Edited by: Herman Kingma, Maastricht University, Netherlands
Reviewed by: Alexandre Bisdorff, Hospital Center Emile Mayrisch, Luxembourg; Tjasse Bruintjes, Gelre Hospitals, Netherlands
Specialty section: This article was submitted to Neuro-Otology, a section of the journal Frontiers in Neurology
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To develop and validate the Pediatric Visually Induced Dizziness Questionnaire (PVID) and quantify the presence and severity of visually induced dizziness (ViD), i.e., symptoms induced by visual motion stimuli including crowds and scrolling computer screens in children.
169 healthy (female
The PVID showed high internal consistency (11 items; α = 0.90). A significant between-group difference was noted with higher (i.e., worse) PVID scores for patients vs. healthy participants (
ViD is common in children with a primary concussion, migraine, or vestibular diagnosis. The PVID is a valid measure for identifying the presence of ViD in children and should be used to identify and quantify these symptoms, which require specific management incorporating exposure to optokinetic stimuli.
Vertigo and dizziness are common but often ignored (
Visually induced dizziness is the term used to define dizziness and/or unsteadiness symptoms triggered by a complex, distorted, large field/moving visual stimulus including the relative motion of the visual surround associated with body movement (
Visually induced dizziness responds well to rehabilitation incorporating structured exposure to optokinetic stimulation (
This study aimed to develop and validate the Pediatric Visually Induced Dizziness Questionnaire (PVID), to identify and quantify subjective ViD in children aged 6–17 years. Secondary study aims were to investigate ViD symptom severity in children with migraine, concussion, and/or vestibular disorders and to investigate the relationship between ViD and behaviors indicative of psychological problems in these children vs. healthy controls.
The PVID design and validation (
Three consultant pediatric audio-vestibular physicians, two physical therapists, and a psychologist constructed and selected questionnaire items from symptoms recorded in clinic reports for children diagnosed with a vestibular disorder at the Audiological Medicine Department, Great Ormond Street Hospital (GOSH), London, UK and the validated Situational Characteristic Questionnaire (SCQ) (
The 11-item questionnaire was modified (wording alterations, bigger font size) after review for ease of completion and acceptability by 10 healthy children and 5 with a vestibular disorder aged 6–15 years. Each item was rated on a 0 (never) to 3 (most of the time) scale; a “don’t know” category was also included. The total score ranged from 0 to 33 and was normalized using the equation: total score/(total question number − “don’t know” replies) to yield a score of 0–3 with higher scores indicating greater symptom severity. For the final questionnaire, see Table
The pediatric visually induced dizziness questionnaire.
The following questions ask about how often you feel dizziness and unsteadiness in different places and situations. Please circle the best answer for you. | ||||
---|---|---|---|---|
How often in the past month have you felt the following? | ||||
1. Riding in a car | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
2. Walking down a supermarket aisle or in a busy shop | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
3. Standing in the middle of a wide open space (e.g., large football field or square) | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
4. Watching T.V. or at the cinema | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
5. Riding on a bus | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
6. Looking at striped or moving surface (e.g., curtains, flowing water) | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
7. Using the computer (e.g., emails, computer games) | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
8. Watching moving traffic or trains (e.g., trying to cross the street or at the station) | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
9. Playing in the playground | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
10. Doing schoolwork | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
11. Participating in sports (swimming, football, basketball, dancing) | ||||
3 | 2 | 1 | 0 | ? |
MOST OF THE TIME | SOMETIMES | ALMOST NEVER | NEVER | DON’T KNOW |
The study comprised of completing the (a) PVID; (b) question set asking about clinically diagnosed migraines, frequent dizzy spells, severe stomach pain, vomiting, loss of consciousness, binocular vision or hearing difficulty, medication, and regular doctor visits (
Primary school children in years 1 and 2 completed the PVID and PVSQ together with a parent or guardian at home; those in year 3 and above or in secondary school completed them independently in the classroom under the standardized direction of a research team member. General questions were completed together with a parent or guardian at home. Children with a vestibular disorder or concussion and their parents completed the questionnaires during their clinic appointment.
Fifty-six children experiencing dizziness and/or unsteadiness due to a peripheral vestibular disorder (
Three hundred children aged 6–17 years were recruited from three primary and two secondary mainstream schools in the Greater London area. Of these,
Children with a migraine diagnosis (
Written informed consent was obtained from all children and their parents before participating in the study in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institute of Child Health/GOSH Research Ethics Committee, London, UK and the institutional review board at the University of Pittsburgh, PA, USA.
IBM SPSSv.23 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. Data are presented as mean (standard deviation, SD). Reliability was tested using the Cronbach alpha score for total PVID items less one item at a time to examine whether reliability decreased when an item was excluded. Exploratory factor analysis with principal axis factoring (PAF) determined construct validity. The Kaiser criterion (eigenvalue ≥1), a scree plot, and parallel analysis based on minimum rank factor analysis of polychoric correlations identified how many factors should be retained (
Receiver operating curves (ROC) assessed discriminant validity to calculate the PVID’s sensitivity and specificity in discriminating normal vs. abnormal ViD symptoms. Mann–Whitney tests determined between-group (healthy vs. patient) differences for age and questionnaire data. A Chi-Squared test determined between-group gender differences. Spearman’s correlation investigated associations between PVID, SDQ, and PVSQ scores, age, gender, binocular vision, hearing difficulty, and migraine history; only significant correlations are reported. Significant results were assumed if
Kruskal–Wallis test determined if differences existed in PVID and PVSQ scores between children with a primary migraine, concussion, or vestibular diagnosis. Pairwise comparisons were subsequently performed using Dunn’s procedure (
Mean age significantly differed between-groups (
Participant characteristics.
Variable | Patient group ( |
Healthy children ( |
---|---|---|
Age (years) (mean, range) | 12.8 (6–17) | 11.9 (6–17) |
Female, |
62 (54.4%) | 89 (52.7%) |
Male, |
52 (45.6%) | 80 (47.3%) |
Presence of migraine, |
82 (71.9%) | – |
Binocular vision difficulty, |
23 (20.5%) | 18 (10.7%) |
Astigmatism, |
2 (3.5%) | 5 (3.0%) |
Hearing difficulty, |
13 (11.6%) | 1 (0.6%) |
VN (+M) | 8 (2) | |
BVH (+SNHL) | 3 (2) | |
Post-traumatic secondary hydrops (+overlap M) | 1 (1) | |
PVD following OM (+M) | 2 (1) | |
Concussion (+M) | 42 (18) | |
Migraine | 58 |
The PVID obtained a Cronbach alpha score of 0.90. Item-deleted statistics showed no significant change in alpha scores (range 0.88–0.90). All items correlated significantly with the total score; a corrected total-item correlation ≥0.4 suggested each item had discriminative capacity.
The PAF’s suitability to the 11 PVID items was assessed prior to analysis. The correlation matrix revealed all variables had many correlation coefficients >0.3 and its factorability was confirmed (Kaiser-Meyer-Olkin value = 0.9, Bartlett’s Test of Sphericity
The PVID score significantly differed between the healthy and patient group (
Mean (SD) for questionnaire scores.
Questionnaires | Patient group; |
Healthy children; |
---|---|---|
PVID | 1.18 (0.74) | 0.28 (0.33) |
PVSQ | 1.35 (0.59) | 0.33 (0.31) |
SDQ informant rated, |
||
Total score | 19.86 (9.00) | 10.64 (4.80) |
Emotional symptom score | 4.52 (2.82) | 3.02 (2.19) |
Conduct problems scale | 2.81 (2.40) | 1.87 (1.10) |
Hyperactivity scale | 4.52 (2.00) | 3.44 (1.98) |
Peer problems score | 2.57 (1.86) | 2.31 (1.82) |
Prosocial behavior score | 8.10 (2.02) | 8.84 (3.42) |
SDQ self rated, n | ||
Total score | 13.38 (6.55) | 8.89 (4.60) |
Emotional symptom score | 4.26 (2.64) | 2.07 (1.63) |
Conduct problems scale | 2.59 (2.14) | 1.81 (1.38) |
Hyperactivity scale | 4.62 (2.36) | 3.21 (2.15) |
Peer problems score | 1.91 (1.87) | 1.81 (1.92) |
Prosocial behavior score | 7.86 (1.94) | 7.15 (2.22) |
Receiver operating curves (ROC) for various cut-off levels of the pediatric visually induced dizziness questionnaire to discriminate between healthy children and the patient group.
The only significant correlation noted was between PVID and PVSQ scores for both groups, whereby, higher scores for the former correlated with higher scores for the latter (healthy:
A significant between-group difference was noted for each individual patient group vs. the healthy group (vestibular:
Mean number ViD triggers per person were 7.94 (SD 2.65, range 1–11), 6.77 (SD 2.90, range 0–11), 5.27 (SD 3.31, range 0–11), and 2.05 (SD 2.34, range 0–10) in the vestibular, concussion, migraine, and healthy groups, respectively. No triggers were reported by 2 (
Percentage endorsement for each Pediatric Visually Induced Dizziness Questionnaire (PVID) item for the healthy and individual patient groups based on primary diagnosis.
Endorsement for each item (%) |
||||
---|---|---|---|---|
PVID item | Healthy ( |
Migraine ( |
Concussion ( |
Vestibular ( |
Riding in a car | 68.3 | 71.4 | ||
Walking down a supermarket aisle or in a busy shop | 7.7 | 46.6 | 61.0 | 76.9 |
Standing in the middle of a wide open space | 8.9 | 43.1 | 32.5 | 71.4 |
Watching T.V. or at the cinema | 14.8 | 51.7 | 66.7 | |
Riding on a bus | 17.4 | 44.8 | 62.5 | 72.7 |
Looking at striped or moving surface | 22.6 | 63.4 | ||
Using the computer | 71.4 | |||
Watching moving traffic or trains | 17.8 | 50.0 | 65.9 | |
Playing in the playground | 14.9 | 41.4 | 37.5 | |
Doing schoolwork | 78.6 | |||
Participating in sports | 14.9 | 56.9 |
Pediatric Vestibular Symptom Questionnaire score distribution was similar across patient groups. Median PVSQ scores showed no significant differences between patient groups. 100, 97.6, and 86.2% of children with a primary vestibular, concussion, or migraine diagnosis, respectively, had abnormal PVSQ scores (
Significant between-group differences were noted for the self-rated SDQ with significantly higher scores for the patient vs. healthy group for the emotional (
In the healthy group, a significant relationship was noted between mean self-rated SDQ emotional and both PVID (
This is the first study to provide evidence that ViD exists in childhood, with significant differences noted between the healthy and patient group for ViD symptom severity, number of PVID items endorsed, and SDQ scores. The number of children reporting visual environmental triggers, mean number of items endorsed by each child in the patient groups, and percentage endorsement for each item is significantly greater than that noted in adults with a vestibular disorder (
Children with a vestibular disorder endorsed all PVID items highly. The main triggers endorsed by children with concussion and/or migraine were also diverse, with computer use and doing schoolwork identified as key triggers. Recent studies have indicated an association between increased screen time, headache frequency (
Visually induced dizziness is believed to be due to visual dependency (
The relationship between motion sickness and increased visual dependence also exists with a stronger influence of disorienting visual stimuli on verticality perception (
No relationship was noted between the presence of a binocular visual abnormality and PVID scores. This finding is in agreement with adult data showing no difference in baseline ViD scores between persons with a vestibular disorder with and without binocular vision abnormalities (
Children with a primary migraine diagnosis had been diagnosed by their primary care physician. An abnormal PVSQ score was noted in 86.2%, indicating increased vestibular symptoms, while PVID scores were abnormal for 72% with 95% endorsing at least one symptom trigger. Vestibular symptoms of dizziness and ViD may indicate vestibular migraine (
Children with concussion, migraine, and/or vestibular disorder should also be screened for associated psychological symptoms, perceived handicap, and QOL (
Increased sensitivity to visual motion stimuli has been reported in persons with persistent postural-perceptual dizziness (PPPD), functional dizziness, and chronic subjective dizziness (CSD) (
Greater difficulties at school and decreased academic performance are reported for children with concussion or migraine, with contributing factors including headache severity and impact, work accumulation from missing school, potential stress associated with this, and cognitive effects particularly following concussion (
A significant relationship was also noted between PVID, PVSQ, and self-rated SDQ scores in healthy participants. In healthy adolescents, a significant correlation exists between subjective health complaints (i.e., dizziness, fatigue), focusing on re-occurring symptom frequency rather than diagnoses, and higher SDQ scores, indicating greater emotional/behavioral problems (
The PVID provides a valid tool that may reliably identify ViD. A ROC area under the curve indicates a test with “good accuracy” in separating those with and without abnormal ViD symptom levels (
Some study limitations were present. No neuro-otological assessment was completed for children with a primary migraine diagnosis as they were recruited from mainstream schools and no information was collected about migraine characteristics, academic performance, and QOL, which may have provided greater insight into the relationships between these factors and ViD. The absence of data regarding wearing glasses and further details of squints and stereoscopy is also a study limitation. Further research on test–retest reliability and responsiveness to change over time is needed to further validate the PVID for clinical use. Currently, the questionnaire is not validated for children with learning disabilities, as questionnaires should be specifically adapted for populations experiencing reading and comprehension difficulties (
Increased ViD symptoms are present in children with migraine, concussion, and/or vestibular disorders. Increased knowledge translation is required so that health-care professionals are aware of these symptoms and how to identify them. The PVID is a reliable and valid measure for assessing ViD presence and severity in children. A better understanding of the relationships between symptoms, symptom triggers, functional domains, and QOL may improve the management approach and outcome for these children.
This study was carried out in accordance with the recommendations of the Institute of Child Health/GOSH Research Ethics Committee, London, UK and the institutional review board at the University of Pittsburgh, PA, USA. Ethical approval was obtained from the Institute of Child Health/GOSH Research Ethics Committee, London, UK and the institutional review board at the University of Pittsburgh, PA, USA. Written informed consent was obtained from all children and their parents before participating in the study in accordance with the Declaration of Helsinki.
MP conceptualized and designed the study, contributed to the design of the data collection instrument, collected data for children with vestibular disorders from GOSH, London, UK, contributed to data analyses, drafted the initial manuscript, and approved the final manuscript as submitted. SW contributed to the design of the data collection instrument, coordinated and supervised data collection at UPMC, Pittsburgh, PA, USA, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. AA was involved in data collection at UPMC and carried out the initial analyses. MH coordinated and supervised data collection at all five sites for the healthy control group, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. EG contributed to the study design, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. LL, ER, and DEB contributed to the design of the data collection instrument, recruited children with vestibular disorders from GOSH, critically reviewed and revised the manuscript and approved the final manuscript as submitted. DEB also contributed to data analyses.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We would like to thank Dr. Victoria Cornelius, Senior Lecturer in Medical Statistics and Clinical Trials, Imperial College London, and Joint Academic Lead for the Research Design Service for West London, for her review of the statistical analysis and results.
PVID, pediatric visually induced dizziness questionnaire; ViD, visually induced dizziness; QOL, quality of life; GOSH, Great Ormond Street Hospital; UPMC, University of Pittsburgh Medical Center; SDQ, strength and difficulties questionnaire; PVSQ, pediatric vestibular symptom questionnaire; PAF, principal axis factoring; ROC, receiver operating curves; PPPD, persistent postural-perceptual dizziness; CSD, chronic subjective dizziness; SD, standard deviation.
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