Gunnarson, and Clark (1990) found that mild, uc-

tuating hearing loss during infancy disrupted both

expressive and receptive language acquisition.
Auditory processing and language decits re-
sulting from early OME episodes can persist into the
elementary school years, and children with a his-
tory of OME have been found to produce lower
verbal than performance scores on the WISC-R (Zin-
kus, Gottlieb, & Schapiro, 1978; Zinkus & Gottlieb,
1980). Thus, language decits are common among
children who suffer repeated episodes of OME dur-
ing early language acquisition (Bergstrom, 1980).
Because learning to read draws heavily on language
skills (Vellutino, 1987), repeated early OME epi-
sodes during early language acquisition might well
be a precursor of delayed reading. Thus, we posed
the following hypothesis.
Children who experienced multiple OME epi-
sodes during primary language acquisition will nd
learning to read more difcult than age-matched
peers who were free of this disorder. That is, chil-
dren with a history of OME should perform worse
Journal of Pediatric Psychology, Vol. 25, No. 1, 2000, pp. 1518
Otitis Media: Precursor of Delayed Reading
Joan S. Kindig, EdD, and Herbert C. Richards, PhD
University of Virginia
Objective: To investigate the connection between otitis media in the language acquisition years and the
occurrence of delayed reading between the ages of 8 and 10.
Method: Participants were 40 children, half of whom had a history of otitis media between the ages of
birth and three years and half who were free of the disease. These children, now ages 810, were tested
with the WISC-R and a variety of reading measures.
Results: Children with a history of otitis media scored over a year below grade level in reading and signifi-
cantly below controls on a variety of literacy measures as well as on the Verbal Comprehension factor on
the WISC-R.
Conclusions: Children with early onset otitis media (birth to three years) tend to be at greater risk for
delayed reading than age-matched controls.
Key words: otitis media; language acquisition; literacy; reading.
Otitis media (OME), an infection of the middle ear
cavity, is one of the most common afictions of
childhood. OME is caused by an accumulation of
uid in the middle ear, and sound traveling through
the ear canal is impeded. Most young patients expe-
rience a mild-to-moderate hearing loss during OME
episodes, especially in the decibel range critical for
discriminating speech sounds (Feagans, Sanyal,
Henderson, Collier, & Applebaum, 1987; Friel-Patti,
1990). Hearing loss is usually temporary, but peri-
ods of impairment often persist for 6 to 24 months.
Lengthy periods of uctuating sensitivity to
speech sounds can delay early language develop-
ment and impair the formation of linguistic cate-
gories (Berko-Gleason, 1983; Friel-Patti, Finitzo,
Formby, & Brown, 1987). The stable auditory basis
for constructing the rules and vocabulary of lan-
guage is interrupted as well (Menyuk, 1989). Finitzo,
2000 Society of Pediatric Psychology
All correspondence should be sent to Joan Kindig, 405 Emmet St., 123 Ruff-
ner Hall, Charlottesville, Virginia 22903-2495. E-mail: jsk7n@virginia.
edu.
on measures of basic reading skills-phonology and
verbal comprehension-than nonotitic age-mates.
Method
Participants
Participants were 40 second, third, fourth, and fth
graders, 28 boys and 12 girls, between the ages of
eight and ten. The children were mostly (98%) Cau-
casian, and all lived in suburban and rural neigh-
borhoods near the University of Virginia. Half had
a history of repeated episodes of OME before age
three; the others served as matched controls.
Measures
Wechsler Intelligence Scale for Children-Revised. The
Wechsler Intelligence Scale for Children-Revised
(WISC-R) was used to assess the overall intellectual
strengths and weaknesses of the participants (Wech-
sler, 1974; the WISC-III was unavailable at the time
of testing). In addition to a full scale IQ score, the
WISC-R yields three factor-analytically distinct
scores: Verbal Comprehension (VC), Perceptual Or-
ganization (PO), and Freedom from Distractibility
(FFD).
Word Recognition in Isolation. To assess word rec-
ognition in isolation (WRI), the child is presented
with word lists, each containing words at a com-
mon grade level. The primer level list is shown rst,
then progressively more difcult word lists are pre-
sented until the child fails to recognize 25% of the
words on the list. Two WRI scores are generated,
one timed (for about
1
4 second), the other untimed.
In practice, the timed and untimed scales are highly
correlated and will, in this study, be combined into
a single WRI scale.
Word Recognition in Context. Word recognition in
context (WRC) is assessed by instructing respon-
dents to read aloud from a series of graded passages.
The child is given progressively more difcult pas-
sages until more than 10% of the words are read
incorrectly (Stauffer, Abrams, & Pikulski, 1978). The
WRC score represents the highest grade level pas-
sage the child is able to read in context with at least
90% accuracy.
Hearing Capacity. Hearing capacity (HC) refers to
the highest grade level a child can comprehend
when freed from the constraints of print. The exam-
iner reads passages aloud rather than requiring the
child to do so. Passages of progressively more ad-
vanced grade levels are read, and each is scored for
comprehension accuracy. The HC score represents
the highest grade level the child comprehends with
more than 70% accuracy.
Diagnostic Test of Phonic Skills. The Diagnostic
Test of Phonic Skills (DTPS) was used to assess pho-
netic capability (Bryant, 1963). Respondents were
asked to pronounce nonsense words constructed ac-
cording to commonly understood rules of English
phonics. Because DTPS items are not in anyones
sight vocabulary, they assess tacit phonetic knowl-
edge. Monosyllabic and polysyllabic word scores
were combined into a single score representing the
number of words correctly pronounced.
Spelling. To test for spelling prociency, the
Schlagal Spelling Inventory (Form A) was adminis-
tered (Schlagal, 1982; Zutell, 1994). The inventory
contains words culled from basal readers across
grade levels that illustrate targeted orthographic
features. When a childs grade level score slips be-
low 50%, the test is terminated. In this study, a
score was obtained by counting the total number of
correctly spelled words.
Reading Level. All the data collected from the lit-
eracy measures were given to three professionals in
the eld of reading: two reading professors and the
senior author. Based on this information, each inde-
pendently rated the overall reading level of the par-
ticipants. There was high agreement among the
judges (98%). After the initial ratings, the three met
as a committee to assign a single set of reading
level designations.
Procedures
Thirty children with four or more diagnosed epi-
sodes of OME before the age of three were identied
by a pediatric otolaryngologist. The senior author
contacted the parents of these children to enlist
their childs participation and collect information
about occupation and level of education. Initially,
22 parents volunteered their children. One girl suf-
fered from mild cerebral palsy and another had re-
cently experienced a severe emotional trauma. Both
were excluded from the study. Based on informa-
tion about parental occupation and level of educa-
tion, socioeconomic status (SES) was then assessed
on the remaining 20 participants using procedures
detailed by Hollingshead (1957).
Control participants were solicited by letter
through the public schools. The letter explained the
16 Kindig and Richards
ence remained signicant, approximate F(2, 36)
3.26, p .05.
Discussion
The results accorded well with the hypothesis of the
study. Children with a history of OME underper-
formed their nonotitic peers on all Verbal Compre-
hension and reading skill measures. They scored
signicantly lower, in most cases more than two
thirds of a standard deviation lower, on every liter-
acy indicator of the study. Moreover, the otitic chil-
dren were, on average, more than a year (M
1.15) below grade level in reading. Conversely,
control children scored nearly a year above grade
level (M .99). It appears, then, that children
with a history of repeated OME episodes during pri-
mary language acquisition nd learning to read
more difcult than those who have no such history.
We found little evidence, however, that otitic chil-
dren exhibit a similar disadvantage on nonverbal
measures.
Although otitic children scored nearly a full
standard deviation below their control peers on Ver-
bal Comprehension, the clinical importance of this
WISC-R trend may be limited for children like those
in this study. Few participants in either group per-
formed at substandard IQ levels. In fact, only four
in the otitic group scored below 100 on the VC scale
(the lowest score was a 93). Moreover, there were
exceptions to the general nding. Four of the 20
nature of the study as well as criteria for inclusion
and promised a free educational evaluation. To be
included as a control, the child must have had only
one (or no) OME episode before age three and must
have met the matching criteria for gender, age, and
SES. In the end, each control child was closely
matched with an otitic counterpart.
All participants were brought to a university
clinic for individual assessment. Ten examiners
(three professors and seven graduate students), all
experienced psychometricians and reading special-
ists, were trained by the senior author in the proto-
cols of the study. To avoid criterion contamination,
examiners were unaware of the childs status (otitic
or control). Each child was tested over the course of
a day in two sessions. Tests were administered in a
xed order: intelligence testing in the morning, the
remaining assessments in the afternoon. Sessions
lasted from 90 to 120 minutes.
Results
Participants were grouped according to OME his-
tory. For each group, means and standard devia-
tions were computed on the ve literacy measures
and the reading level judgments, and t tests were
conducted. To determine the extent to which the
children were accelerated or delayed in reading, dis-
parity scores were computed by subtracting actual
grade in school from judged reading level. (e.g., a
fourth grader reading at a second grade level would
have a disparity score of 2.0.) Results are also
shown in Table I. On every literacy task, otitic chil-
dren scored signicantly (p .05) lower than con-
trols. As for the disparity between reading level and
grade in school, they scored nearly a standard devi-
ation below their nonotitic counterparts (p .01).
We conducted similar analyses on the three
WISC-R subscales and full scale IQ. The results are
again shown in Table I. Compared to controls, the
otitic children scored nearly a full standard devia-
tion lower on Verbal Comprehension (p .01).
There were no signicant differences on any other
subscale.
Finally, to control for Type I error, we conducted
a two-group, multivariate analysis of variance using
judged reading level and Verbal Comprehension
scores as criteria. The difference between the mean
vectors of otitic and control groups was signicant,
approximate F(2, 37) 4.16, p .05. When nonver-
bal IQs were controlled by covariance, the differ-
Table I. Means, Standard Deviations, and t values of Literacy
Task Scores and WISC-R by Group Membership
Control (N 20) Otitis (N 20)
M SD M SD t value
Literacy tasks
WRI 255.65 131.88 169.40 127.50 2.10*
WRC 5.20 2.97 3.22 3.11 2.05*
HC 6.05 2.21 4.29 2.75 2.23*
DTPS 32.05 11.83 22.25 13.73 2.42*
Spelling 63.80 46.55 41.20 37.44 1.69*
Reading level 4.30 2.83 2.41 2.55 2.18*
Disparity .99 2.39 1.15 2.23 2.93**
WISC-R scales
VC 126.10 12.41 114.40 14.55 2.76**
PO 113.55 12.88 110.25 11.28 .86
FFD 100.15 9.92 95.35 12.09 1.37
Full scale 119.45 12.07 109.75 12.92 2.45**
*p .05, one-tailed.
**p .01, one-tailed.
Otitis Media and Delayed Reading 17
otitic children scored higher on verbal IQ than the
control group mean (M 126.10).
Because we selected children who were ethni-
cally homogeneous and lived in an educationally
favored community, our results may have limited
generality. More research is needed to determine
whether our ndings can be applied to the general
population. Nevertheless, it seems likely that early
onset OME would affect the early reading of chil-
dren in other circumstances. For those already at
risk-those receiving inadequate medical attention,
little exposure to literacy at home, inappropriate
early reading instruction, or grappling with other
References
Bergstrom, L. (1980). Continuing management of conduc-
tive hearing loss during language development. Inter-
national Journal of Pediatric Otorhinolaryngology, 2, 39.
Berko-Gleason, J. (1983). Workshop on effects of otitis me-
dia on the child: Otitis media and language develop-
ment. Pediatrics, 71, 639652.
Bryant, N. D. (1963). Diagnostic Test of Phonic Skills. New
York: Author.
Feagans, L., Sanyal, M., Henderson, F., Collier, A., &
Applebaum, M. (1987). Relationship of middle ear dis-
ease in early childhood to later narrative and atten-
tion skills. Journal of Pediatric Psychology, 12, 581594.
Finitzo, T., Gunnarson, A. D., & Clark, J. L. (1990). Audi-
tory deprivation and early conductive hearing loss
from otitis media. Topics in Language Disorders, 11,
2942.
Friel-Patti, S. (1990). Otitis media with effusion and the
development of language: A review of the evidence.
Topics in Language Disorders, 11, 1122.
Friel-Patti, S., Finitzo, T., Formby, E., & Brown, K. (1987).
A prospective study of early middle ear disease and
speech-language development. Tejas, 13, 3943.
Hollingshead, A. (1957). Two factor index of social position.
New Haven, CT: Author.
Menyuk, P. (1989). Effects of persistent otitis media on
language development. Recent Advances in Otitis Media
with Effusion, 3, 257263.
cognitive, motivational, or social impairments-the
added burden of otitis media could be substantial.
Acknowledgments
This research is based on the doctoral dissertation
of Joan S. Kindig. We thank Marcia Invernizzi, John
Bonvillian, James Deese, and Charles Johnson, MD,
for their support throughout this project.
Received December 16, 1997; revisions received July 8,
1998; accepted September 15, 1998
Schlagal, R. C. (1982). A qualitative inventory of word
knowledge: A developmental study of spelling, grades
one through six (Doctoral dissertation, University of
Virginia, 1982). Dissertation Abstracts International, 47
03, A0915.
Stauffer, R. G., Abrams, J. C., & Pikulski, J. J. (1978). Diag-
nosis, correction, and prevention of reading disabilities.
New York: Harper & Row.
Vellutino, F. R. (1987). Dyslexia. Scientic American, 256
(3), 3441.
Wechsler, D. (1974). Manual for the Wechsler Intelligence
Scale for Children-Revised. New York: Psychological Cor-
poration.
Zinkus, P., & Gottlieb, M. (1980). Patterns of perceptual
and academic decits related to early chronic otitis
media. Pediatrics, 66 (2), 246253.
Zinkus, P., Gottlieb, M., & Schapiro, M. (1978). Develop-
mental and psychoeducational sequelae of chronic
otitis media. American Journal of the Disabled Child,
132, 11001104.
Zutell, J. (1994, December). Establishing the reliability of al-
ternate forms of the qualitative inventory of word knowl-
edge. Paper presented at the National Reading
Conference, San Diego, CA.
18 Kindig and Richards