John O. Willis, Ed.D., Rivier College, 2/16/98
Post-Otitis Auditory Dysfunction (POAD) is a serious and
underestimated cause of multiple learning problems in school
children. Despite Boucher's (1986) dramatic findings, the problems of
POAD often go unrecognized and untreated.
Middle Ear Dysfunction
Episodes of middle ear fluid build-up (serous otitis media) are a
common plague of early childhood. Because young children often are
not aware of the blockage and because the episodes are not life threatening, many such episodes go untreated or are treated too
little and too late. Fluid accumulations may remain, blocking
hearing, after any painful and visible symptoms have disappeared. A
new episode may begin soon after the previous one and not be noticed.
One consequence of these events is that a child may be deprived
intermittently and unpredictably of usable hearing during critical
stages of language acquisition.
That intermittent and unpredictable hearing loss can, at its
worst, interfere with acquisition of basic oral language skills, both
vocabulary and grammar. More subtle effects can include deficiencies
in auditory perception and development of phonemic awareness or the ability to recognize the separate sounds that
make up a word, skills that are essential for the development of
reading and spelling skills (e.g., Brody, 1994; Stanovich, 1994).
Other essential auditory processes may be impaired, such as the
ability to hear against background noise and the capacity to sustain
listening attention, even when highly motivated. The central nervous
system tends to abandon sensory systems that prove ineffective during
critical developmental periods. For example, a strabismus (deviation
of an eye off-center), causes overlapping, conflicting visual
projections in the visual cortex of the brain, which eventually copes
by shutting down the input from the lazy eye,
resulting in amblyopia, a dimness of vision which cannot be corrected
by prescription lenses. This self-destructive reaction is sometimes
prevented by patching the straight eye so that the off-target eye is
forced to work alone, sending a single, unambiguous projection to the
brain. Similarly, intermittent hearing loss can sometimes severely
impair development of listening skills. The young child, without knowing why, sometimes is able to hear and understand and sometimes
is not. The child begins to learn that hearing is, at best, an
unreliable process, and the development of listening skills, auditory attention, and auditory perception is impaired. Attention span and
organizational skills may also develop poorly, mimicking Attention
Deficit Hyperactivity Disorder (ADHD).
Effects of POAD on Academic Achievement
The impairment of communication skills has many consequences. Not
only do auditory, language, pre-reading, and pre-writing skills
suffer delays, but the child also suffers confusion and embarrassment
from frequent social misunderstandings. The child is likely to spend
considerable time not really understanding what is going on and
therefore often saying and doing the wrong thing. Public ridicule is
often the lot of the child with middle ear dysfunction, sometimes
resulting in extreme shyness.
If episodes of fluid build-up continue into the child's school years, the consequences can be
especially severe. Confusion,
misunderstanding, and embarrassment are exacerbated by difficulties
with beginning academic skills. Even if the child no longer suffers
from episodes of hearing loss, the problems with auditory perception,
phonemic awareness, vocabulary, grammar, listening skills, hearing
against background noise, and attention and organization persist,
putting the child at risk for school failure and further
embarrassment and confusion. Compounding the problem is the evidence
that the child can hear, at least some of the time, even if the fluid
build-up continues into grade school.
Even very sympathetic teachers find it difficult to believe
ñ certainly to remember ñ that the child has serious
auditory problems, since the child does hear adequately, under ideal
listening conditions, between episodes of fluid build-up and after
the episodes have finally ceased.
Boucher (1983) used pure-tone and impedance audiometry records to
study all of the readiness and primary students with middle ear
dysfunction in ten New Hampshire towns. The students whose impedance testing showed evidence of previous otitis, even though they had
regained normal hearing, showed double the normal rates of readiness
placements, disability identifications, and repeated grades.
Ways of Teaching the Student with POAD More Effectively
The most prudent and helpful approach for teachers is to assume
that the student has listening difficulties at all times. Even after
the episodes of fluid build-up have long since ended, the continuing problems with auditory perception, phonemic awareness, vocabulary,
grammar, listening skills, hearing against background noise, and
attention and organization make it wise to work with the student as
if the student actually were hard of hearing and as if the student
had Attention Deficit Hyperactivity Disorder.
It is helpful to insist that the student sit where the teacher
can be seen and heard most easily (not always front-row-center,
depending on the teacher's habitual movement in the room).
Without further embarrassing the student, you can inconspicuously
make frequent eye contact and call on the student when you are
certain the student is ready and able to respond.
Visual teaching methods and materials can be extremely helpful.
Charts, maps, graphs, diagrams, models, time lines, dioramas,
illustrations, demonstrations, hands-on activities, and role-playing
may be effective means of teaching the student and allowing the
student to demonstrate mastery of the material.
It is essential to evaluate the student's oral and written
work for indications that the student is missing some essential skill
or piece of information and to remedy those deficiencies. Students
with POAD almost always miss out on key facts and skills, deficits
which haunt them as they try to progress through the higher grades.
If the gaps are too large or too pervasive to handle with brief
instruction, the student may need specific tutoring from you or from
the special education department.
If the student struggles with reading, or in the higher grades,
reads slowly or inefficiently, the most probable causes are, in order
of probability, deficient phonemic awareness, deficient phonetic word
attack skills, limited reading vocabulary, and difficulty
comprehending complex written language. You may be able to identify
the problem by working individually with the student or you may wish
to refer the student for a comprehensive reading assessment. The
student may require remedial reading services.
Examine the student's tests and quizzes to see if the
student may require additional time or a quieter environment for
taking tests. That should not be an automatic response for all
students, but may be helpful for some.
Despite your best efforts in class, the student is very likely to
miss essential details about assignments, long-term projects,
upcoming events, and missing assignments. For the student to derive
the full benefit of your instruction, it is essential to check in
with the student (or have the student's case manager do so)
frequently to be certain the student is aware of what needs to be
done. It is highly likely that student will be too shy or
embarrassed to initiate the checking. It is a valuable long-term
goal, especially in the higher grades, for students to become
independent in monitoring their own assignments and progress.
However, that will not happen overnight, and it will not happen
without direct assistance from teachers by gradual steps. Simply
telling the student to be more responsible or giving failing grades
will not overcome the life-long effects of POAD.
Students with POAD often need additional explanations of material
that has been presented in class. It is safe to assume that if any of
your students with other learning disabilities or ADHD are having
difficulty with some of the material, your students with POAD will
also be confused, even if they are too shy to ask, are too confused
to know what to ask, or are too discouraged to try without
It is important to be gentle with students who have POAD. They
have spent a lifetime being criticized and yelled at. They need
support and encouragement, and most respond very well once they come
to believe and trust what may be to them a very unusual and
Students with POAD present teachers with special challenges and
require hard work, but it can also be very rewarding to help a
struggling student achieve his or her potential in your class.
Special Education Identification
If the student's POAD seriously impairs academic
performance and is the primary cause of that impairment, if the
student is no longer suffering a current hearing loss, and if the
student requires a uniquely designed program of special education,
the student is eligible for identification as having a specific
learning disability (NH Standards, 1996, pp. 10-11, 26-27; Willis,
1990). If the other considerations apply, but the student needs
classroom modifications without a uniquely designed program of
special education, it might be more appropriate to provide the
student with a plan under Section 504 of the Rehabilitation Act of
1973 (PL 93-112).
Boucher, J. P. (1986). An investigation of the relationship
between middle ear dysfunction and school difficulty in young
children. Dissertation Abstracts International, 47, 6, 2115A.
Brody, S. (Ed.) (1994). Teaching reading: Language, letters, and
thought. Milford, NH: LARC Publishing. [PO Box 801, Milford, NH
03055; 603 880-7691].
New Hampshire standards for the education of students with
disabilities (10/21/96). Concord, NH: NH Department of Education.
Stanovich, K. E. (1994). Romance and reality. Reading Teacher, 47,
Willis, J. O. (1990). Guide to identification of learning
disabilities. Concord, NH: NH Department of Education. [419 Sand
Hill Road, Peterborough, NH 03458-1616; 603 924-0993]
Willis, J. O. & Dumont, R. P. (1998). Guide to identification
of learning disabilities, 1998 New York Ed. Acton, MA: Copley.
[available from sr. author: 419 Sand Hill Road, Peterborough, NH
03458-1616; 603 924-0993]