This week, the National Institute for Health and Clinical Excellence (NICE) released their guidelines about the assessment and management of tinnitus. I thought it would be timely to refresh our knowledge about this area and its impact on everyday life. If you’re supporting a Deaf child, or a child who has had a brain injury, they are likely to be experiencing tinnitus, to a greater or lesser extent. As parents and professionals, we sometimes forget what this experience might be like for a child.
What causes tinnitus?
Tinnitus is a central auditory phenomenon. It is what happens when the brain starts processing internal electrical activity as if it were a sound signal. That is, the parts of the brain which would usually interpret sound information start to notice and grab on to other internal sensations which would otherwise be filtered out. Because the brain very much wants to make sense of the incoming information, it tells the person that these internal sensations are sound even though it isn’t linked to anything outside.
In everyday terms, people sometimes describe tinnitus as
having “ringing in your ears”, but there’s actually a huge range of what it can sound like. Sometimes it can sound quite soothing, like heavy rain outside. At other times it can be loud, intrusive and sometimes even a little frightening like moaning or a whipcrack. It’s a really common experience for deaf adults and children. Deaf adults have described tinnitus experiences to me which include hearing a rumbling sound like a loud tumble drier or a cement mixer, a fuzzy sound like a badly-tuned radio, or even in one really bad case, “like I’m sitting in a motorboat full of canaries”.
The recent research around tinnitus suggests that perhaps 55% of deaf children get tinnitus at a level which bothers them (compared to 13% of children without a hearing loss), although the figures vary across studies from a low of 23.5% to 62.2% depending on the how it was measured. The studies also suggest that tinnitus is more likely for children who have mild to moderate level of hearing loss rather than those with a severe to profound loss, and that it’s more common in children with a conductive (middle ear) hearing loss than a sensorineural (cochlear) hearing loss.
How is it assessed?
At this point, there is no reliable external or subjective assessment for tinnitus. It is an internal experience where assessment relies on the individual being able to report and self-evaluate. Many of the questionnaires to measure tinnitus ask about what it sounds like for the person, and how bothersome or intrusive it is. This means that there isn’t an objective or normed measure of severity – the experience is unique to the individual. Self-evaluation questionnaires, of course, rely on a child having the vocabulary and insight to be able to describe that experience.
How will you know if a child you’re working with is getting tinnitus? Well, either you’ll have to ask them, or you’ll have to watch out for changes in behaviour. Most deaf children don’t report tinnitus, because to them it’s part of their everyday experience. How would they know that not everyone has it?
What is the impact?
Firstly, if you’re one of the 10% or so of the general population who experiences tinnitus – I’m really sorry. I know nothing makes your tinnitus worse than thinking about your tinnitus.
For many deaf people, having some sound coming in through hearing aids or cochlear implants, even if the sound isn’t enough to be useful for listening to speech, can help to mask any tinnitus. However, this means that for lots of people, when they take their hearing aids or speech processors off at night, they become very aware of any tinnitus, and this can make it very much harder to get to sleep.
For children, having just a few nights of disrupted sleep can have a big impact on attention and participation and consequently you might see either listlessness, distractibility, and downright grumpiness. It can be harder for children to focus, and to inhibit their attention being distracted by every new stimulus in the environment. They may become anxious or depressed.
Coping with intrusive tinnitus is exhausting. You may see an increase in listening effort and in the child’s levels of fatigue, particularly towards the end of the day and the end of the week.
What can we do?
Consider getting the child’s hearing checked to make sure there hasn’t been a change in their hearing levels. If hearing levels drop, the brain isn’t getting the sounds it is expecting and this can sometimes trigger an upswing in tinnitus.
Reassure the child that tinnitus is common and usually not a symptom of anything more sinister – but don’t dismiss or belittle the child’s experiences and feelings about what it happening to them. The British Tinnitus Association has some leaflets you can download to start the conversation.
Sound masking refers to environmental adaptations to reduce any sudden changes from noise to silence (which can cause tinnitus to exert itself). This might be using a soundmaker app in the bedroom while the child falls asleep if they have some residual hearing. I really like the White Noise Ambience HD app. You might consider whether it would be helpful for the child to keep one hearing aid or speech processor on while they fall asleep, and then have their parent remove it later.
Working on strategies to enable the child to get themselves calm and regulated will be particularly helpful. Anxiety and tinnitus mutually trigger each other, and both can interfere with sleeping. From an Ayres Sensory Integration perspective, we’d be looking firstly at using proprioceptive input (muscle and joint movement) in enjoyable everyday activities to help achieve and maintain that calm and organised state. Consider what sports and active leisure pursuits the child enjoys, and look for opportunities to build pull-push-stretch into learning activities and household routines.
For children and teenagers who would be able to access the language and concepts required, Cognitive Behavioural Therapy (CBT) or Acceptance and Commitment Therapy (ACT) can be helpful.
More information and further reading:
NICE Guidelines https://www.nice.org.uk/guidance/ng155 (accessed online 12 March 2020)
British Tinnitus Association: https://www.tinnitus.org.uk/ Downloadable leaflets for children: https://www.tinnitus.org.uk/support-for-children (accessed online 12 March 2020)
British Society of Audiology Practice Guidelines – Tinnitus in Children: http://www.thebsa.org.uk/wp-content/uploads/2014/06/Paed-Tin-Guide-Pub-Consul-Compressed.pdf
Cima, R.F.F., Mazurek, B., Haider, H. et al. 2019 A multidisciplinary European guideline for tinnitus: diagnostics, assessment, and treatment. HNO 67, 10–42 https://doi.org/10.1007/s00106-019-0633-7
 ROSING, S. N., SCHMIDT, J. H., WEDDERKOPP, N. & BAGULEY, D. M. 2016. Prevalence of tinnitus and hyperacusis in children and adolescents: a systematic review. BMJ Open, 6, e010596.
 BARTNIK, G., STĘPIEŃ, A., RAJ-KOZIAK, D., FABIJAŃSKA, A., NIEDZIAŁEK, I. & SKARŻYŃSKI, H. 2012. Troublesome tinnitus in children: epidemiology, audiological profile, and preliminary results of treatment. International journal of pediatrics, 2012, 945356-945356.
 BAUER, C. A. 2018. Tinnitus. New England Journal of Medicine, 378, 1224-1231.