PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1037-1042

Early Childhood Otitis Media in Relation to Children's Attention-Related Behavior in the First Six Years of Life

Karin R. Minter, MPH^*, Joanne E. Roberts, PhD^*, , Stephen R. Hooper, PhD^{*, ¶}, Margaret R. Burchinal, PhD^{*, #}, and Susan A. Zeisel, EdD

From the ^* Frank Porter Graham Child Development Center,  School of Public Health, ^§ Department of Pediatrics,  Division of Speech and Hearing Sciences, Department of Allied Health Sciences, Departments of ^¶ Psychiatry and ^# Psychology, and the ^** School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and  Duke University School of Medicine, Durham, North Carolina.

	ABSTRACT

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Objective.  This study examined whether otitis media with effusion (OME) and associated hearing loss during the first 4 years of life were related to the ratings of parents, teachers, and clinicians of children's attention and behavior in the first 6 years of life.

Methods.  In a prospective study, 85 black children were recruited from community-based child care programs when they were between 6 and 12 months old. OME and hearing status were monitored repeatedly from 6 months to 4 years old. Measures of attention and behavior were collected from parents, teachers, and clinicians when the children were infants, preschoolers, and first graders.

Results.  On average, children experienced either bilateral or unilateral OME 30% of the time and hearing loss 19.9% of the time between 6 months and 4 years old. Descriptive and inferential analyses revealed no significant associations between OME or hearing loss and the measures of attention or behavior completed by parents, teachers, and clinicians.

Conclusions.  In this sample of children, there was no relationship between amount of early childhood OME or hearing loss and measures of attention or behavior in the first 6 years of life as reported by parents, teachers, and clinicians.otitis media, hearing, attention, behavior.

Otitis media with effusion (OME) is a common early childhood disease that is typically associated with mild to moderate hearing loss.^1-3 It is unclear whether children who experience persistent OME and associated hearing loss early in childhood are at risk for cognitive, language, and learning deficits.^1,4-6 It is also not certain whether early childhood OME and fluctuating hearing loss affect children's later attention and behavior. Several studies have reported significant associations between early childhood OME and attention or behavior problems.^7-14 Still other studies have found no significant correlation between OME and attention or behavior.^15-20 Unfortunately, many of these studies had methodological problems including retrospective study design, which is threatened by recall bias,^7,10,17-19 imprecise OME detection methods,^7,10,17-19 and use of only teacher or parent reports of attention and behavior.^8-17,19

Attention is a multidimensional construct that has been generally defined as the responsiveness or capacity to react (both internally and externally) to the environment.^21,22 Cognitive psychologists, neuropsychologists, and behavioral psychologists all describe attention slightly differently; however, they agree about the complexity of the construct and emphasize the importance of quantifying it with multiple measures.²³ Researchers often consider behavior to measure external reactions to the environment (eg, attention-related behavior). This is particularly appropriate in studying attention in young children, particularly when direct measures of attention are difficult to obtain. It has been hypothesized that children who have early childhood OME and associated hearing loss also experience changes in the intensity of signals and learn to tune-out environmental stimuli. As a result, children may experience attention and behavioral difficulties.

As part of a larger study^24-26 on the relationship between OME and children's later language development, this study prospectively followed a group of 85 black children from 6 months old through first grade. Children's OME experience and associated hearing loss during the first 4 years of life were compared with measures of attention and behavior collected from parents, teachers, and clinicians when the children were infants, preschoolers, and first graders.

	METHODS

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Study Population

The study participants were 85 black children (46 females and 39 males) with no known medical abnormalities, recruited from center-based child care programs between 6 and 12 months old (mean: 8.2 months). The children participated in a longitudinal study investigating otitis media and several developmental outcomes.^24-26 All of the children were enrolled in the study without previous knowledge of their ear histories. On entering the study, 72.9% of the children lived in low-income families (family income was <185% of the federal poverty threshold) and 67.1% lived with primary guardians who were single. By 1 year of age, 7 children did not live with their biological mothers (3 lived with grandmothers, 3 with foster or adoptive mothers, and 1 with a father). Caregivers reported their highest level of education as follows: 29.4% had less than a high school degree; 28.2% had a high school degree; and 42.4% had some college, other training after high school, or a college degree. The study was reviewed annually and approved by the Academic Affairs Institutional Review Board at the University of North Carolina at Chapel Hill.

Otitis Media Documentation

Detailed descriptions of the OME diagnostic and treatment procedures have been described previously.^24,25,27,28 In brief, children's ears were examined weekly for the first 15 months of the study by 2 pediatric nurse practitioners trained in pneumatic otoscopy. Because of a protocol change, children's ears were examined biweekly after the 15th month of the study. This schedule of ear examinations continued from study entry until the children reached 4 years old. On average, children received 71.7 ear examinations (standard deviation [SD] = 18.4). The interval between ear examinations varied from ~1 week (13.3% of the time) to 2 months (2.9% of the time). Most of the ear examinations occurred in 2-week (54.8% of the time) or 1-month (28.9% of the time) intervals.

The diagnosis of OME was based on pneumatic otoscopy and corroborated by routine tympanometry (226-Hz probe tone). A diagnosis of OME was given when there was fluid in the middle ear and the tympanic membrane was immobile. The otoscopic diagnosis was used in instances when otoscopy and tympanometry were inconsistent. Based on 10 841 ear examinations, there was 92% agreement on the degree of mobility of the tympanic membrane as assessed by pneumatic otoscopy versus tympanometry. Appropriate antimicrobial treatments were prescribed for acute otitis media, and the children's primary health care providers were notified. After each ear examination, parents were informed of findings.

The duration of an episode of OME was determined by subtracting the date of onset (calculated as midway between the last day that the ears were observed as normal and the first day that OME was detected) from the date of resolution (calculated as midway between the last day that OME was present and the first day that the ears were normal). For each child, the percentage of time with unilateral OME, bilateral OME, and total OME (unilateral or bilateral) was computed from study entry to 4 years old.

Hearing Assessment

Hearing assessment procedures have been described in detail in previous studies.^24-26 Visual reinforcement audiometry (VRA) and play audiometry (PLAY) were used to assess hearing sensitivity. VRA testing (which involved presenting 500-, 2000-, and 4000-Hz pure tones through a loudspeaker in a calibrated sound field) was performed when the children were between 6 months and 21/2 years of age. PLAY (pure tones at 500-, 1000-, 2000-, and 4000-Hz presented through earphones) was performed when the children were between 21/2 and 4 years old. Routine hearing assessments were performed on entry to the study and every 3 months thereafter. Furthermore, children's hearing was tested after diagnosis of OME and after any change in ear status (eg, change from bilateral to unilateral OME). On average, 20.6 hearing assessments (SD = 4.07) were performed on each child between study entry and 4 years old. Audiologists, blind to the ear status of the children, performed hearing assessments in a mobile testing van that housed a single-wall sound unit.

Significant hearing loss was defined as a mean VRA threshold 25 dB hearing loss and mean PLAY thresholds, by left and right ear, 20 dB hearing loss. The amount of time that each child experienced significant hearing loss was then calculated using the same method described above for OME.

Attention and Behavioral Measures

Measures of attention and behavior were collected from questionnaires completed by parents, teachers, and clinicians when children were infants, preschoolers, and at the end of first grade.

A rating of the children's attention-related behavior was obtained from the Behavior Rating Scale (BRS) of the Bayley Scales of Infant Development, Second Edition²⁹ at 1, 2, and 3 years old. The BRS is a 43-item questionnaire, which assesses a child's attention/arousal, orientation/engagement, emotional regulation, and quality of movement. The total score from the BRS reflects both neurobehavioral integrity in younger children and adaptation to the environment in older children. Clinicians use a 5-point scale that is uniquely defined for each question to rate behaviors. The BRS maintains high content, construct, and criterion-based validity as well as moderate to high internal consistency and test-retest reliability.

The Parenting Stress Index (PSI)³⁰ was completed on entry to the study, at 18 months, and at 30 months old. Parents rated their children's distractibility/hyperactivity using a 1- to 5-point Likert scale ranging from 1 = strongly agree to 5 = strongly disagree. The Distractibility/Hyperactivity Subscale (9 items) of the PSI is highly reliable in terms of internal consistency and test-retest reliability. The PSI has moderate to high content and construct validity and has been shown to be valid and reliable with black families.³¹

The Social Skills Rating System (SSRS)³² was used to assess the children's problem behaviors at home and in school as rated by parents and teachers at kindergarten entry and during first grade. The problem behaviors portion of the SSRS has 17 items that are answered using a 3-point scale ranging from 0 = never to 2 = very often. The SSRS is highly reliable in terms of internal consistency and test-retest reliability, and it demonstrates high criterion-related validity. The problem behaviors score from the SSRS and the total behavior problems score from the Child Behavior Checklist³³ are highly correlated (r = .81).

The Hyperactivity Index of the Conners' Teacher/Parent Rating Scale³⁴ was completed by teachers and parents at kindergarten entry and at the end of first grade. The Hyperactivity Index is a 10-item measure, which provides a rating on the extent to which a child engages in behaviors that are indicative of an underlying diagnosis of hyperkinesis. The Conners' uses a 4-point Likert scale ranging from 1 = not at all to 4 = very much. Test-retest reliability for the Conners' Hyperactivity Index is moderate, and internal consistency, construct validity, discriminant validity, and content validity are high.

Data Analysis

Both descriptive and inferential analyses were used to test the association between OME or hearing loss and attentional and behavioral outcomes. A rank transformation was applied to the OME and hearing loss variables because both OME and hearing loss were skewed within this sample. Pearson correlations among rank of total OME, rank of hearing loss, and the child attention/behavior outcomes were generated.

Mixed model repeated-measures analyses of variance and multivariate multiple regression examined the extent to which the amount of OME and hearing loss in early childhood related to children's attention and behavior in infancy, preschool, and first grade. Repeated-measures analyses examined the longitudinal assessments of infancy outcomes, total BRS at 12, 24, and 36 months, and PSI child distractibility at study entry, 18, and 30 months. The amount of OME and hearing loss experienced during the year before the assessment were the predictors of interest. The analyses tested whether OME or hearing loss predicted either overall level or rate of change in these measures of infant attention. Next, multivariate regression analyses of the preschool measures examined the Conners' Hyperactivity and SSRS Behavior Problems at entry to kindergarten separately for the parent and the teacher. For the first grade measures, multivariate regression analyses examined Conners' Hyperactivity and SSRS Behavior Problems together for parents and teachers. The amount of OME and hearing loss experienced during the first 4 years of life were the predictors of interest. The analyses tested whether children with more OME or hearing loss tended to show reliably more attention problems at entry to kindergarten or first grade according to parents, teachers, and clinicians.

Separate regression analyses were run using rank of the proportion of time with OME and hearing loss as the predictor variables of interest. Mother's education, child's gender, child care quality, and HOME total score (a measure of the home environment) were included as covariates in all analyses. Child care quality was assessed using the Infant/Toddler Environment Rating Scale³⁵ during the first and second years that children were in child care, and the Early Childhood Environment Rating Scale³⁶ the third, fourth, and fifth years that children were in child care. Mean Infant/Toddler Environment Rating Scale/Early Childhood Environment Rating Scale scores from the first, second, and third years of child care were used in the infancy analysis and means from the first, second, third, and fourth years were used in the preschool and first grade analyses. The Home Observation for Measurement of the Environment-Inventory for Infants³⁷ assessed the overall quality and responsiveness of the home environment throughout the first 6 years of life. Mean Home Observation for Measurement of the Environment scores for the infancy analysis included data from 9, 18, and 30 months old and the preschool and grade 1 analyses included data from 9, 18, 30, and 42 months old. See Roberts and colleagues^24-26 for details about the home and child care environments. These repeated assessments of home and child care environments were included as time-varying covariates in the repeated-measure analyses and were averaged over time for the multiple regression analyses.

	RESULTS

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Completed Questionnaires and Exclusion Criteria

Study participants for the present study included all 85 children whose data were eligible for analysis. History of OME and hearing loss was compared with attention and behavior in infancy, preschool, and first grade. One-year attention data were not included in the mixed model analyses for 19 children who entered the study too close to their first birthday to reliably measure OME or hearing loss during the first year. A few children were missing child care observations or infant attention ratings, resulting in slight variations in the sample size between 24 and 36 months in the analysis of infant attention. Thirteen children were excluded from the preschool and first grade data analyses because of incomplete datasets (children were excluded if they were missing any one of the attention/behavior assessment tools in preschool or first grade). The demographic characteristics of the 13 children excluded from the preschool and first grade analyses did not significantly differ from those who were included in the preschool and first grade analyses.

Otitis Media and Hearing Loss

The total proportion of days with OME was 87.9% (SD = 21.3%) during the first year, 54.8% (SD = 30.5%) during the second year, 20.3% (SD = 26.0%) during the third year, and 14.9% (SD = 24.3%) during the forth year of life. As expected, the amount of total OME experienced by the study participants decreased significantly as they aged. Because bilateral OME and total OME were highly correlated for all of these age periods (r = 0.75-0.91), total OME was used in all analyses. The total proportion of days with hearing loss was 44.6% (SD = 35.6%) during the first year, 25.9% (SD = 30.2%) during the second year, 14.1% (SD = 24.0%) during the third year, and 10.8% (SD = 22.5%) during the forth year of life. Total OME and hearing loss were highly correlated for each of the age periods (r = 0.47-0.69). The OME and hearing loss experiences have been described previously.^24-28

Otitis Media, Hearing, and Attention/Behavior Outcomes

Attention and behavior were assessed using several instruments completed by parents, teachers, and clinicians. Tables 1 and 2 present means for all of the attention/behavior outcomes and correlations between attention/behavior outcomes and both OME and hearing loss. Intercorrelations between the attention/behavior measures for infancy, preschool, and first grade were examined. Generally, there were negligible to mild correlations among the infancy measures (0.30 < r < 0.53; M = 0.003), low to moderate correlations among the preschool measures (0.19 < r < 0.76; M = 0.12), and moderate to high correlations among the first grade measures (0.24 < r < 0.81; M = 0.46). OME and hearing loss showed negligible associations with gender (0.04 < r < 0.16; M = .08), poverty (0.13 < r < 0.23; M = 0.19), and maternal education (0.11 < r < 0.02; M = 0.08). They also showed negligible to mild associations with home environment (0.30 < r < 0.16; M = 0.21) and quality of child care (0.29 < r < 0.10; M = 0.17).

Descriptive analyses included correlations, which were used to examine the relationship between OME or hearing loss and measures of attention and behavior (see Table 1 for infancy and Table 2 for preschool and first grade). Partial correlations were used to describe the association after accounting for other variables. Regression analyses were performed using OME and hearing loss as separate predictors of attention and behavior outcomes in infancy, preschool, and first grade. Children's scores on the BRS and the SSRS were at or close to the established means for those assessment tools. Children's scores on the PSI distractibility subscales were slightly above the normative mean of 2.74 (SD = 0.53). Finally, children's scores on the Conners' Hyperactivity Index varied but remained within 1 SD of the normative mean of 50.

Attention and Behavior in Infancy

OME correlated with 1 attention/behavior outcome in infancy (behavior at 24 months old according to the BRS), but none of the other variables were significantly correlated. Pearson's partial correlation revealed no significant correlation, however, after gender, poverty, maternal education, and home and child care environment were included. Repeated-measures analyses also indicated no significant correlation between OME and attention or behavior outcomes as assessed by the BRS (OME main effect: F[1109] = .00; P = .97; OME × age: F[2109] = 1.07; P = .35) and the PSI (OME main effect: F[1128] = 0.02; P = .90; OME × age: F[2128] = 0.43; P = .65). Hearing loss was not significantly correlated with any of the outcomes from the BRS (hearing loss main effect: F[1106] = 0.24; P = .90; hearing loss × age: F[1106] = 1.28; P = .28) or the PSI (hearing loss main effect: F[1125] = 3.81; P = .053; hearing loss × age: F[2125] = 0.14; P = .87).

Attention and Behavior in Preschool

OME was correlated with parental report of hyperactivity from the Conners' Rating Scale in preschool. The results of the partial correlation and multivariate multiple regression indicated that neither parent report of behavior was related to OME (F[2,64] = 2.05; P = .14) or hearing loss (F[2,64] = 0.83; P = .44) nor teacher report of behavior was related to OME (F[2,54] = 0.33; P = .72) or hearing loss (F[2,54] = 0.67; P = .52) once covariates were considered. Hearing loss was not correlated with any attention/behavior outcomes.

Attention and Behavior in First Grade

Neither OME nor hearing loss correlated with attention and behavior outcomes in first grade. Again, after selecting for covariates, multivariate regression revealed no association between OME (F[4,55] = 2.50; P = .053) or hearing loss (F[4,55] = 1.53; P = .21) and attention-related behavior measures.

	DISCUSSION

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This study found no statistically significant relationships between early childhood otitis media or hearing loss and measures of attention or behavior in the first 6 years of life. Although some studies have reported similarly that a history of OME was not related to later attention-related behaviors,^15-20 others have reported significant associations between history of OME and later attention and behavior.^7-13 Consistent with findings from the recent study by Paradise and colleagues,¹⁶ the present study found that children with more extensive OME or hearing loss histories were no more likely than children with less extreme histories to have difficulties with attention, hyperactivity, or behavior.

These findings are consistent with 1 prospective¹⁵ and 2 retrospective^18,19 studies, and inconsistent with 3 prospective^9,13,14 and 2 retrospective^7,10 studies examining the relationship between early childhood OME and attention. Arcia and Roberts¹⁵ did not find a significant relationship between OME and attention among 70 children from low-income families using the Test Behavior Inventory at 2, 3, and 4 years old or measuring attention in a laboratory setting. Two retrospective studies of children between 6 and 13 years old also found no significant associations between otitis media and attention. In contrast, Roberts and colleagues¹³ prospectively studied the relationship between OME and classroom behavior in 44 children from low-income families and found a significant correlation between the number of days with OME before 3 years old and teacher's ratings of attention. Again, on the same population of study participants, Feagans and colleagues¹⁴ found that children who had more OME experienced more behavior problems at 5 to 7 years old. Furthermore, in another prospective study of a different population, Feagans and colleagues⁹ found that children who experienced more OME received significantly higher inattention/distractibility ratings from direct classroom observation than did those with less extensive OME histories. Two retrospective studies^7,10 found significant associations between the frequency of OME and hyperactivity between 6 and 13 years old.

The findings of the present study are also consistent with 1 prospective¹⁶ and 1 retrospective¹⁷ study, and inconsistent with 1 prospective²¹ and 2 cross-sectional studies^11,12 examining the relationship between early childhood OME and behavior. In a prospective study of 2278 children, Paradise and colleagues¹⁶ considered parental ratings of child behavior at 2 and 3 years old and found no significant relationship between OME history and behavior problems using the Child Behavior Checklist and the Difficult Child scale of the PSI short form. Black and Sonnenschein¹⁷ reported no association between otitis media and behavior in a retrospective study of 31 children. In contrast, McGee and colleagues²¹ found a significant correlation between OME and behavior problems using the Rutter Scales to assess behavior in a prospective study of 951 socioeconomically advantaged children in New Zealand. In a series of cross-sectional studies, Silva and colleagues^11,12 found behavior problems as reported by teachers to be significantly associated with OME history, whereas parental reports of behavioral problems showed no association.

The findings of the present study do not support the hypothesis that recurrent OME and associated hearing loss cause children to have difficulties with attention and/or behavior.¹⁷ Several measures of attention and behavior, including ratings from parents, teachers, and clinicians, were included in this study. Although we did not limit our investigation to attention deficit/hyperactivity disorder,³⁸ our measures of attention focused on important aspects of that clinical diagnosis, including poor sustained attention, hyperactivity, impulsivity,²¹ and other major components of attention, such as arousal, divided attention, distractibility, and selectivity of focus.³⁹ Attention and behavior are highly intertwined in young children. Behavioral problems associated with attentional difficulties often begin in the preschool years and persist over time.⁴⁰

This study had many strengths. First, a major strength was the prospective design that allowed children to be followed over time with comprehensive documentation of OME, hearing, and attention/behavior. Another strength of this study was the standard OME diagnostic procedure and hearing assessment protocol. A third strength of this study was the inclusion of hearing assessments in addition to OME status. Hearing loss is a possible mediating factor in the relationship between OME and attention or behavior.⁴¹ Few studies have considered hearing loss in addition to OME history. Finally, the present study considered information on attention and behavior collected from multiple perspectives (teachers, parents, and clinicians) and attention-related behaviors are extremely likely to be influenced by situation. The present study attempted to address this issue by using information obtained from a variety of sources.

This study also has a number of limitations. First, our relatively small sample size and homogeneous population (race, socioeconomic status, child care participants) limit the generalizability of the results. Furthermore, a higher incidence of OME was found in our study population than in the general population.^22,23 Second, our small sample size and large number of variables limit the statistical power within our analyses. Third, attention-related behaviors are difficult to measure and results might vary if different attention measures were used. This might explain some of the diversity of findings within the literature relating OME to attention. Finally, this study used a correlational design, which only looks for association, not causation.

	CONCLUSION

Top Abstract Methods Results Discussion Conclusion References

The study results indicate that there was not a significant relationship between early childhood OME or hearing loss and measures of attention and behavior in infancy, preschool, or first grade. Additional investigation is necessary to evaluate the relationship between OME or hearing loss and attention or behavior as the children progress in school, where demands for attention increase.

	ACKNOWLEDGMENTS

This work was supported in part by the Maternal and Child Health Program (MCJ-370599 and MCJ-370649, Title V, Social Security Act), Health Resources and Services Administration, US Department of Health and Human Services, and National Institute of Health (National Institute on Deafness and Other Communication Disorders) Grant 01R01-CD03817-01A1.

We thank the children and families who participated in this study. We greatly appreciate the hard work and support of Eloise C. Neebe and Sarah Henderson in this work.

	FOOTNOTES

Received for publication Jun 30, 2000; accepted Aug 30, 2000.

Reprint requests to (J.E.R.) Frank Porter Graham Child Development Center, University of North Carolina at Chapel Hill, 105 Smith Level Rd, CB# 8180, Chapel Hill, NC 27599-8180. E-mail: joanne_roberts{at}unc.edu

	ABBREVIATIONS

OME, otitis media with effusion; SD, standard deviation; VRA, visual reinforcement audiometry; PLAY, play audiometry; BRS, Behavior Rating Scale; PSI, Parenting Stress Index; SSRS, Social Skills Rating System.

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