Running head: PHONOLOGICAL AWARENESS AND READING SKILLS

Phonological Awareness and Reading Skills in Children with Cerebral Palsy Jaylene Bettcher APSY 652 Academic and Language Assessment Dr. Michelle Drefs June 26, 2010

PHONOLOGICAL AWARENESS AND READING SKILLS Phonological Awareness and Reading Skills in Children with Cerebral Palsy Cerebral Palsy (CP) is a neurodegenerative disorder that presently effects over 764,000 children and adults in the United States (Palisano et al., 2009). According to Larsson and Dehlgren Sandberg (2008), many individuals with CP, especially those with verbal communication disabilities, develop reading disorders. Phonological awareness is highly correlated with reading abilities, and therefore, weak phonological processing skills may be an early implication of a future reading disorder. Phonological awareness is developed through letter knowledge, vocabulary, further reading acquisition, and oral repetition; however, these exercises may not be possible for children with CP who are unable to speak. Are children with CP who are unable to speak able to develop phonological awareness and increase their reading capabilities? Or is verbal language a necessary precursor to develop phonological awareness and subsequently reading skills? Cerebral Palsy (CP) is a persistent posture and movement disorder that occurs because of interference in the developing fetus or newborns brain (Palisano et al., 2009). An individual with CP typically experiences motor difficulties and muscle spasms that may hinder movement (e.g., walking, running, self-feeding) and/or academic success (e.g., writing, spelling, reading). There are many different symptoms, severities, and classifications of CP, but for the purpose of this paper I am merely going to explain the speech classification system, which classifies individuals with CP that have a speech disorder as either dysarthric (severe speech impairment) or anarthric (cannot speak at all) (Swinehart-Jones & Wolff Heller, 2009). It is also important to gain a basic understanding of what phonological or phonemic awareness is. According to Cohen and Spencer (2011), A phoneme is the smallest unit of sound that has meaning in a language... For example, the word bat consists of three phonemes: ba, aah,

PHONOLOGICAL AWARENESS AND READING SKILLS tuh (p. 224). Derived from the word phoneme, phonological awareness is when an individual is able to recognize, manipulate, separate and blend phonemes (Cohen & Spencer, 2011). Phonological awareness may be developed by repeating words, practicing syllable counts, and continual reading practice; however, these things may not be possible for children with CP, especially those who are dysarthric or anarthric, because of their verbal language impairments. The purpose of this paper is to explore previous literature on phonological awareness and its relationship with childrens reading skills. This will enable us to create a better understanding of the relationship between phonological awareness and reading performance and whether or not verbal communication skills are needed to develop phonological awareness. Many children with reading disorders struggle with self-esteem, academic achievement, and social skills, and consequently they are unable to successfully integrate into society. The implications of this paper may be useful for developing new methods to teach children with verbal communication disorders phonological awareness, and subsequently increase their reading skills. Method The eight peer reviewed journals that were reviewed in this paper were obtained from the online databases; EBSCO, and PsychINFO. To obtain my results, the following key words were utilized: cerebral palsy, literacy skills, learning disorders, reading assessment, phonological awareness, and academic assessment. Exclusion criterion was if any the participants were considered mentally impaired (by trained professionals). Most children with anarthric or dysarthric CP have difficulties reading compared to children without disabilities who have a normal intelligence; however, there are discrepancies in the literature as to what contributes to reading disorders. The results from the following studies suggest that children with CP who have severe speech impairments either do not differ from their typically developing peers, which

PHONOLOGICAL AWARENESS AND READING SKILLS may imply that speech is not a precursor for phonological awareness, or differ (did not perform as well) from their typically developing peers, which may imply that speech is a precursor for phonological awareness. Results Speech may not be a Precursor for Phonological Awareness In Dahlgren Sandbergs (2006) longitudinal study on the development of reading and spelling skills in children with CP and severe speech and physical impairments (SSPI), she assessed six children with CP/SSPI and six children without CP/SSPI. The participants were tested at age 5 to 6 (test one), 8 to 9 (test two), and 11 to 12 (test three) for their intelligence (Ravens Coloured Progressive Matrices (RCPM)), reading, spelling, phonemic awareness and short term memory. The results indicated that children with CP/SSPI displayed an increase in intelligence, reading, spelling, and short term memory from the first test period to the second test period, but a decrease from the second test period to the third test period. Surprisingly, they also displayed a slight increase in phonological awareness over the six year assessment period. Dahlgren Sandberg concluded that although phonological awareness may be acquired without speech, it is not acquired at a level that is sufficient to develop reading skills. The data in this study should be interpreted with caution because there was no available reliability data, which means that the test may not be valid or reliable. Larsson and Dehlgren Sandberg (2008) assessed the phonological awareness of 15 Swedish children with CP who had complex communication needs (CCN) and 15 typically developing Swedish children. The two groups were matched according to gender, mental age (measured with the RCPM), and linguistic age (measured with the Peabody Picture Vocabulary Test- PPVT). The children were individually given nine phonological awareness tests that

PHONOLOGICAL AWARENESS AND READING SKILLS differed in difficulty and presentation (verbal vs. pictorial). The results indicate that the only task where the typically developing children scored significantly better than the CP/CCN children was the rhyming task because it may have placed too much strain on the CP/ CCNs working memory. Overall, the CCN children demonstrated slightly greater phonological awareness than the comparative group, which demonstrates that speech is not necessary in order to acquire phonological skills. The results from the study should be interpreted with caution because the RCPM and the PPVT were translated to Swedish, and the standardized norms were taken from British children. Despite this limitation, the purpose of this test was to compare CP/CCN children with the comparative group, and the test conditions remained consistent in both groups. Another limitation is that the mean chronological age between the groups differed by three years, which may account for the higher phonological performance by the CP/CCN children because they may have had more exposure to literacy skills. Bishop and Robson (1989) investigated if the ability to articulate is correlated with the ability to spell words and non-words correctly in both adolescents with CP, and adolescents without disabilities. The CP adolescents were divided into two groups; 38 had motor speech impairments, but could still articulate, and 12 were unable to speak. The control group was composed of 24 adolescents that were matched to the experimental group based on their chronological age and intelligence (tested with RSPM). All of the participants were tested for intelligence (RSPM), speech and language ability (tested with British Picture Vocabulary scale), and spelling ability (tested with Vernon spelling test). Although the CP groups, particularly the CP group that could not speak, did not perform as well as the control group in the subtests, they still demonstrated that they were competent in each of the areas and were able to spell. Bishop and Robson not only concluded that there is no relationship between speech and language ability

PHONOLOGICAL AWARENESS AND READING SKILLS and spelling skills in persons who could articulate, but also concluded that people who cannot speak still demonstrate phonological awareness. In 2009, Swinehart-Jones and Wolff Heller explored if four students with anarthric CP (age 8 to age 12) who used augmentative and alternative communication (AAC) were able to learn a decoding strategy that focused on phonological recoding (blending graphemes in phonemes) to figure out unknown words. The participants were taught a decoding strategy through a nonverbal reading approach, and then they were asked to learn a list of 10 unknown words. The results indicated that all four of the participants were independently able to learn their 10 target words, and a six month follow up study determined that all of the participants were still able to independently decode unknown words. Swinehart-Jones and Wolff Heller believe that verbal language is not a necessary prerequisite to develop phonological awareness. The results of this study need to be interpreted with caution because all of the participants used an AAC, which does not guarantee that the participants were in fact using internal speech (blending graphemes into phonemes) to decode unknown words. Speech may be a Precursor for Phonological Awareness Card and Dodd (2006) assessed phonological awareness and reading abilities in children with CP that were able to speak (five children), and that were unable speak (six children). The children were matched with a control group of 10 typically developing children based on intelligence, which was assess with the Test of Non-Verbal Intelligence (TONI), to ensure similar cognitive capacities. The participants were assessed for their phonological awareness skills with the Queensland University Inventory of Literacy (QUIL). After careful analysis, Card and Dodd concluded that children with CP who could speak performed better on the phoneme manipulation task and the visual rhyme task compared to children with CP who could not speak.

PHONOLOGICAL AWARENESS AND READING SKILLS There were no significant differences in the results between the children with CP who could speak and the typically developing children. The results suggest that spoken language may be essential for certain features of phonological processing. Peeters, Verhoeven, de Moor, and van Balkons (2009) longitudinal study investigates whether phonological awareness is the best predictor of reading skills in children with CP and in typically developing children. The participants were 117 children from the Netherlands; 52 children had CP (28 were anarthric and 22 were able to speak), and 65 children displayed typical development. The children were matched for chronological age and were assessed with phonemic assessments when they were five, six, and seven years old. The results implicate that phonological awareness and phonological short term memory are the greatest predictive factors of word decoding and reading skills in the children without disabilities, and speech production is the greatest predictive factor for word decoding and reading skills in children with CP. In 1999, Vandervelden and Siegel compared phonological processing in children with CP who have various motor speech impairments to phonological processing in children without disabilities. The participants had consistent reading abilities and were divided into three groups; children with CP who could speak, children with CP who could not speak and use (AAC), and children without disabilities. All participants were given phonological processing tests that tested who-word phonology, phonological awareness, and phonological recording. The results show that both CP groups scored lower in all areas of phonological processing compared to children without disabilities, which may imply that speech is a necessary precursor for phonological awareness. However, Vandervelden and Siegel explain that the results were largely dependent on the mode of presentation, for instance, children with CP who could not speak, made more errors when the words were presented non-verbally (pictures) compared to when they were

PHONOLOGICAL AWARENESS AND READING SKILLS presented verbally. The results may not be reliable because the participants ranged from age seven to age 17, the adolescent participants may have had more exposure to reading instruction and phonological awareness compared to the elementary aged participants. In their one year longitudinal study, Peeters et al. (2008) question if home literacy environment skills (HLE) increase reading skills in children with CP. The participants were 35 Netherland children with CP (four could not speak) who were assessed for speech and intelligence with the RCPM to ensure reliable results. During the first test period (end of kindergarten) the children completed reading precursor tests (rhyme, phonological awareness, syntactical, and vocabulary), and their parents completed a questionnaire regarding their childs HLE. During the second test period (end of grade one) the children completed similar reading precursor tests, and were also assessed on their reading skills. The results demonstrate that HLE variables, particularly parent/child interaction and child inclusion during story time, indirectly effect the childs reading skills by increasing their phonological awareness. Since the study only included four children that were unable to speak, it is not feasible to conclude that the study implicates whether or not speech is a precursor for reading skills, but rather that there are other variables that increase phonological awareness. Discussion Children with severe verbal language disorders may struggle to develop effective reading strategies and skills, which are important for academic success. This may be due to the childrens trouble to understand instruction from their educational mentor or trouble with applying instruction (motor difficulties), lack of internal literacy skills like phonological awareness, and/or lack of effective reading strategies (decoding). Although there is a consistent consensus that phonological awareness increases reading skills, the results indicate that there are

PHONOLOGICAL AWARENESS AND READING SKILLS uncertainties as to whether speech increases phonological awareness. The difference in the results may be attributed to the different modes of presentation in each study, for example if questions were presented verbally or visually. The contradictory results may also be due to the different procedures, methods, and assessment tools used in each study. Common Strengths and Limitations of the Reviewed Studies The eight empirical journals that were discussed present some strengths that ensure the validity and reliability of the study, and allow the study to have practical implications. A significant strength in most of the studies was that was that the experimental and controls groups were matched according to intelligence and reading level, which eliminates intelligence biases that may be present in the groups were matched according to chronological age. The studies (with the exception of Swinehart-Jones and Wolff Heller, 2009) involved at least 3 participant groups that included children without disabilities, children with CP who could speak, and children with CP who could not speak. This is important because it eliminates the chance that poor reading skills and poor phonological awareness are caused solely by CP. Another significant strength is that all of the studies acknowledged past research and contradictory findings in the field, which increases their reliability. Although there are many strengths to the studies, there are also common limitations that may have altered the reliability of the studies. The studies were composed of small sample sizes in both the experimental and control groups, and consequently the results may not be an accurate representation of the population. According to Sattler (2008), the sample size should contain at least 100 subjects in order to ensure that it accurately represents the population. In each of the studies the participants with CP were granted accommodations, for instance, Sanberg (2006) allowed parents or teachers to point to the answers for the CP participants, which may have

PHONOLOGICAL AWARENESS AND READING SKILLS created biased results. Also, it is important to note that CP is not a homogenous disorder, there numerous symptoms and varying degrees of severity, yet the studies concluded that the results may be applied the general CP population, and furthermore, individuals who cannot speak. Clinical implications The previous studies provide data that can be used to further clinical practices and increase phonological awareness and reading skills in children with CP. According to Larsson & Dehlgren Sandberg (2008), early intervention in children with CP is crucial to develop phonological awareness and increase reading and spelling skills. Early intervention techniques may include word and rhyming exercises found in board games, television programs, and educational software. Peeters et al. (2009) bring to attention that children with CP who cannot speak benefit immensely from AAC devices, in fact, AAC devices improve phonological awareness, and consequently also improve reading skills. Not only is it important to focus on phonological skills and reading skills when children are in school, but also it is important to help foster these skills before children enter school. Peeters et al. (2009) explain that if parents engage their children in early literacy activities at home, children are more likely to strengthen their reading precursors (phonological awareness) and further develop their reading skills. However, it is not sufficient to merely supply children with educational books and software; but instead, parents must interact and cognitively stimulate their children as much as possible. Parents can also stimulate their children by enrolling them in extracurricular activities. Palisano et al. (2009) maintain that children who participate in community events not only increase their self efficacy and self esteem, but also are exposed to vocabulary (from peers and adults), which increases their reading skills. Recommendations for Future Studies

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PHONOLOGICAL AWARENESS AND READING SKILLS The studies in this review focused on phonological awareness as the variable that influences reading skills. Future studies should focus on variables like working memory and attention. A study by Bottcher, Meulengracht Flachs, and Uldall (2010) examined if children with CP have attention deficits. Bottcher et al. believe that attention deficits account for some cognitive impairments found in skills like reading and math. Although future research is needed, working memory and attention may be the missing piece in solving the puzzle of why children with CP, particularly those who are unable to speak, lag behind their typically developing peers in academic skills like reading. The review indicates that there are discrepancies regarding the literature on the correlation between phonological awareness and reading skills. Larrson and Dehlgren Sandberg (2008) reason that there are not enough assessment tools to ensure the validity and reliability of phonological awareness tests. Therefore, it is still uncertain whether phonological awareness is causal, consequent, or co-occuring with verbal language communication. Further studies may be able to use the results of the present review in order to pinpoint the precise correlation between speech and phonological awareness. Many children with CP not only have learning disorders, and more specifically reading disorder, but also, disorders struggle with their self-esteem, academic achievement, and social skills. The results from this review indicate that while phonological awareness is highly correlated with readings skills, verbal language may not be a necessary precursor to develop phonological awareness. The implications from this review emphasize the importance of teaching children phonological processing skills with letter knowledge and vocabulary exercises. Children with CP can develop reading skills despite their speech impairment, and they can integrate into society.

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PHONOLOGICAL AWARENESS AND READING SKILLS References Bishop, D., Robson, J. (1989). Umpaired short-term memory and rhyme judgement in congenitally speechless individuals: Implications for the notion of articulator coding. Quarterly Journal of Experimental Psychology, 40, 123-140. Retrieved from the Academic Search Complete database on June 23, 2010. Bottcher, L., Meulengracht Flachs, E., & Uldall, P. (2010). Attentional and executive impairments in children with spastic cerebral palsy. Developmental Medicine & Child Neurology,16, 42-47. doi:10.1111/j.1469-8749.2009.03533.x Card, R., & Dodd, B. (2006). The phonological awareness abilities of children with cerebral palsy who do not speak. Augmentative and Alternative Communication, 22, 149-159. doi:10.1080/07434610500431694 Cohen. L G. & Spenciner, L. J. (2011). Assessment of children and you with special needs (4th ed.). Boston, MA: Pearson. Dehlgren Sandberg, A. (2006). Reading and spelling abilities in children with severe speech impairments and cerebral palsy at 6, 9, and 12 years of age in relation to cognitive development: a longitudinal study. Journal of Developmental Medicine & Child Neurology, 48, 629-634. Retrieved from the Academic Search Complete database on June 20, 2010. Larsson, M., & Dehlgren Sandberg, A. (2008). Phonological awareness in Swedish-speaking children with complex communication needs. Journal of Intellectual & Development Disability, 33, 22-35. doi:10.1080/13668250701829613 Sattler, J. M. (2008). A primer on statistics and psychometrics. Assessment of children: Cognitive applications (4th ed., pp. 91-133). San Diego, CA: Author.

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PHONOLOGICAL AWARENESS AND READING SKILLS Swinehart-Jones, D., &Wolff Heller, K. (2009). Teaching students with sever speech and physical impairments a decoding strategy using internal speech and motoric indicators. The Journal of Special Education, 43, 131-144. doi:10.1177/0022466908314945 Palisano, R., Kang, L., Chiarello, L., Orlin, M., Oeffinger, D., & Maggs, J. (2009). Social and community participation of children and youth with cerebral palsy is associated with age and gross motor function classification. Physical Therapy, 89, 1304-1314. doi:10.2522/ptj.20090162 Peeters, M., Verhoeven, L., de Moor, J., & van Balkom, H. (2009). Importance of speech production for phonological awareness and word decoding: The case of children with cerebral palsy. Journal of Research in Developmental Disabilities, 30, 712-726. doi:10.1016/j.ridd.2008.10.002 Peeters, M., Verhoeven, L., de Moor, J., van Balkom, H., & van Leeuwe, J. (2009). Home literacy predictors of early reading development in children with cerebral palsy. Journal of Research in Developmental Disabilities, 30, 445-461. doi:10.1016/j.ridd.2008.04.005 Vandervelden M. , & Siegel, L. (1999). Phonological processing and literacy in AAC users and students with motor speech impairments. Augmentative and Alternative Communication, 15, 191211. doi:10.1080/07434619912331278725

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