by Bob Doman

Rewards and consequences are the tools we have as parents, or, for that matter, as a society, to provide feedback, guidance, encouragement, and instruction, and to maintain order. Lack of consistent quality feedback leads to ambiguity, confusion, poor outcomes, and potentially chaos.

We need to reward the behaviors or things our children do that we like and want to see increase. Behaviors we do not like or want also require appropriate feedback. Rewards and consequences are the tools we have, the power we must use to teach our children, encourage them to do more of what we want, and dissuade them from doing things that are harmful or that will negatively impact their lives and futures.

What is a behavior? 

Everything we do can be defined as a behavior. For our children, it’s everything from walking and talking to reading, following directions, complying with requests and rules, and interacting with us and others—essentially, everything they do. 

Sadly, to many, the word “behavior” implies “bad behavior.” “Johnny has a behavior problem.” As stated, virtually everything our children do, whether it is helpful or harmful, is a behavior and is influenced by our response to it.

Feedback

Without feedback, children are in a vacuum, not knowing “Should I?” “Shouldn’t I?” “Does it matter?” or “Who cares?” Lack of quality feedback deprives the child of guidance and produces insecurity, anxiety, doubt, and poor outcomes. Unfortunately, many children receive poor or inconsistent feedback from their parents, schools, and society as a whole. 

Credibility—positive environment

To a significant degree, our influence is determined by our credibility. To create credibility, it is important to establish your primary role as loving, supportive, encouraging, and being on their side. The core of your child’s perception essentially reflects how positive or negative your overall interaction is with them. To have a positive environment, you should create a ratio of positive to negative feedback of 3:1 or 4:1 or greater. Part of the positive-to-negative equation is intensity. The stronger the reaction/feedback intensity, the stronger the impact. Ten smiles or “good” or “nice,” will not, in balance, equal one major hissy fit. Sadly, many parents reserve the intensity for the negative reactions. 

When responding to a behavior, a very important note is that our primary focus is not to specifically encourage or stop that immediate behavior, but to build those behaviors or extinguish them over time. Our measure of success or failure is the long-term results. Are we seeing more of the positive behaviors and less of the negative behaviors? If not, we have not succeeded and need to modify our response and feedback.

Consistency

A phrase often heard by parents from their children is, “It’s not fair.” It’s a safe assumption that you are not being consistent if you hear this from your child. Children seem to have an innate understanding of injustice, and inconsistency is at the top of their list of injustices. “I did this yesterday, and it was okay; why am I being punished for the same thing today?” Consistency is vital to build credibility, not appear unjust, and have the child accept and learn from your response. 

Did you mean it?

Many responses children receive for their “bad” or inappropriate behaviors are what I refer to as the equivalent of a 5-cent speeding ticket. Many of the supposed positive responses are not much stronger. I have referred to intensity as one of the foundational pieces of neuroplasticity. If something happens without sufficient intensity, our brains do not respond or change, and no learning occurs. One of the best gauges of the effectiveness of your responses is whether they worked. I often hear from parents things like, “I keep punishing the behavior, but he still does it.” If this is true, then you have not actually punished the behavior. You may have said or done something but did not punish the behavior. The definition of punishment is a response or consequence to a behavior that decreases the frequency of the behavior. If you haven’t changed it, you haven’t punished it, and doing something negative that doesn’t improve the behavior is cruel, and counterproductive, creates a negative environment, destroys your credibility and effectiveness, and harms your relationship with your child. 

The best consequences are the ones you only need to use once or twice. Do not be afraid when a consequence is warranted to go big. As an example, an age-old consequence has been writing sentences. Johnny picks on his little sister, creating all kinds of issues for the family. His consequence might be to write the sentence 10 times: “I have to be nice to Mary, and I cannot and will not pick on her.” I suspect that for many boys, this task would result in a lot of grumbling, and ten minutes later, they would be finished, and fifteen minutes later, Johnny would be picking on Mary again. What if Johnny had to write that sentence 300 or more times? This would probably take many hours; Johnny will have missed some things he would have liked to do, like his baseball game, and had said to himself 300 times while writing it, “I have to be nice to Mary, and I cannot and will not pick on her.” We call this frequency, and frequency changes the brain, which means learning occurs. Hopefully, this consequence will only be used once or twice to change the behavior.

It should be noted that consequences may only be effective if the overall balance between positive and negative, as mentioned, is 3:1 or 4:1 or greater. In a negative environment, the child may learn that they only get real attention if they do something “bad.” In this scenario, bigger consequences can result in more “bad” or worse behavior.

“Bravo”

We work with many families in Europe, and as we do with all our families, we have them post videos to their NACD Portal showing us how they implement the various activities we give them. When reviewing these videos, the word we often hear as they implement their child’s activities is “Bravo.” “Bravo” is a nice positive word, which essentially means, “Well done.” However, what we often see is “Bravo’’ meaning “you tried but got it wrong,” or “Bravo” meaning “we’re done,” or “Bravo” meaning “let’s do what’s next,” and “Bravo” meaning “good,” or “you did well,” or “you got it right.” In a thirty-second video we could hear ten “bravos.” This is not terribly effective. Although the tone is positive, which we strongly encourage, there isn’t much delineation between positive, negative, and neutral feedback. In such situations, it’s not that we want or need strong negative feedback for getting something wrong; it’s a matter that the positive needs to be much stronger. The response to “wrong” should be simple acknowledgment, such as “Oops, let’s try again,” but the response for getting something correct or done well should be robust and powerful.

Attention

Any attention is potentially reinforcing. Attention must be given with the knowledge that it has the potential to be reinforcing regardless of the intention. Many of our children’s negative behaviors begin as simple attention-getting behaviors. A child’s smile can elicit a smile from Mom. The smile got Mom’s attention, and she smiled back or picked up the child and rewarded the behavior, building that behavior. Johnny burps, and Mom responds, “Johnny, don’t burp.” The burp elicited attention from Mom, which potentially reinforced their behavior. “Johnny, don’t burp” is not a consequence. It’s attention, and any attention from a parent is potentially reinforcing. Of greater consequence are the parent’s response to minor possible hurts—hurts being little physical bumps, to a hurt feeling. If Mom overreacts, picks up the child and loves all over them, the odds are good that the crying doesn’t stop, but increases because of Mom’s attention. This reinforces the child’s overreaction, which essentially is a lie, and can potentially help teach children to lie. These children often become the “drama queens” because it works. Parents mistakenly perceive all the attention they give their children as a display of love and a good thing. Attention must be given judicially, understanding that it can be very influential.

In negative environments, attention gains even greater significance.

Opposite incompatible behaviors

Understanding the concept of opposite incompatible behaviors is very helpful for parents in focusing, creating a positive home environment, and successfully managing and developing their children.

Opposite incompatible behaviors reference the reality that you can’t be good and bad or try and not try, be responsible or irresponsible, etc., simultaneously. In our efforts to create good attitudes, work habits, and other behaviors, we always want to be aware of the opposite incompatible behaviors and focus primarily on building and reinforcing the positive preferred behaviors. This applies across the board, from behavior problems that need to be turned around to increasing focus on academics or responsibility with chores. When possible, focus on building what we want with positive attention/rewards, and when we need to use consequences, do so effectively and judicially.

• Create a positive environment.
• Provide consistent, definitive feedback.
• Be cognizant of the power of attention.
• Focus on rewarding the behaviors you want to build.

Reprinted by permission of The NACD Foundation, Volume 37 No. 3, 2024 ©NACD

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I never tire of hearing stories like the one we are sharing with you today. This family worked together and totally transformed their daughter’s confidence through opening up all new abilities. When I first started with Stella, only a short while ago, it was apparent that we were working with an intelligent, hard working girl with minor issues in several areas. By addressing and accelerating her processing abilities relative to short term memory, working memory, and long term memory, she was able to make great strides in her abilities. In addition to focusing on these pieces, we freed her up from a package of academic busy work and taught her to love learning. Hearing how this has impacted her life and the lives of her family is what keeps the staff at NACD doing what we love to do. Read all about their journey:

From Marie, Stella’s mother

My name is Marie, and I am the mother of Stella. We have been receiving NACD services since September 2022. Over the last nine months our family has gone through multiple challenges and changes, including moving from Texas to Puerto Rico, becoming farmers, and starting homeschooling. NACD has been an important part of this change, as it has provided us with guidance and support. Stella started her education at home with me when she was very small. Before her 1^st year of age, I started reading to her, singing, showing her colors, and stimulating her physical, emotional, and cognitive development as much as I could until the age of 4, when she started going to preschool. She was a smart and eager-to-learn little girl, already bilingual (Spanish and English), even when our main language was Spanish. Later we moved to the States, where Stella started Kindergarten. This is when I started noticing problems with her learning process. The girl that was eager to learn was now crying about sight words, and was struggling switching letters and sounds when reading, and not wanting to go to school. I was heartbroken, but our financial situation would not allow me to stay with her at home, or so I thought. Around that time, we received recommendations to stop reading to her in Spanish, and by the age of 6 she was forgetting Spanish. By second grade we had noticed that the previous issues would not be resolved, and now she was also struggling with mathematical problems. The girl that loved numbers and was able to count and do simple math tasks now was struggling and hating math. Her teachers were instructing us to take her out of her extracurriculars (sports and music), the only areas she was feeling successful about. We refused. Right before we started NACD for her 8^th grade, Stella had good grades at the cost of her peace and rest. She was restless, agitated, and anxious most of the time. Her mood would swing, and she was frequently upset. She would listen to conversations differently than what we said and feel upset about it. She was putting more effort into her schoolwork than any of her peers just to catch up. It was so hard to see her at the dining table completing work from the classroom, and later her homework. When we asked the schools for evaluations or support, they would only notice her excellent grades, but not the extra effort and anxiety she was struggling with. When we started NACD Stella had started a bunch of books but had not finished any yet. She used to say she hated to read and hated math. Now the story is so different. After only nine months of NACD programming, we have seen such a change. Lyn has been an amazing source of wisdom and guidance, and Melody has been the strong and kind hand taking us from point A to point B. Here is a brief list of some of the changes we have noticed:

• More responsibility.
• Increased comprehension of verbal commands, social cues, and even reading.
• Increased attention span: Able to follow multi-step directions and recall appropriately when asked to complete tasks and chores.
• Better self-regulation in conversations, when upset, and when discussing different points of view.
• Is more self-regulated in terms of how to invest time in different activities (fun vs. responsibilities).
• Able to accept her mistakes and point at mistakes appropriately, not taking it personally, but explaining, or accepting whatever is appropriate in the situation.
• Identifies what is working for her and what is not; negotiates.
• Learning to manage money (math), as before she would avoid trying to pay for things and even look at what she was supposed to pay or receive as change (avoidance of the math process).
• She is interested in audiobooks and in reading paper books, when in the past she had no interest in books in general. Has completed about 5 books (paper books) over the course of the year, and multiple audiobooks, when previously it was impossible for her to complete 1 book per year.
• Overall, she seems more mature.

We are thrilled with her progress and the person she truly is. It is beautiful to see my wonderful teen being able to show her true colors, without the anxiety, without the moods and the exhaustion. We are excited about what is to come, and even though we are not done yet, the current progress is so wonderful, and our family is better because of it. We are living a much simpler life. Currently we are farming, and I am working from home, and even when it took a leap of faith to get here, I wouldn’t change it for the world. My daughter’s peace and healthy development is worth the change! Thanks, NACD, for your support throughout these 9 months! We are excited about the journey to come!

            • Reprinted by permission NACD Newsletter, July 2023 ©NACD

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I am a big believer in identifying patterns, collecting data, and building new and better patterns. I would like to suggest to you parents that for a week you collect some data; try to be “normal,” don’t go out of your way to change your behavior—yet. Each day record how much quality targeted time you spend with your kids. You can include time teaching them how to mow the lawn or load the dishwasher, to teaching them how to kick a soccer ball, to talking to them about what they learned at school today, to teaching them about all the important stuff you know and care about over dinner, but to qualify you have to be talking.

After your week of collecting data, evaluate it. Because you were aware of what you were doing, your data is probably going to be a lot better than the previous weeks, but so be it. Look at your data and evaluate how well you think you did. Then think about how you could have done better and then do it. Be conscious, be aware, and strive to create new behavior patterns that provide your children with more of your life-changing attention.

Dads, you might suspect that this was largely directed at you, and you would be correct. We dads have some special power—use it!

      Reprinted by permission of The NACD Foundation, Volume 36 No. 3, 2023 ©NACD

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According to the Yale Center for Dyslexia and Creativity, “Dyslexia affects about 20% of the population and represents 80-90% of those with learning disabilities.” We are talking about as many as 62 million children and adults!

What is “dyslexia?” It’s a developmental reading problem.

Did you know that virtually every child under five could be called “dyslexic” if you tried to teach most of them to read with the same techniques that are used with first and second grade children? The vast majority of children under five have not developed neurodevelopmentally to the point that they can:

• hear/differentiate similar vocal sounds as well as needed to use phonics
• sequentially process a series/sequence of sounds/phonemes
• sequentially process a series/sequence of symbols well
• mentally hold together and manipulate a series/sequence of sounds/phonemes that would permit them to construct a word

In addition, many children under five also have not developed to the point that they have organized their brains such that they have developed a dominant hemisphere, also referred to as the language hemisphere (spoken and written) and are not even sure which hand they should be using. This lack of hemispheric dominance is also what produces reversals (Is it a “b” or a “d”?), which just contributes to the problem.

Logically, if most children under five share the same characteristics as older children labeled as “dyslexic” and would have the same problem learning to read as do the older children that have “dyslexia,” then it follows that “dyslexia” is a developmental problem that can be addressed. It’s not a mystery and it’s not incurable.

For decades millions of parents have seen their children struggling with reading and have ended up having them diagnosed with dyslexia. Generally when they pushed for an explanation and a plan, they were met with the impression that their child had a mysterious, incurable disease and was doomed to having a life long problem, but they would make accommodations for them. But prior to “dyslexia” being widely used as an administrative label, children with reading issues or related problems were perceived simply as typical kids who for some reason were not doing well with reading as it was being taught. Essentially, the uniqueness of each child was perceived as part of who we are; and that we are different; and in the case of reading, some develop differently and at different rates, and some needed different approaches. If the perception was that Johnny was “normal” and had a problem with reading, then his specific problem needed to be identified and addressed.

As special education took root around the country, administratively it became necessary to identify, then label children so that they could receive special placement, have different expectations placed on them, or so that they could receive special services. Once labeled, the door was open for the local school system to receive extra state and even federal funding. Thus all the children who previously simply had a reading problem became children with dyslexia. The result was that the child who had previously been seen as normal now became a child with a mysterious disease—dyslexia. To compound the problem, the disease/label model directly or indirectly implies that everyone with the disease has the same problem, which implies the same solution or cure. If a common cure can’t be found, then no treatment is perceived as valid, as has happened with those labeled as having ADD or ADHD. In the case of ADD and ADHD, when everyone with the “disease” is perceived as having the same problem with a mysterious cause, and if there is then not a universally successful treatment, then the answer is to retreat to a drug. It’s not too surprising that if you look at the list of symptoms used to diagnose ADD, it reads like the description of virtually every three or four year old child: short attention span, distractible, impulsive. As with children labeled with ADD and ADHD, children labeled as dyslexic or who have a learning problem share many of the same developmental issues as younger children. The origin of the problem is usually various issues associated with neurodevelopment. That which is developmental changes, and what changes can be developed. There are solutions.

The answer to the question of why can’t Johnny read changed from, “We need to find the technique that works for him and the root of the problem” to simply, “Johnny can’t read because he’s dyslexic.”

Essentially the term dyslexia means that there is a reading problem. When the “problem” was first identified, it was done so by a German ophthalmologist, an eye doctor who viewed the problem as word blindness. Up until into the sixties, dyslexia was largely categorized as a visual problem that was identified primarily by reversals. Children had difficulty distinguishing between a “b” and “d” or “saw” for “was.” Surprise, many four year olds confuse “b’” and “d” and have reversals. These reversals were, and in reality are still today, perceived as a bit of mystery by most, but are really the reflection of the level of neurodevelopmental organization. The child is young and the brain has not reached a level of organization that has permitted the development of a dominant hemisphere. The recognition that visual issues were involved in dyslexia also led to the belief that the root cause was an issue with visual tracking and convergence. It has been recognized that such visual problems may exist in children with and without dyslexia, but it is not the cause.

Today dyslexia is primarily viewed as an auditory/phonological problem, not a visual problem, because most children are now being taught reading with an auditory/phonological approach–phonics. The trend in perception of dyslexia as being primarily a visual, as opposed to auditory, problem were based on the predominant reading approach at the time.

Elimination of dyslexia can be as simple as using a different approach to reading; but ideally we will identify any of a variety of underlying developmental issues, which once identified are usually fairly easy to remediate. *

When folks ask us at NACD about dyslexia, we tell them that we refer to those who come to us with dyslexia as the “easy ones.”

*Neurologically and functionally there can actually be some advantages to having “dyslexia,” particularly once the actually reading issues have been addressed. When working with specific unique whole children, we can identify their individual issues and their individual strengths and work to help them become successful and even take advantage of some of their uniqueness.

Reprinted by permission of The NACD Foundation, Volume 33 No. 6, 2020 ©NACD

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It appears that middle ear fluid (otitis media with effusion) is a significant problem for children with Down syndrome. Our experience at NACD with literally thousands of children with Down syndrome indicates that middle ear fluid issues are ubiquitous and are of tremendous concern relative to the global development in this population.

For forty years NACD at any given time is working with approximately 300 children and adults with Down syndrome from all over the world. We work with the “whole” individual and look for correlations between issues to determine how to best address problems and global development.

One of the ongoing issues affecting overall medical care and therapeutic intervention, particularly as is it impacts children with developmental issues and complex interdependent issues, is the compartmentalization of the care. At NACD we are acuity aware of the importance of working with the “whole” child. Looking at isolated pieces can lead to ongoing issues that can have very significant impact on the child’s development and could possibly be remediated if the need were perceived based on the totality of the impact.

When looking at the “whole” child, it is possible to identify discrepancies in development. Development in children with Down syndrome typically follows “normal” development. This development, albeit slower than normal, follows the same patterns and exhibits the same associated developmental pieces as ‘typical” children. In areas where there are inconsistencies in the development of associated pieces, it is necessary to identify underlying cause. Often when language is delayed more than other areas, the underlying cause is something that is adversely affecting the hearing.

When dealing with a problem such as middle ear fluid, we want to address cause when possible. Mucus and congestion are virtually synonymous with middle ear fluid. It would appear that we could avoid at least part of the fluid problem by more aggressively addressing the cause of mucus. Many children have allergies that can be treated, but mucus-producing foods are in most every child’s diet. It would appear that if we could eliminate dairy and gluten from our children’s diets, we would probably go a long way toward avoiding or mitigating these issues.

Children with DS have anatomical issues that increase the prevalence of middle ear fluid. These issues include large adenoids, small nasopharynx, impaired swallowing, and narrow and abnormally horizontal Eustachian tubes. These anatomical issues, coupled with the fact that children with DS tend to have excessive mucus and excessive earwax, further complicates the problem. Middle ear fluid issues often resolve themselves in typical children; but the anatomical issues associated with DS make this substantially more difficult.

One of the issues that appears to create problems for children with DS is that middle ear fluid, even if considered in the “normal” range based on tympanic testing, can still have a significant impact on the hearing and development of this population. Over the course of decades, we have seen numerous cases where at parents’ insistence tubes were inserted even though tympanograms indicated that fluid was still within “normal” ranges.¹ Following many of these procedures the doctors commented after the procedure that there was much more fluid than expected. It appears that for the majority of children with DS having received tubes, even when the need based on the exams and testing was questionable, there were virtually immediate positive changes in language development. I leave it to the ENTs (otolaryngologists) to research and determine if different testing, norms, or criteria are needed. This is clearly an area requiring further investigation.

Complicating the issue as to whether or not to place tubes is the issue of what level of baseline testing is needed. Often children will have a flat tympanograms, and the doctor’s recommendation is to wait two, four, or even six months to repeat the testing. For a child, particularly a child with delayed language and cognitive development, two months or more can have tremendous impact on the child’s future development. If the doctor wishes to be cautious, repeat the tympanogram in two weeks. One might also consider the child with chronic congestion who will have some degree of associated chronic middle ear fluid. Why not in such cases insert tubes to assist with the mechanics and help drain the fluid? When this issue is seen relative to its global impact on the development of the child with DS, I believe aggressive treatment can be justified. Tubes would appear to be a relatively simple, inexpensive, benign treatment that can have significant, if not dramatic, impact on a child’s development and future.

To understand the significance of this issue, let’s look at developmental issues that can result from perhaps even a moderate issue with middle ear fluid.

Middle ear fluid issues have a negative developmental impact on numerous foundational developmental issues including:

• Hearing

• Receptive language development

• Expressive language development

• Speech/articulation

• Auditory sequential processing, short term memory, working memory, and cognitive development

• Attention

• Reading

• Balance, mobility, walking

• Visual tracking, convergence, strabismus

Hearing

Hearing involves sound waves moving into and through the outer ear and impacting the eardrum. The sound waves vibrate the eardrum, which in turn produces movement of the three small bones of the middle ear. The middle ear is a cavity containing air that should have the same atmospheric pressure as that outside the body. The pressure is regulated by the Eustachian tubes, which go from the middle ear to the upper part of the throat. The sound waves then produce vibrations on the oval window that then transmits the vibrations to the fluid in the inner ear, which in turn stimulates the hair cells of the cochlea, transforming the vibrations into nerve impulses that enter the acoustic nerve and then the brain. It is the brain that actually interprets the information and “hears” the sounds or words.

One of the immediate issues with middle ear fluid is resulting hearing loss. Numerous studies have equated hearing loss in DS to middle ear fluid. ^2,3 Conductive hearing loss, which is common in DS, is usually caused by middle ear fluid, but can also be caused by excessive wax.

Receptive Language Development

Receptive language refers to the ability to understand language. Every child begins learning to understand language by hearing specific words in association with specific objects or events with sufficient frequency, intensity, and duration. The consistency of this input is imperative for the child to literally learn to hear and understand. A completely deaf child receives none of this auditory input; a child with a hearing loss receives poor input; and a child with inconsistent input resulting from variations in middle ear fluid receives often less than the necessary quality of input needed for receptive language development. Receptive language is the first step in the development of expressive language, speech, and cognition.

Expressive Language Development

Expressive language/talking has been historically one of the biggest concerns for children with DS. Sometimes those not understanding the foundational issues will out of vexation resort to sign language or augmentative communication to facilitate communication and avoid frustration. Lack of function should not be perceived as a lack of potential or inherent ability to develop that function. If a child with DS is not talking, there is a reason that needs to be identified and addressed. Rarely do children with DS have oral motor issues or apraxia to such a degree that it prohibits the development of basic language, even though such issues can affect the speech. Significant delay in the development of language in a child with DS is virtually always a reflection of an issue with hearing or inconsistent hearing.

Speech/Articulation

Developmentally we refer to speech/articulation as the production and clarity of speech. A significant component of speech is oral motor function, which is a very common issue with children with DS. However, you cannot reproduce what you cannot hear. Middle ear fluid issues can produce issues with learning to process specific frequencies of sound. If you cannot hear, or if your brain does not learn to hear, a specific frequency, then it can’t be reproduced. Case in point, there is not an “r” sound in Japanese, and even for a native Japanese speaker who becomes fluent in English, the “r” sound may be next to impossible to learn because when their brains were learning to hear, the opportunity to hear that sound did not exist. Repeating the word “rice” typically comes out as “lice,” regardless of the number of times they hear the word spoken correctly. Audiograms, which only measure typically six frequencies, do not identity very specific frequency issues. We have used voice analysis to gain a better understanding of specific frequency issues and have discovered that they are extremely common. I would like to see research directed at seeing whether voice analysis could be used to accurately assess hearing more specifically and objectively than an audiogram or in conjunction with and audiogram.

Auditory Sequential Processing, Short Term Memory, Working Memory, and Cognition

Language and the development of language is primarily a reflection of the development of auditory sequential processing. Expressive language will not exceed the ability to sequentially process, hold, and mentally manipulate auditory information. Auditory sequential processing/short term memory is measured in pieces of auditory information that can be processed in a sequence or chain. This is often tested and measured by how many numbers you can hear presented in a sequence at one-second intervals. It could also be measure by the ability to listen to and repeat random words also heard at one-second intervals and repeated or how many simple directions one can hear in a sequence and then carry out. Generally, a child who can follow one simple direction will use random isolated words, working into functional use of individual words. As the child moves into being able to follow two-step directions, they will begin using two and then three-word phrases. When they can sequence three pieces, they will start using four, then five words in a sentence. As their auditory sequential processing increases, so does their receptive and expressive language.

The foundation of working memory, which is now appropriately being called the new IQ, is built upon the short-term memory. Working memory essentially represents complexity of thought and is reflected in global maturity and executive function. All of this put together represents cognition, which is simply that which permits us to learn, think, and communicate.

Issues affecting hearing in the first few years can have a negative impact on the development of all of these critical pieces, an impact that may not be able to be entirely remediated, or which requires years of extensive specific targeted intervention.

Attention

Over six million children have been diagnosed with the mysterious “disease” of ADHD, which is termed as a mental disorder, rather than a developmental disorder. Perhaps this delineation is based on a perception that a mental disorder can be treated with drugs, as opposed to a developmental issue that cannot. I believe that one of the most common issues affecting attention is auditory sequential processing and that one of the primary causes of auditory processing issues is recurrent middle ear fluid in children. The inconsistencies in hearing adversely affect the child’s ability to attend to and process language, resulting in slow or underdeveloped auditory development, including auditory sequential processing. Negatively impact auditory processing and you subsequently negatively impact auditory short-term memory, auditory working memory, executive function, and global maturity. The term ADHD is at times used as a secondary or dual diagnosis for those with Down syndrome and other developmental problems, but the symptoms that result in this label exist in every child with a developmental cognitive delay. It is questionable at the very least to ignore the cause or causes and needed developmental intervention by attempting to mask the symptoms with medication.

Reading

Learning to read can be very negatively impacted by even minor hearing or specific auditory tonal processing issues. Teaching reading using an auditory tonal and auditory sequential processing approach, such as phonics, is often disastrous for those with Down syndrome because of their auditory issues. However, children taught reading through a more visually based sight word approach do much better. A visually weighted word attack approach still has a significant auditory component. Issues with auditory tonal and sequential processing have a negative impact regardless of the reading approach, but significantly less of an effect with a sight-reading foundation.

An additional issue relating middle ear fluid and reading is the role of the vestibular-ocular reflex in reading and writing. The vestibular-ocular reflex is a reflex that associates activation of the vestibular system and eye movements. Any interference in this reflex adversely affects the ability to maintain focus. There is almost constant slight head movement when one is reading or writing. Interference in the vestibular-ocular reflex negatively impacts the compensatory eye movements that permit the child to sustain focus.⁴

Balance, Mobility and Walking

Walking has a profound effect on neurological development and is associated with language and cognitive development. Children with DS often have issues with tactility, muscle tone and strength that can delay and or complicate gross motor development and walking. These issues are only compounded if the development of balance is compromised. Middle ear fluid has a negative impact on the inner ear’s balance/vestibular system, as well as the vestibular–ocular reflex, further complicating the development of balance, depth perception and thus walking.⁵

Visual Tracking, Convergence, and Strabismus

The vestibular system plays a significant role in the development of ocular control, tracking, and the development and severity of strabismus. The vestibular system as mentioned previously affects the movement and control of the extraocular muscles that are responsible for visual tracking and which need to work in concert to keep the two eyes working together.

It is not unusual to see children with DS suddenly develop a strabismus or to see it suddenly get worse.⁶ When we become aware of these issues, we suggest that the family visit their ENT first, not their optometrist or ophthalmologist, because the most likely cause of the issue is middle ear fluid. Strabismus, which is a misalignment of the eyes, can take many forms, but generally the family will observe one eye or the other going in toward the nose or out toward the ear. If a strabismus exists the child is unable to perfectly align the eyes together, with a resulting loss of depth perception. It would appear that even slight issues with middle ear fluid could have a negative impact on ocular control and a negative impact on a wide range of functions. 

Conclusion

Seen in isolation some degree of middle ear fluid may not appear to be of great significance. However, in viewing the global aspects of middle ear fluid we have an issue that can have wide ranging and significant impact on a child’s future development.

We urge parents and professional to be vigilant and to address ear fluid aggressively. Remediation of issues associated with middle ear fluid generally requires targeted, vigorous, dynamic, and coordinated intervention.

References

1. Ear Center: Ear Tubes (Bilateral Myringotomy & Transtympanic Tubes)
   http://www.earcentergreensboro.com/medical-education/ear_tubes.php
2. Otitis media with effusion with Down syndrome
   Int J Pediatr Otorhinolaryngol. 2013 Aug;77(8):1329-32. doi: 10.1016/j.ijporl.2013.05.027. Epub 2013 Jun 20.
   In this study one in three eight-year-old children with DS had current middle ear fluid and had verified hearing loss.
3. Balkany, T.J., Mischke, R.E., Downs, M.P. & Jafek, B.W. (1979). Ossicular abnormalities in Down’s syndrome. Otolaryngology: Head and Neck Surgery, 87, 372-384. Middle ear fluid issues account for 83% of hearing loss in children with DS
4. The influence of eye movement and the vestibular-ocular reflex in reading and writing. Rev. CEFAC vol.16 no.6 São Paulo Nov./Dec. 2014 http://www.scielo.br/scielo.php?pid=S1516-18462014000601791&script=sci_arttext&tlng=en
5. The effect of otitis media with effusions on balance in children. Clin Otolaryngol Allied Sci. 2004 Aug;29(4):318-20. https://www.ncbi.nlm.nih.gov/pubmed/15270815
6. Ophthalmic complications of otitis media in child J AAPOS. 2011 Jun;15(3):272-5. doi: 10.1016/j.jaapos.2010.12.018.ren https://www.ncbi.nlm.nih.gov/pubmed/21777800

Reprinted by permission of The NACD Foundation, Volume 31 No. 9, 2018 ©NACD

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