Validity of Italian adaptation of the Vanderbilt Paediatric Dizziness Handicap Inventory| ACTA Otorhinolaryngologica Italica

Abstract

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.
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.

Introduction

Until a few years ago, dizziness in children was considered an extremely rare condition. However, studies on paediatric vestibology have greatly increased over the past decade. Vertigo and dizziness are common but often delayed or missed symptoms in children ¹. Literature has shown that dizziness occurs in > 5% of school-aged children leading to considerable restrictions on participation in school and leisure activities ². Epidemiological data confirm that migraine is the most important cause of vertigo in children ³. The Bárány Society ⁴ recently described a spectrum of three disorders in which the migraine component varies from definite to possibly absent: Vestibular Migraine of Childhood, probable Vestibular Migraine of Childhood and Recurrent Vertigo of Childhood. Other described causes are benign paroxysmal vertigo as a migraine precursor, somatoform, orthostatic, or post-traumatic dizziness.

Paediatricians, otolaryngologists and neurologists often experience difficulty in establishing an appropriate diagnosis in these cases. Moreover, vestibular tests, both clinical and instrumental, are not always reliable in younger patients. As we have previously described ⁵, vestibular assessment process in children is challenging. In fact, evaluation of the vestibular system in children is difficult to perform due to side effects and poor compliance. Assessment is based on bedside examination, video head impulse test (video-HIT), static and dynamic posturography and vestibular evoked myogenic potentials (VEMPs).

Furthermore, the inability of children, especially very young, to explain the characteristics of their vertigo or dizziness may preclude diagnosis, which can lead to difficult evaluation of evolution of symptoms (improving or worsening) over time or after therapy. The administration of self-assessment outcome measures by questionnaires is the routine in a clinical setting for different symptoms and diseases. In fact, disability/handicap self-report measures for vertigo and/or dizziness in the adult population helps physicians in clinical evaluation and follow-up. Jacobson and Newman ⁶ developed the DHI in 1990. In 2015, Mc Caslin ⁷ developed a paediatric adaptation of the Dizziness Handicap Inventory, called DHI-PC, for paediatric patients between 5 and 12 years of age. The questionnaire has 21 items, a maximum score of 84% and caregivers complete it.

Although there is a validated translation of DHI for adults by Nola et al. ⁸, to our knowledge there are no Italian translations of this adapted questionnaire for children. The aim of this paper is to translate and perform a cross-cultural adaptation of the DHI-PC into Italian in order to better assess Italian children suffering from vertigo and/or dizziness.

Materials and methods

Participants

Forty-two children (23 M, 19 F) between 5 and 12 years of age, experiencing dizziness and/or unsteadiness, were recruited in the Audiology Department of the Fondazione Policlinico Universitario A. Gemelli - IRCCS from January 2021 to December 2022.

Inclusion criteria were: (a) aged 5-12 years; (b) clinical history of vertigo or dizziness of any type irrespective of the frequency and intensity of episodes; (c) attend mainstream school. Exclusion criteria included children with: (a) neurological associated disease and cognitive ability impairment which significantly restrict his/her participation in social or educational activities; (b) significant learning difficulties; or (c) orthopaedic deficit affecting balance and gait.

Vestibular assessment included a detailed collection of the medical history and complete neuro-otological examination. It is emphasised that reports of vertigo/dizziness with isolated episodes were not considered. During routine consultations to the Department of Audiology, the adapted version of the DHI-PC was administered to 42 legal guardians with mastery of basic written and oral command of the Italian language.

Demographic and clinical data of patients enrolled are reported in Table I.

Questionnaire translation and cross-cultural adaptation

Preliminary to the beginning of the adaptation work, we contacted by e-mail the authors to obtain the consent to the translation of DHI-PC. They answered with enthusiastic consent.

We translated in Italian and adapted the Vanderbilt Paediatric Dizziness Handicap Inventory for patient caregivers (DHI-PC) ⁷ following stage by stage the Guidelines of Beaton et al. ⁹ for the process of cross-cultural adaptation of self-report measures (Fig. 1).

1. stage I: initial translation (from English to Italian). As suggested by Beaton et al. ⁹ two independent translations were made by bilingual translators, with different profiles and background, mother tongue in Italian language. This is very important because in this way it is possible to have greater accuracy on the nuances of the final language. We compared the two translations, and found no discrepancies or ambiguities. Moreover, each translator produced a written report of the translation. From these comments, no sentences that were too demanding or uncertainties were highlighted;
2. stage II: synthesis of the translation. The two translators and an observer worked together to summarise the results of the translations. They produced a synthesis, starting from the original questionnaire, and then analysing the first translation and the second version. In addition, in this phase, a report was drawn up in which no relevant and unresolved problems were highlighted;
3. stage III: back translation (from Italian to English). Starting from the Italian synthesis obtained in the previous phase, two native English speakers with no medical background translated the new version of the questionnaire in English, blind to the original version. This backward translation was intended to verify its validity, confirming the fidelity of the contents with respect to the original. Even at this stage, we did not highlight any major inconsistencies or conceptual errors in the translation;
4. stage IV: expert committee. The composition of the committee consisted of a methodologist, two health professionals, a language professional and the two previously cited translators. The role of the expert committee was to consolidate the versions of the questionnaire and to develop a pre-final version for clinical experimentation. The committee then examined the translations and reached a consensus in the absence of any discrepancy. In addition, in this case a written report was provided regarding the decisions reached. The ultimate goal was to achieve equivalence between the source and target versions in four areas: semantic, idiomatic, experiential and conceptual;
5. stage V: test of the pre-final version. In this phase, the test was used in its preliminary version, administering the questionnaire to the parents of children with reported 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 understanding of the single items. The distribution of responses was assessed, and no missing elements were identified;
6. stage VI: submission of documentation to the developers or coordinating committee for appraisal of the adaptation process. In this final phase of the adaptation process, the translations and reports of the previous stages were presented to the committee;
7. clinical trial: the DHI-PC Italian version is a 21-item validated questionnaire (Tab. II). The translated and adapted final copy of the questionnaire was administered to the patient caregivers twice (not including the pretest population). The re-test was performed with an interval of 2 weeks after the first collection to avoid changes in the subjects’ 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 representing better quality of life related to vertigo/dizziness.

Statistical analysis

Continuous variables were expressed as means and standard deviation. Categorical variables were summarised as counts and percentages.

Internal consistency reflects the extent to which the questionnaire items are inter-correlated, or whether they are consistent in measurement of the same construct. Internal consistency of DHI-PC questionnaire was tested using Cronbach’s coefficient alpha, which ranges from zero to one. Values at least 0.7 were regarded as satisfactory.

Reproducibility, or test-retest reliability, was assessed using Pearson’s correlation coefficient between the first and the second administrations of the questionnaire. A larger stability coefficient indicates stronger test-retest reliability, reflecting that measurement error of the questionnaire is less likely to be attributable to changes in the individuals’ responses over time.

P-values < 0.001 were considered statistically significant. Statistical analyses were performed using SPSS Version 26 (IBM Corp., Armonk, NY, USA).

Results

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

In our study, 43% of children presented with a history of migraine. The majority of patients did not present vestibular dysfunction (93%). In all, 16.7% of children reported hearing difficulty. The frequency and duration of dizziness was described in many cases as recurrent episodes that came on suddenly during the day and lasted from a few seconds to a few minutes, with high association with migraine.

Most paediatric patients did not have disabilities in the scores analysed.

Internal consistency was excellent, with Cronbach’s alpha = 0.95.

Test-retest reliability for the Italian version was confirmed by the Pearson correlation coefficient (r = 0.95, p < 0.001). A significant test-retest reliability was also found between the Italian and English versions (r = 0.96, p < 0.001).

All items showed a Pearson’s r > 0.70 in the test-retest reliability analysis. Detailed results of the reliability tests for all items are reported in Table III.

Discussion

Dizziness can affect children and adolescents, interfering in psychological behaviour, ability to communicate, learning process and academic performance ¹⁰. Symptoms may include decreased postural control, impaired gaze stability, headache, inability to perform coordinated movements, falls while playing, abnormal spatial and positional perception ^11,12. Only recently, the researchers systematically documented the effects of vestibular impairments on everyday activities of children/adolescents and then the impact on QoL ^13,14.

Our results demonstrated that DHI-PC was satisfactorily adapted both culturally and linguistically in the Italian population. It showed a good reliability and can therefore be recommended in the assessment of disability in Italian children with dizziness. McCaslin et al. ⁷ first developed the questionnaire DHI-PC. They demonstrated that it is a consistent and reliable tool to quantify the degree of dizzying disability in a child’s life. Similar to the widely accepted self-report questionnaire for adults, the paediatric DHI assesses the psychosocial impact of dizziness and the related degree of handicap affecting QoL. It is also useful to assess the effectiveness of treatment and monitoring the progress during rehabilitation ⁷.

There is currently a version of the DHI children/adolescent (DHI-CA) published by Sousa et al. ¹⁵ in Brazilian Portuguese, adapted for use in children over 4 years of age. Very recently, a cross-cultural adaptation of this version was carried by Sommerfleckout et al. ¹⁶ into Spanish (Argentine). To our knowledge, there is not an Italian questionnaire available for the Italian younger population and none referred to caregivers of paediatric patients. Our study is the first leading to the validation of the DHI-PC in Italian language.

It is well known that in the adult population the DHI questionnaire is widely used in clinical practice and translated into several regions, including Germany, France, Spain, Brazil, Portugal, Norway, Holland, Bulgaria, Japan, Israel, China and Colombia. In particular, in 2010 Nola et al. ⁸ translated into Italian the DHI and, more recently, Colnaghi et al. ¹⁷ translated the Situational Vertigo Questionnaire (SVQ) and the Activity-Specific Balance Confidence Scale (ABC). It was demonstrated that when used in association with the medical history and physical examination, the DHI was useful in providing reproducible, quantifiable, and applicable results for patient wellbeing ^16,18. Equally, in the present study, the Italian version of DHI-PC proved to be satisfactory for measurement properties, as a discriminating and evaluative tool.

A difference between adult and paediatric DHI is that the former is useful to evaluate the interference of dizziness self-perceived by the patient in three subscales: emotional, functional and physical ⁶. The DHI-PC, instead, investigates two different handicaps: functional and emotional ⁷. In particular, the functional domain is related to the inability to carry out domestic, school, social and leisure activities as well as basic tasks such as walking in the dark or climbing stairs without help. Emotional impairment includes the psychological and/or psychiatric disadvantages resulting from dizziness, such as frustration, concentration disturbances, changes in social relationships, anxiety and depression.

The statistical analysis of our data showed that the internal consistency of the results obtained with the DHI-PC proved to be adequate (alpha = 0.95). Furthermore, the results obtained in a second application of the instrument showed adequate stability of the measurements obtained in the two applications. In broad terms, the retest confirmed the stability of the instrument with regard to the internal consistency of the items. These data confirm the validity and reliability of our translation. In fact, we followed in an orderly and rigorous manner the phases indicated in the specific literature for the translation of the evaluation questionnaires ⁹.

Based on our experience with the paediatric DHI administered to caregivers, we believe that additional advantages of the DHI-PC questionnaire include its ease of application, short time administration and easy interpretation. The usefulness of the DHI-PC questionnaire is even more evident considering that screening children for dizziness, vertigo and vestibular diseases is still an uncommon practice in most centers and it is well known that conventional diagnostic tests of the vestibular system often fail especially at cause of nonconformity behavior in the child ¹⁹. In our results, we demonstrated that 93% of children did not show vestibular dysfunction at clinical examination and in these conditions, DHI-PC is useful to confirm clinical data.

We therefore propose to use this questionnaire in all children with dizziness or balance disorders as a part of monitoring and assessment protocols. It could be also useful in children with deafness ²⁰ to understand possible impairment of the posterior labyrinth, in candidates to cochlear implant or in implanted children, in patients with syndromic deafness and inner ear malformations. Additionally, knowing the degree of dizziness handicap coupled with diagnostic and functional information should enable clinicians to develop an appropriate rehabilitative treatment plan. Finally, clinicians should administer DHI-PC in the follow up of dizziness to evaluate the results of medical, surgical or rehabilitative therapy.

DHI-PC administered to caregivers achieved benefit in providing information regarding young children who have not developed the language level needed to accurately describe dizziness. This may make it difficult for the specialist to investigate the severity of the symptoms ²¹. For all these reasons, it may be useful for clinicians to have a measure to assess the impact of symptoms on quality of life in addition to the traditional vestibular examination and which could be administered as a parental proxy.

Another interesting finding assessed by the DHI-PC in our study is that 36% (15/42 patients) had moderate disability in the emotional domain. This result confirms the data of Paiva and Kuhn ²² who demonstrated that patients with vertigo have concomitant psychological symptoms in up to 56.38% of patients. Nevertheless, our data revealed that the emotional features were less affected than the functional domain as already shown by other researchers with adult patients ⁸. In line with the authors ²³,²⁴, we suggest that the functional limitation is more prevalent in children feeling dizzy, probably due to the restriction of the activities with the intention of avoiding the onset of acute symptoms. Nonetheless, as highlighted in the literature ¹⁶, the emotional and functional impact of vertigo or balance disturbances in children is less than in the general population. Certainly children improve quickly and compensate more easily than adults: this explains why few children present a DHI-PC with disability indexes and always mild-moderate.

Future perspectives for the DHI-PC may include additional populations such as older children (i.e. 13-17 years) as well as younger children (i.e. less than 5 years of age). Currently, there is not psychometrically dizziness measure available to these paediatric age groups, and the adult DHI has been validated only in adolescents diagnosed with Auditory Neuropathy Spectrum Disorder ²⁵. Additionally, future studies may expand the application of DHI-PC to point out that the use of this tool may positively impact on the evaluation of postural disabilities.

Conclusions

Vestibular diagnostic tests are difficult to perform in children and often cannot be predictive of vestibular system impairment. Moreover, younger children are not able to express the specific nature of their dizziness and the repercussions on the everyday activities imposed by compromised balance. The DHI-PC is a reliable tool to assess the impact of paediatric dizziness on the quality of life of the paediatric population through the perspective of the caregiver. The DHI-PC was culturally and linguistically adapted for use in the Italian population. It should be administered in children with dizziness and postural impairment.

Acknowledgements

We would like to thank Devin L. McCaslin for permission to adapt this questionnaire cross-culturally. Authors thank the parents of the children involved, Professor Franca Cassarà and Professor Alessandra Compagnucci, who contributed to the process of translation and adaptation of the questionnaire.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

PMP: ideation, methodology, draft, supervision and review; PMP, GR: data collection and processing, analysis, literature review, writing, editing; SS, MC: assisted in data management; JG, ARF: critical review. All authors read and approved the last version of the manuscript.

Ethical consideration

This study was performed in accordance with the ethical standards of the National Research Committee and with the 1964 Helsinki Declaration and its later amendments. Informed consent to the use of their data was obtained from all the patient caregivers. Approval from the ethics committee is not required for this type of study in our institution.

Figures and tables

Figure 1.Graphic representation of the stages of cross-cultural adaptation process as suggested by Beaton et al. ⁹.

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