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Behavior and Developmental Effects of Otitis Media
with Effusion in the Teens

Dimitar Marev

Department of Otorhinoloryngology, Prof. P. Stoyanov Varna University of Medicine, Varna, Bulgaria

ABSTRACT

Objective: To examine whether behavioral or cognitive sequelae of otitis media with effusion (OME) continue into late childhood and the early teens (11-18 years).
Setting: Data from a large multipurpose birth cohort study: the Dunedin multidisciplinary health and development study.
Participants: Around 200children from the study. The main independent variable of interest was otological status of the child up to age of 9 years.
Main outcome measures: Parent and teacher rated behavior problems including antisocial, neurotic, hyperactive, and inattentive behavior patterns and tests of academic achievement covering intelligence quotient (IQ), reading, and spelling were available in a high proportion of the cohort at the age of 11to 18years.
Results: After adjustments for covariates such as socioeconomic status, hyperactive and inattentive behavior problems were evident as late as at the age of 15years, and lower IQ associated with OME remained significant to the age of 13years. The strongest effects were observed for deficits in reading ability between 11and 18years.
Conclusion: No previous study considering behavior problems as an outcome has followed-up children long enough to determine whether some of the early sequelae of OME were still present in the early to late teens. Some developmental sequelae of OME, particularly deficits in reading ability, could persist in the late childhood and the early teens.
Key words: Otitis media with effusion,Teenagers, Behavior problems,Academic achievement, Longitudinal birth cohort study.
Pro Otology 2-3:110—112, 2004

Introduction

Evidence of associations between otitis media with effusion (OME) during early childhood and later deficits in language, academic achievement, or behavior is controversial. The number of studies finding such associations is almost equaled by those that do not, but low statistical power in most studies makes it unprofitable to seek a basis for their apparent “disagreements”. Understandably, most studies of behavioral, language, and cognitive sequelae of OME have concentrated on short or medium term effects (up to the age of 7 years) (1,2). Where sequelae have been found in the immediate aftermath of OME in mid-childhood, estimates of their magnitude range from about one third to one half of a population standard deviation. For a common condition, this magnitude although not large merits study and explanation, for example by distinguishing the influences of persistent hearing loss from those of related respiratory and ear disease.

The duration of each long term effect of OME is the chief issue related to intervention policy. Therefore we examined associations between early OME and late developmental and behavioral sequelae in a national birth cohort. The cohort is based on a whole population; it is large enough to permit appropriate statistical control through adjustment for covariates. Cumulative history of OME through mid-childhood is important when considering late sequelae, since only those children with a longer duration of OME would be likely to have problems with behavior and cognitive sequelae later on in life. The repeated otological documentation and high follow-up rates of the Dunedin cohort afford an opportunity to address this.

MATERIAL AND METHODS

A longitudinal investigation of health and development was undertaken on a sample of over 200 children. The otological status of the child defined from age 5 to 9 years in the Dunedin study provides an objective measurement of the cumulative history of OME thus enabling us to exclude those with earlier but shorter term histories. An otological examination was conducted on each child at 5,7,9,11,13,and 15 years according to an assessment protocol using otomicroscopy, impedance audiometry, and pure tone audiometry (4). As the disease generally resolves with growth, children with positive signs in this period will have had these previously. The converse is not true, so we believe it unlikely that we have missed significant cases. Ears were rated by otoscopy into five main categories: normal, fluid present, ventilation tubes present, acute otitis media, and other abnormalities.

Impedance audiometry (tympanometry) was performed on each ear and classified according to Jerger (6). Hearing thresholds were obtained by pure tone audiometry for the complete sample at 500,1000,2000,and 4000Hz. A mean hearing threshold was calculated across these frequencies for each ear at each phase. The information on hearing thresholds could be combined with that for the tympanogram and otoscopy to define middle ear status at each phase (table 1). Those meeting criteria for surgical treatment received ventilation (tympanostomy) tubes.

Rutter parent and teacher behavior scales were available at ages of 11 and 13 years.At age of 15 years only data on parent and self reported behavior problems were available, and at that of 18 years only self reported behavior problems using the more age appropriate revised behavior problem checklist (10). Subscales of antisocial, neurotic, hyperactive, and inattentive behavior problems were derived by summing the relevant items from these behavior questionnaires according to established derivations (9,10).

Results

At the age of 5 years,47.3% of ears were normal (type A or no fluid present), 8.8% had evidence of fluid present (type B), and the remainder were intermediate (type C1 or C2). By the age of 7 years, there were 6.1% type B and 55% type A tympanograms. By the age of 9 years,there were 1.8% type B and 62.3% type A, and at the age of 11 years the figures were 1.6% and 59.6%, respectively.

Table 1 summaries the results of combining information on middle ear status in 962 children over the ages 5,7,and 9 years in order to summarize the OME history of each child during this period. The cumulative history reflects a combination of severity and duration, so is likely to be more predictive of long term outcomes than analyses using single age predictors.

The strongest associations with OME history up to the age of 9 years lie in parent reported total behavior problem score and inattentive behavior at 13 and 15 years and in teacher reported inattentive behavior at 13 years. The strongest associations with OME history up to the age of 9 years were with verbal at 11 and 13 years, non-verbal and full at 13 years, reading deficits at 11,13,15,and 18 years, and spelling at 13 years. No speech and language data were available at these ages. The Burt reading test was available at 11,13,15,and 18 years allowing a repeated measures’ analysis to be performed to examine patterns of association with age. The mean scores by ear status across age in years are given (4). For this purpose, the ear status at the age of 9 years was collapsed to a three category stratification by grouping categories 1 and 2,3 and 4,and 5-7 as given in table1 to represent sustained bilateral, unilateral/transient, and no evidence of OME.

Discussion

Many previous studies considering long term sequelae have methodological problems including a high rate of attrition and inadequate control for probable confounding variables. Only a few studies (15-18) have considered effects of otitis media after the age of 9 years.Their results are inconclusive as to whether behavioral or developmental sequelae continue into the teenage years. However, most of these studies had sample sizes that were too small to detect the modest effect that could reasonably be expected, given the remitting nature of the disease, or they used highly selected populations. One study (16) showed that 12 children with multiple episodes of otitis media in the first year of life performed less well in a variety of communication tasks including language and speech at the age of 9 yearsthan a group of children who were effusion-free in their first year. Second et al, in a group of 84 learning disabled children and adolescents, showed that early onset OME can lead to serious cognitive deficits at the age of 9 years,particularly in auditory-verbal abilities involving sequential processing (17). Roberts et al. found no association between OME in the first 3 years of life and cognitive, academic and behavior problems at 12 years of age in a group of socially disadvantaged children (18).

With such a powerful design, observational studies on population cohorts give somewhat disappointing power relative to the apparently large sample size. In a population (rather than case-control) study, numbers of the order of 1000 are the minimum for showing effects on a condition having a nominal prevalence of 10%; this is partly because of the few extreme cases in an unselected population.

Overall results suggest that correlates of an early OME history, or the sequelae of early OME history, can still exert some influence well into late childhood but not beyond. Against this background, the deficits in reading ability shown here constitute a substantially new finding. The most significant finding was OME history associated with parent reported inattentive behavior at 11,13,and 15 years along with some residual antisocial behavior at 15 years. This would not necessarily have been expected at such a late age.

At the age of 13 years,reading and spelling appeared to be influenced by OME. More restricted data on developmental sequelae were available in the late teens (15-18 years). Reading at 15 and 18 years was significantly associated with ear status at the age of 9 years.The Burt reading test has a ceiling at a score of 110,so by the latter ages there is little room for improvement. This might be expected to reduce the sensitivity of the test in detecting small differences between groups; however, it has been shown to discriminate well even up to the age of 18 years.The expected compression of the variance, and hence of the group differences, is a reason why we believe this result is genuine.

Nevertheless, the findings of various studies examining the effects of OME on children’s reading at various ages gives grounds for believing that effects can be shown under some circumstances. Updike (23) found a significant effect of OME on reading at 6-7 years and correlations between auditory perception skills and word recognition and reading comprehension. As a skill, reading has visual, linguistic, cognitive, motivational, and cultural components.

In a review of speech and language sequelae from OME (2) the evidence on very early speech and language has been found to be quite strong. No data are available in the Dunedin cohort on speech and language (20). Many language studies fail to find effects after 5 years, and as few data have been published on language sequelae after the age of 8 years no conclusions can be drawn whether the reading effects should be attributed to a more general linguistic factor.

CONCLUSION

The results from the analyses of a national birth cohort provide new findings on longer term sequelae of OME. In particular, early middle ear disease history appears to have a deleterious effect on reading ability and behavior problems as reported by parents and teachers including inattentive and hyperactive behavior. Because of the links to academic performance and social behavior in the subset of children persistently affected by OME, the future challenge for health professionals and parents will be to identify persistent, long term cases of OME and to intervene in ways that evidence shows to be justified.

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