj-Kosiak 2011). express their distress of tinnitus or
19 There is some evidence to suggest require intervention in the same way
20 These guidelines have been written that it may be common in children as adults; further research is needed.
21 on the basis of the evidence base with a history of otitis media (Mills For those children whose tinnitus is
22 where it is available, and from the 1984), and more research is needed distressing however, tinnitus can
23 clinical experience and practice of upon this. have a significant effect upon their
24 the working party members. Our aim
25 is that the practical and pragmatic
26 advice offered will enable others to
27 develop their clinical skills in tinnitus
28 management with children, and that
29 in turn this will lead to further clinical
30 developments, research, and
31 ultimately a firm evidence base for
32 the management of tinnitus in
33 children.
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35 These guidelines are intended for
36 the wide range of professionals may
37 be involved in the management of a
38 child with tinnitus. This can include
39 audiologists, medical professionals,
40 nurses, hearing therapists, teachers
41 of the deaf, psychologists and other
42 mental health professionals. Some
43 sections are of more relevance to
44 specific professionals than others.
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46 As an introduction, below are a
47 collection of common questions
48 about tinnitus in children:
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1 physical and psychological well- Several authors have noted that whose tinnitus is troublesome and
2 being and their educational progress, children tend not to spontaneously require intervention.
3 all of which can have lifelong tell adults about their tinnitus.
4 consequences if left untreated. Savastano found that the number of If a child attempts to tell adults about
5 children with tinnitus rose from 6.5% tinnitus and feels dismissed, they
6 There are currently few services in to 34% when children are specifically may worry about why adults won’t
7 the UK available for children with questioned (Savastano 2007). discuss it. The child may then
8 tinnitus. It appears that where such a Children are also unlikely to become scared of the tinnitus, what it
9 service is available, and when spontaneously mention it to their might mean, or fear being ridiculed if
10 children attending audiology parents (Raj-Kosiak et al 2011). When they know it is not a ‘real’ sound.
11 appointments are routinely asked directly asked, children are generally Children will have less opportunity of
12 about tinnitus, that referral numbers able to describe their symptoms, discovering that others have the
13 steadily increase, and this suggests although this may not always be in same symptoms, including their
14 that there is an unmet need. ways that adults are familiar with peers.
15 (Section 2).
16 Healthcare professionals should
Is tinnitus in children the same as
17 Some healthcare professionals and provide children with troublesome
in adults?
18 parents are concerned that asking a tinnitus the opportunity to talk about
19 Research available is limited and of child about tinnitus may create the noises they hear, and offer
20 variable quality, but suggests that awareness and anxiety, and turn non- practical advice for managing it. This
21 children with tinnitus share many troublesome tinnitus into troublesome includes age appropriate information
22 similarities to adults with tinnitus. tinnitus. The experience of the about tinnitus, strategies for
23 There is some evidence that as with working party members is that the managing any distress and
24 the adult population, tinnitus in opposite is the case. Asking about difficulties in the classroom. Further
25 children is associated with higher tinnitus provides the opportunity of suggestions regarding advice are
26 rates of psychological difficulties normalising the experience for the provided in section 4.
27 such as worry, anxiety and child.
depression. Working with children often involves
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Asking children whether they hear two patients, the parent and the child,
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30 The impact of tinnitus upon children noises in their ears or their head, and who may have differing information,
is similar to adults in many ways, whether it bothers or annoys them perspectives, and worries about what
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effecting emotional well- being needs to be done sensitively. Care the child’s tinnitus means and
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(Holgers 2006); concentration and should be taken, particularly with clinicians cannot rely upon
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listening skills (Kentish 2000); sleep very young children who can give information gathered from one or
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difficulties are frequently mentioned answers to questions even if they other alone. Assessing and
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by children and parents (Gabriels don’t fully understand them, in order counselling a child with tinnitus takes
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37 1996; Kentish 2000; Kim 2012) Poor to please the adult. It is important to time and cannot be rushed. These
sleep can in turn lead to other be confident that the child has two factors have implications for
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problems such as poor memory and understood the question. Vague, service providers in terms of the
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concentration; irritability; behavioural fanciful, or inconsistent descriptions amount of time required by clinicians
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problems; and can affect the whole of noises from a child should be working in a paediatric tinnitus
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family’s well-being. treated with caution. service.
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How does tinnitus in children differ Non- troublesome tinnitus will Children also have less access to
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from adults? probably make up a large proportion information. Currently, information on
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of the tinnitus reported, and simple websites is directed to adults and
46 Whilst children and adults with
reassurance will be all that is needed. much of it is inappropriate, especially
47 tinnitus share much in common, there
However, asking about ear noises for young children. There is an urgent
48 are differences that have important
gives the healthcare professional the need for age-appropriate literature for
49 implications for clinical practice.
opportunity to identify those children children. A discussion about their
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tinnitus enables the child and parent
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1 to learn reassuring information about What is a child-friendly approach?
2 tinnitus and practical strategies for A child-friendly approach means
3 managing it. putting the child at the heart of the
4 process, and providing services in
5 Can adult models of tinnitus settings that are appropriate to the
6 needs of children and their families;
management be applied to
7 listening respectfully to the child and
8 children?
communicating at the child’s level
9 Children are not mini-adults and the developmentally and linguistically
10 effectiveness of applying adult and being aware of the factors that
11 models of tinnitus management to will influence the way the child
12 children can be questioned. There is communicates with you; and utilising
13 little or no direct research available to activities such as play, drawing and
14 answer this question. Given that other more visual and concrete ways
15 children with distressing tinnitus of getting across complex ideas
16 share many similarities with adults in (Appendix 3).
17 terms of audiological symptoms,
18 impact and psychological distress, it
I
19 is pragmatic to assume that
20 management strategies applied with
21 adults are of relevance to children.
22 However, these treatment strategies
23 need to be adapted for use with
24 children, and as part of a child-
25 friendly approach. Children should
26 be seen by health care professionals
27 with experience of assessing and
28 managing children and with
29 appointments taking place within a
30 paediatric clinical setting as opposed
31 to being an add-on to an adult
32 tinnitus clinic. This may be difficult
33 for some services, however the
34 recommendation is in line with
35 national guidelines for paediatric care
36 (NDCS 2000; NSFC 2003; DoH
37 2008).
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2
Tinnitus in Children
- Implications for Clinical Practice
1 Audiological testing difficulties associated with hearing
2 Key points: • Changes in the child’s behaviour loss – perhaps because the sound
3 • Practitioners must be alert to “soft” that does not ‘match’ observations has no apparent source and is not
4 signs that a child has tinnitus. of the child outside hearing tests. a shared experience.
5 These include signs of agitation, or • Speech perception difficulties are
6 • Compared to adults, children are avoidance strategies in anticipation described in background noise or
7 much less likely to spontaneously of PTA (Section 3) and audiological acoustically poor environments and
8 tell others about their tinnitus. When assessment has been challenging. in quieter listening environments, or
9 they do, their descriptions may be The child shows low confidence in in quiet situations only.
10 in unfamiliar terms. relation to audiological testing, and
11 their anxiety levels are high, Worries about tinnitus
12 • Children of all ages can have a especially in sound proofed testing Very young children may not know
13 variety of worries about tinnitus. rooms. These children may why they hear sounds in their ears, or
14 possibly be mistaken as having a may believe that there is actually
15 • Parents and children should be non-organic hearing loss. something there, for example bees,
16 asked about their worries and • Difficulty with hearing aid use for no monsters, rice crispies, or voices
17 concerns individually as these may obvious reason. There may be a singing inside their heads. Older
18 not be the same. distrust or dislike of the sound in children can share similar worries
19 one ear, and perception that that there is something in their head,
20 Professionals’ reluctance to talk hearing is worse in this ear, but may be worried that they are
21 although thresholds are similar. losing their hearing, “going mad”, or
about tinnitus – and its
22 of being unable to go to university or
23 consequences Behaviour get a job when they are older.
24 Parents are often unaware that their • Parental reports of sleep difficulties, Parents are often concerned that their
25 child has tinnitus (Raj-Kosiak 2011) particularly in young children. The child’s tinnitus might relate to hearing
26 and an audiological assessment may child may demand sound e.g. story loss; mental health problems, a brain
27 be the first time that a parent tapes, music, the TV or will not fall tumour or other neurological
28 becomes aware of it. Young children asleep on their own or in their room. condition (Kentish 2000). They
29 may lack the cognitive and linguistic • The child shows distress or frequently describe feeling helpless
30 skills to describe their tinnitus in ways avoidance of quiet or noisy about how to help their child. Child
31 that adults are familiar with. If their environments. and parent worries therefore need to
32 tinnitus has always been present, the
be identified separately.
33 child may assume that everyone School
34 shares the same experience and • Unexplained listening difficulties,
35 remains untroubled by it. Clinically, A note about education settings
not usually generalised across the
36 older children describe reluctance to school day, and possibly having a Children with tinnitus report
37 tell people about tinnitus because specific association. difficulties with listening and
38 they do not want to be seen as being • The child reports worry or anxiety concentration (Kentish 2000) and it is
39 different in any way, or feel that they about being able to hear the unlikely that the child has
40 will not be believed if they talk about teacher’s voice easily, and concern spontaneously mentioned it to their
41 it. about being told off for not paying teacher. Tinnitus, like hearing loss, is
42 attention in class. The child may unseen. There are no standard
43 Soft signs of tinnitus describe feelings of anger, management strategies for tinnitus
44 frustration, helplessness, fear, or of within the classroom, or during social
It is important for the practitioner to
45 feeling disconnected from the interaction at school. A pragmatic
be aware of ‘soft’ signs, present in
46 classroom. and personalised approach is
varying combinations, which are
47 • Children with hearing loss or a therefore needed (Section 4).
suggestive of unidentified tinnitus.
48 history of hearing loss may It is helpful for schools and colleges,
49 describe difficulties with classroom as well as students who have tinnitus,
50 listening that are distinct from to have access to written information
51 descriptions of speech perception about management of tinnitus; what it
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1 is and how it can impact on learning
2 in the classroom. In particular, advice
3 regarding exam techniques and
4 silence management can provide
5 teaching staff with enough
6 information to help individual children
7 (Section 4).
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3
Assessment of Tinnitus in Children
1 taken is child-friendly. Putting the the child and family, ascertain any
2 Key points: child and family at ease will help causal or influencing factors and
3 • Tinnitus is a symptom and must be facilitate information gathering during begin to plan the management
4 considered in the context of the appointment. It should be strategy. The following section
5 hearing loss and other audiological routine to ask all children seen for outlines the key elements of the
6 or neurological symptoms. audiological assessment whether clinical assessment. Questions
7 they hear noises in their ears or should be asked in an open, non-
8 • Children require assessment head. For those who report tinnitus judgemental manner to allow the
9 according to their age and level of the level of both distress and impact child to describe their experiences
10 cognitive and linguistic varies enormously. Some will have freely.
11 understanding. As far as possible, habituated to it whilst others are
12 information must be obtained from severely distressed and affected by History taking
13 both child and parent. It is their tinnitus. Tinnitus characteristics –
14 important to appreciate that the Within the appointment it is as
15 description of sounds
parent may also be anxious or important to address any distress the
16 If a child reports that they do have
distressed by the child’s symptoms. parents are experiencing as much as
17 the child. noises in their ears, asking them to
18 tell you more about it can obtain more
• With young children, in addition to
19 information than specific or direct
gathering information from the child The aim of assessment is to establish
20 questioning. Descriptions vary, in part
and parent, the clinician should be the level of distress and impact upon
21 able to utilise other techniques
22 such as play and drawing to gain
23 information about the child’s
24 tinnitus symptoms.
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26 • Audiological assessment can be
27 difficult and anxiety-provoking for
28 children with tinnitus. Plenty of
29 time should be allowed for testing
30 and a flexible approach taken
31 where necessary to ensure
32 accurate results.
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34 • Throughout the assessment, it is
35 important to note any symptoms or
36 findings that suggest an onward
37 referral is required to a specialist
38 multidisciplinary paediatric tinnitus
39 service where available; medical
40 services (ENT or AVM);
41 psychological services (CAMHS,
42 or child psychology service).
43 Signs and symptoms suggestive
44 of onward referral have been
45 highlighted as red flags at the end
46 of this section.
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48 As with any other paediatric
49 appointment it is important that the
50 clinical environment and approach
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1 concentration and school
2 performance (Appendix 7).
3
4 The level of distress, the
5 nature of any worries and
6 the impact of tinnitus should
7 be determined separately
8 for parent and child if
9 possible. The child may
10 have habituated to their
11 tinnitus and be
12 unconcerned about it, and it
13 is the parent that expresses
14 concern and worry about
15 what is wrong with their
16 child. Similarly, parents can
17 be unaware of the impact of
18 tinnitus and the level of
19 distress that it causes their
20 child.
21 depending upon the age of the child. identify whether it is pulsatile,
22 Older children may use familiar terms clicking, tonal, or complex. Information should be gathered about
23 such as ‘ringing’, ‘buzzing’, tinnitus impact in all aspects of the
24 ‘‘wheezing’, ‘peeping’, ‘murmur’ The onset, duration and frequency child’s life, at home and school. This
25 ‘humming’, ‘swishing’ and ‘whistling’ should be ascertained where may include changes in behaviour,
26 sounds. Younger children will often possible, together with identifying the difficulties with sleeping,
27 use creative descriptions, referring site of the sounds (one ear, both ears, concentration, listening or exams,
28 to objects within their experience or in the head). The child’s ability to withdrawal from usual activities,
29 such as ‘buzzing bees’, ‘car beeping’ describe these will depend on their complaints of headaches, dizziness
30 ‘rice crispies’, ‘like drums’, ‘choo age. Parents are sometimes able to or ear pain. Some children describe
31 choo’ or ‘like a faraway train’. The use help link the onset to a particular difficulties with listening and attention
32 of emotive terms for example ‘angry event or circumstance or may have in class when their tinnitus is
33 bees’ helps to identify tinnitus which noticed that the child has a particular intrusive. They may miss information
34 is distressing. dislike of one ear. Very young given by the teacher, and being told
35 children are not always able to off by their teacher for not paying
36 Creative descriptions of tinnitus such provide answers to these questions. attention is a particular worry for
37 as singing or voices can make them. These tinnitus related
38 parents more anxious about what Tinnitus – impact and distress difficulties may compound other
39 their child is experiencing than the There are currently no standardised attention and listening difficulties
40 child themselves. tinnitus questionnaires for use with caused by hearing loss, APD, ADHD,
41 children. Standardised measures do, or speech and language difficulties.
42 Young children or those with limited however, exist for screening Generally speaking, children aged 6
43 language can find it very difficult to psychological difficulties such as or 7 years and upwards can reliably
44 describe their tinnitus. Inviting the anxiety and depression and these use a simple visual analogue scale
45 child to draw a picture of the tinnitus can be of help in assessing the (Appendix 7) to indicate tinnitus
46 can help give it a name and a visual impact of tinnitus on the child’s well- loudness or tinnitus distress. The
47 description of the child’s experience. being. Existing questionnaires for scale can also be used to measure
48 Use the child’s name for the tinnitus children with hearing loss or auditory the child’s tinnitus distress in different
49 as you talk about it in the processing disorder can be adapted situations (such as home and
50 appointment. Older children’s to gather qualitative information school). The term distress describes
51 description of their tinnitus helps to about tinnitus impact on listening, a variety of responses such as worry,
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1 annoyance, fear, and anger. In the (Mills 1984). The child may describe through personal music players or at
2 VAS, the child’s preferred term should 'clicking' and 'popping' sounds and social events). If tinnitus has
3 be used. Some children find it easier have a history of resolving otitis occurred after such exposure,
4 to convey their distress through this media with effusion. Tinnitus that is appropriate advice can be given
5 method rather than trying to describe suggestive of middle ear myoclonus about hearing protection (Appendix
6 it verbally. A VAS rating can be should be referred for a medical 9).
7 repeated at follow-up appointments opinion despite the difficulties in
8 as a measure of change. treating this. Enquiring whether the A line of enquiry regarding a history
9 child has a history of rhinitis or of previous severe illnesses will
10 Family History of tinnitus and hayfever will identify whether there reveal any aetiology related to the
11 hearing difficulties may be a connection with a general use of ototoxic medications;
12 It can be helpful to know if anyone ENT condition. examples being: chemotherapy for
13 else in the family has tinnitus or childhood cancers, or high dose
14 history of hearing problems. How that Establishing whether there are any intravenous antibiotics for severe
15 person has responded to their vestibular symptoms can be difficult infection.
16 tinnitus or hearing difficulty will in children. Parents of younger
17 influence the child and the family’s children may be able to give more Other general medical problems
18 view of tinnitus, it’s impact, and ways general information about whether might be relevant; for example,
19 of coping with it. they feel their child is particularly migraine can be associated with
20 unsteady. Older children will be able auditory sensitivity and tinnitus.
21 to describe any feelings of dizziness
Hearing difficulties and other
22 or unsteadiness and any link between Factors affecting tinnitus
23 audiovestibular symptoms the occurrence of these and their Some children and their parents have
24 It is important to establish whether tinnitus should be noted. already noticed things that make
25 the child has noticed any change in tinnitus better or worse. Parents may
26 their hearing, or any other ear Although the management of have noticed that their child’s tinnitus
27 symptoms such as pain or a feeling hyperacusis is beyond the remit of is affected by illness, stress,
28 that their ears are blocked. It can be these guidelines, it is important to tiredness, or important life events, or
29 difficult to distinguish a change in identify whether the child has any improves during school holidays.
30 hearing level from a feeling that intolerance to loud sounds and Older children may describe times of
31 tinnitus makes it difficult to hear, so responds to this inappropriately. the day, or places or situations when
32 careful questioning is required to they notice their tinnitus is worse, (for
33 avoid any ambiguity. Appropriate Medical and neurological history example at bedtime or the end of the
34 management of any new hearing loss Any history of trauma, both head and school day), or times and places
35 or change in an established hearing noise trauma should be noted. A when they do not notice their tinnitus.
36 loss may help reduce the child's child who has had a significant head Tinnitus rarely exists in a vacuum –
37 tinnitus. injury may well have had further other aspects of a child’s life will
38 investigations performed, but should affect their experience of tinnitus and
39 A history of otological disease (e.g. nevertheless be referred to an ENT will inform the management plan.
40 chronic middle ear disease) or risk surgeon or an audiological physician. Medical or care needs, social care
41 factors for otological problems (e.g. With both younger and older children, support, educational support, and
42 cleft palate) should be noted. prolonged exposure to loud sound psychological support are relevant.
43 Tinnitus in children often occurs in should be enquired about ( for Any external stresses can be
44 children with otitis media with effusion example, listening to loud music carefully and delicately asked about
45 for example family issues, divorce,
46 bereavement, or problems at school
47 such as bullying. Children with
48 tinnitus often present for help at a
49 time of transition, for example,
50 moving to a new school, exams, or
51
52
13Draft version for public consultation - June 2014
1 times of change in family dynamics. Current coping strategies for middle ear disease, occluding wax or
2 This information may not be tinnitus foreign bodies.
3 forthcoming initially, and some How the child and the parent have
4 children and families may open up managed the tinnitus so far provides Audiological assessment
5 more or see the relevance of the information regarding tinnitus From involving the child in the history,
6 questions once a full explanation of severity, impact and family coping hopefully they will be feeling
7 tinnitus and the links between anxiety style. Children are often remarkably comfortable in the clinic prior to
8 and stress have been given. It is resourceful at finding ways to starting any testing. The child may
9 important to remain open to such manage their tinnitus, for example by have previously found audiometry
10 discussions throughout the avoiding silence, or ways to distract stressful due to their tinnitus and
11 assessment. themselves. Information should also therefore be apprehensive about
12 be sought about how the parent has further testing.
13 Other significant stressors or tried to help their child, for example
14 difficulties in the child’s life may be of by distracting the child, giving It is important to establish accurate
15 more concern than tinnitus, and a painkillers, and involving the school. hearing thresholds, both air
16 referral onward should be This information is important for conduction and bone conduction
17 considered. Again, an explanation of planning tinnitus management where where necessary. Age-appropriate
18 the links between anxiety, stress and poor or ineffective coping strategies audiometry, ear-specific wherever
19 tinnitus will help children and their have failed. possible, following BSA
20 families understand the relevance of recommended procedures should be
21 this. completed. Carrying out audiometry
Appendix 4 summarises the key
22 when the tester is in the room with the
elements of the clinical
23 A combination of tinnitus and hearing child is preferable to sitting the child
assessment.
24 loss have been found to place within the test booth and having the
25 children at greater risk for mental tester outside. This way the tester can
26 Clinical examination
health difficulties, substance abuse, observe the child more closely
27 and school problems (Brunnberg Otoscopy should be performed by throughout the test and it is less
28 2008). Where healthcare someone who is confident in daunting and 'clinical' for the child.
29 professionals are concerned that excluding the presence of external or Children with tinnitus can find
30 significant psychological factors are audiometry testing difficult,
31 associated with the child or
32 teenagers tinnitus distress, it may in
33 some circumstances be appropriate
34 for some healthcare professionals
35 with appropriate training and
36 competence to sensitively enquire
37 about any alcohol or drug use.
38 Substance abuse can be indicative
39 of stress and other social and
40 psychological difficulties that may be
41 significant. A referral onwards to a
42 local mental health service such as
43 CAMHS service can be suggested to
44 the child and parent for help with the
45 underlying psychological disorders.
46
47
48
49
50
51
52
14Draft version for public consultation - June 2014
1 particularly close to thresholds and at testing to confirm normal hearing Red flags supporting a referral to
2 frequencies around the tinnitus thresholds. an ENT surgeon or AVP
3 sound. Observing the child • Ear discharge
4 throughout the test, looking for signs It is not recommended to carry out • Persistent ear pain or headache
5 of anxiety such as a change in LDLs or any tinnitus matching tests. • Dizziness/vertigo
6 breathing pattern, fidgeting or There is no evidence for either the • Unilateral or pulsatile tinnitus
7 repeated swallowing allows the tester diagnostic or therapeutic benefit of • Head injury
8 to offer reassurance throughout. these in children. • Middle ear myoclonus
9 The child should be allowed to carry • Abnormal findings in otoscopy
10 out the test in their own time. Pushing Specialist tests • Progression of known hearing loss
11 the child and constant reminders to In cases where there is a complex • Identification of any unmanaged
12 listen can increase their anxiety medical history referral onto an ENT hearing loss, conductive or
13 making the test harder and their surgeon or AVP is necessary for sensorineural
14 responses more erratic. Some further specialist neuro-otological
15 children find that wearing the tests or blood tests.
16 Red flags supporting a referral to
headphones for audiometry makes Imaging is recommended if pulsatile
17 their tinnitus sounds more audible. CAMHS or child mental health
tinnitus, unilateral tinnitus, or
18 Letting them know that this is normal asymmetrical bone conduction is services
19 can be reassuring and reduce identified. Vestibular schwannomas • Depression and significant anxiety
20 anxiety. The use of frequency have been identified in children as • Reports of self-harm or suicidal
21 modulated tones (warble tones) for young as 13 years. Other serious thoughts
22 testing is helpful if the tinnitus is a pathologies have been identified in • Reluctance to attend school or
23 steady tone and vice versa. It can be even younger children. If imaging is socialize with peers
24 helpful to encourage the child to tell indicated an initial referral to an ENT • Reluctance to engage in normal
25 you if the test sounds are like their surgeon or AVP would be activities
26 tinnitus noises. For some children it recommended. • Significant family emotional issues,
27 may be necessary to carry out sound e.g. bereavement
28 field testing, if wearing headphones Red flags and onwards referral
29 causes too much interference from Throughout the history and
30 their tinnitus, to obtain a more audiological assessment it is
31 accurate idea of their binaural important to be aware of signs or
32 hearing. symptoms that would require an
33 onward referral to another agency for
34 Tympanometry should always be further management. Where a referral
35 carried out regardless of whether any is necessary this should be done in
36 hearing loss is detected as the conjunction with any tinnitus
37 presence of middle ear effusion can management plan. Good links with
38 exacerbate the perception of tinnitus ENT and CAMHS or Clinical
39 with or without any associated Psychology are necessary to ensure
40 hearing loss. Using tympanometry to smooth care pathways for these
41 look at eustachian tube function can children.
42 be useful in those children reporting
43 cracking/popping sensations.
44 Where a child has found audiometry
45 difficult and has given erratic
46 responses measuring transient
47 otoacoustic emissions can be useful
48 to establish normal cochlear function.
49 In some cases it may be necessary
50 to carry out electrophysiological
51
52
15Draft version for public consultation - June 2014
4
Management Strategies
1 intended as a prescriptive approach our ears sometimes make when they
2 Key points: to tinnitus management but rather as are working, in the same way that a
3 • A good explanation of tinnitus a tool-kit to guide professionals in tummy rumbles or the sound we
4 forms the basis to all management developing appropriate management make when breathing. A fun
5 plans. plans for each child. approach can be to ask the child
6 (and parent) to listen out for any
7 • Management uses a set of tools Explanation, advice and sounds that their bodies are making.
8 rather than rules. information giving Once they have noticed for example,
9 the sound of their breathing, then one
Reassurance:
10 • Children with significant can compare this to the sound that
A thorough audiological and medical
11 psychological difficulties should be ears sometimes make.
assessment means that concerns of
12 referred on to an appropriate child child and parent can be answered by
13 mental health service or child Explaining tinnitus to older
reassurance that the child’s hearing
14 psychology service. children and parents:
is normal, or hasn’t changed
15 Older children are more likely to have
(assuming this is the case), there are
16 • Advice and strategies need to be developed the linguistic and
no underlying medical causes for the
17 provided to support the child at cognitive skills to understand,
child’s tinnitus (nothing seriously
18 school where tinnitus impacts the through explanation, the complex
wrong) and that tinnitus will not
19 child’s classroom performance. relationship between tinnitus
damage the child’s hearing.
20 symptoms and thoughts, emotions,
21 Effective tinnitus management physiological reactions, and life
Normalise tinnitus:
22 strategies individualise care. No events. There are a number of
Children are generally surprised and
23 single treatment protocol or care tinnitus models used for counselling
pleased to discover that lots of other
24 pathway will fit the needs of all adult tinnitus patients but these are
children hear noises in their ears and
25 children and their families and each generally too complex and ‘wordy’
they are not alone in experiencing it.
26 child will manage their tinnitus and even for older children and need to
27 distress in their own individual way. be simplified and made child-friendly.
Develop a sense of control:
28 The level of distress the child This can be done for example, by
Suggestions can be given for simple
29 presents with does not equate replacing words used in models with
practical strategies, for example the
30 prescriptively to a particular strategy, images of thoughts, worries or
use of environmental sound, coping
31 device or need for onward referral. feelings. Again, images must be
thoughts, or strategies that can be
32 ones with which the child can identify
used in the classroom. However,
33 Effective management needs to as being within their realm of
helping the child to come up with
34 address the impact of tinnitus upon experience. If children can produce
their own strategies and solutions to
35 the child’s health: their psychological their own images, this will be even
the difficulties they experience is
36 well-being, educational progress, more meaningful to them and
often more effective in giving them a
37 and any life stressors both at home increase feelings of ownership. A"
sense of control over their tinnitus.
38 and at school that exacerbate tinnitus This can include identifying times detailed"example"of"this"approach"is"
39 distress. It is important for healthcare when tinnitus is better or worse, and the"Child"Friendly"Tinnitus"Model"
40 professionals to identify children in (Emond"2013)"and"this"has"been"
help the child develop a sense that
41 need of psychological support, and found"to"be"helpful"in"explaining"
“there are things they can do about
42 to refer onwards to appropriate it”. Bnnitus"distress"to"parents"also.
43 services where necessary.
44
Explaining tinnitus to young Tinnitus management strategies
45 It is recognised that currently, each children: Relaxation
46 paediatric tinnitus service will vary in Very young children appreciate very
47 its make-up in terms of the There is no current evidence for the
simple explanations that are within
48 professionals involved, access to use of relaxation in the management
their realm of experience and they
49 devices, skill-sets and roles. The of tinnitus in children. Published
can relate to. For example, tinnitus
50 following suggestions are not studies relate specifically to
can be explained as the sound that
51 relaxation training in adults and
52
16Draft version for public consultation - June 2014
1 suggest there is little evidence of its appropriately. Thus in delivering the environmental sound to the bedroom
2 effectiveness as a stand-alone techniques, on-going guidance and (e.g. fans or gentle music) Parents
3 approach. However, on the basis that help must be provided to ensure that should be encouraged to develop a
4 stress can exacerbate tinnitus, relaxation techniques are carried out good bedtime routine for their child,
5 relaxation is widely suggested as part in a way that offers maximum benefit which includes avoiding mentally
6 of a holistic approach to tinnitus to your agreed management plan. stimulating activities before bedtime
7 management for adults and is such as TV or computer games.
8 consistently suggested by approved Mindfulness Techniques
9 sources promoting information on Evidence for the effectiveness of Case example: Luke, aged 15,
10 current practices, e.g. the BTA: mindfulness techniques in the watched TV in his bedroom to
11 Information & Publications. It is management of tinnitus is still in its distract from the tinnitus sounds at
12 reasonable to assume that the same infancy but pilot studies indicate night. He watched documentaries
13 principle applies to children. positive findings in treating chronic about servicemen in Afghanistan and
14 Lamontagne et al. report findings tinnitus and its co-morbid symptoms was then unable to relax. Luke was
15 which indicate “that relaxation may in adults (Gans 2013). encouraged to use others sounds to
16 be learned by children and may be Mindfulness practice may therefore aid relaxation as and to distract him
17 beneficial in coping with prove useful for children in learning from his buzzing sounds.
18 stress” (Lamontagne 1985). how to manage stress and anxiety,
19 which may in turn relate to more Although the child’s sleep difficulties
20 It is important to identify the causes effective tinnitus management. It has may be ascribed to the tinnitus, other
21 of worry or stress and the intervention been introduced in some UK schools explanations should be considered,
22 needed to reduce it. As part of this and at the time of writing an evidence for example a more general sleeping
23 relaxation can be one useful self- base for its effectiveness is beginning problem due to a poorly established
24 management tool reducing to emerge. (Kuyken 2013). bedtime routine, or long standing
25 physiological arousal in response to Mindfulness is also being introduced sleep onset anxiety – namely,
26 stress and promoting a sense of calm in schools through the .b program for difficulty falling asleep due to
27 and well-being. 11-18 year olds and Paws.b for excessive fears and worries. Children
28 reception to year 6 children with more general sleep difficulties
29 Simple breathing exercises can be (Appendix 10). may benefit from referral to a local
30 carried out anywhere, and in a variety sleep clinic or other community
31 of situations. There are a variety of Sleep service via their GP.
32 more formal techniques, including Sleep difficulties are commonly
33 diaphragm breathing; however reported by children with tinnitus and Noise exposure and evasion
34 techniques need to be suitable for their parents. As a starting point, it is Within the framework of the PINCHE
35 the child’s age. Breathing exercises important to find out what tinnitus project it was concluded that noise
36 change the rhythm and technique of sounds the child hears, what they can have auditory effects on children
37 how we breathe, and it is important to think those sounds are, and any (PINCHE 2006). However, most
38 bear in mind certain potential worries that the child has about the effects are long term and cumulative
39 difficulties such as hyper-ventilation, sounds. and therefore the effects of noise
40 or any other medical conditions upon children and subsequent
41 which may give rise to problems and Case example: Jack, aged 9, worried hearing loss or tinnitus experience,
42 may be contraindications for the use viewed from a life-course
a great deal, and this included fears
43 of breathing exercises. Visualisation perspective.
about people breaking into the house
44 techniques are also frequently used at night. He said that his tinnitus
45 to help children relax. These can be The use of hearing protection is not
sometimes sounded like the stairs
46 either self-directed or guided routinely recommended apart from in
creaking, and this made him feel very
47 (Apeendix 10). particular circumstances where noise
scared
48 levels are unusually loud, such as a
49 It must be noted that in learning concert. Protecting ears from such
Many children are helped by
50 relaxation techniques progress needs introducing quiet, soothing loud sound levels needs a careful
51 to be reviewed and supported
52
17Draft version for public consultation - June 2014
1 approach, and as far as possible an listening, and often as a by-product his favourite console game makes.
2 understanding of the individual’s to this function tinnitus perception is He plans his next move in the game
3 personal preferences. For example - reduced and its impact lessened. and it helps him to sleep.
4 advising volume restricted Hearing aid fitting may be
5 headphones for someone with a love counterproductive in certain cases Devices
6 of loud music is unlikely to be due to ear canal occlusion by the The principle of sound based-therapy
7 successful, but talking about filtered hearing aid mould (Gabriels 1996). can include the use of everyday
8 ear plugs and their use by the music Access to open fitting technology devices. Sweetow and Sabes
9 industry may have more weight. It is where appropriate may of course describe wearable sound generators,
10 equally important that the child is minimise this concern. music, hearing aids, radio, TV, fans
11 provided with a good explanation of and relaxing sounds as devices for
12 noise induced hearing impairment Children with severe to profound sound–based therapy (Sweetow
13 where appropriate (Appendix 9). hearing loss and tinnitus may find 2010). The device should provide
14 tinnitus more noticeable when they sounds that can be incorporated into
15 Case example: Ellie, aged 16, with a take off their hearing aids at bed time the background sound environment.
16 ringing tinnitus was very worried that and environmental sound will be of Sounds should offer a filter between
17 she might have noise damage after little use. Alternative strategies that quiet surroundings and tinnitus
18 PTA testing in an adult setting aim to normalise tinnitus and reduce sounds rather than mask tinnitus.
19 revealed 6 kHz dip binaurally. Re- associated worry and distress are
20 testing in paediatric setting showed required. Sound enrichment is also often used
21 this as an artefact. It was more likely as a tool to aid relaxation and to
22 that Ellie could hear her tinnitus on Case example: Matthew, aged 11, lessen anxiety. With adults, sounds
23 testing this frequency. has a severe bilateral loss. He is only such as white noise, sea waves, rain
24 aware of tinnitus at bedtime when noise, wind sounds or pulse tones
25 Sound enrichment: hearing aids trying to sleep. Matthew hears his are frequently used. Research is
26 and other devices tinnitus and has worked on this noise needed to identify which sounds are
27 being the same noise a character in most meaningful and effective for use
Hearing aids
28
There is limited research indicating
29
the effectiveness of hearing aid use
30
for tinnitus management across the
31
paediatric population. Studies have
32
looked at whether there is correlation
33
between the level of hearing
34
impairment and impact of tinnitus.
35
Their conclusions suggest that those
36
with moderate sensori-neural hearing
37
loss tend to report tinnitus more
38
readily than those with severe to
39
profound loss (Coelho 2007).
40
41
It is generally deemed sensible to
42
offer hearing aids to children with
43
tinnitus where a loss is present and
44
in the adult population it has been
45
suggested that a hearing aid device
46
helps to lessen tinnitus impact in a
47
number of ways, not least the
48
reduction in listening fatigue (Beck
49
2011). Hearing aids are used
50
primarily to enable improved
51
52
18Draft version for public consultation - June 2014
1 with children. Sounds that are Case example: Mia, aged 16, was relevant training in these therapeutic
2 soothing to children and evoke about to sit 3 hour art exam at school techniques.
3 pleasant associations are likely to be in silence. Using sound generators at
4 both age dependent and personal. this time helped her to focus on exam Cognitive Behavioural Therapy
5 There are many ways to access and allowed her to be with other CBT techniques for tinnitus
6 environmental sounds, such as soft classmates whilst sitting the exam. management have a good evidence
7 music and the nature sounds such as base in adults (Cima 2012). There is
8 those mentioned above. Many Psychological approaches to accumulating evidence indicating
9 children will have access to such tinnitus that CBT techniques result in
10 sounds in downloadable formats. There is often a complex relationship clinically significant improvements in
11 Apps on tablets such as relaxation children with anxiety although its
between tinnitus, emotional well-
12 melodies or the material produced by efficacy compared to other active
being, stress and the context of the
13 companies such as child’s life. It seems clear that worries interventions with very young children
14 www.relaxkids.com can be and anxiety about the tinnitus result in has yet to be consistently determined
15 downloaded and also played in CD increased awareness (Halford 1991). (Stallard 2009). Little is known about
16 format. the effectiveness of CBT with children
Psychological disorders such as
17 under 7 years of age and the younger
anxiety and depression may arise
18 Wearable sound generators the child the greater the focus upon
from tinnitus but equally they may
19 The use of sound or wearable sound also reflect other stressful events in behavioural aspects (Stallard 2002)
20 generators originates in the the child’s life, yet be attributed to the Older children are more able to work
21 neurophysiological model of tinnitus with cognitions.
tinnitus by the child (i.e. “if only my
22 management. A 2012 study reports tinnitus went away, then everything
23 significant improvement using sound would be better”). Parents and the Case example: Max, aged 14, was
24 generators as part of Tinnitus not attending school on a regular
child can be helped to understand
25 Retraining Therapy for children that other difficulties in the child’s life basis and was very anxious about his
26 (Bartnik 2012). However, we know hissing tinnitus. He did not sleep well
may co-exist with, or exacerbate
27 little from the study about the because of the anxiety and had
tinnitus distress.
28 counselling input and other strategies begun to miss days of school at a
29 used alongside the devices, or its Treatment for psychological disorder time and to sleep through the day. He
30 benefits compared to other treatment needs to be provided by a trained went out with friends at night. CBT
31 strategies for children. Further techniques were used to help reduce
mental health practitioner, and
32 research is required to determine services such as CAMHS (Child and his anxiety and objectify his reasons
33 whether there are specific child for non-attendance in school which
Adolescent Mental Health Service
34 populations more likely to benefit helped him and his parents manage
Tier 3), local Child Psychology
35 from wearable sound generators, for Service or other similar local services the situation more effectively.
36 example children with complex may be the appropriate place to
37 special needs, ASD, limited language provide psychological support. Early Narrative Therapy
38 and communication skills. Narrative therapy refers to techniques
identification and treatment of
39 developed largely by Michael White
psychological difficulties are
40 Sound generators may prove helpful and his colleagues, and is used with
essential (Appendices 5 and 6).
41 for children who like to use sound people of all ages. The word narrative
42 therapy for their tinnitus but may be in For treating the co-morbid in the context of therapy means
43 a situation where they are unable to psychological symptoms associated listening to others stories. Over time,
44 use environmental sound or music individuals develop narratives or
with tinnitus distress there are a
45 players. number of widely used psychological stories about themselves that help
46
therapies, such as CBT and Narrative make sense of their lives and what
47 happens to them. These ‘stories’ in
Therapy. Their effectiveness in
48
alleviating tinnitus distress in children turn have the effect of filtering future
49
has not been evaluated and they can experiences, selecting what
50 information gets focused in or
only be provided by staff with
51 focused out. Information is selected
52
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