Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years.

BACKGROUND: A main indication for the insertion of tympanostomy tubes in infants and young children is persistent otitis media with effusion, reflecting concern that this condition may cause lasting impairments of speech, language, cognitive, and psychosocial development. However, evidence of such relations is inconclusive, and evidence is lacking that the insertion of tympanostomy tubes prevents developmental impairment. METHODS: We enrolled 6350 healthy infants from 2 to 61 days of age and evaluated them regularly for middle-ear effusion. Before the age of three years 429 children with persistent effusion were randomly assigned to have tympanostomy tubes inserted either as soon as possible or up to nine months later if effusion persisted. In 402 of these children we assessed speech, language, cognition, and psychosocial development at the age of three years. RESULTS: By the age of three years, 169 children in the early-treatment group (82 percent) and 66 children in the late-treatment group (34 percent) had received tympanostomy tubes. There were no significant differences between the early-treatment group and the late-treatment group at the age of three years in the mean (+/-SD) scores on the Number of Different Words test, a measure of word diversity (124+/-32 and 126+/-30, respectively); the Percentage of Consonants Correct-Revised test, a measure of speech-sound production (85+/-7 vs. 86+/-7); the General Cognitive Index of McCarthy Scales of Children's Abilities (99+/-14 vs. 101+/-13); or on measures of receptive language, sentence length, grammatical complexity, parent-child stress, and behavior. CONCLUSIONS: In children younger than three years of age who have persistent otitis media, prompt insertion of tympanostomy tubes does not measurably improve developmental outcomes at the age of three years.

Measurement properties of the MacArthur communicative development inventories at ages one and two years.

In a prospective study of child development in relation to early-life otitis media, we administered the MacArthur Communicative Development Inventories (CDI) to a large (N = 2,156), sociodemographically diverse sample of 1- and 2-year-old children. As a prerequisite for interpreting the CDI scores, we studied selected measurement properties of the inventories. Scores on the CDI/Words and Gestures (CDI-WG), designed for children 8 to 16 months old, and on the CDI/Words and Sentences (CDI-WS), designed for children 16 to 30 months old, increased significantly with months of age. On several scales of both CDI-WG and CDI-WS, standard deviations approximated or exceeded mean values, reflecting wide variability in results. Statistically significant differences in mean scores were found according to race, maternal education, and health insurance status as an indirect measure of income, but the directionality of differences was not consistent across inventories or across scales of the CDI-WS. Correlations between CDI-WG and CDI-WS ranged from .18 to .39. Our findings suggest that the CDI reflects the progress of language development within the age range 10 to 27 months. However, researchers and clinicians should exercise caution in using results of the CDI to identify individual children at risk for language deficits, to compare groups of children with different sociodemographic profiles, or to evaluate the effects of interventions.

Language, speech sound production, and cognition in three-year-old children in relation to otitis media in their first three years of life.

OBJECTIVE: As part of a prospective study of possible effects of early-life otitis media on speech, language, cognitive, and psychosocial development, we tested relationships between children's cumulative duration of middle ear effusion (MEE) in their first 3 years of life and their scores on measures of language, speech sound production, and cognition at 3 years of age. METHODS: We enrolled 6350 healthy infants by 2 months of age who presented for primary care at 1 of 2 urban hospitals or 1 of 2 small town/rural and 4 suburban private pediatric practices. We intensively monitored the children's middle ear status by pneumatic otoscopy, supplemented by tympanometry, throughout their first 3 years of life; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated children for otitis media according to specified guidelines. Children who met specified minimum criteria regarding the persistence of MEE became eligible for a clinical trial in which they were assigned randomly to undergo tympanostomy tube placement either promptly or after a defined extended period if MEE remained present. From among those remaining, we selected randomly, within sociodemographic strata, a sample of 241 children who represented a spectrum of MEE experience from having no MEE to having MEE whose cumulative duration fell just short of meeting randomization criteria. In subjects so selected, the estimated duration of MEE ranged from none to 65.6% of the first year of life and 44.8% of the first 3 years of life. In these 241 children we assessed language development, speech sound production, and cognition at 3 years of age, using both formal tests and conversational samples. RESULTS: We found weak to moderate, statistically significant negative correlations between children's cumulative durations of MEE in their first year of life or in age periods that included their first year of life, and their scores on formal tests of receptive vocabulary and verbal aspects of cognition at 3 years of age. However, the percent of variance in these scores explained by time with MEE in the first year of life beyond that explained by sociodemographic variables ranged only from 1.2% to 2.9%, and the negative correlations were concentrated in the subgroup of children whose families had private health insurance (rather than Medicaid). We found no significant correlations in the study population as a whole or in any subgroup between time with MEE during antecedent periods and children's scores on measures of spontaneous expressive language, speech sound production, or other measured aspects of cognition. In contrast, by wide margins, scores on all measures were consistently highest among the most socioeconomically advantaged children and lowest among the most socioeconomically disadvantaged children. CONCLUSIONS: Our findings suggest either that persistent early-life MEE actually causes later small, circumscribed impairments of receptive language and verbal aspects of cognition in certain groups of children or that unidentified, confounding factors predispose children both to early-life otitis media and to certain types of developmental impairment. Findings in the randomized clinical trial component of the larger study should help distinguish between causality and confounding as explanations for our findings.language, speech, cognition, development, otitis media, middle ear effusion.

Impact of tonsillectomy and adenoidectomy on child behavior.

OBJECTIVE: To measure the impact of tonsillectomy and adenoidectomy (T&A) on children's behavioral and emotional problems using a standardized assessment. DESIGN: Prospective study. SETTING: Tertiary care children's hospital. PATIENTS: Thirty-six children, aged 2 through 18 years, with symptoms of nighttime snoring, observed apneas, and daytime mouth breathing and physical examination results demonstrating 3+ or 4+ tonsils scheduled for T&A. INTERVENTION: Parents completed a standard survey of their children's symptoms of sleep apnea and a standardized measure of children's competencies and problems, the Child Behavior Checklist for ages 2 through 3 years or 4 through 18 years, before T&A and 3 months postoperatively. MAIN OUTCOME MEASURE: The Child Behavior Checklist total problem score. RESULTS: The preoperative Child Behavior Checklist total problem score was consistent with abnormal behavior for 10 children (28%). After T&A (n = 15), only 2 scores were abnormal, but the change was not statistically significant. In contrast, the mean total problem score was 7.5 points lower after surgery (95% confidence interval, 5.1-9.7), indicating a significant decrease (P<.001, matched t test). CONCLUSIONS: This pilot study demonstrates a high prevalence (28%) of abnormal behavior in children undergoing T&A for chronic upper airway obstruction. Scores on a standardized measure of behavior improve following T&A, but larger studies with increased statistical power are needed to clarify the degree of improvement and its clinical importance.

Bone lead levels and language processing performance.

The relation between bone lead absorption and language processing abilities in 156 randomly selected 11- to 14-year-old boys who were asymptomatic for lead toxicity is examined. Tibial lead concentrations were measured by X-ray fluorescence spectroscopy. The language processing outcome variables consisted of the least and most difficult subtests from the Nonword Repetition Task, Competing Language Processing Task, and the Revised Token Test. Participants were classified by quartiles according to bone lead concentrations, and analysis of variance and analysis of covariance measured the impact on language processing scores. Results showed that children in the highest bone lead quartile displayed decreased language processing performance on the most difficult language processing tasks but not on the easier tasks.

Maternal education and measures of early speech and language.

The present study was designed to determine whether 4 measures of children's spontaneous speech and language differed according to the educational level of the children's mothers. Spontaneous language samples from 240 three-year-old children were analyzed to determine mean length of utterance in morphemes (MLUm), number of different words (NDW), total number of words (TNW), and percentage of consonants correct (PCC). A norm-referenced, knowledge-dependent measure of language comprehension, the Peabody Picture Vocabulary Test-Revised (PPVT-R), was also included for purposes of comparison with the spontaneous measures. Three levels of maternal education were compared: less than high school graduate, high school graduate, and college graduate. Trend analyses showed statistically significant linear trends across educational levels for MLUm, NDW, TNW, and PPVT-R; the trend for PCC was not significant. The relationship of maternal education and other sociodemographic variables to measures of children's language should be examined before using such measures to identify children with language disorders.

Parental stress and parent-rated child behavior in relation to otitis media in the first three years of life.

OBJECTIVE: As part of a long-term study of possible effects of early-life otitis media on speech, language, cognitive, and psychosocial development, we tested relationships between parents' ratings of parent-child stress at ages 1, 2, and 3 years, and of their children's behavior problems at ages 2 and 3 years, and the children's cumulative duration of middle-ear effusion (MEE) in their first 3 years of life. METHODS: We enrolled healthy infants by age 2 months who presented for primary care at 1 of 2 urban hospitals or 1 of 2 small-town/rural and 4 suburban private pediatric practices. We obtained standardized baseline measures of parental stress; we intensively monitored the children's middle-ear status by pneumatic otoscopy, supplemented by tympanometry, throughout their first 3 years of life; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated children for otitis media according to specified guidelines. We obtained parent ratings of parental stress using the Parenting Stress Index/Short Form when the children reached ages 1, 2, and 3 years, and parent ratings of children's behavior using the Child Behavior Checklist when the children reached ages 2 and 3 years. RESULTS: In 2278 children we found no substantial relationships between parents' ratings of parent-child stress when the children reached ages 1, 2, and 3 years, or of their children's behavior problems at ages 2 and 3 years, and the cumulative duration of the children's MEE during antecedent periods. On the other hand, ratings both of parent-child stress and of behavior problems were consistently highest among the most socioeconomically disadvantaged children and lowest among the most socioeconomically advantaged children. Ratings also tended to be highest among children whose parents' baseline stress scores were highest. CONCLUSIONS: Parent-child stress and children's behavior problems in the first 3 years of life, as rated by parents, bear little or no relationship to the children's previous cumulative duration of MEE.

Parent-reported language and communication skills at one and two years of age in relation to otitis media in the first two years of life.

OBJECTIVE: As part of a study of possible effects of early life otitis media on children's development, we attempted to determine whether levels of language and communication skills at 1 and 2 years of age are associated with the cumulative duration of middle ear effusion (MEE) in the first 2 years of life. METHODS: Subjects (N = 2156) were followed at one of eight study sites in the Pittsburgh area. Middle ear status was monitored closely throughout the first 2 years of life. For each child, the cumulative percentage of days with MEE was estimated based on diagnoses at visits and interpolations for intervals between visits. For each child also, 1 or both parents completed the MacArthur Communicative Development Inventory-Words and Gestures (CDI-WG) when the child was 1 year of age and the MacArthur Communicative Development Inventory-Words and Sentences (CDI-WS) when the child was 2 years of age. RESULTS: Unadjusted correlations between scores on the CDI-WG and percentage of days with MEE in the first year of life were close to zero, and there were no statistically significant negative correlations. Unadjusted correlations between scores on the CDI-WS and the cumulative percentage of days with MEE in year 2 and in years 1 and 2 combined were generally negative and statistically significant, but the magnitudes of those correlations were no higher than 0.09. After adjustment for sociodemographic variables, only the Vocabulary Production Scale of the CDI-WS remained correlated significantly with the percentage of days with MEE, and the percentage of days with MEE accounted for only a negligible percentage of the variance in scores on this scale. CONCLUSIONS: In this diverse sample of children, parent-reported levels of language skills at 1 and 2 years of age were correlated negligibly with the cumulative percentage of days with MEE in the children's first and second years of life. otitis media, otitis media with effusion, language, communication.

Nonword repetition and child language impairment.

A brief, processing-dependent, nonword repetition task, designed to minimize biases associated with traditional language tests, was investigated. In Study 1, no overlap in nonword repetition performance was found between a group of 20 school-age children enrolled in language intervention (LI) and a group of 20 age-matched peers developing language normally (LN). In Study 2, a comparison of likelihood ratios for the nonword repetition task and for a traditional language test revealed that nonword repetition distinguished between children independently identified as LI and LN with a high degree of accuracy, by contrast with the traditional language test. Nonword repetition may have considerable clinical utility as a screening measure for language impairment in children. Information on the likelihood ratios associated with all diagnostic tests of language is badly needed.

Measurement of functional outcome in preschool children with neurogenic communication disorders.

Intervention programs for preschool children with neurogenic communication disorders are now being evaluated on their ability to achieve functional communication change. Documentation of functional gains in speech and language skills will likely determine who will deliver and receive intervention services in the future. However, few tools are available that measure functional gains in young children with severe communication deficits. This article discusses some of the issues that clinicians must consider when developing and using functional communication measures in a clinical service delivery setting.

Themes in diagnostic decision making.

The diagnosis of communication disorders is a complex clinical task that can have significant clinical, social, and economic consequences for the patient. This issue is about the conceptual process by which clinicians perform this important clinical task. Through the presentation of ten clinical cases, experienced clinicians illustrate a variety of diagnostic decision-making approaches that can be used to answer important clinical questions. In this initial article, the diagnostic themes that have emerged from these cases are summarized and four diagnostic strategies that can be used in making clinical diagnoses are discussed.

Speaking rate, articulatory speed, and linguistic processing in children and adolescents with severe traumatic brain injury.

Two studies were conducted to examine speaking rate following traumatic brain injury (TBI) in childhood and adolescence. Study 1 focused on longitudinal changes in speaking rate in 9 subjects with severe TBI and their age-matched control subjects. Physical measurements of speaking rate (in syllables/sec) were made from spontaneous speech samples obtained from each subject during three sampling sessions over a 13-month period. Although the average speaking rate of the group with TBI was slower than that of the control group at all three sampling sessions, an examination of the data from individual subject pairs revealed markedly slower speaking rates in only 5 of the 9 subjects with TBI at the final sampling session. The perceptual significance of slowed speaking rates in these 5 subjects was confirmed through subjective ratings by naive listeners. In Study 2, the contributions of two potential causes of slowed speaking rate were explored: reduced articulatory speed and increased pausing believed to be associated with linguistic processing difficulties. It is hypothesized that articulatory speed and linguistic processing speed may contribute independently to slowed speaking rates more than 1 year after TBI.

Procedure for assessing verbal working memory in normal school-age children: some preliminary data.

A procedure for assessing children's recall of lexical items in the presence of a competing language task is described. The Competing Language Processing Task was designed to reflect the dynamic processes carried out in working memory during language comprehension and production by requiring that the subject hold words in temporary storage while analyzing and responding as true or false to statements. The development of the procedure is described and results of testing of 68 normal children ages 6, 8, 10, and 12 years are presented.

Pediatric voice disorders.

Voice disorders are common among children, estimated to range from 6% to 23% in school-aged children. The various causes of voice disorders are presented in this article in addition to a discussion of normal laryngeal voice and development. Also presented are the causes of abnormal voice and brief discussion of a framework for multidisciplinary assessment and treatment of pediatric voice disorder.

Expressive language recovery in severely brain-injured children and adolescents.

The spontaneous expressive language abilities of 9 severely brain-injured children and adolescents and their age-matched normal controls were examined seven times over a 12-month period following injury. Analysis of conversational language samples revealed a relatively stable pattern of language performance for the normal subjects over this time interval. The brain-injured subjects, as a group, demonstrated improvement on the majority of measures, but only a few reached the level of their control subjects and interindividual variability was considerable. Results suggest that the prognosis for clinically significant improvement in severely brain-injured subjects is good; however, deficits in expressive skills remain apparent up to at least 12 months following injury.

Video narration as a language sampling context.

Video narration is a context for sampling spontaneous expressive language in which the subject produces an on-line description of the events he or she observes on videotape. Video narration offers a means of reducing the variability among language samples from different speakers, or from the same speaker over time, because the number and complexity of events to be coded linguistically is known and constant. This increased consistency facilitates comparisons among samples, as well as enabling certain analyses requiring a transparent relationship between utterances and events. Advantages and limitations of video narration as an adjunct to conversational sampling are described, and comparisons between longitudinal video narration and conversational samples obtained from brain-injured children and their matched normal controls are presented.

A signal processing component to Broca's aphasia functor deficits.

We conducted a modified replication of K. M. Heilman and R. J. Scholes [Cortex 12, 258-265, 1976] test of functor comprehension in aphasia, controlling the acoustic dimensions of the key function words: 9 Broca patients heard 4 sentence pairs differing only in the post-verb placement of the. They made forced choices between 4 line drawings: one which depicted the correct action, one which depicted the action of the other member in the pair, and two which contained depictions of different figures and actions altogether. Each of the 8 sentences was played in 2 conditions: one with NORMAL intonation, and another with an acoustically more SALIENT post-verbal the. Both of Heilman and Scholes' principal results were successfully replicated, and a SALIENT effect was also discovered, supporting a signal processing component to the Broca syndrome functor deficit.

Effects of presentation rate and divided attention on auditory comprehension in children with an acquired language disorder.

We examined why auditory comprehension in language-disordered children improves when the rate of presentation of speech is slowed. Seven children with an acquired language disorder associated with a convulsive disorder participated in two divided-attention tasks in which pairs of sentences were presented simultaneously. Subjects were instructed to respond first to the sentence produced by a male speaker (primary sentence) and then to the sentence produced by a female speaker (secondary sentence). In the first condition, both sentences were presented at a normal rate of speech. In the second condition, primary sentences were time expanded 75%, and secondary sentences were presented at a normal rate. We hypothesized that when the primary sentences were presented slowly, spare attention would be available for processing the secondary sentences. Results showed that slowing the presentation rate of the primary sentences significantly improved performance on the secondary sentences, even though secondary sentences were presented at a normal rate of speech. Hypotheses of generally slowed processing of auditory information in language-disordered individuals cannot account for these results. They are consistent, however, with a model of defective attention allocation.