Tinnitus in Children: Association With Stress and Trait Anxiety

The Laryngoscope VC 2012 The American Laryngological, Rhinological and Otological Society, Inc. Tinnitus in Children: Association With Stress and Trait Anxiety Young Ho Kim, MD, PhD; Hahn Jin Jung, MD; Seong Il Kang, MD; Kyung Tae Park, MD; Jung-Seok Choi, MD, PhD; Seung-Ha Oh, MD, PhD; Sun O Chang, MD, PhD Objectives/Hypothesis: The aim of this study was to investigate associations between tinnitus and stress factors including anxiety in elementary school students. Study Design: Cross-sectional study. Methods: We conducted a cross-sectional questionnaire survey in 940 students aged from 10 to 12 years. Data on 928 students were collected. The questionnaire comprised 96 questions that were classified into six categories: subjects symptoms, stress factors, State Anxiety (transitory emotional condition characterized by feeling of tension and apprehension) Inventory for Children (SAIC), Trait Anxiety (general tendency to respond with anxiety to environmental threat) Inventory for Children (TAIC), visual analog scale of tinnitus, and Tinnitus Handicap Inventory (THI). Results: Four hundred thirty-five students (46.9%) had experienced tinnitus more than once, and 41 (4.4%) suffered from it continuously. Self-perception of hearing loss, dizziness, headache, and concerns about obesity had significant differences between tinnitus and nontinnitus groups, whereas other stress factors did not show any difference. TAIC scores showed statistically significant differences according to the frequency of tinnitus in children experiencing tinnitus, whereas SAIC scores did not. Annoyance, influence on daily life, disturbance of sleep, and study by tinnitus and THI scores showed significant differences according to the frequency of tinnitus. Conclusions: The present study confirms that many children are aware of tinnitus and that they may be susceptible to stressful environments. In particular, trait anxiety may be associated with tinnitus. Because both tinnitus and anxiety can affect the daily lives and health of children as with adults a detailed strategy for the management of tinnitus in children should be established. Key Words: Tinnitus, children, trait anxiety, stress. Level of Evidence: 3a Laryngoscope, 122:2279 2284, 2012 INTRODUCTION Tinnitus in children is likely to be neglected in the clinical setting, because people in this age group rarely complain about the symptom to their parents spontaneously and report tinnitus infrequently when visiting ear clinics. In addition, there is little information regarding the characteristics of tinnitus in children, although some studies report tinnitus prevalence in children. 1 7 From the Department of Otorhinolaryngology, Head and Neck Surgery (Y.H.K., H.J.J., S.I.K., K.T.P.) and Department of Psychiatry (J.-S.C.), Seoul Metropolitan Government, Seoul National University, Boramae Medical Center; and Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University College of Medicine, Sensory Organ Research Institute, Seoul National University Medical Research Center (S.-H.O., S.O.C.), Seoul, South Korea. Editor s Note: This Manuscript was accepted for publication May 11, 2012. Presented at the 1st Congress of the Confederation of European Otorhinolaryngology and Head and Neck Surgery, Barcelona, Spain, July 2 6, 2011. This study was supported by a clinical research grant provided by Seoul National University Boramae Medical Center. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Young Ho Kim, MD, PhD, Department of Otolaryngology, Head and Neck Surgery, Seoul Metropolitan Government, Seoul National University, Boramae Medical Center, Seoul, South Korea 39, Boramae-Gil, Dongjak-Gu, Seoul 156-707, Korea. E-mail: yhkiment@gmail.com DOI: 10.1002/lary.23482 It is known that the incidence of tinnitus in children is high, although they make complaints of tinnitus only infrequently; children may be more likely to consider tinnitus a normal event than adults and could forget their tinnitus more easily because of external distractions. 4,8,9 Furthermore, there is no definitive way to differentiate between simple perception of tinnitus in children and any annoyance they may experience because of the symptom. Some recent studies suggest that anxiety disorder might be a predisposing factor for tinnitus in children. 3,10 Although tinnitus in children seems to have an anxiety characteristic similar to that seen with tinnitus in adults, active diagnostic and therapeutic approaches are needed. This is because tinnitus in children may cause more serious sequelae than in adults; these include difficulties in concentration and learning, sleep and behavioral disturbances, and emotional distress. Anxiety can display various forms of manifestation, and it is classified into two types: state and trait anxiety. Spielberger developed the State Trait Anxiety Inventory for children and defined state and trait anxiety as follows. 11 State anxiety means a transitory emotional state or condition characterized by subjective, consciously perceived feelings of tension and apprehension. Trait anxiety is a general tendency to respond with anxiety to perceived threats in the environment and shows 2279

relatively stable individual differences in anxiety proneness. That is, state anxiety is the anxiety condition we experience when something induces us to feel appropriately and temporarily anxious, whereas trait anxiety is the previously set anxiety experienced by an individual who has a tendency to be more anxious and react less appropriately to stimuli, finally being a characteristic of the personality. In this study, we performed a cross-sectional analysis on the prevalence of tinnitus in elementary school children. To the best of our knowledge, this is the first study to use questionnaire results to demonstrate the association of state and trait anxiety with tinnitus in children. The aim of the present study was to analyze the relationship between anxiety and tinnitus by comparing anxiety levels between two groups of children with and without the experience of tinnitus. MATERIALS AND METHODS Subjects The cross-sectional questionnaire survey was conducted in an elementary school in Seoul, Korea. The study included 940 students, aged 10 to 12 years. From an initial pool of 940 elementary school children, 928 were enrolled in this study; 12 questionnaires with incomplete answers were excluded. The demographics of enrolled children are summarized in Table I. The study group comprised 494 boys and 434 girls. The mean age of the sample was 11.0 6 0.8 years, and the range was 10 to 12 years. This study was approved by the institutional review board of Seoul National University College of Medicine, Boramae Medical Center (permit No. 06201123). Materials and Measures Before the survey, brief lectures on hearing and tinnitus were given in the classroom during school hours. Subjects symptoms, stress factors, characteristics of tinnitus, and anxiety/tinnitus tests examined in this survey are summarized in Table II. The questionnaire comprised 96 questions (55 questions for all students and an additional 41 questions including the conventional 25-question Tinnitus Handicap Inventory [THI] for those with tinnitus). Among these questions, six categories listed in Table II were used for the analysis of tinnitus: subjects symptoms (hearing loss, dizziness, and headache), stress factors (obesity, exercise, sleep, schoolwork, socioeconomic status, and experience of menstruation in girls), State Anxiety Inventory for Children (SAIC), Trait Anxiety Inventory for Children (TAIC), visual analog scale of tinnitus, and THI. 11,12 All students were asked to choose one among always, sometimes, or Parameter TABLE I. Demographics of Enrolled Subjects. Value Total No. 928 Age, yr Mean 11.0 6 0.8 Range 10 12 Sex, No. Male 494 Female 434 TABLE II. Items of Subjects Symptoms, Stress Factors, Characteristics of Tinnitus, and Anxiety/Tinnitus Tests. Questionnaire Items Questions as factors (nine items) Subjects symptoms Hearing loss Dizziness Headache Stress factors Concern about obesity Lack of exercise Sleep pattern Loading of schoolwork Socioeconomic status Experience of menstruation (in girls) Questions for characteristics of tinnitus Laterality Pitch Noise types Triggers Treatment history *Six categories for the analysis. Subjects symptoms, Stress factors, State Anxiety Inventory for Children, Trait Anxiety Inventory for Children, Visual analog scale for tinnitus, Tinnitus Handicap Inventory. never if they have tinnitus. Among them, subjects who experienced tinnitus always or sometimes were classified into the tinnitus group and the others who never felt tinnitus into the nontinnitus group. All subjects were also asked to choose one among always, sometimes, or never regarding whether they have symptoms such as dizziness or headache. Both SAIC and TAIC scores in each boys and girls group were investigated among the total number of children. Both SAIC and TAIC scores between boys and girls were compared in each tinnitus and nontinnitus group. Using a visual analog scale, two parameters annoyance of tinnitus and its influence on daily life were used to investigate how many children with tinnitus feel it as distressing and how much they experience the inconvenience in their daily life. The two parameters were compared between children experiencing tinnitus always and sometimes. To report tinnitus as troublesome, the parameters were displayed on the visual scale from 0 to 10, with 10 being the worst. We analyzed these factors according to the presence of tinnitus, frequency of tinnitus, and sex. Statistical Analysis Statistical analysis was performed using SPSS software (version 16.0; SPSS Inc., Chicago, IL). The data were analyzed for the entire group, the tinnitus group, and the nontinnitus group according to each factor assessed in the study questionnaires. The differences between tinnitus and nontinnitus groups were verified by Pearson v 2 test, linear by linear test, and Student t test. P value <.05 was considered statistically significant. RESULTS Characteristics of tinnitus and analysis outcomes between tinnitus and subjects symptoms/stress factors/ activities are listed in Table III. 2280

TABLE III. Characteristics of Tinnitus and Analysis Outcomes Between Tinnitus and Subjects Symptoms/Stress Factors/Activities. Parameter Value Total No. 928 Frequency of tinnitus Tinnitus more than once 435/928 (46.9%) Tinnitus always 41/928 (4.4%) Tinnitus treatment history 11/435 (2.5%) Prevalence of tinnitus according to gender Boys 43.4% Girls 51.3% (P ¼.016*) Tinnitus in self-perception 62.3% (P ¼.02*) group of hearing loss Tinnitus in dizziness group 60.4% (P <.01*) Tinnitus in headache group 56.2% (P <.01*) Stress factors for tinnitus Concern about obesity 52.9% (P <.01*) Lack of exercise P ¼.356 Sleep pattern P ¼.963 Loading of schoolwork P ¼.075 Socioeconomic status P ¼.259 Experience of P ¼.81 menstruation (in girls) Tinnitus Laterality Bilateral (30.6%), ND (28.3%) Pitch Middle frequency (36.0%) Noise types Buzzing (34.0%), machinery (32.4%) Triggers Quiet (30.8%), stress (21.8%) Annoyance and frequency VAS 3.59 (P ¼.002*) of tinnitus Influence on daily life and VAS 2.54 (P ¼.002*) frequency of tinnitus Sleep disturbance and 43.6% (P ¼.001*) frequency of tinnitus Learning disturbance and 41.0% (P ¼.007*) frequency of tinnitus *Statistically significant. ND ¼ nondefinite; VAS ¼ visual analog scale. Characteristics of Tinnitus in the Entire Cohort of Subjects Four hundred thirty-five children had experienced tinnitus more than once (46.9%), and 41 always experienced the symptom (4.4%). Only 11 children (2.5%) among subjects who had experienced tinnitus had ever visited clinics. The most commonly involved locations of tinnitus (in descending order) were bilateral ears (30.6%), nondefinite cases (28.3%), right ear (17.3%), head (16.8%), and left ear (7.0%). For the pitch of tinnitus, the largest group answered that it was in the middle frequency (36.0%), followed by high frequency, nondefinite cases, and low frequency. In most cases, the type of noise was a buzzing sound (34.0%) or machinery noise (32.4%). Tinnitus was mainly triggered in a quiet environment (30.8%), followed by stressful conditions (21.8%), and nondefinite cases (19.4%). Analysis Between Tinnitus and Nontinnitus Groups Self-perception of hearing loss was reported in 54 children (5.8%), and 62.3% of children in this group had tinnitus. This contrasts with a tinnitus figure of 45.9% among the 868 children (93.5%) who reported no self-perception of hearing loss, and this difference was statistically significant (P ¼.02, v 2 test, score ¼ 4.75, df ¼ 1). Complaints of dizziness and headaches in the tinnitus group were also significantly higher (dizziness: 60.4% vs. 32.6%, P <.01, linear by linear test, score ¼ 12.13, df ¼ 2; headache: 56.2% vs. 38.6%, P <.01, linear by linear test, score ¼ 30.10, df ¼ 2, for tinnitus vs. nontinnitus group, respectively). Concerns about obesity were significantly correlated with the prevalence of tinnitus. The prevalence of tinnitus in children with concern about obesity was 52.9%, whereas that in children without this worry was 41.0% (P <.01, chi square test, score ¼ 13.08, df ¼ 1). However, other variables such as lack of exercise, sleep pattern, loading of schoolwork, and socioeconomic status did not show any significance (P ¼.356, P ¼.963, P ¼.075, and P ¼.259, respectively, linear by linear test). In addition, girls experiencing menstruation were not found to have a higher prevalence of tinnitus than girls with no menstruation (50% vs. 51.2%, respectively; P ¼.81, v 2 test, score ¼ 0.05, df ¼ 1). Average SAIC and TAIC scores in all enrolled subjects were within the normal range, and average SAIC scores were not significantly different between the tinnitus and nontinnitus groups (P ¼.38, Student t test). However, average TAIC score in the tinnitus group was significantly higher compared to that of the nontinnitus group (P <.01, Student t test; Fig. 1A). Analysis Between the Two Groups According to the Frequency of Tinnitus Children who always experienced tinnitus had more dizziness than those who sometimes experienced tinnitus (82% vs. 65%, P ¼.001, linear by linear test, score ¼ 10.89, df ¼ 1). The frequency of headache in those who always felt tinnitus was higher, showing a significant difference compared to that of the group that sometimes experienced tinnitus (76% vs. 52%, P ¼.00, linear by linear test, score ¼ 14.22, df ¼ 1), but there were no significant differences in other variables, including perception of hearing loss, concern about obesity, lack of exercise, sleep pattern, loading of schoolwork, and socioeconomic status (P ¼.33, P ¼.32, P ¼.19, P ¼.36, P ¼.15, and P ¼.25, respectively, linear by linear test). Annoyance and influence on daily life of tinnitus showed significantly higher visual analog scales in those who always compared to those who sometimes experienced tinnitus (annoyance: 3.59 vs. 1.8, influence on daily life: 2.54 vs. 1.19, both P ¼.002, Student t test). When dividing the frequency of tinnitus into two groups, always and sometimes/never, the prevalence of sleep and learning disturbance was significantly higher when tinnitus was always present (sleep disturbance: 43.6% vs. 21.4%, P ¼.001, linear by linear test, score ¼ 10.12, df ¼ 1; learning disturbance: 41.0% vs. 30.7%, P ¼.007, linear by linear test, score ¼ 7.39, df ¼ 1). The proportion of 2281

was statistically significant (P ¼.016, v 2 test, score ¼ 5.777, df ¼ 1). Among the total number of children, girls had statistically higher TAIC scores than boys (31.46 vs. 29.18, respectively, P ¼.015, Student t test); however, there was no significant difference for SAIC and TAIC scores between boys and girls in each tinnitus and nontinnitus group. Fig. 1. Comparison of State Anxiety Inventory for Children (SAIC)/ Trait Anxiety Inventory for Children (TAIC) scores and the presence of tinnitus/frequency of tinnitus. (A) TAIC scores in children with tinnitus revealed significantly higher scores compared to those of children without tinnitus (P <.01, Student t test). (B) There was a significant difference between SAIC and TAIC scores according to the frequency of tinnitus (P <.01, analysis of variance test). children with mild to severe tinnitus measured by THI was significantly higher when tinnitus was always present compared with when tinnitus was sometimes present (46.2% vs. 17.4%; P <.01, linear by linear test, score ¼ 26.62, df ¼ 1). Analysis Among Three Subgroups in the Tinnitus Group According to the Frequency of Tinnitus Comparative analysis among three subgroups in the tinnitus group according to the frequency of tinnitus (never, sometimes, and always groups) was performed, and there was a significant difference in TAIC scores according to the frequency of tinnitus (P <.01, analysis of variance test; Fig. 1B). By Tukey post hoc analysis, significance was found among each group (always: 38.48; sometimes: 33.12; never: 29.39). There was also a significant difference in THI scores according to the frequency of tinnitus (P <.01, linear by linear test; Fig. 2). Analysis Between Boys and Girls Regarding Prevalence of Tinnitus and Anxiety Scores The prevalence of tinnitus was higher among girls (51.3%) than among boys (43.4%), and this difference 2282 DISCUSSION Tinnitus in children is no longer rare. However, because children rarely complain of their tinnitus, serious attention should be paid to this issue. In addition, as in adult patients with tinnitus, the physician should exclude conditions such as head trauma, retrocochlear tumor, emotional problems, somatosensory disorder, sensory perception disorder, and metabolic or circulatory disorder to make an appropriate diagnosis of tinnitus in children. In particular, evaluations for affective disorders such as stress, anxiety, or depression need to be performed in children with tinnitus. There are several reasons why tinnitus in children should be considered more important than the same symptom in adults. Children are developing their learning and behavioral patterns, as well as their cognitive and psychological attributes, and tinnitus may affect these factors inappropriately. 13 Furthermore, when children suffer from hearing loss associated with tinnitus and this problem is neglected, they may experience a higher risk of learning or behavioral problems. Finally, although the definite mechanism regarding occurrence of tinnitus is yet to be elucidated, any differences in this main mechanism between children and adults could be another important issue. The percentage of children reporting tinnitus has fluctuated in previous studies, and the presence of hearing impairment plays a large role in these variations. The prevalence of tinnitus in children reported in previous studies ranges from 12% to 29% in children with normal hearing and from 7% to 66% in children with a hearing impairment. 2 4,6,7,13 The present study did not screen hearing impairment of subjects by audiological Fig. 2. The proportion of Tinnitus Handicap Inventory (THI) grades between two groups according to frequency of tinnitus. This figure shows that children experiencing tinnitus always tend to have worse THI grades. The proportion of mild to severe grades was significantly different between the two groups (P <.01, linear by linear test).

evaluation, but used questionnaires for hearing loss, which may lead to a tinnitus prevalence higher than those in previous studies. However, differences in study settings and tinnitus cases not related to hearing impairment should be considered. It is also difficult to determine who should be enrolled in tinnitus studies, as there are questions concerning how often or how loudly subjects should experience the symptom before they are included. Thus, the prevalence of tinnitus found in any given study may be influenced by the inclusion criteria used by the authors. Young children as subjects of a questionnaire study may produce incomplete or unreliable answers. The present study enrolled children aged 10 to 12 years, which is in line with a suggestion made in a previous study that tinnitus measurement in children <8 years of age is beset with problems of nonreproducibility. 8 The author of that report also has stated that the age distribution of children with tinnitus increased >10 years of age. However, children may require parental help to complete questionnaires if future studies wish to obtain more accurate information regarding tinnitus in children. The present study showed a significantly higher prevalence of tinnitus in girls. This finding has also been reported in other studies. 14,15 When considering the age of girls enrolled in this study, we assumed that stress about menarche might be a factor of the higher prevalence of tinnitus in girls. Therefore, the difference between tinnitus and presence of menstruation was investigated, but no relevance was found. Some authors suggested that tinnitus was related to anxiety and depression, and noted that girls showed more signs of anxiety disorders than boys. 3,14 Likewise, the present study investigated the difference of anxiety according to tinnitus in children. Although girls had statistically higher TAIC scores than boys among the total subjects, SAIC and TAIC scores between boys and girls according to the presence of tinnitus showed no significant differences. As a result, a higher anxiety index in girls with tinnitus was not seen in this study. TAIC scores were significantly higher in subjects who reported more frequent tinnitus than in subjects who reported less frequent tinnitus. Our finding that trait anxiety rather than state anxiety increases in children with tinnitus may be important in terms of the advance of tinnitus developed in childhood, because trait anxiety is not temporary and can finally influence a characteristic of the personality. The prevalence of children experiencing tinnitus at all times was 4.4%; however, this study did not classify children into normal-hearing and hearing-impaired groups; thus, whether very troublesome tinnitus is associated with hearing impairment remains to be elucidated. In this study, only 2.5% of children who reported tinnitus had sought help in clinics, which may mean that children seldom complain of tinnitus spontaneously to their parents or that their complaints are not taken seriously by adults, as a previous study suggested. 16 Our results has a similarity with one study showing that only 3% of 403 children with tinnitus complained spontaneously. 7 This study also showed that tinnitus in children may be related to concerns about obesity. Future better-designed studies are needed to evaluate stress factors for tinnitus and their influence on daily life, sleep, and schoolwork. One of the limitations of this study may be a lack of audiometric assessment. However, we did not aim to investigate the association between tinnitus and objective hearing loss. One study has reported that the most common finding associated with tinnitus in children was progressive hearing loss. 6 In contrast, some authors have suggested that the degree of hearing loss in children with tinnitus played only a minor role in the severity of tinnitus, similar to the findings in adults. 3,10 In the present study, the inclusion of children with hearing loss may have increased the prevalence of tinnitus when comparing outcomes of other studies that excluded subjects with hearing impairment. Another limitation of this study may be a lack of detailed information on noise exposure; we presumed children aged 10 to 12 years would have limited noise exposure, and this study did not include this issue. However, people could now be exposed to potential acoustic trauma at an increasingly young age, given the rise of karaoke for children and portable music players. Therefore, the relationship between tinnitus and noise exposure should be evaluated using assessment of auditory functions as mentioned above. Finally, this study focused on anxiety instead of depression in relation to comorbidity with tinnitus, because there was insufficient time to collect enough data for the two affective disorders in a cross-sectional questionnaire study. In addition, the frequency of depressive symptoms in the general pediatric population is not likely to be high, 17 21 and even if they are present, such symptoms can be associated with a large variety of other psychiatric disorders, such as anxiety disorders, bipolar disorders, or personality disorders. However, further study on the relationship between tinnitus and depression in children may be helpful for a greater understanding of the pathophysiologic aspects of tinnitus in children. To date, there is no specific guideline or consensus regarding treatment or management of tinnitus in children. Almost all medications for treatment of tinnitus are off label in children younger than 12 years. However, study needs to be done on the application of pharmacological (e.g., antidepressant or anxiolytic agents) and psychotherapeutic (e.g., cognitive behavioral therapy or tinnitus retraining therapy [TRT]) strategies for children with tinnitus. There were few reports on the treatment of tinnitus in children. 22,23 Therefore, there is a need for more clinical and basic research on diagnosis and treatment of tinnitus in children. In particular, the importance of counseling for control of stress, anxiety, or depression as well as audiometric screening and auditory rehabilitation should be emphasized for the proper management of tinnitus in children. One recent preliminary study suggests the application of TRT comprising sound therapy and counseling for children with troublesome tinnitus. 23 The authors report that 48 (81.4%) of 59 children showed a significant improvement after 6 months of 2283

treatment. This therapeutic strategy for tinnitus in children may be helpful in preventing or minimizing the potential damage of tinnitus as one of the affective disorders. However, the long counseling period involved generally at least 18 months may decrease patient compliance, especially in young children. In addition, because approximately half of all children with troublesome tinnitus demonstrate normal hearing, they may need other treatments such as medication and/or psychological counseling besides TRT using sound therapy or auditory rehabilitation using hearing aids. CONCLUSION In summary, the present study suggests that tinnitus in children has a considerable influence on their levels of stress and anxiety. Individualized treatment strategies with parental involvement may be helpful in overcoming this problem. BIBLIOGRAPHY 1. Mills RP, Albert DM, Brain CE. Tinnitus in childhood. Clin Otolaryngol Allied Sci 1986;11:431 434. 2. Aksoy S, Akdogan O, Gedikli Y, et al. The extent and levels of tinnitus in children of central Ankara. Int J Pediatr Otorhinolaryngol 2007;71: 263 268. 3. Holgers KM, Juul J. The suffering of tinnitus in childhood and adolescence. Int J Audiol 2006;45:267 272. 4. Nodar RH, Lezak MHW. Paediatric tinnitus: a thesis revisited. J Laryngol Otol 1984;(suppl 9):234 235. 5. Graham JM. Tinnitus in children with hearing loss. Ciba Found Symp 1981;85:172 192. 6. Aust G. Tinnitus in childhood. Int Tinnitus J 2002;8:20 26. 7. Mills RP, Cherry JR. Subjective tinnitus in children with ontological disorders. Int J Pediatr Otorhinolaryngol 1984;7:21 27. 8. Savastano M. Characteristics of tinnitus in children. Eur J Pediatr 2007; 166:797 801. 9. Viani LG. Tinnitus in children with hearing loss. J Laryngol Otol 1989; 103:1142 1145. 10. Kentish RC, Crocker SR, McKenna L. Children s experience of tinnitus: a preliminary survey of children presenting to a psychology department. Br J Audiol 2000;34:335 340. 11. Spielberger DC. Manual for the State-Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologist Press; 1972. 12. Cho SC, Choi JS. Development of Korean version of State-Trait Anxiety Inventory for Children. Seoul J Psychiatry 1989;14:150 157. 13. Graham J, Butler J. Tinnitus in children. Proceedings, Second International Tinnitus Seminar. J Laryngol Otol Suppl 1984;9:236 241. 14. Holgers KM, Svedlund C. Tinnitus in childhood. J Psychosom 2003;55:135. 15. Coelho CB, Sanchez TG, Tyler RS. Tinnitus in children and associated risk factors. Prog Brain Res 2007;166:179 191. 16. Baguley DM, McFerran DJ. Tinnitus in childhood. Int J Pediatr Otorhinolaryngol 1999;49:99 105. 17. Breton JJ, Bergeron L, Valla JP, et al. Quebec child mental health survey: prevalence of DSM-III-R mental health disorders. J Child Psychol Psychiatry 1999;40:375 384. 18. Sugawara M, Kitamura T, Toda MA, Shima S. Longitudinal relationship between maternal depression and infant temperament in a Japanese population. J Clin Psychol 1999;55:869 880. 19. Briggs-Gowan MJ, Horwitz SM, Schwab-Stone ME, Leventhal JM, Leaf PJ. Mental health in pediatric settings: distribution of disorders and factors related to service use. J Am Acad Child Adolesc Psychiatry 2000; 39:841 849. 20. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003;60:837 844. 21. Ford T, Goodman R, Meltzer H. The British Child and Adolescent Mental Health Survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry 2003;42:1203 1211. 22. Fritsch MH, Wynne MK, Matt BH, Smith WL, Smith CM. Objective tinnitus in children. Otol Neurotol 2001;22:644 649. 23. Bartnik G, Stepien A, Raj-Koziak D, Fabijanska A, Niedzialek I, Skarzynski H. Troublesome tinnitus in children: epidemiology, audiological profile, and preliminary results of treatment. Int J Pediatr 2012;2012: 9453 9456. 2284