Whether recurrent or persistent otitis media during the first few years of life increases a child's risk for later language and learning difficulties continues to be debated. Otitis media is the most frequent illness of early childhood, after the common cold. Otitis media with effusion (OME) denotes fluid in the middle ear accompanying the otitis media. OME generally causes mild to moderate fluctuating conductive hearing loss that persists until the fluid goes away. It has been proposed that a child who experiences repeated and persistent episodes of OME and associated hearing loss in early childhood will have later language and academic difficulties. Unlike the well-established relationship between moderate or severe permanent hearing loss and language development, a relationship between OME and later impairment in language development is not clear. This entry describes the possible effect of OME on language development in early childhood, research studies examining the OME-language learning linkage, and the implications of this literature for clinical practice. For information about the relationship of OME to children's speech development, see EARLy recurrent otitis mEDiA and speech DEvELOpmENT.
More than 80% of children have had at least one episode of otitis media before 3 years of age, and more than 40% have had three or more episodes (Teele, Klein, and Rosner, 1989). The middle ear transmits sounds from the outer ear to the inner ear, from which information is carried by the acoustic nerve to the brain. In OME, the middle ear is inflamed, the tympanic membrane between the outer and middle ear is thickened, and fluid is present in the middle ear cavity. The fluid can persist for several weeks or even months after the onset of an episode of otitis media. The fluid generally results in a mild to moderate conductive hearing loss. The hearing loss is typically around 26 dB HL, but it can range from no hearing loss to a moderate loss (around 50 dB HL), making it hard to hear conversational speech. It has been suggested that frequent and persistent hearing loss during the first few years of life, a time that is critical for language learning, causes later language difficulties.
The OME-associated hearing loss, which is often variable in degree, recurrent, and at times asymmetrical, has been hypothesized to disrupt the rapid rate of language-processing, causing a loss of language information. This disruption has been hypothesized to affect children's language acquisition in the areas of phonology, vocabulary, syntax, and discourse in several ways. First, the disruption and variability in auditory input due to OME may cause children to encode information incompletely and inaccurately into their phonological working memory. Consequently, children's lexical development may be hindered if they have inaccurate representations of words, which may then result in imprecise lexical recognition or production. Second, OME-associated hearing loss may result in difficulties acquiring inflectional morphology and grammar. Children may not hear or may inaccurately hear certain grammatical morphemes that are of low phonetic substance, such as inflections of short duration and low intensity (e.g., third person /s/, past tense /''ed''/) and unstressed function words (''is,'' ''the''). Third, children's use of language may also be affected because they may miss subtle nuances of language (e.g., intonation marks, questions), which interferes with their ability to follow conversations. Children with prolonged or frequent OME may also learn to tune out, particularly in noisy situations, resulting in attention difficulties for auditory-based information. Difficulty maintaining sustained attention could compromise children's ability to sustain discourse (i.e., to follow and elaborate on the topic of the conversation) and to organize and produce coherent narratives (both requiring auditory memory and recall).
Recent models of a potential linkage between a history of OME and subsequent impaired language development hypothesize that not only factors inherent in the child but also the child's environment and the interaction between the child and the environment can affect this relationship (Roberts and Wallace, 1997; Vernon-Feagans, Emanual, and Blood, 1997; Roberts et al., 1998; Vernon-Feagans, 1999). These additional factors include both risk factors (e.g., the child has poor phonemic awareness skills, the mother has less than a high school education, the child care environment is noisy) and protective factors (e.g., the child has an excellent vocabulary, a literacy-rich home environment, and a responsive child care environment). Thus, it is proposed that the potential impact of OME on children's language development depends on the number and timing of OME episodes and associated hearing loss; the child's cognitive, linguistic, and perceptual abilities; the responsiveness and supportiveness of the child's environment; and interactions among these variables.
Over the past three decades, more than 90 original studies have examined whether children who had frequent episodes of OME in early childhood score lower on measures of language than children without such a history. Earlier studies examining an association between OME and later language were retrospective in design (the children's history of OME was documented by parents reporting the frequency with which children had OME or by a review of medical records collected by different medical providers) and were more likely to contain measurement errors. More recent studies of the OME-language linkage were prospective, with children's OME histories documented longitudinally from early infancy and repeated at specific sampling intervals. Prospective studies are more likely to have greater objectivity and accuracy over time, avoiding many of the methodological limitations of previous studies.
Several prospective studies have found a relationship between a history of otitis media in early childhood and later language skills during the preschool and early elementary school years. More specifically, in comparison with children who infrequently experienced otitis media, infants and preschoolers with a history of OME scored lower on standardized assessments of receptive and expressive language (Teele et al., 1984; Wallace et al., 1988; Friel-Patti and Finitzo-Hieber, 1990) and in specific language areas, including syntax (Teele et al., 1990), vocabulary (Teele et al., 1984), and narratives (Feagans et al., 1987). However, many studies failed to find associations between an early history of OME and later measures of overall receptive or expressive language, vocabulary, or syntax (Teele et al., 1990; Peters et al., 1994; Paradise et al., 2000; Roberts et al., 2000).
Several ongoing prospective studies are providing new and important information on whether a history of OME in early childhood causes later language difficulties. Three recent experimental studies (Maw et al., 1999; Rovers et al., 2000; Paradise et al., 2001) examined whether prompt insertion of tympanostomy tubes (to drain the fluid for children with frequent or persistent OME) improved children's language development, compared with delaying the insertion of tympanostomy tubes. Paradise and colleagues (2001) randomized 429 children (at mean age of 15 months) who had persistent or frequent OME to have tympanostomy tubes inserted either promptly or 6-9 months later and reported no language differences between the two treatment groups at age 3 years of age. Rovers and colleagues (2000) also did not find that prompt insertion of tympanostomy tubes improved children's language development. Maw and colleagues (1999) did find effects on language development 9 months after treatment; however, 18 months after treatment there were no longer differences between the groups.
Other prospective studies considered the impact of multiple factors such as the educational level of the mother and the extent of hearing loss a child experienced during early childhood on children's language development. The Pittsburgh group (Feldman et al., 1999; Paradise et al., 2000) reported weak but significant correlations between OME in the first 3 years of life and language development (accounting for 1%-3% of the variance in language skills), after controlling for many family background variables. Roberts and colleagues (1995, 1998, 2000) prospectively studied the relationship of both children's OME and hearing history to language development. They did not find a direct relationship between OME or hearing history and children's language skills between 1 and 5 years of age (Roberts et al., 1995, 1998, 2000). They did find that the caregiving environment (responsiveness of the child's home and child care environments) mediated the relationship between children's history of OME and associated hearing loss and later communication development at 1 and 2 years of age (Roberts et al., 1995, 1998, 2000, 2002). That is, children with more OME and associated hearing loss tended to live in less responsive caregiving environments, and these environments were linked to lower performance on measures of receptive and expressive language skills. More recently, Roberts and colleagues reported that children with greater incidence of OME scored lower in expressive language upon entering school but caught up with their peers in expressive language by second grade. However, a child's home environment was much more strongly related to early expressive language skills than was OME. These and other ongoing prospective studies highlight the importance of examining the multiple factors that affect children's language development.
The potential impact of frequent and persistent hearing loss due to OME on later language skills may be particularly important to examine in children from special populations who are already at risk for language and learning difficulties. Children who have Down syndrome, fragile X syndrome, Turner's syndrome, Wil-liams's syndrome, cleft palate, and other craniofacial differences often experience frequent and persistent OME in early childhood (Zeisel and Roberts, 2003; Casselbrant and Mandel, 1999). This increased risk for OME among special populations may be due to craniofacial structural abnormalities, hypotonia, or immune system deficiencies. A few retrospective studies have reported that a history of OME further delays the language development of children from special populations (Whiteman, Simpson, and Compton, 1986; Loni-gan et al., 1992).
The question of whether recurrent OME affects the later acquisition of language is still unresolved, in part because of the conflicting findings of studies that have examined this issue. There is increasing support from prospective studies that for typically developing children, OME may not be a substantial risk factor for later language development. Although a few studies report a very mild association between OME and later impairment of receptive and expressive language skills during infancy and the preschool years, the effect is generally very small, accounting for only about 1%-4% of the variance. Furthermore, it is clear that the caregiving environment at home and in child care plays a much more important role than OME in children's later language development. Future research should examine if frequent hearing loss due to OME relates to children's language development. The impact of a history of OME and associated hearing loss on the language development of children from special populations should also be further studied. Some typically developing children as well as children from special populations may be at increased risk for later language and learning difficulties due to a history of OME and associated hearing loss. Until further research can resolve whether such a relationship between a chronic history of OME and later language skills exists and can determine what aspects of language are affected, hearing status and language skills need to be considered in the management of young children with histories of OME.
Several strategies have been recommended for young children who are experiencing chronic OME (Roberts and Medley, 1995; Roberts and Wallace, 1997; Vernon-Feagans, 1999; Roberts and Zeisel, 2000). First, a child's hearing, speech, and language should be tested after 3 months of bilateral OME, or after four to six episodes of otitis media in a 6-month period, or when families or caregivers are concerned about a child's development. Second, families and other caregivers (e.g., child care providers) of young children with recurrent or persistent OME need clear and accurate information in order to make decisions about the child's medical and educational management. Third, children who experience recurrent or persistent OME, similar to all children, will benefit from a highly responsive language- and literacy-enriched environment. Caregivers should respond to communication attempts, provide frequent opportunities for children to participate in conversations, and read often to their children. Fourth, children with chronic OME will benefit from an optimal listening environment in which the speech signal is easy to hear and background noise is kept to a minimum. Fifth, some children with a history of OME may exhibit language and other developmental difficulties, and benefit from early intervention. Finally, the results of ongoing research studies combined with previous studies should help determine whether a history of OME in early childhood places children at risk for later language difficulties, and if so, how to then target intervention strategies.
—Joanne E. Roberts
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