10.14639/0392-100X-N2552
Objective. The paediatric caregiver version of the Dizziness Handicap Inventory (DHI-PC) questionnaire is a useful Quality of Life evaluation instrument for children experiencing dizziness, vertigo or unsteadiness. Its English version has been validated for use with a paediatric population between 5 and 12 years of age. The aim of this work is to validate the DHI-PC into Italian for both patient assessment and appropriate rehabilitative treatment planning. Materials and methods. Cross-cultural adaptation of the DHI-PC was performed using standard techniques. Items of the original questionnaire were translated into Italian by two bilingual investigators. Two native English speakers carried out a back translation of the new version that was compared with the original to check that they had the same semantic value. A pre-final version was obtained by an expert committee and was applied in a pilot test. Results. A total of 42 patient caregivers completed the final adapted questionnaire twice with an interval of 2 weeks. Internal consistency was excellent, with Cronbach’s alpha&nbsp;=&nbsp;0.95. Conclusions. Our study showed evidence that the Italian version of DHI-PC is a valid and reliable tool to quantify the degree of dizziness handicap and its application is recommended.
text/xml
1827-675X
2552
en
Jacopo Galli
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
vertigo
Validity of Italian adaptation of the Vanderbilt Paediatric Dizziness Handicap Inventory
Text.Serial.Journal
https://www.actaitalica.it/
43
Vestibology
2023-07-28
2023-03-13
2023-09-29
2023-10-02
341-347
1
Jacopo Galli
2023/07/28
10.14639/0392-100X-N2552
341
Unit of Otorhinolaryngology - Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Head and Neck and Sensory Organs, Catholic University of the Sacred Hearth, Rome, Italy
1827-675X
vertigo
en
347
Validity of Italian adaptation of the Vanderbilt Paediatric Dizziness Handicap Inventory
https://www.actaitalica.it/article/download/2552/1032
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:341-347; doi: 10.14639/0392-100X-N2552




Vestibology


Validity of Italian adaptation of the Vanderbilt
Paediatric Dizziness Handicap Inventory
Validazione in italiano del questionario Vanderbilt Pediatric Dizziness Handicap
Inventory
Pasqualina Maria Picciotti1,2, Giorgia Rossi1, Stefano Settimi1,2, Anna Rita Fetoni3, Maria Coppola4, Jacopo Galli1,2
1
 Unit of Otorhinolaryngology - Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy;
2
  Department of Head and Neck and Sensory Organs, Catholic University of the Sacred Hearth, Rome, Italy; 3 Department
of Neuroscience, Reproductive sciences and Dentistry - Audiology Section, University of Naples Federico II, Naples, Italy; 4 Neonatal
Intensive Care Unit, sub TIN, Neonatal Pathology and Neonatology, San Giovanni Calibita Fatebenefratelli Hospital - Gemelli Isola,
Rome, Italy


SUMMARY
Objective. The paediatric caregiver version of the Dizziness Handicap Inventory (DHI-PC)
questionnaire is a useful Quality of Life evaluation instrument for children experiencing
dizziness, vertigo or unsteadiness. Its English version has been validated for use with a
paediatric population between 5 and 12 years of age. The aim of this work is to validate
the DHI-PC into Italian for both patient assessment and appropriate rehabilitative treatment
planning.
Materials and methods. Cross-cultural adaptation of the DHI-PC was performed using
standard techniques. Items of the original questionnaire were translated into Italian by two
bilingual investigators. Two native English speakers carried out a back translation of the new
version that was compared with the original to check that they had the same semantic value. A
pre-final version was obtained by an expert committee and was applied in a pilot test.
Results. A total of 42 patient caregivers completed the final adapted questionnaire twice with
an interval of 2 weeks. Internal consistency was excellent, with Cronbach’s alpha = 0.95.        Received: March 13, 2023
Conclusions. Our study showed evidence that the Italian version of DHI-PC is a valid             Accepted: April 23, 2023
                                                                                                 Published online: July 28, 2023
and reliable tool to quantify the degree of dizziness handicap and its application is recom-
mended.
                                                                                                 Correspondence
KEY WORDS: quality of life, children, questionnaire, dizziness, vertigo                          Giorgia Rossi
                                                                                                 Unit of Otorhinolaryngology - Head and Neck
                                                                                                 Surgery, Fondazione Policlinico Universitario
RIASSUNTO                                                                                        A. Gemelli IRCCS, largo A Gemelli 8, 00168
Obiettivo. Il questionario Vanderbilt Pediatric Dizziness Handicap Inventory per i caregi-       Rome, Italy
vers (DHI-PC) è uno strumento di valutazione della qualità della vita utile nei bambini che      Tel. +39 06 30154439
soffrono di capogiri, vertigini o instabilità. La versione in lingua inglese è stata validata    E-mail: giorgia.ros@tiscali.it
su una popolazione di età compresa tra 5 e 12 anni. Lo scopo di questo lavoro è validare il
questionario DHI-PC in italiano per migliorare la valutazione del paziente pediatrico e la         How to cite this article: Picciotti PM, Rossi G,
scelta di un appropriato programma di riabilitazione.                                              Settimi S, et al. Validity of Italian adaptation of the
Materiali e metodi. L’adattamento interculturale del DHI-PC è stato eseguito utilizzando           Vanderbilt Paediatric Dizziness Handicap Inven-
un metodo standardizzato. I campi del DHI-PC originale sono stati tradotti in italiano da          tory. Acta Otorhinolaryngol Ital 2023;43:341-347.
due traduttori certificati bilingue. Due persone madrelingua inglesi hanno ritradotto la           https://doi.org/10.14639/0392-100X-N2552
nuova versione che è stata confrontata con l’originale per verificarne l’equivalenza seman-
tica. Una versione preliminare del questionario tradotto è stata elaborata da un comitato        © Società Italiana di Otorinolaringoiatria
                                                                                                 e Chirurgia Cervico-Facciale
di esperti e somministrata in un test pilota.
Risultati. Un totale di 42 caregivers di pazienti pediatrici ha completato il questionario
                                                                                                                OPEN ACCESS
finale due volte con un intervallo di due settimane. La consistenza interna si è rivelata
ottima (alfa di Cronbach = 0,95).                                                                This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
Conclusioni. Il nostro studio ha dimostrato che la versione italiana del DHI-PC è uno stru-      Commercial-NoDerivatives 4.0 International) license. The
mento valido e affidabile per quantificare il grado di handicap dovuto ai sintomi capogiro       article can be used by giving appropriate credit and mentio-
e vertigini; la sua somministrazione è raccomandata.                                             ning the license, but only for non-commercial purposes and
                                                                                                 only in the original version. For further information: https://
PAROLE CHIAVE: qualità della vita, bambini, questionario, capogiro, vertigine                    creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                         341
P.M. Picciotti et al.




Introduction                                                     Materials and methods
Until a few years ago, dizziness in children was considered      Participants
an extremely rare condition. However, studies on paediat-        Forty-two children (23 M, 19 F) between 5 and 12 years
ric vestibology have greatly increased over the past dec-        of age, experiencing dizziness and/or unsteadiness, were
ade. Vertigo and dizziness are common but often delayed          recruited in the Audiology Department of the Fondazione
or missed symptoms in children 1. Literature has shown           Policlinico Universitario A. Gemelli - IRCCS from January
that dizziness occurs in > 5% of school-aged children lead-      2021 to December 2022.
ing to considerable restrictions on participation in school      Inclusion criteria were: (a) aged 5-12 years; (b) clinical his-
and leisure activities 2. Epidemiological data confirm that      tory of vertigo or dizziness of any type irrespective of the
migraine is the most important cause of vertigo in chil-         frequency and intensity of episodes; (c) attend mainstream
dren 3. The Bárány Society 4 recently described a spectrum       school. Exclusion criteria included children with: (a) neuro-
of three disorders in which the migraine component var-          logical associated disease and cognitive ability impairment
ies from definite to possibly absent: Vestibular Migraine of     which significantly restrict his/her participation in social or
Childhood, probable Vestibular Migraine of Childhood and         educational activities; (b) significant learning difficulties;
Recurrent Vertigo of Childhood. Other described causes           or (c) orthopaedic deficit affecting balance and gait.
are benign paroxysmal vertigo as a migraine precursor, so-       Vestibular assessment included a detailed collection of the
matoform, orthostatic, or post-traumatic dizziness.              medical history and complete neuro-otological examination.
Paediatricians, otolaryngologists and neurologists often ex-     It is emphasised that reports of vertigo/dizziness with isolated
perience difficulty in establishing an appropriate diagnosis     episodes were not considered. During routine consultations to
in these cases. Moreover, vestibular tests, both clinical and    the Department of Audiology, the adapted version of the DHI-
instrumental, are not always reliable in younger patients.       PC was administered to 42 legal guardians with mastery of
As we have previously described 5, vestibular assessment         basic written and oral command of the Italian language.
process in children is challenging. In fact, evaluation of the   Demographic and clinical data of patients enrolled are re-
vestibular system in children is difficult to perform due to     ported in Table I.
side effects and poor compliance. Assessment is based on
bedside examination, video head impulse test (video-HIT),        Questionnaire translation and cross-cultural adaptation
static and dynamic posturography and vestibular evoked           Preliminary to the beginning of the adaptation work, we
myogenic potentials (VEMPs).                                     contacted by e-mail the authors to obtain the consent to the
Furthermore, the inability of children, especially very          translation of DHI-PC. They answered with enthusiastic
young, to explain the characteristics of their vertigo or        consent.
dizziness may preclude diagnosis, which can lead to dif-         We translated in Italian and adapted the Vanderbilt Paedi-
ficult evaluation of evolution of symptoms (improving or         atric Dizziness Handicap Inventory for patient caregivers
worsening) over time or after therapy. The administration        (DHI-PC) 7 following stage by stage the Guidelines of Bea-
of self-assessment outcome measures by questionnaires is
the routine in a clinical setting for different symptoms and
                                                                 Table I. Description of participants’ characteristics.
diseases. In fact, disability/handicap self-report measures
                                                                  Characteristics                                         Patients (n = 42)
for vertigo and/or dizziness in the adult population helps
                                                                  Age                                                     6.74 (SD = 1.70)
physicians in clinical evaluation and follow-up. Jacobson
                                                                  Gender
and Newman 6 developed the DHI in 1990. In 2015, Mc
                                                                    Female, n (%)                                            19 (45.2%)
Caslin 7 developed a paediatric adaptation of the Dizziness
                                                                    Male, n (%)                                              23 (54.8%)
Handicap Inventory, called DHI-PC, for paediatric patients
                                                                  Diagnosis
between 5 and 12 years of age. The questionnaire has 21
                                                                    No vestibular disease                                    39 (93%)
items, a maximum score of 84% and caregivers complete it.
                                                                    Presence of migraine                                     18 (43%)
Although there is a validated translation of DHI for adults
                                                                    Hearing impairment                                       7 (16.7%)
by Nola et al. 8, to our knowledge there are no Italian trans-
lations of this adapted questionnaire for children. The aim         Binocular vision difficulty                              9 (21.4%)
of this paper is to translate and perform a cross-cultural ad-      Syndrome with neurological features                       5 (12%)
aptation of the DHI-PC into Italian in order to better assess       Benign paroxysmal positional vertigo (BPPV)              1 (2.4%)
Italian children suffering from vertigo and/or dizziness.           Post-traumatic                                           1 (2.4%)




342
                                                                                    Adaptation of the Paediatric Dizziness Handicap Inventory into Italian




ton et al. 9 for the process of cross-cultural adaptation of                      phase, two native English speakers with no medical back-
self-report measures (Fig. 1).                                                    ground translated the new version of the questionnaire
• stage I: initial translation (from English to Italian). As                      in English, blind to the original version. This backward
   suggested by Beaton et al. 9 two independent translations                      translation was intended to verify its validity, confirming
   were made by bilingual translators, with different pro-                        the fidelity of the contents with respect to the original.
   files and background, mother tongue in Italian language.                       Even at this stage, we did not highlight any major incon-
   This is very important because in this way it is possible                      sistencies or conceptual errors in the translation;
   to have greater accuracy on the nuances of the final lan-                  •   stage IV: expert committee. The composition of the com-
   guage. We compared the two translations, and found no                          mittee consisted of a methodologist, two health profes-
   discrepancies or ambiguities. Moreover, each translator                        sionals, a language professional and the two previously
   produced a written report of the translation. From these                       cited translators. The role of the expert committee was to
   comments, no sentences that were too demanding or un-                          consolidate the versions of the questionnaire and to de-
   certainties were highlighted;                                                  velop a pre-final version for clinical experimentation. The
• stage II: synthesis of the translation. The two transla-                        committee then examined the translations and reached
   tors and an observer worked together to summarise the                          a consensus in the absence of any discrepancy. In addi-
                                                                                  tion, in this case a written report was provided regarding
   results of the translations. They produced a synthesis,
                                                                                  the decisions reached. The ultimate goal was to achieve
   starting from the original questionnaire, and then ana-
                                                                                  equivalence between the source and target versions in four
   lysing the first translation and the second version. In ad-
                                                                                  areas: semantic, idiomatic, experiential and conceptual;
   dition, in this phase, a report was drawn up in which no
                                                                              •   stage V: test of the pre-final version. In this phase, the
   relevant and unresolved problems were highlighted;
                                                                                  test was used in its preliminary version, administering
• stage III: back translation (from Italian to English). Start-                   the questionnaire to the parents of children with reported
   ing from the Italian synthesis obtained in the previous                        vertigo or dizziness. We included 18 children (10 M, 8 F)
                                                                                  aged between 5 and 12 years. All caregivers completed
                                                                                  the questionnaire. In addition, interviews were carried out
                                                                                  to probe the impressions and evaluate the good under-
                                                                                  standing of the single items. The distribution of responses
                                                                                  was assessed, and no missing elements were identified;
                                                                              •   stage VI: submission of documentation to the developers
                                                                                  or coordinating committee for appraisal of the adapta-
                                                                                  tion process. In this final phase of the adaptation pro-
                                                                                  cess, the translations and reports of the previous stages
                                                                                  were presented to the committee;
                                                                              •   clinical trial: the DHI-PC Italian version is a 21-item vali-
                                                                                  dated questionnaire (Tab. II). The translated and adapted
                                                                                  final copy of the questionnaire was administered to the
                                                                                  patient caregivers twice (not including the pretest popu-
                                                                                  lation). The re-test was performed with an interval of 2
                                                                                  weeks after the first collection to avoid changes in the sub-
                                                                                  jects’ medical conditions within this period. The patient
                                                                                  caregivers were asked to identify difficulties that their
                                                                                  child may be experiencing because of his or her dizziness
                                                                                  or unsteadiness in the past 4 weeks, on a 3-point scale:
                                                                                  “yes”, “sometimes”, “no”. Scoring was achieved by rating
                                                                                  the item responses from one to three, with three represent-
                                                                                  ing better quality of life related to vertigo/dizziness.

                                                                              Statistical analysis
                                                                              Continuous variables were expressed as means and stand-
Figure 1. Graphic representation of the stages of cross-cultural adaptation   ard deviation. Categorical variables were summarised as
process as suggested by Beaton et al. 9.                                      counts and percentages.



                                                                                                                                                    343
P.M. Picciotti et al.




Table II. Italian version of the Pediatric Dizziness Handicap Inventory questionnaire for caregivers (DHI-PC).
                                                                                                                             Sì (4)   Qualche     No (0)
                                                                                                                                      volta (2)
 1      A causa del suo problema il bambino/a si sente stanco/a?
 2      La vita del bambino/a è condizionata dal suo problema?
 3      Il problema del suo bambino/a gli impedisce di giocare?
 4      A causa del suo problema, il bambino/a si sente frustrato/a?
 5      A causa del suo problema, il bambino/a si sente imbarazzato/a di fronte agli altri?
 6      A causa del suo problema, il bambino/a ha difficoltà a concentrarsi?
 7      A causa del suo problema, il bambino/a è teso?
 8      Le altre persone sembrano irritate dal problema del suo bambino/a?
 9      A causa del suo problema, il suo bambino/a appare preoccupato?
 10     A causa del suo problema, il suo bambino/a si sente arrabbiato?
 11     A causa del suo problema, il suo bambino/a si sente avvilito?
 12     A causa del suo problema, il suo bambino/a si sente infelice?
 13     A causa del suo problema, il suo bambino/a si sente diverso/a dagli altri bambini?
 14     Il problema del suo bambino/a limita significativamente la sua partecipazione ad attività sociali o educative come
        andare fuori a cena, o in gita, incontrare gli amici, partecipare a una festa?
 15     A causa del suo problema, il suo bambino/a ha difficoltà a camminare in casa al buio?
 16     A causa del suo problema, il suo bambino/a ha difficoltà a salire le scale?
 17     A causa del suo problema, il suo bambino/a ha difficoltà a camminare uno o due isolati?
 18     A causa del suo problema, il suo bambino/a ha difficoltà ad andare in bicicletta o in scooter?
 19     A causa del suo problema, il suo bambino/a ha difficoltà a leggere o fare i compiti?
 20     Il problema del suo bambino/a gli impedisce di svolgere con successo attività che altri bambini della sua età
        svolgono?
 21     A causa del suo problema, il suo bambino/a ha difficoltà di concentrazione a scuola?



Internal consistency reflects the extent to which the ques-                         In our study, 43% of children presented with a history of
tionnaire items are inter‑correlated, or whether they are                           migraine. The majority of patients did not present vestibu-
consistent in measurement of the same construct. Internal                           lar dysfunction (93%). In all, 16.7% of children reported
consistency of DHI-PC questionnaire was tested using                                hearing difficulty. The frequency and duration of dizziness
Cronbach’s coefficient alpha, which ranges from zero to                             was described in many cases as recurrent episodes that
one. Values at least 0.7 were regarded as satisfactory.                             came on suddenly during the day and lasted from a few sec-
Reproducibility, or test-retest reliability, was assessed us-                       onds to a few minutes, with high association with migraine.
ing Pearson’s correlation coefficient between the first and                         Most paediatric patients did not have disabilities in the
the second administrations of the questionnaire. A larger                           scores analysed.
stability coefficient indicates stronger test‑retest reliability,                   Internal consistency was excellent, with Cronbach’s al-
reflecting that measurement error of the questionnaire is                           pha = 0.95.
less likely to be attributable to changes in the individuals’                       Test-retest reliability for the Italian version was confirmed
responses over time.                                                                by the Pearson correlation coefficient (r = 0.95, p < 0.001).
P-values < 0.001 were considered statistically significant.                         A significant test-retest reliability was also found between
Statistical analyses were performed using SPSS Version 26                           the Italian and English versions (r = 0.96, p < 0.001).
(IBM Corp., Armonk, NY, USA).                                                       All items showed a Pearson’s r > 0.70 in the test-retest reli-
                                                                                    ability analysis. Detailed results of the reliability tests for
Results                                                                             all items are reported in Table III.

The results corresponded to 42 individuals, of whom 23 were
male (54.8%) and 19 female (45.2%). The age ranged from
                                                                                    Discussion
5 to 12 years with a mean of 6.74 years (SD = 1.70) (Tab. I).                       Dizziness can affect children and adolescents, interfering in



344
                                                                          Adaptation of the Paediatric Dizziness Handicap Inventory into Italian




psychological behaviour, ability to communicate, learning          Table III. Descriptive item statistics of the Italian version of the DHI-PC.
process and academic performance 10. Symptoms may include                                                                r             P-value
decreased postural control, impaired gaze stability, headache,      Internal consistency test
inability to perform coordinated movements, falls while play-       Cronbach alpha = 0.95
ing, abnormal spatial and positional perception 11,12. Only re-     Test-retest correlation
cently, the researchers systematically documented the effects          Q1                                              0.82           < 0.001
of vestibular impairments on everyday activities of children/          Q2                                              0.87           < 0.001
adolescents and then the impact on QoL 13,14.                          Q3                                              0.80           < 0.001
Our results demonstrated that DHI-PC was satisfactorily                Q4                                              0.90           < 0.001
adapted both culturally and linguistically in the Italian              Q5                                              0.77           < 0.001
population. It showed a good reliability and can therefore             Q6                                              0.88           < 0.001
be recommended in the assessment of disability in Italian              Q7                                              0.82           < 0.001
children with dizziness. McCaslin et al. 7 first developed the         Q8                                              0.76           < 0.001
questionnaire DHI-PC. They demonstrated that it is a con-              Q9                                              0.95           < 0.001
sistent and reliable tool to quantify the degree of dizzying           Q10                                             0.84           < 0.001
disability in a child’s life. Similar to the widely accepted           Q11                                             0.76           < 0.001
self-report questionnaire for adults, the paediatric DHI as-           Q12                                             0.77           < 0.001
sesses the psychosocial impact of dizziness and the related            Q13                                             0.76           < 0.001
degree of handicap affecting QoL. It is also useful to assess          Q14                                             0.82           < 0.001
the effectiveness of treatment and monitoring the progress             Q15                                             0.80           < 0.001
during rehabilitation 7.                                               Q16                                             0.77           < 0.001
There is currently a version of the DHI children/adolescent            Q17                                             0.82           < 0.001
(DHI-CA) published by Sousa et al. 15 in Brazilian Portu-              Q18                                             0.87           < 0.001
guese, adapted for use in children over 4 years of age. Very           Q19                                             0.76           < 0.001
recently, a cross-cultural adaptation of this version was              Q20                                             0.76           < 0.001
carried by Sommerfleckout et al. 16 into Spanish (Argen-               Q21                                             0.82           < 0.001
tine). To our knowledge, there is not an Italian question-             Total                                           0.95           < 0.001
naire available for the Italian younger population and none         Italian - English test-retest correlation
referred to caregivers of paediatric patients. Our study is            Q1                                              0.94           < 0.001
the first leading to the validation of the DHI-PC in Italian           Q2                                              0.95           < 0.001
language.                                                              Q3                                              0.94           < 0.001
It is well known that in the adult population the DHI ques-            Q4                                              0.73           < 0.001
tionnaire is widely used in clinical practice and translated           Q5                                              0.76           < 0.001
into several regions, including Germany, France, Spain,
                                                                       Q6                                              0.99           < 0.001
Brazil, Portugal, Norway, Holland, Bulgaria, Japan, Israel,
                                                                       Q7                                              0.94           < 0.001
China and Colombia. In particular, in 2010 Nola et al. 8
                                                                       Q8                                              0.90           < 0.001
translated into Italian the DHI and, more recently, Colnaghi
                                                                       Q9                                              0.94           < 0.001
et al. 17 translated the Situational Vertigo Questionnaire
                                                                       Q10                                             0.73           < 0.001
(SVQ) and the Activity-Specific Balance Confidence Scale
                                                                       Q11                                             0.73             0.01
(ABC). It was demonstrated that when used in association
                                                                       Q12                                             0.76           < 0.001
with the medical history and physical examination, the DHI
                                                                       Q13                                             0.90           < 0.001
was useful in providing reproducible, quantifiable, and ap-
                                                                       Q14                                             0.90           < 0.001
plicable results for patient wellbeing 16,18. Equally, in the
                                                                       Q15                                             0.76           < 0.001
present study, the Italian version of DHI-PC proved to be
                                                                       Q16                                             0.90             0.01
satisfactory for measurement properties, as a discriminating
                                                                       Q17                                             0.90           < 0.001
and evaluative tool.
                                                                       Q18                                             0.90           < 0.001
A difference between adult and paediatric DHI is that the
                                                                       Q19                                             0.76           < 0.001
former is useful to evaluate the interference of dizziness self-
perceived by the patient in three subscales: emotional, func-          Q20                                             0.73           < 0.001
tional and physical 6. The DHI-PC, instead, investigates two           Q21                                             0.76           < 0.001
different handicaps: functional and emotional 7. In particular,        Total                                           0.96           < 0.001




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P.M. Picciotti et al.




the functional domain is related to the inability to carry out     to the traditional vestibular examination and which could
domestic, school, social and leisure activities as well as basic   be administered as a parental proxy.
tasks such as walking in the dark or climbing stairs without       Another interesting finding assessed by the DHI-PC in our
help. Emotional impairment includes the psychological and/         study is that 36% (15/42 patients) had moderate disabil-
or psychiatric disadvantages resulting from dizziness, such        ity in the emotional domain. This result confirms the data
as frustration, concentration disturbances, changes in social      of Paiva and Kuhn 22 who demonstrated that patients with
relationships, anxiety and depression.                             vertigo have concomitant psychological symptoms in up to
The statistical analysis of our data showed that the internal      56.38% of patients. Nevertheless, our data revealed that the
consistency of the results obtained with the DHI-PC proved         emotional features were less affected than the functional
to be adequate (alpha = 0.95). Furthermore, the results ob-        domain as already shown by other researchers with adult
tained in a second application of the instrument showed ad-        patients 8. In line with the authors 23,24, we suggest that the
equate stability of the measurements obtained in the two ap-       functional limitation is more prevalent in children feeling
plications. In broad terms, the retest confirmed the stability     dizzy, probably due to the restriction of the activities with
of the instrument with regard to the internal consistency of       the intention of avoiding the onset of acute symptoms.
the items. These data confirm the validity and reliability of      Nonetheless, as highlighted in the literature 16, the emotion-
our translation. In fact, we followed in an orderly and rigor-     al and functional impact of vertigo or balance disturbances
ous manner the phases indicated in the specific literature for     in children is less than in the general population. Certainly
the translation of the evaluation questionnaires 9.                children improve quickly and compensate more easily than
Based on our experience with the paediatric DHI adminis-           adults: this explains why few children present a DHI-PC
tered to caregivers, we believe that additional advantages of      with disability indexes and always mild-moderate.
the DHI-PC questionnaire include its ease of application,          Future perspectives for the DHI-PC may include additional
short time administration and easy interpretation. The use-        populations such as older children (i.e. 13-17 years) as well
fulness of the DHI-PC questionnaire is even more evident           as younger children (i.e. less than 5 years of age). Current-
considering that screening children for dizziness, vertigo         ly, there is not psychometrically dizziness measure avail-
and vestibular diseases is still an uncommon practice in           able to these paediatric age groups, and the adult DHI has
most centers and it is well known that conventional diag-          been validated only in adolescents diagnosed with Audi-
nostic tests of the vestibular system often fail especially at     tory Neuropathy Spectrum Disorder 25. Additionally, future
cause of nonconformity behavior in the child 19. In our re-        studies may expand the application of DHI-PC to point out
sults, we demonstrated that 93% of children did not show           that the use of this tool may positively impact on the evalu-
vestibular dysfunction at clinical examination and in these        ation of postural disabilities.
conditions, DHI-PC is useful to confirm clinical data.
We therefore propose to use this questionnaire in all chil-
                                                                   Conclusions
dren with dizziness or balance disorders as a part of moni-
toring and assessment protocols. It could be also useful in        Vestibular diagnostic tests are difficult to perform in chil-
children with deafness 20 to understand possible impairment        dren and often cannot be predictive of vestibular system
of the posterior labyrinth, in candidates to cochlear implant      impairment. Moreover, younger children are not able to ex-
or in implanted children, in patients with syndromic deaf-         press the specific nature of their dizziness and the repercus-
ness and inner ear malformations. Additionally, knowing            sions on the everyday activities imposed by compromised
the degree of dizziness handicap coupled with diagnostic           balance. The DHI-PC is a reliable tool to assess the impact
and functional information should enable clinicians to de-         of paediatric dizziness on the quality of life of the paediat-
velop an appropriate rehabilitative treatment plan. Finally,       ric population through the perspective of the caregiver. The
clinicians should administer DHI-PC in the follow up of            DHI-PC was culturally and linguistically adapted for use in
dizziness to evaluate the results of medical, surgical or re-      the Italian population. It should be administered in children
habilitative therapy.                                              with dizziness and postural impairment.
DHI-PC administered to caregivers achieved benefit in pro-
viding information regarding young children who have not           Acknowledgements
developed the language level needed to accurately describe         We would like to thank Devin L. McCaslin for permission to
dizziness. This may make it difficult for the specialist to        adapt this questionnaire cross-culturally. Authors thank the
investigate the severity of the symptoms 21. For all these         parents of the children involved, Professor Franca Cassarà and
reasons, it may be useful for clinicians to have a measure to      Professor Alessandra Compagnucci, who contributed to the
assess the impact of symptoms on quality of life in addition       process of translation and adaptation of the questionnaire.



346
                                                                                        Adaptation of the Paediatric Dizziness Handicap Inventory into Italian




Conflict of interest statement                                                  10
                                                                                     Bigelow RT, Semenov YR, Hoffman HJ, et al. Association between
The authors declare no conflict of interest.                                         vertigo, cognitive and psychiatric conditions in US children: 2012
                                                                                     National Health Interview Survey. Int J Pediatr Otorhinolaryngol
                                                                                     2020;130:109802. https://doi.org/10.1016/j.ijporl.2019.109802
Funding                                                                         11
                                                                                     Devaraja K. Vertigo in children; a narrative review of the vari-
This research did not receive any specific grant from fund­                          ous causes and their management. Int J Pediatr Otorhinolaryngol
ing agencies in the public, commercial, or not-for-profit                            2018;111:32-38. https://doi.org/10.1016/j.ijporl.2018.05.028
sectors.                                                                        12
                                                                                     Fancello V, Palma S, Monzani D, et al. Vertigo and dizziness in
                                                                                     children: an update. Children (Basel) 2021;8:1025. https://doi.
                                                                                     org/10.3390/children8111025
Author contributions                                                            13
                                                                                     Deissler A, Albers L, Von Kries R, et al. Health-related quality of
PMP: ideation, methodology, draft, supervision and re-                               life of children/adolescents with vertigo: retrospective study from
view; PMP, GR: data collection and processing, analysis,                             the German center of vertigo and balance disorders. Neuropediatrics
literature review, writing, editing; SS, MC: assisted in data                        2017;48:91-97. https://doi.org/10.1055/s-0037-1598645
management; JG, ARF: critical review. All authors read
                                                                                14
                                                                                     Singh A, Heet H, Guggenheim DS, et al. A systematic review on the
                                                                                     association between vestibular dysfunction and balance performance
and approved the last version of the manuscript.                                     in children with hearing loss. Ear Hear 2022;43:712-721. https://doi.
                                                                                     org/10.1097/AUD.0000000000001131
Ethical consideration                                                           15
                                                                                     Sousa MGC, Cruz O, Nery Santos A, et al. Brazilian adaptation of
This study was performed in accordance with the ethical                              the dizziness handicap inventory for the pediatric population: reliabil-
                                                                                     ity of the results. Audiol Commun Res 2015;20:327‑335. https://doi.
standards of the National Research Committee and with                                org/10.1590/2317-6431-2015-1595
the 1964 Helsinki Declaration and its later amendments.                         16
                                                                                     Sommerfleck PA, Piraíno RM, Bisogno JP. Cross-cultural adapta-
Informed consent to the use of their data was obtained from                          tion of the dizziness handicap inventory – child/adolescent to span-
all the patient caregivers. Approval from the ethics commit-                         ish version. Analysis of its application in children. Acta Otorrino-
tee is not required for this type of study in our institution.                       laringol Esp (Engl Ed) 2023;74:23-30. https://doi.org/10.1016/j.
                                                                                     otoeng.2023.01.002
                                                                                17
                                                                                     Colnaghi S, Rezzani C, Gnesi M, et al. Validation of the Italian ver-
References                                                                           sion of the dizziness handicap inventory, the situational vertigo ques-
                                                                                     tionnaire, and the activity-specific balance confidence scale for pe-
1
    Balatsouras DG, Kaberos A, Assimakopoulos D, et al. Etiology of                  ripheral and central vestibular symptoms. Front Neurol 2017;8:528.
    vertigo in children. Int J Pediatr Otorhinolaryngol 2007;71:487‑494.             https://doi.org/10.3389/fneur.2017.00528
    https://doi.org/10.1016/j.ijporl.2006.11.024
                                                                                18
                                                                                     Koppelaar-van Eijsden HM, Schermer TR, Bruintjes TD. Measure-
2
    Jahn K.Vertigo and dizziness in children. Handb Clin Neurol 2016;137:353-
                                                                                     ment properties of the dizziness handicap inventory: a systematic
    363. https://doi.org/10.1016/B978-0-444-63437-5.00025-X.
                                                                                     review. Otol Neurotol 2022;43:E282-E297. https://doi.org/10.1097/
3
    Langhagen T, Lehrer N, Borggraefe I, et al. Vestibular migraine in               MAO.0000000000003448
    children and adolescents: clinical findings and laboratory tests. Front     19
                                                                                     Pavlou M, Whitney SL, Alkathiry AA, et al. Visually induced dizzi-
    Neurol 2014;5:292. https://doi.org/10.3389/fneur.2014.00292
                                                                                     ness in children and validation of the pediatric visually induced dizzi-
4
    Van de Berg R, Widdershoven J, Bisdorff A, et al. Vestibular mi-                 ness questionnaire. Front Neurol 2017;8:656. https://doi.org/10.3389/
    graine of childhood and recurrent vertigo of childhood: diagnostic               fneur.2017.00656
    criteria consensus document of the Committee for the Classification
    of Vestibular Disorders of the Bárány Society and the International
                                                                                20
                                                                                     O’Reilly RC, Morlet T, Nicholas BD, et al. Prevalence of vestibular
    Headache Society. J Vestib Res 2021;31:1-9. https://doi.org/10.3233/             and balance disorders in children, Otol Neurotol 2010;31:1441‑1444.
    VES-200003                                                                       https://doi.org/10.1097/MAO.0b013e3181f20673
5
    Picciotti PM, Fiorita A, Di Nardo W, et al. Vestibular evoked myogenic
                                                                                21
                                                                                     Martín Sanz E, Barona de Guzmán R. Vértigo paroxístico benigno
    potentials in children. Int J Pediatr Otorhinolaryngol 2007;71:29‑33.            infantil: categorización y comparación con el vértigo posicional par-
    https://doi.org/10.1016/j.ijporl.2006.08.021                                     oxístico benigno del adulto [Benign paroxysmal vertigo of childhood:
                                                                                     categorization and comparison with benign positional paroxysmal
6
    Jacobson GP, Newman CW. The development of the dizziness handi-
                                                                                     vertigo in adult] Acta Otorrinolaringol Esp 2007;58:296‑301.
    cap inventory. Arch Otolaryngol Head Neck Surg 1990;116:424‑427.
    https://doi.org/10.1001/archotol.1990.01870040046011
                                                                                22
                                                                                     Paiva AD, Kuhn AMB. Psychological symptoms associated to dizzi-
                                                                                     ness complaint in neurootological patients of Universidade Federal
7
    McCaslin DL, Jacobson GP, Lambert W, et al. The development of the
                                                                                     de São Paulo - Escola Paulista de Medicina. R Bras Otorrinolaringol
    vanderbilt pediatric dizziness handicap inventory for patient caregiv-
                                                                                     2004;70:512-515.
    ers (DHI-PC). Int J Pediatr Otorhinolaryngol 2015;79:1662‑1666.
    https://doi.org/10.1016/j.ijporl.2015.07.017                                23
                                                                                     Nyabenda A, Briart C, Deggouj N, et al. Normative study and reli-
8
    Nola G, Mostardini C, Salvi C, et al. Validity of italian adaptation of          ability of French version of the dizziness handicap inventory. Ann
    the dizziness handicap inventory (DHI) and evaluation of the qual-               Readapt Med Phys 2004;47:105-113.
    ity of life in patients with acute dizziness. Acta Otorhinolaryngol Ital    24
                                                                                     Ten Voorde M, Zaag-Loonen HJ, Leeuwen RB. Dizziness impairs
    2010;30:190.                                                                     health-related quality of life. Quali Life Res 2012;21:961‑966. https://
9
    Beaton DE, Bombardier C, Guillemin F, et al. Guidelines for                      doi.org/10.1007/s11136-011-0001-x
    the process of cross-cultural adaptation of self-report meas-               25
                                                                                     Prabhu P, Jamuar P. Evaluation of dizziness handicap in adolescents and
    ures. Spine (Phila Pa 1976) 2000;25:3186‑3191. https://doi.                      adults with auditory neuropathy spectrum disorder. Int Arch Otorhi-
    org/10.1097/00007632-200012150-00014                                             nolaryngol 2018;22:14-18. https://doi.org/10.1055/s-0037-1602693




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