There is increasing awareness that tinnitus is not restricted to adults. Indeed, the available evidence suggests that some experience of tinnitus in children is fairly common [1]. For many, tinnitus has little effect and requires limited or no intervention. For some however, tinnitus can cause significant distress, impacts the child’s life at home and school, and is associated with the kinds of emotional distress often seen in adult tinnitus patients.
That children with distressing tinnitus are so rarely seen in our clinics may be in part because children are often reluctant to tell us about their tinnitus unless we invite them to do so. They may lack the linguistic skills to describe the noises they hear, be unaware of its significance, or be afraid that we will not believe them. Perhaps we don’t ask the right questions. When adults fail to provide children with openings to talk about it, we deprive them and their parents of the opportunity to hear reassuring information about tinnitus, and practical strategies for managing it.
Conversations about tinnitus with children aren’t always easy. Young children may describe their tinnitus in unfamiliar terms such as “buzzing bees”, “choo choos”, “eees”, or other everyday objects that they are familiar with. They may even believe that the bees are real. Children do not have adult capabilities to articulate verbally their emotions, perceptions and beliefs about their tinnitus and often prefer other ways to convey ideas, other than talking. Tinnitus treatment needs to be carried out in ways that are playful, developmentally appropriate, and that children can relate to. Drawing is a familiar task for most children. It provides them with the opportunity to visually describe their experiences, emotions and their world, through both the drawing itself and the stories that they can tell us about their drawing [2].
Not all children are comfortable with drawing and may find it easier to describe their experiences in other ways, for example using toys or puppets. Adults who assign tasks to children that are not congruent with their developmental stage may seem imposing or frightening to children. It is important that children are invited to draw freely, and that it is not seen as yet another test. Children may not want to draw for a variety of reasons but for those who spontaneously reach for the pencil box, drawing can be a pleasurable and relaxing task. Talking with children about their drawings can help the child convey their thoughts and feelings and can open up opportunities to gather clinically important information they may not otherwise disclose.
Case study
Nine year old Sarah’s drawing visually describes three noises that she called her “noisy noises”: the sound of bees, and a high buzzing noise when she heard singing. It also elicited information not previously known – a sound she described as a photocopier noise when she moved her jaw, that made her ears feel blocked and her voice sound different. The noisy noises frightened her, prevented her from going to sleep and sometimes hearing the teacher at school. This resulted in Sarah being told off for not paying attention. She had not felt able to talk to her teacher about her tinnitus, or to ask for help when she missed information in class. The facial expressions in Sarah’s drawing convey her emotional reaction to the “noisy noises”. Sarah was worried that the “noisy noise” meant she would go deaf, like her uncle.
Many therapists use drawing as part of narrative therapy, a therapeutic approach we have found to be useful in our clinical practice treating children with distressing tinnitus. The word narrative in the context of therapy means listening to others’ stories. In this context, we are listening to the meanings, beliefs and emotions that children and their families have about tinnitus. We all have many stories about ourselves – our abilities, relationships, achievements and failures, and about events that have happened to us. In children, the content and complexity of these stories will reflect not only their experiences, but also their developmental stage, and the social context of their lives. Stories help us to organise and understand our experiences. They are created by selecting and linking certain events together in a sequence, and by the meaning we attribute to these events [3]. Information is selected and attended to because it confirms our existing stories or beliefs, for example that “tinnitus stops me going to sleep”. Contradictory information tends to be filtered out, for example, “last night I went to sleep OK”.
Many children, like Sarah, are faced with problems such as noises in their ears that very likely cannot be removed. They can however be helped to live with tinnitus, without the emotional effects, or the problems that tinnitus can cause. Children often see problems as internal to themselves, a part of their existence, the way things are, and therefore hard to change. Externalisation is a narrative technique that can be used to help children separate themselves from problems and to see ‘the problem’ as being the problem, and not themselves [4]. Externalising the problem can be quite playful and fun. We are inviting the child to put the problem ‘out there’ in the room by giving it a name, be it “Mr Tinnitus” or “Little Miss Worry”. There are many ways to do this, but drawing can be a useful way of externalising the problem by putting it on paper – tangible, visible and at a distance. Once tinnitus, or a problem associated with it is out there and in the open, we can start the process of beginning to construct new stories about the way the child can respond to it differently.
Although we have no reliable research evidence to date regarding the most effective method for treating tinnitus in children, clinical experience suggests that children respond well to tinnitus treatment that uses developmentally appropriate and child friendly techniques. Children are usually remarkably resourceful and creative at coming up with solutions to their problems. Children’s drawings can be a useful way of helping children to develop their new stories, ones where new approaches to problems are found. Sarah found solutions to her difficulties in class whereby she envisaged herself being able to ask for help when she could not hear her teacher. Her drawing conveys that her voice can be heard, even though her tinnitus is present.
References
1. Baguley D, Andersson G, McFerran D, McKenna L. Tinnitus and hyperacusis in childhood and adolescence. In Tinnitus: A Multidisciplinary Approach, 2nd Edition. Oxford, Wiley-Blackwell; 2013.
2. Malchiodi C. Understanding Children’s Drawings. Oxford, Guilford Press; 1998.
3. Morgan A. What is Narrative Therapy? An easy to read introduction. Adelaide, Dulwich Centre Publications; 2000.
4. White M, Epston D. Narrative Means to Therapeutic Ends. London, WW Norton and Co.; 1990.
Recommended further reading
Kentish R,Crocker S. Scary Monsters and Waterfalls: Tinnitus Narrative Therapy for Children. In Tyler R (Editor), Tinnitus Treatment: Clinical Protocols. New York, Thieme; 2005.
Freeman J, Epston D, Lobovits D. Playful Approaches To Serious Problems: Narrative therapy with children and their families. London, WW Norton and Co.; 1997.
www.dulwichcentre.com – provides useful information on narrative therapy.
Declaration of Competing Interests: None declared.
