Otitis Media, the Caregiving Environment, and Language and Cognitive Outcomes at 2 Years
Objective. To examine the relationship between otitis media with effusion (OME) and associated hearing loss between 6 and 24 months of age and children's language and cognitive development at 2 years of age.
Study Design. A prospective cohort design in which 86 African-American infants who attended group child-care centers were recruited between 6 and 12 months of age. Between 6 and 24 months, assessments included serial ear examinations using otoscopy and tympanometry, serial hearing tests, two ratings of the childrearing environment at home and in child care, and language and cognitive outcomes at 2 years.
Results. Children experienced either unilateral or bilateral OME an average of 63% and reduced hearing sensitivity an average of 44% of the time between 6 and 24 months of age. Although proportion of time with OME or with hearing loss was modestly correlated with measures of language and cognitive skills, these relationships were no longer significant when the ratings of the home and child-care environments were also considered. Children with more OME or hearing loss tended to live in less responsive caregiving environments, and these environments were linked to lower performance in expressive language and vocabulary acquisition at 2 years.
Conclusions. Both OME and hearing loss were more strongly related to the quality of home and child-care environments than to children's language and cognitive development. Study results might be explained either by suggesting that children in less responsive caregiving environments experience conditions that make them more likely to experience OME and/or by suggesting that it may be more difficult for caregivers to be responsive and stimulating with children with more OME.
- OME =
- otitis media with effusion •
- dB =
- decibel •
- HL =
- hearing level •
- SD =
- standard deviation •
- Hz =
- Hertz •
- SICD-R =
- Sequenced Inventory of Communication Development-Revised •
- RCA =
- receptive communication age •
- ECA =
- expressive communication age •
- CSBS =
- Communication and Symbolic Behavior Scales •
- CDI =
- MacArthur Communicative Development Inventory •
- MDI =
- mental developmental index •
- HOME =
- Home Observation for Measurement of the Environment-Inventory for Infants •
- ITERS =
- Infant/Toddler Environment Rating Scale
Although several studies have reported associations between frequent and persistent otitis media with effusion (OME) during early childhood and delayed language development during infancy1-3 and the preschool periods,4-6whether OME causes later language sequelae continues to be debated.7 8 The child with OME often experiences a mild-to-moderate fluctuating hearing loss, and thus receives a partial or inconsistent auditory signal making speech more difficult to detect and/or filter from background noise. This may impair the discrimination and processing of speech, and thus cause the child to encode information inefficiently, incompletely, or inaccurately into the database from which language develops. Persistent or recurrent hearing loss because of OME may then impair the development of language skills. Despite the conceptual logic of the hypothesized relationship between OME and language sequelae, several studies have shown no association between early childhood OME and language during the first 4 years of life.9-11 The discrepancies in some study findings related to OME sequelae have been attributed to methodologic problems, such as use of retrospective designs resulting in inadequate documentation of OME.7 11-13 Yet, even among the most rigorously designed studies of OME language sequelae (ie, prospective cohort studies) findings continue to differ even when using the same instruments and similar populations.
Four general limitations in research design may explain the differences in the findings of studies examining OME and later language skills. First, few studies have examined hearing loss as an independent variable, instead they use OME as the predictor variable. However, the degree of hearing loss associated with OME is not constant; some children experience no loss and other children a moderate loss as great as 50 decibel (dB) hearing level (HL). Second, previous studies have not considered recent models of child development that emphasize the transactional and multifactorial nature of development, particularly the importance of the caregiving environment in affecting children's development.14 15 Considerable research supports the influence of a responsive style of interaction by parents16 17 and by child-care providers in child-care programs18 19 in facilitating children's language development. Therefore, studies of OME language sequelae must examine a child's caregiving environment both at home and in child-care settings to adequately understand how OME in early childhood can affect later language development. Third, the dependent measure of language development in previous studies has been measured broadly (eg, receptive language or expressive language), and may not be sensitive to the specific effects of OME and associated hearing loss. Specific language competencies (eg, vocabulary acquisition and language use) also need to be examined when looking for OME sequelae. Fourth, few studies have examined whether certain periods of development were particularly sensitive to language difficulties because of OME. It is possible that specific periods, such as when children are acquiring the sound symbol associations of their native language during the first year of life, may be more vulnerable to language difficulties than later periods when children are expanding their vocabulary and sentence length.
We reported recently a prospective study1 that did not find a direct association of OME-related hearing loss and language and cognitive development at 1 year of age. However, children with more frequent hearing loss tended to have less responsive home environments, and the childrearing environments were linked to lower performance at 1 year of age. The present study is a follow-up to that study and examines how children's OME history, hearing status, and caregiving environments during the first 2 years of life relate to children's language and cognitive development at 2 years of age in a group of children whose OME history and development has been prospectively monitored since infancy. It also examines whether children's development during certain time periods in infancy (ie, 9–14 months vs 15–24 months) is more vulnerable to OME and associated hearing loss.
Eighty-six African-American children (40 boys and 46 girls) participated in a longitudinal study of children's otitis media and development. All of the study children participated in an earlier study of OME experience,20 and 61 of these children were part of another study of OME and 1 year developmental outcomes.1 The current study includes 25 children who did not participate in the earlier study1 because they entered the project after 9 months of age. Children attending any of nine center-based child-care programs were recruited into the study between 6 and 12 months of age (mean, 8.2 months) during a 20-month period. All children had no known medical or genetic abnormalities at the time of entrance into the study. Most children (n = 68) were born at full gestational age (>37 weeks); 11 were born at 37 weeks, 6 at 36 weeks, and 1 at 30 weeks. Study participants were enrolled without previous knowledge of their ear disease.
At entry, the sample was predominantly low income. After entry into the study, 68.6% of families were classified as low income based on whether family income was less than 185% of federal poverty threshold (income less than $20 609 for a family of three) and 66% of the primary guardians were single. At the birth of the child, the mothers' mean age was 24.2 years [standard deviation (SD) = 5.6] and ranged from 14 to 38 years. Seven of the children were not living with their mother at 1 year of age: 3 lived with a grandmother, 3 with a foster or adoptive mother, and 1 with a father. The mean IQ of the primary guardian was 87.2 (SD = 9.8; range, 69–120) as measured by a two subtest (Vocabulary and Block Design) short-form of the Weschler Adult Intelligence Scale–Revised.21 The highest level of education (M = 12.5 years) achieved by the primary guardian varied from less than a high-school degree (29%), a high-school degree (29%), some college or other training after high school (31%), to a college degree (11%). One child was later reclassified as Native American on parental request, but was similar in socioeconomic status and was retained in the study sample. The study protocols were approved annually by the Academic Affairs Institutional Review Board at the University of North Carolina at Chapel Hill. Informed consent was obtained from each child's parent or guardian.
Otitis Media Documentation
Children's ears were examined between study entry and 2 years of age by two pediatric nurse practitioners who were trained in pneumatic otoscopy by a pediatrician. Children's ears were examined weekly for the first 15 months of the study, and because of a protocol change, biweekly thereafter. Children who left their original child-care sites remained in the study and had their ears examined monthly. Children underwent an average of 33.3 ear examinations (SD = 10.7). Of the intervals between observations, 19.7% were approximately 1 week in length, 59.9% approximately 2 weeks, 18.3% approximately 1 month, and 2% were 2 months.
Diagnosis of OME was based on pneumatic otoscopy; tympanometry was used to corroborate the OME diagnosis as has been recommended.7 OME was diagnosed as present when fluid was observed in the middle ear and when the tympanic membrane was immobile. A flat (type B) tympanogram was characterized by low static admittance (<0.2 millimhos), and no discernible pressure peak. When there was disagreement between the otoscopic findings and tympanometry, the otoscopic diagnosis was used. Agreement between judgments of mobility on pneumatic otoscopy and tympanometry based on 5720 ear exams was 91% (κ = 0.67). When otoscopy was unsuccessful (8.4%) because of partial occlusion of the canal by cerumen, the tympanometric findings were used as the primary diagnosis provided that ear canal volume was within normal range. Acute otitis media was treated with antibiotics. The children's primary health care providers were informed of all treatment prescribed for study participants. Parents were informed of ear findings after each ear examination. Decisions regarding referral for further evaluation for tympanostomy tubes were made by primary care providers, not the researchers. Seven children had middle ear ventilation tubes inserted during the study period. Further details about the OME diagnostic and treatment procedures and interobserver agreement can be found in the previous studies.1 20
The percentage of observation time with unilateral OME, bilateral OME, and total OME (unilateral or bilateral OME) from when children entered the study until 2 years of age was computed for each child. For each episode of OME, the date of onset of OME was subtracted from the date of resolution. The date of onset of OME was computed as midway between the last day the ears were evaluated as normal and the first day OME was present. Resolution of OME was computed as midway between the last day the OME was present and the first day ears were normal.
Visual reinforcement audiometry conducted by an audiologist and graduate assistant was used to assess hearing sensitivity. Frequency-modulated pure tones at 500, 2000, and 4000 Hertz (Hz) were presented through loudspeakers in a calibrated sound field. Children's hearing was tested: 1) routinely on entry into the study and every 3 months; 2) during weeks 1, 4, 7, and 13 after diagnosis of OME; and 3) after a change in ear status (eg, bilateral to unilateral OME, bilateral OME to normal). Between study entry and 2 years of age, children's hearing was tested an average of 10.7 times (SD = 2.7). Testing was performed at the child-care center in a mobile testing van that housed a single-wall sound suite. Sound level measurements were conducted periodically at each site and mean ambient noise levels were consistently within 2 dB allowable levels.22 Interobserver agreement between the audiologist and an assistant computed for the presence or absence of a response by the child during visual reinforcement audiometry for 758 sessions (73.3% of the sessions) was 97.6%. The audiologist ranked the validity of each session on a scale of one to five based on the child's state (eg, cooperativeness, interest in reinforcers, noise level) with five representing excellent validity and one representing poor validity. Each week the audiologist and assistant were given lists of children to be tested by the nurse practitioner so they were blind to the child's ear status. Further details about the audiology testing procedures can be found in the previous study.1Tympanometry using the procedures described above was done after the hearing assessment. Sessions with validity rankings of one (nonreliable) were dropped from the data analysis as were sessions with only one frequency tested (9.8%). All other sessions that had a reliability of at least two and in which at least two frequencies were tested were included in the data analysis.
A summary index of hearing loss was calculated by considering response levels of 25 dB HL or greater, for at least half of the thresholds tested (1/2 or 2/3) in a session, as indicative of hearing loss. The percentage of time children had hearing loss was calculated the same manner as described above for OME.
Language and Cognitive Measures
Children's language was assessed at 2 years of age using three standardized measures of language development and one measure of cognitive development. The Sequenced Inventory of Communication Development–Revised (SICD-R)23 measures overall receptive and expressive communication; a receptive communication age (RCA) and expressive communication age (ECA) were computed. The Communication and Symbolic Behavior Scales (CSBS)24examines use of communication; that is, the communicative, social, and symbolic abilities of children and a communication composite score (CSBS-total) was computed. The MacArthur Communicative Development Inventory (CDI)–short form25 uses parent report to examine vocabulary acquisition. The total number of vocabulary words parents reported that children used was determined and a vocabulary percentile computed. The Bayley Scales of Infant Development26 was used to assess cognitive level; a mental developmental index (MDI) was computed.
One of two speech-language pathologists, blind to the children's OME and hearing history, administered the tests when children were 2 years old. They were supervised in the Bayley Scales of Infant Development administration by a licensed psychologist. Tests were given in the sound room of a mobile test van or in a sound room at a university research center. Standard scores for the MDI of the Bayley Scales of Infant Development, the CSBS-total, and vocabulary on the CDI were corrected for gestational age for children 37 weeks of age or less at birth. Because the RCA and ECA from the SICD-R were age-equivalent scores, they could not be corrected for gestational age, but age was included as a covariate in the analysis of SICD-R scores.
The Home Observation for Measurement of the Environment–Inventory for Infants27 (HOME) was used at 9 and 18 months of age to look at the overall quality and responsiveness of the home environment. The HOME, which has high levels of validity and reliability,28 has six subscales: emotional and verbal responsitivity of the parent, acceptance of the child's behavior, organization of the environment, provision for appropriate play materials, and maternal involvement with the child. A HOME-total score was computed for 9 and 18 months by adding together the item scores at each age and then the two scores were averaged (HOME-total). The home visits were conducted by two trained nurse practitioners and two speech-language pathologists. Interrater agreement of at least 95% was established before data were collected.
Quality of the caregiver and the physical environment in each child's classroom in child care was assessed using the Infant/Toddler Environment Rating Scale (ITERS)29 during the child's first and second year. The ITERS, which has high levels of reliability and validity,29 examines the following: furnishings and display for children, personal care routines, listening and talking, learning activities, interaction, program structure, and adult needs. The total score at each age was computed as a mean of the child-related item scores and then averaged across the two ages. An examiner who was blind to children's OME and hearing status rated the classroom during a 3- to 4-hour observation in the spring of the child's first and second year in child care. During the 2-year period, three trained observers who had achieved good interrater reliabilities (r = .85 or better) with the test developers and trained ITERS observers did the observations.
Both descriptive and inferential analyses tested the associations between OME or hearing loss, quality of care environments, and infant outcomes. The distributions of both OME and hearing loss were skewed within this sample so a rank transformation was applied to all of the OME and hearing loss variables. One child did not have complete hearing data and was included only in the OME analyses. Descriptive analyses involved correlating the rank of OME and hearing loss with the HOME-total, ITERS-total, and the five language and cognitive measures: SICD-R RCA, SICD-R ECA, CSBS-total, MacArthur Vocabulary, and the Bayley Scales of Infant Development MDI. Inferential analyses involved fitting a series of multiple regression models to the five outcome measures. The first set tested hypotheses about the mediating role of the caregiving environments and the second set tested hypotheses about whether OME or hearing loss is more strongly related to developmental outcomes of particular ages. All five outcome measures were analyzed separately after preliminary analyses indicated that they were only modestly intercorrelated.
The inferential analysis involved fitting a series of multiple regression models using the approach described by Baron and Kenny30 to test mediating hypotheses. This approach involves running a series of nested models to determine the extent to which the hypothesized mediator accounts for observed associations between the predictor and outcome. The first regression model tests the independent contribution of the predictor using a model that excludes the mediator. The second regression model tests the independent contribution of the predictor using a model that includes the mediator. Evidence for mediation is obtained when the mediator and predictor are correlated and when the predictor is a much stronger predictor of the outcome in the regression analysis that excludes the mediator than in the regression analysis that includes the mediator.
Otitis Media Experience
Percentage of time with bilateral OME, unilateral OME, and total OME (unilateral and bilateral OME combined) from 6 to 14 months, 15 to 24 months, and 6 to 24 months is shown in Table1. Total OME occurred in 82.5% of the observation time between 6 and 14 months (more than four-fifths of this was bilateral), decreasing to 45.8% from 15 to 24 months (more than two-thirds was bilateral). As shown in Fig1, children's OME experience varied considerably in this time period. Between 6 and 14 months, almost all children experienced very high amounts of OME, but the number decreased considerably during the age period of 15 to 24 months. Children who had more bilateral OME had more total OME (r = .94;P = .0001). Because of the high correlation between total OME and bilateral OME, total OME was used in the analyses of OME and the childrearing and outcome measures as described below.
Children had hearing thresholds 25 dB HL or greater in 38.5% of the sessions at 500 Hz, 41.9% of the sessions at 2000 Hz, and 60.4% of the sessions at 4000 Hz. Applying the hearing loss criteria of 25 dB HL or greater for half the frequencies tested (Table 1), hearing loss occurred an average of 54.9% of the time from 6 to 14 months, decreasing to 33.1% from 15 to 24 months. Fig2 shows the variability in percent of time with hearing loss across the age groups. Between 6 and 14 months, more than 90% of the children experienced considerable (greater than 51% of the time) hearing loss; however, from 15 to 24 months, approximately one-third of the children continued to experience considerable hearing loss. Fig 3 shows the distribution of mean thresholds (average of the thresholds tested) when children had bilateral OME, unilateral OME, and no OME during the 6 to 24 month time period. When children had bilateral OME, average thresholds were greater than 25 dB HL (mild hearing loss) approximately one-half of the time and approximately one-fifth of the time greater than 40 dB HL (moderate loss). When unilateral OME occurred, thresholds averaged greater than 25 dB HL 17% of the time, whereas for normal ears, average thresholds were greater than 25 dB HL only 5.9% of the time. Using the study criteria for hearing loss, it occurred in 65.2% of the sessions when children had bilateral OME, 32.6% of the sessions when children had unilateral OME, and in 17% of the sessions with no OME. Children who experienced more total OME from 6 to 24 months had more hearing loss (r = .71;P = .0001) and higher mean thresholds (r = .65; P = .0001); children who had more hearing loss also had higher mean thresholds (r = .82; P = .0001) throughout this time period.
Otitis Media, Hearing, Quality of Childrearing, and Developmental Outcomes
Zero-order Pearson correlations related the rank of OME and hearing loss with measures of the care environments, and the language and cognitive outcomes. The means (Table2) indicate that the outcome measures were close to the normative means for the standard scores (MDI, CSBS), percentile scores (CDI), and age equivalents (RCA, ECA) expected for children this age. The correlations showed that children with more total OME had significantly lower scores on the two caregiving environment and the four outcome ECA, CSBS-Total, CDI, and MDI measures. Children with more frequent hearing loss had lower scores on the HOME and three outcome (ECA, CSBS, MDI) measures. The ITERS-total was positively correlated with all of the language and cognitive outcomes and the HOME was correlated with all of the measures but the ECA. All of the language and cognitive measures were positively correlated to a moderate degree with each other as were the home and child-care environmental measures (Tables 2 and3).
Two sets of regression analyses tested the direct and indirect associations between the language and cognitive outcomes at 2 years of age and rank of total OME and rank of hearing loss. In one set of analyses, proportion of time with total OME between 6 and 24 months was the predictor of interest; in the other, it was proportion of time with hearing loss. Two regression models were contrasted to test hypotheses that OME may be associated with child outcomes indirectly through the quality of the family and child-care environments. Model 1 included OME or hearing loss as the predictor of interest and maternal IQ, child's gender, and whether the family lived in poverty as covariates. Model 2 added the HOME-total and ITERS-total as hypothesized mediators. According to Baron and Kenny,30 evidence for mediation is obtained when the predictor of interest is a substantially stronger predictor when the mediator is excluded than when it is included in the analysis.
Results of these analyses are reported in Table4, listing the standardized regression coefficients for the two models. These analyses indicated that total OME was significantly negatively related to ECA, CSBS-total, and MacArthur Vocabulary in the analyses that ignored HOME-total and ITERS-total, but not in analyses that included them. In addition, the proportion of days with hearing loss was significantly related to the ECA only in the analyses that ignored the quality of the childrearing environments. Follow-up analyses tested whether OME or hearing loss interacted with gender, HOME-total, or ITERS-total in predicting the language and cognitive measures. The analyses including these interactions suggested that there was no evidence that OME or hearing loss differentially impaired performance related to gender, the quality of home environment, or the quality of the child-care environment.
Developmental Age Period
Follow-up multiple regression analyses were conducted to determine whether OME or hearing loss during a specific age period in infancy [early (6–14 months) versus later infancy (15–24 months)] was differentially related to language and cognition at 2 years of age for children who had at least 120 days of observation time in both the 6 to 14 months and 15 to 24 month periods (n = 76 for analyses including OME and n = 73 for the analyses including hearing loss). Comparisons of included and excluded children indicated that the two groups did not significantly differ on any analysis variables. The predictors included two caregiving environment variables, the selected covariates, and two OME variables representing the rank of proportion of time with OME from 6 to 14 months and from 15 to 24 months in the first analysis and two corresponding hearing loss variables in the second analysis. None of the regression analyses provided any evidence of differential age associations for OME or hearing loss. Neither OME nor hearing loss during early or later infancy independently contributed to predicting the language and cognitive outcomes.
Study findings indicate that OME and associated hearing loss are common among African-American children attending group child care through the age of 2 years, yet prevalence decreases after 15 months of age. Although there was a modest correlation between both OME and hearing loss with several measures of language and cognitive development at 2 years of age, these direct relationships were not significant when the quality of the home and child-care environments were considered in the analyses. This was because both OME and hearing loss were more strongly correlated to the quality of home and child-care environments than with children's language and cognitive development, and because the caregiving environmental variables were stronger predictors of children's language and cognitive development than was OME and associated hearing loss. The association between OME and three language outcomes (ie, expressive language, vocabulary learning, and language use) and between hearing loss and one language outcome (ie, expressive language) could be accounted for by their joint relations with the caregiving environment indicating either mediating or confounding explanations. The results did not support a critical period of early (6–14 months) versus later infancy (15–24 months) in which OME or hearing loss matters most.
According to the mediating explanation, persistent or recurrent OME and associated hearing loss may cause a child to miss or confuse important information. Thus, a child with hearing loss attributable to OME may be less responsive in interactions and may initiate interactions less often. A caregiver, in turn, often may not receive the necessary cues to establish an optimal responsive and facilitative interaction style, which has been shown in other research to be linked to later language learning.16 17 These patterns of interactions can then negatively impact children's language development. This mediational explanation is consistent with studies that found that the mothers of children with a history of OME were less warm and sociable with their children31 and viewed themselves as more depressed and less competent.32 This explanation is also consistent with studies suggesting that parenting style (ie, parent stimulation and directiveness) may interact with OME experience to affect later language skills,33 34 and that child care quality (ie, caregiver-child ratio) interact with OME experience to affect attention, but not language skills.10 Yet, other researchers33 35 failed to show differences in the interaction patterns of mothers of children with differing OME experience.
In contrast, the study findings could be interpreted as simply reflecting a confound between OME and associated hearing loss and the caregiving environments. Such a confounding would occur when children experience both more frequent OME or associated hearing loss and poorer developmental outcomes because they are in lower quality caregiving environments, not because their OME affects the quality of caregiving. That is, children from lower quality home and child-care environments experience more OME and associated hearing loss because of factors commonly associated with lower quality caregiving such as more crowding in the household, exposure to more children in child-care programs, more frequent use of bottle propping, and poorer overall hygiene.7 36 Lower quality caregiving environments also are associated with lower scores on language and cognitive outcomes because of factors such as less frequent interactions and less scaffolding and support of children's communication.6 19 Thus, the confounding interpretation suggests that OME is not linked to child outcomes, but both OME and the child outcomes are both related to quality of caregiving.
The failure to find a direct association between both OME and associated hearing loss with language and cognitive outcomes at 2 years of age is consistent with the findings of other studies.9-11 However, the findings are inconsistent with those of two previous prospective studies33 37 that did find a direct association. These previous studies failed to consider the role of the caregiving environment in affecting children's language and cognitive development.
A growing body of research supports the role of the quality of the home16 17 and child-care environments18 19 in infancy in affecting children's language and cognitive development. Thus, the findings of the present study highlight the importance of examining the multiple factors known to influence a child's development when studying OME developmental sequelae.
The present study has many strengths not found in earlier studies. First, the study was prospective, following a group of children who attended child care from infancy. Second, repeated measurements using a standard protocol were used to assess OME status, hearing experience, and children's development. Third, hearing loss in addition to OME experience was measured frequently when children were well and when ill with OME. Fourth, multiple variables in each child's home and child-care environment that are known to affect children's development were measured. Finally, multiple aspects of children's language development were examined including vocabulary, language use, and overall language comprehension and production.
Despite these strengths, the results of this study should be interpreted cautiously for several reasons. First, a higher incidence of OME was found in this population of children attending community-based child-care programs as described by Zeisel and colleagues20 than has been reported in other prospective studies.36 38-40 However, the median proportion of time with bilateral OME was only 14.4% of the observation time between 15 and 24 months. This means that 50% of the children had bilateral OME less than 40 days between 15 and 24 months of age. The reason for the considerably higher prevalence of OME in this study of primarily low-income African-American children is unclear, although other studies did not include a substantial number of children in community-based child-care programs. Further, Paradise and colleagues36recently reported a higher incidence of OME among African-American children and lower socioeconomic families than previously reported. It is also possible that the frequency of surveillance, diagnostic procedures, or variations in illness rates affected the rates of OME. Regardless, because of the high incidence of OME among this group of primarily low-income African-American children, the results should be generalized with caution. Second, in this study, children experienced the most hearing loss during periods of bilateral OME; however, even during periods of unilateral OME and no OME, some children demonstrated elevated hearing levels. We speculate that this is because the ears, although free of OME, were frequently characterized by retraction of the tympanic membrane or other mechanical changes in the conductive mechanism secondary to recurrent OME. In the present study, children had hearing loss (using the study criteria) 17.7% of the time when negative middle ear pressure (greater than −200 daPa) was present. In addition, we41 and other researchers42 have shown that young children with recurrent OME are likely to have lower static admittance and wider tympanograms during periods of no OME that can result in a mild conductive hearing loss. Third, we examined specific measures of children's language and cognitive development and did not study other aspects of communication such as speech perception or speech production, nor attention and behavior. Using these other measures as outcomes may lead to different results. Further, studies have shown that infant tests do not predict well test scores into later childhood or adulthood,43 44 and interpretation of these results should be done cautiously. Fourth, we did not begin documenting OME until a mean age of 8.2 months, thus data are not available on OME experience a good part of the first year of life. Fifth, we did not look at how the severity of hearing loss related to language and cognitive outcomes; instead, we looked at this relationship only for the presence of a hearing loss (which could be mild or moderate in degree). We did find, however, that children's average mean thresholds across sessions were highly correlated with the amount of time children experienced hearing loss. Sixth, the modest levels of the association indicate that a complex array of factors, in addition to the variables studied, likely affect children's development. Finally, in any observational research, causality—that is, whether OME or hearing loss cause differences in childrearing patterns that affect later language abilities or whether OME or hearing loss directly affect such abilities—cannot be inferred directly from this study. Thus, we cannot distinguish between the mediational or confounding explanations attributable to the correlational nature of the study.
We will continue to follow these children longitudinally into the preschool years to explore the interrelationships among OME and hearing loss, family and child-care environments, and language and cognitive development.
Supported by: Maternal and Child Health Program (MCJ-370599 and MCJ-370649, Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.
- Received December 22, 1997.
- Accepted March 2, 1998.
Reprint requests to (J.E.R.) Frank Porter Graham Child Development Center, 105 Smith Level Rd, CB# 8180, Chapel Hill, NC 27599-8180.
- Wallace IF,
- Gravel SJ,
- McCarton CM,
- Ruben RJ
- Teele DW,
- Klein JO,
- Rosner BA,
- the Greater Boston Otitis Media Study Group
- ↵Stool SE, Berg AO, Berman S, et al. Managing Otitis Media With Effusion in Young Children. Clinical Practice Guideline, Number 12. AHCPR Publication No. 94–0622. Rockville, MD: US Department of Health and Human Services; 1994
- Paradise JL,
- Rogers KS
- ↵Roberts JE, Wallace IF. Language and otitis media with effusion. In: Roberts JE, Wallace IF, Henderson F, eds. Otitis Media in Young Children. Baltimore, MD: Paul H. Brookes Publishing Co; 1997
- ↵Sameroff AJ. Developmental systems: contexts and evolution. In: Kessen W, ed. History, Theories, and Methods, I. From: Mussen PH, ed. Handbook of Child Development. New York, NY: Wiley; 1983
- ↵Wechsler D. Wechsler Adult Intelligence Scale–Revised. San Antonio, TX: Psychological Corporation, Harcourt Brace Javonovich, Inc; 1981
- ↵American National Standards Institute. Criteria for Permissible Ambient Noise During Audiometric Testing. (ANSI 3.1–1977.) New York, NY: American National Standards Institute; 1977
- ↵Hedrick DL, Prather EM, Tobin AR. Sequenced Inventory of Communication Development–Revised. Seattle, WA: University of Washington Press; 1984
- ↵Wetherby AM, Prizant BM. Communication and Symbolic Behavior Scales (Research Edition). San Antonio, TX: Special Press; 1990
- ↵Fenson L, Pethick S, Cox JL. The MacArthur Communicative Development Inventories: Short Form Versions. San Diego, CA: San Diego State University; 1994
- ↵Bayley N. Bayley Scales of Infant Development. New York, NY: Psychological Corporation; 1969
- ↵Caldwell BM, Bradley RH. Home Observation for Measurement of the Environment (Revised). Little Rock, AR: University of Arkansas; 1984
- ↵Harms T, Cryer D, Clifford RM. Infant/Toddler Environment Rating Scale. New York, NY: Teachers College Press; 1990
- Paradise JL,
- Rockette HE,
- Colborn DK,
- et al.
- Roberts JE,
- Sanyal MA,
- Burchinal MR,
- Collier AM,
- Ramey CT,
- Henderson FW
- Copyright © 1998 American Academy of Pediatrics