Observations of Distortion Product Otoacoustic Emission Components in Adults With Hearing Loss Objectives: Distortion product otoacoustic emissions (DPOAEs) measured in the ear canal are composed of OAEs generated by at least two mechanisms coming from different places in the cochlea. Otoacoustic emission (OAE) models hypothesize that reduction of cochlear gain will differentially impact the components. The purpose of the current experiment was to provide preliminary data about DPOAE components in adults with hearing loss in relation to OAE models and explore whether evaluation of the relative amplitudes of generator and reflection components can enhance identification of hearing loss. Design: DPOAEs were measured from 45 adult ears; 21 had normal hearing (≤15 dB HL) and 24 with mild-to-severe sensorineural hearing loss (>15 dB HL). The higher frequency primary (f2) was swept logarithmically between 1500 and 6000 Hz, and f2/f1 was 1.22. The two equal-level primaries varied from 55 to 75 dB SPL in 5 dB steps. The swept primary procedure permitted the measurement of the amplitude and phase of the DPOAE fine structure and the extraction of the two major components (generator and reflection) by varying the predicted delays of the analysis windows. Results: DPOAE fine structure was reduced or absent in ears with hearing loss. DPOAE generator and reflection components were lower in ears with hearing loss than those with normal hearing, especially for the reflection component. Significant correlations were found between the generator component and hearing threshold but not between reflection levels and hearing threshold. Most ears with normal hearing had both components, but only a small number of ears with hearing loss had both components. Conclusions: The reflection component is not recordable or low in level in ears with hearing loss, explaining the reduced or absent DPOAE fine structure. DPOAE generator components are also lower in level in ears with hearing loss than in ears without hearing loss. In ears that had both measurable generator and reflection components, the relationship between the two did not depend on the presence or absence of hearing loss. Because reflection components are not measurable in many ears with hearing thresholds >15 dB HL, stimuli that evoke other types of reflection emissions, such as stimulus-frequency or long-latency transient-evoked emissions, should be explored in conjunction with DPOAE generator components. ACKNOWLEDGMENTS: The authors thank Lisa Lamson, Stefania Arduini, and Devon Pacheco for article preparation. This research was funded by the March of Dimes Birth Defects Foundation. The authors have no conflicts of interest to disclose. Received May 3, 2018; accepted July 15, 2019. Address for correspondence: Beth A. Prieve, Department of Communication Sciences and Disorders, Syracuse University, 621 Skytop Road, Syracuse, NY 13244, USA. E-mail:baprieve@syr.edu. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Modality Effects on Lexical Encoding and Memory Representations of Spoken Words Objectives: The present study investigated presentation modality differences in lexical encoding and working memory representations of spoken words of older, hearing-impaired adults. Two experiments were undertaken: a memory-scanning experiment and a stimulus gating experiment. The primary objective of experiment 1 was to determine whether memory encoding and retrieval and scanning speeds are different for easily identifiable words presented in auditory-visual (AV), auditory-only (AO), and visual-only (VO) modalities. The primary objective of experiment 2 was to determine if memory encoding and retrieval speed differences observed in experiment 1 could be attributed to the early availability of AV speech information compared with AO or VO conditions. Design: Twenty-six adults over age 60 years with bilateral mild to moderate sensorineural hearing loss participated in experiment 1, and 24 adults who took part in experiment 1 participated in experiment 2. An item recognition reaction-time paradigm (memory-scanning) was used in experiment 1 to measure (1) lexical encoding speed, that is, the speed at which an easily identifiable word was recognized and placed into working memory, and (2) retrieval speed, that is, the speed at which words were retrieved from memory and compared with similarly encoded words (memory scanning) presented in AV, AO, and VO modalities. Experiment 2 used a time-gated word identification task to test whether the time course of stimulus information available to participants predicted the modality-related memory encoding and retrieval speed results from experiment 1. Results: The results of experiment 1 revealed significant differences among the modalities with respect to both memory encoding and retrieval speed, with AV fastest and VO slowest. These differences motivated an examination of the time course of stimulus information available as a function of modality. Results from experiment 2 indicated the encoding and retrieval speed advantages for AV and AO words compared with VO words were mostly driven by the time course of stimulus information. The AV advantage seen in encoding and retrieval speeds is likely due to a combination of robust stimulus information available to the listener earlier in time and lower attentional demands compared with AO or VO encoding and retrieval. Conclusions: Significant modality differences in lexical encoding and memory retrieval speeds were observed across modalities. The memory scanning speed advantage observed for AV compared with AO or VO modalities was strongly related to the time course of stimulus information. In contrast, lexical encoding and retrieval speeds for VO words could not be explained by the time-course of stimulus information alone. Working memory processes for the VO modality may be impacted by greater attentional demands and less information availability compared with the AV and AO modalities. Overall, these results support the hypothesis that the presentation modality for speech inputs (AV, AO, or VO) affects how older adult listeners with hearing loss encode, remember, and retrieve what they hear. ACKNOWLEDGMENTS: Supported by research grant numbers R29 DC01643 and R29 DC00792 awarded to P.F.S., from the National Institutes on Deafness and Other Communication Disorders, National Institutes of Health. The identification of specific products or scientific instrumentation is considered an integral part of the scientific endeavor and does not constitute endorsement or implied endorsement on the part of the authors, DoD, or any component agency. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, the Department of State, or U.S. Government. Received December 11, 2017; accepted August 2, 2019. Address for correspondence Lynn M. Bielski, Speech Pathology & Audiology Department, Ball State University, HPB 410, Muncie, IN 47306, USA. E-mail: lmbielski@bsu.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

An online wideband acoustic immittance (WAI) database and corresponding website. No abstract available

Discrepancies in Hearing Thresholds between Pure-Tone Audiometry and Auditory Steady-State Response in Non-Malingerers Objectives: To evaluate discrepancies between pure-tone audiometry (PTA) and auditory steady state response (ASSR) tests in non-malingerers and investigate brain lesions that may explain the discrepancies, especially in cases where the PTA threshold was worse than the estimated ASSR threshold. Design: PTA, speech audiometry, auditory brainstem response, ASSR, and neuroimaging tests were carried out on individuals selected from 995 cases of hearing impairment. Among these, medical records of 25 subjects (19 males, 6 females; mean age = 46.5 ± 16.0 years) with significant discrepancy between PTA and estimated ASSR thresholds were analyzed retrospectively. To define acceptable levels of discrepancy in PTA and ASSR hearing thresholds, 56 patients (27 males, 29 females; mean age = 53.0 ± 13.6 years) were selected for the control group. Magnetic resonance images, magnetic resonance angiograms, and positron emission tomograms were reviewed to identify any neurologic abnormalities. Results: Pathologic brain lesions were found in 20 cases (80%) in the study group, all of which showed a significant discrepancy in hearing threshold between PTA and ASSR. Temporal lobe lesions were found in 14 cases (70%), frontal lobe lesions in 12 (60%), and thalamic lesions without the frontal or temporal lobe in 2 cases (10%). On repeated PTA and ASSR tests a few months later, the discrepancy between ASSR and behavioral hearing thresholds was reduced or resolved in 6 cases (85.7%). Temporal lobe lesions were found in all 3 cases in which the estimated ASSR threshold worsened with unchanged PTA threshold, and frontal lobe lesions were found in all 3 cases in which the PTA threshold improved but the estimated ASSR threshold was unchanged. No neurological lesions were found in 5 cases (20%) of patients with a discrepancy between ASSR and behavioral hearing thresholds. Conclusions: Clinicians should not rely exclusively on ASSR, especially in cases of central nervous system including temporal, frontal lobe, or thalamus lesions. If no lesions are found in a neuroimaging study of a patient with a discrepancy between PTA thresholds and estimated ASSR thresholds, further functional studies of the brain may be needed. If clinicians encounter patients with a discrepancy between PTA thresholds and estimated ASSR thresholds, an evaluation of brain lesions and repeat audiologic tests are recommended in lieu of relying solely on ASSR. The authors have no conflicts of interest to declare. Received January 7, 2019; accepted July 15, 2019. Address for correspondence: Dong-Hee Lee, Department of Otolaryngology-Head and Neck Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 271 Cheonbo Street, Uijeongbu City, Gyeonggi-do, 11765, Republic of Korea. E-mail: leedh0814@catholic.ac.kr. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Deep Learning in Automated Region Proposal and Diagnosis of Chronic Otitis Media Based on Computed Tomography Objectives: The purpose of this study was to develop a deep-learning framework for the diagnosis of chronic otitis media (COM) based on temporal bone computed tomography (CT) scans. Design: A total of 562 COM patients with 672 temporal bone CT scans of both ears were included. The final dataset consisted of 1147 ears, and each of them was assigned with a ground truth label from one of the 3 conditions: normal, chronic suppurative otitis media, and cholesteatoma. A random selection of 85% dataset (n = 975) was used for training and validation. The framework contained two deep-learning networks with distinct functions: a region proposal network for extracting regions of interest from 2-dimensional CT slices; and a classification network for diagnosis of COM based on the extracted regions. The performance of this framework was evaluated on the remaining 15% dataset (n = 172) and compared with that of 6 clinical experts who read the same CT images only. The panel included 2 otologists, 3 otolaryngologists, and 1 radiologist. Results: The area under the receiver operating characteristic curve of the artificial intelligence model in classifying COM versus normal was 0.92, with sensitivity (83.3%) and specificity (91.4%) exceeding the averages of clinical experts (81.1% and 88.8%, respectively). In a 3-class classification task, this network had higher overall accuracy (76.7% versus 73.8%), higher recall rates in identifying chronic suppurative otitis media (75% versus 70%) and cholesteatoma (76% versus 53%) cases, and superior consistency in duplicated cases (100% versus 81%) compared with clinical experts. Conclusions: This article presented a deep-learning framework that automatically extracted the region of interest from two-dimensional temporal bone CT slices and made diagnosis of COM. The performance of this model was comparable and, in some cases, superior to that of clinical experts. These results implied a promising prospect for clinical application of artificial intelligence in the diagnosis of COM based on CT images. ACKNOWLEDGMENTS: We appreciate the suggestions provided to improve our methodology by Dayi Bian, Shunxing Bao, Yiyuan Zhao from Vanderbilt University, and Chenghua Tao from Indiana University at Bloomington. We acknowledge Maria Powell from Vanderbilt University Medical Center for her invaluable opinions in manuscript writing. Supported by the National Key Research and Development Program of China (2016YFC0905200, 2016YFC0905202) to F.-L.C.; the National Natural Science Foundation of China (NSFC) (Grant Nos. 81420108010 to F.-L.C. and 81771017 and 81570920 to D.-D.R.); the “Zhuo-Xue Plan” of Fudan University to D.-D.R.; the Shanghai Outstanding Young Medical Talent Program to D.-D.R.. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Y.L. conceptualized and designed the study, reviewed and analyzed the data, performed computer programming, evaluated the AI model, wrote and edited the manuscript; Y.-M.W. retrieved and validated the data; Y.-S.C. retrieved the data and evaluated the AI model; Z.-Y.H. retrieved and validated the data; J.-M.Y., J.-H.X., and Z.-C.C. evaluated the AI model; F.-l.C. provided funding support and data resources; D.-D.R. conceptualized the study, provided funding support and data resources, administered the project and edited the manuscript. All authors have reviewed, discussed, and approved the manuscript. The authors have no conflicts of interest to disclose. Received May 28, 2019; accepted July 22, 2019. Address for correspondence: Yike Li, Department of Otolaryngology, Vanderbilt University Medical Center, 1313 21st Avenue South, 602 Oxford House, Nashville, TN 37232, USA. E-mail: yike.li.1@vumc.org; Dong-Dong Ren, Department of Otorhinolaryngology, Eye and ENT Hospital, 83 Fenyang Road, Shanghai, 200031, China. E-mail: dongdongren@fudan.edu.cn This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Association Between Saccule and Semicircular Canal Impairments and Cognitive Performance Among Vestibular Patients Objectives: Growing evidence suggests that vestibular function impacts higher-order cognitive ability such as visuospatial processing and executive functioning. Despite evidence demonstrating vestibular functional impairment impacting cognitive performance, it is unknown whether cognitive ability is differentially affected according to the type of vestibular impairment (semicircular canal [SCC] versus saccule) among patients with diagnosed vestibular disease. Design: Fifty-four patients who presented to an academic neurotologic clinic were recruited into the study. All patients received a specific vestibular diagnosis. Forty-one patients had saccule function measured with the cervical vestibular-evoked myogenic potential, and 43 had SCC function measured using caloric irrigation. Cognitive tests were administered to assess cognitive performance among patients. One hundred twenty-five matched controls were recruited from the Baltimore Longitudinal Study of Aging to compare cognitive performance in patients relative to age-matched healthy controls. Results: Using multivariate linear regression analyses, patients with bilaterally absent cervical vestibular-evoked myogenic potential responses (i.e., bilateral saccular impairments) were found to take longer in completing the Trail-Making test (β = 25.7 sec, 95% confidence interval = 0.3 to 51.6) and to make significantly more errors on the Benton Visual Retention test part-C (β = 4.5 errors, 95% confidence interval [CI] = 1.2 to 7.8). Patients with bilateral SCC impairment were found to make significantly more errors on the Benton Visual Retention test part-C (β = 9.8 errors, 95% CI = 0.2 to 19.4). From case–control analysis, for each SD difference in Trail-Making test part-B time, there was a corresponding 142% increase in odds of having vestibular impairment (odds ratio = 2.42, 95% CI = 1.44 to 4.07). Conclusions: These data suggest that bilateral saccule and SCC vestibular impairments may significantly affect various domains of cognitive performance. Notably, the cognitive performance in patients in this study was significantly poorer relative to age-matched healthy adults. Cognitive assessment may be considered in patients with saccule and SCC impairments, and cognitive deficits in vestibular patients may represent an important target for intervention. ACKNOWLEDGMENTS: Supported in part by the National Institutes of Health (NIDCD K23 DC013056, NIDCD T32 DC000023). K.P. interviewed clinic patients, collected data, assisted in analysis, and wrote the article. D.P. recruited and interviewed clinic patients and collected data. E.W., R.K., and B.K. assisted in editing the article. E.W. performed most of the analyses. Y.A. designed the project and edited the entire article. The authors have no conflicts of interest to disclose. Received March 29, 2019; accepted July 25, 2019. Address for correspondence: Kevin Pineault, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 2308 E. Fairmount Ave., Baltimore, MD 21224, USA. E-mail: kpineau1@jhmi.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cochlear Implant Use Remains Consistent Over Time in Children With Single-Sided Deafness Objectives: To measure the acceptance of a cochlear implant by children with single-sided deafness (SSD) using datalogging technology in the cochlear implant processor. Design: Datalogs from follow-up clinical audiology appointments for 23 children with SSD were extracted from their cochlear implant processors ranging from 1 to 8 visits (M = 3.74, SD = 1.79). The number of hours the cochlear implant was in use per day, the number of times the coil disconnected from the internal device, and the percentage of daily cochlear implant use in different auditory environments were collected from the datalogs. Linear mixed-effects regressions were used to analyze the relationship between age, hearing experience, cochlear implant use, and coil-offs per day. Nonlinear regressions were conducted to evaluate cochlear implant use in different environments. Results: Children with SSD wore their cochlear implants for 6.22 (SD = 2.81; range = 0.0004 to 14.74) hours per day on average. No significant change in cochlear implant use was seen as the children grew older or gained more hearing experience. As hearing experience increased, the number of coil-offs per day was reduced. Preschoolers spent more time in “music” and “speech” and less time in “noise” and “quiet” than older and younger children while older children spent more time in “speech-in-noise.” Conclusions: Children with SSD consistently wear their cochlear implants. However, the auditory environments to which they are exposed vary over time. Regular cochlear implant use by this population suggests that it does not detract from a normal-hearing ear and that children with SSD appreciate access to bilateral input. ACKNOWLEDGMENTS: The authors have no conflicts of interest to disclose. Received November 20, 2018; accepted July 7, 2019. Address for correspondence: Hillary V. Ganek, Archie’s Cochlear Implant Laboratory, The Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8, Canada. E-mail: hillary.ganek@sickkids.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Word Identification With Temporally Interleaved Competing Sounds by Younger and Older Adult Listeners Objectives: The purpose of this experiment was to contribute to our understanding of the nature of age-related changes in competing speech perception using a temporally interleaved task. Design: Younger and older adults (n = 16/group) participated in this study. The target was a five-word sentence. The masker was one of the following: another five-word sentence; five brief samples of modulated noise; or five brief samples of environmental sounds. The stimuli were presented in a temporally interleaved manner, where the target and masker alternated in time, always beginning with the target. Word order was manipulated in the target (and in the masker during trials with interleaved words) to compare performance when the five words in each stream did versus did not create a syntactically correct sentence. Talker voice consistency also was examined by contrasting performance when each word in the target was spoken by the same talker or by different talkers; a similar manipulation was used for the masker when it consisted of words. Participants were instructed to repeat back the target words and ignore the intervening words or sounds. Participants also completed a subset of tests from the NIH Cognitive Toolbox. Results: Performance on this interleaved task was significantly associated with listener age and with a metric of cognitive flexibility, but it was not related to the degree of high-frequency hearing loss. Younger adults’ performance on this task was better than that of older adults, especially for words located toward the end of the sentence. Both groups of participants were able to take advantage of correct word order in the target, and both were negatively affected, to a modest extent, when the masker words were in correct syntactic order. The two groups did not differ in how phonetic similarity between target and masker words influenced performance, and interleaved environmental sounds or noise had only a minimal effect for all listeners. The most robust difference between listener groups was found for the use of voice consistency: older adults, as compared with younger adults, were less able to take advantage of a consistent target talker within a trial. Conclusions: Younger adults outperformed older adults when masker words were interleaved with target words. Results suggest that this difference was unlikely to be related to energetic masking and/or peripheral hearing loss. Rather, age-related changes in cognitive flexibility and problems encoding voice information appeared to underlie group differences. These results support the contention that, in real-life competing speech situations that produce both energetic and informational masking, older adults’ problems are due to both peripheral and nonperipheral changes. ACKNOWLEDGMENTS: The authors thank Sarah Laakso, Kimberly Adamson-Bashaw, Peter Wasiuk, and Michael Rogers for their assistance with this project. This study was supported by NIH NIDCD R01 012057. The authors have no conflicts of interest to disclose. Received September 14, 2018; accepted July 1, 2019. Address for correspondence: Karen S. Helfer, Department of Communication Disorders, University of Massachusetts Amherst, 358 N. Pleasant St., Amherst, MA 01002, USA. E-mail: helfer@umass.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Neural Modulation Transmission Is a Marker for Speech Perception in Noise in Cochlear Implant Users Objectives: Cochlear implants (CIs) restore functional hearing in persons with a severe hearing impairment. Despite being one of the most successful bionic prosthesis, performance with CI (in particular speech understanding in noise) varies considerably across its users. The ability of the auditory pathway to encode temporal envelope modulations (TEMs) and the effect of degenerative processes associated with hearing loss on TEM encoding is assumed to be one of the reasons underlying the large intersubject differences in CI performance. The objective of the present study was to investigate how TEM encoding of the stimulated neural ensembles of human CI recipients is related to speech perception in noise (SPIN). Design: We used electroencephalography as a noninvasive electrophysiological measure to assess TEM encoding in the auditory pathway of CI users by means of the 40-Hz electrically evoked auditory steady state response (EASSR). Nine CI users with a wide range of SPIN outcome were included in the present study. TEM encoding was assessed for each stimulation electrode of each subject and new metrics; the CI neural modulation transmission difference (CIMTD) and the CI neural modulation transmission index (CIMTI) were developed to quantify the amount of variability in TEM encoding across the stimulated neural ensembles of the CI electrode array. Results: EASSR patterns varied across the CI electrode array and subjects. We found a strong correlation (r = 0.89, p = 0.001) between the SPIN outcomes and the variability in EASSR amplitudes across the array as assessed with CIMTD/CIMTI. Conclusions: The results of the present study show that the 40-Hz EASSR can be used to objectively assess the neural encoding of TEMs in human CI recipients. Overall reduced or largely variable TEM encoding of the neural ensembles across the electrode array, as quantified with the CIMTD/CIMTI, is highly correlated with speech perception in noise outcome with a CI. ACKNOWLEDGMENTS: The authors thank all participants for their patience and willingness to join this study, and the authors are grateful to Ann Dierckx for her help in recruiting participants. Jana van Canneyt and Hanne Deprez helped with some of the data collection. Nancy Jennings is acknowledged for her constructive comments on an earlier version of the manuscript. Robert Luke is currently at Department of Linguistics, Australian Hearing Hub, Macquarie University, Sydney, NSW 2109, Australia. The work leading to this deliverable and the results described therein has received funding from the People Programme (Marie Curie Actions) of the European Unions Seventh Framework Programme FP7/2007–2013/under REA grant agreement PITN-GA-2012–317521 (I Can Hear), and from grants from FWO (G.0662.13), IWT (IWT-150432), and the HermesFonds (IWT-141243). J.W., A.V.W., R.L, and R.G. contributed to the design of the study; R.L. contributed to the development of the programming code to obtain the behavioral results; R.G. and A.V.W. contributed to the participant recruitment; R.G. and R.L. contributed to the data collection; R.L. and J.W. contributed to the initial analysis; R.G. and J.W. contributed to the final analysis; J.W., A.V.W., R.L, and R.G. contributed to the interpretation of the results and conceptual advice; R.G., R.L., and J.W. contributed to the writing of the initial manuscript; R.G. and J.W. contributed to the writing of the final manuscript; J.W. and R.G. contributed to the conceptualization of the CIMTI metric; J.W. and A.V.W. contributed to the project supervision; J.W., A.V.W., and R.G. contributed to the funding acquisition. All authors read the final version of the manuscript. A.v.W. is a member of the editorial board of Ear & Hearing. Received August 21, 2018; accepted June 25, 2019. Address for correspondence: Robin Gransier, KU Leuven, Department of Neurosciences, ExpORL, Herestraat 49, P. O. Box 721, B-3000, Leuven, Belgium. E-mail: robin.gransier@kuleuven.be Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Association Between Hearing Impairment and Problem Behaviors in 11-Year-Old Pacific Children Living in New Zealand Objectives: Hearing impairment in childhood is a serious disability that can impose a heavy social and economic burden on individuals and families. It was hypothesized that hearing loss or middle ear disease in 11-year-old Pacific children living in New Zealand would be associated with higher levels of engagement in (1) delinquent behaviors, and (2) clinical level internalizing and externalizing problem behaviors than Pacific children with no hearing loss or middle ear disease. Based on earlier findings, peer pressure, self-perception, physical punishment (slapping), sex, and ethnicity were controlled for in the association between hearing difficulties and behavioral outcomes. Design: In the school setting, pure-tone audiometry and immittance audiometry assessments were used to establish the hearing level in 11-year-old Pacific children (n = 920). These children also completed multidisciplinary questionnaires, which included questions about involvement in delinquent behaviors, peer pressure, and self-perception. In the home setting, maternal reports were gathered on internalizing and externalizing problem behaviors in their offspring, their parenting style, and sociodemographic details. Results: A significant effect of hearing level was detected for the odds of reporting mild delinquency versus no delinquency (odds ratio: 1.02, 95% CI: 1.00 to 1.05), and odds of moderate delinquency versus no delinquency (odds ratio: 0.97, 95% CI: 0.94 to 1.00). No significant effect was detected for hearing level and severe delinquency or internalizing or externalizing behavioral problems in the clinical range. Middle ear disease (abnormal tympanogram in the worse ear) was not significantly associated with delinquency at any level or with internalizing behaviors in the clinical range. However, children with middle ear disease were significantly less likely than all other participants to exhibit disruptive externalizing behavior in the clinical range. Conclusions: Relatively young children with hearing loss reported engagement in moderate levels of delinquency that represent serious antisocial and potentially violent acts. This finding provides evidence of the significant effect that hearing loss has on child behavior. This association between hearing loss and moderate delinquency requires ethnic-specific interventions that are targeted for maximum benefit at appropriate times in childhood to mitigate potentially long-term health, educational, and behavioral risks. ACKNOWLEDGMENTS: The authors thank the study participants and the Pacific Peoples Community Advisory Board. Funding to support the PIF study is from the Foundation for Research, Science & Technology, and the Health Research Council of New Zealand. J.P. wrote the article, worked with statisticians to analyze the data, and coordinated the article through to submission. S.C.P. provided expert advice and feedback through the process. R.S. and P.J.S. were the biostatisticians on the team and were responsible for the data analyses, the results section, and the tables. L.I. and E.-S.T. and all other authors discussed the results and implications and commented on the manuscripts at all stages. The authors have no conflicts of interest to disclose. Received September 20, 2018; accepted May 27, 2019. Address for correspondence: Janis Paterson, School of Public Health & Psychosocial Studies, Faculty of Health & Environmental Sciences, Auckland University of Technology, Auckland, New Zealand. . E-mail: janis.paterson@aut.ac.nz Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.