EFFECT OF CHRONIC OTITIS MEDIA ON LANGUAGE AND SPEECH DEVELOPMENT

(Received August 30; revision accepted for publication December 27, 1968.)

This study was supported by funds made available from the Children’s Bureau, U.S. Department of

Health, Education, and Welfare.

ADDRESS: (V.A.H.) Division of Child Health, Department of Pediatrics, University of \Vashington

Medical School, Seattle, Washington 98105.

PEDIATRICS, Vol. 43, No. 5, May 1969

833

EFFECT

OF

CHRONIC

OTITIS

MEDIA

ON

LANGUAGE

AND

SPEECH

DEVELOPMENT

Vanja A. HoIm, M.D., and LuVern H. Kunze, Ph.D.

Departments of Pediatrics and Speech, Clinical Training Unit, Child Development and Mental Retardation Center, University of W7ashington, and Cii iidren’s Orthopedic Hospital

and Medical Center, Seattle, Washington

ABSTRACT. Two groups of children were

com-pared in order to determine the effect on language and speech development of the fluctuating conduc-tive hearing loss which accompanies chronic otitis

media. The experimental group consisted of 16

children, aged 5 to 9 years, with chronic otitis media and with hearing fluctuations documented

by audiograms. The control group was matched for

age, sex, and socioeconomic background. The

lan-guage performances of the groups were compared by means of the Illinois Test of Pss’chohinguistic

Abilities, the Peabody Picture Vocabulary Test, the

Templin-Darlev Picture Articulation Screening

Test, and the Mecham Verbal Language

Develop-ment Scale. The result shows that the experimental

group was delayed to a statistically significant de-gree in all language skills requiring the receiving

or )roCe5Siflg of auditory stimuli or the production of verbal responses. No significant differences were

found in tests measuring PrimarilY visual and

niotor skills. This would suggest that the

fluctuat-ing hearing loss accompanying chronic otitis media was the cause of the delay in language develop-ment found in the experiniental grout). Physicians, parents, and educators need to be aware of the

im-plication of this language handicap, as it might

af-feet performance. Further studies are needed to

evaluate the influence on permanent language

abil-ity l)y the I)(rio(lic lack of sensory stimulation

cx-Perienced (luring conductive hearing loss due to frequent episodes of otitis media. Pediatrics,

43:833, 1969, OTITI5 MEDIA, HEARING, LANGUAGE,

CHILD DEVELOPMENT, SENSORY DEPRIVATION, SPEECH

DEVELOPMENT.

O

TITIS MEDIA is a common cause of

tem-porary conductive hearing loss in young children. In most instances these epi-sodes are infrequent and of short duration,

and there is little reason to suspect that

they adversely influence language

develop-ment. However, a small group of children

are severely affected. For this group the ep-isodes of otitis media start during the first

few months of life and recur frequently. A

number of these children continue to have

recurrent and chronic otitis media

accom-panied by fluctuating hearing acuity

through the years of most rapid language

development.

In general, the air conduction hearing

loss accompanying otitis media varies from

20 dB to 40 dB, ISO. Bone conduction is

normal. The average level of conversational

speech is such that a child with a hearing

loss resulting from otitis media will appear

to hear in that he exhibits an awareness of

speech. However, he will understand what

is being said only under the most favorable

conditions

(

i.e., when facing a person who speaks fairly loudly at close range) but will

not understand much of what is said under

less favorable conditions

(

i.e., as in a class-room

)

. In the opinion of Goetzinger,2 this

degree of hearing loss, when assumed to be

permanent and non-fluctuating, as in

chil-dren with sensorineural loss, results in

lan-guage delay. Eisen3 discusses behavioral

changes in a child with fluctuating hearing losses but does not include language.

A search of the literature reveals no statement concerning the language deficit resulting from fluctuating hearing acuity

experienced in recurrent and chronic otitis

a group of matched controls.

SUBJECTS

The subjects were patients at the

outpa-tient department of Children’s Orthopedic

Hospital and Medical Center in Seattle,

Washington. The outpatient facility of this

hospital serves primarily the lower

socio-economic groups, as children are seen only

if it is determined that the family cannot

afford private medical care; family income, parents’ health, family size, and the

poten-tial cost of the child’s medical problem are

taken into consideration. Identical

socioeco-nomic criteria were used in determining

eli-gibility for care at the different outpatient clinics utilized by the subjects. The subjects were seen in the hospital setting either

dur-ing waiting periods for appointments or

shortly after admission to the inpatient de-partment for elective minor surgery.

Experimental Group

The experimental group, from the

ear-nose-throat clinic, consisted of 16 children

between the ages of 53 and 9 years with

chronic otitis media but no other known

medical problems. Through review of the

hospital chart, interview with the parent

accompanying the child, and examination

of the child, it was determined that each

child in the experimental group met the

fol-lowing criteria:

1. The child had been assigned to a

pa-tient group eligible for free care at the

hos-pital’s outpatient department.

2. The child’s age fell within the limits (53 to 9) chosen to insure that the subjects

(

d

)

chronic illness, excluding otitis.

5. The child’s middle ear disease (a)

had its onset before two years of age,

(

b)

was still present at the time of evaluation,

and

(

c

)

had been accompanied by

fluctua-tions in hearing over the years as observed

by the parents.

6. The child’s middle ear disease had

been assigned the diagnosis of serous otitis

media, chronic otitis media, or both by

at-tending otolaryngologists in the ENT

Clinic. Most children had had one or more

surgical procedures performed on their

ears.

7. Examination showed effects of chronic

bilateral middle ear involvement such as

scarring and perforation.

8. At least two audiograms, at different times, by an audiologist showed

(

a

)

consis-tently normal bone conduction bilaterally,

(

b

)

at least one record with bilateral air

conduction loss of 25 dB or greater, ISO,

and

(

c

)

at least one record with unilateral

near normal air conduction in the speech

frequency range. Most subjects had many

additional audiograms confirming the

flue-tuation in hearing.

9. Hearing acuity at the time of testing

was not sufficiently depressed to affect the child’s test performance.

Control Group

The children in the control group were

selected from patients being seen in the

general pediatric, urology, orthopedic,

der-matology, and ophthalmology clinics. These

children exhibited minor or self-limiting

dis-4

tO(

1.5C

1.oc

.5c

0

-.5(

-1.0(

-1.5

-2.0

-t5

E*nol Group

Control Gro

+

ARTICLES 835

2’ 4 6 7 S’ 9 10 11 12

FIG. 1. Standard score means and standard deviations for the experimental and control groups on tests

administered to the children. ( 1 ) Temphin-Darley Articulation Screen, ( 2 ) Peabody Picture Vocabulary

Test, (3) ITPA-Total, (4) ITPA-Auditory Decoding, ( 5) ITPA Visual Decoding, (6) ITPA Auditory Vocal Association, (7 ) ITPA Visual Motor Association (8) ITPA Vocal Encoding, (9) ITPA Motor

En-coding, ( 10) ITPA Auditory Vocal Automatic, (11 ) ITPA Auditory Vocal Sequencing, ( 12 ) ITPA

Visual Motor Sequencing. *Tests for which group differences are significant at 0.05 level of confidence.

comfort nor required frequent medical care

or repeated hospitalizations in the past.

Typical reasons for clinic attendance

in-eluded common warts, esotropia,

hypospa-dia, and pes planus. Each child in the

con-trol group was matched with a child in the

experimental group on the basis of sex,

race, and age within 6 months. Using the

same procedure as for the experimental

group-chart review, parent interview, and

examination-it was determined that the

children in the control group fulfilled crite-na one through four outlined for the exper-imental group. In addition they met the fol-lowing three criteria:

1. There was no documented ear

infec-tion by hospital record or parent

recollec-tion. No child had complained of an

ear-ache more than three times in his life. The

parents had never noticed any behavior

suggestive of hearing loss.

2. Examination showed normal external

ears, ear canals, and tympanic

mem-branes.

3. Hearing was normal at the time of the

evaluation by gross testing. Audiological

screening in public schools had shown

nor-ma! hearing. After using the described

matching procedures and the criteria listed,

the groups were found to show the

follow-ing characteristics:

1. There were 10 boys and 6 girls in

each group.

subject were evaluated through the use of

(

1

)

a group of standardized language mea-sures administered to the child, and

(

2

)

a language development scale which pro-duces a score based on the child’s language

skills as observed and reported by a parent.

The measures administered to the

chil-dren included the following.

Illinois Test of Psycholinguistic Abilities (ITPA)

The ‘ incorporates nine subtests, each

of which assesses a particular

psycholin-guistic

(

language

)

skill. The skills tested

are those which are represented in a model

of the communicative process developed by

the authors and include reception and inte-gration of aurlitory and visual stimuli,

cx-Pressioli through speech and motor acts,

and syntactic and sequential usage.

The Peabody Picture Vocabulary Test

The child chooses from four pictures, one

representing a word spoken by the

exam-iner. The vocabulary presented is

grad-siated according to d5

The Templin-Darley Picture

Articulation Screening Test

\Vords containing selected sounds or

sound combinations

(

blends

)

are elicited

from the sul)ject through the presentation of l)ictulres. The child is scored on the basis

of the number of the sounds or blends

cor-rectly produced.’

Mecham Verbal Language

Development Scale

The child’s language in the home

situa-tion as observed by the parents was

esti-mated through the use of this test.7 The

number of correct responses. In order to

equate the several tests and to remove the

variability due to age, each raw score was

converted to standard score. This measure

relates the child’s earned score to the

cx-pected score for a child of his age in terms

of standard deviation. Thus, a standard

score of + 1.5 indicates that the child per-formed at a level 1.5 standard deviations

above the expected score for children of his

age, while a score of - 0.5 indicates a

per-formance 0.5 standard deviations below the

expected score. The standard score mean

and standard deviation for each test are

plotted for the two groups in Figure 1.

The standard score data were submitted

to an analysis of variance. The significant

difference among tests

(

F = 3.40, F001 =

2.37

)

confirms that the several tests used

evaluate separate and distinct aspects of

the total communicative process. This is to

be expected and, so far as the subtests of

the ITPA are concerned, is consistent with

the standardization studies.

Since the F-ratio

(

F 81.96, F,,1

6.72) indicated a significant difference be-tween groups on the combined tests, t-tests

were applied to the between group

differ-ence for each test. Those tests for which

the differences between means were

signifi-cant at 0.05 level of confidence or better as indicated in Figure 1 include:

1. Templin-Darley Articulation

Screen-ing Test, which evaluates the child’s ability

to produce the sounds used in English

speech;

2. Peabody Picture Vocabulary Test, which assesses vocabulary in terms of the

words which the child understands,

ARTICLES 837

3. ITPA Total Score, which is a

compos-ite score representing the child’s

compe-tence to communicate through the use of

both auditory-vocal and visual-motor

mo-dalities;

4. Visual Decoding subtest of ITPA,

which tests the child’s capacity to relate

pictures on the basis of similar meaning,

e.g., two unlike shoes are matched on the

basis of their belonging to the category “shoe;”

5. Auditory-vocal Association subtest of

ITPA, which assesses the ability to use

ver-hal analogies;

6. Vocal Encoding subtest of ITPA,

which evaluated capacity to express ideas

through the use of spoken language;

7. Auditory-vocal Automatic subtest of

ITPA, which assesses the child’s use of

grammar and syntax; and

8. Auditory-vocal Sequencing subtest of

ITPA, which appraises capacity to

remem-ber and reproduce digits he hears in the

order in which they are presented.

On the other tests there was no statisti-cally significant difference between the two

groups. These included the following

sub-tests of the IT.PA:

1. Auditory Decoding, which assesses

the child’s ability to respond to simple

questions requiring “yes” or “no” answers;

2. Visual-motor Association, which tests

the child’s capacity to relate pictured

ob-jects on the basis of associations such as

use, shape, or category;

3. Motor Encoding, which assesses the

child’s skill in expressing ideas by manipu-lating objects or pantomiming from pictures of objects; and

4. Visual-motor Sequencing, which

ap-praises the child’s competence to remember

things he sees and arrange them in the

order in which they were presented.

Raw scores on the Mecham Verbal

Lan-guage Development Scale were employed

to compare the parents’ observations of the

language skills of the two groups. When a

t-test was applied to the data, the

differ-ence between groups was found to be

sig-nificant at the 0.01 level of confidence. The

parents of the control group reported more

advanced language skills for their children than did the parents of the experimental group.

DISCUSSION

From the data presented, the following

conclusions about the groups studied seem

justified:

1. The group who suffered from

fiuctuat-ing hearing loss resulting from chronic oti-tis media were delayed in the acquisition of

all language skills tested when compared

with a matched control group.

2. The experimental group was deficient

to a statistically significant extent

(

at 0.05

level of confidence

)

on all tests which

re-quired the receiving or processing of

audi-tory stimuli or the production of a verbal response, except in the Auditory Decoding sul)test of the ITPA. \Vhile the lack of

sig-nificance between groups on this test may

be interpreted as representing a real

inter-group similarity, clinical use of this test

would suggest that the lack of significance

may well reflect poor test reliability

result-ing from the unusually great guessing

fac-tor.

3. The two groups did not differ signifi-cantly in their performance on tests requir-ing visual, rather than auditory skills, with

the exception of the Visual Decoding

sub-test of the ITPA. This may well be

ac-counted for by the fact that performance in

this test depends upon the child’s having

names for the items pictured. The

acquisi-tion of names of objects is dependent upon

auditory learning, an area apparently

defi-cient in the experimental subjects.

4. The measured language deficiency of

the group suffering from fluctuating

hear-ing loss was confirmed by the parents when

they were asked to report on their child’s

performance of specific language skills in

the home.

Three aspects of the study merit further

discussion:

(

1

)

possible factors other than

the hearing handicap which might

contrib-ute to the language delay found in the

cx-perimental group, (2) practical

tests employed to measure intelligence are

generally language dependent. Because of

this, socioeconomic background was chosen

as an indirect control of intelligence in this

study. This assumes that the children

at-tending the ENT clinic are as intelligent as

children attending other hospital clinics.

The fact that all the children were found to

function in regular classes in school systems

with comparable standards of education

might be cited as another evidence against

a selective intelligence bias against the

chil-dren with chronic otitis media. In future

studies consideration could be given to the

use of intelligence tests specially designed

to be independent of language ability. In

evaluating the findings, the other factors

that influence language development

men-tioned here cannot be disregarded, even

though they are unmeasurable. For

exam-pie, it is possible that the same parent that offers less language stimulation in the home

also disregards middle ear disease in his

children so that it becomes chronic and

long lasting. A factor also to consider, when

evaluating the difference found between

the two groups, is the fact that the children

with chronic otitis media had suffered a

handicap, albeit minor, over the years.

They had endured low grade infection,

pe-riodic discomfort and pain, and probably

increased incidence of medical contact

compared to the control group, whose

prob-lems for which medical care was sought did

not entail any of the foregoing elements.

The influence of these on language

devel-opment is, of course, unknown but has to

be considered. However, the argument that

the difference between the two groups is

in-Practical Implication

The findings in this study, that children

with chronic otitis media have a marked

language handicap, seem to have a number

of practical implications. This is so whether

one assumes that this delay is due to the

fluctuation in hearing, which the authors

tend to do, or speculate that it is the result of the parents’ combined neglect to provide

medical care and language stimulation, or

the effect of a long-term minor handicap

per se. The extent to which these deficien-cies in language will have a dilatory effect on general learning rate might be consider-able, since our educational system is heavily

dependent upon language as a primary tool

in teaching. Indeed, some of the children

in the experimental group were already

be-ginning to experience school difficulties.

\Vith this in mind, it becomes important that parents and teachers be alert to

fluctua-tions in the attention and responsiveness of

young children which are suggestive of

mid-die ear pathology. It is incumbent upon the

schools to evaluate the hearing status of

young children repeatedly and

systemati-cally, especially in areas where the

socio-economic level is such that regular medical care is not sought by the parents. The

chil-dren in this socioeconomic group appear

least able to compensate for the added

lan-guage handicap resulting from hearing loss.

The physician caring for these children

faces a complex medical problem that often

requires aggressive and persistent

treat-ment. Medical factors, for example

aller-gies,1’8’9 contributing to middle ear disease

ARTICLES 839

surgical intervention. It is incumbent on

the physician to find ways to impress upon

the parents the need for his continued mcdi-cal supervision of the child, to be alerted to the educational implications of the child’s

disability, and to inform the educator of

the hearing problems of the individual child under his care.

SPECULATION

One can only speculate on the theoretical significance of the findings of this

investiga-tion. This was a pilot study with all the

problems inherent in a retrospective design.

Further prospective studies evaluating the

influence of mild and fluctuating hearing

deficiencies on language development are

obviously needed. These might help

deter-mine the extent to which the concept of

“imprinting”bOhl is applicable to the child

with a mild fluctuating hearing loss. This

concept, developed from animal studies,

postulates that a lack of appropriate stimu-lation during a critical period of

develop-ment results in reduced function of the

de-prived sensory organ, not only at the time

of deprivation but throughout the life of

the organism. It would also require a longi-tudinal study to determine if the periodic

sensory deprivation experienced by these

children is sufficiently debilitating to

pro-duce continuing lack of responsiveness to

sound and permanent language deficits. If

not, it would be of interest to ascertain how long the deficit persists after normal hear-ing is established.

SUMMARY

An experimental group of children with

histories of fluctuating hearing losses

re-sulting from chronic otitis media was

com-pared with a control group on their

lan-guage skills as measured by standardized tests. Results showed that the experimental group was deficient to a statistically

signifi-cant degree in the acquisition of

vocabu-lary, articulation skills, ability to receive and

express ideas through spoken language, the

use of grammar and syntax, and auditory

memory skills.

REFERENCES

1. Chan, J. C. M., Logan, C. B., and McBean, J.

B. : Serous otitis media and allergy. Amer. J.

Dis. Child., 114:684, 1967.

2. Coetzinger, C. P. : Effects of small perceptual

losses on language and on speech

discrimi-nation. Volta Rev., 64:408, 1965.

3. Eisen, N. H. : Some effects of early sensory

de-privation on later behavior: quondam hard

of hearing child. J. Abnorm. Soc. Psychol.,

65:338, 1962.

4. McCarthy, J. J., and Kirk, S. A. : Illinois Test of Psycholinguistic Abilities, Experimental Edition. Urbana, Illinois: Institute for Re-search on Exceptional Children, University of Illinois, 1961.

5. Dunn, L. M. : Peabody Picture Vocabulary

Test. Minneapolis, Minnesota : American

Guidance Service, Inc., 1959.

6. Templin, M. C., and Darlev, F. L. : The

Temphin-Darley Test of Articulation. Iowa City, Iowa: Bureau of Educational Research and Service, University of Iowa, 1960.

7. Mecham, M. J.: Verbal Language Develop-ment Scale. Minneapolis, Minnesota: Amen-can Guidance Service, Inc., 1959.

8. Derlacki, E. L. : Duet: Allergy and otology. Ann. Allerg., 23:288, 1965.

9. Whitcomb, N. J.: Allergy therapy in serous oti-tis media associated with allergic nhinitis.

Ann. Allerg., 23:232, 1965.

10. Maccoby, E. E. : Developmental psychology. In

Farnsworth, P. R., McNemar, 0., and

McNemar,

Q.

: Annual Review of

Psychol-ogy, Vol. 15. Palo Alto, California, Annual

Reviews, Inc., p. 206-207, 1964.

11. Cottlieb, G., and Klopfer, P. H.: The relation of developmental age to auditory and visual

imprinting. J. Comp. Physiol. Psychol.,

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

1969;43;833

Pediatrics

Vanja A. Holm and LuVern H. Kunze

DEVELOPMENT

EFFECT OF CHRONIC OTITIS MEDIA ON LANGUAGE AND SPEECH

http://pediatrics.aappublications.org/content/43/5/833

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.