Otitis
Media
in Children
With Learning
Disabilities
and in Children
With Attention
Deficit
Disorder
With Hyperactivity
Andrew
R. Adesman,
MD; Lisa A. Altshuler,
PhD;
Paul H. Lipkin,
MD;
and Gary
A. Walco,
PhD
From the Division of Developmental and Behavioral Pediatrics, Schneider Children’s
Hospital, Long Island Jewish Medical Center, New Hyde Park, New York
ABSTRACT. A retrospective study was conducted to
com-pare history of middle ear disease children with an
atten-tion deficit disorder with hyperactivity (ADD-H) and
children with a learning disability. Of 138 children eva!-uated in a child development clinic, learning disability without ADD-H was diagnosed in 45 (29 boys, 16 girls; mean age = 9.5 years) and ADD-H without learning disability was diagnosed in 21 (17 boys, 4 girls; mean age
= 8.5 years). Based on parental report, children with
ADD-H had significantly more complaints of earaches
during the preceding 3 months and significantly more ear infections during the preceding year. Specifically, no between-group differences were observed for total num-her of ear infections since birth, extended antibiotic
therapy, tympanostomy tube placement, or recent hear-ing problems. Although middle ear disease in preschool
children has repeatedly been linked to later language
deficits, this study suggests that middle ear disease in
school-age children may also be associated with hyper-activity and/or inattention, independently of learning disability. Pediatrics 1990; 85:442-446; learning disability,
otitis media, attention deficit disorder with hyperactivity.
Otitis media is one of the most prevalent child-hood infectious diseases and it is the single most common diagnosis made by pediatricians.’ Al-though physicians have long been attentive to the acute symptoms and potential complications of oti-tis media, only recently has there been a clinical focus and research emphasis on its potential
long-term effects.
Middle ear effusion, the most common compli-cation of otitis media, frequently results in a
tnan-sient conductive hearing loss of mild on moderate
Reprint requests to (A.R.A.) Division of Developmental and Behavioral Pediatrics, Schneider Children’s Hospital, Long Is-land Jewish Medical Center, New Hyde Park, NY 11042. PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the American Academy of Pediatrics.
severity.2 Many believe it is this compromise of hearing that is responsible for the language deficits
noted in children with recurrent middle ear disease. These children have been shown to have deficien-cies in vocabulary, auditory processing, and other
indices of spoken and written language.39 Although
some of this research has been criticized on meth-odologic grounds,’#{176}” many of the well-designed
studies seem to support a relationship between middle ear disease and language deficits.8’9
Middle ear disease has also been linked to hyper-activity and other behavior pnoblems.’2’4 Although
less work has been done in this area, this
associa-tion has been noted in both retrospective and pro-spective studies. Recent data show that middle ear disease may also be associated with deficits in at-tention.’4’6
In a study of 44 children from birth to age 7
years, Feagans et al.’6 noted that the 13 children
with frequent otitis media (nine on more episodes) were significantly more inattentive and distractible than were the other 31 children. Although these
investigators also noted an association between oti-tis media and language skills, they interpreted their
findings as supportive evidence for a model of at-tention processes mediating the relationship be-tween otitis media and later language deficits.
Hagenman and Falkenstein’2 very recently ne-ported that school-age children who met DSM-III criteria’7 for attention deficit disorder with hyper-activity (ADD-H) experienced more ear infections during their preschool years than did the nonhy-peractive children in their cohort of children ne-fenned to a child development clinic. Moreover, both
groups experienced more ear infections during their
Given that Hagerman and Falkenstein’2 did not address whether some of the hyperactive children had a specific learning disability as well, learning disability may have been a confounding variable in their study. It was the purpose of this study to
compare children with ADD-H (but no learning
disability) and children with learning disability with respect to middle ear disease.
METHODS
Subjects
Subjects were 138 children referred consecutively during a 6-month period to the Child Development/ Learning Diagnostic Program of Schneider Chil-dren’s Hospital. This outpatient service performs multidisciplinary evaluations of school-age children
TABLE 1. DSM-III-R Diagnoses on
Total Sample (N = 138)*
Axes I and II for
Diagnosis No. of Children Axis I
Attention deficit disorder with 33 hyperactivity
Rule out attention deficit disorder 11
with hyperactivity
Overanxious disorder 17
Adjustment disorder 8
Parent/child problem 7
Oppositional-defiant disorder 6 Other (dysthymia, separation anxi- 8
ety disorder, depressive disor-den, functional encopresis)
No diagnosis on axis I 52
Axis II
Developmental expressive language 31 disorder
Developmental reading disorder 10
Mental retardation (mild + moder- 7 ate)
Specific developmental disorders
Writing, articulation, arithmetic 6
Not otherwise specified 24
Rule out not otherwise specified 4
No diagnosis on axis II 59
* Some children had more than one diagnosis on axis I
and/or axis II.
for whom there are developmental concerns. All
children were between 5 and 13 years of age and received individualized, standardized testing by a psychologist as well as a learning disabilities spe-cialist. Diagnoses were made in accordance with
DSM-III-R criteria’8; the clinical syndromes (axis I) and developmental disorders (axis II) for the
total sample of 138 children are listed in Table 1.
Two subgroups from this cohort were then
des-ignated for comparison. The group with learning disabilities consisted of those 45 children with sig-nificant language or learning deficits not explaina-ble by mental retardation, inadequate schooling, visual or hearing defects, on a neurologic disorder. Although a clinically significant discrepancy
be-tween mental age and academic achievement was documented in each case after multidisciplinary evaluation, no single statistical criterion was uni-versally applied. Children who were thought to have
ADD-H were excluded from this group.
Conversely, the group with ADD-H consisted of those 21 children who met DSM-III-R criteria18 for
ADD-H and who did not have a specific learning
disability. The diagnosis of ADD-H was likewise
based on multidisciplinary evaluation as well as
parent and teacher responses on the Conners
Rat-ings Scales (ie, 2 SD above the mean on the
Hyperactivity index).
Twenty-three children with both ADD-H and a specific learning disability were not included in any analyses; these subjects were eliminated to ensure that the comparisons were made between two dis-tinct groups (learning disability vs ADD-H).
The children with learning disabilities and those
with ADD-H were compared with respect to age,
sex, and socioeconomic status (as assessed by
pay-ment source: Medicaid vs non-Medicaid) (Table 2). The mean ages of the two groups were 9.5 and 8.5 years, respectively. Given this discrepancy, age was
entered as a covaniate for some of the analyses. Not
surprisingly, there were more boys than girls in
each of the groups; however, no significant
differ-ences were noted with respect to the percentage of children receiving Medicaid or the percentage of males in each group.
TABLE 2. Demographic
Children With Attention
Characteristics of Children With Learning Deficit Disorder With Hyperactivity
Disabilities and
Demographic Charac-teristic
Children With Children With At-Learning Disabilities tention Deficit
Dis-(n= 45) order With
Hyper-activity (n= 21)
Significance
Mean age
Boys
Medicaid recipients
9.5 y 8.5 y
64% 81%
11% 9%
P = #{149}#{216}7* NSt
NSt
* Student’s t test.
Instrument
Information about past and current health status was obtained for each child by using the Pediatric
Health Survey. This questionnaire is a 56-item survey that was developed for this study; it focused on retrospective accounts of medical history
nelat-ing to middle ear disease as well as other health parameters. The survey was typically completed by the child’s mother.
RESULTS
Differences between the two groups on the Pe-diatnic Health Survey were assessed by means of
x2
analysis, t tests, and ANCOVA (with age as the covaniate). Children with ADD-H had experienced more ear infections during the past year than did learning-disabled children (ANCOVA, F = 4.19, P< .05). However, no significant differences in total
number of ear infections since birth were noted. Similarly, when parents were asked whether prob-lems with ear infections or fluid necessitated at least 4 consecutive weeks of antibiotic treatment on surgical placement of tympanostomy tubes, no dif-ferences between the two groups were found (Table 3).
The general health status of the children with
ADD-H vs that of those with learning disabilities
was evaluated by using answers to questions on the Pediatric Health Survey about injuries, medical procedures, and absence from school, as well as questions about the occurrence of 23 symptoms during the past 3 months (Table 4). Significant differences between the two groups were noted for only two symptoms-earache (ANCOVA, F = 7.58,
P < .01) and upper respiratory infection (ANCOVA,
F = 4.72, P < .04)-with ADD-H children expeni-encing each symptom more frequently. A signifi-cant correlation was noted between these two
symp-toms(r= .49,P< .001).
TABLE 3. Middle Ear Disease Parameters:
Compari-son of Children With Learning Disabilities and Children
with Attention Deficit Disorder With Hyperactivity
Middle Ear Disease Parameter Significance No. of ear infections (previous 12
mo)
No. of ear infections (since birth) NS*
Antibiotic treatment for at least 4 NSt consecutive wks
Tympanostomy tube placement NSt
* ANCOVA (covariate = age). NS indicates not
signifi-cant.
t x2 test.
TABLE 4. General Health Parameters: Comparison of Children With Learning Disabilities and Children With
Attention Deficit Disorder With Hyperactivity
Health Parameter ANCOVA*
Past 3 mo
Earaches <.01
Upper respiratory infection <.04 21 symptoms (excluding earache and
upper respiratory infection)
Tested singly NS
Summed together NS
Past 12 mo
Minor injury (no medical attention) NS Major injury (medical attention) NS
Roentgenograms NS
Laboratory tests (blood, urine) NS
Emergency room visit NS
Surgery NS
Hospitalization NS
Stitches NS
School absence (due to illness) NS
* NS indicates not significant.
DISCUSSION
In this retrospective study of children referred to a child development clinic, 48 learning-disabled children were compared with 21 children with ADD-H with respect to middle ear disease.
Al-though children with ADD-H had experienced
sig-nificantly more middle ear problems during the past
year (ie, eanaches during the past 3 months, ear infections during the past year), no between-group
differences were noted with respect to parental report of total number of ear infections since birth,
tympanostomy tube placement, extended antibiotic
therapy for middle ear disease, on recent hearing problems. Similarly, when the two groups were compared with respect to various other health pa-nametens, no differences were noted except that the children with ADD-H had experienced more colds
within the past 3 months than the children with learning disabilities.
The results of our study do not replicate the
findings of Hagerman and Falkenstein.’2 Whereas
they demonstrated differences in middle ear disease during the preschool years, our study identified differences during the school-age years only. It
should be noted that our methodology differed in many respects from that of Hagenman and Falken-stein. To begin with, they compared hyperactive
and nonhyperactive children with respect to otitis media during their preschool years only; they did
not assess middle ear disease during the grade school years. Second, they did not examine any
health parameters other than otitis media; thus,
they did not establish whether the two groups
problems among the nonhypenactive children, non did they address whether some of the hyperactive children also had a significant learning disability.
The major shortcoming of the present study is its reliance on parental recall of children’s medical history. It is possible that parents of children with
ADD-H may have been more sensitive to recent
middle ear symptoms in their children given their concern about their children’s problems with atten-tion; however, no differences were reported with respect to hearing problems, making this explana-tion less likely. On the other hand, it is equally possible that the two groups may indeed have dif-fered with respect to middle ear disease during their infant and toddler years (as in Hagenman and Fal-kenstein’s study) and that the imprecision of
paren-tal recall of preschool health problems obscured
true group differences. A review of medical records would have provided more precise information.
In addition to the limitations of parental recall,
bias may also have been inherent in the mechanism
for case ascertainment and the demographic
differ-ences noted between the two comparison groups.
The two samples used in this study were derived
from a hospital-based clinic at a tertiary-cane
pe-diatnic facility. It is possible that this cohort may
have had more medical problems than children with academic underachievement evaluated in a
nonhos-pita! setting. Our data permitted only
between-group comparisons with respect to the relative fre-quency of middle ear problems; no comparison
could be made with respect to the incidence of otitis
media reported for the general population.
Epidemiologic studies have shown that otitis
me-dia is less prevalent among girls and among children older than 7 years of age.’9 Although the group with
ADD-H was somewhat younger and had a greaten percentage of boys than the group with learning
disabilities, no significant differences were
identi-fled with respect to age (P = .07) on sex (P > .10);
moreover, age was entered as a covaniate in the data
analyses. Therefore, it is unlikely that demographic variables accounted for differences observed in the
frequency of earaches (past 3 months) and ear
infections (past 12 months) between the study groups.
Although not the primary focus of this study, the
two groups were also compared with respect to other
health parameters (eg, injury, recent symptomatol-ogy, and use of health cane services). Previous
stud-ies have described hyperactive children as being at
greater risk for accidental injury.20’2’ In this study, no differences on this variable were noted between the two groups. This finding may be explained by the relatively small size of our sample; it is equally
possible that learning-disabled children may
like-wise be at increased risk for accidental injury given that motor-planning problems are frequent in this population.
Some researchers have documented increased so-matic complaints (ie, stomachaches) in learning-disabled children,22 and others have suggested that they may experience more frequent allergic symp-toms.23 Had our study included a control group, consisting of children with neither learning disabil-ities nor ADD-H, further comparisons could have been made with respect to the relative frequency of middle ear disease as well as these other health
parameters, which have previously been suggested to distinguish children with learning disabilities or
ADD-H from other children.
CONCLUSION
Children with language delay and learning disa-bilities have long been regarded as being at high risk for middle ear disease. Two recent studies have demonstrated an association in preschool children between middle ear disease and later problems with hyperactivity’2 and inattention.’6 Although our study failed to identify any differences between learning-disabled and ADD-H children with respect
to middle ear disease during their preschool years, ADD-H children were reported to have more middle
ear disease during their grade school years.
Given the prevalence of middle ear disease, learn-ing disability, and ADD-H among children in this
country and the controversy surrounding their pu-tative interrelationships, it is imperative that
well-designed studies be conducted in the near future to establish specific relationships between middle ear disease and subsequent learning, attentional, on behavior problems.
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