Treating young people with tinnitus
Audiologist Megan Hayden discusses the challenges of seeing a young person with tinnitus as they transition to adult services.
Sixteen-year-old ‘Sarah’ attended our direct referral clinic for under-50’s. She presented with normal hearing; her main complaint was tinnitus. She was identified as requiring further support, but which support route was the best avenue?
We offer two in-house options for tinnitus support: the group Tinnitus Education Session (TES) or an individual appointment. The TES has a number of benefits that can’t be experienced in a one-to-one setting such as camaraderie, the opportunity to identify with others, validation of experience and symptom/social comparison. However, if a TES is not suitable, an individual session may be offered.
Technically the transition from paediatrics to adults can start at 16, but the child/family typically chooses to delay transition to 18. For this reason, it is unusual to see Sarah’s age group in a TES.
An individualised one-to-one appointment was considered to be the best management option.
1. If her age group is not represented in the TES, would the benefits of the group session be accessible to Sarah, or could it possibly contribute to feelings of isolation? 2. Sarah may still benefit from symptom/social comparison. However, this could potentially cause health anxiety. Is emotional maturity something to consider? 3. Sarah was very shy and quietly spoken - would she feel comfortable raising her own concerns and opinions, or would she become lost in the group?
In preparation, I considered whether I would approach Sarah’s appointment any differently to that of one of our older patients but decided that I would not. My main objectives of the appointment would remain unchanged. These were:
- to gain understanding and insight into Sarah’s tinnitus, her reaction and feelings towards it
- to understand causal and influencing factors
- to clarify the wider application/potential impacts to quality of life (sleep, mood, behaviour changes)
- to provide reassurance and education on tinnitus/tinnitus management strategies
As in all my appointments, I would need to ensure that the information (verbal and written) given was accessible to Sarah.
I consulted two documents, namely the British Society of Audiology’s Tinnitus in Children Practice Guidance (currently under revision) and the National Institute of Health and Care Excellence (NICE) guidelines, Tinnitus: assessment and management, recommendations. There are no NICE guidelines specific to children/young people with tinnitus, however, the NICE guidelines apply to all patients (adults, children and young people) with tinnitus unless otherwise stated.
These helped reassure me that I was correct in my approach. Research available is limited and of variable quality but suggests that children with tinnitus share many similarities to adults with tinnitus. Like adults, 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 management to help with distress or the impact upon their lives.
My appointment with Sarah aimed to establish the level of distress and impact upon her and her family, ascertain any causal or influencing factors and begin to plan the management strategy. I was able to draw upon both the information leaflets from Tinnitus UK (then the BTA) for adults and their leaflets for older children, having taken into account Sarah’s age, cognitive and linguistic ability and individual circumstances.
Sarah’s appointment was online, and it was not easy as Sarah didn’t have a webcam, and the lack of information from body language/visual cues made this more counselling style interaction difficult. Sarah is not naturally very chatty, though when prompted with questions, was happy to talk. However, her answers were often short, and did require further questioning/prompting to get further information.
I felt any further follow-up appointments would have benefited from attending clinic and being seen in person but at the end of this session, Sarah was happy to be discharged and contact us if further support was required.
Overall, the goals of the appointment were achieved, and the outcome was a positive one. However, there were several challenges:
- Sarah’s choice to not have her webcam on/the lack of visual information. Non-verbal information is critical in a counselling style appointment, and without this visual information it was very difficult to gauge Sarah’s understanding.
- Difference in disclosure/communication style. During the conversation Sarah was happy to talk and answer questions asked, but with limited elaboration unless further prompted. I was prompting and guiding disclosure/conversation much more than I am used to in an adult appointment (despite using open-ended questions) and it was much less free-flowing than adult conversation
- The role of the parent. There seemed to be an awkward balance between being a dependent and wanting independence. It was difficult to know whether I could share information and make appointments with the parent, or whether I should be making it solely with Sarah. It was also unusual not ‘debriefing’ the parent on what has occurred, and not seeing the patient as a child.
A colleague shared that from her experience parent anxiety can be a large contributor, and so having them attend the management discussion part of the appointment (with the patient’s consent) can be beneficial.
For our area, our usual signposting to local support services does not apply to patients under 18. Should there have been need for further support, a referral to CAMS would have been required.