Damian McShane and Jeanette Mitchell

MIDDLE EAR disease, otitis media, is the leading identifiable disease in the American Indian population; the majority of cases occur in young children. Episodes of middle ear disease are often accompanied by periods of mild-to-moderate conductive hearing loss. Recent studies indicate that the auditory and educational consequences of episodes of otitis media extend far beyond the period of observable disease. Numerous perceptual, speech, language, cognitive, behavioral and educational correlates of middle ear disease have been identified. This article summarizes a number of studies which have attempted to document the prevalence of otitis media in the American Indian population. It then reviews the findings concerning psychoeducational sequelae of middle ear disease and mild-to-moderate hearing loss, discussing the importance of this knowledge in providing effective educational services for American Indian children.

Infections of the middle ear, otitis media, are characterized by an accumulation of fluids in place of the air which normally occupies the middle ear (behind the ear drum), and/or negative pressure in the middle ear resulting from poor middle ear ventilation. While the literature contains several theories regarding the etiology of otitis media, its actual cause, and thus prevention, is not known. Viral infections and upper respiratory diseases, allergy, health care and eustachian tube dysfunction may play a part in the problem. Methods of treatment, including decongestants, antihistimines, antibiotics, allergy treatment and surgery focus on the relief of secondary symptoms.

While many children experience occasional episodes of acute otitis media, studies have identified certain groups of children that are at high risk for chronic middle ear disease. The estimated incidence of middle ear disease in the general childhood population is around 5%, but for poor children, the incidence rate has been found to be closer to 20% or 25% (see Note 2).

American Indian children have even more middle ear disease than can be explained by their relatively low socioeconomic status. Using audio-metric screening, Clifford, Hull and Greg’ found a failure rate of 27.2% among South Dakota Indian children. In studying a cohort of 378 Alaskan Eskimo children, Reed, Struve and Maynard’ found two-thirds of the children had otorrhea (draining ears) one or more times. By four years of age, 31% had a unilateral hearing loss of at least 25dB. Sixty-five percent of the children with otorrhea had the first episode by their first birthday; 89% by their second. Kaplan (see Note 3) in a study of 489 Alaskan Eskimo children, found that 76% had an ear infection during their first two years.

The Indian Health Service reported that: "For the calendar year 1975, there were more than 56,000 reported new cases of otitis media among American Indians . . . 65% occurred in children under five years of age."

In a pilot study (Note 10) at an inner city public school complex in Minneapolis, children from kindergarten through third grade were randomly selected for screening by a certified audiologist with an impedance audiometer. Results indicated that about 20% of the non-Indian children and nearly 50% of the American Indian children had evidence of otitis media.

In summary, even though the primary cause of chronic otitis media is not now known, certain children are clearly at greater risk for ear infections than others. While ear problems are estimated to occur at a rate of about 5% among children in the general population, they are far more prevalent among American Indian children: estimates range from 20% to 70%.

Psychoeducational Consequences

There has been mounting evidence in the past ten years that middle ear disease causes language and educational problems; this evidence is of special relevance for Indian children, given the extremely high incidence of middle ear disease for them.

In his review of research into the effects of hearing loss, Katz (Note 4) summarizes: "Conductive hearing losses in young children, even mild to fluctuating: 1) can interfere with the acquisition of good auditory perceptual skills, 2) can adversely influence language development, 3) can increase the likelihood of having a significant learning disability, and 4) in adults and children, can lead to aberrant results on auditory tests that might be mistaken for signs of gross retrocochlear or brain lesions." He concludes that the auditory deprivation resulting from the "earplug" effect of conductive hearing loss may cause continuing abnormal auditory function even after the infection or fluid has subsided.

Zinkus (Note 7) observed parallels between central auditory processing disturbances (one form of "special learning disability") and the long-term effects of fluctuating hearing loss and distorted auditory signals due to middle ear disease during the critical periods of language and auditory processing development. He observed substantial delay in speech and language, disturbances in auditory-visual integration, reading disorder, poor spelling skills and, especially, deficits in specific verbal tasks with strong auditory sequential memory components (which is a characteristic pattern exhibited by learning disabled children with specific auditory processing deficit).

Other studies of children with chronic, fluctuating, mild-to-moderate hearing loss have identified a number of learning-related problems. These include decreased vocabulary, poorer aural discrimination and integration, poorer performance on a wide variety of intellectual functions requiring aural input (but not on those functions independent from aural input) and more problems with behavior and adjustment.

One of the few studies to relate the high incidence of otitis media, the degree and characteristics of hearing loss, and its history to possible learning and language difficulties for Indian and Native children was attempted by Kaplan (Note 3) with 489 Alaskan Eskimo children over a ten-year period. As already mentioned, 76% of these children had experienced one or more episodes of otitis media since birth. On the Wechsler Intelligence Scale for Children (WISC), these children obtained a mean verbal score of 77 (range: 45-120), and mean performance score of 98 (range: 40-140). Children in the groups with either a record of middle ear disease or greater than 26 dB current hearing loss had significantly lower verbal scores (means of 70 and 72) than children with no history of otitis media and no hearing loss (mean: 81). Lower verbal scores also correlated with number of episodes of otitis media.

Both grade placement and achievement test results showed that children who experienced otitis media and resulting hearing loss, were behind non-affected children in school achievement. This gap tended to widen with increasing grade level. One sub-group of children, whose only residual effect from otitis media was slight (15 dB) hearing loss in what was considered the "normal" range, continued to experience deleterious effects which the authors suggested could only have been due to their past history of otitis media and transitory hearing loss. The authors conclude: "These findings indicate that otitis media has been a significant cause of morbidity in Alaskan Eskimo children, and its onset during the critical years of language development as well as the number of episodes play an important role in impairing verbal development."

McShane’s (Note 8) review of the use of the Wechsler scales with American Indian children confirms a consistent verbal-performance discrepancy for every study reviewed. It is important to ask to what extent the very high incidence of otitis media in this population nationally contributes to these significantly lower verbal scores. The average verbal score, considering all the studies, was about 18 points below the performance score.

Relationships between mild-to-moderate conductive hearing loss and impaired development of language, serious educational difficulty, learning disability, and specific processing problems have increasingly been documented. Although American Indian children probably have the highest incidence of this kind of hearing problem of any population group and also exhibit serious language and educational difficulties as a group, in only a few instances have these relationships been explored. Professionals dealing with Indian children, as well as Indian communities, are for the most part completely unaware of the prevalence of otitis media and its psychoeducational consequences. Detrimental effects of middle ear disease in Indian children are seriously complicated and heightened by cultural difference factors; they need to be investigated with special attention to this fact. Focused community education about middle ear problems as well as adequate medical and psychoeducational assessment and intervention are critical for American Indian children. Katz (Note 4) reported: "Of considerable importance is that, if caught in time, many effects of auditory deprevation are reversible." Specific programs must be developed to adequately address the multiple aspects of this problem.

Recommendations for Parents and Teachers

It is safest to assume that a child with a history of chronic middle ear disease constantly experiences auditory effects - either reduced loudness, reduced clarity, or perceptual impairment. Subtle behavioral clues of mild hearing problems can include irritability, short attention span, high activity level, disrupted peer relationships, "uncooperative" behavior, and inappropriate conversational responses, as well as more obvious signs, such as failure to follow directions or respond when spoken to. The educational consequences of this type of hearing problems can be reduced by providing a special hearing and language environment that will minimize the auditory deprivation. Parents and teachers can follow these procedures to create an optimal language-listening environment:

1) Reduce the background noise level when speaking to the child. At home, this may mean turning off the TV or stereo; at school, covering large surfaces with carpet and other sound-absorbent materials and providing separate "quiet" areas for intensive verbal interaction or simply retreat from a stressful sound environment.

2) When it is important for the child to hear a verbal message, a) be sure the child is attentive before you begin speaking; b) stand as close to the child as necessary (this may mean preferential classroom seating or not calling to the child from another room); c) face the child (to increase non-verbal information from lips, facial expression, gestures); and d) check to be sure the message has been received (repeat, rephrase, or demonstrate, if necessary).

3) Provide periods of intense, one-to-one language stimulation - reading aloud, verbal play or conversation - as a regular part of the child’s home and school education, within an optimal listening environment, as described above.

In many cases, the psychoeducational consequences of middle ear disease, described above, will be serious enough to require therapeutive intervention by a hearing, speech and language clinician and/or a resource teacher for children with learning disabilities.

There are important aspects of language development and use within American Indian communities about which little is known. Educators working with children with the dual interference of language through cultural difference and hearing impairment are urged to observe children in natural settings and include parents in gathering information, before reaching diagnostic conclusions.

1. Clifford, S., Hull, R.H., and Gregg, J.B. Survey of Disorders of Speech and Hearing and Ear, Nose and Throat Pathology Among Children of the South Dakota Indian Population. Paper read at the 42nd annual convention of the American Speech and Hearing Association, Washington D.C., 1966.
2. Fay, T.H., Hochbert, I., Smith, C.R., Rees, N.S., and Halpern, H. Audilogic and Otologic Screening of Disadvantaged Children. Arch. Orolaryngol., 1970, 91, 366-370.

3. Kaplan, G.J., Fleshmen, J.K., Bender, T.R., Baum, C., and Clark, P.S. Long Term Effects of Otitis Media: A Ten-Year Cohort Study of Alaska Eskimo Children. Pediatrics, 1973, 52, 577-85.

4. Katz, J. The Effects of Conductive Hearing Loss on Auditory Function. ASHA, 1978, 20 (10), 879-886.

5. Reed, D., Sturve, S., and Maynard, J.E. Otitis Media and Hearing Deficiency Among Eskimo Children: A Cohort Study. American Journal of Public Health, 1967, 57, 1957-62.

6. Vital Events Branch, POS/DRC/IHS. February 1, 1978.

7. Zinkus, P.W., Gottlieb, M.I., and Schapiro, M. Developmental and Psychoeducational Sequalae of Chronic Otitis Media. Am. J. Dis. Child., 1978, 132, 1100-1104.

Research Notes
8. McShane, D.A. Assessment of American Indian Children Using the Wechsler Intelligence Scales: A Review. (in press, 1979).

9. McShane, D.A., Mitchell, J.L. Otitis Media, Psychoeducational Difficulty and American Indian Children: A Minneapolis Indian Health Board Clinic Project, 1979.

10. McShane, D.A., Nordin, J. Middle Ear Disease, Tympanometry Screening, and Language and Educational Delay in High Risk Groups Such as American Indian Children, 1978.

Damian McShane and Jeanette Mitchell are on the staff of the Minneapolis Indian Health Board Clinic, Mental Health Unit.