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EDUCATIONAL IMPLICATIONS OF RECURRENT OTITIS MEDIA AMONG CHILDREN AT RISK FOR LEARNING DISABILITIES BY Frances Fein Loose A DISSERTATION Submitted to Michigan State Universitc in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Counseling, Educational Psychology, and Special Education 1984 ABSTRACT EDUCATIONAL IMPLICATIONS OF RECURRENT OTITIS MEDIA AMONG CHILDREN AT RISK FOR LEARNING DISABILITIES BY Frances Fein Loose The purpose of this research was to determine incidence rates of recurrent otitis media among twenty-five learning disabled and twenty-five non—handicapped elementary school children, and to compare allergy incidence and patterns of school experience between the children with recurrent otitis history and those with minimal otitis history. Otitis media is middle ear inflammation manifested as an infection and/or significant negative pressure causing collection of fluid in the middle ear space. Subjects' parents completed developmental histories and Fisher's Auditory Problems Checklists. General education teachers completed questionnaires concerning their knowledge of the children's medical history, their rating of the children's school performance and the frequency of parent contact with school. A count of school absences per year since kindergarten was obtained from school records. All children received diagnostic audiological evaluations meas- uring peripheral hearing, middle ear status, and central auditory processing. The learning disabled(LD) students com- pleted self assessments of school performance. Special edu- cation teachers recorded the ages at which LD students were first identified as handicapped, student scores on the Wechsler Intelligence Scale for Children-Revised(WISC-R), and ratings of student academic performance. Both the learning disabled and non-handicapped children exceeded the normal incidence rate of otitis media reported in the literature. Often teachers were unaware of which students had recurrent otitis media. The LD and recurrent otitis groups had higher hearing thresholds at some frequencies, and they experienced more difficulty with some central auditory processing tasks. The otitis students had higher absenteeism rates. The learning disabled children with recurrent otitis performed more poorly on some verbal subtests on the WISC-R, had higher than average incidence of allergy, and were reported as being weaker in oral expression than their peers. While there were marked differences between LD and non-handicapped students in attention to task and unusual activity levels, there was no significant difference between low and high incidence otitis LD students. Frequency of parent contact with school did not differ significantly across groups, nor were there differences between the low and high incidence otitis LD groups on their self assessments. ACKNOWLEDGEMENTS The writer wishes to acknowledge and thank the fol- lowing individuals for their time, support, and guidance in the completion of this study. Norman Bell, Ph.D., Michigan State University, Counseling, Educational Psychology, and Special Education Steven Carlson, Ph.D., Rutgers University, Educational Psy- chology and Special Education Michael Chial, Ph.D., Michigan State University, Audiology and Speech Sciences Richard Featherstone, Ph.D, Michigan State University, Ad- ministration and Curriculum Rasem Ghannam, M.D., allergist Charles Henley, Ph.D., Michigan State University, Coun- seling, Educational Psychology, and Special Education Ruth Johnson, Toledo Public Schools, Project C.H.I.L.D. William Kothman, Telex Communications, Inc. John, Geoffrey, and Christopher Loose James McLoughlin, Ph.D., University of Louisville, Special Education David Sciamanna, D.O., Edward W. Sparrow Hospital, Neona- tology and Developmental Medicine May Shayne, A.C.S.W., Vanderbilt University Catherine Stewart, Michigan State University, Audiology and Speech Sciences Michael Stewart, Ph.D., Michigan State University, Audiology and Speech Sciences Marilyn Willhoit, American ElectroMedics Corporation Staff Members in the participating school districts and Parents and Children participating in the study ii TABLE OF CONTENTS I. Introduction II. III. Purpose. 0 O O O O O O O O O O O O I O O O O O O O O O O O O O I O O O O O O O O O O O O O O O O 0 Cl PrOblem. O O O O O O O O O O O O O O O O O O O O O O O ..... O O ...... O O O O O O O O 0 .1 Research Hypotheses ........................ . ......... .3 DefinitionSOOOOOOOOOOOOO00......0.0.0000000000000000004 Review of the Literature Introduction..........................................9 Incidence of Otitis Media............................10 Symptoms Warranting a Medical Referral...............16 Allergy..............................................l7 Audiological and Medical Diagnosis of Otitis Media...20 Early Identification of Learning Disabilities........23 Effects of Otitis Media..............................26 Communication Among the Parents and Professionals....39 Medical Treatment of Otitis Media....................45 Methodology Criteria for Selection of Subjects ............ . ...... 47 Description of Subjects..............................49 Procedures for Selection of Subjects..... ...... ......50 Child Development Questionnaire......................52 Teacher Report.......................................56 Special Education Report.............................S7 Student Report.OOOOOCOOOOOOOOOOO0.0.00.0000000000000060 iii iv Fisher's Auditory Problems Checklist ................ .60 Audiological Evaluation ....... . ....... . ......... .....61 Follow-Up Screening..................................63 IV. Analysis Hypothesis #1...................... ..... .............65 Hypothesis #2.. ...................................... 73 Hypothesis #3........................................75 Hypothesis #4..... ................ ...... ........... ..77 Hypothesis #5........... ......... ....... ..... ........79 Hypothesis #6........................................80 Hypothesis #7....... ..... ............................81 Hypothesis #8........................................83 Hypothesis #9............. ................. . ..... ....84 Speech Perception in Noise...........................86 V. Summary and Discussion Summary of Research Problem, Method, and Findings....88 Limitations of the Study.............................89 Conclusions........... ....... .. ......... .... ...... ...93 Implications.........................................97 Early Intervention... ......... ......... ........... ..lOO School-Age Children.. ............... ................104 FM Wireless Systems.. ..... .......... .............. ..106 Follow-Up Screening......... ................ . ..... ..111 Environmental Modification..........................112 Summary.................... ....... ............ ...... 113 VI. Reference Material Appendices Forms A. B. C. D. E. F. G. H. used in Data Collection Parent Letter...............................llS Audiological Appointment Letter.............118 Child Development Questionnaire.............119 Teacher Report..............................124 Special Education Teacher Report............125 My School Work Script.......................126 My School Work..............................128 Fisher's Auditory Problems Checklist........129 Additional Resources Bannatyne & Kaufman WISC-R Recategorization scores.OOOOOOOOOOOOOOOOO0.0.0.00000000000000130 Diagram of Ear (Project HEAR)...............l3l Northern and Downs Frequency Chart..........l32 Denver Developmental Screening Test.........133 Other Preprimary Tests......................134 Model Programs..............................138 Resource Organizations......................l40 Bibliography........................................l4l 10. 11. 12. 13. 14. 15. 16. 17. 18. LIST OF TABLES Project CHILD Survey of Physicians: Effects of Otitis Media....IOOOOIOOOOOOO...0.00.00.00.000000000029 Project CHILD Survey of Physicians: Referral Criteria.42 Frequency of Ear Infections...........................65 Current Audiometric Findings..........................68 Audiometric Findings--Eagles' vs. Current Population..7l Adjusted Audiometric Findings--Excluding Students With Active Otitis Media.O..0...0.0.0.00000000000000072 Actual vs. Expected Allergy Incidence.................75 WISC-R Performance: Learning Disabled Low vs. High InCidence Otitis Media Groups.0.00.00.00.0000000000076 Attention to Task: Parent Reports about Learning Dis- abled Children..0.00000000COOOOOOOOOOOOOOO0.0.0.0....79 Parent Report of Learning Disabled Students' Activity Level-8.0.0.0...00.0.00......OOOOOCOOOOOOOOOOO00......80 Teacher Report of Learning Disabled Students' ActiVitY LeveISOOOOOOOOOOOOOOOOO0.00.00.00.000000000080 Average Number of Absences per Year per Child.........81 Locus of Control: Learning Disabled Low vs. High Incidence Otitis Media Groups........................82 Teacher Awareness of Otitis Media Among Their Student583 Comparison of Parent and Teacher Reports of Home/School Communication Frequency..................85 Home/School Communication for Learning Disabled Population.0.....OOOOOOOOCOO...0.0.0.00000000000000085 SpeeCh Perception in NOiSe.00.......OOOOOOOIOOOOOOO0.086 Bannatyne and Kaufman Recategorization Scores........130 vi INTRODUCTION The purpose of this research was to determine the inci— dence rates of recurrent otitis media in learning disabled children and the relationship between otitis, allergy inci- dence and various aspects of the elementary school experi- ence among learning disabled and non-handicapped children. Problem Otitis media is an inflammation of the middle ear which may be manifested as an infection (acute otitis media) and/ or significant negative pressure causing collection of fluid in the middle ear space (serous otitis media). It is one of the most common health problems among young children. It often causes mild, fluctuating hearing loss, which some re- searchers believe may influence the development of language problems, behavior difficulties, and chronic medical prob- lems if the otitis persists or reoccurs frequently. Children at risk for learning disabilities by virtue of heredity or medical history are often also medically at increased risk for recurrent otitis media. This would likely compound their already high risk for the language and behavior problems listed above.(Hanson 1979, Bierman 1980,Wiig 1976) This dissertation is directed at the analysis of medi- cal and developmental histories, current school performance 2 and audiological status of 25 learning disabled and 25 non- handicapped children with a focus on the incidence rates of otitis media and the differences in patterns of performance seen between those with and those without a recurrent pat— tern of otitis media. For purpose of analysis, students are compared in two ways: learning disabled vs. non-handicapped (control) and low incidence vs. high incidence otitis media. The length of this research project was limited to ap- proximately one year, negating the possibility of a longitu- dinal study of a large number of high risk infants from birth through early elementary school. This required reli- ance on retrospective reports from parents about child de- velopment. Another point to consider is that relative to children currently in first and second grades, the high risk infants today typically receive markedly more sophisticated medical care during the mother's pregnancy, delivery, and during the neonatal period. Some of the factors which may affect the health of current school age children are likely to be different for the population entering school in five years. A second time limitation of the study resulted from the fact that the audiologist and audiology clinic were only available during late spring on Saturdays and between 4:00 and 8:00 P.M. on weekdays. If testing could have been done during the winter months, probably more active otitis media would have been detected. 3 An advantage of the study occurring in spring was that teachers were as well acquainted with the children in the study as they were ever likely to be, and their responses to the questionnaires would be more reliable. Also, the fairly broad systems approach, contacting parents, children, audi- ologists, and school personnel, as well as records on file permit the results to be useful in planning follow-up re? search as well as school intervention strategies for the next academic year. In addition to the time constraints in the study, the writer worked within a limited geographic area with volun- teer students who had already been identified as learning disabled by a variety of multidisciplinary teams which may have applied different guidelines for eligibility. Research Hypotheses 1. Incidence of serous and acute otitis media among learning disabled students is higher than in the non-handicapped pop- ulation. 2. Among learning disabled students with recurrent otitis media, defined as at least six occurrences of otitis within two years, there is a higher than average incidence of re- ported allergy symptoms which may continue to affect school adversely after the otitis resolves. 3. Learning disabled children with recurrent otitis media exhibit greater verbal deficits relative to their non-verbal performance than do other learning disabled children. 4 4. More learning disabled children with recurrent otitis media experience difficulty attending to task than other learning disabled children. 5. A higher percentage of learning disabled children with history of recurrent otitis media experience abnormally high or low activity levels than their learning disabled peers. 6. Children with recurrent otitis media miss more school, hence more opportunity for instruction than most students. 7. Learning disabled children with a history of recurrent otitis are more likely to perceive an external locus of con- trol for their school progress than are other learning dis- abled children of similar ages. 8. The majority of teachers working with young learning dis- abled children do not routinely consider the possibility of a history of otitis media contributing to the students' learning problems. 9. Parents of learning disabled children with a history of recurrent otitis are likely to perceive themselves or be perceived by school personnel as different in the frequency of their interaction with their child's teachers. Definitions allergy: unusual sensitivity to small amounts of foreign substances or to physical conditions, which cause no adverse reactions in most people, even when exposed to large amounts of that substance 5 conductive hearirg loss: failure of the ear to transmit sound waves from the environment to the inner ear and then to the brain, usually lS-30dB, primarily a loss of loudness of some sounds gs: decibel, unit of sound wave height or intensity. Average young adults 18-24 years perceive sounds at OdB. Whispers register at about 30dB, conversation at 45-50dB, rock con- certs at 100dB or more. Hg: hertz, the unit of measurement of sound wave frequency, 1 cycle per second; <500Hz low-pitched, >2000Hz high- pitched, middle C 256Hz with each octave above doubling the frequency, and each octave below halving it. Humans can hear frequencies from 20-20,000Hz.(Batshaw, 1981, p.272) impedance audiometry: test of middle ear function in which a probe placed in the ear canal creates an airtight seal. Then air is pumped in or removed so that the pressure ranges from -500 to +200 mm of water. When a sound is presented through the probe, a measurement of how it reflects off the eardrum at different pressures is recorded on a Tympanograph. Be- cause of the flexibility of normal eardrums, a normal Tym- panogram results in a bell-shaped curve.(Batshaw, 1981, p.280) learning disability: See Specific Learning Disability middle ear: area from the eardrum to the cochlea 6 myringotomy: minor surgical procedure in which an incision is made in the tympanic membrane, often accompanied by the insertion of ventilating tubes, which serves to equalize the pressure between the middLe ear and the ear canal and en— ables fluid to drain(Batshaw, 1981, p.276) otitis media: inflammation of the middle ear which may be manifested as an infection (acute otitis media) and/or sig- nificant negative pressure causing collection of fluid in the middle ear space (serous otitis media) otolarmgologist: a physician specializing in problems of the ear, nose, and throat preprimary impaired: l) ”...a child up to 5 years of age whose primary impairment cannot be determined through exist— ing criteria within R340.l703 to R340.1710 or R340.1713 to R340.l714 and who manifests l or more of the following char- acteristics: a) Impairment in l or more areas of development equal to or greater than 1/2 of the expected development for chronological age as measured by more than 1 develop- mental scale and which cannot be resolved by medical or nutritional intervention. b) Lack of appropriate response to visual or auditory stimuli. c) Inappropriate behavior or affective responses which interfere with normal developmental functioning. 2) A determination of impairment shall be based upon a com- prehensive evaluation by a multidisciplinary evaluation team which shall include a psychologist. 3) A determination of impairment shall not be based solely on behaviors relating to environmental, cultural, or eco- nomic differences....“(Michigan Special Education Rules, 1980,R340.l7ll) recurrent otitis media: middle ear inflammation which occurs at least six times within two years specific learning disabilipy: 1)"a disorder in one or more of the basic psychological processes involved in under- standing or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, think, .7 speak, read, write, spell, or to do mathematical calcula- tions. The term includes such conditions as perceptual han- dicaps, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. The term does not include chil- dren who have learning problems which are primarily the re- sult of visual, hearing, or motor handicaps, of mental re- tardation, of emotional disturbance, or of environmental, cultural, or economic disadvantage. 2) The individualized educational planning committee: may determine that a child has a specific learning disability if the child does not achieve commensurate with his or her age and ability levels in l or more of the areas listed in this subrule, when provided with learning experiences appropriate for the child's age and ability levels, and if the multidis- ciplinary evaluation team finds that a child has a severe discrepancy between achievement and intellectual ability in l or more of the following areas: a) Oral expression. b) Listening comprehension. c) Written expression. d) Basic reading skill. e) Reading comprehension. f) Mathematics calculation. 9) Mathematics reasoning. 3) The individualized educational planning committee may not identify a child as having a specific learning disability if the severe discrepancy between ability and achievement is primarily the result of any of the following: a) A visual, hearing, or motor handicap. b) Mental retardation. c) Emotional disturbance. d) Environmental, cultural, or economic disadvantage. 4) A determination of impairment shall be based upon a com- prehensive evaluation by a multidisciplinary evaluation team which shall include at least both of the following: a) The child's regular teacher... b) At least 1 person qualified to conduct individual diagnostic examinations of children, such as a school psychologist, a teacher of the speech and language impaired, or a teacher/consultant."(Michigan Special Education Rules, as amended 8/13/80,R 340.1713) speech and language impaired: "manifestation of l or more of the following communication impairments which adversely af- fects educational performance: a) Articulation impairment, including omissions, substitutions, or distortions of sound, persisting beyond the age at which maturation alone might be expected to correct the deviation. b) Voice impairment, including inappropriate pitch, loudness, or voice quality. c) Fluency impairment, including abnormal rate of speaking, speech interruptions; and repetition of 8 sounds, words, phrases, or sentences, which interferes with effective communication. . d) One or more of the following language impairments: phonological, morphological, syntactic, semantic, or pragmatic use of aural/oral language as evidenced by both of the following: i) A spontaneous language sample demonstrating inadequate language functioning. ii) Test results, on not less than 2 standardized assessment instruments or 2 subtests designed to determine language functioning, which indicate inappropriate language functioning for the child's age. 2) A handicapped person who has a severe speech and language impairment but whose primary disability is other than speech and language shall be eligible for speech and language ser- vices pursuant to R340.l745(a). 3) A determination of impairment shall be based upon a com- prehensive evaluation by a multidisciplinary team. which shall include a teacher of the speech and language impaired. 4) A determination of impairment shall not be based solely on behaviors relating to environmental, cultural, or eco- nomic differences.(Michigan Special Education Rules, as amended 8/13/80, Lansing, R340.1710) REVIEW OF THE LITERATURE Introduction The major issues reviewed in the literature were inci- dence of otitis media, incidence of allergy, identification of otitis media and learning disabilities, effects of oti- tis on school performance, and communication among parents and professionals relative to recurrent health problems such as otitis media. Otitis media often occurs following the onset of upper respiratory or sinus infections or allergy flare-ups. Ade- noid obstruction frequently occurs simultaneously, and may contribute to the problem. The otitis may be caused by viral or bacterial agents. Some environmental variables thought to be involved in triggering middle ear changes in vulnerable individuals are crowded, urban living, and early attendance at day care centers. Djupesland hypothesized that anxiety and teeth clenching caused contraction of the muscles of the middle ear, giving rise to changes in middle ear pressure. (Djupesland in Jerger, 1975,p.ll9) Northern (l976,p.120) reports that sudden temperature changes or chemical irri- tants in the environment may disturb the function of the cilia and normal bacterial flora in the middle ear. In healthy individuals the emstachian tube which con- nects the ear to the throat serves three functions relative to the middle ear. It regulates pressure, protects the ear from contamination from nasopharyngeal secretions, and helps 9 10 to clear middle ear secretions. Serous otitis media occurs when the eustachian tube becomes obstructed from inflamma- tion caused by infection or allergy, closing off the middle ear space. As a result, air is absorbed, creating negative pressure and fostering the accumulation of fluid in the mid- dle ear cavity. A conductive hearing loss results when the retraction of the tympanic membrane, or eardrum, and the negative pressure or fluid combine to impede the passage of sound waves from the environment to the inner ear. While significant controversy remains about some of the causes, diagnostic procedures, definitions, treatment, and longterm effects of otitis media, some commonly accepted guidelines are emerging about incidence rates as new research is repor- ted. Incidence of Otitis Media Otitis media is one of the most common organic diseases among young children, second only to simple upper respira- tory infections.(Paradise,1980,p.9l7) As children grow from infancy through their third to fifth year of life, the eu- stachian tube which is central to most middle ear problems changes. The infant's tube may collapse, because the amount and rigidity of supporting cartilage are still inadequate. Also, as the child grows, the tube shifts from a narrow, horizontal one to a wdder, more vertical tube facilitating proper drainage. Also, children begin to spend more time awake and vertical, assisting in the drainage of fluid and healthy functioning of the eustachian tube. 11 Ear infections cost $2 billion a year in the United States. This figure includes doctor bills, transportation to and from doctor's offices, medication, and surgery. During one year, one million sets of ventilating tubes were in- serted, and more than 600,000 tonsillectomies and adenoidec- tomies were performed, many primarily for prevention of fur- ther otitis media.(Bluestone, 1982) Kramer reports that among 1905 pediatric office visits 30.5% were for well child care, 20.2% were for initial treatment of otitis, and 13.9% were follow-up examinations of children recovering from oti- tis media. In the outpatient clinic at a Children's Medical Center most of the 2256 appointments monitored were for treatment of upper respiratory infections. Second and third in frequency of complaint were initial and follow-up care for otitis media, accounting for 20.3% and 6.6% of the ap- pointments. (Jazbi,5979,p.229) Virgil Howie(l975), a pediatrician interested in otitis media followed 488 of his patients. He identified 149(30.5%) as being otitis prone, which he defined as six or more epi- sodes of otitis before age six. All of these children had their first otitis episode before eighteen months of age. Children. with pneumococcus infections ‘were 2.5 times as likely to have multiple episodes. Project CHILD (Conductive Hearing Impairment/Language Delay), an early education pro- gram for otitis media children in Toledo, reports that 12% of preschoolers are otitis prone, using Howie's criterion. 12 Beginning in 1956, the American Academy of Ophthalmol- ogy and Otolarygology's Subcommittee on Hearing in Children began work with the Maternal and Child Health Section of the University of Pittsburgh's Graduate School of Public Health in a study of children's hearing. Their goals included: 1. Evaluate methods for testing hearing in children . Help establish norms on hearing in children . Study factors related to levels of hearing sensitivity . Identify physical signs and symptoms which may predict hearing impairment 5. Establish case-find methods to determine the prevalence of hearing impairment in children in the United States 6. Contribute to the understanding of academic, psychological, and social effects of hearing impairment.(Eagles,l963,pp.l-2) 7. Help develop standards for medical and surgical rehabilitation 8. Assist professionals in improving programs for the hearing impaired(Eagles,l967,p.5) 2 3 4 This longitudinal study collected and analyzed compre- hensive data on 4078 school children, who as a group were representative of the area population in terms of age, race, sex, socioeconomic status, and parent employment. 97.5% of the children enrolled in the four study schools participated in the project.(Eagles,l967,p.27) The research team included otolaryngologists and trained audiometric technicians work- ing with tightly controlled procedures and carefully cali— brated equipment in closely monitored acoustic environments. The study's findings continue to be cited as a standard of comparison for pediatric audiology. Seasonal variations occurred with the highest incidence during the winter months, when there are more respiratory 13 infections. Most middle ear problems observed during the study among school-age children were subacute, a type children and parents wouLd not be likely to identify, but one which causes pressure and fluid changes affecting hearing.(Eagles,l967,p.23) Among the 714 otoscopically normal children who partic- ipated for the duration of the study and submitted medical histories, 4% had experienced more than six ear infections during their lives.(Eagles,l967,pp.69-70) Among the 349 oto- scopically abnormal, 7.8% had more than six ear infections. (Eagles,l967,p.92) A recent report from Australia assessed 879 5-year-olds and found only 357(40%) of those children to have normal results on physical examination, impedance testing, and pure tone audiometry. The remaining youngsters had some middle ear abnormality or had ventilation tubes in place for a pre- viously diagnosed middle ear problem.(Silva,l982,pp.26,496) A smaller study by Onion(l977,p.472) followed 165 chil— dren (birth to ten years) for twelve months. They were all seen for index, or first episodes of otitis media. Forty- seven percent had at least one additional episode during the year. Eighteen percent had two or more recurrent epi- sodes, and three percent had three or more. Three-fourths of those experiencing two or more recurrent episodes were male. Eight percent of the children were referred to an otolaryn- gologist. Certain populations seem to be particularly at risk for l4 recurrent otitis media: American Indians and Eskimos, those with Downs Syndrome, brain damage, immune deficiency syn- dromes, cleft palate, inadequate exposure to language, Whites more than Blacks, and graduates of neonatal intensive care units(NICUs). At Colorado Medical Center's NICU, 28% of the newborns had acute otitis media.(Brooks,l979,p.30) The NICU graduates at greatest risk are those who were born pre- maturely, received ototoxic drugs without close monitoring of serum levels, and those who required intubation and breathing assistance from a respirator following birth asphyxia. High Risk Registers have been developed to focus limit- ed resources on screening children most likely to develop problems. The Joint Committee for recommendations for new- born infant hearing screening from the Academy of Pediat- rics, Academy of Ophthalmology and Otology, and the American Speech and Hearing Association suggest the following crite- ria for including a child in the Register. A. History of hereditary childhood hearing impairment B. Rubella. or' other nonbacterial intrauterine fetal infection (e.g. cytomegalovirus, herpes) C. Defects of ear, nose, or throat (e.g.cleft palate) D. Birthweight < 1500g E. Serum bilirubin(newborn jaundice) judged to be toxic Hearing impairment in this group is likely to occur about fourteen times more frequently than in the general popula- tion. (Northern & Downs,l978,p.206) 15 Freeman and Parkins(1979) report a 20% incidence rate of middle ear disease among learning disabled children(N=50, mean age=10.3 years) and 9.5% incidence rate among those with no apparent learning problems(N=32,mean age=9.8 years). The authors do not identify the guidelines used to label the learning disabled children as being handicapped, nor the techniques for selecting controls. The ages of the children exceed those in the current study. Ingham Intermediate School District, the coordinating and funding organization for constituent school districts in Ingham County, Michigan, conducted an audiometric screening of 104 students attending special education classrooms for the pre- primary impaired in 1981. Audiologists used pure- tone and impedance testing to identify hearing losses or middle ear problems which might interfere with school suc- cess. Eight students already had ventilating tubes in place. One student was newly identified as having a sensorineural hearing loss. Twenty-eight additional students failed the screening and were referred for further testing. Twenty- three of those referred participated in the follow-up and nineteen of them were found to need treatment of middle ear problems ranging from removal of impacted cerumen (wax) to surgical intervention. These students had already been iden- tified as having a handicap, including a language delay in most cases. Typically, the twenty students newly identified as having hearing problems would not have received audiomet- ric testing' beyond the routine public health technician 16 puretone screening. When the screening was repeated in 1982, thirty-six (35.51%) of the 107 children tested had confirmed middle ear problems.(Dickie,Stewart,Johnson,1981) A study at the University of Indiana Speech and Hearing Center reports that. among clinic children. with language problems, many of whom have been identified as learning dis- abled, 60% have some degree of hearing loss, and most of those have histories of chronic otitis media.(Naremore,54) In summary, most young children experience at least one episode of otitis media. Many, particularly those in high risk groups, experience multiple episodes which sometimes continue into the school years. The causes vary, but most commonly otitis media is seen in conjunction with other upper respiratory symptoms. Symptoms Warranting a Medical Referral With the onset of acute, or infectious otitis media, there is often rapid onset of pain, fever, congestion, and malaise. With serous otitis media, however, the observable signs are often more subtle, and persist as an acute episode appears to be resolved. The student may: look tuned out when the teacher speaks to the class respond inconsistently to sound confuse similar sounds need to have verbal directions repeated have difficulty monitoring loudness of own voice not remember names of people, places, objects be unusually sensitive to noise experience difficulty sequencing sounds correctly attend only to part of a message have difficulty localizing sounds complain of bubbling or clicking noises in the ear upon swallowing or changing position complain about food making loud noises when chewing \DCDxlO‘UI-thH o o o o o o o 0 Hr4 rho O O H N o 17 13. show temper outbursts from frustration or confusion l4. fatigue easily from listening 15. complain about tinnitus, or ringing in the ears 16. experience vertigo, a sensation of spinning If a student exhibits several of these behaviors, it may well be appropriate to refer the child for multidisci- plinary diagnostic testing. This would be particularly true if there were a history of recurrent otitis media, language delay, or if the child is in a high risk category. The fact that the child may have passed routine public health hearing screenings would not change this recommendation. One behavior which often confuses staff members and causes them to be reluctant to refer for testing is that the student appears to hear well in noisy situations. This is explained by a phenomenon called paracusis Willisii. As the noise level increases, people compensate and speak louder. (Davis,l978) Allergy The expected incidence of allergy is 15% for the gener- al population according to the National Institute of Aller- gies and Infectious Diseases. Children with allergies can have any of a broad range of substances affect them in one or more ways. Congestion, hives, wheezing, eczema, stomach cramps, excessive perspiration, sallow complexion, circles under the eyes, and itching eyes are among the more commonly noticed symptoms. The allergic-tension-fatigue syndrome in which the child tends to be irritable, anxious, or exces- sively tired is commonly present as well. Medical treatment 18 and environmental control can alleviate the problems to varying degrees. Laboratory tests sometimes ordered by pediatricians to determine whether to refer to a specialist are not as reli- able as had been thought for young children.(Nelson,l982; Roach,l98l) Some families are told by physicians that their child's problem is not one of allergy, when actually the serum complement and IgE tests had false negative results. Allergic rhinitis, commonly referred to as hay fever, occurs in five to ten percent of the elementary school age population. When. allergic rhinitis occurs in combination with serous otitis media, the primary treatment according to many physicians is allergy control. Management typically includes elimination of suspected food allergens from the diet, environmental control, prevention of complicating bacterial infections, oral antihistamines or decongestants, and hyposensitization to certain inhalants with allergy shots.(Dockhorn,1977,p.lll) Among the 714 otoscopically normal children who partic- ipated for the duration of Eagles' study and submitted medi- cal histories, 11.5% had history of food allergy, asthma, eczema, hay fever, and/or hives.(Eagles,l967,pp.69-70) Among the 349 otoscopically abnormal, 11.2% had history of aller- gy.(Eagles,l967,p.98) There was no increased allergy rate among those with otologic problems. Reisman and Bernstein found the incidence of allergy to be 35% among 200 children who required multiple tympanostomy 19 procedures for otitis media, that the otitis was a complica- tion of nasal allergy.(Ghory,1982) McLoughlin(l983) recently completed a study concerning the relationship of allergies and allergy treatment to school performance and behavior. His sample included 316 allergic and 84 nonallergic children ranging in grade from nursery school to grade twelve. The problems reported were allergic rhinitis(86%), eustachian tube dysfunction or serous otitis media(57%), asthma(58%), gastrointestinal symptoms(36%), and hives(29%). The allergic children missed one to three days of school per month, which was more than their peers. Most of their absences were in winter. Drowsi- ness in school was reported significantly more often for the allergic children. Eustachian tube dysfunction was signifi- cantly related to inattentiveness and excessive talking. It was also significantly associated with lower ratings by par— ents on reading, math, spelling, writing, listening, and speaking. In terms of treatment, parents considered antihistamine use to correspond with hyperactivity. Theophyllin bronchodi- lators correlated with inattentiveness, hyperactivity, irri- tability, drowsiness, withdrawn behavior, and being diffi- cult to handle. McLoughlin concluded that respiratory prob- lems related toallergy may influence allergic children's ability to attend to auditory information, particularly dur- ing early speech and language development. He went on to say that the ”general feeling of illness...associated with 20 allergies may deter a child from normal behavior. This may be particularly true of the learning disabled child who must cope with many other problems.”(McLoughlin,1983,p.ll) In an earlier presentation McLoughlin spoke of parents sending allergic children to school regularly, because they are sick all the time. Teachers need to be sensitive to the child's symptoms and help the parent determine when medical treat- ment is warranted. Another point in the same presentation was that part of the reason for chronic drowsiness may be difficulty sleeping at night due to allergy symptoms. (McLoughlin,l982,CLD) He encouraged more systematic moni- toring of school effects of medical treatment. Audiological and Medical Diagnosis of Otitis Media Puretone testing is generally accepted as one part of the assessment for otitis media, but the frequencies to be tested and the intensity of sounds presented at a screening level continue to be cause for debate. Katz(1978,p.53) rec- ommends including 500Hz and 6000Hz in addition to the 1000, 2000, and 4000Hz measures. He also recommends testing at 15dB(ANSI,l969) as opposed to the commonly used 20 or 25dB levels. Northern and Downs(1978,p.219) believe that 20dB is the softest practical screening level in schools because of ambient noise. They also reject use of the 500Hz component for screening because these results are particularly af- fected by the ambient noise. In response to concerns such as these, for school screenings Katz(l978,p.54) recommends that 21 testing room be distant from fluorescent lights, water cool- ers, rest. rooms, and elevators to minimize auditory back- ground problems. He also suggests minimizing visual dis- tractors. Recommendations for who should be screened vary. Nor- thern and Downs(1978,p.221) suggest testing all kindergar- teners, lst, 3rd, 5th, and 7th graders, plus all transfer students kindergarten through high school. In addition, they recommend rechecking all students who failed a screening previously, until they have three years with no decline in pure tone performance. Many studies report that puretone screening only iden- tifies about 50% of otitis media hearing losses. If children fail initial screening tests, they typically are re-screened with threshold testing in the school, identifying the soft- est sound levels at which they can perceive sound. Usually if they fail this second test they are referred to their doctor and/or an audiologist. Speech reception thresholds tested in diagnostic evalu- ations measure the softest level at which the child can un— derstand 50% of what s/he hears. The test includes spondaic words presented by tape or live voice for the child to re- peat. A spondee is a simple, two syllable, compound word with equal stress on each syllable (e.g. cowboy, ice cream). The test's primary contribution is to verify the accuracy of the puretone results. In the past several years, a simple, painless procedure 22 called impedance audiometry has become one of the primary diagnostic aids for otitis media, generally being coupled with puretone threshold testing and speech reception thresh- old testing. It requires minimal cooperation and no active responses from the patient. A probe with a soft cuff is in- serted into the patient's ear canal and forms an air seal. A known amount of sound is sent to the ear through the probe, and then the quantity reflected back from the tympanic mem- brane is recorded. The Tympanometer records middle ear pres- sure, eustachian tube function, and information about ear- drum mobility as it measures the flow of sound energy under conditions of changing ear canal pressure. The American Speech and Hearing Association(ASHA) considers -50 to +50mm water to be the normal range. Readings beyond -100mm are outside the 90th percentile and are frequently recommended by audiologists as the criteria for medical referral.(Rin— telman,l979,p.290) Often physicians do not become concerned until the negative pressure exceeds -150mm and persists at that level. The Tympanometer also tests the acoustic reflex, which measures whether the stapedius muscle contracts when a sud- den, loud tone is sent to the ear. The acoustic reflex is frequently absent in the presence of otitis media. It is typically suggested that any mildly abnormal findings be rechecked at two or four week intervals before referring to a physician. In the event of a referral, a physician supple- ments the puretone, speech reception, impedance, and 23 acoustic reflex tests with a physical examination and occa- sionally a fluid culture. A position statement from the American Speech and Hear- ing Association in 1980 encouraged participation of speech- 1anguage pathologists and audiologists in initial assess- ments of students suspected of having a learning disability. There has been a continuing increase of language disordered individuals on speech-language caseloads, many of these stu- dents being learning disabled. Members of the Association feel that "the majority of learning disabled students have concomitant language disorders and that it is essential that professionals qualified to determine the absence or presence of language learning disorders... be included on the multi- disciplinary team.”(Byrne,l980) ' Early Identification of Learning Disabilities There are developmental attributes, which permit evalu- ation of risk for learning disabilities in the preschool years. They are measurable prior to many of the characteris- tics listed in the federal definition. Parents often report observing differences from the norm with their child from an early age. These differences in pattern and rate of develop- ment are supported by professionals. Wiig(l976,p.4) finds they may have allergies, colic, and other physical problems which require parents to handle them differently as infants, and that deficits may result in subtle changes in the quan- tity and quality of interaction between parent and child. Parent responses of guilt, overprotection, and rejection may 24 contribute to the development of secondary emotional prob- lems. Ack(l982,p.l9) states the following. Ideally, a child who may have a learning disability should be evaluated as early as age three, before he begins to view himself as a failure and to be regarded as slow by others.... Feeding, sleeping, and regulating temperature are the reading, writing, and arithmetic of the first three years of life. Be alert for the child who has diffi- culty listening or attending to others, or putting his own thoughts together. A short attention span or a tendency to impulsiveness in the hyper- or hypoactive child may be a tip off...abnorma1 difficulties for his age in integrating visual input with proprioceptive input, auditory input with visual input, and so on... abnormally poor posture and extraocular muscle control ...underdeveloped visual orientation to space,... 0- verly distractible, or...hypersensitive to noise, late in learning to speak and difficult to understand when he does speak,--a child who stutters,...(has) problems with word finding, sound sequencing, narrative organi- zation or speech comprehension Wiig(l976,p.304) lists similar indicators for three year olds and adds aggression, poor interpersonal relation- ships, disinterest, and anger. By' school age, some ‘visual-motor difficulties often associated with learning disabilities include difficulty holding pencils, cutting with scissors, tying shoes, and zipping zippers. Wiig(l976,p.304) feels that the best pre- dictors for learning disabilities from kindergarten reports are immaturity, poor social and emotional adjustment, poor speech and language, and impulsiveness. Willeford mentions a problem of not being able to follow class activities well which often results in the child not being selected for gym or recess teams, because his peers say that he "goofs up too much.” He may also prefer to be alone or with individuals 25 younger or older than him/herself.(Willeford in Clark,l978) Language problems common to learning disabled children are easily missed in an assessment done only by a psycholo- gist, teacher/consultant, and classroom teacher. The subtle difficulties often are not tapped by many standard assess- ment batteries. Issues Wiig recommends for review include: 1. Normal spontaneous speech, but problems with structured linguistic tasks such as sentence repetitions,completions, or transformations. 2. Poor knowledge of morphology--plurals, tenses... 3. Long response latencies 4. Difficulty understanding jokes, puns, metaphors, or words with multiple meanings 5. Poor recall of details pertaining to space, time, and quantity 6. Poor sensitivity to nonverbal social cues 7. Delay in comprehension of abstract concepts 8. Classification difficulties 9. Poor semantic relations or analogies 0. Use of many indefinite nouns and pronouns, limited bank of adjectives and adverbs ll. Difficulty decoding blends with L,W, or R as the second letter in the word 12. Confusion in reading and spelling words with short A,E,I beyond the first grade 13. Difficulty understanding sentences written in pes- sive voice(Wiig,l976) Cole and Wood(l978,p.120) add to the list of problems that learning disabled children are often unable to use ver- bal information to make inferences or draw conclusions. Dobie(1979,p.50) suggests that syllable counts may be pre- served, but words and their meanings may change--e.g. ”me- ticulously done” may be understood as "ridiculously dumb". No one or two of the characteristics would qualify a child as being learning disabled, but if a significant clus- ter exists in combination with the child's inability to meet regular classroom expectations, then identification would be 26 appropriate. Effects of Otitis Media Some of the effects researchers frequently attribute to recurrent otitis media are l. Mild, low frequency hearing loss, especially prob- lematic in suboptimal listening conditions 2. Reduced verbal skills and scholastic performance, particularly in language areas 3. Distractibility and fatigue caused by pain and malaise or by medications prescribed to treat the otitis Serous otitis is the most common cause of hearing im- pairment in five and six year olds.(Naunton,l6) Conductive hearing loss, the type often associated with otitis media, accounts for 90% of school age hearing impairment.(Brooks, 1978,ch.25) Most researchers agree that otitis media trig- gers a 15-30dB conductive hearing loss, and that even this slight loss in young children may affect language develop- ment and later school performance even though the actual hearing loss will have resolved. The loss tends to be great- est at low frequencies(250-1000Hz) with some recovery at 2000 and 4000Hz. The loss may be intermittent or persis- tent, and has the greatest potential of affecting language when it occurs before the age of two, reoccurs frequently, and persists for at least several months. The mean hearing levels across frequencies from Eagles' project are reported in chapter four as a contrast to the 27 findings in the current study. They found differences be- tween mean levels of all right and left ears to be less than ldB, with differences in standard deviations of £0.5dB. They found neither ear to be consistently more sensitive. This finding is not usually recognized as being representative of the population as a whole, with many researchers identifying the right ear as being dominant for most individuals. Girls had slightly (gZdB) more sensitive hearing at most frequen- cies. Across races the difference in means was <2dB. There was some increase in hearing sensitivity across age, but primarily with 11-13 year olds, children older than those in the current study. The researchers correlated this finding with the decreased prevalence of upper respiratory infec- tions and related middle ear problems in the older children. Among children with complaints about recent colds or ear problems the hearing sensitivity was about 5dB higher than those without this history. Also, they felt that students' increasing familiarity with the testing might affect the results. This fairly stable picture across sex, 6-9 years of age, and race help to make the results more easily general- ized to areas other that Pittsburgh. (Eagles,l963,pp.87-94;l967,p.12). Among the 41.7% of the 4078 children with history of at least one ear infection, there was a greater frequency of slight hearing loss, but some with ear infection history had normal hearing. 8.5% of the subjects had one hearing im- paired parent, and 0.3% had two hearing impaired parents. 28 (Eagles,1963,p.217) Some with otitis history showed a pro- gressive hearing loss over the course of the study. Kessner(l974) completed a study for the National Acad- emy of Science assessing 1639 4-11 year old children in the Washington, D.C. area. He found that in the speech frequen- cies(500-2000Hz), the mean difference in hearing thresholds between children without history of otitis media and those with recurrent otitis history was 7.4dB(ANSI,1969). Thresh- olds for the normals were 7.8dB, and the children with def- inite serous otitis media had a mean threshold of 15.2dB. Using lSdB as the criterion for significant hearing loss, 78.8% of the six and seven year olds had normal hearing in both ears across speech and non-speech frequencies, and 84.8% of the eight and nine year olds had normal hearing. (Northern & Downs,l978,p.2) Project CHILD (Conductive Hearing Impairment/Language Delay) serves preschool otitis media children (0-5 years) through the Toledo Public Schools, The Medical College of Ohio Department of Pediatrics, and Toledo Headstart. As part of the needs assessment, Project staff sent a survey to 310 Toledo physicians who specialize in pediatrics, family prac- tice, and otolaryngology. One hundred fifty-nine responded. 29 Their responses indicated the following: TABLE 1 Project CHILD Survey of Physicians: Effects of Otitis Media To what extent does chronic otitis media cause: Not at all Rarely Occasl Often No Resp. language delay 2.6% 18.5% 39.1 29.1% 10.6% social delay 4.0 22.5 34.4 27.8 11.3 learning problems 2.6 15.9 35.8 35.8 9.9 articulation prob 2.6 19.9 37.7 28.5 11.3 The majority of physicians responding to the survey felt that otitis media had the potential of affecting school success.(Project CHILD,1981) In Freeman and Parkins' learning disability study, the audiometric and physical examinations were done blind rela- tive to school and middle ear history. The testing was done in a ”relatively quiet classroom", not a sound suite. The work is more recent than Eagles', and includes impedance testing. The average hearing thresholds in the speech range was 3.9dB for the controls and 7.5dB for the learning dis- abled children. The results suggested to the researchers that ”middle ear disease and its resultant hearing loss may be an additive factor in causing greater learning difficul- ties for an already deprived child.” The researchers do not define "deprived", which may represent cultural deprivation, deprivation of the usual opportunity for success in school 30 because of a learning disability, or possibly some other meaning. Because these characteristics of the children are indefinite it is difficult to generalize the results to other populations. Some environmental variables reported to affect the severity of an otitis child's difficulty in school include: 1. signal to noise ratio 2. vocal power output and sex of teacher 3. acoustic environment of classrooms 4. school absences due to medical appointments 5. school absences due to illness Harrison completed a study of ambient noise in thirteen schools and found the median level of 44dBA with prolonged periods of greater than 50dBA and peaks of up to 60dBA. In follow—up simulations testing children with the background noise, only thirty of the thirty-two children with normal hearing passed the test.(Brooks,p.37) Byron's study in an open school yielded an average level of 68dBA, a range of 62-74dBA, and the only room quieter than SOdBA was the head- master's office.(Brooks,p.37) Bess reports that modern, acoustically treated classrooms are about 4ldBA unoccupied and 56dBA occupied. The signal to noise ratio(S/N) is about +5dB in high schools and +ldB in lower grade rooms. He re— ports that the most important factor in determining S/N ra— tio is the distance between speaker and listener, that sound pressure decreases by 6dB when the distance is doubled. A teacher speaking in a normal voice to an elementary child 31 three feet away will have a +9dB S/N ratio. At six feet, it will be +3dB.(Bess,198l,p.l90) In addition to coping with problems with the school acoustic environment and school absences, the fluctuation in a child's own hearing sensitivity makes it necessary for the child. to .re-adjust listening skills, because. s/he hears words and sentences differently at different times. The ef- fects of otitis media on language have been studied in two ways. 1. assessment of individuals with known history of middle ear problems 2. simulations of speech, filtered in such a way as to be comparable to middle ear problems--and then assessment of individuals' performance under those conditions(Dobie,48). Holm and Kunze(l969) tested thirty-two children five to nine years of age. They were in good health except that the sixteen students in the experimental group had a history of early onset otitis media. They experienced fluctuating, mild hearing losses, and lower scores on language tests relative to a matched control group. Their performance on visual tests was similar to the control group's. Kaplan(1973) completed a study among Eskimos, a known high risk group for otitis media. He followed 489 children from birth to seven or ten years. In addition to finding hearing loss, he found that 34% of all children were behind in school placement, but that 63% of children repeating a 32 grade in elementary school had their first episode of otitis media before age two. The early onset otitis media children had scores on the Wechsler Intelligence Scale for Children and the Metropolitan Achievement Test which were statisti- cally significantly below the norm. Also, it appeared that the school performance of the early otitis media group and the control group widened as time went on.(Northern & Downs, l978,pp.6-7) One implication of this study for schools, is that it costs well in excess of $1000 for any child to re- peat one year of school. One caution with this study is that the impact of socioeconomic status is not controlled in con- sidering the outcomes. In the Australian study,(Silva,l980) those experiencing bilateral otitis media with effusion(N=47) as determined by a Type B Tympanogram in conjunction with microscopic charac- teristics of otitis media were compared with otologically normal children.(N=355) The otitis media children shared a pattern of developmental disadvantages and behavioral prob- lems including poor speech articulation, low verbal compre- hension, poor motor development, lower intelligence, depen- dency, short attention span, weak goal orientation, rest- lessness, peer rejection, and frequent. disobedience. The authors note the similarity of this constellation of charac- teristics with the constellation often viewed with learning disabled children. The type and severity of effects reported were influenced by the age of onset of the condition, its severity, and the length of time over which it continued to 33 occur. The effects may also be compounded by cultural dep- rivation, bilingualism, and. other situations which often hinder successful school participation. Another Australian study by Lewis(1976) reports similar results with a conclu- sion that serous otitis media tends to encourage inefficient listening strategies that can persist well beyond the epi- sodes of active ear disease.(Northern & Downs,l978,p.5) A number of animal studies show that anatomical changes occur causing permanent central auditory processing problems if there is sound deprivation during key developmental peri— ods.(Webster & Webster,l980) Peripheral hearing occurs from the outer ear through the 8th cranial nerve, and central auditory processing relates to brainstem and cortical func- tion. In humans central auditory processing encompasses at- tention, sequential memory, sound blending, discrimination, and closure skills. Willeford(1977) questions whether memory is actually a problem, or whether the material is never learned in the first place. Problems with central auditory processing based on minimal hearing losses can be better understood if the speech sounds most affected are reviewed. The unvoiced consonants (f,k,p,s,sh,t,th) are generally very soft, easily missed, and affect the understanding of the word meanings as well as grammar issues such as pluraliza- tion or tense. Zinkus and. Gottlieb(l978) focused their research on auditory processing and academic achievement as they relate to otitis media. A team assessed forty white, middle class, 34 elementary school children referred to a multidisciplinary evaluation team because of academic underachievement. The students were divided into a mild otitis and a severe, chronic otitis group. The students in the "mild” group had experienced no more than one mild episode during each of their first three years of life. The chronic group had all experienced multiple otitis episodes that had required sur- gical intervention to alleviate the problem. The average ages of the students were 8.6 years in the mild group and 8.3 years in the severe group. Excluded from the population were subjects with (1) suspected central nervous system(CNS) disease or injury; (2) severe emotional or behavior disor- ders; (3) visual perception disorders: or (4) 105 below 85. They found normal motor development in the chronic group, but delayed language development. All three mean summary scores for the chronic group on the Wechsler Intelligence Scale for Children-Revised(WISC-R) were lower by 8 to 10 points. The subtests on which the groups performed differ- ently at a .05 level were those which relied heavily on au- ditory processing or language. Children in the chronic group also experienced difficulty performing tasks requiring inte- gration of visual and auditory skills. The correlation be- tween the WISC-R full scale and reading level was not sta- tistically significant. The list of exclusion characteristics eliminated from this study many students who might be identified as learning disabled. Most learning disabled students have a combination 35 of visual and auditory problems, and their medical histories typically include some significant CNS risk factors. The nature of the population may have contributed to the some- what atypical finding that WISC-R Performance scores were depressed in the chronic group. Most studies report that there is no effect on non-verbal intelligence.(Rapin,ll) During the 1981-1982 school year the writer completed a field placement at Sparrow Hospital's Developmental Assessment Clinic, a follow-up service for all graduates of the hospital's regional neonatal intensive care unit. In that setting, where most of the children could be considered at high risk for learning disabilities, it appeared that an unusually high percentage of the children were experiencing otitis media, often repeatedly, and often beginning within the first year of life. In many of those cases there was also concern about the possibility of mild hearing impair— ment which may affect language development. To assess the otitis media and language link an addi- tional study was completed during which the Clinic's primary physician completed a checklist on all 13-40 month old chil- dren who visited the clinic when he was scheduled there from November, 1982, to September, 1983. Of the seventy-one chil- dren followed, forty-nine had language within normal limits for age. Fourteen had questionable language skills, and eight had clearly abnormal language for age. The language assessment included. the ‘Bayley' Scales. or Stanford-Binet, combined with the Bzoch-League_Receptive Expressive Emergent 36 Language Scale (REEL), and staff observation. The mean num- ber of ear infections per year for the three groups in order were 0.7, 1.4, and 3.9, a statistically significant pattern on an Analysis of Variance (df=2,F=16,p=.0000). With the intermediate group removed from the analysis, because the prognosis is less certain, the F score increased to 34.08. Paradise(1981,p.870) wrote an article discussing the problems often observed in individuals who have a chronic history of otitis media. He raised questions of association, cause/effect, and reversibility. He does not believe that conclusive cause/effect evidence exists yet for most of the problems identified, and he emphasized that the initial fac— tor that led to the otitis media may also be responsible for the other problems. One example he used was that individuals with poor parenting skills might not employ consistently good hygiene for their child, might not notice or respond to mild symptoms of illness, and might frequently prop feed a baby its bottle, which is known to contribute to blocking the eustachian tube. The same parents at a later time could be minimally involved in fostering their child's formal edu- cation. To attribute the later academic deficit to the oti- tis is inappropriate. A preferred approach is to suggest that an otitis child who is also at risk for school problems for other reasons, is more likely to be handicapped by the health history. Looking at interaction of variables from another psy- chological perspective can be done with the locus of control 37 concept usually associated with Rotter. It addresses peo- ple's beliefs about connections between their behavior and their achievements or others' responses to them. Individuals who believe that their own efforts and skills are the pri- mary bases for rewards or punishments they receive are con- sidered to have an internal locus of control. Those who at- tribute their successes or failures to luck or influence of others are said to have an external locus of control. It is also possible to be Internal for success or failure, and External for the other. It is generally accepted that indi- viduals with an internal locus of control work harder to control their environment, persist longer’ on challenging tasks, have better mental health, and achieve higher levels of academic success than those with an external locus of control.(Gordon,l977;Williams,1979:Travers,l979) As children grow from infancy through the elementary school years they tend to shift from viewing their experi- ences as being externally controlled to believing in an in- ternal locus of control as they see ways they can influence outcomes through their own behavior.(Bachrach,l977,p.l340) It is a reciprocal growth pattern with success yielding in- creased self-confidence, yielding increased effort for fur- ther success, and so forth. The rate of this cognitively based develOpment can be affected and sometimes permanently impaired by a variety of factors such as socioeconomic sta- tus as well as rate and pattern of reinforcement for on-task behavior.(Gordon,l977:Bradley,l977) 38 Some recent research indicates that learning disabled children, like others who experience wchool failure, are more likely to maintain an external locus of control than their classmates. In particular, they tend to attribute their successes to external factors, more than their fail— ures.(Nicholls,l979;Pearl,l980:Dudley-Marling,1982) The Van- derbilt study on chronic illness in children reports re- search which clarifies that the presence of a continuing illness often fosters a reality based external locus of con- trol for both child and parent. A couple of reasons identi- fied for this include the unpredictability and limited con- trol over recurrent episodes of illness or hospitalization and reduced parent career flexibility because of health in- surance needs and geographic ties to individual specialists or facilities. In a limited way the Vanderbilt research may be applicable to learning disabled, otitis media students. Pearl and Bryan's research(1982) about mothers' locus of control relative to their learning disabled children found a pattern of external locus of control for achievement and internal locus of control for failure. The population was small, eighteen parochial school families, but provided an initial look at how members of a family can reinforce less than optimal motivation strategies for children with learn- ing disabilities. Otitis media can have a range of longterm effects for some individuals who experience recurrent episodes. The most thoroughly documented effect is slight conductive hearing 39 loss with varying duration. There are reports of effects on language development, particularly if the otitis occurs dur- ing key language development periods and if the child is a member of a high risk category for learning problems. Re— ports of effect on behavior vary, with some studies identi- fying distractibility, altered activity levels, and irrita- bility being directly related. Studies of locus of control among chronically* ill. or learning disabled children and their families may be applicable to learning disabled chil- dren with recurrent otitis media. Communication Among the Parents and Professionals Johnson and Morasky(l980,p.l89-l90) identify three gen- eral categories of communication problems among profession- als working with learning disabled youngsters: 1) problems relevant. to interpersonal relationships and role definitions; 2) problems related to clarity, form, and structure: needs to reduce jargon, to describe behaviors in meas- ureable terms, to state specifically what is sought from the other professional, and 3) problems related to purpose, knowing how the re- quested information will be used guides the profes- sional in presenting it appropriately These types of problems are identified repeatedly in the literature as affecting open, complete communication among parent, teacher, and doctor. In the Sparrow DAC and Ingham ISD studies, it appeared that the parents who were most actively involved in acting 40 as advocates for their children, had been under prolonged, significant stress relative to medical problems and had re- ceived conflicting medical or educational diagnoses or rec- ommendations for their child previously. Some expressed that doctors were insensitive to this stress. Most believed their child had a problem long before doctors or school personnel acknowledged or confirmed it. These parents quickly con- tacted progranl supervisors in school settings both when pleased with their child's curriculum and support personnel and when there was any confusion or question about compli- ance with details of the child's Individual Education Plan. In health situations, these tended to be the parents who called doctors quickly when they suspected an illness might be starting. Some mothers stated explicitly that they were uncomfortable with some of their own actions, but felt they had to act this way to get the services their child needed. Paradoxically, another set of parents with experiences similar to the former group's comprised the majority of the opposite end of the involvement continuum, refraining from contact with school and medical personnel whenever possible. When they did meet with personnel, their involvement tended to be noticeably more passive than many other parents. In the hospital and ISD screenings, communication re- garding children's performance following initial referral was a problem. The hospital's clinic receives limited feed— back from schools and private agencies to which they refer 41 children for treatment, making it difficult for them to as- sess the appropriateness of the referrals and the outcomes for the children. Ingham ISD had difficulty obtaining parent consent for free follow-up medical evaluations on the chil- dren with abnormal audiometric findings. When they re- screened the following year, several of the same children were again found to have middle ear problems. Also, the ISD data is not organized in a way to permit progress checks on the children who "graduated" from the preprimary programs into other general and/or special ed programs. Historically, communication between schools and physi- cians has been limited and strained. Often it has been easi- est to have parents act as liaisons with clearly written information to be shared. Direct communication is preferable concerning observed behaviors in school, possible side ef- fects of medications, and manageable modifications in the school environment which may assist the child's perform- ance. A related problem occurs when the school and/or parents feel that a medical specialist's opinion is warranted and the primary care physician disagrees. The reasons for this vary, and often take time to resolve to the satisfaction of all involved parties. The pediatrician may be reticent to alarm parents, a reaction that may be anticipated with any referral to a specialist. The pediatrician may also feel that medical treatment of the problem or physical growth of 42 the child may yield resolution if given a longer period of time, and that an otolaryngologist might insert ventilating tubes prematurely. Some health professionals view the risks and problems of ventilating tubes to be greater than the risks and problems of otitis media. Project CHILD's survey of 310 Toledo physicians in- cluded a section on referral practices. Their responses in- dicated the following: TABLE 2 Project CHILD Survey of Physicians: Referral Criteria If a child has both a hearing problem and a language delay, do you refer to: Never Some Freq. No Resp. Child's School District 15.9% 18.5% 11.3% 54.3% Toledo Hrg/Speech Center 7.9 23.8 33.1 35.1 Toledo Public Schools 17.2 17.9 7.3 57.6 Other 1.3 9.3 27.2 62.3 Twenty-eight percent of the 159 respondents evaluate language development formally, with most using the Denver Developmental Screening Test. During the past two years, 51.7% had attended a continuing education program on otitis media, and 86% had read material on otitis media. Forty per- cent had changed their mode of therapy for otitis during this time. Forty percent reported using screening audiometry in their' office, and 14.6% reported using tympanometry. 43 15.9% reported no contact with school personnel about chil- dren at risk from otitis media, 34.4% very little contact, 25.8% some, 9.9% quite a bit, 2.6% a great deal, and 11.3% no response. In the presence of hearing impairment and lan- guage delay, most refer the child for some special service. (Project CHILD,1981) The information gathered represents a far more ambi- tious effort than most school districts have undertaken, but the utility of the findings is limited. Since there are no stated parameters of hearing impairment or language delay, it is not clear how severe a problem would have to be before a referral would occur. Responses wouLd be more meaningful if the source of referral concern (parent or doctor) were also disclosed. A 1983 study by the American Academy of Pediatrics re- viewed physicians' roles in planning programs for children with handicaps. Physicians' participation is school district Individualized Educational Planning(IEP) meetings is re- ducing according to a survey responded to by 216 pediatri- cians. The physicians' perceptions were that: Primary care physicians seem willing to assist with school related problems, however, few engage in serv- ices or methods of communication considered productive i.e.visiting classrooms, attending staffings. They generally would not mmdify their practices to permit more involvement even under ideal conditions. Primary' care physicians have little opportunity to contribute to IEP decisions directly. Only 55% had any contact with a school regarding a placement, and only 21% report being informed of an IEP before it oc- curred. Parents informed physicians of IEP placements twice as often as school personnel. 44 No consistent pattern of communication between physi- cians and school personnel exists across schools, and provision of medical information is incomplete. A standard communication mechanism was identified as the factor most likely to produce change. Primary care physicians have minimal contact with schools. 41% report no contact. Another 43% report communication about once a month. When the school re- quests medical expertise, it is generally sought from a specialist, with the primary care physician's com- pletion of the school physical form being seen gener- ally as the physician's chance to provide all the in- formation s/he can. The school nurse tends to value the physician's contributions more than other person- nel do. School personnel generally do not perceive primary care physicians as playing a large role in placement decisions, nor do they perceive it as their own role to inform physicians of placement decisions. The relationship that a school district develops with its local physicians seems to depend, in part, on the interest and availability the physicians. When they are responsive to the needs of the child and school, they may be used extensively. Based on the survey, the American Academy of Pediatrics rec- ommends that the school physical form be revised to include more opportunities for primary care physicians to provide input, and to let the physicians know that this may be their only mechanism for participating in IEP placement decisions. School districts should notify primary care physicians prior to IEPs, and they should include a request for additional relevant, medical information and an invitation to partici- pate in the IEP. Through continuing education, both school and medical personnel should be made aware of the potential value of a more systematic method of communication and some techniques for achieving this end. A variety of communication problems exist among 45 parents, teachers, and physicians concerning children with current or previous medical problems and children with learning problems. There are varying opinions about who has the authority to speak with whom about what subjects, in what degree of detail, and for what purposes. Frustration with the current situation has been expressed by many individuals involved, and some recommendations for change are surfacing. Medical Treatment of Otitis Media One way to improve communication among parents, teach- ers, and physicians is for the parents and teachers to have a better understanding of the medical condition, possible treatments, and what concerns physicians might have about certain treatments. Some cases of otitis media are self-limiting, require no medical or surgical intervention to resolve, and leave no residual effects. The treatment in infants can sometimes be as simple as explaining to parents the importance of holding the baby upright when feeding a bottle, rather than allowing it lie flat, making proper swallowing and drainage possible. Medications can include prophylactic and standard use of antibiotics over a longer period of time than the stan- dard course. Oral decongestants and/or antihistamines help relieve related upper respiratory congestion in many cases. In some situations, special diets, pneumococcal ‘vaccine, mucolytic agents to thin the middle ear fluid, nasal steroid inhalants, allergy avoidance programs or desensitization 46 series are prescribed. Sometimes myringotomies, incisions in the tympanic mem- branes, may be effective without the insertion of ventila- tion tubes. Occasionally this is done in combination with an adenoidectomy. In some cases however, insertion of ventila- tion tubes is the treatment of choice, typically after non- surgical interventions have failed. The concerns typically associated with tubes include the risks of general anesthe- sia, the daily difficulties of keeping water out of the ears during bathing, and the occasional problems of permanent damage to the tympanic membrane. The risk of the latter is usually considered to be less than the risk of damage from allowing the otitis media to continue unresolved. The risks to be considered across procedures include parent noncompliance with prescribed procedures, adverse reactions to drugs prescribed, stigma for the child from peers or adults, and the burden of financial costs to the families. In the recurrent cases of concern here, there is often a delay in medical treatment taking effect or surgical intervention being arranged even after diagnosis has occurred and treatment has begun. If parents and teachers know what to expect from physi- cians and the medical or surgical treatment provided, they can be more helpful in the child's care and providing the appropriate accommodations in school. METHODOLOGY Criteria for Selection of Subjects School. districts, buildings, and. personnel were se- lected in the Lansing area according to participating local district research guidelines and following staff member in— dications of willingness to participate. Twenty-five learn- ing disabled students in the Lansing area were selected ac- cording to the following criteria: A. 6,7,8 or 9 years of age B. Child and parents fluent in English C. Parent/guardian a biological relative of the child D. Singleton (not a twin...) E. No known significant stress in immediate family during three :months prior to this study: birth, major illness, separation, death F. Wechsler Intelligence Scale for Children--Revised (WISC-R) on file Children must be at least six years old to have the WISC-R administered, and this was to be the only consistent school performance indicator collected. Relatively few chil- dren are identified as being learning disabled before age seven, so the age range was set at four years in order to limit the number of participating school districts needed for the study. The English fluency requirement was adopted in order to minimize the number of variables affecting the 47 children's performance as well as to insure parent under- standing and correct completion of the Child Development Questionnaire. Only students living with a biological rela- tive were included in order to maximize the likelihood of the availability of complete family history information. 48 One set of twins was included after approval was re- ceived from two committee members. The reasons for origi- nally planning to exclude twins were A. Twins are generally born prematurely at very low birthweights, and are therefore considered to be neurologically at greater risk for learning problems. B. The second born(B) twin is generally considered to be particularly at risk for learning problems C. It seemed to the writer that it would be diffi- cult for parents to remember with accuracy per child some of the details requested in the child development form In this situation, the male fraternal twins' gestational ages were 42 weeks(normal term + 2 weeks), and their birth- weights were 61bs.13oz. and 71bs.0302. It was the A twin who was learning disabled, and the B twin was excelling academ- ically. Finally, the pediatrician serving the family from the time of the twins' birth was doing research on twins. As a result of this family's participation in that research, the mother had extremely detailed developmental records on both boys. The issue of family stress was based on a concern about overloading a family unnecessarily as well as a pragmatic question about whether a family with recent, major problems would comply with all aspects of the study with as much at- tention and accuracy as other participants. Twenty-five matched control subjects were selected from the same schools, who met criteria A-E above, had not been identified as handicapped at any time in the past, and par- alleled their learning disabled peer in the following ways: 49 A. Same sex B. Same race C. Birthdate within six months of peer's birthdate Sex, race, and age have been significant 'variables identified in some previous studies, so an attempt was made to control for these factors. Description of Subjects The students who participated in the project came from first through third. grade classrooms in nine: elementary buildings in three suburban school districts which ranged in enrollment from 1900 to 4300 K-12 students. Eight of the schools were public, and one was parochial. Fifteen boys and ten girls made up each group. There were 6 six year olds, 15 seven year olds, l4 eight year olds, and 15 nine year olds, with the mean age being 7.8 years. Forty-nine students were Caucasian, and one female, learning disabled child was His- panic. The Hispanic child and both of her parents were flu- ent in English. Both parents were professionals who have spent the majority of their lives in the United States and attended American schools. It was not possible to find a matched control for this child, so she was paired with a Caucasian female from the same school building, grade, and age group. Socioeconomic data was not gathered or considered, be- cause in some informal Effective Schools research conducted recently in one of the districts, three factors were iden- tified which reduced the usual predictive value of this type of data. 50 A. Given the large university community, there are many temporarily poor graduate students. B. There are many middle income automobile factory line workers with limited educational background. C. The recent, high Michigan unemployment rate has caused large numbers of professionals and others who are typically in middle or upper income brackets, either to be unemployed or employed in lower paying positions than they usually experience. Procedures for Selection of Subjects After receiving district administrative approval and speaking ‘with elementary' building principals, the ‘writer gave elementary special education teachers an outline of the project and asked them to send consent letters to the par- ents of all learning disabled children on their caseloads who met criteria A-F listed on page 47 (N=45). All students had been assessed by a multidisciplinary evaluation team including a school psychologist, special education teacher/ consultant, and classroom teacher at a minimum. As a part of this designation as learning disabled, the assessment in all cases included the use of multiple standardized instruments and a classroom observation. Mathematical formulas were not employed as the primary basis for determining learning disa- bility eligibility. Once the number of participating learn- ing disabled students was known, general education teachers were to assist in sending the control children's letters. The initial plan for selection of controls was to choose the first name following the learning disabled stu- dent's on the general education teacher's class list who met all the criteria. For a number of reasons this plan was not 51 manageable, and only a few consents were obtained. One par- ticipating district's research policies required that the parent consent letter had to include much more detail than the standard consent form requires. The same district did not allow researchers to ask teachers to call prospective family participants to explain the project informally before sending the letter. In order to maintain consistency in the project, comparable procedures were followed in each of the school districts. The letter may well have intimidated many parents. Another factor was the time of year. Since the audiolo- gist's services were not available until late May, the par- ents received the consent form at the same time that they were receiving' many announcements of year-end. activities related to graduation, parties, and so forth. The alternative plan established to acquire the re- maining control subjects included distributing a similar letter to 200 first, second, and third graders to be carried home for parent signature. This letter specified that the first consent forms received would be the ones included in the study. Twenty-six learning disabled students had signed up to participate. Twenty-seven controls signed up. One of those had a family emergency and 'had to be out of town during the time the audiological examinations were run. The other participated, but her data was not included in the analysis, when her matched learning disabled student failed to come to three audiological appointments scheduled for 52 her. Child Development Questionnaire The questionnaire completed by all families focused on the child's health and developmental history beginning with the mother's pregnancy. Items on the form were based pri- marily on a questionnaire developed by the Central Diag- nostic Team of the Ingham Intermediate School District. It was modified to focus on the particular areas of concern for this study. Other resources reviewed in arriving at the cur- rent form included questionnaires used by Sparrow Hospital's Developmental Assessment Clinic and Dr. James McLoughlin. Most responses were in "yes/ no" or "mark the appropriate number" form. Much of the in- formation requested was to provide descriptive information about the participating stu- dents: control vs. learning disabled, and low incidence oti- tis media vs. recurrent otitis media. The mothers' ages at time of this child's birth were recorded to provide information about high risk with mothers younger than eighteen or older than thirty-five. Similarly, pregnancy problems with the study child were reported. Birth histories were compared to the first 10 items on the fol- lowing list of high risk factors for neonatal intensive care unit graduates. 1) very low birthweight (<15009) 2) need for ventilator 3) birth asphyxia a)five minute Apgar of $6 b)need for resuscitation 4) bilirubin of 120mg 5) seizures 53 6) intracranial hemorrhage 7) failure to regain or maintain birth weight by 21 days of age 8) sepsis/meningitis 9) intrauterine growth retardation 10) <33weeks gestation 11) high risk social status 12) team member discretion (Mich Perinatal Association Developmental Assessment Task Force,l983 ) In the Health and Medical History section of the ques- tionnaire, frequencies of illnesses and other health prob- lems were reported as a reliability check for other reports of otitis and allergy history. They also served as a means of sorting the severity and effects of health problems. Be- cause the number of ear infections were reported as ranges in this study in order to accomodate reasonable limits of parent memory, exact totals could not be computed, but the criteria of at least six episodes in two years could be mea- sured. The lower number in each range was used in summing the total number per child over the years, producing a con- servative estimate of the reported incidence rate. Family history of developmental or chronic health prob- lems were reported, reflecting problems experienced by par- ents, siblings, aunts, uncles, cousins, and/or grandparents of the study child. To be counted, The problems had to be ones which began in childhood or with young adults and were chronic or recurrent in nature. They were included, because family patterns are prevalent for allergyp asthma, hearing loss, speech problems, sinus difficulties, and learning problems. The study children could be sorted according to 54 whether family history of these problems existed. Also, in families where a member had been identified in the past as having one of these problems, many parents become more at- tuned to early identification of the problem in other family members. The General Development section of the questionnaire was included to provide further information about allergies, activity patterns, and differential rates of language vs. motor development. The mean number of speech and language delays was the focus of that section rather than any spe- cific delay. Most of the items included here were taken from the Denver Develpmental Screening Test(DDST) with the crite- rion for delay being the age at which 90% of the children in the norm group showed skill mastery. A few items were se- lected from the Receptive-Expressive Emergent Language Scale (REEL). The items chosen were believed to be the ones par- ents would be most likely to remember. The question about difficult to understand speech was included to check on several reports that articulation is often less obviously affected by recurrent otitis media than is language development. Several other questions in that section looked at parent perceptions of problems sometimes associated with otitis media: problems finding the right word or expressing their ideas clearly, complaints about noise sensitivity, or difficulty understanding or remem- bering directions. An estimate of parent awareness of pos- sible hearing problems and their attempts to resolve the 55 issue in the past was the basis for the questions about spe- cial hearing tests beyond the regular public health school screening, and parent reported concerns about whether their child hears well. Relative to behavior and feelings, the mean number of concerns was the focus, primarily to provide descriptive information about the control and learning disabled young- sters. The mean number of motor development delays was com- pared to the number of speech and language delays to help identify differential rates of development in the otitis media group as well as with the learning disabled vs. con- trol groups. The items were taken from the DDST with the breaking point between normal and delayed being the age at which 90% of children in the norm group had mastered the skill. Parent assessments of their child's school performance were included to provide descriptive information about the control and learning disabled groups and to check for consis- tency of ratings across parent, classroom teacher, special education teacher, and student to evaluate whether these informal ratings could be considered reliable. Another reliability check in the study was the question as to whether parents completed the questionnaire from mem- ory alone, or whether they also referred to baby books, scrapbooks, health record booklets, and if they called their doctor's offices for verification. 56 Teacher Report The release of information form obtained from each par- ticipating family allowed the school to share with the re- searcher: l. The child's number of absences for each preceding year in school plus the current year's attendance to date, 2. The teacher's awareness of history of repeated mid- dle ear problems or allergy--and if the teacher be- lieved that either have been present, his/her belief about whether they currently affect school perform- ance 3. The teacher's rating of the child's activity level relative to other students 4. The listing of any areas of concern identified on the most recent report card The writer gave the teachers these forms and offered to assist in the completion of attendance data. The local spe- cial education teachers and principals in some buildings also assisted in form completion. Teacher responses to items 1-3 are covered in chapter four. The intent of the question about areas of weakness, was to have them report areas of concern great enough to warrant special notations on the formal report card. The question was open in format to allow inclusion of areas other than those in the learning disabil- ity definition and to compare with parent ratings. 57 Special Education Report The families of the learning disabled students were asked for permission to allow the special education teacher to share: 1. WISC-R scores 2. A brief rating form of the teacher's impressions of the child's current performance in each area considered in the learning disability definition 3. Age when child first identified as handicapped 4. Identification of any additional special school ser- vices received The WISC-R scores were requested, because they served as the only common, cognitive measure on file for the entire learning disabled group, and would help assess the school performance of the recurrent otitis media students relative to the group with minimal otitis media history. Also, they provided a fairly objective view of whether each student was within the normal range of intelligence. The teacher rating was an informal reliability check on school achievement re- lative to the ratings provided by parents, classroom teach- ers, and the students themselves. The age when subjects were first identified as handicapped provided an estimate of the severity of the handicapping condition, although the age would also be affected by individual parent, physician, and teacher sensitivity to developmental delays and differences, as well their feelings about what special education could offer the child. The final question was exploratory, with 58 the primary interest being in how many students received speech and language help, and whether significantly more of the recurrent otitis media students received that type of help than the other group. Only twenty of the twenty-five learning disabled stu- dents had WISC-Rs on file with scores available. One girl had the WISC-R administered, but only narrative information was available, no scores. The others had been tested with the Stanford—Binet(N=2), McCarthy Scales(N=l), or wechsler Preschool and Primary Scales(WPPSI)(N=l). One of the twenty students with a WISC-R was excluded from this analysis, be— cause it did not seem to his parents, teachers, or this wri- ter that the scores obtained a year ago were representative of his learning aptitude. He is a nine year old multiply handicapped child who just completed the first grade. He receives adapted physical education as well as speech and language therapy, and private psychological therapy. He takes Ritalin for Attention Deficit Disorder. Among the fif- ty children participating in the study he stood out as having markedly the highest activity level of all the young- sters. Both his verbal(59) and performance(61) scores were more than two standard deviations below the mean. According to most interpretations of the learning disability defini- tion, his would not be considered a primary LD pattern. The determination to exclude this child from the WISC-R analysis was made prior to review of his middle ear history. All other students had Full Scale summary scores above 70, and 59 16 had Full Scales above 85. The special educators rated each learning disabled child on each skill area identified in the federal defini- tion of learning disabilities. They used a three point scale: l=within normal limits, 2=slight weakness(SS 80-90), 3=significant weakness(SS<80). This system was used rather than recording specific scores on achievement tests for three reasons. First, a wide variety of tests are used for each of the key skill areas. The correlations among tests are low. Second, in a research project in the local area which concerned patterns of change in WISC-R scores, achievement tests were also reviewed. Many errors were de- tected in level of test administered, as well as determining raw and derived scores. Given that it was not possible in the current project to administer personally a specific achievement battery, it did not appear that scores on pre- viously given achievement test data would be appropriate. Third, test scores are not necessarily representative of how a learning disabled child performs in the mainstream in a given content area. The appropriateness of the given instru- ment as well as the child's test anxiety may affect the re— sults. Special education teachers were asked to rate the child's level of functioning considering the combination of test data and observation of daily performance. Summary results are listed in the appendix on a special education questionnaire. 60 Student Reports The final piece of data collected prior to the audio- logical examination was a student self-assessment of school performance completed. by the learning’ disabled students. The child's listening and picture survey included ratings in various school subjects and two locus of control questions. The smiling/frowning face format was chosen, because it is one familiar to the students. The sample exercises on the right side of the page provided an opportunity to verify the students' understanding, and to teach the symbols if neces- sary. The student ratings of their academic performance could then be compared to their parents' or special educa- tion teachers' ratings. An audio tape as well as a written script for administration was prepared by the writer and the local special education consultants administered the ques- tionnaire to their caseload students. Fisher Auditory Problems Checklist During the students' audiological assessment, parents completed the Fisher Auditory Problems Checklist with the writer. This list addresses parent perceptions about a child's (auditory' attention, comprehension, :memory, speech and language, response rate, and learning motivation. This was information the audiologist needed for data analysis and provided this writer with more reliability checks on atten- tion and speech and language to compare with responses on the Child Development Questionnaire. It also provided more descriptive data about all the subjects. 61 Audiological Evaluation During the students' testing, which generally required about forty-five minutes, a licensed audiologist evaluated peripheral hearing, middle ear status, and central auditory processing. Speech reception thresholds as well as puretone air and bone conduction threshold testing were administered in a double-walled audiometric sound suite with a Grason & Stadler 1701 diagnostic audiometer at the Michigan State University audiology clinic. Frequencies tested were 250Hz, 500Hz, 1000Hz, 2000Hz, 4000Hz, and 8000Hz. Impedance audiom- etry using a Teledyne bridge measured middle ear pressure and compliance. Because of equipment problems, the acoustic reflex testing was unreliable and is not reported. An oto— scopic examination checked ears for wax, ventilation tubes, and signs of infection or other pathology. Finally, a Speech Perception in Noise(SPIN) test as- sessed the students' speech reception in the presence of controlled background noises comparable to those encountered in the school setting. After a pilot study with the five students tested the first day, the remaining students were tested at a +10dB signal to noise(S/N) ratio. Forty scores were reported and analyzed, guaranteeing equal numbers of learning disabled and control student scores and equal num- ber of students taking form A first, form B first, compet- itor A first, and competitor B first. Scores were not re- ported for the multiply handicapped student whose WISC-R scores were excluded from the study. 62 Each student was administered two different fifty sen- tence tests, each paired with one of two competing messages and delivered monaurally to the right ear,using a JVC cas- sette tape player and headphones. The target sentences were presented at 60dBSL (lOdB louder than the student's speech reception threshold), and the competing messages were at 50dBSL. The student was asked to repeat the last word of each target sentence presented. An Advent cassette tape player delivered competing multi-talker(8) speech in 'one part of the test. In the other part the competitor was noise derived from and modulated by the speech competitor, but was void of semantic content. It retained the same spectral, amplitude, and temporal characteristics as the speech stimu- lus. In both parts of the test, there were two types of sen- tences, high and low' predictability. The ‘high predicta- bility sentences contained two or three pointer words which provided semantic links to the key word which the student had to repeat--e.g.”This key won't fit in the 1225.” The low predictability sentences contained IN) pointer words-— e.g.”They hope he heard about the £233". Sentence length did not exceed eight syllables. The two types of sentences were intermixed in each of two forms both containing twenty-five items of each type randomly intermixed.(E11iott,l979,p.651) Prior to beginning the scored exercise, the student spent as much time as necessary to complete correctly sample items to become accustomed to the task. The order of presentation of the two forms, the two competitors, and the pairing of 63 competitor with list was counterbalanced. Follow-Up Screening American ElectroMedics Corporation made a 95-A Screen- ing Audiometer/Tympanometer available to the writer to do follow-up screening of children who were found to have ab- normal hearing or middle ear function at the time of the audiological examination. It was also available to use with— in the participating schools for staff inservice and to test other students following parent consent. Forty individuals were tested. Four of the study children who went to their physicians for treatment following the initial examination, were retested and found to be within normal limits on two consecutive tests at two to four week intervals. Two study children waited for the retest to consult their physician. One was within normal limits. The other had more negative pressure than during the initial testing and went to the family doctor for treatment of what was then diagnosed as an ear infection. None of these students had complained of any pain or hearing problem when they had abnormal findings. The other people tested or their parents had concerns because of allergy problems, history of repeated otitis me- dia, or current symptoms of ear infection. A few indicated that because of the ready availability of the equipment that they would like to have their child checked. They had no plan to go to a physician prior to the test, but when l of the children had abnormal findings, he was taken to the doc- tor and treated medically for an ear infection. Among the 25 64 adults tested, one had abnormal middle ear status, and five had abnormal puretone thresholds(45dB, 35dB, 55dB, 65dB, 70dB). Only the person with the 65dB loss wore amplifica- tion. The others had suspected a loss and requested the testing, but did not follow up with diagnostic testing to the writer's knowledge. Most of the inservice included help- ing the teachers realize what impedance test felt like and what it measured. Also, they expressed that it was helpful for them to realize the sound levels that children with con- ductive losses are not able to hear. As a result of the ex- perience they expressed more concern about what they had previously considered to be negligible losses. ANALYSIS The findings relative to each of the nine hypotheses were prepared with technical assistance from the Statistical Package for the Social Sciences run on a Cyber 750 computer. This information is supplemented by some historical and de- scriptive data which helps place the findings in perspective relative to other populations. Research Hypothesis #1: Incidence of serous and acute otitis media among learning disabled students is higher than in the non-handicapped population. Statistical Hypothesis #1: Incidence rates of otitis media among learning disabled students are not significantly dif- ferent from those found in the non-handicapped population. Rates were compared among the learning disabled group, the control group and what is reported in the literature. Historical Information The number of ear infections per child which were diag- nosed by doctors reveal the following frequencies. TABLE 3 Frequency of Ear Infections infancy: 23 none 15 l or 2 _§ 3 or 4 _4 5 or 6 _l_>6 1-2 yrs: 23 none 11 l or 2 10 3 or 4 _§ 5 or 6 _l_>6 2-3 yrs: {28 none _1 l or 2 _g 3 or 4 _§ 5 or 6 _l_>6 3-4 yrs: 28 none 14 l or 2 _§ 3 or 4 _3 5 or 6 _Q_>6 4-5 yrs: 32 none 14 l or 2 _2 3 or 4 _l 5 or 6 _Q_?6 since 5: 31 none 13 l or 2 5 3 or 4 1 5 or 6 0 >6 65 66 Twelve students (24% of the study population) had no reported history of any ear infections. This parallels the incidence rates reported in the literature, which indicate that 75-90% of all children experience at least one ear in— fection by age ten. This data also follows the pattern gen- erally reported of peak incidence between one and three years of age. Beyond this, however, the rates in this study begin to diverge from rates reported for general pediatric populations. Thirty students (60% of the study population) experienced at least two occurrences as opposed to the 35-40% that would be expected. A liberal estimate of the percentage of children in the general population who experi- ence a total of six or more episodes would be 15%, but with this group the mean was six infections. Ten students, or 20% of the group, experienced between six and at least eleven infections, and another eleven students(22%) reported twelve to twenty-eight infections. For the purpose of further analysis, the group was sub- divided into low and high incidence groups, with the low incidence children (n=29) reporting no more than two infec- tions per year. This group's mean number of reported infec- tions was 1.7 per child. The high incidence group (n=21) included those with at least six infections during a two year period. Eleven of these received medical treatment. Ten were treated surgi- cally as well, with the insertion of ventilating tubes and/ or the removal of adenoids. The mean number of infections 67 for the second group was 12.6. Another helpful way to review the data is to look at the incidence rates per group during the first year of life. The low incidence group had seven (24%) who experienced one or two infections during the first year of life. In the high incidence group, however, there was only one infant free from ear infections, eight with one infection, and ten with at least three. One family could not recall the frequency during infancy, but the child was later included in the high incidence group based on the reported health history between one and three years of age. There is no statistically significant difference in recurrence between the learning disabled children in the study and the controls. The statistical test applied was a Chi-square at the .05 level. There were ten learning dis- abled and eleven control students in the high incidence. group. This 40% rate in both groups exceeds the findings of the Freeman learning disability study. Even if all twenty non-participating learning disabled students notified of the study had no history of otitis media, the incidence rate for a population of forty-five learning disabled students would still exceed the norm. Current Information The puretone thresholds at each of seven frequencies are reported for both the better(B) and worse(W) ear of each child. The average threshold in the speech range (500Hz to 2000Hz) were computed based on those results. There were 68 also evaluations of the speech reception thresholds and im- pedanee in each ear. The following table reports means in dBHL for each group--all fifty students, control vs. LD, and low vs. high incidence groups. The statistical test applied was an Analysis of Variance at the .05 level. TABLE 4 Current Audiometric Findings ___ Total T Otitis Fre- Mean Ctrl LD F p Low Recur F p quency (dBHL) (25) (25) (29) (21) 2508 9.5 7.4 11.6 5.91 .05 9.7 9.3 0.04 NS 250W 13.6 11.8 15.4 6.03 .05 12.9 14.5 1.04 NS 5003 7.6 _6.6 8.6 1.59 NS 6.2 9.5 4.50 .05 500W 12.3 11.2 .13.4 2.07 NS 10.9 14.3 5.20 .05 10008 4.9 3.4 6.4 2.34 NS 3.1 7.4 4.86 .05 1000W 8.6 7.3 9.1 1.88 NS 6.4 11.7 7.23 .01 2000B 2.8 2.4 3.2 0.60 NS 1.7 4.3 3.00 NS 2000W 7.2 7.2 7.4 0.07 NS 5.7 9.3 5.81 .05 4000B 3.5 2.6 4.4 1.04 NS 3.1 4.0 0.27 NS 4000W 8.2 7.0 9.4 1.71 NS 6.7 10.2 3.73 NS 80003 12.9 12.0 14.0 0.87 NS 10.7 16.0 5.28 .05 8000W 17.0 17.0 17.0 0.00 NS 13.6 21.7 11.4 .005 AvThrB 5.1 4.1 6.1 1.73 NS 3.7 7.1 5.55 .05 AvThrWl 9.4 8.5 10.3 1.59 ns 7.7 11.7 9.3 .005 SRTR 5.3 3.9 6.7 4.96 .05 4.9 5.9 0.54 NS SRTL 5.8 4.2 7.4 5.60 .05 4.7 7.4 3.82 NS ImpedR-39.8 -25.2 -54.4 2.29 NS -36.6 -44.3 0.15 NS Imped b48.l -32.4 -64.4 1.16 NS -53.4 -40.3 0.19 NS 69 At pure tone frequencies from 250Hz through 4000Hz and with speech reception, the learning disabled students had higher thresholds than the controls, but all of the differ- ences were less than the 5dB step size used in the testing. Some group differences between the low incidence group and high incidence groups are statistically significant, but only at 1000Hz and 8000Hz does the difference exceed the 5dB step size. The greatest discrepancies in scores occurred at the highest frequencies rather than the expected lower fre- quencies. The recurrent otitis media group showed some recov- ery at 2000 and 4000Hz. Almost all students tested within the normal range for hearing according to the American Speech and Hearing Association standards' of thresholds <25dB. The data on average thresholds was computed by aver- aging the speech frequency(500Hz, 1000Hz, and 2000Hz) thresholds for each ear, except in cases where the range of the three thresholds equalled or exceeded lSdB. In those cases, a standard audio- logical procedure was employed, dropping out the highest threshold and averaging the remain- ing two. A test was done comparing average thresholds to speech reception thresholds. It would be expected that these would be within lOdB of each other if there was good inter- nal test validity. Two learning disabled and no control stu— dents had ZlOdB discrepancies. The speech reception thresholds were statistically dif- ferent(p<.05) between the learning disabled group and the 70 control group. Again, the discrepancy was less than the 5dB criterion. The impedance data reveals six cases (12% of the study population) of active middle ear pathology. Only two right .ears had negative pressure gelsomm, and five left ears met the same criteria. One child had an open ventilating tube in the left ear which negated a valid impedance reading for that ear. His right ear had significant negative pressure and a dislodged or plugged ventilating tube. The vast major- ity of readings were within the normal range using -150mm as the cut-off point, and there was no significant difference across groups. As a result of participation in the study, four chil- dren were taken to their physicians for diagnosis and treat- ment of their middle ear status. Two had tubes inserted, and two were treated medically. None of these children had been expressing complaints about pain or poor hearing prior to the evaluation. One of the children who went on to surgery had been in the doctor's office two days prior to the audio- logical for a recheck on a respiratory infection, and at that time her ears looked all right, and the physician dis- continued her antibiotic. A pattern emerges indicating that relative to the means in Eagles' landmark study, members of both groups in the current study have slight conductive losses. After convert— ing the means in Eagles's study from the ASA(1951) scale used at the time he began his study, to the ANSI(1969) scale 71 used currently, a series of 2-tai1ed T-tests were run at each frequency tested to compare his population to the students in the current study. It was assumed that Eagles' results were representative of this age population nation— ally, given the size and diversity of the group members and the number of recent studies citing his work as a standard. TABLE 5 Audiometric Findings--Eagles vs. Current Population (N=50) Frequency Current Eagles T ‘Jp 2508 9.5d8 6.0dB 3.86 .001 250W 13.6 9.88 .001 5008 7.6 8.5 -0.80 NS 500W 12.3 4.92 .001 10008 4.9 6.3 -1.41 NS 1000W 8.6 2.23 .05 20008 2.8 5.0 -2.96 .01 2000W 7.2 0.77 NS 40008 3.5 3.5 0.00 NS 4000W 8.2 5.09 .001 80008 12.9 7.0 5.00 .001 8000W 17.0 7.73 .001 (Eagles,l967,p.37) The differences were significant for both ears at the .001 level for two frequencies, exceeding the 5dB step size at 250 and 800082. Given that Eagles established his means 72 by using the better ear of otoscopically normal children, and the worse ear of those with problems(Eagles,l967,p.10), those are probably the only statistics powerful enough to warrant attention. Eagles' finding that differences between mean or median hearing levels of all right and left ears were less than one d8.(Eagles,1963,p.85) was not shown in the current study. Because of the unusually high thresholds found at most frequencies, students were removed from the averaging pro- cess if they had thresholds greater than 10dB at the lower frequencies in combination with having significant negative middle ear pressure, since it is likely that a current in- fection or pressure problem was skewing the typical hearing threshold of those students. The following means were ob- tained. TABLE 6 Adjusted Current Audiometric Findings: Excluding Students with Active Otitis Total Otitis Fre- Mean Ctrl LD F p Low High F p guency (N=44) (22) (22) (25) (19) 2508 9.1 6.6 11.3 6.46 .05 9.3 8.9 0.03 NS 250W 13.3 11.4 15.0 5.27 .05 13.0 13.9 0.30 NS 5008 7.2 6.8 8.4 1.02 NS 5.6 9.7 6.25 .05 500W 11.9 10.9 13.0 1.47 NS 10.4 14.2 5.54 .05 10008 4.6 3.6 6.1 1.56 NS 3.0 6.9 3.73 NS 1000W 7.9 7.3 9.1 0.72 NS 5.6 11.4 8.08 .01 73 The adjustment changes the means slightly, but the pat- tern of significant differences remains essentially the same with the 100082 reading in the worse ear being the only one with a >5d8 discrepancy between the Low and High groups. There were no such splits between the controls and learning disabled youth. In summary, there was no significant difference between the reported incidence rates of recurrent middle ear prob- lems between learning disabled and control children in this population lending support to the null hypothesis. The dif- ferences, however, in hearing acuity noted at several fre- quency thresholds between the current study population and Eagles' population, as well as the retrospective parent re- ports of otitis media incidence rates relative to several studies, support that the learning disabled students in the current study appear to have greater problems with otitis media than does the population in general. This supports rejection of the null hypothesis. Research. Hypothesis #2: Among learning' disabled students with recurrent otitis media, defined as at least six occur- rences of otitis within two years, there is a higher than average incidence of reported allergy symptoms which may continue to affect school adversely after the otitis is re- solved. Statistical Hypothesis #2: Among learning disabled students with recurrent otitis, there is no significant difference from other learning disabled students in reported incidence 74 of allergy problems which may affect school adversely after the otitis is resolved. The reported incidence rates of allergy were computed for the learning disabled group, the control group, what is reported in the literature, and for children in families where one or both parents have a history of allergy. The expected incidence rate for allergy is 15% (Nation- al Institute of Allergies and Infectious Diseases) for the general population, and approximately 60% for individuals who have one or two parents with allergy problems. In this study, that would translate to eight of the fifty students being expected to experience allergy symptoms with some not developing problems until they became young adults. Some of those eight would experience insect sting or drug allergies, hives, gastrointestinal allergy symptoms and/or eczema. These cases, unless they occurred with respiratory symptoms as well were not considered in the current study focusing on respiratory problems. Fifteen students among the fifty total were reported to have allergies, and their parents also in— dicated these children have experienced two or more respira- tory' problems frequently’ associated. with. allergies. Five control and seven learning disabled students with allergy problems also had a recurrent otitis media history. Twelve of the fifteen allergic students came from families where at least one parent had a history of respiratory allergy, and there were eleven families where at least one parent has allergies, but the study child has no allergy problems to 75 date. The statistical test applied was a Chi-square proce- dure(df=l) at the .05 level. TABLE 7 Actual vs. Expected Allergy Incidence N Actual Expected x3 _p Total Group 50 15 7.5 8.82 .005 Control 25 5 3.75 0.49 NS LD 25 .10 3.75 12.26 .005 LD-Low Otitis 15 3 2.25 0.29 NS LD-High Otitis 10 7 1.5 23.72 .005 Parent Allergy 23 12 13.8 1 0.59 NS Among students reporting non-respiratory allergy symp- toms, seven reported histories of hives, eczema, and in some cases GI symptoms generally associated with allergy. Those individuals would have been counted as "allergic" in the national incidence figures bringing the total to twenty-two of fifty. Again this population appears to be atypical. In summary, among the learning disabled population, the incidence rate for allergy far exceeds the national av- erage, particularly for those children with a history of middle ear problems. This would support the rejection of the null hypothesis. Research Hypothesis #3: Learning disabled children with re- current otitis media exhibit greater verbal deficits rela- tive to their non-verbal performance than do other learning disabled children. 76 Statistical Hypothesis #3: Learning disabled children with a history of recurrent otitis media exhibit no significantly greater verbal deficits relative to their non-verbal perform— ance than do other learning disabled children. Within the LD population the profiles from the Wechsler Intelligence Scale for Children-Revised(WISC-R) were compared between the group with history of recurrent otitis media and those without that history. The following Analysis of Variance summarizes the findings. Since the sample size was too small to run a Multivariate Analysis of Variance, the test should be applied at the .01 level to reduce the probability of a Type 1 error in reviewing the five core verbal subtests. TABLE 8 WISC-R Performance: Learning Disabled Low vs. High Incidence Otitis Media Groups Mean N RangelLow N High N F P Information 7.6 I9 -1 9.1 11 5.6 8 8.39 .01 Similarities 10.4 19 2-19 12.2 11 8.0 8 7.84 .05 Arithmetic 9.2 19 5-14 9.0 11 9.4 8 0.10 NS Vocabulary 11.1 19 4-18 12.4 11 9.4 8 3.41 NS Comprehension 10.7 19 6-15 11.7 11 9.3 8 3.56 NS Digit Span 7.8 19 3-13 8.2 11 7.4 8 0.40 NS Picture Comple. 10.2 19 7-16 10.7 11 9.5 8 1.44 NS Picture Arrang. 11.1 19 4-18 11.7 11 10.1 8 1.10 NS Block Design 10.1 19 2-13 10.6 11 9.0 8 1.86 NS Object Assembly 10.5 18 3-17 11.0 11 9.7 7 0.76 NS Coding 8.9 17 4-15 8.5 10 9.6 7 0.54 NS Mazes 10.9 13 7-15 10.3 6 11.4 7 0.58 NS Verbal 98.4 75-124 104.8 89.5 6.10 .05 Performance 102.2 67-136 103.6 100.1 0.20 NS Perf - Verbal 9.1 -15 to 59 3.8 16.4 1.53 NS 77 The low incidence group had higher means than the high incidence group on the Verbal summary scale, on the Informa- tion subtest, and to a lesser extent on the Similarities subtest. The low incidence group demonstrated a greater fund of general information and stronger ability in systematic linguistic reasoning, two important skills for school success. These students also exceeded the high incidence group on the mean difference score of Performance - Verbal: however, the standard deviation there was 1arge(22.3), and the difference did not reach the .05 level of significance. According to a study of significant verbal/performance discrepancies for children in this age group, eight students of the nineteen had discrepancies greater than twelve points, which is significant at the .05 level when compared to the general population of six to nine year olds. Three of these students had discrepancies greater than sixteen points, which are considered to be significant at the .01 level.(Piotrowski and Grubbs,1976) The two children with the greatest discrepancies(24 and 59 points) were both members of the high incidence group. The comparison of the profiles of the two learning dis- abled subgroups in this study as well as the comparison of verbal/performance discrepancy in the literature supports rejection of the null hypothesis. Research Hypothesis #4: More learning disabled children with recurrent otitis media experience difficulty attending to 78 task than other learning disabled children. Statistical Hypothesis #4: There is no significant differ— ence in attention to task between learning disabled children with a history of otitis media and those without that health problem. Reported concerns about student attention to task were compared across the controls and two learning disabled groups. A Chi-square(df=l) was applied at the .05 level based on teacher ratings and then separately, based on par- ent ratings. Teachers reported no attention problems among the con- trol subjects and six with the learning disabled students. Two of those students were in the low incidence group and four in the recurrent otitis group. No attention difficul- ties were noted for six learning disabled students who had otitis media history. A Chi-square(df=1) based on teacher ratings showed rm) statistically significant difference be- tween the low and high incidence groups. Parents of learning disabled children were more severe in their ratings of their child's attention. Parents were asked in the Child Development Form and in the Fisher Check- list about attention problems. In all twenty-five cases par- ents marked the same responses on both questions. When these were compared to teacher ratings, marked differences ap- peared. There was agreement in fourteen cases(9 no's and 5 yes'). One teacher identified a problem when a parent had not, and ten parents identified a problem when teachers had 79 not. Because of the varied perceptions, the Chi-square anal- ysis of parent reports is questionable in its accuracy. TABLE 9 Attention to Task: Parent Reports about Learning Disabled Children (N=25) Low Incidence OM High Incidence OM Attention OK 7 3 Attention Problem 8 7 There was run statistically significant difference be- tween the two groups. It should be noted, however, that 70% of the high incidence students vs. 53% of the low incidence students were considered by their parents to have attention problems. There is not enough substantive and consistent evidence to reject the null hypothesis. Research Hypothesis #5: A higher percentage of learning dis- abled children with history of recurrent otitis media expe- rience abnormally high or low activity levels than their learning disabled peers. Statistical Hypothesis #5: Learning disabled children with histories of recurrent otitis media experience abnormally high or low activity levels at a rate not significantly dif- ferent from their learning disabled peers. Both parents and teachers were asked to rate activity level. The groups rated the children quite differently again, making the reliability of the data questionable. 80 TABLE 10 Parent Report of LD Student Activity Level r Low OM High OM Normal Activity 9 2 (11) High Activity 6 4 (10) Low Activity 0 4 ( 4) TABLE 11 Teacher Report of LD Student Activity Level Low OM High OM Normal Activity 3 3 ( 6) High Activity 5 2 ( 7) Low Activity 7 5 (12) When the two abnormal activity levels are combined to collapse the empty cell in the parent report of unusually low activity level, the null hypothesis is supported. There are no significant differences applying a Chi-square at the .05 level between the low and high incidence groups as re- ported by parents or teachers. Two patterns emerge, however. 1) According to parents, 40% of the low incidence group has abnormal activity levels, while 80% of the high incidence group are placed in that category. 2) There is more agree- ment between parent and teacher groups among the ratings for the high incidence group. Research Hypothesis #6: Children with recurrent otitis media instruction miss more school, hence more opportunity for than most students. 81 Statistical Hypothesis #6: Children with recurrent otitis media miss an average number of school days per year and hence an opportunity for instruction not significantly dif- ferent from others in the population. The number of absences on file from each preceding school year and the current school year were totalled and averaged for each group, and then compared to the average number of absences per year among the total grade 1—3 popu- lation of one of the participating districts. The statis- tical test applied was a 2-tailed T-Test at the .05 level (df=20). TABLE 1 2 Average Number of Absences per Year per Child Group N #Days Low Otitis 29 7.22 Recurrent Otitis 21 9.76 Total Group 49 8.44 District-Wide Average 6.99 The number of absences is near the district average for the low incidence otitis media group. The recurrent otitis group 'was statistically' significantly' different from. the district population (T=2.23), which supports rejection of the null hypothesis. Research Hypothesis #7: Learning disabled children with a history of recurrent otitis are more likely to perceive an external locus of control for their school progress than are 82 other learning disabled children of similar ages. Statistical Hypothesis #7: Learning disabled children with a history of recurrent otitis are not likely to perceive a locus of control significantly different from other learning disabled children of similar ages. The children's beliefs about who is responsible for their school successes and failures were reported on the "My School WOrk Questionnaire". Twenty-four students completed the inventory. A Chi-square test was applied(df=2) at the .05 level. TABLE 1 3 Locus of Control: Learning Disabled Low vs. High Incidence Otitis Media Groups Attribution of Success/Failure Low Recurrent Child Success/Child Failure 4 1 Child Success/Adult Failure 2 2 Adult Success/Child Failure 5 4 Adult Success/Adult Failure 3 3 No statistically significant difference appeared. The most frequent rating for both groups was that adults were responsible for the students' good work, and the students themselves were responsible for their poor performance. This supports the null hypothesis. This contrasts in mood mark- edly from the responses about the students' perceptions of their own performance in various areas of the curriculum. The majority recorded that they were doing all right in 83 their work, frequently rating themselves higher than their parents, special education teachers, or classroom teachers- -but possibly feeling that this progress was largely depend- ent on the help they received rather than their own capa- bilities. Research Hypothesis #8: Most teachers working with young children suspected of being learning disabled do not rou- tinely consider the possibility of a history of otitis media contributing to the students' learning problems. Statistical Hypothesis #8: Most teachers responsible for working with young children suspected of being learning dis- abled are not aware of history of recurrent otitis media which may contribute to the students' learning problems. The frequency with which teachers coded the same re- sponse as did the parents about the presence or absence of otitis media was compared as well as the teachers' beliefs about whether these problems affected these children's school performance. TABLE 14 Teacher Awareness of Otitis Media Among Their Students Control Lmnisahled Actual recurrent otitis 11 10 Teachers aware of recurrent otitis 5 3 Teachers see effect of recurrent otitis 1“?" 2 Among the forty-five teachers who responded to the 84 . question about whether they felt the student's performance might be adversely affected by recurrent otitis, the fol- lowing pattern emerged. The teachers of twenty-five children agreed with parent reports and felt this health factor has not been a problem for the child. The teachers of thirteen children stated that they were not aware of the presence of the health problem, although according (x) parent reports, these youngsters had recurrent otitis media. In two of these cases the teachers believed that only allergies were a prob- lem for the children. The five children reported by teachers as having many ear infections were consistent with parent reports is questionable in its accuracy. This information supports rejection of the null hypothesis. Research Hypothesis #9: Parents of learning disabled chil- dren with a history of recurrent otitis are likely to per- ceive themselves or be perceived by school personnel as dif- ferent in 'the frequency’ of their interaction with 'their child's teachers. Statistical Hypothesis #9: Parents of learning disabled children with a history of recurrent otitis media do not perceive themselves nor are they perceived by school person- nel as being significantly different in the frequency of their interaction with their child's teachers. Parent and teacher perceptions of parent involvement in their child's school program were compared between the two learning disabled groups. As a reliability check, a Spearman Correlation Coefficient was used to compare teacher vs. 85 parent rating of contact frequency for all forty-three stu- dents whose teachers completed the form. Its level of sig- nificance was .002, with parent/teacher agreement occurring about half the time. TABLE 15 Comparison of Parent and Teacher Reports of Home/School Communication Frequency Parent Report of Contact Frequency 1—3 4-6 >6 Teacher Report l-3 9 4 l of Parent Contact 4-6 4 7 7 Frequency >6 2 3 6 no report 1 2 1 Given the limited consistency among responses, the learning disabled group's were sorted by otitis incidence, but the results were not weighed heavily. The Chi-square (df=2) was not significant for parent or teacher reports which supports acceptance of the null hypothesis. TABLE 16 Home[School Communication for Learning Disabled Population Contacts/Yr. Parent Report Teacher Report Low Recurrent OM Low Recurrent OM 1-3 . 3 4 5 2 4-6 6 2 7 5 >6 6 3 3 3 86 This data supports the null hypothesis. There is no evidence that parents of children with histories of recur— rent otitis media communicate with school with different frequency than other parents. Speech Perception in Noise Testing These results are part of the audiologist's research, but seemed appropriate to report here, so that the findings could be considered along with the other results. The sta- tistical test applied was an Analysis of Variance applied at the .05 level. TABLE 17 Speech Perception in Noise Compe- Predicta- Mean Ctrl LD 95%Confid. F g p titor bility (N=40) Interval Speech High 85.6 90.6 80.6 81.9-88.9 8.65 .01 Low 61.9 62.7 61.2 58.5-67.2 0.10 NS Noise High 91.0 93.5 88.4 88.7-93.3 4.38 .05 Low 73.2 77.9 68.6 69.8-77.3 5.93 .05 Students did best on high predictability sentences with a noise competitor and worst on low predictability sentences with a speech competitor. In general, group performance im- proved on high predictability items during the second half of each test and became less accurate on the low predicta- bility items. The only exception was on the noise competi- tor/low predictability items for the control group. The 87 skill in which the learning disabled students' performance was weaker than the controls' at a .01 level was perception of high predictability sentences with a: speech competitor. It appears that it took the learning disabled group longer to become acclimated to that auditory environment, and that their performance became more like that of their peers as they had more practice. There was a statistically signifi- cant difference at the .05 level between the learning dis- abled and control students on the high and low predictabil- ity sentences with a noise competitor. In contrast, the learning disabled group performed similarly to the controls on low predictability sentences with a speech competitor. These observations are preliminary and would need to be con- firmed in a future study. Error patterns informally observed among learning dis- bled youngsters were substitutions of vowels, unvoiced con- sonants, B's and D's, M's and N's, D's and T's. These are among the more common decoding and spelling errors among learning disabled students. SUMMARY AND CONCLUS IONS Summary of Research Problem, Method, and Findings The purpose of this research was to study the relation- ship between recurrent otitis media during early childhood and various aspects of elementary school performance by learning disabled children. Parents, general education teachers, and special education teacher/consultants provided developmental information, current performance ratings, and recent test scores. The children completed self-rating scales and received diagnostic audiological examinations. The major findings of the study follow. 1. The incidence rates of recurrent otitis media for this population of learning disabled students were significantly higher than the rates reported in the literature. 2. Learning disabled students with recurrent otitis media had a significantly higher incidence of allergy than other learning disabled students and the control population. The other groups experienced incidence rates comparable to rates reported in the literature. Twelve students (five control and seven learning disabled) had histories of both recurrent otitis and respiratory allergy. 3. Learning disabled students with recurrent otitis media received significantly lower verbal scores on the WISC-R relative to learning disabled students with minimal otitis media history. This was particularly evident on the Informa- tion subtest. The scores on the Performance half of the test 88 89 were similar between the two groups. 4. While the learning disabled group as a whole had many more problems with attention to task than the control group, there was no significant difference in this skill between the two learning disabled subgroups. 5. No significant differences were found between the two learning disabled subgroups in frequency of abnormally high or low activity levels. 6. The learning disabled students with a recurrent history of otitis media missed significantly more school than their learning disabled peers or the general school population. 7. Learning disabled students with high and low incidence histories of otitis media responded similarly to a locus of control questionnaire. The majority saw adults as primarily responsible for their school successes (63%) and themselves responsible for their poor school performance (58%). 8. Classroom teachers were not aware of otitis history for most of the students who had recurrent episodes, and there- fore did not take this information into consideration when evaluating these students' learning problems. 9. Parents of learning disabled students with high and low incidence otitis histories communicated with teachers with similar frequency. Limitations of the Study One limitation of the study was the small sample size. Several changes in procedure might have increased the number of participants. 90 1. Time of year--Se1ect a month when fewer family so- cial obligations would compete with the audiological ap- pointment time. 2. Time of day--If the audiology clinic were available during school hours, the resource room groups and possibly control classrooms of participants could be provided with transportation and a classroom on campus for the day. Two students at a time could be tested while class was conducted as usual in the same building. Someone from the audiology and speech department might do a presentation to the class for one-half to one hour about hearing and language which could tie in with curriculum units on health or communica- tion. Also, a tour of the special facilities in Michigan State University's Communication Arts building could be pro- vided. This plan would relieve parents of time and transpor- tation obligations, encouraging more families to partici- pate. 3. Choice of districts--Select only districts or build- ings who have investment in the project. This would facili— tate positive communication and cooperation from the fam- ilies. 4. Reliance on others' WISC-R testing--If a psycholo- gist were part of the research team, WISC-Rs could be of- fered to families whose child had been given a different intelligence test. About fifteen students who might have participated were not asked to, because they only had McCar- thy, WPPSI, or Stanford-Binet tests on file. Some of the 91 participants actually should not have been selected, because they did not have a WISC-R on file, but their special educa- tion teacher/consultants had not realized that when they invited the family to partipate. The second problem with the study was the atypical con- trol group. The group's incidence rates of otitis media were higher than average which may mean that the dichotomy be- tween the high and low incidence groups for ratings of ab- sences, attention, (activity' level, allergyy parent-school communication, and verbal-performance discrepancy may not have been as significant as it would have been with a more normal control group. A possible composite explanation of this was gathered from the writer's conversations with the fifty sets of parents at the time of the audiological exams. Many families of the learning disabled children chose to participate in the study, because they wanted to rule out the possibility of a hearing loss contributing to their child's learning problems. Among the control children, where the students were, on the whole, performing successfully in school, parents commented about this being an opportunity to find out if earlier perforations of eardrums during infec- tions were still affecting their children's hearing, if ven- tilating tubes were still in place, if previous failures on school hearing tests were significant, or generally if their repeated concerns about middle ear problems could now be put to rest. A few families said that they participated because they believed that the experience would be interesting to 92 their children or they were doing it as a favor to the re- searcher. The majority, however, had concerns about repeated and/or severe ear infections. Possibly some of the proce- dures suggested in the previous paragraph would alleviate this problem. A third limitation in the research was design of the questionnaires. There was much inconsistency between teacher and parent ratings of school-home communication and chil- dren's attention skills, academic skills and activity lev- els. More clearly structured checklists indicating frequency and severity of given behaviors would probably have reduced the inconsistency. The researchers could also administer uniform achievement tests and language tests to provide ad- ditional standardized data for analysis. Fourth, the acoustic reflex testing was not usable be- cause of equipment problems. This data would have been a valuable indicator of the presence of otitis media. Children who showed an absent reflex should have been rechecked on a back-up machine for confirmation. Also related to the audio— logical assessment, apparently there is some difficulty maintaining exact equipment calibration at 800082, and testing at 600082 might have provided more valid data. Fifth, the population was fairly homogeneous. Partici— pation was on a voluntary basis by students readily avail- able to the researcher, which makes it impossible to gener- alize the results beyond the participants and the limited, geographic area. All but one student was white, making it 93 difficult to generalize the findings to non-white students. This is significant, because the literature typically re- ports differential incidence rates per race. What is unclear in the literature is the different weight to be assigned to race as opposed to socioeconomic status. Although socioeco— nomic data was not formally gathered, there was a range. Some of the children came from families where one or both parents were professionals with one or more college degrees. Others were from families where at least one parent had a maximum educational experience of a high school diploma. Nothing is known about many of the families' economic sta- tus, and this data would have helped to determine applica- bility of the results to other populations. Sixth, the audiologist knew which students were learn- ing disabled and which were controls when he tested them. The results might. have ‘been. different. if he had tested blind. Conclusions The incidence of recurrent, early childhood otitis me- dia and allergy are higher than average in the suburban Lansing area among white children who are identified by third grade as being learning disabled. This learning disabled group with a history of recur- rent otitis media had lower than average verbal ability as measured on the WISC—R which corresponds to difficulty with language tasks in the early elementary curriculum. Looking at the test profiles from two of the learning disabled 94 students excluded from the analysis in chapter four provides additional support for the discrepancy pattern. The WPPSI scores for the child in the high incidence group show the following: Information=5, Similarities=4, Verbal=67, Per- formance=103, Performance - Verbal=36. His performance fol- lows the pattern observed in this study, although the data cannot be cmossed statistically. The narrative information for the student in the high incidence group who took the WISC-R reported a Performance score more than two standard deviations above the Verbal score. The Bannatyne and Kaufman Recategorization scores are often used by psychologists as another way to sort subtests to identify learning strengths and weaknesses as a baseline for developing educational plans. It would seem that their clusters which included subtests from the Verbal portion of the WISC-R might provide additional patters of difference between the low and high incidence otitis media groups. The results from this study are presented in Appendix I. These patterns can be formally tested in the future. It appears that the greatest difference between low and high incidence otitis student scores occurs on tests which assess knowledge which young children learn primarily by listening. The least difference occurs with concepts and skills that young chil- dren often learn with greater visual and tactile influence. Also, the less the students with recurrent otitis media have to describe in their own words, the closer their performance is to the low incidence students. 95 From observing some of the students' facial expressions during testing, it appeared that the learning disabled group encountered more unfamiliar vocabulary in the sentences than did the control group. These observations were informal and very tentative, but suggest that in a future study the stu— dents should be asked to complete some additional tasks with the SPIN material for analysis: (1) decode from print, (2) demonstrate vocabulary comprehension, and (3) spell the words missed on the listening skills tasks. The language skill difficulty is compounded for many of these children who need as much instructional time as pos- sible during the school day. Because of high absenteeism, they receive less instructional time than most of their classmates. Compared to their non-handicapped peers, learn- ing disabled students as a group also make less effective use of the instructional time available because of diffi- culty attending to task and unusually high or low activity levels. Many of the learning disabled youngsters have hearing which is slightly less acute than most children's. This may reduce their ability to hear correctly the instruction pro- vided, particularly if the classroom acoustics are poor. Many of the allergic students take medications regularly, and parents reported that there seems to be a relationship between the administration of medication and the activity level and concentration skills observed. The findings do not imply a causal link between otitis 96 media and school problems. The eleven control children with history of recurrent otitis media were performing satisfac- torily in school according to teacher and parent reports. There is evidence in the literature that one or more biolog- ical or environmental elements common to both conditions caused or worsened the course of both the otitis media and school performance. One possibility relates to the differ— ences in number of newborn risk factors between the control and learning disabled groups. The need for and use of cer- tain medications, respiratory support, etc, have been linked to recurrent middle ear problems and hearing losses. A few of the learning disabled had multiple problems at birth-— e.g.low gestational age, low birthweight, and need for res- piratory support. The same general problem may have simulta- neously affected hearing, cognition, motor skills, and so on. With a child at high risk for school problems, the his- tory of otitis is likely to compound the degree of diffi- culty experienced. Support for that exists in the literature and within this study. Another possible factor relative to the audiological findings concerns self confidence among learning disabled youth and willingness to risk responding to the audiologist before being absolutely certain of the accuracy of re- sponses. Although the learning disabled students in this study seemed fairly positive in their self assessments on "My School Work”, it would not be unusual for students with this handicap to hold back in responding to a barely audible 97 sound until they were clearly certain of the accuracy of their responses. A third possible explanation for the differences be- tween the performance of control and learning disabled stu- dents relates to the severity of the otitis media. Among the recurrent otitis media students only three of the control students had ventilating tubes inserted at some time, while seven of the learning disabled students had the surgery. This may be an indication of the physicians' beliefs that the risks of permanent hearing loss, auditory perception problems, or language difficulties outweighed the risks of general anesthesia and possible permanent tympanic membrane damage as a result of the surgical procedure. Implications By considering only maternal pregnancy risk factors, newborn risk factors, and history of family learning prob- lems, seventeen of the learning disabled students could have been predicted at birth to develop learning problems, and three control students would have been incorrectly placed in the learning disabled group. By two years of age, the abil- ity to predict or identify correctly learning disabilities in the study population would increase, particularly with respect to language development. If a child were found to be at high risk for learning disabilities, were language de- layed and had recurrent otitis media at age two, it would be judicious to consider offering service to that child and his parents through special education prior to age three. It 98 would be wise from appropriate identification, cost of ser- vice, and treatment outcome perspectives to be more aggres- sive in child find activities for certain high risk children between the ages of eighteen months and three years. Also, it might be wise to include puretone audiometric and impe- dance testing as part of all initial preschool and early el- ementary referral evaluations where there is both language delay and history of otitis media. If the service were ac- cepted, the effectiveness of early intervention could then be studied prospectively to validate the retrospective find- ings of this and other studies. A first step would be to as- sure that the parents of all referred students are at least asked if there was a history of otitis media. Finally if a student's learning is found to be impeded by a previous or continuing mild hearing loss, there would be implications for the type of intervention and the training of assigned specialists who would be most appropriate to further this child's development. For this to occur there would need to be improved com- munication among parents, schools and the medical community. It would be worthwhile to help staff members understand bet- ter the history of some parents' experiences and frustra- tions concerning their handicapped child as well as some of the medical information. Also, increased communication be- tween school and medical personnel could benefit some of the learning disabled children with recurrent otitis media if physicians and teachers knew specifically' what kinds of 99 information would be beneficial to exchange and had a mutu- ally acceptable way to exchange it. Handicapped children often represent medical failures to the medical community, affectively although not usually in fact. This often makes it particularly difficult for some physicians to deal with referral issues. Physicians, how- ever, would be among the most appropriate special education referral agents for most of these children. A first step could be to encourage physicians to display in their of- fices, brochures and. posters about early' identification. Specific referral criteria would need to ‘be identified, strategies for communicating the language development con- cerns offered, and different service models explored to find ones acceptable to the local community which were education- ally effective . Youngsters being followed by developmental assessment clinics(DAC) following neonatal intensive care unit(NICU) hospitalization receive thorough evaluations including impe- dance audiometry in many clinics and developmental testing which would. permit appropriate referrals if the: clinics could be convinced that beneficial service would be forth- coming. Another quality of DACs and other early identification services is that they often have the effect of increasing parent awareness of their child's developmental strengths and weaknesses and revitalize parent energy to foster the child's further development. 100 Early Intervention Some commonly discussed problems with early identifica- tion of mild handicaps, in addition to poor communication between professionals involved, include questionable eligi- bility criteria and ways to assess them, risk to parent— child attachment, and the risk of providing a diagnosis with no follow-up service. The most liberal special education preprimary rule comes from Maryland (Chap.22 8-401 and 8-413). Services are available to "handicapped children under the age of 6 l) with a physical, mental, or emotional impairment that, in the judgment of the Department, makes a spe- cial educational and training program necessary or de- sirable to help the child reach a scholastic achieve- ment as near normal as feasible 2) includes a child who suffers from a mild, moderate, severe, or profound hearing loss" Handicapped person is defined as "child who has been determined through appropriate as- sessment as having temporary or longterm special edu- cational needs arising from cognitive, emotional, or physical factors,...and whose ability to meet general education objectives is impaired to a degree whereby the services available in the general education pro- gram are inadequate in preparing one to achieve his educational potential." Maryland has a specific special education category labelled ”child in need of assessment." Frankenburg identifies eight reasons supporting early intervention.(l981,p.8) 1. Early experiences affect all areas of development. 2. Environmental experiences modify the consequences of perinatal distress. 3. There may be early critical periods for the devel- opment of certain skills. 4. Lack of early stimulation can lead to atrophy of lOl sensory abilities and developmental regression. 5. Failure to remediate a handicap can produce secon- dary deficits (emotional/social) 6. When recognition of a handicap is delayed, cognitive gaps between a delayed child and other children widen over time. 7. Parents need support and special instructions for raising a handicapped child. 8. Early intervention should be evaluated on the basis of reducing the effects of a handicapping condition, not on dramatically curing the condition. While these were written for a broad range of handicaps, each one of them applies to children who become labelled as learning disabled who also experience early, recurrent oti- tis media. The dollar implication of these issues is that it costs less in the long run to begin intervention as soon as (1) an appropriate diagnosis can be made and (2) the child can benefit from a service. The Wabash and Ohio Valley Special Education District in Illinois annualLy does mass screenings, which includes tympanometry of zero to five year old youngsters in their nine county area. Eight to ten percent of the children tested fail the screening and are rescreened and/or referred for medical follow-up. A Michigan project in its early stages may help with early, more accurate prediction of mild handicaps. A state- wide organization of Developmental Assessment Clinic teams are following graduates of NICUs. Uniform types of data re- garding the initial hospitalization will be collected and then compared to child outcomes on standardized measures at uniform marker ages. Unfortunately, it will be several years before much school data will be available for analysis. 102 A practice already common in Michigan is for the local public health department to offer audiometric screenings for preschool siblings of school age children. A few weeks be- fore the school screening is scheduled a note is sent home with the school children offering the additional service at no charge. The parent needs only to make a local phone call or return a letter to confirm an appointment. More children with mild conductive losses might be detected if the letter from the school or from the public health department recom- mended strongly that children with language delays (samples to be specified) and history of repeated otitis media be brought in for testing. Including tympanometry would also assist with the accuracy of preschool identification of re- current otitis media. Headstart is required to attempt to have 10% of its population be handicapped individuals. Developmental kinder~ gartens also include a higher than average percentage of handicapped and academically high risk children. More ag- gressive otitis casefinding with this group would be likely to identify many children in need of medical treatment for and educational service related to recurrent otitis media. In Toledo's Project CHILD, clear entrance criteria fa- cilitate program evaluation. Children must have no evidence of sensorineural hearing loss. Their language must be at least one standard deviation below chronological age on the Sequenced Inventory of Communication Development (SICD), but other areas of development must not be more than six months 103 below chronological age. Clear parameters exist for audio- logical evidence of conductive hearing loss, middle ear fluid or abnormal middle ear pressure which must be present as well. There must be medical confirmation of treatment for serous otitis media, ruptured eardrum, chronic upper respi- ratory infection(URI), or allergy. Parent reports must indi- cate problems with draining ears, tugging at ears, earaches, chronic URI, inconsistent hearing, or other behaviors asso- ciated with otitis media. Fifty children are enrolled. The program objectives bridge medical, developmental and educational concerns. 1. Preschool children handicapped by the effects of recurrent otitis media will demonstrate measurable improvements in speech and language skills. 2. Children with otitis media will receive appropriate medical care through community medical resources. 3. Parents of enrolled children will demonstrate un- derstanding of their child's medical and develop- mental language needs by providing appropriate home language stimulation and using community medical resources. 4. An interagency agreement will provide for the con- tinuation of medical, educational and parent training services for the target population on an interdisci- plinary basis. Following comprehensive assessment of the children's medical status and language and intellectual functioning, profes- sionals work with the children on a language curriculum. This curriculum is shared with the parents for home rein- forcement and with preschool teachers in the community to foster improved language skill development across a broader population. Parents meet in groups and have access to a toy lending library and information about otitis media and other 104 handicapping conditions. Bi-weekly impedance testing mon- itors middle ear status, and medical referrals are made as needed. Parents are encouraged to seek second opinions. A few students receive amplification. One component of their outreach efforts is that kindergarten teachers who partici- pate in project inservices can then refer students to the project for impedance and pure tone screening. School-Age Children Some school age children with otitis history continue to have mild, undetected otitis media which are likely to impede their effective use of instruction. In most districts the audiological screenings available include only puretone testing and assess only three speech frequencies. Because most otitis media is treatable, it would be to the chil- dren's advantage to add impedance and acoustic reflex test- ing to the screening at least for those students with know otitis media history and those experiencing learning prob- lems. Teachers should receive inservice about the diagnostic procedures and the implications of otitis media. For school age children with history of language delay or otitis media who are referred for learning disability assessments, it should be routine procedure to include a speech and language therapist on the multidisciplinary eval- uation team. A diagnostic audiological examination should be completed including central auditory processing testing. Special education teachers would need inservice on the in- terpretation and application of the results. Many of the 105 language problems detected are subtle and not obvious to those not trained to look for them, but even these minor problems can have significant impact on a child's ability to make effective use of the instruction offered in general education classes. For any school age children with recurrent otitis media, a variety of options should be explored to improve the classroom acoustic environment and the teacher's sensi- tivity to problems the students were likely to experience. Some strategies commonly suggested in the literature are l. Preferential seating: near the sound source . Focus child's attention before speaking . Use overhead projections Face the student when speaking to the class . Avoid standing in the glare of a window 0“.”th 0 Speak clearly at reasonable rate without over- enunciating 7. Provide multi-sensory learning opportunities Minimize the noise level in the classroom 9. Avoid a strictly phonetic approach to reading 10. Minimize extraneous motor activities during speech ll. Minimize expectations for writing while student is to be listening 12. Review known material while making transitions to new material 13. Use buddy system for extra help 14. Record instructions on tape for repeated listening 15. Use simple vocabulary 16. Use advance organizers so students know key points to listen for 17. Be positive, but realistic in grading. Specific language remediation techniques available to 106 the regular classroom teacher supplement those. For exam- ple, the teacher should. speak using language 'within the child's expressive ability to describe what the child is doing or will be asked to do. Restate the child's responses in grammatically correct form, as a reaffirmation of his or her idea rather than a correction of the grammar. Model new language structures maintaining the child's ideas, such as combining three brief sentences into one complex sentence. In the past few years, the use of direct auditory per- ception training, provided in isolation from classroom con- texts has been found to be of limited value. It does not ap- pear to improve significantly a child's ability to perceive and integrate auditory stimuli.(Willeford,l978) Occasionally low-powered hearing aids are recommended until the otitis is resolved.(Naunton,531) This is feasible only with highly motivated parents, continuing availability of an audiologist or speech therapist to monitor the equip- ment, and a period of diagnostic use with a loaner aid to judge its effectiveness.(Northern & Downs,l978,p.l3) FM Wireless Systems FM wireless systems, or auditory trainers, have been used effectively for many years in oral programs for the hearing impaired to maximize students' effective use of their residual hearing. In group settings hearing aids am- plify speech and background noise to a similar degree, while FM systems amplify primarily the key speech signal, im- proving the signal to noise (S/N) for the listener. 107 A unique approach to service was tried by Project MARRS (Mainstream Amplification Resource Room Study) in the Wabash and Ohio Valley Special Education District in Illinois. The two goals of the project were to determine whether students with minimal hearing loss experienced educational deficits and whether deficits could be remedied in a regular class- room program. The concerns when beginning the project were similar to those listed in chapter one of this paper. Par- ticipants were enrolled in grades 4-6, were at least 1/2 year below expectation on any part of the Wide Range Achievement Test(WRAT), and had puretone thresholds between lOdBHL and 40dBHL. Students who scored low on the Otis- Lennon Mental Abilities test were given a low priority for inclusion in the project. Seventy-nine students were eli- gible to participate<35.8% of 4th graders, 60.9% of 5th graders, and 75.1% of 6th graders). Special amplification equipment was installed in the classroom of half of the target students with special loud- speakers placed in the corners of the room to adjust the S/N ratio of the entire sound field. For about three hours each day, the teacher wore a microphone connected to a wireless transmitter. The system caused the teacher's voice to sound clearer, slightly louder, and the background noise in the room to be slightly less obvious. The other half of the stu- dents received resource teacher and aide assistance with regular classroom work on a 7.5:1 ratio. Progress was assessed. annually' with. SRA. achievement 108 tests over a three year period. Twenty-four students par—- ticipated for the entire length of the study. The classroom amplification group demonstrated more improvement. Both teachers and students reported satisfaction with the ampli- fication system. Listening was easier, and teachers reported less fatigue than usual. There was less frustration about students missing class instruction to receive special in- struction. Teachers also became more aware of the ambient noise problem.(Sarff,l981) Problems with the MARRS study limit its usefulness. The original concern was with learning disabled youngsters, but the criteria for subject selection included a much broader range of students than what most districts would typically call learning disabilities. Their mean scores on the SRA battery before and after the project ranged between the 4lst and 50th percentiles. The student/resource teacher ratio was better than most programs can provide as well. In spite of the problems, based on the formal research and some informal replications, it seems that this method warrants further in- vestigation. Some preliminary research being conducted by a nation- ally recognized audiology researcher concerns the value of individual FM wireless systems, or auditory trainers, for students with learning disabilities or central auditory pro- cessing disorders. Based on this, Telex Corporation lent two dozen low power units to this writer for informal evaluation in elementary classrooms and during physical education. The 109 improved S/N ratio was similar to that found with the Phonic Ear equipment. Telex assured the writer that there was no danger of ear damage from loud noise with these low power units. Teachers wore one of two transmitters, and students were offered a variety of transducers, or listening devices which were hooked to belt-level receivers. Many were both- ered somewhat by the weight and warmth of the headsets. The most satisfactory solution was a chin tube similar to those worn by secretaries when transcribing dictation. It worked best when the tube was worn behind the neck with the cords from the belt level receiver running up the back. This elim- inated the problem of a few students chewing on the cords and others being generally distracted by them. The equipment was used for thirty minutes to two hours per day for three to six weeks. There were several positive outcomes from this experi- ence. Teachers became more sensitive to ambient noise in their classes as they took turns wearing the units them- selves and heard how much difference there was in signal clarity. They mentioned less fatigue from talking loudly. One use of the equipment which was particularly helpful was to provide quiet, individual cues to the student wearing the equipment about attention to task. A teacher could circulate around the room or work with another student while contin- uing to give frequent feedback to the target student without being obvious to other members of the class. This strategy would not be possible with the MARRS arrangement. 110 Initial inservice for all school personnel involved in the project would alleviate substantially the minor concerns encountered in this informal evaluation. Most of these con- cerns related to equipment management, ways to optimize the effectiveness of the systems and minimize time and attention required to keep it operating correctly. The other type of concern related to optimal timing for use. For example, the system is unlikely to enhance auditory learning in group discussions, because the difficulty that the target student would experience hearing classmates clearly would counter- balance the improved signal to noise ratio the teacher's voice. Also implementing the project at the beginning of a term when classroom routines are being established and more open to change would facilitate the system's incorporation into the regular routine. Students were enthusiastic about trying the equipment, and their classmates were given opportunities to wear a unit periodically as well. Initially it was seen as a privilege. After the first two weeks, the newness wore off, but most students were still willing to use the systems. Informal re- actions by teachers were that most students who initially expressed interest in wearing the units did seem more atten- tive, productive, and accurate in their work while using them. The difference was slight, but a controlled study of the systems, particularly with some technical modifications Telex is considering, would be worthwhile. lll Follow-Up Screening American ElectroMedics Corporation made a 95-A Screen- ing Audiometer/Tympanometer available to the writer to do follow-up screening of children who were found to have ab- normal hearing or middle ear function at the time of the audiological examination. It was also available to use with- in the participating schools for staff inservice and to test other students following parent consent. Forty individuals were tested. Four of the study children who went to their physicians for treatment following the initial examination, were retested and found to be within normal limits on two consecutive tests at two to four week intervals. Two Study children waited for the retest to consult their physician. One was within normal limits. The other had more negative pressure than during the initial testing and went to the family doctor for treatment of what was then diagnosed as an ear infection. None of these students had complained of any pain or hearing problem when they had abnormal findings. The other people tested or their parents had concerns because of allergy problems, history of repeated otitis me— dia, or current symptoms of ear infection. A few indicated that because of the ready availability of the equipment that they would like to have their child checked. They had no plan to go to a physician prior to the test, but when one of the children had abnormal findings, he was taken to the doc- tor and treated medically for an ear infection. Among the twenty-five adults tested, one had abnormal middle ear 112 status, and five had abnormal puretone thresholds(45dB,35dB, 55dB,65dB,70dB). Only the person with the 65dB loss wore am- plification. The others had suspected a loss and requested the testing, but to the writer's knowledge, they did not follow up with diagnostic testing. Most of the inservice in- cluded helping the teachers realize what impedance test felt like and what it measured. Also, they expressed that it was helpful for them to realize the sound levels that children with conductive losses are not able to hear. As a result of the experience they expressed more concern about what they had previously considered to be negligible losses. Continued availability to a school district of a screening audiometer/ Tympanometer could further the appropriate identification of individuals in need of further assessment and medical treat- ment as well as continue to increase teachers' understanding of the implications of slight conductive hearing losses on school performance. Environmental Modification Changes in the school's physical plant can provide stu- dents with recurrent otitis media a better acoustic environ- ment for instruction with or without amplification. Walls are better than windows for reducing noise in classroom, as well as for reducing visual distractions. Landscaping around the windows which do exist reduces noise from outside the building. Carpeting in the corridors help, as well as avoid- ance of long, straight corridors. One of the simplest and cheapest modifications is to cover desk and chair legs in ll3 classrooms with felt or rubber.(Bess,l981,pp.l9l-l92) For allergic otitis media students it would be prudent to have a physician determine the nature of the allergies and see whether minor modifications in the school environ- ment might reduce the students' allergy symptoms or need for medication. The exclusion of plants, animals, some cleaning compounds, and perfumes combined with careful attention to dust and mold accumulation, humidity, and window opening could improve the health and learning of some of these chil- dren to a significant degree. Having enclosed bookcases, window' shades instead. of blinds, continuous vinyl sheet floors or low nap rugs instead of tiles and shag rugs in reading corners are examples of modifications which could help significantly with dust and mold minimization. Minor substitutions in foods served in the school cafeteria or for classroom snacks could help many students' symptoms. Atten- tion to some details in the careful administration of medi- cation according to directions (e.g. whether it should be taken before or after meals, with water, or not within an hour of certain foods such as milk) would enhance the effec- tiveness of some medications and reduce physical and behavi- oral side effects of others. Summary To maximize the learning opportunities for learning disabled children who also have a history of recurrent oti- tis media, some special considerations need to be made. Early, comprehensive evaluations should be encouraged. 114 Communication among professionals and parents should be maintained at regular intervals. Specific language enhance- ment and environmental modification should be incorporated into the regular classroom program to the degree manageable for the teacher and the school. Most of these changes would require continuing education for all of the professionals who work with these children. APPENDICES APPENDIX A Dear Parents/Guardians: This letter describes a research project being conducted in our school district and, with your consent, may include your child. A total of eighty 6-9 year old children in our county will participate. A.‘description of the project follows. Additional information regarding the project, as well as a copy of all measuring instruments being used, are available in your child's school office. Please sign either the Consent to Project. Participation. or Refusal. for ZProject Participation and return it to the office of your child's school. No child will participate without written parent consent, but we would appreciate having a signed refusal on record if you choose that option. If you agree to have your child participate in the research described here but later change your mind, you may withdraw your child from the project by contacting the school principal. The project titled ”School Effects of Common Early Health or Developmental Problems” is being conducted by Frances Loose and Michael Stewart. They are both completing MSU doctoral programs, Mike a licensed audiologist in the department of Audiology and Speech, Fran in the department of Counseling, Ed Psych and Special Education. Also, they both have extensive experience working in the public schools. The major project advisor is Dr. David Sciamanna, a physician specializing in neonatology & developmental medicine. The research is being conducted between April 18, 1983, and July 29, 1983. All children participating in the project will receive a 45 minute, diagnostic audiological examination to be conducted by Mike in the MSU audiology facilities on campus. This will be done after school hours and on Saturdays during May and June. Participating families will receive an appointment card within 1 week of the time their signed consent is received. If needed, Fran can provide transportation to the appointment for children who would otherwise be unable to attend. In the audiological exam the children will wear headphones and listen and respond to a variety of pure tones and speech directions. They will also have an impedance test which measures middle ear function. A probe with a soft cuff is inserted into the ear canal. There is no discomfort involved in any of these procedures. The tests being done measure pure tone air and bone conduction thresholds, speech reception thresholds, 115 116 speech discrimination ability, tympanic membrane compliance, acoustic reflex, and central auditory processing. Results will be shared with parents in writing immediately following the testing. For those children whose initial exam is abnormal, follow-up testing can be done at the clinic and Fran has access to a screening Tympanometer/audiometer to monitor changes at 2 week intervals in the home school district. The reason for this is that many children experience mild, fluctuating hearing problems due to wax build up, infection, or fluid in the middle ear. None of the tests should be upsetting to a child. If for some reason a child were to become upset, the procedure would be terminated immediately and permanently, and the researcher's focus would shift to settling the child. Parents will be asked to complete a child development questionnaire about their child's attainment of udlestones and his or her illnesses. The report is primarily in checklist form. It will be mailed to partipating families with the audiological appointment card. Teachers will complete a brief form recording the number of parent contacts they have had this year, a quick rating of the children's performance and activity level, and a question about whether they have been aware of any chronic health problems the children may experience. Fran will pull children's attendance history from the cumulative file. No other data will be reviewed about any of the participating children. Resource teachers will record the initial IEPC date, other special school services received, and. scores from the WISC-R. No other data will be reviewed about any of the participating children. The research is being done to determine the local incidence of educationally' significant chronic middle ear problems which may be easily screened for and often easily treated/assisted. Several groups will benefit from the research. All participating students will receive a much more comprehensive audiological evaluation than they would routinely receive through public health screening. Several major studies have reported that screening audiometry done in schools identify less than half of the hearing problems experienced by young children. The cost of an exam comparable to the one done in this study would be $40-80 per child in clinics in the Lansing area. Staff directly involved in the study will receive informal inservice on identification, significance, and. types of treatment available for middle ear problems. Future students will benefit from any changes in staff awareness or district screening procedure related to this common health problem. 117 The information gathered will be analyzed and reported in summary form in Fran's MSU dissertation. No names of individuals or specific school districts will be reported. Mike will analyze the details of the audiological data and report that in a study of his own, again without names of specific individuals or districts. American ElectroMedics, which is lending the screening equipment, will receive the summary data mentioned above and any follow-up screening records gathered, coded by student number. Telex Communications Inc. which is providing auditory trainers for some children in the study will receive the summary data to help them assess if the equipment was helpful to the students who used it. CONSENT TO PROJECT PARTICIPATION I consent to the participation of name b.date in the research project described above. I understand what the project involves. I also understand that I am free to withdraw from the project at any time. I understand that neither the researcher nor her approved assistants nor any other group or individual will use the material gathered in any way that would invade the privacy of this child or his/her family. I understand that the rights of this child with regard to confidentiality will be paramount. date parent/legal guardian signature address To help us begin scheduling the audiological appointments, please look at the appointment times listed here and CROSS OUT any times that your child COULD NOT be available. Also, if you will be unable to bring your child to the MSU campus for the testing, please note here that Fran should contact you about arranging for a ride. Thanks Monday, May 23: 4-5PM 5-6PM 6-7PM 7-8PM Tuesday, May 24: 4-5PM 5-6PM 6-7PM 7-8PM Wednesday, May 25:4-5PM 5-6PM 6-7PM 7-8PM Thursday, May 26: 4-5PM 5-6PM 6-7PM 7-8PM Friday, May 27: 4-5PM 5-6PM 6-7PM 7-8PM REFUSAL FOR PROJECT PARTICIPATION I do not consent to the participation of in any way in the research project described above. date parent7legal guardian signature APPENDIX B May, 1983 Dear , Thank you for allowing to participate in the research project. His/her appointment for the audiological exam has been scheduled for ' day date time Please come to the Audiology and Speech Sciences Building on the southwest corner of Wilson 5 Red Cedar on MSU's campus. A map is provided at the bottom of this letter. If you need to change your appointment, please call me as soon as pos- sible in the evening or on week-ends at 349-1648. I've also enclosed the Child Development Form and a stamped, self-addressed envelope. Please return it as soon as pos- sible. It will help us to be able to review it before your audiological appointment. As you complete the form, if you find that you just can't remember when your child mastered a skill or how often s/he had a certain health problem; mark a g by the answer that is your best Guess. Otherwise code check marks, numbers, and comments as needed. Thanks again for your time and your help. T3"‘T' Sincerely, sadxvrt L4“”L£’ Frances F. Loose Ira-In Tracks Appendix C CHILD DEVELOPMENT QUESTIONNAIRE Child's name Birthdate Sex PREGNANCY/BIRTH: Mother's age when child born: 46 18—34 yrs., (l/3)* >35 yrs Were there difficulties with the pregnancy?g;no (l/6)* yes pre-eclampsia, Rh incompatabilityL attempted abortionL sur- gepy when six weeks pregnantL migraines, C-sectiony induced labor, concern because of previous miscarriage and premie Length of pregnancy:(40 wks=full term) (0/1)* <33 wks 42 34-42 wks Birth weight: X=7.5 lbs. Did the baby need any special medical care at birth? 46 no (l/3)* yes breech, doctor recommended hydrocephalus shunt, cord around neck--b1uishL needed oxygen for a few hours How long did the baby stay in the hospital? 45 less than 1 wk (0/4)* 1-4 wks (0/l)* over 1 month During the first month of life, did the baby need treatment for any of these conditions? breathing difficulty no 2 yes(describe) jaundice(yellowness)requiring exchange transfusion __no__yes infection ‘___no _g_ yes eye, skin staph seizures(convulsions) no _0_ yes hemorrhage ___no _9_ yes HEALTH & MEDICAL HISTORY: Check any of these illnesses and other health problems that your child has experienced. Mark a P by any which you feel have been a major problem: l§--allergy l;--eczema/hives lg--frequent colds _g--headache lQ--sinus trouble _§-—draining ears 23--earaches _§-—asthma lg--pneumonia l_--croup/ gg--tonsilitis/ _g--diarrhea bronchitis strep throat /stomach ache _g—-food sensitiv.(0(3)*-seizures l;--high fevers How many ear infections did your child have diagnosed by a doctor-- as an infant 23 none 15 1-2 5 3-4 5 5-6 _l_>6 _l_? 1-2 yrs of age 22 none 11 1-2 10 3-4 5 5-6 _l_>6 2—3 yrs of age 28 none 7 1-2 9 3-4 5 5-6 _l_>6 3—4 yrs of age 28 none 14 1—2 5 3-4 2 5-6 _Q_>6 _l_? 4-5 yrs of age 32 none 14 1-2 2 3-4 1 5-6 _Q_>6 since 5th b'day 31 none 13 1-2 5 3—4 1 5-6 _Q_>6 If the child is now on medication, give the name(s) and purpose: allergy shotstantibiotic, antihistamine * (number of Controls/number of LD): reported when frequencies vary significantly between two groups 119 120 Check the types of medication that your child has taken for more than three weeks in a row.(22=none,l3=one type,15=22) l7 antihistamine/decongestant (e.g.Dimetapp, Novahistine, Benadryl, Phenergan, Triaminic, Sudafed, Dimetane, Actifed, Ornade) 14 antibiotics(e.g.ampicillin,Amoxycillin,Gantrisin, Ilosone, Septra,Bactrim,Polymox) 3 allergy shots 5 other: Ritalin, anticonvulsantsL bronchodilators, eczema cream Has your child had problems tolerating medications, or have any seemed to affect his/her behavior? 35 no (4111)* yes (describe): (l/7)hyperactivity or irritabilityL 2-sedation, 3-GI, l—multiple List surgery your child has age N=9 tonsillectomy had on his/her ears,nose, age N=l3adenoidectomy or throat. age N=9 ventilating tubes age other enlargement sinus passage(N=l) (34 had no surgery, 5 had one type, 11 had multiple) (Surgery by age: 2 before 2 yrs., 4 while 2 yrs, 6 while 3, 1 each while 4,5,6, and 7) List other hospitalizations. age reason. neurology(2), eye(3),pneumonia/bronchitis(9)Lhernia(2),orthopedic(4), append i c i t i s 7gastroenteritis ( 2) , nephrectomy( 1) , dehydration/ fever & vomiting(3)burns(l)stallowed object(1) Please check the types of doctors and other professionals who have seen your child. 42 pediatrician 26 family doctor 21 ear, nose, & throat specialist 9 psychologist 6 allergist 15 audiologist(hearing tests) 11 other: urologistL orthopedist, neurosurgeon How many times total during the past 12 months have you taken your child to appointments with these professionals? l_none 2§_1-3 13_4-6 _g_7-12 _Q_13-24 _g_25-36 _Q_>36 What kinds of experiences with these professionals have felt particularly helpful, negative, or a waste of time for you or your child in the past? positive, helpful, thorough, caring, sincere, secure experi- ence, patient, takes time to explain, listens, willing to try various management plans, good with children(16) adequate to good--"but then I'm a very concerned parent who asks a lot of questions and demands answers(l)“ specialists particularly helpful--improvement in child's health/behavior after misdiagnosis or no improvement with primary care physician (4) waste of time, not good with children, poor communication, 121 opposed. to referral. to specialist. when. appropriate, neglectful, no/inadequate follow-up, insensitive, frustrating' waiting' for child. to “outgrow” repeated illnesses which could be treated surgically (l2) misleading statements--i.e. "Girls don't get learning dis- abilities." (1) FAMILY HISTORY: Have any members of the family (father, mother, brother, sister, aunt, uncle, cousin, grandparent) experienced any of the following? family member(s) age began duration treatment (chi,adol) required allergy/hay fvr 23parentLllother asthma 5 10 hearing impair. 9 6 learning problem 3 10 _ sinus problem 15 1 speech problem 5 9 GENERAL DEVELOPMENT: Eating: Breast fed? 27 Type of formula used: milk base--21L soy--2, other--l any problems with certain foods?milk--2y common allergens--l, other--2 Sleeping: Age when began to sleep through night: X=7months, median=3.4months, mode=lmonth Is sleep pattern now regular? (21/14)* yes (4/ll)* no (describe) 3 restless,g 8 night sweatsL 3 grind teeth, 2 night terrors, 1 sucks thumb Activity Patterns:(Mark YES or NO for each) (X=3.2 areas of concern for Controls, X=5.0 for LD) underactive(l/4)* overactive(4110)* fidgets(5/12) can't keep hands to self(3/9)* impulsive l9 stubborn 24 short. attention span(37l6)* unusually alert, aware of everythingZS mood swings widely 7 upset by change in routine l4 easily frustrated(6/l4)* rocks body frequently, especially when younger (0 3)* Speech and Language: (X=1.6 delays) Noticed approaching sound 42 under 2 months 8 over 2 m. began to laugh 43 under 3 months 7 over 3 months understood "no, bye-bye, daddy" 38 under 7months lg_over 7m. began to babble 42 under 9 months 8 over 9 months spoke first word with understandingmwnaamwnanz __F_ 7.39 6.30 6.06 5.45 5.43 4.82 4.56 4.52 2.44 0.15 .2. .05 .05 .05 .05 .05 .05 .05 .05 NS NS ¢E H24m2>8 AmOEHQD< zOmZME Adzzmflxm mum<9m was? 2 ‘ca' ‘ (\er/ O) q~t$ \éfii’ "fa C <-‘ i” Q 'C 90 l ’("\ w m J . , ' I " ' JazJ‘." ’j‘ ,_ . 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N 9266.832 80338.. 8.3.... $5.33.... 893! E g IIIIIIIIIIIIIIIIIIIIIIIII P . bl! . .F D I D D D F I I .D : = o s. a a: . so a s. a 2 E a R o. 2 : o. 2 3 2 2 .. o. c u . o a e a a . t m... .3. t... 133 APPENDIX M OTHER PREPRIMARY TESTS Bayley Scales of Infant Development(0-30 months) Psychological Corporation 757 3rd Avenue New York, NY 10017 A. Mental Scale B. Motor Scale Boehm Test of Basic Concepts Psychological Corporation 757 3rd Avenue New York, NY 10017 Brigance Inventory of Early Development(0-7 years) Curriculum Associates, Inc. 5 Esquire Road North Billerica, MA 01862-2589 Pre-Ambulatory Motor Skills and Behaviors Gross Motor Skills and Behaviors Fine Motor Skills and Behaviors Self Help Skills Pre-Speech Speech and Language Skills General Knowledge and Comprehension Readiness Basic Reading Skills Manuscript Writing Math NQHZBQ'UFIUOFDS’ Carolina Developmental Profile(2-5 years) Kaplan Press 600 Jonestown Road Winston-Salem, NC 27103 . Gross Motor . Fine Motor . Visual Perception . Reasoning . Receptive Language . Expressive Language G. Social Emotional "SJMUOUID' Colorado Sound Screener(2-6 years) Colorado Dep't. of Public Health Hearing and Speech Services 4210 East 11th Ave. Denver, CO 80220 Attn: Harold J. Weber 13h 135 Developmental Indicators for Assessment of Learning DIAL, INC. Box 911 Highland Park, IL 60035 Goldman-Fristoe-Woodcock Auditory Skills Test Battery(>3yrs) American Guidance Service Publishers' Building Circle Pines, MN 55014 A. Selective Attention Diagnostic Discrimination Auditory Memory (Recognition, Content, Sequence) Sound-Symbol (Mimicry,Recognition, Analysis, Blending, Association, Reading, Spelling) can: Hawaii Early Learning Profile (0-12+ years) VORT Corporation PO Box 11757 Palo Alto, CA 94306 A. Cognitive B. Language C. Gross Motor D. Fine Motor E. Social-Emotional F. Self Help Kaufman Assessment Battery for Children (2-6 to 12-6 years) American Guidance Service Publishers' Building Circle Pines, MN 55014 A. Sequential Processing . Simultaneous Processing . Achievement . Mental Processing Composite 00w Learning Accomplishment Profile (0-6 years) Kaplan Press 600 Jonestown Road Winston-Salem, NC 27103 A. Fine Motor B. Social Skills C. Self-Help D. Cognitive E. Language Development 136 Miller Assessment for Preschoolers (2-9 to 5-8 years) KID Technology 11715 E. Slst Ave. Denver, CO 80239 A. Foundations B. Coordination C. Verbal D. Non-Verbal B. Complex Tasks Peabodericture Vocabulary Test (>2-6 years) American Guidance Service Publishers' Building Circle Pines, MN 55014 Pediatric Examination of Educational Readiness Educators Publishing Service, Inc. 75 Moulton St. Cambridge, MA 02238-9101 A. Orientation B. Gross Motor C. Visual-Fine Motor D. Sequential E. Linguistic F. Preacademic Learning Preschool Attainment Record (0-7 years) American Guidance Service Publishers' Building Circle Pines, MN 55014 , A. Physical (Ambulation, Manipulation) B. Social (Rapport, Communication, Responsibility) C. Intellectual (Information, Ideation, Creativity) Pre-Speech Screening Questionnaire (3-12 months) Suzanne Evans Morris, Ph.D. 202 Shepard Terrace Madison, WI 53705 A. Feeding B. Early Sound Production Receptive-Expressive Emergent Language Scale (0-3 years) University Park Press 300 N. Charles Street Baltimore, MD 21201 Sequenced Inventory of Communication Development(4-48months) University of Washington Press Seattle, WA 98105 A. Receptive (Awareness, Discrimination, Understanding) B. Expressive(Imitate,Initiate,Response, Verbal Output) 137 Test of Language Develoment--Primary (4-0 to 8-11) Pro-Ed 5341 Industrial Oaks Blvd. Austin, Q'UMUOED? TX 78735 Grammatic Understanding Sentence Imitation Grammatic Completion Word Articulation Word Discrimination Picture Vocabulary Oral Vocabulary APPENDIX N MODEL PROGRAMS American Association of university Affiliated Programs for the Developmentally Disabled 1234 Mass. Ave., N.W., Suite 813 Washington, D.C. 20005 Community Workbook for the Collaborative Services to Preschool Handicapped Children Boys Town Institute for Communication disorders in Children Omaha, NB Comprehensive multidisciplinary evaluations and remediation Child Development Unit, Ambulatory Care Center Children's Hospital of Pittsburgh 125 DeSoto Street Pittsburgh, PA 15213 Multidisciplinary diagnostic, consultative, and therapeutic services for children (0-18) with developmental problems Parent education courses Center for the Study of Families and Children Institute for Public Policy Studies Vanderbilt University 1208 18th Avenue South Nashville, TN 37212 Public Policies Afecting Chronically Ill Children and Their Families Developmental Evaluation Services for Children (DESC) 2000 Dennis Avenue Silver Springs, MD 20902 Interagency, interdisciplinary identification and assessment of developmentally delayed preschoolers 4 visits to 4-6 week placement in diagnostic nursery Elks Purple Cross Deaf Detection and Development Program 4908 Dewdney Avenue Regina, Saskatchewan S4t 1B8 Preschool Program Board of Cooperative Educational Services Yorktown Heights, NY 10598 Transdisciplinary training, assessment, and con- sultation model Parent Activity Catalog 138 139 Project C.H.I.L.D.(Conductive Hearing Impairment/Language Development) Toledo Public Schools 1624 Tracy Street Toledo, Ohio 43605 Improving Your Child's Listening and Language Skills: A Parent's Guide to Language Development Instructional Curriculum Consultation Guidelines Project TAP (Tapping Achievement Potential, Tapping Adult Potential, Teenage Awareness Program) PO Box 19643 Department of Education North Carolina Central University Durham, NC 27707 ‘ Nursery School-—developmentally delayed and others integrated ' Parent education component Teen training in child development and handicaps Project WELCOME 333 Longwood Avenue Boston, MA 02115 Family support program Transition program linking NICU families to needed services Outreach training for health care providers about needs of high risk infants WESTAR (Western States Technical Assistance Resource) University District Building 1107 N.E. 45th, Suite 915 Seattle, WA 98105 Distribute materials relative to effecxtive early intervention APPENDIX 0 RESOURCE ORGANIZATIONS American Speech-Language-Hearing Association 10801 Rockville Pike Rockville, MD 20852 Association for Children & Adults with Learning Disabilities 4156 Library Road Pittsburgh, PA 15234 Asthma and Allergy Foundation of America 19 West 44th Street New York, NY 10036 Council for Exceptional Children Division of Early Childhood 1920 Association Drive Reston, VA 22091 Council for Learning Disabilities c/o Gaye McNutt College of Education University of Oklahoma Norman, OK 73019 Handicapped Children's Early Education Program Department of Education 400 Maryland Avenue, SW 4 Donohoe Building, Room 4046C Washington, D.C. 20202 National Association for Hearing and Speech Action 10801 Rockville Pike Rockville, MD 20852 Project FIND Michigan Department of Education Special Education Services Box 30008 Lansing, MI 48909 1h0 BI BLIOGRAPHY BIBLIOGRAPHY Ack,M., Andrews, P., Levine, M., & Prugh, D. 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