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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 1  |  Page : 45-53

Assessment of phonological awareness in children with delayed language development


1 Phoniatrics Unit, Otorhinolaryngology Department, Ain Shams University, Cairo, Egypt
2 Phoniatrics Unit, Otorhinolaryngology Department, Cairo University, Giza, Egypt
3 Phoniatrics Unit, Otorhinolaryngology Department, Menoufia University, Menoufia, Egypt

Date of Submission12-Jan-2017
Date of Acceptance09-Apr-2017
Date of Web Publication17-Apr-2019

Correspondence Address:
Eman F El-Domiaty
Phoniatrics Unit, Otorhinolaryngology Department, Faculty of Medicine, Shibein El-kom, Menoufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_16_17

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  Abstract 


Objective
To study the relationship between language disorders in children and phonological awareness (PA) to identify children with reading difficulties as early as possible.
Background
PA is an important determiner of success in learning to read and spell. Early speech and early language difficulties are considered to be risk factors associated with future reading difficulties. Children with language difficulties are particularly at risk for poor literacy outcomes.
Patients and methods
Fifty cases (aged from 5 to 8 years) with delayed language development of average intelligence quotient participated in our study at Phoniatrics unit outpatient clinic in Menoufia University Hospital, from March 2015 to March 2016. They were divided into three groups (A, B, and C) and assessed by Arabic Phonological Awareness Test and Standardized Arabic Language Test. The results of cases were compared with the results of 50 controls matched for age and sex. Moreover, the results of the PA test were correlated with the results of standardized Arabic language test.
Results
By comparing the performance of PA skills for cases and control in the three age groups, there were significant differences in all skills (P < 0.05), except in segmenting words into syllables (P = 0.06) and blending syllables (P = 0.1) in group A. By studying the correlation between PA age and total language age, receptive language age, expressive language age, and semantics age, there were highly significant positive correlations (P = 0.000). Significant positive correlation was found between PA age and articulation (P = 0.029). Moreover, there was a significant negative correlation between PA score and the gap between language age and chronological age (P = 0.045).
Conclusion
Children with specific language impairments require specific therapy that includes explicit focus on PA and letter identification.

Keywords: articulation, delayed language development, language age, phonological awareness, reading difficulties


How to cite this article:
Baraka M, El-Dessouky H, Ezzat E, El-Domiaty EF. Assessment of phonological awareness in children with delayed language development. Menoufia Med J 2019;32:45-53

How to cite this URL:
Baraka M, El-Dessouky H, Ezzat E, El-Domiaty EF. Assessment of phonological awareness in children with delayed language development. Menoufia Med J [serial online] 2019 [cited 2019 May 24];32:45-53. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/45/256088




  Introduction Top


Phonological awareness (PA) refers to the explicit awareness of the abstract units that compose spoken words, including syllables (onset and rime units) and individual phonemes. PA is a critical precursor to the acquisition of reading [1].

It is estimated that 88% of children with reading difficulties have trouble with PA. Children with poor PA skills in kindergarten, preschool, and first grade are among the poorest readers in later grades, whereas children with good PA skills in early grades are among the best readers in later grades [2].

Early speech and early language difficulties are considered to be risk factors associated with future reading difficulties. Vocabulary sizes as well as other measures of receptive and expressive semantics, syntax, and morphology are consistent, concurrent, and longitudinal predictors of PA. Consistent with this finding, children with communication disorders often have poor PA [3].

Although reading development is influenced by numerous factors [PA, phonics (letter-sound relationship), fluency, vocabulary, and text comprehension], scientific and educational researches have documented the fact that PA is the key to the process of learning to read and is a reliable predictor of later reading skill [4].

Language disorders are defined as persistent difficulties in the acquisition and use of language across modalities (i.e., spoken, written, sign language, or other) owing to deficits in comprehension or production [5].

Specific language impairment (SLI) is one of the most frequent disturbances in the development of higher mental functions in children. One of the main criteria for the diagnosis of SLI is the difference between cognitive linguistic and nonlinguistic abilities, evident through the testing of nonverbal intelligence, which is usually normal [6].

Many studies have shown that children with SLI have a higher risk of having later learning difficulties. These later learning difficulties may take the form of problems acquiring higher levels of spoken language comprehension and expression as well as with reading and writing [7].

Catts et al. [8] noted that late emerging poor readers (e.g., students who start to show reading problems around fourth grade but who had adequate reading achievement in early school years) may have had unidentified deficits in language and/or other cognitive abilities at younger ages.

Converging evidence indicates that children with language impairment are at significant risk for delayed PA skills. Researchers have demonstrated that phonological disability on its own is not as high a predictor of reading disability as when combined with other language deficits. In particular, children who present with phonological syntactic disability, seem most at risk for later literacy problems [9].

The aim of our work is to study the relationship between language disorders in children and PA – a prereading skill thought to be a significant predictor of later reading difficulties – to identify children who experience difficulties with reading as early as possible. This will prevent a host of negative outcomes that could be associated with reading difficulties.


  Patients and Methods Top


This study was conducted on 50 children with delayed language development of average intelligence quotient (IQ) attending Phoniatrics unit outpatient clinic in Menoufia University Hospital and 50 normal controls matched for age and sex. Based on past review of literature [10], sample size had been calculated at power 80% and 95% confidence interval, giving a total sample size of 100 (50 participants for every single group). They were collected randomly from March 2015 to March 2016. The age range of the selected cases and controls was from 5 to 8 years. Children with mental retardation, hearing impairment, pervasive developmental disorders, or attention-deficit hyperactivity disorder were excluded from the study. The study protocol was approved by the local ethics committee of the Menoufia University. All participant' parents gave written informed consent before inclusion into the study.

All cases and controls were subjected to the protocol of assessment of language, which includes elementary diagnostic procedures and clinical diagnostic aids. Elementary diagnostic procedures include analysis of complaint, personal history (prenatal, natal, and postnatal history), milestones of development, general examination, and full ENT examination. Clinical diagnostic aids include language evaluation, audiological evaluation, and evaluation of cognitive abilities.

Language was evaluated by applying Standardized Arabic Language Test [11] to determine total language age, receptive language age, expressive language age, semantics age, and pragmatic age. Moreover, the articulation test was applied to detect articulation disorders.

Cognitive abilities were evaluated by applying Stanford Binet Intelligence Scale, 4th edition, Arabic version [12], and only children with an IQ of 90 or above participated in this study.

PA was assessed through Arabic Phonological Awareness Test [13] which is composed of two sections: PA section and phoneme/grapheme section.

PA section includes the following subtests.

  1. Segmentation subtests:


    1. Segmenting sentences into words (SSW)
    2. Segmenting words into syllables (SWS)
    3. Segmenting words into phonemes (SWP)


  2. Isolation subtests:


    1. Isolation of initial phoneme (IIP)
    2. Isolation of final phoneme (IFP)
    3. Isolation of middle phoneme


  3. Deletion subtests:


    1. Deletion of compound words and syllables (DCS)
    2. Deletion of phonemes (DP)


  4. Substitutions with manipulative subtest
  5. Blending subtest:


    1. Syllables (BS)
    2. Phonemes (BP)


  6. Rhyming subtest:


    1. Discrimination (RD)
    2. Production (RP).


Phoneme/grapheme section includes the following subtests.

  1. Phoneme-grapheme subtests:


    1. Consonants
    2. Long and short vowels
    3. Consonant clusters


  2. Decoding subtest.


Statistical analysis

The data collected were tabulated and analyzed by statistical package for the social science software program for statistical analysis (version 13; SPSS Inc., Chicago, Illinois, USA).

The results were expressed by applying ranges, means ± SD, Mann–Whitney test, and P values. P value less than 0.05 was considered to be significant, and P value less than 0.01 was considered to be highly significant.

Pearson's correlation was used for normally distributed quantitative variables, whereas Spearman's correlation was used for quantitative variables that were not normally distributed.


  Results Top


Our study included 50 cases, with 30 (60%) males and 20 (40%) females, and 50 controls. Cases were diagnosed as having delayed language development with average IQ (mean ± SD, 99.24 ± 6.42) and normal hearing abilities, with age ranged from 5 to 8 years (mean ± SD, 6.13 ± 0.77 years). The mean ± SD age of controls was 5.9 ± 1.3 years.

The children were divided into three groups as follows:

  • Group A consisted of 24 cases, and their ages ranged from 5 years to 5 years and 11 months
  • Group B consisted of 16 cases, and their ages ranged from 6 years to 6 years and 11 months
  • Group C consisted of 10 cases, and their ages ranged from 7 years to 7 years and 11 months.


Each group was assessed by Arabic Phonological Awareness Test and Standardized Arabic Language Test. On applying PA test in males and females, it was found that there was a nonsignificant difference [Figure 1].
Figure 1: Comparison between males and females in performance of phonological awareness skills. BP, bending subset phonemes; BS, blending subtest syllables; DCS, deletion of compound words and syllables; DP, deletion of phonemes; IFP, isolation of final phoneme; IIP, isolation of initial phoneme; RD, rhyming subtest discrimination; RP, rhyming subtest production; SSW, segmenting sentences into words; SWP, segmenting words into phonemes; SWS, segmenting words into syllables.

Click here to view


Comparison between cases and controls regarding performance in PA skills in the three age groups revealed the following.

Group A showed a highly significant difference between cases and controls in SSW, SWP, total segmentation, IIP, IFP, total isolation, DCS, DP, total deletion, BP, total blending, RD, RP, total rhyming, total phonological awareness, total phoneme grapheme, and total test score, whereas there was a nonsignificant difference in SWS and BS [Table 1] and [Figure 2].
Table 1: Comparison between cases and control in group A (5 years to 5 years and 11 months) regarding performance on phonological awareness test

Click here to view
Figure 2: Comparison between cases and control in group A (5 years to 5 years and 11 months) regarding performance on phonological awareness test. BP, bending subset phonemes; BS, blending subtest syllables; DCS, deletion of compound words and syllables; DP, deletion of phonemes; IFP, isolation of final phoneme; IIP, isolation of initial phoneme; RD, rhyming subtest discrimination; RP, rhyming subtest production; SSW, segmenting sentences into words; SWP, segmenting words into phonemes; SWS, segmenting words into syllables; TB, total blending; TD, total deletion; TI, total isolation; TR, total rhyming; T.seg, total segmentation.

Click here to view


Group B showed a highly significant difference between cases and controls regarding SSW, SWP, total segmentation, IIP, IFP, total isolation, DCS, DP, total deletion, BP, total blending, RD, total rhyming, total phonological awareness, total phoneme grapheme, and total test score, whereas a significant difference was detected regarding SWS, BS, and RP [Table 2] and [Figure 3].
Table 2: Comparison between cases and control in group B (6 years to 6 years and 11 months) regarding performance on phonological awareness test

Click here to view
Figure 3: Comparison between cases and control in group B (6 years to 6 years and 11 months) regarding performance on phonological awareness test. BP, bending subset phonemes; BS, blending subtest syllables; DCS, deletion of compound words and syllables; DP, deletion of phonemes; IFP, isolation of final phoneme; IIP, isolation of initial phoneme; RD, rhyming subtest discrimination; RP, rhyming subtest production; SSW, segmenting sentences into words; SWP, segmenting words into phonemes; SWS, segmenting words into syllables; TB, total blending; TD, total deletion; TI, total isolation; TR, total rhyming; T.seg, total segmentation.

Click here to view


Group C showed a highly significant difference between case and control groups in all PA tasks [Table 3] and [Figure 4].
Table 3: Comparison between cases and control in group C (7 years to 7 years and 11 months) regarding performance on phonological awareness test

Click here to view
Figure 4: Comparison between cases and control in group C (7 years to 7 years and 11 months) regarding performance on phonological awareness test. BP, bending subset phonemes; BS, blending subtest syllables; DCS, deletion of compound words and syllables; DP, deletion of phonemes; IFP, isolation of final phoneme; IIP, isolation of initial phoneme; RD, rhyming subtest discrimination; RP, rhyming subtest production; SSW, segmenting sentences into words; SWP, segmenting words into phonemes; SWS, segmenting words into syllables; TB, total blending; TD, total deletion; TI, total isolation; TR, total rhyming; T.seg, total segmentation.

Click here to view


By studying the correlation between PA age and receptive language age, expressive language age, total language age, and semantics age, it was found that there were highly significant positive correlations [Table 4]. Significant positive correlation was detected between PA age and articulation [Table 4].
Table 4: Correlation between phonological awareness age and receptive language age, expressive language age, total language age, semantics age, and articulation

Click here to view


By studying the correlation between PA score and gap between chronological age and total language age, there was a significant negative correlation [Table 5] and [Figure 5].
Table 5: Correlation between phonological awareness test score and gap between chronological age and language age

Click here to view
Figure 5: Correlation between phonological awareness score and gap between chronological age and total language age.

Click here to view



  Discussion Top


PA is the ability to think about the sounds in a word (the word's phonological structure) rather than just the meaning of the word. A variety of tasks that differ with respect to not only the level of linguistic complexity but also the type of cognitive operation required to successfully perform the task have been used to assess PA [14].

With respect to the linguistic complexity, the size of the target unit can vary from words, syllables, onsets, and rimes to phonemes. Converging evidence has been provided that children as they grow older become increasingly sensitive to smaller and smaller linguistic units [15].

The type of cognitive operation used to assess PA could be one of the following operations: deletion, blending, segmentation, and manipulation. Children detect similar and dissimilar phonological units within words before they can manipulate the previously mentioned units within words. The most difficult operations involve the manipulation of sounds (phonemic awareness) [16].

Language is the basis for reading, and spoken language is the starting place for written language or reading. This principle is paramount when we teach children to read. We do not begin solely with letters or letter names. We actually begin before that point with PA. Therefore, PA is the first step in teaching a child the code of reading. The direction is from speech to print. Speech is made up of words, which are made of syllables, which are made of sounds. This makes written language possible. The method we use to identify each sound with a particular grapheme constitutes the reading code. To learn that code, students must be able to hear phonemes, see letters and relate them to each other. When this process becomes automatic and efficient, the student can read words [17].

Assessment of PA serves essentially two purposes: to initially identify students who appear to be at risk for difficulty in acquiring beginning reading skills and to regularly monitor the progress of students who are receiving instruction in PA [18].

The presence of relationship between the performance in PA tasks and reading ability is undisputed. A large amount of evidence has been accumulated to show that the more knowledge the children have about the constituent sounds of words, the better they tend to be at reading [19]. In fact students' level of PA at the end of kindergarten is one of the strongest predictors of future reading success, in grade 1 and beyond. Some seem to develop these skills fairly easily within a stimulating classroom environment, whereas others need more instructions that consciously and deliberately focus on PA. Early intervention is crucial and can make a real difference to students with limited levels of PA [20].

In our study, we assessed PA skills in a group of delayed language children, and these data were compared with controls matched for age and sex. It was found that there was nonsignificant difference between males and females in the performance of PA skills, and this agrees with the findings of Rosal et al. [21] who investigated the relationship between PA and phonological development in children of public and private schools.

Their initial analysis did not reveal significant differences between students in public and private schools, as well as between sexes. However, Chipere [22] found female superiority in PA and reading ability among children in early primary school.

By comparing the performance of PA skills for cases and control in the three age groups, there were significant differences in all skills except in SWS and blending syllables in group A, because the term syllable is not taught in Egyptian schools, so children do not know what it means, so they cannot segment words into syllables; therefore, even normal children performed poorly in these tasks. Although in deleting syllable tasks, there was a significant difference between the normal and delayed language children. However, overall, these nonconstituent results in syllable awareness level are constituent with the results of Badin [23] who examined syllabic segmentation skills in 238 preschool children. He found that performance on this skill accounted for nonindependent variance in reading ability in first or second grade.

On the rhyme level of awareness presented in rhyme discrimination and production, there was a highly significant difference between normal and delayed language children, and this goes with the results of De Jong and Van der Leij [24] who found that rhyme awareness at the end of first grade predicted later on reading achievement.

On the phonemic awareness tasks, there were highly significant differences between the normal and delayed language children, and this goes with the findings of Hulme et al. [25] who found that their combined measures of phonemic awareness were highly significant with concurrent and longitudinal predictors of reading skills when the effects of age were excluded.

This study demonstrated that there was a significant positive correlation between PA age and articulation, which agrees with the study of Rvachew et al. [26] who proved that children with expressive phonological delays demonstrated significantly poorer phonemic perception and PA skills than their normally developing peers. So they concluded that preschool children with delayed expressive phonological abilities should be screened for their PA skills even when their language skills are otherwise normally developing. However, Catts [27] found that children who have articulation disorders without accompanying language disorders are not at risk for PA difficulties.

The results of this study demonstrated highly significant positive correlations between PA age and receptive language age, which agrees with the study of Preston and Edwards [28] who concluded that poorer PA is associated with lower receptive vocabularies and more atypical sound errors.

It was found that there is a significant negative correlation between PA score and the gap between chronological age and language age, which mean that decreased PA scores corresponded to an increase in the level of language impairment. This agrees with the study of McNamara et al. [29] who concluded that children with SLIs were most at risk for PA difficulties and future reading difficulties, whereas the severity of phonological disorders was not a significant risk factor.


  Conclusion Top


PA is a critical precursor to the acquisition of reading. Children with SLIs are at risk for PA difficulties. Children demonstrating SLIs, with or without comorbid speech impairments require specific therapy that includes explicit focus on PA and letter identification skills. Building early language therapies that include components of PA and letter identification may decrease the likelihood that these children will develop reading difficulties.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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