British Society of Audiology Good Practice Guidance for the management of children with tinnitus

Full text

Tinnitus in
Children
Practice Guidance
March 2015
For revision March 2017

The James Lind Alliance Tinnitus Priority Setting Partnership was set up at the instigation of the British Tinnitus
Association. Its aim was to identify the top ten research uncertainties for tinnitus. In 2011 and 2012, the Partnership
carried out an extensive, nationwide consultation of tinnitus patients and clinicians and at the 2012 British Society of
Audiology annual conference, an appeal to address these top ten research priorities was launched. One of the top
ten questions is: “what is the optimal set of guidelines for assessing children with tinnitus?”
It was hoped that the identification of research priorities would be a catalyst for more research and encourage funders
and researchers alike to rise to the challenge of addressing the selected priorities. The Tinnitus in Children Practice
Guidance is a response to that challenge. We welcome comments and feedback, which can be sent to:
bsa@thebsa.org.uk.
The development of this Practice Guidance was undertaken through the Paediatric Audiology Interest Group (PAIG) of
the British Society of Audiology by a working party of national specialists in paediatric tinnitus. The project was kindly
supported by the British Tinnitus Association.
This document presents Practice Guidance by the British Society of Audiology (BSA). This Practice Guidance
represents, to the best knowledge of the BSA, the evidence-base and consensus on good practice, given the stated
methodology and scope of the document and at the time of publication.
Although care has been taken in preparing the information supplied by the BSA, the BSA does not and cannot
guarantee the interpretation and application of it. The BSA cannot be held responsible for any errors or omissions,
and the BSA accepts no liability whatsoever for any loss or damage howsoever arising. This document supersedes
any previous recommended procedure by the BSA and stands until superseded or withdrawn by the BSA.
Foreword
2

Foreword!2
Contents!3
Terminology & Abbreviations!4
Executive Summary!5
1!Introduction & Overview!6
2!Tinnitus in Children - Implications for Clinical Practice!9
3!Assessment of Tinnitus in Children!10
!History taking!10
!Clinical examination!13
!Audiological assessment!13
!Specialist tests!14
!Red flags for onward referral!14
4!Management Strategies!15
!Explanation, advice and information giving!15
!Tinnitus management strategies!16
!Sound enrichment: hearing aids and other devices!17
!Psychological approaches to tinnitus!18
!Tinnitus management in the classroom!20
5!Development of a Paediatric Tinnitus Service!22
Appendices!23
1!Service Provision!23
2!Evidence Base!24
3!Child-Friendly Interview Techniques!26
4!Key Elements of the Clinical Assessment!27!
5!Signs of Tinnitus Distress!28
6!Psychological Associations with Tinnitus!29
7!Assessment Measures!30
8!Tinnitus in the Classroom: Information Booklet!32
9!Hearing Protection!34
10!Further Resources!35
References!36
Authors! ! 39
Contents
3

Child
The term ‘child’ is used throughout
this document to include children up
to the age of 16 years.
Parents
This includes mothers, fathers, carers
and other adults with responsibility for
caring for a child or young person,
including for example, those with
responsibilities for looked after
children and young offenders.
Professional
This term has been used generically
to refer to doctors, audiologists,
teachers and any other allied
professionals that may be involved in
the child’s care.
Red Flags
Red flags are used as indicators for
onward referral to another specialty
as appropriate.
Management
This term has been used to refer to
both assessment and treatment.
Tinnitus Distress
This term is used to cover the range
of negative emotions that children
and parents may feel as a
consequence of their tinnitus, such as
annoyance, anger, fear, worry,
anxiety.
ADHD
Attention Deficit Hyperactivity
Disorder
APD
Auditory Processing Disorder
ASD
Autistic Spectrum Disorder
AVM
Audiovestibular Medicine
BSA
British Society of Audiology
BTA
British Tinnitus Association
CAMHS
Child and Adolescent Mental Health
Service
CBT
Cognitive Behavioural Therapy
ENT
Ear, Nose and Throat
GP
General Practitioner
IEP
Individual Educational Plan
IHP
Individual Hearing Profile
LDLs
Loudness Discomfort Levels
LIFE
Listening Inventory for Education
Efficiency
PINCHE
Policy Interpretation Network on
Children’s Health and Environment
PTA
Pure Tone Audiogram/Audiometry
SENCO
Special Educational Needs
Co-ordinator
VAS
Visual Analogue Scale
Terminology! ! Abbreviations
4

•Tinnitus is a common experience in
childhood.
•The evidence base on paediatric
tinnitus is scarce. In view of this, the
underlying principles of managing
adult tinnitus are applied to the
management of children with
tinnitus. However the aetiology,
presentation and management of
the child’s tinnitus needs to take
into account the child’s age,
cognitive and linguistic ability and
individual circumstances. The
evidence base for the management
of childhood anxiety and pain is
relevant to aspects of the tinnitus
profile of children.
•This practice guidance offers a
pragmatic approach to the
management of children with
tinnitus at all levels of severity, for
children up to 16 years, as this is a
common age for transition into adult
services.
•In general, in hearing appointments
other than routine ENT audiometry
and school screening, children
should routinely be asked whether
they ‘hear noises in their ears or
head’ and if they do, whether they
are bothered by them. The vast
majority of children are untroubled
by these noises and a simple
explanation and reassurance are all
that is required. Further assessment
will be required for the minority of
children where tinnitus distress is
identified.
•Whenever possible, healthcare
professionals should involve
children in the assessment and
management of their symptoms and
should not rely upon information
provided by parents alone.
•The focus of management should
be on the child and not the ear or
tinnitus. A holistic approach (child,
family and school) is required to
meet the needs of children who
present with tinnitus.
•Where tinnitus impact and distress
is found to be minimal, simple
information counselling will
frequently be sufficient, and this
may prevent tinnitus distress from
developing.
•Skills for the management of
children with mild to moderate
distress should be available within
most paediatric audiology services.
•Children with severe distress and/or
complex presentations should be
managed within regional centres of
excellence where specialist skills in
paediatric tinnitus assessment and
therapy are available (DoH 2008).
The exact members and roles of
this team will vary according to the
service.
•Children should be managed in an
appropriate paediatric setting by
health care professionals with
appropriate paediatric skills and
knowledge of care pathways and
legislation relevant to the paediatric
population.
•This practice guidance
acknowledges that hyperacusis
often co-exists with tinnitus, but
hyperacusis requires different
assessment and management
methods and therefore is not
covered here.
•This practice guidance has been
developed and promoted as a
result of public and professional
consultation exercises.
Executive Summary
5

How to use this
practice guidance
This practice guidance has been
composed to provide key text within
the body of the main chapters for a
broad range of professionals that
may see children with tinnitus. More
detailed information has been
provided in the appendices to allow
the reader to acquire more
information where necessary, or
where particularly relevant to their
interest.
Aims of this practice
guidance
Tinnitus in children is a neglected
area, from both a clinical and a
research perspective. To date,
research provides information about
prevalence and co-morbidity of
tinnitus in children, but very little, if
anything, about managing
distressing tinnitus in a children's
clinic, or effective therapies for
alleviating the distress it can cause.
Given the lack of an evidence base,
many views about tinnitus in children
are held largely on the basis of
common belief or personal opinion.
This practice guidance has been
written on the basis of the evidence
base where it is available, and from
the clinical experience and practice
of the working party members. Our
aim is that the practical and
pragmatic advice offered will enable
others to develop their clinical skills
in tinnitus management with children,
and that in turn this will lead to
further clinical developments,
research, and ultimately a firm
evidence base for the management
of tinnitus in children.
This practice guidance is intended
for the wide range of professionals
who may be involved in the
management of a child with tinnitus.
This can include audiologists,
medical professionals, nurses,
hearing therapists, educational
audiologists, teachers of the deaf,
psychologists and other mental
health professionals. Some sections
are of more relevance to specific
professionals than others.
As an introduction, below are a
collection of common questions
about tinnitus in children:
Do children experience tinnitus?
A commonly held view is that tinnitus
only occurs in adults, relates to an
ageing auditory system, and occurs
very rarely in children. A number of
research studies internationally have
looked at the prevalence of tinnitus in
children (see appendix 2). Although
the quality of these studies are
variable, the overall findings suggest
that children commonly experience
tinnitus (Sheyte 2010). Juul et al
have suggested that tinnitus in
children may be on the increase (Juul
2012), but this may be a reflection of
increased awareness and therefore
reporting. Tinnitus appears to be
twice as common in children with
hearing loss compared to children
with normal hearing (Graham 1987;
Raj-Kosiak 2011). There is some
evidence to suggest that it may be
common in children with a history of
otitis media (Mills 1984), and more
research is needed into this.
Whilst the experience of tinnitus is
common, most children with tinnitus
are not bothered by it, and a simple
explanation and reassurance are all
that is required. Only a small number
of children will require further
1
Introduction & Overview
6

management to help with distress or
impact upon their lives.
Is tinnitus in children a clinical
concern?
There is some debate as to whether
tinnitus in children is a significant
clinical concern. Referral numbers
for children with tinnitus are reported
to be low (Baguley 2013a),
suggesting that children do not
express their distress of tinnitus or
require intervention in the same way
as adults; further research is needed.
For those children whose tinnitus is
distressing however, tinnitus can
have a significant effect upon their
physical and psychological well-
being and their educational progress,
all of which can have lifelong
consequences if left untreated.
There are currently few services in
the UK available for children with
tinnitus. It appears that where such a
service is available, and when
children attending audiology
appointments are routinely asked
about tinnitus, that referral numbers
steadily increase, and this suggests
that there is an unmet need.
Is tinnitus in children the same as
in adults?
Research available is limited and of
variable quality, but suggests that
children with tinnitus share many
similarities to adults with tinnitus.
There is some evidence that, as with
the adult population, tinnitus in
children is associated with higher
rates of psychological difficulties
such as worry, anxiety and
depression.
The impact of tinnitus upon children
is similar to adults in many ways,
affecting emotional well-being
(Holgers 2006); concentration and
listening skills (Kentish 2000). Sleep
difficulties are frequently mentioned
by children and parents (Gabriels
1996; Kentish 2000; Kim 2012): poor
sleep can in turn lead to other
problems such as poor memory and
concentration, irritability, behavioural
problems, and can affect the whole
family’s well-being.
How does tinnitus in children differ
from adults?
Whilst children and adults with
tinnitus share much in common, there
are differences that have important
implications for clinical practice.
Several authors have noted that
children tend not to tell adults
spontaneously about their tinnitus.
Savastano found that the number of
children with tinnitus rose from 6.5%
to 34% when children are specifically
questioned (Savastano 2009).
Children are also unlikely to mention
it spontaneously to their parents (Raj-
Kosiak et al 2011). When directly
asked, children are generally able to
describe their symptoms, although
this may not always be in ways that
adults are familiar with (Section 3).
Some healthcare professionals and
parents are concerned that asking a
child about tinnitus may create
awareness and anxiety, and turn non-
troublesome tinnitus into troublesome
tinnitus. The experience of the
working party members is that the
opposite is the case. Asking about
tinnitus provides the opportunity to
normalise the experience for the
child.
Asking children whether they hear
noises in their ears or their head, and
whether it bothers or annoys them
needs to be done sensitively and in a
non-leading manner. Care should be
taken, particularly with very young
children who can give answers in
order to please the adult, when they
don’t fully understand the question. It
is important to be confident that the
child has understood the question.
Vague, fanciful, or inconsistent
descriptions of noises from a child
should be treated with caution.
Non-troublesome tinnitus will
probably make up a large proportion
of the tinnitus reported, and simple
reassurance will be all that is needed.
However, asking about ear noises
gives the healthcare professional the
opportunity to identify those children
whose tinnitus is troublesome and
require intervention.
If a child attempts to tell adults about
tinnitus and feels dismissed, they
may worry about why adults won’t
discuss it. The child may then
become scared of the tinnitus, what it
might mean, or fear being ridiculed if
they know it is not a ‘real’ sound. The
child will have less opportunity to
discover that others have the same
symptoms, including their peers.
Healthcare professionals should
provide children with troublesome
tinnitus the opportunity to talk about
the noises they hear, and offer
practical advice for managing it. This
includes age appropriate information
about tinnitus, strategies for
managing any distress and
difficulties in the classroom. Further
suggestions regarding advice are
provided in section 4.
Working with children often involves
two patients, the parent and the child,
who may have differing information,
perspectives, and worries about what
the child’s tinnitus means and
clinicians cannot rely upon
information gathered from one or
other alone. Assessing and
counselling a child with tinnitus takes
time and cannot be rushed. These
two factors have implications for
7

service providers in terms of the
amount of time required by clinicians
working in a paediatric tinnitus
service.
Children have limited access to
information. Currently, information on
websites is directed to adults and
much of it is inappropriate, especially
for young children. There is an urgent
need for age-appropriate literature for
children. A discussion about their
tinnitus enables the child and parent
to learn reassuring information about
tinnitus and practical strategies for
managing it.
Can adult models of tinnitus
management be applied to
children?
Children are not mini-adults and the
effectiveness of applying adult
models of tinnitus management to
children can be questioned. There is
little or no direct research available to
answer this question. Given that
children with distressing tinnitus
share many similarities with adults in
terms of audiological symptoms,
impact and psychological distress, it
is pragmatic to assume that
management strategies applied to
adults are of relevance to children.
However, these treatment strategies
need to be adapted for use with
children, and used as part of a child-
friendly approach. Children should
be seen by health care professionals
with experience of assessing and
managing children. Appointments
should take place within a paediatric
clinical setting as opposed to being
an add-on to an adult tinnitus clinic.
This may be difficult for some
services, however this
recommendation is in line with
national guidelines for paediatric care
(NDCS 2000; NSFC 2003; DoH
2008).
What is a child-friendly approach?
A child-friendly approach means
putting the child at the heart of the
process, and providing services in
settings that are appropriate to the
needs of children and their families.
It means listening respectfully to the
child, and communicating at the
child’s level both developmentally
and linguistically, while being aware
of the factors that will influence the
way the child communicates with
you. It means utilising activities such
as play, drawing and other more
visual and concrete ways of getting
across complex ideas (Appendix 3).
8

2
Tinnitus in Children
- Implications for Clinical Practice
Key points:
•Compared to adults, children are
much less likely to spontaneously
tell others about their tinnitus. When
they do, their descriptions may be
in unfamiliar terms.
•Practitioners must be alert to “soft”
signs that a child has identified
tinnitus.
•Children of all ages can have a
variety of worries about tinnitus.
•Parents and children should be
asked about their worries and
concerns individually as these may
not be the same.
Professionals’ reluctance to talk
about tinnitus – and its
consequences
Parents are often unaware that their
child has tinnitus (Raj-Kosiak 2011)
and an audiological assessment may
be the first time that a parent
becomes aware of it. Young children
may lack the cognitive and linguistic
skills to describe their tinnitus in ways
that adults are familiar with. If the
tinnitus has always been present, the
child may assume that everyone
shares the same experience and
remains untroubled by it. Clinically,
older children describe reluctance to
tell people about tinnitus because
they do not want to be seen as being
different in any way, or feel that they
will not be believed if they talk about
it.
Soft signs of tinnitus
Tinnitus may have an impact on
different areas of a child’s life.
Information about this may not be
spontaneously volunteered. So the
practitioner needs to be mindful of
this. It is important for the practitioner
to be aware of ‘soft’ signs, present in
varying combinations, which are
suggestive of unidentified tinnitus.
Behaviour
•Parental reports of sleep
difficulties, particularly in young
children. The child may demand
sound e.g. story tapes, music, the
TV or will not fall asleep on their
own or in their room.
•The child shows distress or
avoidance of quiet or noisy
environments.
School
•Children with tinnitus report
difficulties with listening and
concentration (Kentish 2000) and it
is unlikely that the child has
spontaneously mentioned it to their
teacher.
•Unexplained listening difficulties,
not usually generalised across the
school day, and possibly having a
specific association.
•The child reports worry or anxiety
about being able to hear the
teacher’s voice easily, and concern
about being told off for not paying
attention in class. The child may
describe feelings of anger,
frustration, helplessness, fear, or of
feeling disconnected from the
classroom.
•Children with hearing loss or a
history of hearing loss may
describe difficulties with classroom
listening that are distinct from
descriptions of speech perception
difficulties associated with hearing
loss – perhaps because the sound
has no apparent source and is not
a shared experience.
•Speech perception difficulties are
described in background noise or
acoustically poor environments and
in quieter listening environments, or
in quiet situations only.
Audiological testing
•Changes in the child’s behaviour
that do not ‘match’ observations of
the child outside hearing tests.
These include signs of agitation,
avoidance strategies in anticipation
of PTA (Section 3) or an
audiological assessment that has
been challenging. The child shows
low confidence in relation to
audiological testing, and their
anxiety levels are high, especially
in sound proofed testing rooms.
These children may possibly be
mistaken as having a non-organic
hearing loss.
•Difficulty with hearing aid use for no
obvious reason. There may be a
distrust or dislike of the sound in
one ear, and perception that
hearing is worse in this ear,
although thresholds are similar.
Worries about tinnitus
Very young children may not know
why they hear sounds in their ears, or
may believe that there is actually
something there, for example bees,
monsters, rice crispies, or voices
singing inside their heads. Older
children can share similar worries
that there is something in their head,
but may be worried that they are
losing their hearing, “going mad”, or
of being unable to go to university or
get a job when they are older.
Parents are often concerned that their
child’s tinnitus might relate to hearing
loss; mental health problems, a brain
tumour or other neurological
condition (Kentish 2000). They
frequently describe feeling helpless
about how to help their child. Child
and parent worries therefore need to
be identified separately.
9

3
Assessment of Tinnitus in Children
Key points:
•Tinnitus is a symptom and must be
considered in the context of
hearing loss and other audiological
or neurological symptoms.
•Children require assessment
according to their age and level of
cognitive and linguistic
understanding. As far as possible,
information must be obtained from
both child and parent. It is
important to appreciate that the
parent may also be anxious or
distressed by the child’s
symptoms.
•With young children, in addition to
gathering information from the child
and parent, the clinician should be
able to utilise other techniques
such as play and drawing to gain
information about the child’s
tinnitus symptoms.
•Audiological assessment can be
difficult and anxiety-provoking for
children with tinnitus. Plenty of time
should be allowed for testing and
a flexible approach taken where
necessary to ensure accurate
results.
•Throughout the assessment, it is
important to note any symptoms or
findings which suggest that an
onward referral is required to a
specialist multidisciplinary
paediatric tinnitus service where
available, medical service, or child
mental health service. Signs and
symptoms suggesting onward
referral have been highlighted as
red flags at the end of this section.
•Appendix 4 summarises the key
elements of the clinical
assessment.
The aim of assessment is to establish
the level of distress and impact upon
the child and family, ascertain any
causal or influencing factors and
begin to plan the management
strategy. The following section
outlines the key elements of the
clinical assessment.
As with any other paediatric
appointment it is important that the
clinical environment and approach
taken is child-friendly. Putting the
child and family at ease will help
facilitate information gathering during
the appointment. It should be
routine to ask all children seen for
audiological assessment whether
they hear noises in their ears or
head.
Questions should be asked in an
open, non-judgemental manner in
order to allow the child to describe
their experiences freely. For those
who report tinnitus, the levels of both
distress and impact vary enormously.
History taking
Key elements to consider are:
1. Tinnitus characteristics –
description of sounds
If children report that they have
noises in their ears, asking them to
tell you about it can obtain more
information than specific or direct
questioning. Descriptions vary, in
part depending upon the age of the
child. Older children may use familiar
terms such as ‘ringing’, ‘buzzing’,
‘‘wheezing’, ‘peeping’, ‘murmur’
‘humming’, ‘swishing’ and ‘whistling’
sounds. Younger children will often
use creative descriptions, referring
to objects within their experience
such as ‘buzzing bees’, ‘car beeping’
‘rice crispies’, ‘like drums’, ‘choo
choo’ or ‘like a faraway train’. The use
of emotive terms for example ‘angry
bees’ helps to identify tinnitus which
is distressing.
Creative descriptions of tinnitus such
as singing or voices can make
10

parents more anxious about what
their child is experiencing than the
child themselves.
Young children or those with limited
language can find it very difficult to
describe their tinnitus. Inviting the
child to draw a picture of the tinnitus
can help give it a name and a visual
description of the child’s experience.
Use the child’s name for the tinnitus
as you talk about it in the
appointment. Older children’s
description of their tinnitus helps to
identify whether it is pulsatile,
clicking, tonal, or complex.
The onset, duration and frequency
should be ascertained where
possible, together with identifying the
site of the sounds (one ear, both
ears, or in the head). The child’s
ability to describe these will depend
on their age. Parents are sometimes
able to help link the onset to a
particular event or circumstance or
may have noticed that the child has a
particular dislike of one ear. Very
young children are not always able to
provide answers to these questions.
2. Tinnitus – impact and distress
There are currently no standardised
tinnitus questionnaires for use with
children. Standardised measures do,
however, exist for screening
psychological difficulties such as
anxiety and depression and these
can be of help in assessing the
impact of tinnitus on the child’s well-
being (Appendix 7). Existing
questionnaires for children with
hearing loss or auditory processing
disorder can be adapted to gather
qualitative information about tinnitus
impact on listening, concentration
and school performance.
The level of distress, the nature of
any worries and the impact of tinnitus
should be determined separately for
parent and child if possible. The child
may have habituated to their tinnitus
and be unconcerned about it, and it
is the parent that expresses concern
and worry about what is wrong with
their child. Similarly, parents can be
unaware of the impact of tinnitus and
the level of distress that it causes
their child.
Information should be
gathered about tinnitus
impact in all aspects of
the child’s life, at home
and school. This may
include changes in
behaviour, difficulties with
sleeping, concentration,
listening or exams,
withdrawal from usual
activities, complaints of
headaches, dizziness or
ear pain. Some children
describe difficulties with
listening and attention in
class when their tinnitus is
intrusive. They may miss
information given by the
teacher, and fear being
told off by their teacher for
not paying attention. Tinnitus related
difficulties may compound other
attention and listening difficulties
caused by hearing loss, APD, ADHD,
or speech and language difficulties.
Generally speaking, children aged 6
or 7 years and upwards can reliably
use a simple VAS to indicate tinnitus
loudness or tinnitus distress
(Appendix 7). The scale can also be
used to indicate the child’s tinnitus
distress in different situations (such
as home and school). The term
distress describes a variety of
responses such as worry,
annoyance, fear, and anger. In the
VAS, the child’s preferred term
should be used. Some children find
it easier to convey their distress
through this method rather than trying
to describe it verbally. A VAS rating
can be repeated at follow-up
appointments as an indication of
change.
11

3. Family History of tinnitus and
hearing difficulties
It can be helpful to know if anyone
else in the family has tinnitus or a
history of hearing problems. How that
person has responded to their
tinnitus or hearing difficulty will
influence the child and the family’s
view of tinnitus, it’s impact, and ways
of coping with it.
4. Hearing difficulties and other
audiovestibular symptoms
It is important to establish whether
the child has noticed any change in
their hearing, or any other ear
symptoms such as pain or a feeling
that their ears are blocked. It can be
difficult to distinguish a change in
hearing level from a feeling that
tinnitus makes it difficult to hear, so
careful questioning is required to
avoid any ambiguity. Appropriate
management of any new hearing
loss, or change in an established
hearing loss, may help reduce the
child's tinnitus.
A history of otological disease (e.g.
chronic middle ear disease) or risk
factors for otological problems (e.g.
cleft palate) should be noted.
Tinnitus in children often occurs in
children with otitis media with effusion
(Mills 1984). The child may describe
'clicking' and 'popping' sounds and
have a history of resolving otitis
media with effusion. Tinnitus that is
suggestive of middle ear myoclonus
should be referred for a medical
opinion despite the difficulties in
treating this. Enquiring whether the
child has a history of rhinitis or
hayfever will identify whether there
may be a connection with a general
ENT condition.
Establishing whether there are any
vestibular symptoms can be difficult
in children. Parents of younger
children may be able to give more
general information about whether
they feel their child is particularly
unsteady. Older children will be able
to describe any feelings of dizziness
or unsteadiness and any link between
the occurrence of these and their
tinnitus should be noted.
Although the management of
hyperacusis is beyond the remit of
this guidance, it is important to
identify whether the child has any
intolerance to loud sounds and
respond to this appropriately.
5. Medical and neurological
history
Any history of trauma, both head and
noise trauma should be noted. A
child who has had a significant head
injury may well have had further
investigations performed, but should
nevertheless be referred to an ENT
surgeon or an Audiovestibular
Physician. With both younger and
older children, prolonged exposure to
loud sound should be enquired about
(for example, listening to loud music
through personal music players or at
social events). If tinnitus has
occurred after such exposure,
appropriate advice can be given
about hearing protection (Appendix
9).
A line of enquiry regarding a history
of previous severe illnesses will
reveal any aetiology related to the
use of ototoxic medications;
examples being: chemotherapy for
childhood cancers, or high dose
intravenous antibiotics for severe
infection.
Other general medical problems
might be relevant; for example,
migraine can be associated with
auditory sensitivity and tinnitus.
6. Factors affecting tinnitus
Some children and their parents have
already noticed things that make
tinnitus better or worse. Parents may
have noticed that their child’s tinnitus
is affected by illness, stress,
tiredness, or important life events, or
improves during school holidays.
Older children may describe times of
the day, or places or situations when
they notice their tinnitus is worse, (for
example at bedtime or the end of the
school day), or times and places
when they do not notice their tinnitus.
Tinnitus rarely exists in a vacuum –
other aspects of a child’s life will
affect their experience of tinnitus and
will inform the management plan.
Medical or care needs, social care
support, educational support, and
psychological support are relevant.
Any external stresses can be
carefully and delicately asked about
for example family issues, divorce,
bereavement, or problems at school
such as bullying.
Children with tinnitus often present for
help at a time of transition, for
example, moving to a new school,
exams, or times of change in family
dynamics. This information may not
be forthcoming initially, and some
children and families may open up
more or see the relevance of the
questions once a full explanation of
tinnitus and the links between anxiety
and stress have been given. It is
important to remain open to such
discussions throughout the
assessment.
A combination of tinnitus and hearing
loss has been associated with mental
health difficulties, substance abuse,
and school problems (Brunnberg
2008). Where there is concern that
significant psychological factors are
associated with the child or
12

teenagers tinnitus distress, it may in
some circumstances be appropriate
for some healthcare professionals
with appropriate training and
competence to sensitively enquire
about any alcohol or drug use.
Substance abuse can be indicative of
stress and other social and
psychological difficulties that may be
significant. Onward referral to a local
mental health service, such as
CAMHS, should be considered as the
child and parent may need help with
underlying psychological disorders.
7. Current coping strategies for
tinnitus
How the child and the parent have
managed the tinnitus so far can
provide helpful information regarding
tinnitus severity, impact and family
coping style. Children are often
remarkably resourceful at finding
ways to manage their tinnitus, for
example by avoiding silence, or
finding ways to distract themselves.
Information should also be sought
about how the parent has tried to
help their child, for example by
distracting the child, giving
painkillers, and involving the school.
This information is important for
planning tinnitus management where
poor or ineffective coping strategies
have failed.
Clinical examination
Otoscopy should be performed by
someone who is confident in
excluding the presence of external or
middle ear disease, occluding wax or
foreign bodies.
Audiological assessment
By involving the child in the history
taking, hopefully the child will be
feeling comfortable in the clinic prior
to starting any testing. The child may
have previously found audiometry
stressful due to their tinnitus and may
therefore be apprehensive about
further testing.
It is important to establish accurate
hearing thresholds, both air
conduction and bone conduction
where necessary. Age-appropriate
audiometry, ear-specific wherever
possible, following BSA
recommended procedures, should
be completed. Carrying out
audiometry when the tester is in the
room with the child is preferable to
sitting the child within the test booth
and having the tester outside. This
way the tester can observe the child
more closely throughout the test and
it is less daunting and 'clinical' for the
child. Children with tinnitus can find
audiometry testing particularly
difficult close to thresholds and at
frequencies around the tinnitus
sound.
Observing the child throughout the
test, looking for signs of anxiety such
as a change in breathing pattern,
fidgeting or repeated swallowing
allows the tester to offer reassurance
throughout.
Case example: Ellie, aged 16, had a
ringing tinnitus and was very worried
that she might have noise damage,
after PTA testing in an adult setting
revealed a 6 kHz dip binaurally. Re-
testing in a paediatric clinic, that was
familiar with assessing children with
paediatric tinnitus, identified this to
be an artefact. It was more likely that
Ellie could hear her tinnitus when
tested at this frequency.
The child should be allowed to carry
out the test in their own time. Pushing
the child and constant reminders to
listen can increase their anxiety,
making the test harder and their
responses more erratic. Some
children find that wearing the
headphones for audiometry makes
their tinnitus sounds more audible.
Letting them know that this is normal
can be reassuring and reduce
anxiety. The use of frequency
modulated tones (warble tones) for
testing is helpful if the tinnitus is a
steady tone and vice versa. It can be
helpful to encourage the child to tell
you if the test sounds are like their
tinnitus noises. For some children it
13

may be necessary to carry out sound
field testing, if wearing headphones
causes too much interference from
their tinnitus, in order to obtain a
more accurate idea of their binaural
hearing.
Tympanometry should always be
carried out, regardless of whether
any hearing loss is detected, as the
presence of middle ear effusion can
exacerbate the perception of tinnitus
with or without any associated
hearing loss. Using tympanometry to
look at eustachian tube function can
be useful in those children reporting
cracking/popping sensations.
Where a child has found audiometry
difficult and has given erratic
responses, measuring transient
otoacoustic emissions can be useful
in order to establish normal cochlear
function. In some cases it may be
necessary to carry out
electrophysiological testing to
confirm normal hearing thresholds.
It is not recommended to carry out
LDLs or any tinnitus matching tests.
There is no evidence for either the
diagnostic or therapeutic benefit of
these in children.
Specialist tests
In cases where there is a complex
medical history referral to an ENT
surgeon or Audiovestibular Physician
is necessary so that further specialist
neuro-otological tests or blood tests
can be considered. Imaging is
recommended if pulsatile tinnitus,
unilateral tinnitus, or asymmetrical
bone conduction is identified.
Serious pathologies, such as
vestibular schwannomas, or palatal
myoclonus have been identified in
young children. If imaging is
indicated an initial referral for a
medical assessment would be
recommended.
Red flags for onward referral
Throughout the history and
audiological assessment it is
important to be aware of signs or
symptoms that would require an
onward referral to another agency for
further management. Where a referral
is necessary this should be done in
conjunction with any tinnitus
management plan. Good links with
medical and mental health services
are necessary to ensure smooth care
pathways for these children.
Red flags supporting a referral for
medical assessment
•Ear discharge
•Persistent ear pain or headache
•Dizziness/vertigo
•Unilateral or pulsatile tinnitus
•Head injury
•Middle ear myoclonus
•Abnormal findings on otoscopy
•Progression of known hearing loss
•Identification of any unmanaged
hearing loss, conductive or
sensorineural
Red flags supporting a referral to
child mental health services
•Depression and significant anxiety
•Reports of self-harm or suicidal
thoughts
•Reluctance to attend school or
socialize with peers
•Reluctance to engage in normal
activities
•Significant family emotional issues,
e.g. bereavement
14

4
Management Strategies
Key points:
•A good explanation of tinnitus
forms the basis of all management
plans.
•Management uses a set of tools
rather than rules.
•Children with significant
psychological difficulties should be
referred on to an appropriate child
mental health service or child
psychology service.
•Advice and strategies need to be
provided to support the child at
school where tinnitus impacts the
child’s classroom performance.
Effective tinnitus management
strategies individualise care. No
single treatment protocol or care
pathway will fit the needs of all
children and their families and each
child will manage their tinnitus and
distress in their own individual way.
The level of distress the child
presents with does not equate
prescriptively to a particular strategy,
device or need for onward referral.
It is important to acknowledge any
anxieties or distress the parents may
experience, as this may need to be
addressed separately.
Effective management needs to
address the impact of tinnitus upon
the child’s health: their psychological
well-being, educational progress,
and any life stressors, both at home
and at school, that exacerbate
tinnitus distress. It is important for
healthcare professionals to identify
children in need of psychological
support, and to refer onwards to
appropriate services where
necessary.
It is recognised that, currently, each
paediatric tinnitus service will vary in
its make-up in terms of the
professionals involved, access to
devices, skill-sets and roles. The
following suggestions are not
intended as a prescriptive approach
to tinnitus management but rather as
a tool-kit to guide professionals in
developing appropriate management
plans for each child. This tool-kit
includes: explanation, advice and
information giving; tinnitus
management strategies; sound
enrichment including hearing aids;
psychological approaches; and
tinnitus management in the
classroom.
Explanation, advice and
information giving
Reassurance:
A thorough audiological and medical
assessment means that concerns of
child and parent can be answered by
reassurance that the child’s hearing
is normal, or hasn’t changed
(assuming this is the case), there are
no underlying medical causes for the
child’s tinnitus and that tinnitus will
not damage the child’s hearing.
Normalise tinnitus:
Children are generally surprised and
pleased to discover that lots of other
children hear noises in their ears and
they are not alone in experiencing it.
Develop a sense of control:
Suggestions can be given for simple
practical strategies, for example the
use of environmental sound, coping
thoughts, or strategies that can be
used in the classroom. However,
helping the child to come up with
their own strategies and solutions to
the difficulties they experience is
often more effective in giving them a
sense of control over their tinnitus.
This can include identifying times
when tinnitus is better or worse, and
helping the child develop a sense
that “there are things they can do
about it”.
Explaining tinnitus to young
children:
Very young children appreciate very
simple explanations that are within
their realm of experience and they
can relate to. For example, tinnitus
can be explained as the sound that
our ears sometimes make when they
are working, in the same way that a
tummy rumbles or the sound we
make when breathing. A fun
approach can be to ask the child
(and parent) to listen out for any
sounds that their bodies are making.
Once they have noticed for example,
the sound of their breathing, then one
can compare this to the sound that
ears sometimes make.
Explaining tinnitus to older
children and parents:
Older children are more likely to have
developed the linguistic and
cognitive skills to understand,
through explanation, the complex
relationship between tinnitus
symptoms and thoughts, emotions,
physiological reactions, and life
events. There are a number of
tinnitus models used for counselling
adult tinnitus patients but these are
generally too complex and ‘wordy’
even for older children and need to
be simplified and made child-friendly.
This can be done for example, by
replacing words used in models with
images of thoughts, worries or
feelings. Again, images must be
ones with which the child can identify
as being within their realm of
experience. If children can produce
their own images, this will be even
more meaningful to them and
increase feelings of ownership.
15

A"detailed"example"of"this"approach"
is"the"Child"Friendly"Tinnitus"Model"
(Emond"2013)"and"this"has"been"
found"to"be"helpful"in"explaining"
Bnnitus"distress"to"parents"also.
Tinnitus management strategies
Relaxation
There is no current evidence for the
use of relaxation in the management
of tinnitus in children. Published
studies relate specifically to
relaxation training in adults and
suggest there is little evidence of its
effectiveness as a stand-alone
approach. However, on the basis that
stress can exacerbate tinnitus,
relaxation is widely suggested as part
of a holistic approach to tinnitus
management for adults and is
consistently suggested by approved
sources promoting information on
current practices, e.g. the BTA:
Information & Publications. It is
reasonable to assume that the same
principle applies to children.
Lamontagne et al. report findings
which indicate “that relaxation may
be learned by children and may be
beneficial in coping with
stress” (Lamontagne 1985).
It is important to identify the causes
of worry or stress and the intervention
needed to reduce it. As part of this
relaxation can be one useful self-
management tool, reducing
physiological arousal in response to
stress, and promoting a sense of
calm and well-being.
Simple breathing exercises can be
carried out anywhere, and in a variety
of situations. There are a variety of
more formal techniques, including
diaphragm breathing; however
techniques need to be suitable for
the child’s age. Breathing exercises
change the rhythm and technique of
how we breathe, and it is important to
bear in mind certain potential
difficulties such as hyper-ventilation,
or any other medical conditions
which may give rise to problems and
may be contraindications for the use
of breathing exercises. Visualisation
techniques are also frequently used
to help children relax. These can be
either self-directed or guided
(Appendix 10).
It must be noted that in learning
relaxation techniques, progress
needs to be reviewed and supported
appropriately. Thus in delivering the
techniques, on-going guidance and
help must be provided to ensure that
relaxation techniques are carried out
in a way that offers maximum benefit
to the agreed management plan.
Mindfulness Techniques
Evidence for the effectiveness of
mindfulness techniques in the
management of tinnitus is still in its
infancy but pilot studies indicate
positive findings in treating chronic
tinnitus and its co-morbid symptoms
in adults (Gans 2014).
Mindfulness practice may therefore
prove useful for children in learning
how to manage stress and anxiety,
which may in turn relate to more
effective tinnitus management. It has
been introduced in some UK schools
and at the time of writing an evidence
base for its effectiveness is beginning
to emerge. (Kuyken 2013).
Mindfulness is also being introduced
in schools through the .b programme
for 11-18 year olds and Paws.b for
reception to year 6 children
(Appendix 10).
Sleep
Sleep difficulties are commonly
reported by children with tinnitus and
their parents. As a starting point, it is
important to find out what tinnitus
sounds the child hears, what they
think those sounds are, and any
worries that the child has about the
sounds.
Case example: Jack, aged 9, worried
a great deal, and this included fears
about people breaking into the house
at night. He said that his tinnitus
sometimes sounded like the stairs
creaking, and this made him feel very
scared and then he can’t get to
sleep.
Many children are helped by
introducing quiet, soothing
environmental sound to the bedroom
(e.g. fans or gentle music) Parents
should be encouraged to develop a
good bedtime routine for their child,
which includes avoiding mentally
stimulating activities before bedtime
such as TV or computer games.
Case example: Luke, aged 15,
watched TV in his bedroom to
distract from the tinnitus sounds at
night. He watched documentaries
about servicemen in Afghanistan and
was then unable to relax. Luke was
encouraged to use other sounds to
aid relaxation and to distract him from
his buzzing sounds.
16

Although the child’s sleep difficulties
may be ascribed to the tinnitus, other
explanations should be considered,
for example a more general sleeping
problem due to a poorly established
bedtime routine, or long standing
sleep onset anxiety – namely,
difficulty falling asleep due to
excessive fears and worries. Children
with more general sleep difficulties
may benefit from referral to a local
sleep clinic or other community
service via their GP.
Noise exposure and evasion
Within the framework of the PINCHE
project it was concluded that the
auditory effects of noise on children
can be long-term and cumulative
(PINCHE 2006). Subsequent hearing
loss or tinnitus experience should be
viewed from a life-course
perspective.
The use of hearing protection is not
routinely recommended apart from in
particular circumstances where noise
levels are unusually loud, such as a
concert. Protecting ears from such
loud sound levels needs a careful
approach, and as far as possible an
understanding of the individual’s
personal preferences. For example -
advising volume restricted
headphones for someone with a love
of loud music is unlikely to be
successful, but talking about filtered
ear plugs and their use by the music
industry may have more weight. It is
equally important that the child is
provided with a good explanation of
noise induced hearing impairment
where appropriate (Appendix 9).
Sound enrichment: hearing aids
and other devices
If a child with tinnitus is found to
have a hearing loss, hearing aids
should be considered as a first line
of treatment. The selection, fitting
and programming of a hearing aid in
a child should follow current
guidance (MCHS 2005).
Hearing aids
Currently there is no evidence to
support or refute the effectiveness of
hearing aid use for tinnitus
management across the paediatric
population.
Studies have looked at whether there
is a correlation between the level of
hearing impairment and impact of
tinnitus. Their conclusions suggest
that children with moderate sensori-
neural hearing loss tend to report
tinnitus more readily than those with
severe to profound loss (Coelho
2007).
It is generally deemed sensible to
offer hearing aids to children with
tinnitus where a loss is present. In
the adult population, it has been
suggested that a hearing aid device
helps to lessen tinnitus impact in a
number of ways, not least the
reduction in listening fatigue. Hearing
aids are used primarily to enable
improved listening, and often, as a
by-product to this function, tinnitus
perception is reduced and its impact
lessened. Hearing aid fitting may be
counterproductive in certain cases
due to ear canal occlusion by the
hearing aid mould (Gabriels 1996).
Access to open fitting technology
where appropriate may of course
minimise this concern.
Children with severe to profound
hearing loss and tinnitus may find
tinnitus more noticeable when they
take off their hearing aids at bed time
and environmental sound will be of
little use. Alternative strategies that
aim to normalise tinnitus and reduce
associated worry and distress are
required.
17

Case example: Matthew, aged 11,
has a severe bilateral loss. He is only
aware of tinnitus at bedtime when
trying to sleep. Matthew hears his
tinnitus and has worked on this noise
being the same noise a character in
his favourite console game makes.
He plans his next move in the game
and it helps him to sleep.
Devices
The principle of sound based-therapy
can include the use of everyday
devices. Sweetow and Sabes
describe wearable sound generators,
music, hearing aids, radio, TV, fans
and relaxing sounds as devices for
sound–based therapy (Sweetow
2010). The device should provide
sounds that can be incorporated into
the background sound environment.
Sounds if used, should be used at a
quiet level.
Sound enrichment is also often used
as a tool to aid relaxation and to
lessen anxiety. With adults, sounds
such as white noise, sea waves, rain
noise, wind sounds or pulse tones
are frequently used. Research is
needed to identify which sounds are
most meaningful and effective for use
with children. Sounds that are
soothing to children and evoke
pleasant associations are likely to be
both age dependent and personal.
There are many ways to access
environmental sounds, such as soft
music and the nature sounds such as
those mentioned above. Many
children will have access to such
sounds in downloadable formats.
Apps on tablets such as relaxation
melodies or the material produced by
companies such as
www.relaxkids.com can be
downloaded and also played in CD
format.
Wearable sound generators
There is no research on wearable
sound generators as a stand-alone
treatment for tinnitus in children. A
2012 study reports significant
improvement using sound generators
as part of Tinnitus Retraining Therapy
for children (Bartnik 2012). However,
we know little from the study about
the counselling input and other
strategies used alongside the
devices, or its benefits compared to
other treatment strategies for
children. Further research is required
to determine whether there are
specific child populations likely to
benefit from wearable sound
generators, for example children with
complex special needs, ASD, limited
language and communication skills.
Sound generators may prove helpful
for children who like to use sound
therapy for their tinnitus but are in a
situation where they are unable to
use environmental sound or music
players.
Case example: Mia, aged 16, was
about to sit a 3 hour art exam at
school in silence. Using sound
generators at this time helped her to
focus on the exam and allowed her to
be with other classmates whilst sitting
it.
Psychological approaches to
tinnitus
There is often a complex relationship
between tinnitus, emotional well-
being, stress and the context of the
child’s life. It seems clear that worries
and anxiety about the tinnitus result in
increased awareness (Halford 1991).
Psychological disorders such as
anxiety and depression may arise
from tinnitus but equally they may
also reflect other stressful events in
the child’s life, yet be attributed to the
tinnitus by the child (i.e. “if only my
tinnitus went away, then everything
would be better”). Parents and the
child can be helped to understand
that other difficulties in the child’s life
may co-exist with, or exacerbate,
tinnitus distress.
Treatment for psychological disorder
needs to be provided by a trained
mental health practitioner, and
services such as CAMHS (Child and
Adolescent Mental Health Service
Tier 3), local Child Psychology
Service or other similar local services
may be the appropriate place to
provide psychological support. Early
identification and treatment of
psychological difficulties are
essential (Appendices 5 and 6).
For treating the co-morbid
psychological symptoms associated
with tinnitus distress there are a
number of widely used psychological
therapies, such as CBT and Narrative
Therapy. Their effectiveness in
alleviating tinnitus distress in children
has not been evaluated and they can
only be provided by staff with
relevant training in these therapeutic
techniques.
Cognitive Behavioural Therapy
There is support for CBT techniques
for tinnitus management in the
literature (Martinez-Devesa 2010).
There is accumulating evidence
indicating that CBT techniques result
in clinically significant improvements
in children with anxiety although its
efficacy compared to other active
interventions with very young children
has yet to be consistently determined
(Stallard 2009). Little is known about
the effectiveness of CBT with children
under 7 years of age and the younger
the child the greater the focus upon
behavioural aspects (Stallard 2002)
Older children are more able to work
with cognitions.
18

Case example: Max, aged 14, was
not attending school on a regular
basis and was very anxious about his
hissing tinnitus. He did not sleep well
because of the anxiety and had
begun to miss days of school at a
time and to sleep through the day. He
went out with friends at night. CBT
techniques were used to help reduce
his anxiety and objectify his reasons
for non-attendance in school which
helped him and his parents manage
the situation more effectively.
Narrative Therapy
Narrative therapy refers to techniques
developed largely by Michael White
and his colleagues, and is used with
people of all ages. The word narrative
in the context of therapy means
listening to others’ stories. Over time,
individuals develop narratives or
stories about themselves that help
make sense of their lives and what
happens to them. These ‘stories’ in
turn have the effect of filtering future
experiences, selecting what
information gets focused in or
focused out. Information is selected
because it confirms existing beliefs,
leading to dominant stories, for
example that “tinnitus stops me
getting to sleep”. Narrative therapy
aims to help the child bring to mind
other stories, for example, of a time
when the child got to sleep, even
though they had tinnitus.
Externalisation is a key component of
narrative therapy. A problem is often
seen as integral to the person, and a
part of the person’s existence, and
hence there is a perception that
nothing that can be done to change
it. Externalisation techniques are
used to reverse this belief and to
separate the person from the
problem by putting it “outside the
person” for example by drawing it or
by giving it (the problem) a name.
Once the problem (i.e. tinnitus) is
separated from the child, one can
then begin the process of
constructing new stories about the
way the child can respond to it
differently.
There is no research to date
demonstrating the effectiveness of
narrative therapy for children with
tinnitus. Nevertheless it is well suited
for use particularly with young
children because its techniques can
be playful, imaginative and fun, and
utilise storytelling, with which children
are very familiar. A more detailed
description of the use of narrative
therapy for children with tinnitus is
available (Kentish 2006; Kentish
2014).
Case example: Cara aged 5 called
her tinnitus “wiggly worm” and said
that it had got into her head through
her ears and was banging on it with a
stick, making a noise. It stopped her
getting to sleep, and she was very
frightened of it. Cara wanted help to
be brave and tell “wiggly worm” to be
quiet when she was trying to get to
sleep. She drew another picture of
“brave Cara” who stroked the wiggly
worm, told him to be quiet and go to
sleep. This brought forward a new
story in which Cara could feel brave
and in charge, rather than helpless.
19

Tinnitus management in the
classroom
There are no standard management
strategies for tinnitus within the
classroom, or during social
interaction at school. A pragmatic
and personalised approach is
therefore needed. It is helpful for
schools and colleges, as well as
students who have tinnitus, to have
access to written information about
management of tinnitus; what it is and
how it can impact on learning in the
classroom. In particular, advice
regarding exam techniques and
silence management can provide
teaching staff with enough
information to help individual
children.
Tinnitus can impact on the functional
listening abilities of children in the
classroom, and therefore on
educational progress. For teachers
and support staff the impact of
tinnitus in class may be observed as
an unexplained change in level of
attention, reduced learning focus,
and student frustration.
Compromised speech perception
may be described in the presence of
background noise and in quiet
listening situations. When intrusive
tinnitus is present, listening,
concentrating, and learning is likely
to be tiring and effortful for the child,
and this may well impact upon their
psychological well-being as well as
their educational progress.
Comments about experiencing
tinnitus in class
•‘I ‘catch words’ but I can’t
understand them. It’s not like that
when my tinnitus isn’t there’.
•‘Competing signals (tinnitus vs.
speech) are confusing and it’s all
muddled so I make mistakes’.
•‘It’s like I’m disconnected from
what’s going on in class’.
•‘I try hard but all I can do is focus
on my tinnitus’.
•‘I feel stressed and unhappy’.
Assessing tinnitus in the
classroom
Exploration of everyday listening
difficulties, in a range of classroom
learning scenarios, is essential (see
appendix 4 for recommended
assessment measures). The
assessment can also include a VAS
for listening effort (from ‘no effort/ not
tiring’ to ‘lots of effort / very tiring’), a
detailed exploration of classroom
listening geography, personal
learning style and levels of academic
confidence.
Tinnitus may also be identified during
investigations and assessment for
other difficulties.
Case example: Matthew, aged 9, had
a mild left sided conductive
fluctuating hearing loss and was
assessed by a teacher of the deaf for
functional listening difficulties,
assumed to be hearing loss related.
Using drawings of his classroom and
a LIFE questionnaire he commented
that ‘when my friend chats and it’s
noisy I can’t hear my teacher’s
words’. Matthew didn’t enjoy some
parts of the school day as he couldn’t
hear as well. He also said he heard a
‘train like noise followed by a ringing
sound’, and this occurred when his
functional listening should have been
good i.e in a quiet environment.
In silent reading he felt ‘overwhelmed’
by his tinnitus, and he found
concentration difficult. During
spelling tests his tinnitus often
masked his teacher’s voice, and he
made mistakes as a result of
mishearing.
Simple information about tinnitus was
provided. We looked at the times he
had difficulty in class linked to his
hearing loss, and times when tinnitus
alone impacted on his functional
listening skills. Action points were
devised.
Action Plan: Discussion points for a
meeting with the SENCO, Matthew
and his mother:
•Matthew wanted to tell his teacher
about his tinnitus himself
•He wanted to design his own
tinnitus ‘alert card’ for use in class
•We considered that a different
room be used for quiet reading
along with a small group who had
teacher/TA supervision
•His choice for dealing with spelling
tests was for his teacher to look at
him to make sure he had ‘heard’
the word; to time presentation so
he looks before she speaks
Classroom based strategies
A pragmatic and personalised
approach is suggested, for each
individual case. Advice assumes that
teachers have been well informed
about tinnitus, and that the child’s
self-help strategies and teacher led
management have been agreed
formally with the school.
20

Key points for discussion with
student and school team
•Tinnitus impact to be assessed and
summarised into key areas of
concern.
•Keep things simple, manageable
and achievable.
•Together with the student, work out
what strategies will help – linked to
their key difficulties.
•Communication with the SENCO
through direct approach and face
to face discussion. It is very
important that students are
encouraged to talk to a trusted
teacher / SENCO about their
tinnitus.
Planning
An action plan for when tinnitus
impacts on functional listening and
causes some level of distress, may
include:
•Time away from the classroom so
the student can ‘rest’ quietly for a
few minutes.
•Use of environmental sound (e.g.
fan, low level music through iPod /
computer).
•Use of other techniques (such as
relaxation) that the student has
been taught.
•Change in the seating plan in class
if tinnitus is triggered by particular
loud environmental sound, or
people’s noise.
•Avoidance of trigger situations
when practical e.g. quiet library
time .
•Student self-help skills: Ask a
friend; ask the teacher for help.
Professional support and
management
Where a child with tinnitus is already
known to have special educational
needs it is important to liaise with
relevant professionals, especially the
school SENCO. Additional
information and targets can be
included in the child’s IEP, and
methodology of input, such as
teacher assistant support (TA),
reviewed. If the child has a statement
of Special Educational Needs,
information about tinnitus and its
management can be included at the
annual statement review.
For a student not already known to
the SENCO, and where tinnitus
requires management in school, the
SENCO needs to be informed. This
facilitates whole school awareness
and training, if required. IEP targets
may need to be devised and
management changes put in place.
School counselling services can be
considered where emotional distress
or anxiety are part of the child’s
profile. Access to projects such as
‘.b’ - a mindfulness in school project -
may be a positive way forward
(Kuyken 2013).
Teacher of the Deaf / Sensory
Support Service
If a school has a specialist teacher of
the deaf already visiting, or can
request the services of a local team
in an advisory role, it is suggested
that contact is made with the team.
Initially this may be for assessment
and advice around hearing and
listening function, when the child’s
tinnitus is as yet unknown, but school
have concerns about the child’s
performance and auditory access.
Where tinnitus has recently been
identified then referral to the local
Teacher of the Deaf team would be
indicated to provide advice and
training.
Additional information
When tinnitus impacts upon a
student’s performance during
external formal examinations, advice
and support can be requested from
the SENCO regarding access
arrangements or reasonable
adjustments. Recommendations for
internal school examinations, where
the quiet environment combined with
tinnitus causes difficulty, may include
use of a separate room, and
introduction of an additional low level
sound source (such as a fan).
21

5
Development of a Paediatric Tinnitus Service
The findings of the surveys outlined in
Appendix 1 suggest that many
healthcare professionals in the UK
are not confident in their
management of children with tinnitus.
NHS services already face a wide
range of demands upon their hard
pressed resources. These two factors
have been taken into account, as well
as national frameworks and other
relevant guidelines, when making our
recommendations for future
organisation of tinnitus services for
children. Our recommendations are:
•Children should be seen in
appropriate paediatric settings and
not in adult settings. This will
inevitably create difficulties for
centres with established tinnitus
services for adults wishing to
extend this to children.
Nevertheless, this recommendation
is in line with national guidelines
(NDCS 2000; NSFC 2003; DoH
2008)
•Given the variety of professions
involved in paediatric audiology,
we do not recommend specific job
titles or professions, but rather that
there is a skill set that needs to be
fulfilled. It is highly likely that to
cover all the skills a variety of
professionals will be involved.
Access to psychological services is
necessary, so referral routes for the
service must be identified.
•Healthcare professionals should
have, or will need to acquire, the
essential skills and knowledge that
enables them to work with children.
These include knowledge of
policies and legislation relevant to
children, local and national
protocols for audiological and
medical assessment and skills in
listening and communicating with
children, including children with
disability. They also need to be
able to work with families and liaise
with local education support
services.
•Paediatric tinnitus services may
attract vulnerable children where
safeguarding issues are
particularly relevant. This must be
appreciated and processes put
into place to ensure that all staff
have the appropriate level of
training for local safe guarding
procedures.
•Skills for the management of
children with mild to moderate
tinnitus distress should be available
within most paediatric audiology
services and community paediatric
services. Children in this category
will benefit from assessment and
information counselling, which can
be provided by a number of
different professionals. Many
paediatric audiology services will
already have the skill set and
facilities to see these children
without making significant changes
to the clinical structure or
resources.
•Ideally, multidisciplinary, regional
centres of excellence, where there
are specialist skills in paediatric
tinnitus management, will be
available for children with severe
distress and/or complex
presentations of tinnitus. The exact
members and roles of this team will
vary (DoH 2009).
2222

Appendix 1
Service Provision
There is no published information
about the current services available
in the UK for children with tinnitus. In
2009, a survey of British Society of
Audiology (BSA) members was
conducted of working practices of
managing children with tinnitus.
There were 94 respondents to the
survey which included audiologists,
audiovestibular physicians,
audiological scientists, paediatricians
in audiology, hearing therapists, a
teacher of the deaf, and a
psychologist.
Most respondents felt that tinnitus
was very rarely mentioned
spontaneously as a problem. Only
6% routinely asked children in clinic if
they had tinnitus. Around one third
(36.7%) usually asked, or did so on
special occasions. Approximately
half (55%) never or rarely asked.
Factors influencing their decision
included the child’s age and
communication level, whether tinnitus
was the presenting symptom, and the
nature of other audiovestibular
symptoms.
Under half (41%) of respondents
routinely or sometimes investigated a
child with tinnitus, 30% did not
investigate, while 15% said that they
would like to do so. Whether
investigations were carried out
depended on the severity of the
tinnitus and the presence of other
symptoms and findings.
Investigations offered were those
recommended by the adult tinnitus
care pathway and considered if, for
example, there is sensorineural
hearing loss, a family history of
hearing loss, developmental delay, or
asymmetric hearing loss were
present. Investigations included
standard hearing tests/
tympanometry, acoustic reflexes,
OAE’s and, if indicated, ABR or MRI.
On the other hand, several
respondents said that the
investigations were not considered as
there is no clear care pathway for
children.
The use of hearing aids, and
counselling were the most common
management strategies. Sound
generators were used by a third of
respondents. Voluntary bodies,
websites and leaflets were
recommended by around half,
although many commented that there
was little or nothing suitable for
younger children.
A few respondents felt tinnitus was
not a sufficient problem to warrant
treatment, or a paediatric service.
Most however felt that managing
tinnitus in a child was beyond their
scope of practice. Around three
quarters were unhappy with their
current level of knowledge and
management skills, felt they needed
further training, and expressed a
desire for a standardised approach,
guidelines for referral, age
appropriate counselling strategies,
and tinnitus information geared
towards children. Many respondents
felt that they did not have suitable
networks currently in place or access
to a specialist interested in paediatric
tinnitus.
A small scale survey in 2012 by the
BTA* of paediatric tinnitus service
provision found that currently the vast
majority of paediatric tinnitus services
are located in paediatric audiology
departments, and a small number
located in hearing therapy, ENT,
AVM, and adult audiology
departments. Respondents
expressed a wish for advice on
performing a good paediatric and
audiology assessment, a specific
assessment to rule out neurological
or ENT causes of tinnitus and
successful management strategies
including age appropriate
explanations to parents and age-
appropriate information for children.
_________________________________
*Survey by the BTA on service provision
for children with tinnitus was sent to past
delegates of the UCL Tinnitus and
Hyperacusis Masterclass and to
members of BAAP, BAPA and the BSA’s
Paediatric Audiology Special Interest
group. There were 35 respondents.
23

Appendix 2
Evidence Base
Prevalence of tinnitus
Studies looking at tinnitus in children
have a number of methodological
difficulties, including the wide age
range of the children; the child’s
linguistic ability to describe tinnitus;
reliance upon parental report; and
definition of tinnitus. Taking this into
account, research suggests that
tinnitus is a relatively common
experience in children, and in terms
of prevalence, is on a par with the
adult population. Reported
prevalence figures vary from 12% to
36% in children with normal hearing
(Sheyte 2010) and is more common
in children with hearing loss
compared to those with normal
hearing (Graham 1987; Viani 1989;
Stouffer 1991; Brunnberg 2008; Raj-
Koziak 2011). A comprehensive, and
recent review of the prevalence and
incidence of tinnitus in children, can
be found in the following recent
chapter: ‘Tinnitus and Hyperacusis in
Childhood and Adolescence’ In
‘Tinnitus – a multidisciplinary
approach’ (Baguley 2013c). The
prevalence of tinnitus in children with
cochlear implantation has yet to be
conclusively determined. However,
one study suggests it may be
prevalent in this population also
(Chadha 2009). Of the 40 children,
aged 3 -15 years in this study, 38%
reported tinnitus, most commonly in
the implanted ear and when the
implants were not in use. Tinnitus was
most common in implantees with an
inter–procedure delay of at least two
years. The children were generally
untroubled by it although two
reported difficulties sleeping.
In a recent study (Juul 2012) of 706
children, 41% of children with normal
hearing reported some experience of
tinnitus and 58% of the children with
hearing loss reported tinnitus
sensations, either noise induced or
spontaneous. Increased exposure to
loud noise can be considered to be
one worrying cause for this.
Incidence of tinnitus in children
There is very little research relating to
the incidence of tinnitus In a recent
publication, Baguley et al. conducted
a retrospective case review of
patients under 18, referred to four
international specialist centres in
2009 with a primary complaint of
tinnitus (Baguley 2013b). In total, 88
children were referred, which
represented 3.8% of the paediatric
clinical workload in that year. Of
those referred, 93% were aged 10
years or older. In 18%, tinnitus
classified as severe. Tinnitus was
accompanied by hyperacusis in 39%.
The authors suggest that
epidemiological data for the
prevalence of childhood tinnitus
should be interpreted with caution as
it is dissonant with the data
presented in their study. However, it
is also likely that, as with adults, most
children with tinnitus self manage
and/or are not referred for treatment.
Co-morbidity
Tinnitus commonly occurs with
hyperacusis. Baguley (2013) found
nearly 40% of children with tinnitus
had associated hyperacusis. Coehlo
found the presence of hyperacusis to
be the highest risk factor for tinnitus
suffering, however the presence of
tinnitus was not found to be a risk
factor for hyperacusis (Coehlo
2007b). Tinnitus has also been
associated with otitis media (Mills
1984; Ben-David 1995). Associated
reported physical health symptoms
include headache dizziness and
vertigo (Aust 2002; Aksoy 2007; Kim
2012). It has been associated with
juvenile Meniere’s disease, and with
vestibular schwannoma, particularly
in relation to neurofibromatosis type 2
(Evans 2009). Exposure to noise has
been identified as a risk factor in
studies by both Holgers (Holgers
2005) and Coehlo (Coehlo 2007a).
Psychological factors and tinnitus
in children
Research is very limited, but
suggests a similar pattern to adults,
with rates of anxiety and depression
in a child with troublesome tinnitus
being higher than in the general
population. Predisposing factors for
tinnitus severity include hearing loss,
anxiety and depressive disorders
(Holgers 2006). A combination of
tinnitus and hearing loss has been
reported to increase the risk for
mental health symptoms, substance
use and school problems (Brunnberg
2008) In a study of 10 -12 year olds
with tinnitus, Kim et al. conclude that
tinnitus in children had a
considerable influence on their levels
of stress and anxiety (Kim 2012).
Tinnitus treatment in children
To date, only one study has directly
looked at treatment outcomes for
children with tinnitus (Bartnik 2012).
Given the lack of an evidence base,
there is an urgent need for further
research in this area to help clinicians
determine the most effective
treatment strategies for children with
tinnitus.
24

Pain and anxiety in children
Tinnitus is considered to be similar to
pain in a number of ways (Moller
2000). Both result from an interplay
between biological, psychological
and social factors. Both are
subjective experiences and with a
strong component in the form of
accompanying disorders such as
anxiety, depression and sleep
disorders. Neuroplastic changes
have been shown to be important for
the development and maintenance of
both pain and tinnitus suffering
(Weise 2013).
Pain is a relatively common childhood
experience, and impacts all aspects
of a child’s life. The prevalence of
chronic pain in children is estimated
to range from 15% to 30% with
headache and abdominal pain being
the commonest recurrent pain
problems (Huguet 2008). Currently,
paediatric chronic pain is theorised to
be an interplay between the physical
experience, emotional reactions and
cognitions (Mahrer 2012). Parental
behaviours have been shown to
influence the child’s adaptation to
pain, with parental solicitousness and
parental discouragement associated
with increased disability. In a
systematic review of randomised
controlled trials of psychological
therapy for chronic pain in children
and adolescents, Eccleston et al.
concluded that there is strong
evidence that psychological
treatments, principally relaxation and
Cognitive Behaviour Therapy (CBT),
are highly effective in reducing the
severity and frequency of chronic
pain in children and adolescents
(Eccleston 2002). In view of this,
relaxation and CBT could be
considered as promising treatments
for children and adolescents with
severe tinnitus, and this is an
important area to be researched.
25

Appendix 3
Child-Friendly Interview Techniques
We recommend that children with
tinnitus are assessed and managed
within a paediatric service.
Healthcare professionals who work
within paediatrics are familiar with the
skills required to obtain information
from children and families and also in
family friendly ways of delivering
information.
Learning to listen to a child’s point of
view takes time, but can be a time-
saver in the long run as it will
inevitably help the intervention to be
more effective. However in a time-
limited appointment, skill is needed to
manage the conversation well so that
it remains open enough for a child’s
point of view to come out, and
narrowed enough to hone in on the
specific information needed. Parents
and children in audiology clinics want
access to clear unbiased information
given in a respectful manner, and
don’t want professionals who provide
quick answers to complex questions.
(Spencer 2000). To aid those
professionals not used to working
with families or those with limited
experience, the following key points
can help to make the appointments
child and family friendly.
Environment
We are often limited by the
appearance of the rooms in which
clinics are held, but a simple
rearrangement of the furniture can
make a room appear less formal. It
helps to keep medical and
audiological equipment out of sight
as far as possible. The healthcare
professional should position
themselves and the child at relatively
equal eye level to diminish an
authoritative image. Sitting on low
chairs around a small table rather
than at a desk is less intimidating
and clinical. Having a variety of toys
or activities available that can serve
as rapport-builders or props for the
assessment session also makes the
environment child-friendly. Access to
drawing materials or story boards
(e.g.’ My World’ Paediatric
Counselling Tool from http://
idainstitute.com/tool_room/
pediatric_audiology/ ) can provide
prompts to help a child describe their
symptoms and difficulties.
Time
Giving the child a few minutes at the
beginning of the appointment often
enables them to adjust and feel
comfortable in their surroundings,
enabling communication to happen
more effectively. Allow the child to
explore the room and give them
some simple choices such as where
to sit or what to play with initially. Get
an idea from the child about why they
think they are there, and make a plan
together with the parents as to what
everyone wants to accomplish in the
appointment time.
Communication
Quality communication is unlikely to
happen without taking the time to
establish trust initially. Allowing the
child to honestly share their feelings
and thoughts about their tinnitus
experience is important. Asking open
questions allows the child to express
what is most important to them. As
children present with tinnitus at a
variety of ages, it is important to use
age-appropriate vocabulary and
language.
26

Appendix 4
Key Elements of the Clinical Assessment
History:
•Child’s description of noises or
sounds heard
•Tinnitus characteristics (e.g. onset,
location)
•Annoyance / distress
•Impact (e.g. health, home, school)
•Family history (e.g. tinnitus, hearing
loss)
•Otological (e.g. hearing loss,
dizziness, vertigo, hyperacusis, ear
infections)
•Medical history (e.g. meningitis,
head injury)
•Neurological (e.g. headache, facial
nerve palsy)
•Noise exposure
•Drugs (e.g. chemotherapy,
antibiotics, all other medications)
•Social / psychological (e.g. school
performance, bullying, family
break-up etc)
•Mental health (e.g. depression,
anxiety)
•Current coping strategies
Clinical tests:
•Otoscopy
•Audiometry
•Tympanometry
27

Appendix 5
Signs of Tinnitus Distress
•Reluctance to talk about tinnitus
•Seems scared, poor eye contact
especially during audiological
testing
•Moody, outbursts of temper,
difficulty sleeping
• Description of tinnitus as
personified: “alive” “monsters”
“have to fight it”
•Tinnitus occurs in specific
circumstances e.g. home vs.
school
•Triggers (e.g. quiet, noise, stress,
emotionally charged situations -
people shouting, being told off by
teacher, particular lessons)
•Seems helpless in ability to
manage tinnitus
•Unable to describe successful
coping strategies
•Onset of tinnitus linked to
significant life event
•Complains about an uncomfortable
“something” in the ear
•Strong dislike of sounds or distrusts
sounds in one or both ears
28

Appendix 6
Psychological Associations with Tinnitus
There is often a complex relationship
between tinnitus, emotional well-
being, stress, and the context of the
child’s life. Psychological disorders
such as anxiety and depression may
arise from tinnitus but equally they
may also reflect other stressful events
in the child’s life and exacerbate
tinnitus distress. Research suggests
that the prevalence of anxiety and
depression is higher in children with
tinnitus. It is important to be able to
recognise significant psychological
distress and refer onwards to a child
mental health service.
Anxiety disorders
Worries in children are common and
a normal part of child development.
The three most common areas of
worry relate to school, health, and
personal harm (Silverman 1995)
Children with anxiety disorders tend
to have more intense, excessive and
persistent worries. There are a
number of different types of anxiety
disorders, but these share in
common a perception of threat that
generates anxiety. Children with
distressing tinnitus frequently
experience tinnitus as a threat to their
well-being and hence it is anxiety
provoking.
In the general population, anxiety
disorders are among the most
prevalent disorders in children and
adolescents. Diagnosable anxiety
will affect up to one in ten children
during childhood and adolescence
(Davis 2011). It often goes
undetected and untreated, and can
cause significant impairment in
social, academic and familial
functioning.
Childhood anxiety disorder frequently
persists into early adulthood.
Warning signs of anxiety include child
descriptions of:
•Breathlessness or breathing fast,
butterflies in tummy, “jelly legs”,
panic attacks
•Tingling sensations, heart beating
fast, dry mouth
•Dizziness, feeling sick, increased
need to go to toilet,
•Intense, worried thoughts about
present or future events
Depression
It has been estimated that 1 in 33
children and 1 in 8 adolescents are
suffering from depression at any one
time. Depression often occurs with
other mental disorders, including
anxiety. Recognising depression in
children can be more difficult
because the way symptoms are
expressed varies with the
developmental age of the individual.
Children who experience loss, high
levels of stress, learning disorders or
conduct disorders are at higher risk
for depression. Younger boys and
girls are at equal risk, but during
adolescence, girls are twice as likely
to develop depression (NICE 2005).
Signs of depression include:
•Unhappy, tearful, may show
troublesome behaviour, low mood
•Headaches, tiredness or vague
physical complaints with no
obvious cause
•Sleeping badly or waking early
•Irritability, quiet or introverted
•Lack of self- worth, feeling
hopeless
29

Appendix 7
Assessment Measures
It is well documented in both the
adult and paediatric literatures that
information provided by proxy
respondents is not equivalent to that
reported by the patient (Varni 2007).
Parental responses can be
complicated by unresolved concerns
and distress over their child’s health
and well-being, thus influencing their
perceptions of their child’s health and
well-being. Whilst parental
information is important, it cannot be
substituted for child reports.
Baseline Tinnitus Questionnaires
There are currently no standardised
tinnitus questionnaires for use with
children and there is an urgent need
for one to be developed.
These are a number of widely used
measures within the adult tinnitus
population, but they are not
standardised for use in children. If
adult questionnaires are used with
older children and teenagers, they
can be helpful for the gathering of
qualitative information, but should be
used with great caution. They cannot
be formally scored. Where
appropriate, a questionnaire can be
to read to the child, ensuring that
questions and vocabulary are
understood. Whilst descriptive
measures such as the Likert and VAS
are subjective, they can be a useful
measure of a child’s distress. This
also provides the opportunity to talk
in more detail about the child’s
answers.
Likert Scale
This is a three, five or seven point
scale which allows the individual to
express how much they agree or
disagree with a particular statement.
It has the advantage of being easily
understood and quantifiable, and is a
quick and efficient means of
gathering information. A child’s ability
to complete a Likert scale will
depend upon their age, cognitive and
reading ability. Younger children tend
to use the extremes of any Likert
scale which means that if used to
measure tinnitus severity, distress or
impact, young children’s responses
should be treated with a degree of
caution. (Chambers 2002). Even
school age children, can find it
difficult to acknowledge they can
experience multiple feelings at the
same time, for example feeling both
happy and sad about different things,
and a more complex evaluation of
feelings does not fully develop until
around 12 years of age.
There is some research to suggest
that children prefer the Likert Scale
over the numeric and simple VAS and
find it easier to complete (Van
Laerhoven 2004).
Visual analogue scales
This is a similar, but more visual form
of rating, with the advantage that it
does not force children into fixed
categories as does the Likert. The
minimum age at which children are
able to complete VAS is debated,
with some claiming it can be reliably
used by children as young as 5
years. Others argue that children
below the age of 7 may not have the
conceptual ability to complete a VAS
reliably (Van Laerhoven 2004).
Cognitive ability, combined with
chronological age are the best
predictors of a child’s accurate use of
a VAS. Again, younger children have
been found to have a position bias
when using VAS, tending to choose
the first answer among response
options (Pantell 1987).
Psychological well-being
Questionnaires can be used to
screen for associated psychological
difficulties. Their use can sometimes
facilitate referral to child mental
health services, when necessary.
There is very little comparative data
between the available questionnaires.
Paediatric Index of Emotional
Distress Questionnaire (PI-ED)
(O’Connor 2010)
This is a paediatric version of HADS
(Hospital Anxiety and Depression
Scale). It has UK Standardisation. A
reading age of 7 year is required. The
PI-ED screens 8 –16 year olds for
symptoms of emotional distress and
somatic symptoms of distress. It may
be useful for research or as an index
of clinical change in emotional
distress associated with tinnitus.
Strengths and Difficulties
Questionnaire (SDQ)
(Goodman 1991)
This is a widely used screening
questionnaire for use with 3 -16 year
30

olds. There are separate scales for
parent and teacher rating of 4-16
year olds, and a self- rating scale for
11-16 year olds. The questionnaire
covers emotional symptoms, conduct
problems, hyperactivity/inattention,
peer relationship problems, prosocial
behaviour.
A follow up version can be used to
measure change. It is freely
downloadable from the internet at
www.sdqinfo.org
Revised Children’s Anxiety and
Depression Scale (RCADS)
(Chorpita 1998)
This is a well standardised
questionnaire for 6-17 years. It is a
47 item self–report. There is a
separate parent version - RCADS-P.
The RCADS has 6 subscales
covering: separation anxiety disorder
(SAD), social phobia (SP),
generalised anxiety disorder (GAD),
panic disorder (PD), obsessive
compulsive disorder (OCD), and
major depressive disorder (MDD). It
yields a Total Anxiety Scale (sum of
five anxiety scales) and a Total
Internalising Scale (sum of all 6
scales). Items are rated on a 4 point
scale. It is downloadable from the
internet (www.childfirst.ucla.edu) and
includes an automated scoring. It is
available in a number of different
languages, although norms are
currently based upon English (US).
Questionnaires for educational
assessmentThe CHAPS, LIFE-R
and SIFTER questionnaires can be
accessed freely from: http://
successforkidswithhearingloss.co
m
CHAPS
The Children’s Auditory Performance
Questionnaire evaluates listening,
comprehension, memory and
attention in different listening
conditions. It helps to identify
children who are at risk and need
additional support related to auditory
performance.The questionnaire is
completed by a teacher, and does
not ask students about their
experience of functional listening and
factors that may be impacting on the
quality of the experience. However
the questionnaire may provide
information that can be used to guide
a discussion with the student to
establish factors influencing their
learning and listening profile, and
whether tinnitus is part of this.
LIFE
The Listening Inventory For Education
Efficacy Tool Package is intended
mainly for use with children with
hearing loss. There are separate
student and teacher sections. The
Student section includes preliminary
questions, 15 listening scenarios, and
a measure of self- advocacy. The
Teacher section includes pre- and
post- questions and measure of self-
advocacy of students. It has been
adapted to UK context with LIFE –
UK, and LIFE-UK IHP (Canning
1998).
Student section: Compromised
speech perception is often described
in background noise and in quiet
listening conditions (separate
questions in the LIFE questionnaire).
In the case of a student experiencing
speech perception difficulties
associated with hearing loss, the
question relating to listening in
background noise will be the more
challenging situation in school.
Where a student indicates difficulty in
quiet situations as well, it is important
that this is explored carefully as a
possible indicator of tinnitus
impacting on listening ability.
As tinnitus can be triggered by
increased noise levels, a student with
hearing loss may describe both
difficulties – hearing difficulty in noise
and intrusive tinnitus that extends on
into school situations where
background noise levels have
become much quieter. Spending time
exploring the sequence of events and
how each factor may be at play
provides important information
regarding tinnitus impact, and its
future management (Canning1998).
SIFTER
Screening Instrument For Targeting
Educational Risk. This is designed to
screen children with a hearing loss
who may be experiencing
educational difficulties as a result of
their hearing-impairment. It covers
five content areas: Academics,
Attention, Communication, Class
Participation and School Behaviour.
The questionnaire is completed by a
teacher, who compares the student
to hearing peers. It does not ask
students about their own classroom
learning experience. However the
information can be explored further
with teachers / staff working with the
student to gain a fuller understanding
of the student’s classroom
performance, and whether tinnitus is
a factor in reduced academic skills.
My World Tool, Ida Institute
This is a set of moveable boards and
figures to represent various listening
situations and allows the child to
qualitatively indicate how they are
managing within the school
environment.
31

Appendix 8
Tinnitus in the Classroom - Information Booklet
The following can be used as the
basis for a personalised workbook
and guide. As a resource, it includes
an explanation about tinnitus and
examples of how tinnitus can impact
in the classroom.
This booklet can also be a resource
for teachers and support staff. It can
be part of an educational approach
with a student, to assess their
experience of tinnitus, and develop a
management plan with them. This
may be included in the child’s
Educational Health and Care Plan.
_________________________________
Tinnitus is a noise heard in your ears
and /or in your head. This noise is
described in many ways. Sometimes
our brains focus on this internal
sound, and it can be annoying, or
make listening to people speaking
quite difficult. Lots of children,
teenagers and adults experience
tinnitus and it’s only a problem if it
affects how you hear, how you sleep,
or if it makes you feel worried.
Tinnitus may affect you in school
when you are trying to listen to your
teacher, or to your friends. Everyone
is different – your tinnitus may be a
problem to you when the class are
very quiet (maybe when you are
having a test or time in the library).
Other people find that classroom
noise can make their tinnitus sound
louder. Perhaps a certain subject is
hard for you and being in the lesson
makes you feel anxious – for some
people this may trigger their tinnitus.
So working out when tinnitus is a
bother for you is very important.
Step I:
When is your tinnitus a problem?
The noise/s I hear sound like:
…………………………….....................
When I’m in school it becomes a
problem in:
…………………………….....................
…………………………….....................
…………………………….....................
Tinnitus can’t be seen. People will
have no idea you hear tinnitus and
that it bothers you sometimes, unless
you tell them. We want to help you
learn how to explain to your teachers
and friends what’s happening. Here
are some ideas on how you can do
this.
Step 2:
Telling someone
‘I try hard to listen to what you say but
the noise I hear in my ears is louder
than your voice. This is difficult for
me, and you may think I’m not
concentrating in your lesson. I find
this is very annoying and upsetting,
as I can’t just listen and learn easily’
‘I need to talk to you about the test
we had last week. I kept asking you
to repeat the questions, and I know I
didn’t do very well. I wasn’t being out
of order, and I was trying hard. The
reason I was having a problem is
because I have something called
tinnitus – noises in my ears or my
head. Lots of people have it, and
mine becomes a problem when it’s
very quiet in class. Then I can’t hear
you very well, and my brain fixes on
the tinnitus noise. It sounds
like………………………………………
So what else can be done? Well,
there are lots of ways to reduce the
impact of your tinnitus when you are
at school and you may have tried
some already. Here are some
situations and ideas from other
people on what could be helpful.
Step 3:
What can be done?
‘My tinnitus becomes really loud
when the class are noisy or my
teacher’s voice is loud. Even when
everyone settles down my tinnitus
carries on. I can’t hear what my
teacher says very well and I often try
to guess what she said and then
make mistakes’ (do make sure you
tell your teacher Step 2)
•Ask to be moved away from very
noisy groups / people
•Carefully explain to your teacher
about voice level
•If you are in a lesson and your
tinnitus is triggered, agree a way
you can alert your teacher to help
you – this could be a laminated
card with a message that you show
your teacher, or some other agreed
signal (we can talk about this)
•During group work ask if you and
your group can go somewhere
quieter to work
•You may be able to have some
time out if you are really struggling,
but this needs a lot of planning and
agreement with your teacher and
school about how long for and
where you will go.
32

‘Its quiet in class and my tinnitus
becomes very loud. Its upsetting and
can stop me concentrating on my
work. Then when my teacher starts to
speak I can’t hear her words, just my
noise. I get very upset and I can get
into trouble for asking my friends
what’s been said. I mess up my work
too because I don’t really know what
to do. It also takes ages for my noise
to go away’
•Agree a way with your teacher you
can alert them / another adult /
friend to help you – this could be a
laminated card as before or maybe
you can think of a better way to
quietly let them know.
•Have your own support card – this
could remind you about how to
relax and to breathe to take your
mind away from your tinnitus. It
could be a lovely picture of your
favourite place, or a big smiley
face.
•Sometimes there is a low level
noise in classrooms – a computer
or heating fan perhaps. If you can
sit close to this sound, it may help
you ignore your tinnitus.
•Sometimes you may be working in
a quiet place for a long time –
maybe during library time, or in
exams. If this is distressing for you
and makes concentrating on your
work very difficult, here are a few
ideas that have worked for other
students:
!- Sit near a sound source - this
!may be a fan or near some
!environmental sound (e.g the
!window is open) that is low level
!but loud enough to help you
!ignore your tinnitus.
!- Use iPod music at a low level
!just when you need it.
!- Use headphones linked to the
!library computer so you have
!another sound source.
All these suggestions will need to be
agreed with your school in discussion
with a teacher or the SENCO in the
school. As there are strict rules
about use of headphones / iPod /
technology in schools it may not be
possible for this to happen, but other
ways forward may be agreed.
33

Appendix 9
Hearing Protection
Exposure to loud noise and music,
either directly to the ear through a
personal music player, or
environmentally, is a risk factor for
hearing damage. Headphones and
in-the-ear playback devices may
produce significantly higher SPLs in
younger children because of their
smaller outer ear volumes,
particularly the small canal volumes
in very young children.
Noise induced tinnitus is often
reported as a consequence of
attending music events, where there
may be exposure to high volume
music (up to 100–115dBA) and for
prolonged periods, may be
experienced. Loud levels are also
likely using a personal music player –
the sound level at the eardrum can
be up to 100dBSPL, especially when
ear buds are used in
noisy environments.
Concerns are well
documented about the
use of ear-buds which
provide poor isolation
from background noise
thus resulting in higher
listening levels (Hodgetts
2007).
Although ear damage
and experience of noise
induced tinnitus is likely,
it is not possible to
predict how much
damage there will be,
and for whom. It has
been suggested (Davis
1998) that there may be
a group of young people
who are more
susceptible to cochlea
damage; indeed these
children / teenagers may
be within the cohort
being seen in tinnitus
clinics.
Research also suggests that older
children and teenagers, the age
group most likely to be using
personal music systems and listen to
high volume music at concerts, do
not relate to taking preventative
action to protect their hearing. A
discussion about reasons to look
after their hearing system should be
approached from an imaginative and
relevant stance.
A successful educational approach
needs to give clear information about
listening behaviours – e.g. why
volume levels on personal music
systems are increased in some
listening environments – and how this
simple change can impact on ear
health.
Discussions about how to protect
ears from loud sound levels needs a
careful approach, taking into account
the individual’s personal preferences.
For example: advising volume
restricted headphones for someone
with a love of loud music is unlikely to
be successful, but filtered ear plugs
and their use by the music industry
may have more weight.
Choices of action:
•Use of software to limit volume
levels at source.
•Use of filtered ear plugs, including
‘off the shelf’ plugs, can reduce
volume levels by approximately
16dB across the sound spectrum –
for environmental high volume
listening.
•Use of volume restricted or noise
cancelling headphones for
everyday listening.
Care needs to be taken if listening to
music is being used to help with the
tinnitus. Music volume should be
kept as low as possible to avoid
triggering tinnitus.
For a large range of technical support
for listening / protecting hearing:
www.connevans.com
34

Appendix 10
Further Reading, Resources and Websites
Further reading and resources
Baguley D Andersson G, McFerran
D, McKenna L. (2013) Tinnitus and
hyperacusis in childhood and
adolescence” Chapter 18 in “Tinnitus
A Multidisciplinary Approach second
edition Wiley-Blackwell.
Faber A and Mazlish E (1980) How to
Talk So Kids Will Listen & Listen So
Kids Will Talk. Avon Books.
Kabat-Zinn J. (1996) Full Catastrophe
Living. London: Piakus Books.
Kentish R, Crocker S. (2006) Scary
Monsters and Waterfalls: tinnitus
narrative therapy with children. In
Tinnitus Treatment. Clinical
Protocols. Ed: Tyler, R. Thieme
Medical Publishers.
Williams M, Penman D. (2011)
Mindfulness: A Practical Guide to
Finding Peace in a Frantic World.
London: Piatkus.
Stallard P. Think Good, Feel Good. A
cognitive-behaviour therapy
workbook for children and Young
People. (2002) John Wiley and Sons
Stallard P. A Clinician’s Guide to
Think Good, Feel Good: using
cognitive behaviour therapy with
children and young people. (2005)
Wiley–Blackwell.
Websites
Action On Hearing Loss
www.actiononhearingloss.org.uk
British Tinnitus Association (BTA):
www.bta.org.uk
British Society of Audiology (BSA):
www.thebsa.org.uk
The Mindfulness in Schools Project
www.mindfulnessinschools.org
My World Paediatric Audiology
Counselling Tool.
www.idainstitute.com
Narrative therapy:
www.dulwichcentre.com
Relaxation, visualisation and
mindfulness techniques for children :
www.relaxkids.com
Strengths and Difficulties
Questionnaire:
www.sdqinfo.com
Supporting Success for Children with
Hearing Loss
www.successforkidswithhearingloss
.com
Sounding Board
www.soundingboard.earfoundation
.org.uk
35

Aksoy 2007
Aksoy S, Akdogan O, Gedikli Y,
Belgin E. The extent and levels of
tinnitus in children of central Ankara.
International Journal of Paediatric
Otorhinolaryngology 2007;71(2):
263-268.
Andersen 2011
Andersen KL, Smaldino JJ, Spangler
C. LIFE-R Listening Inventory For
Education – R and SIFTER Screening
Instrument for Targeting Educational
Risk. 1998. http://
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Aust 2002
Aust G. Tinnitus in childhood.
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Baguley 2013a
Baguley D, Barnik G, Kleinjung T,
Savastano M, Hough. Troublesome
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Baguley 2013b
Baguley D, Andersson G, McFerran
D, McKenna L. Tinnitus: a
multidisciplinary approach. Second
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Baguley 2013c
Tinnitus and Hyperacusis in
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Andersson G, McFerran D, McKenna
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Bartnik 2012
Bartnik G, Stepien A, Raj-Koziak D
Fabiajanska A, Niedzialek I,
Skarzynski H. Troublesome Tinnitus
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Ben-David 1995
Ben-David J, Podoshin L, Fradis M.
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Brunnberg 2008
Brunnberg E, Linden-Bostrom M,
Berglund M. Tinnitus and hearing
loss in 15 – 16 year old students:
mental health symptoms, substance
use and exposure in school.
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Canning 1998
Canning D. (1998) LIFE – UK IHP
http://
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Chada 2009
Chadha NK, Gordon KA, James AL,
Papsin BC. Tinnitus is prevalent in
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Chambers 2002
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Chorpita 1998
Chorpita B, Ebesutani C. Revised
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Coelho 2007a
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Davis 1998
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38

This practice guidance was produced on behalf of the British Society of Audiology as the result of the collaborative
efforts of the Paediatric Tinnitus Working Group. This group was composed of experts from a variety of specialist
fields.
Chair:
Ms Rosie Kentish
Consultant Clinical Psychologist
Royal National Throat Nose and Ear Hospital, University College London Hospital NHS Foundation Trust
Members:
Ms Claire Benton
Clinical Lead for Paediatric Audiology
Nottingham Audiology Services
Dr Veronica Kennedy
Consultant in Audiovestibular Medicine
Bolton NHS Foundation Trust
Ms Caroline Munro
Specialist Teacher of the Deaf
Royal National Throat Nose and Ear Hospital, University College London Hospital NHS Foundation Trust
Mr John Phillips
Consultant ENT Surgeon
Norfolk and Norwich University Hospitals NHS Foundation Trust
Ms Charlotte Rogers
Hearing Therapy Lead
Nottingham Audiology Services
Ms Joy Rosenberg
Course Leader, MSc in Educational Audiology
Mary Hare School (University of Hertfordshire)
Ms Sue Salvage
Principal Hearing Therapist
Royal Devon and Exeter NHS Trust
All artwork was obtained and reproduced with permission.
Photographs of Lydia Phillips, Benson Phillips and Leah Cooper were taken and are reproduced with permission.
Authors
39