Friday, May 22, 2009

Childhood Ear Infections and ADHD: Why the link?

When we scan the literature for statistics on ADHD and search for early warning signs or tip-offs that a young child may be prone to the disorder, a few common trends seem to pop up again and again. One of these is the high rates of ADHD and attentional difficulties in kids suffering infection of the middle ear (Otitis Media) in early childhood.

During early childhood, the actual positioning of the ear canal is still adjusting, the pathway into the middle part of the ear is actually at a flatter angle than in a mature adult. This difference in positioning actually makes younger children much more prone to ear infections than older children or adults. Unfortunately, these infections may increase the risk of further complications down the road, including an increased onset of attentional difficulties, including ADHD. Here is what some of the literature has to say about the ADHD/ear infection connections:

Relationship between middle ear infections and inattention: The basis for inattentive ADHD?

The main culprit for attentional deficits is often believed to be the result of hearing loss (even mild), early in a child's life due to complications with the middle ear, including infections, allergy-related causes or build-up of fluids in the canal. As a result, the child begins to miss out on verbal cues, and does not develop the same level of response to an adult voice. Auditory deficiencies (including auditory processing disorders) may stem from this key development period, even if the hearing difficulties are only temporary.

Not surprisingly, there is a wealth of data associated with hearing loss due to middle ear complications can lead to language processing difficulties. We have seen how auditory processing disorders can often occur as a comorbid factor in ADHD, and may be linked to seemingly unrelated behaviors including comorbid anxiety and conduct-related disorders.

It is important to note, however, that other early childhood studies have not seen a link between infection and attentional difficulties (observed by parents, teachers, or clinicians).

Interestingly, environment may play a huge role in explaining this discrepancy between study results. One study found that children who had middle ear complications early on along with poor home environments were significantly more likely to develop attentional difficulties (along the lines of what would be classified as ADHD). Therefore, the effects of early ear infections on compromised attentional difficulties may be significantly reduced if a supportive home environment is maintained for a child. This is good news for parents of children with ear infections. But what about the hyperactive component of ADHD?

The link between hyperactive behaviors and middle ear complications: The basis for hyperactive/impulsive or combined subtype ADHD?

While it seems more intuitive that ear infections could lead to auditory problems and subsequent attentional difficulties (especially to auditory cues), the relationship between ear infections and hyperactivity is less inherently obvious. This association would be more relevant to the hyperactive/impulsive and combined subtypes of ADHD.

For over 30 years, researchers have linked high rates of ear infections and hyperactivity (this study used the term "minimal brain dysfunction", a phrase which this blogger has personal objections, nevertheless, it is a relatively common term in the literature). Later studies confirmed these findings, including one which reported the majority of children medicated for hyperactivity had a past history of 10 or more childhood ear infections. These numbers were in sharp contrast to the prevalence of ADHD in non-hyperactive children.

One thought may be that ADHD which includes a significant hyperactive component (as opposed to the more inattention-dominated form of the disorder) is more likely to be associated with comorbid disorders that correspond to ear infections. We have seen previously that comorbid disorders to ADHD are often related to particular subtypes.

For example, anxiety and depressive-like symptoms are often more likely to co-exist with primarily inattentive ADHD, while conduct disorders are more likely to co-exist if there is a high hyperactive/impulsive behavior (especially in the combined subtype). In general, the prevalence of more severe learning disabilities is often more associated with the inattention-dominant form of ADHD, while motor tics are more likely to be a hyperactive/impulsive trait. Carrying these associations in mind, are the studies linking early ear infections to hyperactivity simply due to associations with hyperactive subtype-dominated comorbid disorders?

One particular study found that children with hyperactivity vs. children with learning disabilities (and not hyperactivity, remember, learning disabilities are often seen at higher rates in the inattentive forms of the disorder) had similar numbers of total childhood ear infections. However, the timing of the infections did seem to matter. Children with hyperactivity experienced more recent ear infections (within the previous year) compared to the learning disability kids.

In other words, the question surrounding hyperactivity and ear infections may be more of a "when" question than a "how many" question. This may also suggest the possibility that hyperactivity due to middle ear troubles may be more of a temporary condition (this is supported by trends as an individual with ADHD ages, typically, the hyperactive symptoms of the disorder begin to subside as a child gets older and reaches adulthood, while the inattentive symptoms are more likely to plateau) as opposed to inattentive problems stemming from ear infections. Severity of the infections may also be a triggering cause or associated warning sign of an increased risk of developing hyperactive behaviors. The same study found that earaches and upper respiratory tract infections were higher in the hyperactive group than in the less-hyper learning disability group.

So what's going on with the connection between ear infections and ADHD-like hyperactivity?:
Although none of the above studies mentioned this possibility, as a blogger I have a few ideas on the subject. One of the most probable reasons for the ear infection/hyperactivity correlation may be due to the treatment process of ear infections. Let me explain:

Ear infections are typically treated with antibiotics. While these drugs work wonders for most infections, they also can disrupt the healthy bacterial counts in the digestive tract (that is, they kill off many of the "good" bacteria in our digestive systems in addition to the "bad" bacteria which may be causing our infections).

If the "good" digestive bacterial counts fall too low, the digestive process is compromised. The absorption and digestion process may suffer, as key nutrients may now be compromised (even if no major dietary changes occur). We have spoken extensively about nutrient deficiencies and ADHD as well as ADHD-related nutrition strategies in earlier posts.

Additionally, if good bacterial counts fall low, incomplete digestion results, which can lead to byproducts such as higher concentrations of organic acids, as well as incomplete breakdowns of potential allergens (which can increase sensitivity to food allergens, among others). These allergens and acids can actually begin to penetrate the blood brain barrier and show up in higher concentrations in the brain. Neurological disorders, including abnormal hyperactivity may actually be triggered by digestive imbalances (to a degree beyond what most of us realize). We are just beginning to recognize the huge degree of inter-relationship between the nervous and digestive systems, including brain-gut interactions.

There has been a longstanding "hot" discussion surrounding food allergies and ADHD (as well as possible connections between food allergies and disorders like fibromyalgia and chronic fatigue syndrome), and the disrupted bacterial balance in the digestive system due to frequent antibiotic usage for recurrent ear infections may be a governing factor. This seems to make sense, especially considering the fact that hyperactivity was more linked to recent ear infections (and resultant antibiotic treatment), while the more inattentive behaviors and learning disorders seem to be a more long-standing symptom. Since bacterial counts begin to re-stabilize following antibiotic treatment (if a proper diet is maintained), the food-related hyperactivity may begin to subside, but for recent infections and treatments, the digestive bacteria may still be imbalanced, triggering an onset of ADHD-like hyperactive behaviors.

Of course this is just the blogger's personal hypothesis, but it at least seems plausible that the actual treatment for ear infections may play an equally strong role on the high rate of occurrence between ADHD and ear infections.

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Anonymous said...

There's also a link between ear infections in autism, but I don't think that anyone seriously suspects that autism is a result of hearing problems. A possible culprit, in my opinion, is low reduced glutathione levels. I don't know if there are any studies of glutathione levels in the ADHD population, but low glutathione is not uncommon in autistics. Glutathione protects against infection and is also a natural anti-oxidant. Low reduced glutathione levels are indicative of oxidative stress.

Children with chronic ear infections tend to have low reduced glutathione levels.


: Otolaryngol Head Neck Surg. 2004 Dec;131(6):797-803.Click here to read Links
The role of oxidants and antioxidants in otitis media with effusion in children.
Yilmaz T, Koçan EG, Besler HT, Yilmaz G, Gürsel B.

Department of Otolaryngology--Head and Neck Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey.

OBJECTIVE: Determine the possible role of oxidants and antioxidants in the pathogenesis of otitis media with effusion in children. STUDY DESIGN AND SETTING: Randomized controlled trial, tertiary referral center. The study group was made up of children with otitis media with effusion who were to undergo bilateral ventilation tube insertion and adenoidectomy. The control group was comprised of otherwise healthy children. The blood levels of antioxidants (retinol, beta-carotene, alpha-tocopherol, laycopene, ascorbic acid, superoxide dismutase, glutathione peroxidase, GSH) and oxidation products (malondialdehyde) were determined before and 1 month after the operation in the study group and once only in the control group. These substances were also measured in the adenoid tissue and middle ear fluids. RESULTS: In the study group, the blood levels of antioxidants and oxidants before and after the operation were significantly different when compared with the control group (P < 0.05). In the study group, the blood antioxidant levels increased and oxidant levels decreased significantly after the operation (P < 0.05). The levels after the operation never reached those of the control group. CONCLUSIONS AND SIGNIFICANCE: Oxidants and antioxidants played a significant role in the pathogenesis of otitis media with effusion in children. These children are under significant oxidative stress. Insertion of a ventilation tube and adenoidectomy significantly decreased the oxidative stress in these patients, but could not normalize it completely. Additional studies are necessary in the clinical use of antioxidants in otitis media with effusion.

Anonymous said...

OK, this is the only study I can find on pubmed that looks at glutathioine levels in ADHD subjects. My reading of the abtract is that the study found that ADHD subjects have lower amounts of reduced glutathione than the controls.

Bookwurm 2

Redox Rep. 2006;11(4):163-72.Click here to read Links
The effect of polyphenolic extract from pine bark, Pycnogenol on the level of glutathione in children suffering from attention deficit hyperactivity disorder (ADHD).
Dvoráková M, Sivonová M, Trebatická J, Skodácek I, Waczuliková I, Muchová J, Duracková Z.

Department of Medical Chemistry, Biochemistry and Clinical Biochemistry, Faculty of Medicine, Comenius University, Bratislava, Slovak Republic.

Attention deficit hyperactivity disorder (ADHD) belongs to the neurodevelopmental disorders characterized by impulsivity, distractibility and hyperactivity. In the pathogenesis of ADHD genetic and non-genetic factors play an important role. It is assumed that one of non-genetic factors should be oxidative stress. Pycnogenol, an extract from the pine bark, consists of bioflavonoids, catechins, procyanidins and phenolic acids. Pycnogenol acts as powerful antioxidant, chelating agent; it stimulates the activities of some enzymes, like SOD, eNOS, and exhibits other biological activities. AIM: The aim of this randomized, double-blind, placebo-controlled trial was to investigate the influence of administered Pycnogenol or placebo on the level of reduced (GSH) and oxidized (GSSG) glutathione in children suffering from ADHD and on total antioxidant status (TAS). This is the first investigation of the redox glutathione state in relation to ADHD. RESULTS: One month of Pycnogenol administration (1 mg/kg body weight/day) caused a significant decrease in GSSG and a highly significant increase in GSH levels as well as improvement of GSH/GSSG ratio in comparison to a group of patients taking a placebo. TAS in children with ADHD was decreased in comparison with reference values. Pycnogenol administration normalizes TAS of ADHD children.

Anonymous said...

One last comment: Pycnogenol is a strong anti-oxidant that readily passes through the blood brain barrier... Coincidence?

Anonymous said...,_ECAP_2008,_Pelsser_et_al.pdf

Mrs. Ed said...

Very interesting. I was looking for something like this for a friend. One of her children has adhd and had severe ear infections when young. I was looking for something that would explain the link with antibiotics. Although another friend has an adhd child who's always been healthy.

barry said...

I work every day with children with AD/HD. I have clearly seen the link between ear infections and behavioral disorders. It is my opinion that ear infections do not cause AD/HD. Ear infection can and do trigger symptoms of AD/HD, but these symptoms are related to the maladaptive defense mechanisms of the child and not AD/HD. The best diagnosis for behaivoral disruptions related to ear infections is probably Reactive Attachment Disorder.

Tami said...

You should test your hypothesis. I have to say I had chronic ear infections with ear tubes and antibiotics and hearing loss from aged 3-12. When I was 7, I was diagnosed with ADHD and I had a poor home environment, in that my father was physically and verbally abusive and my parents fought. I was made fun of at school with such severity! When I was 13, I decided to sto my meds and something amazing happened, my ADHD symptoms slowly disappeared. Now I have sucessfully become an RN, and have no concentration issues whatsoever. I'm in grad school and all is well. I think you are onto something.

Anonymous said...

This is very interesting. My 8year old son has been dio with ADD/ADHD. Diet has controlled his ADHD but ADD is a whole other animal. When he was small he had cronic ear infections. At 6years of age we found he had an cholesteatoma (tumor in his middle ear). They removed it with one surgery and then with another repaired his hearing bones that had dissolved by the tumor. He is in 3rd grade now and struggling. We are now testing for learning disabilities. We have not put him on any drugs. We are doing the supplement route. He takes multi-vit, probiotics, enzymes, B12, Vit D, Fish Oil, phosphate and Magnesium. His diet is all natural, no ref. sugars, No adds/preservs, no high fructose corn syrup, and I'm sure I"m missing one. But that really helped the ADHD.

Miss Dipsy said...

I have a theory I've been pondering for a long time that explains these odd links between things like ear infections and ADHD\autism quite well. I think problems like ear infections reduce the individual's ability to compensate for the negative aspects of their condition, thus making it more obvious. The key point is that there seems to be a connection between these problems and diagnosed cases of ADHD or autism, and for diagnosis the individual must be impaired beyond a certain level. Many people seem to fit the profile of things like ADHD or Aspergers, yet aren't diagnosed as they manage to get by OK in life. Generally these individuals have had many advantages such as a stable family background, good health, high IQ and so on. When you look at those who suffer the most severe forms of ADHD and ASDs, there is often a history of other health problems, a family who have found it very hard to cope with the child's difficulties, birth complications &/or comorbid disorders.

I say this from personal experience, from close observation of other people, and from reading a range of literature on the subject. I almost certainly have ADHD but am unable to even get an assessment since I compensate so well that Drs can't grasp the fact that I struggle with the most basic things (in the UK it's hard to get an ADHD diagnosis anyway). In many respects my life's a mess, but I do a surprisingly good job of just about holding it together and appearing relatively normal (to an outside observer who doesn't know how bad things are behind the scenes, anyway! Those who know me well know just what a mess it all is), or at least bouncing back after I've f***ed everything up for the millionth time! However, I have a high IQ, a supportive and stable family, a decent education, an optimistic outlook on life and a thirst for learning. Although my actions may not appear conscientious, I have a conscientious attitude, I try to be thoughtful and caring about other people, to be reliable, organised and careful, and to do my best, although it might not look that way to others. I think my positive qualities help me keep some of the most undesirable aspects of ADHD under some semblance of control. I care deeply about whether I do things to upset or irritate others, and want to do well in life, and although my brain tends to sabbotage my best efforts, I mostly manage to avoid messing things up beyond repair! Although I struggle, I know everything would be much worse if I were not able to compensate to some extent.

I also believe that my theory explains part of why these conditions tend to be diagnosed more in males than females; females tend to exhibit more compensatory traits than males (whether this is innate or learnt is largely irrelevant, although personally I feel it's a mixture of both). Girls tend to be more eager to please, more aware of other people's feelings and thoughts, less physically boisterous, more socially able, and more skilled verbally. All of these things will help mitigate some negative symptoms of ADHD and ASDs. It is already widely accepted that female autistics tend to exhibit different symptoms to males and are usually more able to compensate and "blend in".

I can see my daughter's ear infections having exactly this effect; I always had strong suspicions that my son might have ADHD but it didn't occur to me until recently that my daughter could too as she exhibited all of the classic "female" traits listed above. She has had bad ear infections her whole life, which have affected her hearing and I have noticed over the years that her ability to concentrate and her overall behaviour has worsened, while my son seems to have improved slightly. It seems that my son has been learning to improve his behaviour as his only impairment is the ADHD, whereas my daughter has been struggling in the face of a hearing difficulty which has reduced her capacity to compensate for some of her other problems and has thus made them much more obvious.

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Barry Swope said...

I just compiled a database of 317 children that we have served in the last 3 years that were diagnosed with ADHD and/or ODD. Of that group a full 70% experienced severe trauma in the first 14 months of life in the form of Chronic Otitis Media,Severe Asthma, Multiple Surgeries, and/or abuse. More than 50% had Otitis Media alone. (8 infections and/or tubes). I feel that the best explaination for the ADHD/Ear Infection connection is Trauma, not hearing loss. The early trauma disrupts the developmental stage of Trust Vs Mistrust (Erikson) and damages the Norephineprine transport system. (See Bruce Perry's work on Trauma at am pretty sure about this. I see the patterns of trauma on the CPT tests as well. Lots of data. Anyone know how to do a better study? I am a clinician and not a researcher.

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Anonymous said...

I believe the link is the use of antibiotics!! I have suffered all my life with ADD. Recently I started taking probiotics and interestingly it seemed to resolve my ADD issues to such a shocking extent that I started telling everyone about the probiotics. Well 2 days ago I stop the probiotics and starting taking an antibiotic doxycycline which my doctor said was very safe and had no known side effects for an infection in my uterus and within a few hours my mood started to really go down. It is now 2 days later and I have been walking around my house in a fog unable to get myself together to go to work!! My son had severe ear infections as a baby and has really suffered with ADD. He has to work hard just to be organized. He amazingly got probiotics on his own and is reporting great results on them!!!

Anonymous said...

There is a study just published in Science suggesting inner ear disorder in ADHD. "I don't think that anyone seriously suspects that autism is a result of hearing problems". I do, actually, or to be more precise, I think all the symptoms of autism arise from primary fluctuating or distorting auditory and vestibular inner ear function in infancy, together with secondary induced brain malfunction. See ResearchGate for my publications on this and related topics.

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Scott Huffman said...

Now I have heard it all. Ear infections cause ADHD? There are these little things called "facts" that should be involved with these types of discussions. No, I am not a highly educated person like whoever wrote this rubbish probably is. I have common sense, which could have been caused by my early ear infections I am guessing.

Ear Specialist in Chicago said...

If the child has regular attacks of a runny nose with all of the symptoms that accompany such as drainage in their throat and altered inhalation, their sleep is most likely going to suffer. Knowing that sleep deficiency many times provokes hyperactivity in children, it makes sense that there are high rates of ADHD and ear infections.

Erika Natori said...

okay, I have ADHD and also was diagnosed with hyperacusis in Junior high school. This article is very true and makes complete sense now.. Wow I have been to several psychologists and doctors and everyone said either that my disability was from my siezures as a baby, or because of the hypeacute hearing, not BOTH. Wow thank you so much for writing this article!! I have struggled in school for far too long. At least I understand why College is so difficult for me.

Erika Natori said...
This comment has been removed by the author.
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Anonymous said...

ADHD is linked to people historically doing the work of two people that is why children are born with two lots of energy levels. I have seen patterns in a particular culture who do not know what adhd is. sometimes you can work out what type of child is going to be born next. Attention deficient is due to ancestors not having time for social interactions because they were too busy working and staying by themselves -it is also about imbalance of roles - like women doing all the work in the culture because of polygamy, lifestyles etc - that is why they can multitask...a lot of time its due to history of lifestyle causing adhd. Where you get too much positive there must be a negative.ADHD on one side and learning difficulties or slow development on the other side ( floiya.

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James Jamieson said...

I am a 57 old (male) with ADHD/hyperactive sub type who also experienced chronic ear infections and food allergies as an infant, was prescribed antibiotics ( again as an infant), had a tendency to develop bronchitis at the drop of a hat, suffered fairly severe allergies and skin related issues as a child and then later as an adult and have had a mild hearing loss for the entirety of my life as long as I can remember. Did I miss anything here? I should be the poster child for your hypothesis because every speculated symptom and relationship you mentioned here has manifested in me to the letter! I do want to come back and contribute more to this blog/topic and will with some of my own thoughts and conclusions that I have come to myself as I have been aggressively researching, educating, medicating and managing my ADHD symptoms now for over 10 years to the point that I have made some discoveries myself that tie into the things that are hypothesized and speculated by other who have commented here outside of one nay sayer who from my view, is full of shit and talking straight out of their ass. I could not confirm or agree with your findings and thinking more. I know too much about this topic of ADHD to know how connected so many things can be already to know that there is definitely a relationship to myself and my hearing issues and not a mere coincidence. Thanks for creating this blog. It has been enlightening and extremely useful for me.

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