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Centre for Evidence-
Based Medicine

Middle ear disease - Uncertain whether it increases the risk of behaviour problems at 10 years

Clinical Bottom Line

Middle ear disease is associated with a small increase in behaviour problems at 10 years but the difference may not be clinically significant and may be partly explained by socio-economic factors.


Bennett, K.E. Haggard M.P.Behaviour and cognitive outcomes from middle ear disease. Arch Dis Child 1999;80:28-35 .

Clinical Question

Are children with middle ear disease at increased risk of behaviour problems?

The Study

  1. Large, national birth cohort of 12,000 children.
  2. Middle ear disease (discharge or hearing difficulty) and behaviour measured at 5 and 10 years by parental responses to questions and child assessment. Behaviour at 10 years also measured by teacher responses.
  3. Follow up of about 12, 000 at 5 years and about 9,000 at 10 years. Authors state that loss to follow up did not significantly affect proportions that had middle ear disease.

The Evidence

Difference in behaviour score (measured in SD units) for children with reported hearing difficultly (adjusted for socio-economic status, 95% confidence interval)
Antisocial Neurotic Hyperactive Poor Conduct
Difference in Behaviour Score @ 5 years 0.12
(0.06 to 0.18)
(0.14 to 0.25)
(0.12 to 0.25)
(0.01 to 0.13)
Difference in Behaviour Score @ 10 years -0.01
(-0.07 to 0.06)
(0.08 to 0.22)
(0.18 to 0.32)
(0.00 to 0.14)


  1. The differences in behaviour score are small. However, middle ear disease is common (10% in this cohort) and at a population level, these small differences may be clinically important.
  2. The slightly higher adverse behaviour scores in children with hearing difficulty could be partly explained by residual confounding due to socio-economic factors.
  3. Occurence of middle ear disease was based on parental reports and misclassification of exposure was likely. This may reduce the strength of true associations.

Appraised By

R. Gilbert; 4 March 1999

Expiry Date

March 2000