Hello. This presentation is going to be focusing on how to make an appropriate referral for formal vestibular testing and/ or a physical therapy evaluation. In general, anyone who fails a screening, we've talked about tools that can be used to screen for vestibular loss, so any child who fails that screen should be referred for formal evaluation. Also, children who complain of dizziness, we already addressed that some children might not have the language to really describe what they're feeling but as much as possible, it's good to get them to try and talk about what they're actually experiencing when they are dizzy. It's important to distinguish between true vertigo or the sense of spinning, either the person spinning or the environment spinning and of light headedness because that differentiation will help determine what the likelihood of a vestibular impairment or some other cause of the feelings of dizziness. Also, children who complain of falling or feeling off balance, that's a frequent category of children that are seen for evaluation. Do parents say they fall more than their peers? A lot of children are described as feeling clumsy or off balance or may just be running down the hallway and fall easily. Then finally, children with delayed gross motor milestones which we've already talked about in another module. These are some signs of dizziness in children. So unexplained fright or alarm, which just means being constantly scared of their environment or some changes in their environment. Delayed motor skills, we've already described what's appropriate in terms of motor skills at various ages so anyone with delayed motor skills. Trouble walking in the dark, the vestibular system is really important for helping navigate in the dark and so children who have trouble walking in the dark should be referred. Fear of or craving of movement, so in other words, a child that is really afraid when moving from one position to another, or children who want to be constantly moving, either of those are signs of problem in children. Also, kids who clutch their caretakers all the time, so really holding on for dear life is a sign of dizziness in children. Loss of postural control, so a parent might notice that a child has more trouble in certain environments than in others and that would be a sign that something may be wrong. Motion sickness is a vague one, there are conditions that result in motion sickness. For children, they may report car sickness or a parent might notice car sickness and that is definitely a sign of a potential problem in the vestibular system. Then finally, complaints of blurred vision, particularly with head movement but the child might not appreciate that they're really moving the head. For example, something as simple as looking up and down when you're reading or moving from reading a book to looking up at something else, that's enough head movement to cause oscillopsia or blurred vision with head movement if there's a vestibular loss. So any complaint of blurred vision should be paid attention to. So referrals should be made when there's any evidence of delayed motor milestones or the inability to stand on one foot. We've talked about that as an important screening tool. Especially in the context of children with sensorineural hearing loss, children with chronic otitis media with effusion, otherwise sometimes referred to as middle ear pathology. Individual with anomalies that affect their cochlear or vestibular structures so for example, children with CHARGE Syndrome typically have quite abnormally formed inner ears and there's a whole variety of severity of those anomalies. Also children with enlarged vestibular aqueduct syndrome which we've already talked about. Then children with infectious diseases we're particularly concerned with bacterial meningitis and congenital cytomegalovirus. Children with auditory neuropathy spectrum disorder should be referred if any evidence of a failed screen is present. Then also children who have been exposed to ototoxic medications such as aminoglycoside antibiotics and chemotherapy. Of course, the goal of referral for testing is to be able to determine if a problem exists and to deal with it. So physical therapy happens to be, for most children, the most effective help in addressing concerns about dizziness imbalance. Of course, the moral of the story is that we are interested in helping facilitate successful and happy children.