Psychology, 2010, 1: 220-228
doi:10.4236/psych.2010.13029 Published Online August 2010 (
Copyright © 2010 SciRes. PSYCH
Middle Ear Effusion, Attention, and the
Development of Child Behavior Problems*
Jannette Cross1, Dale L. Johnson1, Paul Swank2, Constance D. Baldwin3, David McCormick4
1University of Houston, Houston, USA; 2University of Texas Medical School, Houston, USA; 3University of Rochester, Rochester,
USA; 4University of Texas Medical Branch, Galveston, USA.
Received April 7th, 2010; revised June 23rd, 2010; accepted June 25th, 2010.
Objective: Much interest centers on whether middle ear effusion (MEE) early in life has lasting developmental conse-
quences. It was hypothesized that ep isodic loss of hearing acuity asso ciated with MEE results in a deficit in attention, a
core factor in the development of child behavior problems, and that impaired attention is related to behavior problems
during the early years of childhood. Method: This was a prospective study of a large sample of children (n = 698) that
was representative of th e local population in terms of socioeconomic and ethnic characteristics. The children were re-
cruited at birth and were monitored with regula r home visits for 3 years to check for the presence of MEE. Assessment
of attention occurred at 2, 3, 5, and 7 years. Behavior problems were assessed at 3, 5, and 7 year s. Results: Th e results
did not support the hypothesis that children with greater duration of MEE experience greater attention deficits and
more behavior problems than children with a shorter duration of MEE. Structural Equation Modeling parameter esti-
mates resulted in no support for the primary hypothesis. Correlational analyses also did not support the hypothesis.
Attention and behavior problems were related significantly. Conclusions: Our negative findings call into question the
results of previous studies relating MEE to behavior and attention problems, studies that may have been biased by
small, non-representative samples and retrospective designs that lacked careful documentation of MEE.
Keywords: Middle Ear Effusion, Attention, Behavior Problems
1. Introduction
Middle ear effusion (MEE), an inflammation of the mid-
dle ear accompanied by effusion or a collection of liquid
in the middle ear, is one of the most commonly diag-
nosed illnesses among young children. Estimates of MEE
incidence rates in the United States range from 49% to
97% during the first year of life [1]. Incidence peaks be-
tween 6 and 18 months with a stead y declin e un til around
5 years, when there is a second smaller peak [1,2]. Al-
most one-third of all children suffer with chronic MEE
and it is estimated that some spend an average of 38% to
70% of their first 3 years with MEE [3]. Most children
with MEE have an average hearing loss of 20 to 30 dB [4]
during an episode. The conductive hearing loss associ-
ated with MEE causes sounds to be muffled and dis-
The fluctuating hearing loss caused by episodes of
MEE is believed to cause developmental problems, in-
cluding child behavior problems. Problems in language
and speech have been the focus of much research [5,6]
and it has also been proposed that attention processes
may be effected [7]. It has been hypothesized that fre-
quent episodes of MEE during early childhood produce
initial language delays and a reduction in atten-
tion-to-language. In the later preschool years, when the
number of MEE episodes is reduced and hearing returns
to normal, basic language skills recover. However, chil-
dren with recurrent MEE may not be able to attend to
language input consistently and may develop the habit of
not attending because of the greater effort required. This,
in turn, may lead to an attention deficit for lan-
guage-related tasks that require sustained attention, a
deficit that persists after hearing is normal [8,9]. In addi-
tion to effects on language and attention, behavior prob-
lems may ensue. Children may withdraw and become
less responsive to their environment, or act out because
they cannot respond to the positive cues in the environ-
*This project was supported under award # HD20988 R01, from the
ational Institute of Child Health and Development, “Impact on Child
Development of Early Otitis Media”.
Middle Ear Effusion, Attention, and the Development of Child Behavior Problems 221
ment. Parents and teachers may have more difficulty
providing responsive stimulation. They may perceive the
child as willfully ignoring them, and change their own
interactive behavior accordingly [10].
1.1 MEE and Attention
Several prospective studies have found persistent MEE
and attention to be linked [7-11]. In a prospective study
with a sample size of 433, Mohr-Sperduti [12] found that
children with recurrent MEE showed an enduring shift in
temperament. MEE was negatively associated with two
dimensions of temperament: attention and difficult/fus-
Four studies did not find an association of MEE to at-
tention or obtained mixed results [13-16]. It should be
noted that sample sizes were small in these projects and
they used different measures of attention from those that
had positive results.
There is evidence that MEE and attention are related,
particularly during the early years or during periods of
active MEE. However, because of methodological issues,
verification of a causal relation between MEE and atten-
tion remains inconclusive. Most of the retrospective and
all of the prospective studies except the Mohr-Sperduti
[12] study used small samples. Many of the samples in-
volved special populations that were defined by socio-
economic status or clinical status. These studies used a
variety of measures of attention, from rating scales to
observational techniques and continuous performance
1.2 MEE and Behavior Problems
Four research groups have carried out prospective studies
of MEE and behavior problems. Silva et al. [11] and
Bennett et al. [17] found an association between MEE
and behavior problems; but Roberts et al. [16] and Para-
dise et al. [18] did not. MEE assessment for the Bennett
and Silva projects was conducted at 5 years of age and
the Roberts and Paradise projects examined ears in the
first 3 years. Silva assessed behavior problems at age 5
years and Bennett at age 10 years. Roberts assessed be-
havior problems at age 12 years and Paradise at age 4
Although evidence is limited, results of some studies
support the hypothesis that MEE is associated with the
development of behavior problems. In addition to being
few in number, these studies include populations of lim-
ited generalizability and small samples. The question of
how MEE is related to behavior problems remains unre-
1.3 Attention
Although there is considerable agreement that attention
plays a role in the development of behavior problems in
children, research on the issue has been slowed by a lack
of consensus about the definition and measurement of
attention [19]. Children with attention problems are
noted to be inconsistent in their behavior over time or
across situations in the performance of socialization,
communicative, and self-care skills at age appropriate
levels, despite generally average intelligence levels
[20,21]. One problem for researchers is that attention
measures are only moderately stable over time [22,23].
Measures of inattention tend to be more stable than those
of attention [23,24]. That attention is a complex and
multi-factorial process has led to the development of a
wide range of measures. Mirsky [25] suggested that the
multi-faceted nature of attention and the different ap-
proaches often used to assess attention from study to
study could account for the variability in outcome among
studies of attenti on.
1.4 Attention and Behavior Problems
Research with children who have been referred for
treatment of behavior problems, attention deficit disorder
or learning disorders has found a consistent association
between attention difficulties and behavior problems
[26-31]. These studies tend to examine the relation be-
tween attention and behavior problems using concurrent
assessment of the variables and to include samples of
special populations and school-age children. We found
no prospective studies of young children outside the
clinical setting. We also found no studies of MEE, atten-
tion and behavior problems.
1.5 Research Hypotheses
Based on our review of the literature we formed two hy-
potheses: 1) attention difficulties are core factors in the
development of child behavior problems, and attention is
affected adversely by the hearing loss associated with
persistent or intermittent MEE during the early years of
childhood; 2) the relation of MEE and, therefore, atten-
tion, on behavior problems would exhibit a stronger ef-
fect at 3 years of age, a time when the child would more
recently have experienced moreMEE, than at 7 years.
Improvement is expected because of the return of normal
hearing as episodes become less frequent during the later
preschool years. With advancing age, children have time
for adaptation and previous deficits become less severe
or disappear altogether.
Also this study examined whether duration of MEE
was related directly to child behavior problems at ages 3
and 7 and to attention problems at these ages. Finally, we
asked whether SES, home environment, or gender mod-
erate the negative effect of MEE. For example, children
with persistent MEE and low attention, but who are
reared in positive and highly stimulating environments,
may not develop more behavior problems due to the
buffering effects of positive environmental stimulation.
Copyright © 2010 SciRes. PSYCH
Middle Ear Effusion, Attention, and the Development of Child Behavior Problems
2. Method
2.1 Sample
The study was part of a longitudinal study of middle ear
effusion and its effects on child development. Infants (n
= 698) were recruited at birth from two hospital newborn
nurseries in the Galveston and the near mainland Texas
area. Only normal term infants were included. Low
birthweight babies, babies with known neurological dis-
orders and babies from families whose primary language
was not English were excluded. Subjects were recruited
while the mother and baby were still in one of the mater-
nity units. Written informed consent from parents was
obtained. Parents agreed to have a research assistant
come to their homes on a frequent basis to check the
childs ears and agreed to come into the research center
for more psychological assessments during the first few
years of their childs life. Parents were paid for their par-
ticipation at each of the major assessments conducted at
the research center at 2, 3, 5, and 7 years. The payment
was $35 early in the project was later raised to $50. In
almost all cases, these assessments occurred within 4
weeks of the child’s birthday.
This project was approved by institutional review
boards at both the University of Texas Medical Branch
and the University of Houston.
2.2 Procedures
MEE status was assessed regularly from birth to 3 years.
At 2, 3, 5, and 7 years, a battery of cognitive, language
and behavioral assessments was administered to children
at the research center at the University of Texas Medical
Branch in Galveston. Examiners were four graduate stu-
dents in psychology (3) and in speech communication
disorders (1) who were especially trained in administra-
tion of the tests. Only children with normal hearing as
indicated by audiometric testing carried out at the time of
the examinations were tested. All children but one had
normal hearing and this one was dropped from the study.
Examiners were blind to the MEE condition of the chil-
The participant’s gender and ethnicity were obtained
by parental report at the time of enrollment at birth. At 2
years, data on socioeconomic status (SES) and level of
educational stimulation in the home environment were
collected. Assessment of attention was obtained through
parent report questionnaires at 2, 3, and 5 years. Exam-
iner rating of attention occurred at 3, 5, and 7 years. At 7
years, a computerized continuous performance task as-
sessed attention. Behavior problems were assessed with
parent report questionnaires at 3, 5 and 7 years, and with
teacher reports at 5 and 7 years.
2.3 Measures
Variables included in this study of children were MEE,
infant and young child attention, and young child emo-
tional and behavioral problems. Control variables in-
cluded gender, SES, and Home Observation of the
Measured Environment (see below).
2.4 MEE
MEE status was defined as the presence of otitis media
with effusion independent of other symptoms. Every 2 to
4 weeks from birth to 18 months and every 4 weeks from
18 to 36 months, scheduled visits at the home or daycare
were conducted by trained technicians to monitor pres-
ence of MEE with tympanometry [3]. Acoustic reflectiv-
ity was measured at the initial 30% of the visits, but was
replaced with tympanometry, which was performed at all
visits. Diagnosis of MEE occurred if either ear met any
of these criteria: (1) presence of otorrhea, or purulent pus
draining from the ear canal visible without otoscopy; (2)
acoustic reflectivity > 5; or (3) a Type B tympanogram
(i.e., compliance of 0.0 or 0.1, or compliance of 0.2 or
0.3 only if the absolute gradient was < 0.1 ml). For chil-
dren with tympanostomy tubes, a diagnosis of MEE was
made by the presence of purulent otorrhea or a Type B
tympanogram in the presence of an external ear canal
volume which indicates that the tube was not patent. At
each home visit, both ears were evaluated by this criteria
and categorized at either “normal” or “MEE”. A com-
puter-generated algorithm calculated the percentage of
time each child spent with MEE for a given period (total
days with MEE/total days in the ex amination period). To
calculate time with MEE, two consecutive visits positive
for MEE would equal 28 days with MEE. If only one
visit of the two consecutive visits was positive for MEE,
half of the intervening days (up to 14) were counted as
days with MEE. This resulted in a maximum of 28 days
of MEE was counted for any o ne MEE-positiv e visit [32 ].
Unilateral, bilateral or combined days of MEE were cal-
culated. Parents were informed of the childs middle ear
status and encouraged to see a physician if MEE was
diagnosed. Duration of time and proportion of time spent
with bilateral MEE was calculated for each child at 6, 12,
18, 24, and 36 months. The two measures were highly
correlated and proportion of time was used for the
2.5 Attention
The strategy we adopted for the measurement of atten-
tion was to use four different measures that were age-
appropriate; 1) parent ratings, 2) teacher rating, 3) exam-
iner observation, and 4) computerized test.
Attention was assessed with parent report at 2, 3, and 5
years with the Task Orientation scale of the Revised Di-
mensions of Temperament Survey (DOTS-R) [33]. The
alpha coefficient for preschool children was .79. At 3, 5,
and 7 years, upon completing the cognitive assessment
with the Stanford-Binet Intelligence Scale: Fourth Edi-
Copyright © 2010 SciRes. PSYCH
Middle Ear Effusion, Attention, and the Development of Child Behavior Problems 223
tion [34], examiners rated children’s attention with two
items on the Stanford-Binet for examiners’ ratings of
overall test performance: a) absorbed by task; and b) per-
sistent. Examiners were trained by having pairs of ex-
aminers rate the same test-taking behavior. This was
continued until ratings agreed 80% of the time. There
was a follow-up repetition of this procedure to check on
persistence of agreement. At 5 and 7 years, attention was
assessed with parent report using the Attention scale of
the Child Behavior Checklist for Ages 4-16 [35]. The
Attention scale of the Teacher Report Form [36] was
used to assess teacher-report of attention at 5 and 7 years.
At 7 years, attention was assessed by a computerized
continuous performance test, the Test of Variables of
Attention (TOVA) [37]. The 5-year-old test length of 11
minutes was used to save time in a lengthy battery of
tests and because it was found to be highly correlated
with the longer version. In addition, children found the
longer version unbearably tedious. The test was always
administered last. Four TOVA variables were used: 1)
Errors of Omission or failure to respond to a target; 2)
Errors of Commissio n or resp onding to the non-target; 3)
Mean Correct Response Times; and 4) Variability, the
standard deviations of response times. The occurrence of
errors of omission was considered an indication of inat-
tention whereas the occurrence of errors of commission
was an indicator of impulsivity. Mean correct response
time was an indicator of processing and response time.
Variability relates to consistency in speed of responding.
2.6 Behavior Problems
Behavior problems were assessed by parent report at 3
years with the Child Behavior Checklist for Ages 2-3
(CBCL/2-3) [35] and at 5 and 7 years with the Ch ild Be-
havior Checklist for Ages 4-16 (CBCL/4-16) [36]. At 5
and 7 years, teachers completed the Teachers Report
Form (TRF) [36]. Attention scale items are not included
in either the Internalizing or Externalizing factors of the
CBCL that are used as dependent variables. The Internal
scale includes depression and anxiety and the External
scale includes acting out disorders. One-week test-retest
reliability for the Total Problems for the CBCL/2-3 was r
= 0.91 and for the CBCL/4-16 it was r = 0.93. The CBCL
and TRF were used because they were measures most
often used by behavior problem researchers and the
measures are well-standardized and have good reliability
and validity [35,36,38].
2.7 Moderating Variables
The Hollingshead Four-Factor Index of Social Status was
used to assess family SES [39]. This index makes use of
parental occupation and education. Educationally stimu-
lating characteristics of the home environment were as-
sessed with the Home Observation for Measurement of
Environment Inventory (HOME) [40]. The mother was
interviewed and observed with her child in the home.
The Total Score was used .
2.8 Reliabilities
All measures used had adequate reliability. Details may
be found in the key manuals for each measure.
2.9 Statistical Analysis
Descriptive analyses of each variable were conducted.
Bivariate correlations among all variables were com-
puted. To test the overall hypothesized relation between
MEE, attention and behavior problems, structural equa-
tion modeling (SEM) using LISREL 7 [41,42] was used.
SEM was selected because of its ability to run multiple
paths simultaneously and to test for possible networks of
causality, using goodness of fit test for evaluation. Also,
because SEM examines relations among latent variables,
the errors in the indicators are eliminated giving more
powerful tests of the hypotheses. See Figure 1 for the
hypothesized model. Only attention and behavior vari-
ables at 3 and 7 years were included, omitting data
available at 5 years in the SEM. This was done to reduce
the number of path estimates to compensate for the sam-
ple size, which was considered marginal for SEM.
Goodness of fit indices and parameter estimates between
the hypothesized model and comparison models were
3. Results
From the initial sample of 698 recruited at birth, attrition
occurred because families moved out of the research area
or lost interest in participation and for various other rea-
sons. One child was excluded after documentation of a
sensory-neural hearing loss. The demographics for the
sample initially recruited and at age 7 are as follows:
female, 51% and 50%; African-American, 32% and 31%,
Euro-American, 55% and 53%, and Hispanic, 14% and
16%; mothers married or co-habiting, 72% and 69%;
Hollingshead Socioeconomic Status mean 37 (s. d., 13)
and 37% (s. d. 13), and HOME mean, 39 (s. d. 5) and 39
(s. d. 5). Demographic characteristics of the sample re-
maining after attrition were very similar. Further evi-
dence of the normal distribution of scores for this sample,
and the normality of the sample, may be seen in the re-
sults for the Stanford-Binet Fourth Edition [34] adminis-
tered to children at ages 3, 5 and 7. Their IQ scores were,
100.6 (SD = 12.2), 98.3 (12.6), and 98.0 (14.00), respec-
tively, which are close to the normative sample IQ of
100.0 (SD = 15.0). Sample sizes at the evaluation time
points were approximately 395 at age 2, 360 at age 3,
310 at age 5 and 200 at age 7.
We found no significant correlations between any of
the MEE by time period and behavior problem scales.
Correlations ranged from –0.14 to 0.11. Correlations
etween MEE and attention rating s were also low. Of 24 b
Copyright © 2010 SciRes. PSYCH
Middle Ear Effusion, Attention, and the Development of Child Behavior Problems
Copyright © 2010 SciRes. PSYCH
Figure 1. Hypothesized structural equation modeling
correlations, only two were significant. One was for
Stanford-Binet-Attention (SB-Attn) and MEE, r = 0.14, p
< 0.05. MEE and continuous performance task (TOVA)
correlations were non-significant for all TOVA measures
except Variability. The significant MEE correlation with
Variability was r = –0.21, p < 0.01.
Attention ratings and behavior problems were signifi-
cantly related. For the CBCL Externalizing, Internalizing
and Total scores at age 3, five of six correlations with
DOTS were significant (range: r = –0.14 to –0.25)).
None were significant at age 7. All 6 of the CBCL atten-
tion ratings at ages 5 and 7 were significantly related to
CBCL scores at age 7 (range, r = 0.38 to 0.80). None of
the TOVA scores were related to CBCL scores at age 7.
Using the CBCL Attention scale with a cut-off of 68 at
age seven 4.4% of the children were found to have atten-
tion problems. The teacher version showed 4.5% with
such problems. There were no gender differences.
For the primary inferential analysis, structu ral equation
modeling (SEM) was used to test the adequacy of the
theoretical model. SEM was selected because of its abil-
ity to run multiple paths simultaneously and to suggest a
possible network of causal relations. The first step was
model specification. Initial interest was in obtaining an
adequate measurement model between the observed
variables and the latent variables. However, th e hypothe-
sized measurement model could not be identified and
major revisions were made before testing the structural
model of relations between the latent variables. The first
step involved elimination of observed variables in order
to increase covariances among variables within each
construct. The SB-Attn at 3 and 7 years and the TOVA
variables of Omission and Variability were eliminated.
The latent variable for Attention at 7 years was divided
into two separate latent variables. One consisted of
CBCL and TRF Attention scales and the other consisted
of the two remaining TOVA variables, Omission and
Variability. In addition, SES and HOME were changed
from estimating two separate latent variables to estimat-
ing one latent variable of environment. Lastly, the dis-
turbance terms for CBCL Attention at 7 years and CBCL
Externalizing at 7 years and for TRF Attention and TRF
Externalizing were allowed to be correlated to account
for method effects. These modifications did produce a
workable model, but one that still did not meet meas-
urement requirements according to the chi-square results.
Additional changes were made based on examination of
the fitted residuals and modification indices which lead
to the removal of the observed variables, TRF and CBCL
Internalizing at 7 years. The revised measurement model
resulted in a large improvement in chi-square, good-
ness-of-fit and adjusted goodness-of-fit. The root mean
square residual also decreased slightly. Any further
changes would have resulted in major deviations from
the hypothesized measurement model.
Once an adequate measurement model was established,
the next step involved model identification and parameter
estimation of the structural model based on maxi-
Middle Ear Effusion, Attention, and the Development of Child Behavior Problems 225
mum-likelihood estimates from the covariance-variance
matrix with pairwise deletion of missing values. Signifi-
cance of parameter coefficients was based on the ratio of
the statistic to its standard error, which are asymptoti-
cally normal. Z values < –2 and > 2 are considered sig-
nificant. This model had direct effects from MEE to each
of the latent endogenous variables. Home environment
and gender also had direct effects on attention and be-
havior problem variables. However, no solution conver-
gence was obtained. Parameters from the exogenous
variables were redefined to allow a direct effect on each
of the endogenous variables. This change resulted in
model convergence.
The hypothesized structural model with parameter es-
timates is presented in Figure 1. A summary of the
specification and fit indices for the hypothesized model
is presented in Table 1. Regarding the primary research
hypothesis that children with persistent MEE tend to
have attention deficits and that d eficits in attention result
in more behavior problems, examination of parameter
coefficients did not support that MEE has an effect on
either attention or behavior problems. Between attention
and behavior problems, there was one significant pa-
rameter estimate from Attention-A (CBCL and TRF) and
Behavior Problems at 7 years. This finding also did not
support a secondary research hypothesis that proposed
stronger relations between MEE, attention, and behavior
problems at 3 years than at 7 years. Lastly, regarding the
hypothesis that SES, home environment and gender
would moderate the negative effect of MEE, several sig-
nificant parameter estimates were found for Home Envi-
ronment (SES and HOME) predicting behavior problems
at 3 years and to deficits in Attention A (CBCL and TRF)
at 7 years. In addition, significant parameter estimates
were found from gender to both endogenous attention
variables at 7 years. Significant relations are marked with
asterisks (Figure 2).
4. Discussion
This study provided a prospective examination of the
impact of MEE on attention and behavior problems. It
was hypothesized that a deficit in attention is a core fac-
Table 1. Summary of specification and fit statistics for
structural equation models of MEE, attention and behavior
Measurement Modelt2 df p GFI AGFIRMSEA
Revised Model A 235.7793 .00 .8699 .7608.0881
Revised Model B 75.1069 .2875 .9434 .8884.0157
Structural Model t2 df p GFI AGFIRMSEA
Hypothesized 84.411480 .3464 .9359 .89100.0118
Comparison A 84.745482 .3959 .9355 .89300.0041
Comparison B 85.418784 .4363 .9347 .89430.0
Note: GFI = goodness of fit index; AGFI = adjusted goodness of fit
index; RMSEA = root me an s qu are error of appro xi mation.
Figure 2. Significant parameters for comparison structural equation: Model B
Copyright © 2010 SciRes. PSYCH
Middle Ear Effusion, Attention, and the Development of Child Behavior Problems
tor that contributes to the development of a range of be-
havior problems and that attention is adversely affected
by persistent MEE. Important strengths of the present
study are its prospective design, early and regular moni-
toring of MEE, and selection of a large non-clinical sam-
ple representative of the general population. These char-
acteristics contrast with those of the majority of studies
using retrospective methods to investigate the relation of
MEE to either attention or behavior problems [43]. Most
had small samples [7-10,13-15,43-46]. Only a few stud-
ies relied on a large sample [11,12,18]. Often the samples
were limited to low SES subjects [7,9,10,13,14,16], chil-
dren with restricted SES representation [8], or to ch ildren
referred for clinical evaluation [7,44]. Thus, this study
provides an important perspective on the relations be-
tween MEE, attention, and behavior problems because of
its methodological strengths.
The results of this study g enerally failed to support th e
hypothesis that children with greater duration of MEE
experience greater attention deficits and more behavior
problems than children with a shorter duration of MEE.
SEM parameter estimates provided no support for the
first hypothesis. Correlational analyses also did not sup-
port the hypothesis. Correlations between MEE and at-
tention resulted only in association between examiner
ratings of attention at 7 years and earlier MEE. Also
TOVA Variability at 7 years was associated negatively
with MEE, instead of positively, as expected. These two
correlations were small and could be attributed to the
increase of a Type I error due to familywise error. In
addition, there were no significant associations between
MEE and behavi or problem s, even at 3 years of age.
These results are consistent with those obtained by
Roberts et al. [16] and Paradise et al. [18] who used pro-
spective methods to identify duration of MEE in the first
three years. Roberts et al. [18] found that duration of
MEE was not related to number of behavior problems at
12 years of age. On the other hand, the present results
contrast with those of Silva and associates [11], who did
find persistent MEE to be related to more behavior prob-
lems. The Silva group used a cross-sectional method with
behavior problems assessed at age 5. Having impaired
hearing at that age was related to behavior problems and
this relation was still present at ages 7, 9, and 11 [48].
The second hypothesis that attention mediates the ef-
fects of MEE on behavior problems was not supported.
MEE was not related to either attention or behavior
problems. However, some support was found for a rela-
tion between attention and behavior problems, excluding
the role of MEE. Examination of individual parameters
indicated that impaired attention at 7 years was related to
behavior problems at 7 years, with both variables as-
sessed by parent and teacher report. The second hypothe-
sis, which proposed that there would be stronger effects
of MEE on behavior problems at age 3 than at age 7, was
not supported. There were no effects at either age.
An important limitation of this study derived from the
LISREL analysis that demonstrated a lack of association
among variables within constructs and between the con-
structs. The originally hypothesized measurement model
required significant rev isions in order to get a solution to
converge, resulting in a weak fitting measuremen t model.
The small to moderate correlations among the measures
of attention and behavior problems call into question the
construct validity of the measures. Within attention
measures, although some significant correlations were
found across parent, teacher and examiner reports, these
correlations were low.
Given these methodological limitations, our results
lead to the cautious conclusion that MEE in the first 3
years of life is not related to behavior problems that are
present at ages 3 and 7.
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