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Children with atypical phonological development : assessment profiles and rates of change Erickson, Kristin Heather 2007

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CHILDREN WITH A T Y P I C A L PHONOLOGICAL D E V E L O P M E N T : ASSESSMENT PROFILES A N D RATES OF C H A N G E by KRISTIN HEATHER ERICKSON B.A., Simon Fraser University, 2005 A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF M A S T E R OF SCIENCE in THE F A C U L T Y OF G R A D U A T E STUDIES (Audiology and Speech Sciences) THE UNIVERSITY OF BRITISH C O L U M B I A June 2007 © Kristin Heather Erickson, 2007 Abstract Children with protracted phonological development (PPD) require an assessment that reflects factors associated with their speech delay, in order to formulate maximally effective intervention goals. This study examined issues relating to the assessment and classification of children with PPD, as having a perceptual or motoric basis, and factors or patterns of performance that might be predictive of severity or change in PPD. Thirteen English-speaking preschool children (4;0 to 5;6) with moderate to severe PPD participated in this study. A l l children had normal oral structures, hearing and vocabulary comprehension. Data were collected in an initial assessment and again 3-5 months later. Tasks at assessment included the Computerized Articulation and Phonology Evaluation System (CAPES, Masterson & Bernhardt, 2001), the Speech Assessment and Interactive Learning System (SAILS, A V A A Z , 1994) perceptual test, the Prereading Inventory of Phonological Awareness (PIP A , Dodd, Crosbie, Mcintosh, Teitzel & Ozanne, 2003), maximum performance tasks (MPTs) using monosyllabic and trisyllabic sequences, and the gross and fine motor subscales from the Child Development Inventory (CDI, Ireton,1992) parent questionnaire. The follow-up assessment consisted of CAPES, a subset of SAILS, a selection of MPTs, and a parent version of the Speech Participation and Activity of Children (SPAA-C, McLeod, 2004) questionnaire. At follow-up, all children showed improvement in phonology. Analysis of the initial assessment tasks did not clearly reveal motoric or perceptual bases for the PPD or factors that were predictive of gain in phonology 3-5 months later. Descriptive comparisons of children's performance patterns on the initial assessment tasks suggested that phonemic perception might be correlated to severity and/or change in phonology. i i Table of Contents Abstract i i Table of Contents i i i List of Tables v List of Figures vi Acknowledgements .. vii 1. INTRODUCTION 1 1.1 Overview of the thesis 1 1.2 Protracted Phonological Development 2 1.3 Attempts at identifying sub-types of PPD 3 1.4 Which variables are related to impairments in speech production (i.e. PPD)? 6 1.5 Phonological awareness skills of children with PPD 7 1.6 Designing an assessment battery 8 1.7 Prospective evaluation of children with PPD 9 1.8 Non-phonological factors in outcomes of speech intervention 12 1.9 The current study 13 2. METHOD 16 2.1 Participants 16 2.2 Procedure :' 18 2.2.1 Time 1: Assessment of phonology, perceptual, and motor skills 20 2.2.1.1 Phonology: Computerized Articulation and Phonology Evaluation System (CAPES) 20 2.2.1.2 Phonemic perception: Speech Assessment and Interactive Learning System (SAILS, Version 1.2) 23 2.2.1.3 Phonological awareness: Prereading Inventory of Phonological Awareness (PIPA) 24 2.2.1.4 Articulatory-motor proficiency: Test of Children's Speech+ (TOCS+) 26 2.2.1.5 General motor abilities: Child Development Inventory (CDI)... 29 2.2.2 Time 2: Follow-up session 30 2.2.2.1 CAPES Profile and IPE level 2 30 2.2.2.2 SAILS 31 2.2.2.3 TOCS+: MRRtri ...'...„ 31 2.2.2.4 Speech Participation and Activity of Children (SPAA-C) 31 2.2.2.5 Peabody Picture Vocabulary Test - 3 r d Edition (PPVT-III) 32 3. RESULTS : 33 3.1 Summary of children's performance on the assessment tasks 34 , 3.2 Statistical analyses 36 ii i 4. DISCUSSION 42 4.1 Summary of findings 42 4.1.1 Group changes from T1 to T2 42 4.1.2 Identifying types of PPD 46 4.1.3 Assessment performance, severity of PPD and predictors of change 49 4.1.4 Qualitative characteristics related to change in phonology 52 4.2 Implications 53 4.3 Limitations 56 References 59 Appendix A: T l and T2 CAPES transcriptions 65 Appendix B: Summary of CAPES measures 78 Appendix C: Parent SPAA-C Questionnaire ". 79 Appendix D: Summary of information collected from the SPAA-C 81 Appendix E: Raw SAILS T l scores 82 Appendix F: PIPA scores 83 Appendix G: TOCS+ Raw T l data 84 Appendix H: TOCS+ Summary of T l and T2 MRRtri raw rate, consistency and accuracy scores 85 Appendix I: Results of Child Development Index Gross and Fine Motor Tasks 86 Appendix J: Results of PPVT-III (1997) 87 Appendix K: U B C BREB Ethics Approval 88 iv List of Tables Table 1: Demographic information 17 Table 2: Test administration 19 Table 3: Summary statistics for age, phonology, motor and perceptual/processing tasks (upper and lower limits, means and standard deviations) 34 Table 4: Results of paired-sample t-tests 35 Table 5: Significant Pearson correlations among assessment tasks at T l 37 Table 6: Z-scores 40 v List of Figures Figure 1: Measures with significant changes between Time 1 and Time 2 36 Figure 2: T l Cluster 1: P2, P4, P5, P6, P7, P9 ,. 37 Figure 3: T l Cluster 2: P3, P8, PI 1, P13 38 Figure 4: T2 Cluster 1: P4, P5, P6, P8, P9, P12, P13 39 Figure 5: T2 Cluster 2: PI, P2, P7, PI 1 39 Figure 6: Relationship between T l SAILS scores and GainPCM 41 vi Acknowledgements Thank you first and foremost to my research supervisor, Dr. May Bernhardt, for supporting me over the past two years. This project would not have been possible without her guidance, encouragement, support and amazingly quick revisions. I would also like to thank the members of my committee, Dr. Stefka Marinova-Todd and Dr. Joe Stemberger, for their assistance, insightful questions and comments about my study. I am grateful for the support of the Speech-Language Departments from Vancouver Coastal Health and Fraser Health, including the communities of Vancouver, Burnaby, North Shore and Richmond for their help with recruitment. I would also like to thank the participants and their parents for their enthusiasm, time and cooperation in this study, which made this project possible. Finally, I would like to thank my parents, family and friends for their many words of encouragement and support. This study was supported by a grant from the Canadian Language and Literacy Research Network. vii 1. INTRODUCTION 1.1 Overview of the thesis Preschool children with protracted phonological development (PPD) constitute a large proportion of speech-language pathology caseloads in Canadian public health units. Children whose speech has not normalized prior to school-entry are at significant risk of ongoing problems with academic achievement (Shriberg & Kwiatkowski, 1988). In order to achieve the best outcomes possible, it is important these children receive early intervention for their speech impairment. Intervention goals are based on assessment of children's speech at the time of intake. Assessments reflecting factors that contribute to the severity of a child's PPD may be most beneficial for determining effective therapy goals. The current study examined issues relating to the assessment and classification of children with PPD, and factors or patterns of performance that might be predictive of severity or change in PPD. The first chapter is a review of the research associated with issues of assessment and their implications for treatment of children with protracted phonological development (PPD) (of unknown origin). It will focus on (a) attempts that have been made to classify different sub-types of PPD, (b) factors that might contribute to the severity of a child's PPD, (c) the importance of phonological awareness and the phonological awareness skills of children with PPD, (d) considerations regarding designing an assessment battery and follow-up session for children with PPD, and (e) the research questions and hypotheses addressed by this study. The second chapter provides methodological details regarding the participants, tasks and assessment measures, scoring, data interpretation and analysis. Chapter three presents the results as they relate to the research questions. The final chapter discusses the study's findings, implications and limitations. 1 1.2 Protracted Phonological Development A number of terms have been coined over the years to describe a condition in which children's phonological systems are slow to mature: articulation disorder, speech sound disorder and phonological disorder or impairment. For the current research study, the term Protracted Phonological Development (PPD) will be used. PPD is defined as delayed development of a child's phonological system that occurs in the absence of any other condition, such as cleft palate, hearing loss, Down syndrome, autism or cerebral palsy. A child's speech may be characterized by limited phonetic inventories, word lengths, and/or syllable shapes and reduced phonemic contrasts in his/her language. Estimates of prevalence of PPD of unknown origin vary widely (Law, Boyle, Harris, Harkness, & Nye, 2000). A recent large-scale epidemiological study predicted the prevalence to be 3.8% among 6-year-olds (Shriberg, Tomblin, & McSweeny, 1999), while other studies estimate the prevalence among 3-year-olds to be 14% (Law, Boyle, Harris, Harkness, & Nye, 2000). Children with PPD are delayed in the acquisition of speech sounds and word and syllable structures, which results in decreased intelligibility (Raitano, Pennington, Tunick, Boada, & Shriberg, 2004). PPD is a developmental condition that can persist for many years after the initial diagnosis (Law et al., 2000) and can have significant negative academic and social implications i f it is not resolved prior to school entry. It has been well established that preschool children with PPD are at significant risk for delays in the acquisition of literacy skills (Larrivee & Catts, 1999; Rvachew, Ohberg, Grawburg, & Heyding, 2003; Raitano et al., 2004). Raitano et al. (2004) found that children with PPD showed lower scores than control participants on tasks assessing phonological awareness skills and letter knowledge skills, even after controlling for such variables as nonverbal IQ and socioeconomic status. This study also found that a history of PPD is a risk factor for deficits in pre-literacy tasks that have been found to be very predictive of later reading abilities (Raitano et al., 2004). Larrivee and Catts (1999) compared first-grade word-2 recognition abilities of children with PPD with those of children developing typically. They found that, on average, scores of children with PPD were approximately one standard deviation below those of typically developing children on measures of word recognition in the first grade, i.e., at the lower bounds of normal. This indicates that these children were already performing at a level below their typically developing peers by first grade. Shriberg and Kwiatkowski (1988) found that speech of over 80% of children with PPD did not normalize prior to school entry, despite their having received speech therapy as preschoolers; the children required special education services during the elementary school years. Although some researchers have reported that poor academic outcomes are specific to children with PPD who have concomitant language impairment, recent research has shown that children with PPD are at greater risk for academic difficulties, whether or not language impairment is present (Raitano et al., 2004; Rvachew & Grawburg, 2006). Social victimization is another potential negative consequence for school-aged children with PPD (Hall, 1991; Silverman, 1992). Furthermore, the consequences of PPD can persist through the school years and into adulthood (Felsenfeld, Broen, & McGue, 1992). Felsenfeld et al. (1992) found that adults with PPD performed significantly worse than a control group on tests of articulation accuracy, vocabulary knowledge and language skills. The adults with PPD had required more remedial help at school, achieved poorer grades, and completed fewer years of formal education. These adults were also more likely to hold unskilled or semiskilled occupations in comparison with gender-matched siblings and the control group, who were more likely to hold professional positions (Felsenfeld et al., 1992). 1.3 Attempts at identifying sub-types of PPD Several attempts have been made to define and describe different sub-types of PPD. For example, Shriberg, Austin, Lewis, McSweeny and Wilson (1997) described four sub-types: (1) speech delay-unknown origin (60%), (2) speech delay-otitis media with effusion (30%), (3) speech delay-developmental apraxia of speech (5%), and (4) speech delay-psychosocial 3 involvement (5%). Dodd (2005) used information regarding the child's articulation of individual phonemes, his/her phonological error patterns, the syllable structures used and the variability of the child's productions to determine sub-types of speech impairment. Dodd described five sub-types: (1) an articulation disorder, (2) delayed phonological acquisition, (3) a consistent phonological disorder (use of some non-developmental error patterns), (4) an inconsistent disorder, or (5) "other" (speech disorders not listed previously) (Dodd, 2005). The Dodd (2005) model also looks at the severity of the speech impairment by considering the effect of the impairment upon speech intelligibility, the degree of concern the disorder causes the child, parents and teachers, and the consequences of the impairment. Speech impairments may have multiple diagnostic subgroups; however, no consensus has yet been reached regarding what the subgroups are and how they are best differentially diagnosed. The Shriberg et al. (1997) and Dodd (2005) classification schemes reflect a distinction between PPD with and without a motoric origin. The motoric impairments are hypothesized to affect actual articulatory movements, while general phonological impairments are presumed to result from difficulty constructing the linguistic system that underlies articulation. The consistency or inconsistency in terms of patterns of substitution or deletion is considered an additional important feature by Dodd (2005); she claims that inconsistency may be characteristic of a unique subgroup of children with PPD. Tyler and Lewis (2005) explored the inconsistency variable further. They divided 20 children (ages 3;0 to 5;11) into two equal-sized groups on the basis of selected phonological measures of consistency/variability (percent consonants correct, phonological mean length of utterance, percent word match and error consistency index). The 'consistent' group showed a pre-intervention error consistency index (ECI) at the extreme consistent end of the ECI distribution (low ECI score) and the 'inconsistent' group showed scores at the extreme variable end of the ECI distribution (high ECI score). The latter group had substitutions both within and 4 • across word positions for a number of consonants, and were considered by Tyler and Lewis (2005) to have a more severe form of PPD. The children were assessed at the beginning of the study (Time 1), at 12 weeks through the treatment period (Time 2) and again at 24 weeks (Time 3). Both the consistent and variable groups showed similar, gradually increasing, percent consonant correct (PCC) scores, and a similar gradual decrease in target consistency index (TCI, a quantitative measure of variability for each child's intervention targets) scores. Based on these similar trends for change among children with variable substitution patterns and children with consistent patterns of substitution, Tyler and Lewis (2005) concluded that, although the children displayed different surface variable/consistent phonological systems before treatment, this did not necessarily imply that they needed different types of intervention (Tyler & Lewis, 2005). Following the publication of the Tyler and Lewis (2005) study, Dodd, Holm and Crosbie (2006) replied that the Tyler and Lewis study used measures of consistency/variability for group selection (i.e. ECI) that tested differences in phoneme variability, but did not reflect two different groups in terms of their consistency of word production. As such, the groups of children in the Tyler and Lewis study were very different from the children with inconsistent PPD described by the Dodd (2005) classification scheme. In their response, Dodd et al. (2006) stated that children respond differentially to an intervention approach when groups are identified as having consistent or inconsistent PPD, based on whole-word consistency. In a subsequent letter to the editor, Tyler and Lewis (2006) agreed that while different subgroups may need different interventions, their data from the 2005 study clearly indicate that two groups differing in error consistency and severity responded similarly to the same kind of speech-language intervention. They also admitted that their results could not be extended to children with PPD that have been grouped by whole-word inconsistency, as in the Dodd (2005) classification scheme. The identification of unique and relevant subgroups of children within the heterogeneous population of children with PPD, and testing different types of intervention for them remains art area open 5 for further investigation (Tyler & Lewis, 2006). The question of whether it is possible to define individual profiles/sub-types of PPD and subsequently whether it is important to match the intervention to the child's PPD profile/sub-type remains unresolved. There is very little research evidence suggesting that interventions tailored to identified sub-types of PPD are more effective than the typical intervention children currently receive for disordered speech. The severity of a child's PPD, as evidenced by their performance on various assessments of phonological processing and motor tasks, may be more important in predicting the need for intervention, the course of intervention and expected outcomes. 1.4 Which variables are related to impairments in speech production (i.e. PPD)? In the study of speech impairment, many researchers have attempted to identify variables related to the presence of the impairment. For many children with PPD, it is difficult to determine the factors related to speech delay. The structure and function of the speech and hearing mechanism is clearly relevant in children with cleft palate or hearing disorders. This study, however, is concerned with examining factors that might influence the severity of PPD in children with PPD of unknown origin. In order to investigate this latter group of children, it is important to have an understanding of the processes involved in the perception and production of speech. A number of perspectives can be adopted when attempting to understand a child with persisting speech difficulties, and when planning his/her assessment and management programme. Stackhouse, Pascoe and Gardner (2006) illustrate a psycholinguistic approach to investigating children's speech and literacy difficulties. The basic premise of this perspective is that children's speech and literacy development is the product of an intact speech processing system that includes (1) speech input processing (e.g. auditory discrimination), (2) lexical representations (of the semantic, phonological, motor, grammar and orthographic components of words), and (3) speech output processing (e.g. programming and production of speech (Stackhouse et al., 2006). It is assumed that children's speech difficulties arise from a breakdown 6 of one, two or all of these components. Therefore, the broad aims of a psycholinguistic approach to the management of a child with speech difficulties are to discover at which point within the model the speech errors are occurring, examine the relationships with other aspects of development, determine the strengths and weaknesses of the speech processing system, select targets for intervention from the output data and evaluate the intervention outcomes (Stackhouse et al., 2006). An important element of this approach is to select or devise assessment tasks to test hypotheses regarding the nature of the child's difficulties. The attempts at classifying children with PPD into various sub-types, as discussed previously, highlight the importance of including tasks measuring a variety of factors believed to be contributing to PPD in an assessment. Stackhouse et al. (2006) presented a number of questions asked during assessment of a 7-year-old boy with unintelligible speech that addressed input skills, output skills and the nature of the stored representations. Within this framework, a comprehensive assessment of children's phonology and underlying skills includes measures of both speech input processing (e.g., phonemic perception and phonological awareness skills) and speech output skills (e.g., motor-based tasks involving the speech articulators and other fine motor skills). Investigation of the factors contributing to severity of PPD and change in a child's phonology over time is an area that is open to further study. The following two sections highlight important elements to include when designing a battery to assess the factors contributing to the severity of PPD and predictors of change. 1.5 Phonological awareness skills of children with PPD Phonological awareness is defined as the ability to attend to, reflect on or manipulate speech sounds in larger units such as sub-syllabic units (onsets, rimes), syllables, words or phrases (Catts & Kamhi, 1999). Tasks for measuring phonological awareness include those involving alliteration or rhyming, and those involving segmentation of syllables, words or 7 phrases into their component parts. Children with impaired phonological production have been shown to be at risk for delays in the acquisition of 'phonological awareness' skills, suggesting that such skills are important to test during phonological assessment (Bird, Bishop & Freeman, 1995; Major & Bernhardt, 1998; Rvachew et al., 2003). Bird, Bishop and Freeman (1995) found that 31 children with PPD scored lower on tasks of rime and onset matching, onset segmentation, and reading than a control group matched for age and nonverbal skills. Similarly, in a study by Rvachew et al. (2003), 13 preschool children with PPD (mean age of 4;7) showed significantly poorer phonemic perception and phonological awareness skills than a control group of typically developing peers. In a 2006 study of 95 4- and 5-year-old children by Rvachew and Grawburg, tasks of speech perception and vocabulary comprehension were most highly correlated with performance on phonological awareness tasks (Rvachew & Grawburg, 2006). Phonological awareness skills have also been highly correlated with later literacy skills (Liberman & Liberman, 1990; Snowling & Nation, 1997; Stackhouse & Wells, 1997; Larrivee & Catts, 1999). Thus, assessment and subsequent intervention for phonological awareness skills may be especially important for laying a foundation for later literacy. The following section further discusses factors that need to be considered when designing an assessment battery for children with PPD. 1.6 Designing an assessment battery The discussion in Section 1.3 above concerning potential sub-types of PPD (e.g., Dodd, 1995; Shriberg et al, 1997) suggests the need for inclusion of speech motor tasks in phonological assessment. In. contrast, studies of phonological awareness (as in Section 1.5 above) suggest the need for inclusion of tasks of speech perception, phonological awareness and vocabulary comprehension. A randomized control trial is being proposed through McGi l l University, the University of Alberta, the University of Toronto and the University of British Columbia. The overall goal of the proposed project (A Randomized Trial of Interventions for Child Speech, 8 ARTICS) is to enhance the effectiveness of phonological intervention so that children with PPD may be more likely to achieve age-appropriate speech prior to school entry. Based on previous attempts at classifying sub-types of PPD as having a more motoric versus a more cognitive-linguistic basis, a variety of tasks have been selected to assess a child's cognitive/perceptual and motor skills. The current study was designed in part as a pilot study for the proposed trial. Thus, the impetus for the assessment battery used in the current study came from the ARTICS proposal. The tasks are discussed in detail in the methods section, with further background given in sections 2.2.1 and 2.2.2. The ARTICS battery, however, is a one-time evaluation of a child's performance. After a period of time has passed (with or without intervention), questions remain about the profile of a child's PPD. Will a child's phonology change or remain at least partially stable? Are factors in the first assessment predictive of change or stability over time in phonological development? The following section outlines research of two types that are relevant to the questions of stability: (1) issues relating to the number of treatment hours and/or the minimum amount of time that can elapse before significant improvements in phonology can be expected, and (2) issues of the context of impairment, as defined by the International Classification of Functioning, Disability and Health (ICF). 1.7 Prospective evaluation of children with PPD Very few prospective studies have been conducted to predict change in phonology for a given time interval for children with different PPD profiles (except Hua & Dodd, 2000, discussed at the end of this section), although many intervention studies have reported change in phonological development over time in children with PPD. A study concerned with functional change over time was conducted by Jacoby, Lee, Kummer, Levin and Creaghead (2002) with 234 children three to six years of age. The authors reported the average number of treatment 9 hours needed to achieve improvements in the A S H A National Outcomes Measurement System (NOMS) functional communication measures (FCMs), rating scales for articulation/intelligibility and spoken language production. In each functional communication level there are seven steps, ranging from completely non-functional to normal. Because the rating scales relate to overall function and do not measure the accomplishment of individual goals, children generally must achieve several goals in order to move up a level on the scale. Therefore, a gain of one level represents a significant improvement in functional communication (Jacoby et al., 2002). For the F C M of articulation/intelligibility in Jacoby et al.'s (2002) study, the levels of improvement were as follows: 28% of children had no improvement (average of 15.0 hours of treatment), 41% showed some improvement through advancing by one level (average of 13.9 hours of treatment), 26% showed moderate improvement by increasing by two levels (average of 30.4 hours of treatment), and 5% showed significant improvement by increasing F C M score by 4 or 5 levels (average of 65.8 hours of treatment). An average of 15 hours of treatment was required to see any improvement in F C M level, and an average of nearly 66 hours was required to achieve an improvement of 4 to 5 F C M levels. These overall means indicate that F C M level improved as the average number of treatment hours improved, with the exception of the difference between levels 0 and 1 in the articulation/intelligibility group. Given a once-weekly therapy schedule, 15 hours would represent about four months of intervention. Another study concerned with outcomes of phonological intervention over time was conducted by Almost (1998). Thirty preschool children with severely protracted phonological development were randomly assigned to two treatment groups. Group 1 received treatment for 4 months, followed by 4 months without treatment, while Group 2 had no treatment for 4 months followed by 4 months of treatment. One treatment program was considered inappropriate for all children; therefore, 4-6 treatment targets (phonological processes) were chosen for remediation for each child, based on his/her patterns of phonological mismatches with the adult target. The 10 phonological target changed about every four sessions. Group 1 children showed significant improvement at the 4-month assessment point, both within the group and in comparison with Group 2, the no-treatment control. After the 8-month study period, Group 1 's measures for conversational speech intelligibility continued to be significantly higher than Group 2's measures. The Jacoby et al. (2002) study and the Almost (1998) study show that significant change can occur in phonological intervention after 15 sessions, or approximately 4 months. However, neither study evaluated change in terms of the children's initial PPD profiles. Hua and Dodd (2000), in contrast, utilized Dodd's (1995) classification to investigate the speech error patterns of seven Putonghua-speaking children with speech difficulties, who received no clinical intervention over a period of 11 months. Qualitative (phonetic inventory, phonemic inventory, and phonological processes used) and quantitative (severity score and inconsistency rating) measures were used to determine the different patterns of phonological change. The children were identified as having (1) a phonetic/articulation disorder, (2) delayed phonological acquisition, (3) a consistent disorder in which the child consistently used error patterns that are atypical of normal phonological development, or (4) an inconsistent disorder in which the child pronounced the same words or phonological features in a variety of inconsistent ways (Hua, & Dodd, 2000). The results from this study suggest that children with different sub-types of speech disorder may follow different developmental courses as a result of different underlying deficits. For example, children with consistent or inconsistent disorder showed very little evidence of change in their phonological systems relative to a group of children with phonological delay, suggesting that unusual phonological processes may be more resistant to change than typical developmental processes (Hua & Dodd, 2000). While this study offers interesting insights into the potential patterns of change of speech errors, it is constrained by its very small sample size. At the time of initial assessment, there was only one child with normal development, three children with delayed phonological acquisition (who displayed different 11 patterns of development), two children with a consistent disorder and one child with an inconsistent disorder. More participants were needed to determine whether these patterns of development were consistent with the different subgroups of phonological disorder. However, the Hua and Dodd (2000) study highlights the possible relevance of identifying predicting factors for stability/rate of change of PPD and led to the major question of the current study: to determine whether change over a 3-5-month period (a timeframe suggested by Jacoby et al., 2002 and Almost, 1998) is related to a child's initial assessment profile, both in terms of phonological patterns, and severity of performance on a variety of assessment tasks. Type of phonological patterns and/or performance on perceptual and motor assessment tasks might affect rate of change in phonological development and response to intervention. 1.8 Non-phonological factors in outcomes of speech intervention In addition, change over time may reflect non-phonological factors. For example, in preliminary studies, researchers have found a child's attention and focus to be relevant for outcomes of phonological intervention (Kwiatkowski & Shriberg, 1998; Weiss, 2004). Non-phonological factors are further suggested by the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF). The ICF provides a framework that classifies health and health-related domains in terms of body structures and functions, and an individual's activities and participations (WHO, 2006). The domains are classified from body, individual and societal perspectives (WHO, 2006), in addition to environmental factors (because a health condition always occurs in a context). A beta version of the ICF addresses health and health-related issues in children and youth, known as the ICF for Children and Youth (ICF-CY). The ICF and ICF-CY have specific applications for people with communication disorders, including children with PPD (McLeod, 2006). Children with speech impairments may function fully within their daily context, or may experience limitations affecting their ability to participate (McLeod, 2004, 2006). There are many reports concerning 12 negative social effects of communication impairment, including bullying (Knox & Conti-Ramsden, 2003), being perceived negatively (Hall, 1991; Silverman, 1992) and poor academic achievement (Lewis, Freebairn, & Taylor, 2000). McLeod (2004) designed a Speech Participation and Activity of Children (SPAA-C) questionnaire, following two workshops in which SLPs met to discuss the topic of working with children with speech impairment, using materials from the ICF framework. The SPAA-C is designed to be used by SLPs and educators to provide information about the child with PPD in his/her context and to inform goal-setting. The SPAA-C is a preliminary attempt at applying the concepts of Activity and Participation from the ICF to children with speech impairment. It may be useful prospectively or retrospectively to look at Activity and Participation factors relevant to the stability of a child's profile and thus the current study included a questionnaire with selected questions from the SPAA-C, as a preliminary investigation of activity and participation factors related to changes over time. 1.9 The current study The preceding literature review highlights the importance of a comprehensive assessment approach for a child with persisting speech difficulties. The psycholinguistic model proposed by Stackhouse et al. (2006) suggests that speech development is the product of a system including speech input processing (e.g. phonemic perception, phonological awareness), stored lexical representations and speech output processing (i.e., the programming and production of speech), with a breakdown in one or more of these areas leading to spoken language difficulties. Assessment of specific input and output processing skills in children with PPD consequently may help identify factors contributing to the severity and outcomes of their speech impairment. To date, very few studies have examined the various underlying perceptual/processing and/or motoric factors that might be related to a child's PPD, or that might be predictive of the severity of PPD and the child's response to intervention. The current study thus had two objectives: (1) to determine whether sub-types of PPD could be determined based on an 13 assessment battery including both input and output processing tasks and (2) to determine whether a child's phonological patterns would be more subject to or resistant to change, according to his/her profile on the original assessment tasks (as set out in the ARTICS project battery), the SPAA-C questionnaire and/or the severity of his/her performance on the assessment tasks. Specifically, the following research questions were investigated: (1) Are there identifiable subgroups of PDD, as indicated by a consistent pattern of performance at Time 1 (Tl) and Time 2 (T2) on the motor versus perceptual/processing tasks, and/or do children with more/less severe PPD pattern together on the various T l assessment tasks? It was predicted that it would be possible to determine sub-types of PPD based on performance on a variety of motor versus perceptual/processing tasks (as suggested by, e.g., Dodd, 1995; Shriberg et al., 1997; Stackhouse et al., 2006). (2) Is performance on assessments of phoneme discrimination, phonological awareness and motor speech tasks predictive of severity of.PPD and degree of change following a 3- to 5-month period? It was predicted that children's initial phonological processing, phonemic perception and/or motor speech skills might be related to the severity of their PPD and/or might predict the rate of change in phonology and response to treatment (as suggested by studies such as Hua and Dodd, 2000). The final question concerned non-phonological factors in outcomes of speech intervention as determined by positive or negative Activity or Participation factors in parent questionnaires and the experimenter's impressions of a child's attention during assessment. The third research question was therefore: (3) Wil l attention during testing and information from a parent questionnaire reveal qualitative characteristics related to gains in phonology or lack thereof over time? 14 It was predicted that children's ability to attend to linguistic input in their environments and to engage attentively with assessment (and treatment) activities might affect the severity of PPD and/or rate of change in their phonology (as suggested by Kwiatkowski & Shriberg, 1998; McLeod, 2004, 2006). 15 2. METHOD 2.1 Participants The participants' in this study were 13 preschool children with PPD of unknown origin. The participants were recruited through private and public health speech-language pathologists in Vancouver, Burnaby, Richmond and North Vancouver. A l l children except P10 were able to complete the task battery. Due to difficulty sustaining attention, P10 did not complete the Time 1 (TI) Test of Children's Speech+ (TOCS+, Hodge & Daniels, 2004) Maximum Performance Tasks (MPTs) or the Prereading Inventory of Phonological Awareness (PIPA, Dodd, Crosbie, Mcintosh, Teitzel, & Ozanne, 2003) or the Time 2 (T2) trisyllabic maximum repetition task (MRRtri, [pataka]). P10 data are thus not included in all analyses. It was originally thought that the data gathered from PI and P2 would be removed from analysis because the period of time elapsed between the assessment sessions and the follow-up session exceeded five months. After running the t-tests and correlations with and without the data from PI and P2, the relationships and significance levels among variables remained constant; therefore, their data were retained in order to increase the robustness of the statistical analyses. Table 1 below describes relevant demographic information about the participants for the purpose of this study. Of the 13 participants, 10 were boys and 3 were girls. Their ages at the time of initial assessment ranged from 4 years, 0 months to 5 years, 3 months. Children who participated in the study met the following inclusion criteria: (1) a score at or below the 16 t h percentile on the Goldman-Fristoe Test of Articulation (second edition) (Goldman & Fristoe, 2000), (2) normal oral structure and hearing (although a history of otitis media was acceptable), (3) a standard score of at least 80 on the Peabody Picture Vocabulary Test-Ill (Dunn & Dunn, 1997) (standard scores of 80 and above are considered to be average or above average) and (4) 1 P = Participant. The participants in this study will hereafter be referred to as PI , P2, P3, etc. 16 use of English at home at least 75% of the time according to parent report. Potential participants were excluded from the study i f they had any known primary disorder causing their PPD (e.g. cleft palate, cerebral palsy, Down syndrome, sensory-neural hearing impairment, autism). Table 1: Demographic information Child Age Age Prenatal or Perinatal Ongoing #ofTx Attention at a tT l atT2 difficulties?3 Tx? a sessions T l A x b T l to T2 a PI 5;2 5;11 No No 0 8 mo. P2 4;0 4;9 No Yes (weekly) P3 5;3 5;8 No Yes Unknown P4 5;2 5;7 No No 0 Inattentive P5 4;5 4;10 Hypotonic; low initial Apgar score but average after 5 min. Yes Unknown P6 4;2 4;6 No Yes 6 sessions 1-2 P7 4;3 4;7 No 'Blocked tube' and 'stopped growing,' bed Yes sessions P8 4;0 4;5 rest from 3 mos. gestation during pregnancy; emergency Caesarian delivery Yes + phonics class lx/wk 15 P9 4;2 4;6 Bed-ridden at 6 mos.; Caesarian delivery at 39 weeks Yes 34 Inattentive P10 4;l 4;6 No Yes 16 (group sessions) Inattentive P l l 4;0 4;5 No Yes Unknown PI 2 4;8 5;1 No Yes 8 sessions P13 4;5 4;9 No Yes Unknown Note. T l = time of first assessment, T2 = time of second assessment; Tx = treatment, Ax = assessment. aParent report on the study questionnaire bAuthor impression during assessment process Parents completed a short case history questionnaire. A l l parents of the children participating in this study reported similar educational backgrounds: the fathers were reported to 17 have a minimum of a high school diploma, with the majority of fathers having completed some form of post-secondary training. A l l mothers reported completion of some post-secondary training, with the majority of mothers holding a bachelor's degree. The children in this study were reported to have no history of disability other than speech delay. A l l of the study's participants had siblings except P9: nine children were second-born, P5 was a fraternal twin, P8 and P10 were first-born and P12 was the 4 t h and youngest child in his family. Parents of P2, P3, P9, P10, P12 and PI3 reported at least one other family member with speech and/or language difficulties. P2, P8, P9 and P10 reported a history of ear infections. However, all parents noted that results of their child's most recent hearing test indicated hearing within normal limits. These children had not had any major illnesses or hospitalizations, although PlO's mother reported he had had his tonsils and adenoids removed. Growth and weight gain were reported as normal for all children except P5 and P8, who were both somewhat small for their age. 2.2 Procedure Data were collected during two initial 1-hour sessions with each child (Tl), and a 1-hour follow-up session conducted 3-5 months later (T2). In the Jacoby et al. (2002) study, the minimum average number of treatment hours required for preschool children to improve by one functional communication level was 15. Assuming that children would receive one hour of therapy per week (typical of children receiving treatment from health units), the T2 assessment was scheduled at least 3 months after T l assessment (although, as noted in Table 1, not all received even 15 hours of treatment). It was hypothesized that, after at least three months, children would show gain consistent with their original assessment profile. (Note that divergence in months between T l and T2 assessments across participants reflected scheduling issues for the T2 follow-up.) A l l sessions were videotaped using a Canon ZR100 miniDV digital video camcorder for future transcription and analysis, and the speech samples were digitally audio-recorded as described below. 18 Table 2 lists the tests used and order of administration during the three sessions of data collection. Table 2: Test administration Task Type TI: Session 1 TI: Session 2 T2: Follow-Up Session Phonology Perceptual/Processing Motor Vocabulary Comprehension CAPES: Profile SAILS: cat, lake, rat, Sue CDI: Parent Checklist TOCS+: MRRmono, MRRtri CAPES: IPE Level 2 CAPES: Profile CAPES: IPE Level 2 PIPA SAILS - rat, Sue MRRtri PPVT - III Note. CAPES = Computerized Articulation and Phonology Evaluation System SAILS = Speech Assessment and Interactive Learning System CDI = Child Development Inventory (gross and fine motor subscales) TOCS+ = Test of Children's Speech + MRRmono = Maximum repetition rate, monosyllabic MRRtri = Maximum repetition rate, trisyllabice PPVT - III = Peabody Picture Vocabulary Test (3rd Edition) The tasks for the study are described in the following sections. The rationale for including each task is provided along with the description of the task, citing relevant literature where appropriate and available. The tasks focused on speech production and input processing versus output processing (motor) as derived from the ARTICS proposal battery. 19 2.2.1 Time 1: Assessment of phonology, perceptual, and motor skills TI assessments of the children's phonology, perceptual/processing ability and motor skills relating to speech took place over two 1-hour sessions. The sessions were conducted in the child's home or in Dr. May Bernhardt's lab space in the Mather Building at the University of British Columbia. 2.2.1.1 Phonology: Computerized Articulation and Phonology Evaluation System (CAPES) A single-word task, the Computerized Articulation and Phonology Evaluation System (CAPES) Profile word list (Masterson & Bernhardt, 2001) was used to provide a thorough evaluation and analysis of each child's phonological system. Use of one single-word list across multiple participants and at different testing points enhances intra- and inter-client reliability, facilitating identification of impairment and standard evaluation of outcomes over time (Masterson, Bernhardt, & Hofheinz, 2005). Some studies have shown that children achieve a higher percent consonants matched (PCM) score and fewer consonant targets in conversational speech, suggesting they are avoiding certain phonological targets with that elicitation method (Morrison & Shriberg, 1992; Wolk & Meisler, 1998). Single-word elicitations, however, can be structured to include all structures and phonemes of the target language, in all applicable word positions (Masterson et al., 2005). While such a list may not be fully representative of the child's everyday speech, it has greater content validity with respect to the child's language, providing relevant information for the SLP regarding the child's current limitations and potential (Masterson et al., 2005). The CAPES single-word task involves administration of two parts: an initial 46-word "Profile" and a subsequent "Individual Phonological Evaluation (IPE)." The Profile list was administered during the first TI testing session 1, and the IPE Level 2 was administered during 20 the second TI session. The IPE Level 2 stimuli include 40 additional mono- and multisyllabic words. The combination of the CAPES Profile and IPE Level 2 tests all English phonemes except [3] at least twice in each word position, and samples many consonant clusters. CAPES selects IPE Level 2 words when the productions in the Profile include substitutions for more than four consonants, or i f consonant sequences are reduced. Rather than allowing CAPES to automatically determine the appropriate level for the IPE assessment, each child was assessed using Level 2 during the second TI testing session in order to ensure consistency of the measures across participants. A PowerPoint computer-based slideshow of the CAPES photographs was used for the elicitation. The digital audio files were recorded using a Sennheiser e935 microphone, and an M -Audio MobilePre USB preamp audio interface was used to enhance the quality of recordings. The audio files were recorded onto an Inspiron 6000 Dell computer using the Wavepad software. The CAPES data were transcribed by the author using narrow transcription and the International Phonetic Alphabet (IPA), with the following exceptions, necessary to satisfy the CAPES program and thus generate accurate analyses: [?] was omitted before vowel-initial words, as was vowel length and nasalization of vowels before nasal consonants. In addition, dentalized alveolar stops were transcribed as regular alveolar stops (see discussion below). Sennheiser HD 595 headphones were used to transcribe the CAPES words from digital audio files. Where the audio files failed to record, the words were transcribed from the digital video recordings. Syllabic lil was transcribed as [9J] because of how it is analyzed in CAPES: [J] was included in the consonant count, and [a] was included in the vowel count. Inter- and intra-judge reliability was completed on 10% of the CAPES transcriptions. For inter-judge reliability, the author and a second experienced transcriber independently transcribed 10% of the data. Inter-judge reliability was as follows: for consonants, 90.34% agreement; for vowels, 86.3% agreement and for diacritics: 58.33%. Variations in vowel transcriptions were found between [9] 21 versus [u], and for [I] versus [e]. The relatively low inter-judge reliability found for diacritics was due to the notation of dental placement for alveolar stops by the second transcriber, but not by the first. Children's dentalization of alveolar stops in this study was typical of preschool children's speech, and was therefore not transcribed by the author. Overall articulation of alveolar stops by the children in this study is thus likely more dental than is reflected by the transcriptions of the author. These inter-judge reliability figures were comparable with other measures of reliability for phonetic transcription (e.g., Holm & Crosbie, 2006; Shriberg & Lof, 1991), with the possible exception of the dental diacritic as previously discussed. Transcriptions of speech assessments analyzed in the Holm and Crosbie (2006) study of a 7-year-old child with severe phonological impairment achieved inter-judge reliability of 77.2% for vowels and 73.4% for consonants. Intra-judge reliability for the CAPES transcriptions was calculated for the same measures: consonants: 91.19%, vowels: 93.57%, and diacritics: 92.50%. In Gooch, Hardin-Jones, Chapman, Trost-Cardamone, and Sussman (2001) an intra-judge agreement score of 92% was achieved by the transcriber who served as the standard for that study of compensatory articulations in children 3;9 to 9 years. Intra-judge reliability for the phonetic transcriptions in the present study was thus consistent with at least one other study. Administration of CAPES provided an opportunity to quantify aspects of each child's phonological system, and to track the stability of this system between the initial assessments and the follow-up session. The information gathered through CAPES also allowed for comparison of the phonological system relative to a child's performance on the various motor and perceptual assessment tasks. In order to examine the severity of phonological difficulties and their change over time, the following relational measures were extracted from the CAPES data: match-mismatch analyses for word shape (in C V sequences), consonants and vowels. The percent consonants matched at T l (T1PCM)) score was determined by calculating the percentage of consonant matches between the child's production and the adult target for all word-initial, word-22 medial and word-final consonants. A score for word shape (e.g. CVC) match at TI (TI WSM) was determined by calculating the percentage of words the child produced that matched the target word shape. The word shape and consonant analyses were included in the statistical analyses; however, because the children's vowels remained relatively stable (and fairly high) between TI and T2, the vowels were not analysed statistically. 2.2.1.2 Phonemic perception: Speech Assessment and Interactive Learning System (SAILS, Version 1.2) SAILS Version 1.2 ( A V A A Z Innovations, 1994) was used because it is the major commercially available tool for evaluating children's phonemic perception, and was chosen to be part of the ARTICS battery. This tool was included in the present study to assist in the identification of children with PPD with underlying difficulties in phoneme discrimination/perception. Phonemic perception tasks are distinct from phonological awareness tasks (see discussion of the PIPA in section 2.2.1.3 below) because the child does not have to segment the word into smaller units and manipulate these units as during such phonological awareness tasks as sound isolation and sound segmentation (Rvachew, 2006). SAILS focuses the child's attention on those aspects of speech that are the basis for distinguishing the various speech sound categories in a computer game format that assesses a child's ability to identify words that are produced correctly or incorrectly. Natural speech recordings from many children and adults are used, contrasting typical real-world errors with correctly produced sounds. The off-target words each begin with a commonly misarticulated consonant. The test words are organized into modules consisting of 10-30 tokens recorded from children and adults (Rvachew, Nowak, & Cloutier, 2004). Half of the words are articulated correctly, and half are articulated incorrectly. 23 In the present study, the recorded words were presented one at a time over computer speakers, due to the young children not wanting to wear headphones. The children were presented with two response alternatives on the computer screen: a picture of the target word and a picture of a large X . The children were instructed to point to the picture of the target word i f they heard it correctly and to point to the X i f they heard a word that "sounds funny." The "cat," "lake," "rat" and "Sue" modules were used at TI for this study because these contain phonemes with which children with PPD frequently experience difficulty (/k/, I si, III, 111). In the SAILS program, the phoneme [t] was substituted for Ik/; [hw], [w] and [j] for III; [w] and [ JW] for 111, and [j], [d3], [tj], [ts], [J], [sj], [0] and [t] for Is/. Across the four modules, 110 items were presented in total, including practice trials. SAILS scores were obtained by adding up the number of words-correctly identified for each module, excluding the practice sets, for a total raw score out of 70. These scores were also averaged across the seven sets to determine each child's average score (out of 10). 2.2.1.3 Phonological awareness: Prereading Inventory of Phonological Awareness (PIPA) To complement the phonemic perception test, and in order to help characterize a child's perceptual/processing profile, the Pre-reading Inventory of Phonological Awareness (PIPA) (Dodd et al., 2003) was used. Although there are many commercial tools available for evaluating phonological awareness, the PIPA is a norm-referenced test designed to assess phonological awareness in children as young as age 4, the youngest age for children in the present study. (Most other commercially available tests only have norms for children aged 5 and up.) The PIPA consists of six subtests: rhyme awareness, syllable segmentation, alliteration awareness, sound isolation, sound segmentation, and letter-sound knowledge. The following subtests were administered: 24 Rhyme Awareness. Rhyme awareness reflects the child's ability to judge the phonological similarity of spoken words (Dodd et al., 2003). The child was asked to choose the word that does not rhyme from a set of four words. The test administrator pointed to a picture of each word while simultaneously naming it, and asked the child "Which word does not belong?" Syllable Segmentation. Syllable segmentation reflects the child's ability to process words at a syllabic level, and is one of the earliest phonological awareness skills to emerge (Dodd et al., 2003). The test administrator asked the child to segment a spoken word into individual syllables, by simultaneously clapping and saying the words. Alliteration Awareness. Alliteration awareness reflects the child's ability to segment words at the phoneme level, and to compare the similarity of onsets (Dodd et al., 2003). The administrator asked the child to choose the word that did not begin with the same sound from a set of four words. The administrator pointed to a picture of each word while simultaneously naming it, and asked "Which word does not begin with the same sound?" Sound Isolation. Sound isolation reflects the child's ability to recognize onsets, segment them from the rime, and pronounce the isolated sound (Dodd et al., 2003). The administrator pronounced a word and asked the child to say the first sound of the word. Sound Segmentation. Sound segmentation reflects the child's ability to segment words at the phoneme level, and to pronounce each phoneme as an isolated sound. It is a more difficult task than alliteration awareness and sound isolation. The administrator asked the child to segment a spoken word into individual sounds using some kind of marker to help isolate each individual sound. Letter-Sound Knowledge. The letter-sound knowledge subtest demonstrates the child's understanding of the alphabetic nature of the written language (Dodd et al., 2003). The 25 test administrator asked the child to say a sound when presented with a letter, i.e.,"What sound do/es these/this letter/s make? For statistical analysis, raw scores for the first three subtests (rhyme awareness, syllable segmentation and alliteration awareness) were summed to create a total PIP A score for each child. The last three subtests (sound isolation, sound segmentation and letter-sound knowledge) were not included in this total score (or the statistical analyses) because many children had scores of zero. Although zero was considered to be within normal limits for this age group, having many zero scores added minimal information for analysis purposes. 2.2.1.4 Articulatory-motor proficiency: Test of Children's Speech+ (TOCS+) The Test of Children's Speech Plus (TOCS +, Hodge & Daniels, 2004) is a computer program designed to facilitate administration and measurement of what are called maximum performance tasks (MPTs) with children (Rvachew, Hodge & Ohberg, 2005). The purpose of the TOCS + task is to help determine the extent to which motoric factors may contribute to a child's difficulties with the acquisition and production of different speech sounds. MPTs are procedures for evaluating articulatory-motoric proficiency in children and adults (Rvachew et al., 2005). Thoonen, Maassen, Wit, Gabreels and Schreuder (1996) and Thoonen, Maassen, Gabreels and Shreuder (1999) investigated the variable performance of children with dysarthria, 'developmental apraxia of speech' (DAS), PPD of unknown origin and typically developing speech. In their studies, MPTs differentiated non-specific speech disorders (PPD) from dysarthria and DAS. Children with PPD required more practice in order to produce MRRtri 's than children with dysarthria or children from a normally developing control group; however, a large number of children with PPD were capable of producing a correct trisyllabic sequence after prolonged practice. On measures of MRRmono and Maximum Phonation Duration (MPD) of sustained [a], [fj, [s] and [z] phonemes, children with PPD had longer MPDs 26 than children with dysarthria and DAS, but shorter MPDs than children in the control group (Thoonen et al., 1999). In spite of some overlap between diagnostic categories, these MPTs yielded discriminatory indices reflecting the observed primary speech deficits of each of their participants. Therefore, inclusion of MPTs in an assessment battery was considered potentially helpful in determining the relative involvement of motor speech problems in children with PPD. For the current study, only two TOCS+ measures were used: MRRmono, obtained through repetition of [pa], [ta] and [ka], and MRRtri, measured through repetition of the trisyllabic sequence [pataka]. The vowel and fricative prolongation tasks were omitted to avoid over-testing the children. The M R R tasks provided sufficient information to determine whether the children in this study had a motor component to their PPD through comparison with the data gathered by Rvachew et al. (2005). The TOCS+ MRRtri task was administered during the initial assessment and the follow-up session in order to examine these children's ability to produce the trisyllabic sequence correctly. Comparison of the children's MRRtri 's between TI and T2 allowed for analysis of the change in their MRRtri productions over a 3- to 5-month period, and determination of whether articulatory-motor difficulties were a contributing factor in their PPD. A Plantronics computer microphone and Dell Inspiron 2000 computer was used to obtain recordings of the child's responses. Analysis and interpretation of the maximum performance tasks (rate of articulation) was done according to the protocol developed by Rvachew et al. (2005). MRRmono was measured by loading the sound file into the waveform display window in WavePad and marking off 10 consecutive repetitions of the syllable. If 10 repetitions were not available for a trial, the next highest number of consecutive repetitions was measured. Although the protocol developed by Rvachew and colleagues (2005) required that children produce all repetitions on the same breath, the children in that study ranged in age from 4; 1 (4 years, 1 month) to 6;11, with 5;9 as the mean age of that cohort. The children in the present study had difficulty with the concept of producing 27 a large number of syllables all on one breath. Because these children were younger (mean age 4;5 at T l ) than the children in the Rvachew et al. (2005) study, short gasps of breath were acceptable. The total duration of these syllables was measured and the number of syllables produced per second was calculated by dividing the number of repetitions by the total time in seconds. The same procedure was used to determine MRRtri except that four consecutive repetitions of the sequence [pataka] (i.e., 12 syllables) were marked off. For the trials in which a child did not produce four consecutive repetitions of [pataka], the maximum number of repetitions that were produced (usually three) was used to determine MRRtri. The number of syllables per second was calculated as described previously for MRRmono, resulting in a number that reflected M R R rates. A total score for maximum repetition rates for monosyllabic and trisyllabic sequences at T l (preMPTavg) was calculated by averaging the syllables per second from all MRRmono and MRRtri trials. If a child could not articulate the target consonant, the syllable was still included in the rate calculation: inaccurate consonants were ignored for that analysis, and the syllable was included as part of the rate measure. However, the Williams and Stackhouse (2000) study of rate, accuracy and consistency of diadochokinetic performance of typically developing 3-5-year-old children illustrated the importance of scoring accuracy and consistency of MRRtri sequences in additional to the measure of rate (in syllables per second) as described above. The results of their study showed that accuracy and consistency of response are more sensitive MRRtri measures for preschoolers than traditional rate production. Accuracy and consistency scores for the MRRtri sequences were thus also calculated. Each child was assigned a raw score out of 36 (1 point for each syllable) for accuracy of the first three trials of [pataka]. The syllable had to be produced with the correct target consonant, and without syllable deletion or epenthesis in order to obtain a score of 1. Syllables with consonant substitutions and/or syllable deletion or epenthesis received no points. Each child's ability to repeat the sequence in a form consistent with their own sound system was 28 also assessed (MRRtriCons), a procedure in keeping with the Williams and Stackhouse (2000) results. They observed that some children repeated the adult model incorrectly, but maintained the same production over each of the repetitions of [pataka], while other children repeated the items incorrectly, but then produced a different pronunciation of the target for each of the repetitions. Each trial of four repetitions of the first three [pataka] sequence was scored out of 4, for a total raw consistency score out of 12. Repetitions within a trial were considered consistent if the same sequence of syllables was produced for [pataka], irrespective of the accuracy of the utterance. This measure was included to help distinguish between children who used consistent and inconsistent patterns of response. 2.2.1.5 General motor abilities: Child Development Inventory (CDI) The Child Development Inventory (CDI) (Ireton, 1992) was used to gain information about a child's general motor abilities. This tool is a parent questionnaire that assesses the development, symptoms and behaviour of young children from age 15 months to 6 years. Parents or guardians were asked to complete the Gross Motor and Fine Motor subscales of the CDI. Information from the Gross Motor and Fine Motor subscales was initially hoped to be helpful for determining whether delays in gross or fine motor development contribute to the severity of a child's PPD. Unfortunately, this test was not very sensitive for this age group and for the purposes of this study. A l l children achieved scores on the Gross Motor subtest that were at or near ceiling for their age, except P5 and P8 who were -1.3 SD and -1.5 SD respectively below the mean. Eight children achieved scores on the Fine Motor subtest that were at or near ceiling for their age, exceptions being P4, P6, P9, P10 and PI3 who were -1.3 to > -2 SD below the mean. Because of this, the CDI data were not included in statistical analysis. However, the individual performance of children noted above is discussed qualitatively in the Discussion. 29 2.2.2 Time 2: Follow-up session A single 1-hour follow-up session was conducted with each child 3-5 months following the initial two sessions of assessment (T2). The additional session was conducted in order to address the question of whether children who achieve a certain profile on the phonological processing and motor skills tasks have underlying deficits that are more subject to change, and whether there is a profile of phonological disorder that is more resistant. The second purpose was to assess the context of the speech impairment in terms of the SPAA-C to determine whether factors in the SPAA-C are more, less or equally relevant in terms of phonological changes or stability. It was not possible to administer all of the tests at the follow-up session that were done during the two initial assessment sessions due to constraints on time and resources. Young, preschool children can usually sustain attention for up to an hour, after which the reliability of their responses can decrease, due to fatigue and lack of attention. As such, only a subset of the TI tasks were selected for administration during the follow-up session. 2.2.2.1 CAPES Profile and IPE level 2 Administration of the original stimuli used to assess the child's phonological system allowed a comparison of any changes and/or progress in the child's phonological system between the initial assessment sessions and the follow-up session, due to intervention, maturation or a combination of the two. Percent Consonant Match (PCM) scores were calculated for each child's T2 CAPES data using the same method described in section 2.2.1.1, and the P C M score from TI was subtracted from this T2 P C M score in order to obtain a measure of the progress the child had made in number of consonants produced correctly (GainPCM). Word shape scores were also calculated using the method described in section 2.2.1.1, and the TI word shape score was subtracted from this T2 word shape score in order to obtain a measure of the progress the child had made production of the correct word shapes (GainWordShape). 30 2.2.2.2 SAILS The purpose of re-administering several SAILS modules was to assess the stability and reliability of the child's scores on the SAILS modules. Each participant was re-tested on the "rat" and "Sue" modules, because many children with PPD experience difficulty with the phonemes /J/ and /s/. Due to time constraints, it was not possible to re-administer all modules ("cat", "lake", "rat" and "Sue") at T2. Knowledge of a child's ability to discriminate between words pronounced correctly and incorrectly at T2 compared with T l (on the same modules) facilitated comparison with the child's phonological system as assessed at T l and T2. Time 2 SAILS scores were obtained for the "rat" and "Sue" modules using the procedure described in section 2.2.1.2. 2.2.2.3 TOCS+: MRRtri The TOCS+ MRRtri task was repeated using the [pataka] trisyllabic sequence. The [pataka] sequence was used for the follow-up task because the majority of children with PPD could produce each syllable in isolation, but experienced difficulty when attempting to sequence the three different syllables with their different places of articulation. The purpose of repeating a MPT in the follow-up session was to determine whether the subgroup of SSD children with motoric problems demonstrated improvement in this motor skill after a period of 3-5 months, with or without therapy. Time 2 measures of MRRtri were obtained using the procedure described in section 2.2.1.3. Scores reflecting the accuracy and consistency of these trials were also measured using the procedure described in section 2.2.1.4. 2.2.2.4 Speech Participation and Activity of Children (SPAA-C) The Speech Participation and Activity of Children (SPAA-C, McLeod, 2004) is a preliminary attempt at applying the concepts of Activity and Participation from the ICF to children with speech impairment. (See section 1.9 above for a more complete discussion of the ICF-CY and development of the SPAA-C.) Parents or guardians were asked to respond to ten 31 questions selected from the SPAA-C for parents using a written questionnaire format (Appendix B). The data collected using the SPAA-C was more qualitative in nature, and were therefore not included in the statistical analysis of this data. A table summarizing information gathered using the SPAA-C from the parents can be found in Appendix C, and the implications of this information are reviewed in the Discussion chapter. 2:2.2.5 Peabody Picture Vocabulary Test - 3rd Edition (PPVT-III) The PPVT-III (Dunn & Dunn, 1997) is commonly used as a measure of vocabulary comprehension for standard English and as a screening test of verbal ability. In a study by Naglieri and Pfeiffer (1983), the PPVT was found to be a consistent and reliable measure of verbal comprehension over time with a group of 29 students with cognitive challenges. In Rvachew and Grawburg (2006), phonological awareness was shown to be associated with performance on vocabulary comprehension. The PPVT - III was thus used in this study to obtain a consistent measure of language comprehension ability for the participating children. 32 3. RESULTS The present study was designed to (1) investigate issues relating to the assessment and classification of children with PPD, and (2) to examine factors or patterns o f performance on the T l tasks that might determine whether children's phonological patterns were more subject to or resistant to change. Thus, a number of concurrent and longitudinal analyses were performed across tasks. In order to determine whether the children's performance on any of the initial assessment tasks at time 1 ( T l ) was related to their performance on any of the other tasks at T l , a series of bivariate Pearson correlations was performed across the group. Another series of bivariate Pearson correlations was performed on the assessment tasks administered at time 2 (T2). In order to examine whether children's performance changed between T l and T2, a series of paired samples t-tests was performed comparing the average performance of the group on tasks at T l to the average group performance on the same tasks at T2. Means were calculated for the following measures at T l and T2: percent consonants matched ( P C M ) and percent word shapes matched ( W S M ) from the C A P E S words, raw scores from the "rat" and "Sue" S A I L S modules, and measures of rate, consistency and accuracy of M R R t r i . In order to examine whether performance on the assessment tasks could predict stability or rate of change in their phonological systems, a series of bivariate Pearson correlations was run on T l variables and the change in percent consonant match (GainPCM) and change in word shape match (GainPWM). This analysis also assisted in determining whether severity of P P D (as indicated by a low T1PCM and/or T1PWM score) is a factor in predicting P C M and P W M scores at the time of the follow-up assessment. A l l statistical analyses were performed using SPSS 12.0. Finally, z-scores were calculated for tasks to help determine whether groups of children patterned together on the assessment tasks and their subsequent scores of phonological skil l (in cluster analyses). 33 3.1 Summary of children's performance on the assessment tasks Appendix A contains IPA transcriptions of the participants' TI and T2 CAPES word lists. Upper and lower limits, means and standard deviations of the children's overall scores on each perceptual/processing task, motor, and assessment of phonological development are shown in Table 3 for Time 1 (TI) and Time 2 (T2). Table 3: Summary statistics for age, phonology, motor and perceptual/processing tasks (upper and lower limits, means and standard deviations) Variables N Minimum Maximum Mean Std. Deviation TIAge 13 48 63 53.31 5.65 T2tAge 13 53 71 58.62 6.21 Phonology T1PCM 13 24.12 80.40 54.30 16.48 T2PCM 13 28.14 80.90 61.91 16.72 T1PWM 13 10.47 86.05 59.38 22.38 T2PWM 13 34.88 82.56 68.58 13.96 %GainPCM 13 -5.02 24.51 7.61 8.96 %GainWSM 13 -7.13 47.67 9.20 13.63 Maximum Performance Tasks TIMPTavg 12 2.67 4.21 3.52 .46 TI MRRtri 12 2.42 4.66 3.55 .72 T2MRRtri 12 2.45 3.96 3.09 .43 TI MRRtriAcc 12 6.00 35.00 20.08 6.96 T2MRRtriAcc 11 19.00 36.00 25.18 6.16 TIMRRtriCons 12 4.00 11.00 7.67 2.39 T2MRRtriCons 11 4.00 12.00 9.73 2.37 Perceptual/Processing Ability T1PIPA 12 3.00 33.00 15.42 8.96 TISAILSavg 13 5.80 8.20 6.62 .76 T2SAILSavg 13 5.40 9.00 7.26 1.03 TISAILSraw 13 39.00 59.00 47.85 5.87 TISAILSRatSueraw 13 29.00 41.00 33.08 3.80 T2SAILSRatSue raw 13 27.00 45.00 36.31 5.14 Valid N (listwise) 11 Note. P C M = Percent Consonants Matched (from CAPES data) P W M = Percent Word Shapes Matched (from CAPES data); MRRmono = Maximum Repetition Rate for monosyllabic repetitions; MRRtri = Maximum Repetition Rate for trisyllabic repetitions; MRRtriAcc = Accuracy of MRRtri's; MRRtriCons = Consistency of MRRtri 's. (Test titles and descriptions are available in Method section 2.2.1.) Raw scores for the Table 3 measures can be found in Appendices B, E, F; G and H. 34 Paired samples t-tests were used to evaluate changes in children's phonological systems and their performance on the assessment measures between TI and T2 (Table 4). Table 4: Results of paired-sample t-tests Task N t E T1PCM-T2PCM 13 -3.06 0.01 T1%WSM-T2%WSM 13 -2.43 0.032 T1 MRRtri-T2MRRtri 12 1.95 0.077 T1 MRRtri Acc-T2MRRtri Acc 12 -2.08 0.064 T1 MRRtriCons-T2MRRtriCons 12 -2.67 0.024 TI SAILSratSue raw-T2SAILSratSueraw 13 2.93 0.013 Note. Refer to Table 3 for expansion of acronyms. Significant differences (minimum of p<0.05 two-tailed) were found between (a) children's P C M at TI and T2, (b) percent word shape match (WSM) at TI and T2, (c) raw SAILS scores for "rat" and "Sue" modules at TI and the same modules at T2, and (d) the consistency of children's [pataka]'s at TI and T2 (MRRtriCons). Figure 1 compares children's TI and T2 scores. 80 -, PCM WSM SAILSraw MRRtri Cons Assessment Meaures Figure 1: Measures with significant changes between Time 1 and Time 2 In the following section, the various questions from the introduction are addressed in turn. 35 3.2 Statistical analyses (1) Are there identifiable subgroups of PDD as indicated by a consistent pattern of performance at T l and T2 on the motor versus perceptual/processing tasks, and/or do children with more/less severe PPD pattern together on the various T l assessment tasks? A cluster analysis was performed to examine whether children's performance on the various assessment tasks patterned together to suggest different subgroups of PPD. PlO's data were not included because he did not complete all tasks. Bivariate Pearson correlations were first run to determine which T l variables were highly correlated (see Table 5). Of the factors assessed at T l , it is interesting to note that age at assessment was not significantly correlated with any of the factors assessed in this study, and in particular, phonological development, as indicated by P C M and P W M match. Table 5: Significant Pearson correlations among assessment tasks at T l Factors r E T l P C m - T l % W S M 0.889** 0.010 T1PCM-PIPA 0.607* 0.036 TIPCM-TlMPTavg -0.599* 0.039 T l%WSM-TlMPTavg -0.587* 0.045 TlMRRtr ip-Tl MPTavg 0.776** 0.003 T1 MRRtri-T 1 MPTavg 0.776** 0.003 T1 MRRtri Acc-PreS AILSraw 0.629* 0.028 TlSAILSraw-PIPA 0.645* 0.024 *Correlation significant at the 0.05 level (2-tailed). **Correlation significant at the 0.01 level (2-tailed). Refer to Table 3 for expansion of acronyms. 36 For ease of cluster analysis, variables within a construct that were highly correlated were clumped together as one measure. The T l phonology measures, T1PCM and T1PWM, were highly correlated and were therefore combined into a single "Phonology" variable (average of the two scores). The T l motoric measures (T1 MRRtri, TIMRRTtriAcc and TIMRRtriCons), were not significantly correlated, suggesting that these measures patterned differently for these children; therefore, these measures were entered individually into the cluster analysis. The PIPA and SAILS were entered individually into the cluster analysis because they measure different constructs, i.e., phonological awareness, and phonemic perception respectively. The cluster analysis was based on z-scores (calculated for the group) for each of these variables: ztl Phon, zt lMRRtri , ztlMRRtriAcc, ztl MRRtri Cons, ztl PIPA and zt lSAILS. Figures 2 and 3 below show the two groups.that emerged from the T l analysis. 1.5 o o 0.5 c 01 Q. O CO Q. 0) 5-0.5 < -1 ztlMhon ztl MRRtrifl cc ztiMRRtriCons ztiPlPA t1 SAILS Input, Output and Phonology Measures Figure 2: T l Cluster 1: P2, P4, P5, P6, P7, P9 37 1.5 to 0) i o o to c ro Q_ o t ro Q_ O 0) O) ro i > < 0.5 -0.5 -1 —, 1 | ' 1 zt lPhon ztiMRRtri ztlMRRtriAcc ztiM|RRtri(tons ztiPlPA zt1 SAILS Input, Output and Phonology Measures Figure 3: TI Cluster 2: P3, P8, PI 1, P13 P1 and P12 did not cluster with any of the other children at T1. A cluster analysis was also performed among measures at T2 in order to determine whether the children who cluster together at TI continued to pattern together at T2. Because it was not possible to re-administer all of the TI assessment tests at T2 due to the constraints addressed in the Methods chapter, only the following measures were included in the T2 cluster analysis: T2PCM and T2PWM (combined into a single T2Phon measure), T2 MRRtri, T2MRRtriAcc, T2MRRtriCons and T2SAILS. Individual z-scores were calculated for each of these T2 measures, resulting in the following variables that were included in the cluster analysis: zt2Phon, zt2MRRtri, zt2MRRtriAcc, zt2MRRtricons and zt2SAILS (where lower case t=Time). Figures 4 and 5 show the T2 clusters that emerged from this analysis. P3 did not cluster with the others at T2. 38 1.5 to 1 o o CO • N I 0.5 Q. r a. v CO 2 < -0.5 :t2Phor T 1 1 1 i zt2MRRtri zt2MRRtriAcc zt2MRRtriCons z t2SAIL 3 I n p u t , O u t p u t a n d P h o n o l o g y M e a s u r e s Figure 4: T2 Cluster 1: P4, P5, P6, P8, P9, P12, P13 1.5 (0 _^ o u w 2 0.5 O to o- 0 a> a> g -0.5 > < -1 zt2Phon 2MRR ri zt2MRRtriAcc zt2MRRtriCons zt2SAILS Input, Output and Phonology Measures Figure 5: T2 Cluster 2: PI, P2, P7, P l l 39 (2) Is performance on assessments of phoneme discrimination, phonological awareness and motor speech tasks predictive of severity of PPD and degree of change following a 3- to 5-month period? The statistical analyses revealed few associations between the factors assessed at T l and the amount of progress the children made in their phonology, as indicated by GainPCM and GainPWM. Bivariate Pearson correlations were run between the following T l factors and GainPCM and GainPWM: TIAge, T1PCM, T1PWM, PIPA, TISAILSraw, TISAILSavg, T l MPTavg, T l MRRtri, TIMRRtriCons, and T l MRRtri Acc. There were no significant correlations found between perceptual/processing and/or motor T l factors and GainPCM and/or GainPWM. Age at the time of initial assessment was not found to be significantly related to GainPCM or GainPWM, as one might expect for children whose phonological systems should continue to develop between assessment points. It is interesting to note that T l SAILS scores were approaching significance for predicting GainPCM. The children's T l SAILS scores were positively correlated with GainPCM scores (r = .392, r> = .186), but not at a level that achieved statistical significance. Figure 6 on the next page demonstrates the trend emerging between T l SAILS scores and GainPCM. Bivariate Pearson correlations were also run among T2 measures and GainPCM and GainPWM to determine whether the children's gain (or lack thereof) in phonology was related to their proficiency at the assessment tasks at T2. Bivariate Pearson correlations were run among the following T2 measures: T2PCM, T2WSM, T2MRRtri (rate), T2MRRAcc, T2MRRCons, T2SAILSratSueraw, GainPCM and GainPWM. There were no statistically significant correlations between any of the T2 measures and/or GainPCM and/or GainWSM. 40 20.00 H IO.OOH o 0-c 're 0 0.00 H -io.ooH TISAILSraw Figure 6: Relationship between TI SAILS scores and GainPCM (3) Will attention during testing and information from a parent questionnaire reveal qualitative characteristics related to gains in phonology or lack thereof over time? The information collected from the parent questionnaire at TI and the SPAA-C at T2 was qualitative in nature, and was not included in statistical analyses. The patterns noted in these data and their potential implications are reviewed in the Discussion chapter. The issue of inattention to tasks as noted by the author and subsequent performance is also addressed in the Discussion chapter. 41 4. DISCUSSION 4.1 Summary of findings The purpose of the current study was to examine issues relating to the assessment and classification of children with PPD, and factors or patterns of performance that might be predictive of severity or change in PPD. The results of this study suggest that, at least for this sample of 13 children: (1) it was not possible to derive profiles for the children as having a clearly perceptual/processing versus motoric basis for their PPD, (2) there were no perceptual/processing or motor factors assessed in this study that were significant predictors of change in phonology across children and (3) there were no particular profiles that were related to more or less gain in phonology as measured by P C M and P W M following a 3- to 5-month . period. In this chapter, the group's overall performance on the tasks at Time 1 and Time 2 will be reviewed, and the results will be discussed with reference to the research questions posed at the end of the introduction. 4.1.1 Group changes from TI to T2 Significant differences were found between children's TI and T2 performance on the following measures: percent consonants matched (PCM), percent word shapes matched (PWM), raw scores on the "rat" and "Sue" SAILS modules (SAILSratSueraw), and consistency of the maximum repetition rate of trisyllabic sequences measure (MRRtriCons). This indicates that a 3-5 month period is sufficient to see a significant change in children's phonology, phonemic perception and motor proficiency. These results are consistent with previous research showing that about 4 months of intervention is optimal for achieving significant change in phonology (Jacoby et al., 2002; Almost, 1998). Not all children in this study received therapy between TI and T2; however, the children still showed overall improvement in P C M and W S M . Some of this improvement was likely due to maturation since these children were young and in a (possibly 42 rapid) stage of linguistic development. P4 was discharged from preschool speech service when he entered kindergarten, and was unable to continue speech therapy due to limited services in the school system. PI was only seen for approximately three private therapy sessions because he made rapid progress with the therapy goals. Both PI and P4's P C M and P W M scores were within one standard deviation of the group mean, suggesting that a discontinuation of speech services did not affect phonological development. However, PI and P4 were also two of the three oldest children in the study. Development in other cognitive areas, such as attention, may have contributed to their gains in phonological development. The small sample size and lack of knowledge about the children's therapy goals and number of intervention sessions attended limit the ability to sort out the relative impact of intervention versus natural maturation on phonological development. In addition to changes in phonology, the children in this study overall showed significant progress in their ability to distinguish target word-initial consonants from off-target foils in the SAILS "rat" and "Sue" modules. While there was overall group improvement in SAILS scores, there were two children (P4 and P8) whose scores actually decreased at T2, P4 also showing lower phonology scores at T2. Because P4 was identified by the author as experiencing difficulty sustaining attention, the decrease in SAILS score between T l and T2 may have been due to lack of attention to task by this child. P8, however, was attentively engaged in all sessions as reported by this author; therefore, it is not as likely that attention was a factor for this participant. Eleven of the 13 children who participated in this study continued to receive speech therapy between T l and T2, but because therapy goals were unknown to the author, it was difficult to determine contributing factors for overall improvement in the group's SAILS scores. If speech perception training had been part of the children's intervention programs, the improvement in SAILS scores observed here would support the findings of the Rvachew (1994) study, which showed that improvement in speech perception and production were correlated. On the other hand, 43 improvements in phonology (regardless of therapy goals), may have improved children's awareness of phonetic distinction in their own and others' speech, which could also account for the significant improvement in SAILS scores between TI and T2 found here. For the children in the current study who continued to receive intervention between TI and T2, there was a wide range in the number of therapy sessions (between one or two sessions to up to about 34 sessions) the children received. The number of therapy sessions received my also have influenced the nature and rate of change in children's phonology and their performance on the input and output tasks, An increased ability to sustain attention may have also facilitated the increase in SAILS scores found in this study. If the decrease in P4's SAILS score was due to lack of attention, this would provide evidence to support this hypothesis. Familiarity with the task may also have contributed to the increase in SAILS scores between TI and T2 for 11 of the children. The children had completed this task previously in the TI assessment and as such were familiar with the task (and perhaps P4 and P8's scores decreased due to lack of interest in the task). In addition, only two of the four SAILS modules presented at TI were used. The children may have been able to sustain more focused attention because the number of trials presented at T2 was significantly reduced. The overall consistency of children's MRRtri sequences also improved significantly from TI to T2. It is interesting that consistency improved significantly for the group, while rate and accuracy did not. Because the children involved in this study were of the age during which speech is still developing, and many of the children had yet to acquire the velar place of articulation and other phonetic features, normal developmental processes such as velar fronting were evident. These processes reduced the children's MRRtri accuracy scores when compared with an adult model. Overall, the findings are consistent with Williams and Stackhouse's (2000) study of rate, accuracy and consistency of diadochokinetic performance of typically developing 3-5-year-old children. With respect to the developmental progression in the accuracy of 44 performance on MRRtri tasks young children with typically developing speech, Williams and Stackhouse (2000) found there was a general increase in accuracy with age. The current cohort was not typically developing by definition, and thus their accuracy might take longer to resolve. In contrast to the accuracy measure, Williams and Stackhouse (2000) found no clear developmental progression in their participant's MRRtri syllable repetition rate. The children in the current study also did not show a significant improvement in MRRtri rate. The Williams and Stackhouse (2000) study found, however, that children's consistency of productions improved significantly between 3- and 4-years of age. By age four, the children in the Williams and Stackhouse study produced both accurate and consistent MRRtri sequences. The children in the current study showed significant improvement on the measure of MRRtri consistency, which supports the Williams and Stackhouse hypothesis that consistency versus inconsistency may be a significant diagnostic feature for speech difficulties when investigating preschool children. Children with PPD who show simplifying phonological processes may do so in a consistent way (Williams & Stackhouse, 2000). Other children who have differently underlying difficulties (e.g. motor programming and/or perceptual processing difficulties) may be more inconsistent in their responses (Williams & Stackhouse, 2000). The Williams and Stackhouse paper suggests that inconsistent responses on repetition tasks may be suggestive of more pervasive speech processing difficulties. As a group, the children in the current study showed significant improvement in MRRtri consistency, but not in their accuracy or rate of productions. In keeping with the Williams and Stackhouse (2000) interpretation, this data suggests that at least 11 of the children in the current study did not have an especially pervasive form of PPD and improvements in phonological development could be expected. The significant difference in this study's children's P C M and P W M between T l and T2 lends support to this perspective. 45 4.1.2 Identifying types of PPD Both the Shriberg et al. (1997) and Dodd (2005) classification schemes for PPD reflect a distinction between PPD with and without a motoric origin. The motoric impairments are hypothesized to affect articulatory movements, while general phonological impairments result from difficulty perceiving and constructing the linguistic elements that underlie articulation. This study assessed both perceptual/processing and motoric skills in children with PPD, in order to determine whether there were groups of children who patterned together in terms of their performance on these tasks. The cluster analysis run on the TI data revealed two groups of children with similar patterns of performance on the assessment tasks. The first group (TI Cluster 1) consisted of P2, P4, P5, P6, P7 and P9. This group of children had a tendency to show a slight weakness in perceptual/processing ability, as evidenced by slightly lower scores on the SAILS than the second group. The second cluster of children (TI Cluster 2) to emerge from this analysis (P3, P8, PI 1 and P13) showed a slight weakness on one of the measures of motor speech ability (TIMRRtri consistency), and this group's average performance on SAILS was higher than TI Cluster 1. These two clusters should be interpreted with caution, however, due to the small sample size and the limited number of measures that differentiated TI Cluster 1 from TI Cluster 2. TI Cluster 1 showed slightly poorer performance on the SAILS (minimum, maximum, and cluster mean on the lower side of the overall group mean). Both TI Cluster 1 and 2's average z-scores for the PIPA, however, were within 0.6 standard deviations of the mean. Bivariate Pearson correlations run among TI measures revealed that the TISAILSand PIPA scores were significantly correlated. If TI Cluster 1 was to be taken as evidence of the existence of a perceptual/processing sub-type of PPD, that cohort of children's performance on the PIPA should be noticeably worse than TI Cluster 2. Neither cluster shows a strong tendency towards better performance on the perceptual/processing and/or motoric tasks since the perceptual/processing and motoric division is not consistent across measures. 46 The data from the fine motor and gross motor subscales of the Child Development Inventory (CDI) were not included in the cluster analysis because this study's participants achieved scores at ceiling that were not very useful for the statistical analyses. A look at individual participants' raw scores shows that children who were below average on the fine and gross motor scales show up in both T l Cluster 1 and T l Cluster 2. P5 is part of T l Cluster 1 and P8 is in T l Cluster 2; however, both P5 and P8 both achieved scores greater than one standard deviation below the norm on fine motor skills. Similarly, P4, P6, P9 and P13 were all greater than one standard deviation below the mean on the gross motor subscale; however, P4, P6 and P9 were part of T l Cluster 1 and PI 3 was in T l Cluster 2. The cluster analysis performed on z-scores from the T2 assessment task measures revealed the following clusters: T2 Cluster 1 (P4, P5, P6, P8, P9, PI2 and PI3) and T2 Cluster 2 (PI, P2, P7 and PI 1). P3 did not pattern with either cluster. There was minimal participant consistency between T l and T2 clusters. Only P4, P5, P6 and P9 were part of both T l and T2 Cluster 1, and PI 1 was the only consistent member of Cluster 2 between T l and T2. In terms of performance on T2 assessment measures, T2 Cluster 1 and T2 Cluster 2 differed on rate of MRRtri. T2 Cluster 1 members had higher rate MRRtri rate scores and lower SAILS scores, phonology and other MRRtri measures (accuracy and consistency); in contrast, T2 Cluster 2 members were lower on MRRtri rate, and higher on SAILS, phonology and other MRRtri measures. This T2 clustering of performance on the various measures is different from T l ; therefore, it is not surprising that the group membership is different. The lack of consistency in the patterning of children's performance on the assessment measures from T l to T2 and the subsequent lack of consistency in group membership between T l and T2 clusters suggests that the clusters are not very robust indicators of different sub-types of PPD. P10 was removed from the cluster analysis since he did not complete all tasks. The difficulty he experienced sustaining attention during assessment (see discussion in section 4.1.4), 47 was important and likely affected his performance. He may have an attention-related sub-type of PPD that is different from the other children in this study. PI and PI2 did not fit with either TI cluster of children, and T3's performance did not pattern with either T2 cluster. These participants' individual patterns of performance could be suggestive of yet another sub-type of PPD, or could be taken as evidence that it is difficult to categorize children with PPD into distinct subgroups. The results of this study do not provide strong evidence in support of the findings by Dodd (2005) and Shriberg et al. (2007) that there are identifiable subgroups of PPD, although the methods used for classification did differ from those in Dodd and Shriberg et al., that is, their classifications are not ruled out by the current data. The current study investigated the proposal that severity of PPD may be more important for predicting the need for intervention, the course of intervention and expected outcomes. The next section addresses this study's findings relating to predictors of change in phonology that could be useful for identifying intervention need, course and outcomes. The Stackhouse et al. (2006) psycholinguistic model of children's speech and literacy development may be a more relevant account for the patterns of performance found in this study. According to this perspective children's speech and literacy development are the products of a system composed of speech input processing, lexical representations, and speech output processing. Speech difficulties arise from a breakdown of one, two or all of these components (Stackhouse et al., 2006). The children in this study might not fit with the subgroups identified by Shriberg et al. (1997) or Dodd (2005), because their difficulties may be the result of a breakdown with some combination of input factors, output factors, or lexical representations as suggested by Stackhouse et al. (2006). 48 4.1.3 Assessment performance, severity of PPD and predictors of change The results from the cluster analysis were compared to GainPCM and GainPWM scores to determine whether patterns of performance on T l assessment tasks were predictive of improvements in phonology. T l Cluster 1 (P2, P4, P5, P6, P7 and P9) show a wide range of GainPCM z-scores, from -1.41 to 1.82, suggesting that the clustering has no predictive effect for this group's gain in phonology (regardless of whether the gains were due to intervention or maturation). P4 and P9 were two of the three children (P10 was not included in the cluster analysis because he was unable to complete all the tasks) that were identified by the author as having difficulty sustaining attention throughout administration of the T l tasks. Please refer to section 4.1.4 for a more thorough discussion of the importance of attention and its potential impact on phonological development. T l Cluster 2 (P3, P8, PI 1 and PI3) showed improvement in z-scores for GainPCM from -0.91 to 0.83, clustering closely around the group mean for GainPCM. In terms of GainPCM, T l Cluster 2 showed gains in phonology that were quite similar to those shown by T l Cluster 1, with the exception of a wider range (consistent with these children's greater range in T l phonology scores) in the GainPCM z-scores for the children in T l Cluster 1. T l Cluster 2's relatively lower performance on MRRtri consistency (a measure of motor speech) might suggest that poor motor skills may be limiting the range of improvement in phonology; however, a look at the raw data from the CDI (another measure of motor speech used in this study at T l ) shows that most children in T l Cluster 2 show scores in fine and gross motor development within normal limits (exceptions being P8's score on the fine motor subscale and P13's score on the gross motor subscale). Comparison of the two T l clusters with the average gain the children showed in phonology suggests that having lower SAILS scores or lower MRRtri consistency scores does not predict change in phonology. Perhaps i f the children had received intervention 49 that matched their pattern of performance on the TI assessment tasks, there might have been change consistent with their TI task performance. It was hypothesized that factors assessed in TI might be predictive of stability or change in phonology at T2. In addition to the lack of relevant cluster analysis variables, the current study did not find any significant correlations between TI factors (including severity in terms of P C M and PWM) and GainPCM and/or GainPWM. This does not imply that there is no way to predict stability and change in phonology, but only that the perceptual and motoric skills assessed in this study were not predictive of the change in phonology experienced by these children. Of note, T1PCM was not correlated with GainPCM but was significantly negatively correlated with GainPWM. This indicates that children with low P C M scores at TI had high GainPWM scores, while children with high P C M scores at TI had lower GainPWM scores. It is likely that a higher T1PCM score does not leave as much room for improvement in word structure at T2 (as would be indicated by a high GainPWM score); therefore, children with low T1PCM scores were able to make larger gains in the percentage of correct word shape matches (and use of consonants across word positions) than children with high T1PCM scores. Using the same reasoning, it is not unusual to see that T1PWM is also negatively correlated with GainPWM. The only other significant correlations in this analysis were between GainPCM and GainPWM, which is to be expected since an increase in the number of correctly matched consonants (GainPCM) is partly due to fewer consonant deletions and cluster reductions at T2, resulting in a higher T2PWM score and a high GainPWM score. While there were no significant predictors of change in phonology among the TI assessment measures, the group of children in this study made significant gains in P C M and P W M . These results parallel the Tyler and Lewis (2005) study reviewed in the Introduction, of children with more or less severe PPD and change in target consistency index (TCI). While the current study did not examine consistency of phonemic productions like Tyler and Lewis, the children had differing severity of PPD, as indicated by the 50 variability in the T l assessment of phonology. Consistent with the Tyler and Lewis (2005) findings, the children in this study showed an overall significant gain in phonological development (except P4 and P7 who had lower T2PWM scores, P9 who had a lower T2PCM score and PI0 who had lower T2PWM and T2PCM scores). There was one trend in the data for one of the T l assessment measures and later phonology. The SAILS scores were positively related to gain scores; however, this result was not statistically significant. When SAILS scores were plotted against GainPCM, it was clear there were two obvious outliers: P2 and P5 (Figure 2). P2 was one of the initial participants for this study. Nine months elapsed between T l and T2 for this participant, exceeding the 3-5 month period that was the standard for the group. This allowed more time for phonological development than was permitted for the study's other participants, which could account for his large GainPCM score. However, P5's T l P C M was the lowest of the group, and he showed dramatic improvement in both P C M and P W M at T2. It is difficult to know what might account for this large increase. P5 was a fraternal twin whose brother showed typical speech and language development. The constant presence of a typical speech model may have facilitated phonological development above and beyond that which would typically be expected from a combination of speech therapy and natural development. Whatever the cause, P5 was also clearly an outlier in the SAILSraw-GainPCM correlation. When P2 and P5's data were removed from the group, several interesting significant correlations emerged. As predicted by the trend between T l SAILS scores and GainPCM previously discussed, the correlation between these measures became statistically significant (, r = .768, p = .006). With a larger sample size, such outliers might have less impact, and phonemic perception at T l might consequently be found to be predictive of stability or change in phonology. With P2 and P5's data removed from analysis, MRRmono (rate) was also found to be significantly correlated with GainPWM (r = .651, p = .041) suggesting that relatively stronger motor skills, as evidenced by a higher MRRmono (rate) 51 score (multi-syllable repetition), might be predictive of gain in P W M . Curiously, consistency of TI MRRtri scores was found to be significantly negatively correlated with GainPWM (r = -.659, p = .038). While rate may prove to be predictive of improvements in W S M with a larger sample of children, consistency of MRRtri may not be. This result supports the Williams and Stackhouse (2000) proposal that is important to analyse accuracy and consistency of MRRtri 's in addition to rate, because they may be more sensitive measure for preschool-aged children. It is clear from the findings of this study that accuracy, consistency and rate of MRRtri can pattern very differently. 4.1.4 Qualitative characteristics related to change in phonology Demographic information collected at the TI assessment was also considered when analyzing the data for factors and/or patterns of performance that could be correlated with more severe PPD. P5's, P8's and P9's parents reported prenatal or perinatal difficulty (see Table 1); however, neither their performance on the TI tasks nor their gains in P C M or P W M pattern together. Prenatal or perinatal difficulty does not seem to be a significant factor contributing to the PPD of children in this study. However, P5 and P8 scored -1.3 and -1.5 SD below the group mean, respectively, on the Gross Motor subscale of the CDI. This suggests that while prenatal and and/or perinatal difficulties do not predict later speech difficulties, they may be indicative of later delays in gross motor development. In terms of fine motor development, P4, P6, P9, P10 and P13 scored between -1.3 and more than two standard deviations below the mean on the Fine Motor subscale of the CDI. One might expect a relationship between fine motor development and performance on the MPT's; however, there was no clear relationship between these two factors for this subset of children: P4, P6, P9, P10 and PI 3 showed very different and variable performance on the measures of rate (MPTavg and MRRtri), accuracy (MRRtriAcc) and consistency (MRRtriCons). Of this group of 52 five participants, however, P4, P9 and P10 also had difficulty attending to tasks administered at T l (see below). These children showed very different patterns of performance on the various assessment tasks, which could be attributed to periodic lapses in attention at different times throughout the sessions. The reason for any further relationship between fine-motor tasks and reduced attention is unclear but may warrant future investigation. Comparison of z-scores across T l tasks, GainPCM and GainPWM suggests interesting patterns of performance that might be related to severity and/or change in phonology; however, a larger sample of children with PPD is required in order to confirm that these patterns and trends are present across the population of children with PPD. Further to attention, this factor has been noted to play a role in children's overall improvement in phonology (Kwiatkowski & Shriberg, 1998). Several of the children had started kindergarten by the time of the follow-up session, and were likely becoming more accustomed to sitting for longer periods of time and to paying attention to structured tasks. As preschool children mature, the period of time during which they can sustain focused attention increases (Shaffer, Wood & Willoughby, 2002). With increased ability to sustain attention, children may be more willing to practice their speech sounds with increased frequency and resolve, resulting in significant improvements in phonology. Concerning performance and task compliance at T l , P4, P9 and P10 were relatively inattentive and showed performance at or below the group mean on all measures (PCM, P W M , PIPA, SAILS, and rate, accuracy and consistency of MRRtri), except accuracy of MRRtri, for which P9 was 0.15 standard deviations above the group mean, and consistency of MRRtri: P4 was 1.4 standard deviations above the group mean and P9's score was 0.98 standard deviations above the group mean. P9 had scores greater than one standard deviation below the group mean on the PIPA, SAILS modules and M R R (rate). Interestingly, all three subjects (P4, P9, and P10) also showed slight decreases in phonology from T l to T2, as evidenced by negative gain P C M and P W M scores, three of six of which were greater than one 53 standard deviation below the group mean. Their lack of attention to assessment tasks relative to other participants (see below), suggests that attention might be an important factor in the development of those children's phonological systems. In order to be able to perceive the difference between his/her incorrect production of a phoneme and the target form, the child must be able to focus on the speech input with enough attention to realize his/her production is incorrect, and to sustain attention long enough to correct it. This supports the hypothesis that attention may be important for facilitation of phonological development although as noted above, lack of attention did not appear to be related to all measures. 4.2 Implications This study has several interesting research, clinical and theoretical implications, some of which have already been mentioned with respect to each major finding. Results of the TI concurrent correlations suggest that children with PPD cannot be clearly classified as having a strictly perceptual/processing or strictly motor type of PPD. A combination of these or other factors not assessed in this study contribute to the children's PPD. This study originated in part as a pilot project for a proposed ARTICS randornized control trial in phonological intervention, to determine whether children can be classified a priori as having a speech sound disorder of a primarily perceptual or motor sub-type. Results of this pilot data were provided to the researchers heading the ARTICS trial, and it was decided that children could not be sub-typed according to these dimensions, and so simple randomization will occur in the ARTICS trial to assign the children to the three types of therapy being evaluated (input-focused, output-focused and traditional clinician-selected therapy). The findings of the current study suggest that sub-typing children may not be as straightforward as the Shriberg et al. (1997) and Dodd (2005) classification schemes imply, and identification of sub-types may not be relevant for achieving optimal outcomes (as in Tyler & Lewis, 2005). 54 This study also has implications for clinicians currently working with children with PPD. The factors that underlie PPD and contribute to the severity of children's speech disorder remain unclear; therefore the issue of what type of intervention is most effective for this population remains unresolved. It is to be hoped the ARTICS randomized control trial or other such trials will provide some insight into this question. The children in the current study showed a wide range of performance on the various assessment measures, suggesting that therapy goals need to be tailored to the individual child's areas of strength and weakness. For children who clearly showed deficits in motor speech ability (e.g., P7), intervention incorporating repeated practice using correct articulator positioning might be more effective. Other children who struggled with both types of tasks might require intervention targeting both speech discrimination and production. There were other children in this study who showed a pattern of performance on the various assessment tasks indicating that no T l factors were related to their PPD. This suggests that there may be other factors not examined here that affect children's phonological development. A further clinical implication concerns the finding regarding factors that might be predictive of change in phonology. There were no factors assessed at T l that were significantly correlated with gain in P C M or P W M . The trends that emerged through descriptive analysis of children's T l assessment scores suggest that with a larger sample size, phonemic perception as tested by a task such as SAILS at the time of initial assessment may be predictive of stability or change in phonology. A larger sample size may also reveal a significant correlation between MRRmono (rate) at T l and gain in P W M . These trends highlight the importance of assessing a variety of input- and output-related factors when working with a child with PPD. This supports Stackhouse et al.'s (2006) psycholinguistic framework, which posits that a comprehensive assessment of children's phonology and underlying skills needs to include measure of both 55 speech input processing and speech output skills. The exact nature of the factors contributing to severity of PPD and change in a child's phonology over time still warrants further investigation. The information collected using selected parent questions from the SPAA-C questionnaire could be useful for setting clinical goals for intervention, as previously discussed in the introduction. A l l of the parents in this study reported noticing improvements in their child's speech at T2. Notably, only one parent indicated that his/her child felt embarrassed about his/her speech. This child was P5, the fraternal twin, and his mother reported that he experienced "feelings of being less advanced than his brother" which were likely resulting in low self-esteem. Mom also reported that he felt embarrassed about his speech. P5 showed the most dramatic gains in P C M and P W M , which could be attributed to the presence of a constant speech model (his twin brother), and to feeling a real desire to improve because of the embarrassment experienced due to his speech problem. 4.3 Limitations As mentioned throughout this discussion, one major limitation of this study is the small sample size. Recruitment issues (over 9 months) made it difficult to locate and retain children with PPD who fit the study's inclusion and exclusion criteria. Therefore, it was difficult to obtain a group of children large enough to achieve adequate statistical power. Some of the trends, such as TI SAILS being predictive of gain in P C M , may have reached statistical significance i f the number of participants in this study had been larger. However, appropriate statistical techniques were chosen in order to help mitigate the effects of the small sample size. In addition, findings that support previous research have been highlighted, and important trends in the data that could be supported with further research have been noted and discussed. Another limitation of this study is the lack of knowledge of the goals that were targeted in speech therapy between TI and T2, and the precise number of sessions that each child attended. As previously discussed, it would be of interest to know whether intervention focussed on motor 56 skills and articulator placement, phonemic discrimination or a combination of the two. Future studies should attempt to gather this information, to assist in determining whether intervention goals are correlated with pattern of performance on tasks at T2. In addition, for the children who received ongoing therapy between TI and T2, the number of therapy session varied widely. Some children received only one or two sessions, while other received upwards of about 34 sessions. The number and frequency of therapy sessions may have influenced the rate and nature of change of children's phonology and their performance on the tasks assessed at T2. Constraints on project time and resources limited the number of T2 sessions to one, 1-hour session. In order to avoid excessive testing of the participants, only the most relevant tasks were selected for testing at T2. This decreased the number of T2 concurrent correlations that could be analyzed, and the number of measures that could be assessed for gain between TI and T2. It would have been interesting to re-assess the children on all tasks administered at TI in order to compare individual and group differences, and to determine whether these correlated with changes in phonology. Despite these limitations, the results of this study have important applications for speech-language pathologists working with children with PPD, and contribute valuable information to the field of developmental phonology. It is evident from the present findings that it is difficult to classify children as having different sub-types of PPD. For now, research into the effectiveness of differently types of theoretically-based treatments approaches for PPD should focus on improving outcomes for all children rather than tailoring treatment approaches to specific sub-types of the speech disorder. 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International Classification of Functioning, Disability, and Health. Retrieved October 16, 2006, from http://www.who.int/classifications/icf/en/. 64 Appendix A: T l and T2 CAPES transcriptions Subject 1 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 i P h i g iP h i g iP h i g 47 iP h ik , p h i k iP h ik 2 l t h OU ,thau ,thou 48 idag idag ,dag 3 !t h OUZ !thauz !t hOUS 49 t^oum ,khaum ,khoum 4 ,t hAb A b ,t hAb 50 , f e i s ^ e i s , f e i s 5 ,dAk , d A k , d A k 51 ,fei3saz i f e i 3 saz ^ e i a s a z 6 ima3mi ima3mi ,ma3mi 52 ,k h a 3 f in , k h a 3 f i r ) 7 ijard ijad ,jod 53 ,sup , s u p isup 8 i gAm igAtn , g A m 54 ,tjer ,J"kea itje: 9 , n o u z ^auz ,1-ious 55 ,hors !haus ,ho"s 10 - f i j i f i j i f i ; 56 ^ b r e iZi3bwa i Z i a b w a 11 , f i 3 J " i r ) i f i a j i r j i f i 3Jir j 57 Jart J a u t Jo"t 12 !SOUp !S80Up ,soup 58 ^est ^est !ves 13 ,w i 3 s a ,WI 3SO 59 ^ a i g V I t ] , d a i 3 v i r ) ,dai 3vin 14 ,haus !haus ,haus 60 ,d3aeakit ^seskit ,d3ae3kit 15 iZ i 3 par izi 3pa ,zi3po 61 ,bitf i b i j ,bitf 16 J u , J a u J u 62 ^ a a t f i r j ,wa 3 t f i r ] 17 ^3311 ,vaen ivaen 63 i d 3 A m p i 3 A m p i d 3 A m p tk haBtr 18 2 l h i i V i 2thhvi 2thi,vi 64 ,k haej 19 ^ J i a k a n J i s k a n i t j i 3 k a n 65 i b a e g ibae^g ,bai 20 iwat f !waj ,wat f 66 ,bn 3d3az ,bwi33az ^oigdsaz 21 ,wa3tr9Z ^aajaz ,wa3tjaz 67 ilif Jif ilif 22 ^333171 ,3aern ^ 3 3 9 0 1 68 ^ a e g b i t 1wa3 3brt ^ ^ b l t 23 ^ e i d s ik hei3 i k h e i 3 69 ,gar3bid3 iga3bi3 ^a'sbids 24 , b u k ibuk , b u k 70 i6iQ ^wirj i f i " 25 1 p h ei 3 d3az ,pheid3 71 imau9 tmauf ,mauf 26 ^sef -,laf ,laef 72 ,6is ,6is ,6is 27 ,n3b9n iwi3ban iWiaban 73 ,brA36ar ,bwA3va !bWA3var 28 tOAm 3 f a i l A m ,flAm 74 iglae3siz 3ga,laa 3siz ^laeasiz 29 ,thi9 ,thif ,thi0 75 Jelf Jeuf J e l f 30 jbee\ ,zaes ,6aet 76 !9au3zand ,fau3zand ^ a u a z a n d 31 ,fe36ar ife3va ife3va 77 ^laeriatir j ,plaen3tir) i p l a e r i s t i r j 32 ,star !Sta !Star 78 ^ i S a p a r ,wip3sa ^ I S a p o " 33 ,slaid ,sklaid ^laid 79 ikrAj ,kWAj" ^ W A j 34 ^wisinir) ,skwe 3mirj , s i 3 m i n 80 ,ski ,ksi ,ski 35 ^win ^win ,kwin 81 ,sil iski3ja ,sil 36 ipre 3zant ^ w e a z a n t ipwe3zant 82 ispei 2Jip J p e i j i p ^ p e i j i p 37 ,tri ,Jkwi itfwi 83 ,blu ,blau ,blu 38 iglAv 3 g a i l A v a ^ a e n a g a ^ a u iglAv 84 iP hi 3kal iP h i 3ka iP h i 3ko 39 2kha3rj3geiru s^ar r^p jua ra r 2khaerj3ga,wu 85 i spul , spaul 40 3k ha,pju 3ra 3k ha,pju 3ra 86 ,drae 3gan ^u^waeggan ,d3ae3gan 41 ,haand ^ae^nd ,haend 42 a k ^ n u a k ^ n u a k ^ n u 43 39igen 3aig en 39igen 44 aba^un abA^aun 2baeilun 45 a g a ^ i g l a 3 g a i W i 3 l a 3go,?i3la 46 ^ A a f a n ^ A ^ a n imAafan 65 Subject 2 Profile IPE Level 2 Target Init ial Assessment Follow-Up Assessment Target Init ial Assessment Fol low-Up Assessment 1 iP h ig i P h i g iP h ig 47 iP h ik iP hik iP h ik 2 ! t h OU ,thou !t h OU 48 ,dag idag ,dag 3 ! t h OUZ , t h oudz , t h ouz 49 i k h o u m , k h o u m 1 k h o u m 4 ,t h Ab , t h Ab / A b 50 ifeis ^eitO ^eis 5 ,dAk ,dAk ,dAk 51 ^ e i a s a z ,tei3ta6 ,fei3saz 6 ^ c i a m i iiria3mi ima3ini 52 ,k ha 3f irj , t „ h a 3 t i n ik h a 3 f in 7 i jard ,jad ijad 53 ,sup itup ,sup 8 i gAm ,dAm i g A m 54 ,tjer itfea itfee 9 , nouz ^ o u d z i n o u 55 ,hors !hot ^ o ^ i 10 , f i j i d i t j , f i j 56 !zi3bra !di 3 bwa izi3ba 11 idi 3 t f in , f i 3 Jm 57 Jart ,d3at Jet 12 !SOUp ,doup !SOUp 58 ,vest ides. ,V£S 13 , w i 3 t o u ,wi 3 sal 59 ^ a i a V i r j ^ a i s d i n , d a i 3 v i n 14 ^aus ^aut !haus 60 , d 3 3 9 3 k i t ^aegkit ,d388 3 k i t 15 iZi 3par 1dzi3po ,zi 3pa 61 ibitf ibitj ibitf 16 J u id3„u J u 62 ^ a a t f i r j iwa 3trin ^ a a t f i n 17 ,vaen ^an ^ a e n 63 ^3 Amp , d 3 A m p ^ A m p 18 2thi,vi 2thHvi 2thi,vi 64 ^aet j , k h 3 9 t f ,khaetj" 19 i t f i akan ,tji 3kan ^Jiakan 65 ibaeg ibaeg ibaeg 20 twatj ^ a t f ,watf 66 ^ r i a d s a z ,bwi 3d3at ,bwi 3 d3az 21 iwa.3traz 1wa3tfazo ,watf 67 Jif !lith ilif 22 ,d3aem ^ a e m 68 ^ a e ^ n ,wae3bit ,wae3bit 23 ,k heid3 ,c heid3 • ,k heid3 69 ^ a r a b i d s !da3bid3 !ga3bidz 24 ,buk ' ,bauk ibuk 70 iQirj ipin ifirj 25 1p hei 3d3az 1 p h e i 3 d z a z ,phei3d3az 71 ^auO ,maut ,mauf 26 Jaef ,lael ,laef 72 ,6is !dits ibiz 27 ,ri3ban ^ i s b a n ^isban 73 !brA36ar !bwA 3da ,bwA3va' 28 tOAm !t A m ,fy\m 74 ^ l a e g S i z id>lae3tit ^ t e a S I Z 29 / i O ,thits / i f 75 i j e l f Jelf 30 ^se t ,daet ,daet 76 ^ a u a z a n d ,t„au 3zand ^ a u s z a n d 31 1fE 36ar ,dt 3du ife3va 77 iplaen3tirj ^ lae r i s t i n ^ l a e n a t i n 32 ,star !taa ,sta 78 ^ i S a p a r iw i 3 p u ,wis3pa 33 ^ l a i d ,l:aid !slaid 79 i k r A j tkWAtJ ^ W A t f 34 ^ w i a m i r j , tswi 3 min ^ w i a i n i n 80 ,ski iki ,ski 35 ^win ^ w i n ^win 81 ,sil ,ti3o ,sil 36 ,pre 3zant ^ W E a d b a n t , p w E 3 z a n t 82 ispei2J"ip ipei 2tj"ip ,spei 2 t f ip 37 ,tri !twi itri 83 iblu ,blu ,blu 38 iglAV ,glAt h iglAv 84 iP hi 3kal iP h i 3kal iPh i 3kal 39 2khaen3gairu . 2 k h an 3 d9 ,wu 2khaen3gaiwu 85 ,spul ipul !spua 40 s^am^jusrar iplu3ta s^em^juara 86 ^raeagan idwae3gan idwae3gan 41" ,haend !haend ^aend 42 3k ha,nu 3t ha 1nu 3k ha,nu 43 3aigen 33iden 33igen 44 aba^un sba^un aba^un 45 a g a ^ a l a 3da,wi 3la 3ga,wi 3la 46 ,mA 3fan ^ A ^ i n imA 3fan 66 Subject 3 Profile IPE Level 2 Target Initial Follow-Up Target Initial Follow-Up Assessment Assessment Assessment Assessment 1 iP h ig iP h ig ip h i g 47 iPhik iPhik iPhik 2 ,t hou ,hou ,t hou 48 idag ,dag idag 3 ,t houz ,t hous 1 th ous 49 1khoum !khoum 1khoum 4 /AD ,thAb Ab 50 ,feis !feis ^eis 5 ,dAk !dAk tdAk 51 ,fei3saz ,feis ^ei^sgz 6 imaami imam ,ma 3mi 52 ik h a 3 f in ,kha 3fir) ,kha 3f ir j 7 ijard ,da ijad 53 ,sup isup isup 8 igAm igAm igAm 54 itfer ,tsew itfes 9 inouz iROUZ !nouz 55 ihors ,110s ^ o s 10 i fx j !flS i f i j 56 izi 3bre iZi3bwa izi3ba 11 if i 3sir) i f i 3 Jir j 57 ,/art !sat Jet 12 iSOUp ,soup ,soup 58 !vest ,ves ,v est 13 ^ IaSel ^I^SOU ,wi3sal 59 ,dai3vir) ,dai3vir) ^a iav i r ) 14 ,haus !haus !haus 60 ,d3ae3kit ^aeakrt ,d3ae3kit 15 izi 3par izi 3 pa iz i 3 pa 61 ,bitf ,bits ibitf 16 J u J u J u 62 iwa 3tfirj ,wa 3tsin gastrin 17 ,veen ivaen ,baen 63 !d3Amp ,dzAmp id3Amp 18 2th i,vi 2th i ,vi 2thinvi 64 ^aetf ,khaets ,khaetf 19 $i3ken it i 3kan ^Jiakan 65 ibaeg ibaeg ibeg 20 iwatj ,wats ^ a t j 66 ,bn3d3az ibwe3dzaz ,bwi3d3az 21 ,wa 3tr9z !wats twaatfaz 67 ilif ilif ilif 22 ^aem idaam ,d3aem 68 ^aesbit ^aesbi t ^aeabit 23 !kheid3 ,kheits 69 ^arabids igo 3bid ,ga3bid3 24 ,buk ,buk !buk 70 i9irj ,SIQ iSIQ 25 ,p hei 3d39Z 1pheids 1phei3d3az 71 ,mau9 imauf iinauf 26 ,l39f ,laef ,laef 72 ,6is idis !dis 27 ,n 3 b9n ,wi 3 ban ,wi3ban 73 ,brA36ar ^WAarO !bwA3doa 28 ^Am ,9Am ,9Am 74 ,glae 3siz tglaeasiz ,gae3siz 29 ,thi9 ,thif !thif 75 Jelf ,self Jelf 30 !daet !dae 76 !9au3zand ^auazan isau3zand 31 ,fe36ar i fe 3da ife 3do 77 ,plaen3tir] ^wasristir) ^laengtir) 32 ,star !Sta tSta 78 iWis3par iWis3po ^ ISapa 33 ,slaid ,slai ,slaid 79 ikrAj !kWAS ^WAJ" 34 ,swi3mirj i s w i 3 m i n ^w ismi r j 80 ,ski ,ski nSkf 35 ,kwin ^ w i " !kwin 81 ,sil isia !SiO 36 ^reszant ^weazen ,pwe3zant 82 ,spei 2Jip ispei 2sip ^ p a i j i p 37 itri ,twi ,tfwi 83 ,blU ,blu ibu 38 iglAv iQAV 2khaer)3ga1wu ,glAV 84 iP h i 3kal iPhi 3ko iph i 3 kal 39 2khaer)3g9iru 2kh3en3g91wu 85 ,spul ,spuo ,spul 40 3 kh 9mipju 3 r9r 3khamipju 3ra 3kham,pju 3ro 86 ^raeagan ,dwae3gan idwae3g9n 41 thaend !haen ,haend 42 3 kh a,nu 3kha,nu 3 kh a,nu 43 3 9igen 33igen 39igen 44 abg^un sbajun aba^un 45 3 gain 3 la 3 ga,w i 3 wa aga^iala 46 ^Asfan imA3f9n ^Asfan 67 Subject 4 P r o f i l e I P E L e v e l 2 Target Init ia l Assessment F o l l o w - U p Assessment Target Init ia l Assessment F o l l o w - U p Assessment 1 i p h i g iP h id iP h id 47 ,phik iPhit iPhit 2 / o u ,thou / O U 48 ,dag idad idad 3 ,thouz ,thous ,thou _ 49 ,khoum i^oun 4 , t h Ab lPhAP , t h Ab 50 ,feis ^eis ifeis 5 ,dAk ,dAt ,dAk 51 ^ei^sez ^ei^sez ifeis 6 ima 3mi ^c^rni ^ a ^ m i 52 ikha 3firj ik ha 3 f in itha 3f in 7 ,jard ,wad ijad 53 isup Jup i sup 8 i gAm ,dAm ,dAm 54 i tfer ,thea i t f ea 9 !nouz ,nou inouz 55 ,hors ihas ,has 10 i f i j i f i j i f i ; 56 tziabra izi3ba izi3ba 11 ifiajin, ifi3J"in i f i 3 Jm 57 Jert Jet J i t 12 ,soup Joup !SOUp 58 !vest !WEf i b e s 13 ,WI 3S9l !WI 3 SO !Wi3sa 59 ^ a i s V i r j ^ a i s V i n , d a i 3 v in 14 !haus ,haus ,haus 60 ,d3ae 3kit ,dae3di ^ a e a k i t 15 izi3par isi 3pa ,zi 3pa 61 ibitf ibitf ,bitf 16 J u J u J u 62 ^ a a t j i r ) ^ a a / i n ,wa3J"in 17 ,vaen iVaen ^aen 63 ^ A m p ^ A m p ,d3Amp 18 2 t h i ,v i 2hhdi ! t i 2 di 64 ,kha3tj" ithaej ikhaets 19 ^Ji^an p la tan i t j i 3 tan 65 ibaeg !be i t ibaeg 20 twatj ,watf !watj 66 ,bn3d3az . ^ v / i ^ e z ibigdsaz 21 ,wa3trez ,wa3tj"az ,wat j 67 ,lif ijif !Wif 22 ,d3aem. tdaem ,d3aem 68 ,rae3bit iWaeaVit ^aeabit 23 , k h e i d 3 i t h e i d 3 itfeiz 69 ^ a r a b i d s ^ O a b l d j ,ga 3bidh 24 ,buk ,but !buk 70 i0irj ^in i6ir) 25 ^eigdsaz iPheid3 iPheid3 71 ^auO ^ a u t imau t 26 ^aef ^aef ,laea 72 ,61s ,dis ,6is 27 ,wi 3ban ^iaban 73 ^rAa&ar tbAara ^ A a d a 28 ,0Am iSAttl ,SAm 74 ,glae3siz igae3siz ^ a e a S i z 29 ,thi9 ,t hit / i t 75 J d f Jef Jef 30 ^aet ^aet !daet 76 i9au3zand ^ a u s z a n Jauazan 31 ,f e36ar ife3da ife3da 77 ^laeriatirj ^aeriatin iP^riatin 32 ^ t a r !Sta !Sta 78 !Wis3par ^ I^va ^ I S a p a 33 ,slaid , sa ia tsaia 79 i k r A j / A J JAJ 34 ,swi3mirj i S i 3 min i S i 3 min 80 iski ,sti !Stit 35 ,kwin , t h in ,tsin 81 ,sil ,sil ,sil 36 ^re^ant iPhe3zan iPhe3zan 82 1spei 2Jip ^ p e i j i p ^ p e i j i p 37 i tri / i J i 83 ,blu ,bu ,bu 38 ,glAV lbAV igAbs 84 iP hi 3kal iPhi 3te iP h I 3 t lS 39 2khaen,ageiru 2khaen3da1wu 2thae3na1wu 85 ,spul !Stua ,stul 40 a^arrHpjUarar iPhi3da ,pu3da 86 ^raesgan ,dai3dan ,dr3e3dan 41 ,haend a k ^ n u ^aent ,haen 42 3 k h a , nu a k ^ n u 43 3 3igen 3a,den 3a,den 44 3ba,lun 3ba,lun 2ba,lun 45 sga^iala 3 t ha 1ni 3na ada^ iswa 46 imA 3fan tiriAspan ,mA 3fan 68 Subject 5 Profile IPE Level 2 Target Initial Follow-Up Target Initial Follow-Up Assessment Assessment Assessment Assessment 1 iP h i g iPhi: iP h i g 47 iP hik iP h i iP hik 2 , t hou ! t h OU , t h ou 48 i d a g !da ,dag 3 1 t h ouz , t h o u ! t h O U Z 49 ikhoum 1 k h o u m , t h oum 4 , t h Ab , t h ou , t h Ab 50 i f e i s ,fei jeis 5 , d A k ,gae: i g A k 51 ^ e i s s a z ,bei 3 ?a ife 3s9z 6 itna 3mi ima 3 mi 52 ,k h a 3 f i r ] i k h a 3 ? i 1 k h a 3 f i n 7 ijard i j a !dad 53 isup i s u p 8 i g A m i g A m i g A m 54 ,tj£r ! t h £ J e a 9 !nouz ,nou i n o u s 55 nhors !hor ^ o s 10 i f i j ,P hi , f i s 56 !zi3bra i ? i 3 b £ i?i 3wr 11 if i 3Jirj iP h i 3?i" i f i 3 ? in 57 Jart !h£r !sat 12 t soup !hou Joup 58 ,V£St ib£ !V£S 13 wx3sa\ ,wi2?a3wa ^ i j o a 59 ^aiaVirj ,dai 3?i" ,dai 3vin 14 !haus , h o u ,haus 60 ^SSBak l t ,gae3?a idzaeskit 15 ,z i 3 per iPhi3?a ivi3?a 61 ibitj ,bi ,bits 16 J u !hu 62 iWa 17 ween !ba" 63 ,d3Amp idAtn 18 2thi,vi 2t hi,vi 2thi,vi 64 ,k h 39tf !khae ^aets 19 t t f iaken , k i 3 k a " ,ki 3ka 3ni 65 ibaeg ,be ibaeg 20 ,watj ,woi ,wats 66 ^riadsaz ib i 3 7a ^ n ^ k e s 21 ,wa 3tf9z !wa3?a ,wa 3 t s i z 67 i l i f i l l i l i f 22 ^ a e m ^ 3 8 " " ^ a e m 68 ^aeabit iWaesba ^ a e s b i t 23 !kheid3 ^ e i !k heiz 69 ,gar3bid3 igar 3 ba iga 3biz 24 ,buk !bu !buk 70 ,9ir] i t ir] i s i n 25 ,phei3d3ez iP hei 1 p h e i z 71 ,m3u9 ,rri3u 1mau9 26 ,laef ^ O U ,?aef 72 ,6is ,di , d i s 27 ^ b a n ^ i a b a ^ i s b a n 73 !brA36ar , b A 3 ? 8 ^ A 3 t £ 3 28 ,0Am , tsou lS33m 74 , g l a e 3 s i z igae3?a ^ a e ^ i s 29 / ie , t h i ,this 75 J e l f ^E' ,h£lf 30 ,6aet ,d33 ,daet 76 !9au3zand ^ a u s h a " iSSUssan 31 ,fe36ar 1pH3337a i f e3tea 77 ^laeris t i r j , l ae" 3 t i " injaeriatin 32 iStar iga i doe 78 ^ i S s p a r iwi 3pa ^ i ^ E a 33 , s l a i d ,lai ! l a i d 79 i k r A j " , k h A !k h AS 34 , s w i 3 m i r j ,bi3?i , f i 3 mirj 80 ,ski i g i 35 ,kwin iki ,khin 81 ^ i l ,hil ,sio 36 ^reszant iPhs3?a ^weaTant 82 1 s p e i 2 / i p ,be i 2 ph i 1 s p e i 2 p i i s 37 itri , t h i ^ia 83 !blu i l u ,blu 38 I^AV , g o u i g A b 84 i P h i 3 k a l i P h i 3 k a l ^ i g k o a 39 2khaerj3gairu 2g3e~3?33iwu 2k h39" 3?a 1wu 85 ,spul !bu3?a ibua 40 a ^ a m ^ j u s r a r ,fu3ta 86 ^ r a e s g a n ^aeaga" ^se^an 41 ihaand i\as~ ^aend 42 3k ha!nu 3k ha!nua 3kha!nu 43 3a,g£n 33ige" 3 a i g e n 44 3 b a i l u n i l u 3ba,lun 45 a g a ^ i g l a iga 3 ?a: 3ga 3l9 46 imAafan iiDAsfan 69 Subject 6 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 iP h i g , p h e d i P h i d 47 iP h i k , p h i t h iP h i t 2 / o u ,t hou / O U 48 idag , d a t h idads 3 / o u z 1 t h o u s / o u t s 49 ,khoum it houm / o u m 4 A b , t h Ab , t h A b 50 ,feis ,feit ifeits 5 ,dAk ,dAt , dAt 51 ,fei3saz ifei 3ta ifei3tsaz 6 ima3mi ima3mi 52 ikh a 3 f in / a / i n . , t h a 3 t i n . 7 , j a r d , d j a d ijats 53 isup Jup Jup 8 i g A m , d A m ^AITI 54 itfer i t f e e i t f e o 9 ! n o u z ! n o u d ^ o u t s 55 ihors ,hot ^ o t s 10 i f i ; if itj ifltj 56 ,zi3bra ,di 3ba izi3ba 11 i f i a j i n , 3f i i tf ir j i f i 3 t f in 57 Jart Jot Jot 12 , s o u p , s o u p h iSOUp 58 ,vest , v e t ,v et 13 ,w i 3 se l ,wi 3 tsoa 59 idax3vir) ,dai 2 dit , d a i 3 d i n 14 , h a u s ihaut ^ a u t s 60 ^ a e a k i t ,d3ae 3 t i t ^ a e a t i t 15 iZi3per i d i 3 p o ^ d i a p o 61 ibitf i b i t f ibitf 16 J u J u J u 62 ^aatfirj ,wa3ti" ^ d s t i n . 17 ^aen ,waen ,waen 63 ^ A m p ^ A m p id3Amp 18 2thiiVi 2thi,di 2tsi,di 64 nts etj / a e t j " 19 , t f i 3 k a n ^Jiadan i t f i 3 t an 65 ibaeg !baeid , b a e d 20 walS ^ a t j , w a t j 66 ,bn 3 d3az ^ i ^ a d ,b i 3 d3az 21 iwa3tfad twa^t/ad 67 T 1 if ,dit !dit 22 ^aem ^aem ,d3aem 68 ^ B e ^ i t ,wae3bit ^ a e s b i t 23 , k h e i d 3 , t h e i d 3 , t j e id3 69 ^arabids , d a 3 b i d 3 ^cbbids 24 , b u k , b u t , b u t 70 iSirj i S i n s i S i r j 25 1 p h e i 3 d 3 8 z 1 p h e i 3 d 3 a d ^aet11 iP h eid3 71 ^auO ^auf" i m a u t 26 ,laef ,laet 72 ,6is idHh idis 27 ^ b a n i W i 3 b e n ,w i 3 ban 73 , b r A 3 6 a r , b A 3 d o u ibA 3 doa 28 ^ A m j A m ,SAIII 74 ^ l a e a S i z ,dae3\i6h i / e l t h t d a e a t s i z Jel t h 29 ,thi9 ,thi3tad / i 3 tad 75 Jelf 30 ,6aet ,daeth ,daet 76 i 6 a u 3 z a n d !fau3dand ^ a u a z a n 31 ife3ro ^ d o a 77 p\een3tir) ^as^tin 1 p h aen 3 t i r | 32 ! s t a r !StD ,tsaa 78 t W i S a p a r , w i 3 p o u ,WI 3 tS0 33 ,slaid ,sai i S a i d 79 i k r A j , t h At; i tSAt f 34 i s w i 3 m i r ] , f i 3 m i n . femin. 80 iski isdi id3i 35 ^win / in ! t s in 81 ,s i l isi i S „ i 3 o 36 ^re^ant 1phe 3dan 1phe 3dant 82 ^ p e i z / i p ^ e i z j i p i be i^ t f ip 37 itri ,tsi ,tsi 83 ,blu i b u ,bu 38 ig lAV , t A d h , d z A d s 84 iP h i 3kal ,p h i 3 ta l iPhi3tal 39 2khaer)3gairu 2thae3naiwu z t s a e n a d a ^ u 85 ,spul ,bu' !bul 40 a^am^jusrar iP h u 3 do atfopjugdos 86 ^raesgan ^ a e i a d a n ,d3ae3dan 41 ^aend ^aen ,haend 42 3k ha 1nu 3k ha,nu 3t ha 1nu 43 3aigen 3 3iden 3 a,d en 44 3ba,lun ,bun 3ba,dun 45 a g a ^ i a l a ^ T ^ W a 3 da ,d i 3 wa 46 ^ A s f a n t m A a t a n , m A 3 t i n 70 Subject 7 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 i p h i g i p h i g iP h i g 4 7 iP h i k iPh i k iP h i k 2 ! t h O U / o u ,t ho: 4 8 ,dag idag i d a g 3 / o u z 1 t h o u s , t h o u s 4 9 , k h o u m 1k houm 1khoum 4 , t h A b , t h A b ! t h A b 5 0 ^ e i s i d e i i f e i s 5 ^ A k , d A k i d A k 5 1 i f e i s s e z , d e i 3 d 3 i f e i s 6 ima^ini i m a a i n i ima 3 mi 5 2 ^ a a f i r j 1 k h a 3 f i r j 7 ijard , j a r t ijad 5 3 ,sup i d u p i s u p 8 i g A m i g A m i g A m 5 4 , t f e r ^Jew itfee 9 , n o u z , n o u z i n o u z 5 5 ! h o r s , h o t i h o r s 1 0 i f i ; i f i j i f i j 5 6 iZ\3bra , d i 3 b a 3 i z i 3 b r e 1 1 i f i 3 J i r j i f i 3 j i n i f i 3 J i t ] 5 7 Jsrt ,det Jot 1 2 !SOUp !SOUp !SOUp 5 8 nvest !b3 , b £ S 1 3 , w i 3 s a l , W I 3 S 9 l ^ i s s a l 5 9 , d a i 3 v i r j ! d a i 3 v i r j ,d3 i 3 v i r j 1 4 ^ a u s n h a u s , h a u s 6 0 ,d3ae 3kit ^ a e a k i t ^ a e g k i ? 1 5 i z i 3 p s r i Z i 3 p a r i s i 3 par 6 1 i b i t f ,bit ibitj 1 6 J u J u J u 6 2 i w a 3 t j " i r ) ,wa 3ti i w a 3 t j i r j 1 7 , v a e n ,baen ^aen 6 3 ,d3Amp i d a p id3Amp 1 8 atVi 2 th i , b i 2 t h i n b i 6 4 ,kha5tj" 1 k h a e 3 t o , k h a e t f 1 9 i t f i a k a n ^Ji^an , t f i 3 kan 6 5 i b a e g i b a e g i b a e g 2 0 , w a t r ,watj iwatf 6 6 ^ r i a d s e z i b i 3 d3 ibnd3 2 1 iwatj nwatj 6 7 ,lif ,wif ilif 2 2 ^aem ,d3aea ,k h eid3 6 8 , r a e 3 b r t ! rae 3 bi? 2 3 ,k h eid3 ,k h eid3 6 9 ^argbids , d a r 3 b i ^ a r a b i c f c 2 4 ,buk , b u k ! b u k 7 0 i9ir j i d i r j ifin 2 5 , p h e i 3 d 3 8 z , ph e i 3 d 3 a z iPheid3 7 1 nmauO imau ^ a u f 2 6 , laef ,la3 jase 7 2 ,6is , d i z ^ I S 2 7 iri3ben i i r 3 b3n n ITaben 7 3 ,brA 3 63r i b o 3 d 3 ! b W A 3 d 3 2 8 , 9 A m , f A m i f A i n 7 4 , g l a e 3 s i z i g a e 3 d i , g l a e 3 s i z 2 9 , t h i9 ,t hif / i t 7 5 Jelf , d e l J 3 l f 3 0 ,6aet ^33 ndae? 7 6 ^ a u ^ e n d ^ a u a d e n ^ a u s z a n d 3 1 ^ e358r ^ e3da ,fe3dar 7 7 , p l a e n 3 t i r j ^ a e r i s t i n ^ l a e r i a t i r j 3 2 ! S t a r i S t a r i S t a r 7 8 ,w is 3 p 3 r iwi 3pe ^ i S a p a r 3 3 , s l a i d i S l a i d ,slaid 7 9 i k r A j " , k h A t , k W A j 3 4 ^ w i s t n i r j , s w i 3 m i n 8 0 ,ski isi , s k i 3 5 i k w i n , k w i n ,k h in 8 1 ,s i l / i l ,s i l 3 6 , p r £ 3 z e n t ,pw£3zan ^re^ant 8 2 i b e i 2 d i p ^ e i s j . b i j " 3 7 itri ! t w i itri 8 3 , b l u ibu ,blu 3 8 i g l A v ^IAV i g l A v 8 4 iP h i 3 k3 l iP h i 3 k3 l , p h i 3 k a l 3 9 a ^ a e r j a g a t r u ^ a e r b g a ^ u 2 k h aer j 3 g 3 i r u 8 5 ,spul lP h U 3 d3l , s p u a 4 0 ^ a r r H p j U s r a r 3kham,pju3rar s k ^ r r h p j u a r e r 8 6 ,drae 3g3n i d a i 3 g o i d r a e a g a n 4 1 , h a e n d i h a e n s ^ a e n d 4 2 3 k h 8 inu 3kha!nu a k ^ n u 4 3 3 8igen igein 3 3igen 4 4 3 ba, lun 3 b a i l u n s b e j u n 4 5 a g ^ i x j l a igra3la 4 6 i m A s f e n ( t r iAsfn ^ A ^ a n 71 Subject 8 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 i p h i g i P h i g i P h i g 47 i P h i k 1 p h i k " ' i P h i k 2 ,thou / o u a /ou 48 ,dag ida3gi idag 3 / o u z ,thouz 1thous 49 ,khoum ,khoum ,k houm 4 A b A b , t h A b . 50 ^ e i s if eis , f e i s 5 ,dAk i d A g i d A k h 51 ^ e i a s a z ^ e i a s a z ifei3saz 6 ima3mi ^ A a t n i ,ma3mi 52 ikha 3 f i r j ,k h a 3 f i t 1 k h a 3 f i n 7 i jard ijard ,jad 53 i sup isup i sup 8 , g A m i g A m i g A m 54 ,tfer i t S E ^ s e a 9 !nouz i n o u z i n o u s 55 ^ors ,hors ihos 10 i f i / i f i j i if es 56 !zi3bra izi 3ba ,zi3bwa 11 i f i a j i n . i f i j i n fesm 57 Jart ^at ,sut 12 ,soup i S O U p ,soup 58 , v £ s t ,v est , vss 13 i W I 3 s a l ^ I a S a l ,wi3sod 59 i da iaV i r j ^ a ^ v m ^ a i s V i n 14 !haus !haus ihaus 60 ^ a e a k i t ^ a e a k i t ^ a e ^ i f 15 iz i 3 per i Z I 3 pa iz i 3 par 61 ibitf ibitj ^its 16 J u ,su 1ZU 62 ^ O a t f i r j iwa 3 ts in ^ a ^ s m 17 ,vaen ^ae" ,van 63 ,d3Amp ^ZAimp ,dzAmp 18 2 t h i i V i 2swiibi 2thhvi 64 ,khaetf ^aets ikhaets 19 ^/i^kar) ^ i a k a n ,tsi3kan 65 ibaeg ibaeg ibaeg 20 ^ a t f ,wats !was 66 ^ r i a d s a z i b i d z ^ w i s d z a z 21 !wats ^c^tses 67 ,lif ilif 22 ,d339m tdzaem ^ a e m 68 !rae3bit ,wae 3 b i t ^ a e a b i t 23 , k h eid3 ,k h ei t h , k h e i d z 69 ^arsbids ,gar 3 bidz ida 3 bidz 24 ,buk ,buk !buk 70 i9in iSirj i9in 25 , p h e i 3 d 3 9 z 1 p h e i 3 daz 1 p h ei 3 dzaz 71 , m a u 0 ^au f ^ a u f 26 Jaef ,laef !laef 72 ,61s ! d i s !dis 27 ^ i a b a n , w i 3 b a n ! W i 3 b i 73 !brA 3 6ar , bA 3 ra ! b A 3 d u 28 , 0 A m ,fAm ifAm 74 ^ l a e a s i z ,d3e 3 s iz i g l a e 3 s i z 29 ,t hi9 / i s / i f 75 ijelf !self i S E l f 30 ,633t ^aet . ,dae 76 , 9 a u 3 z a n d ^ a u a z a n ^ a u a z a n d 31 ,f e3Sar , f e 3 d a i f e 3 d u 77 tplaeriatirj i p a e 3 t i n ^ l a e r i s t i n 32 ,star i sa ^ta^a 78 !Wis 3par ,wis3pa ,wis 3 pu 33 ,slaid isaid islaid 79 i k r A j ,kWAS ,kWAS 34 ^ w ^ r m r ] ^ w i s t n i n ^ W l a l T l i n 80 !ski iski ^ki 35 ,kwin ,kwin ikwin 81 ,sil ,sil isil 36 ^re^ant ^ e s z a n t ^ w E g Z a n 82 , s p e i 2 J i p ^ p e i ^ s i p ^pei^sip 37 ,tri itswi itswi 83 ,blu ,blu iblu 38 iglAV , g A V iglAV 84 iP h i 3 k a l iP h i 3 ka l ,p h i 3 koa 39 ^ a e r f e g a ^ u 2k h irj 3gaiwu 2 kaen 3 ga 1 wu 85 !spul ,sul ,spua' 40 3 k h a r r i i p j u 3 r a r 3 t h a 1 pu 3 ra i P h u 3 r u 86 idrae3gan ^ w e i a g a n ,dzwae 3gan 41 ,haend ,haend ihaend 42 a k ^ n u a k ^ n u a k ^ n u 43 3 9 i g en 3 a i g e n ,gen 44 aba^un 3ba,lun ,blun 45 3ga,n 3 la agaiWiala 3 g a i W i 3 l a 46 ^ A ^ a n ^ A s f i n imA 3fan 72 Subject 9 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 iP h ig iP hid iP h ig 47 iPhik iPhit iPhit 2 /ou /ou /ou 48 idag .dad idag ikhoum 3 / o u z / o u s /oud 49 ,k houm ,phoum 4 / A b lPhAP / A b 50 i f e i s . f e i s . d e i t 5 ^ A k , d A t i d A k 51 ifei3saz !fei 3saz .dei3tad 6 ima 3 mi ^ a s m i 52 ,k ha 3f i0 ik ha 3fin .k ha 3tin 7 ijard .wad !?ad 53 ,sup Jup idup 8 igAtn idAm i gAm 54 i tfer / e a / e a 9 !nouz i n o u , n o u d 55 ,hors ihas .hot 10 i f i j i f i j , d i t 56 .z^bra izi3ba .di3bwa 11 i f i s j i r j i f i 3 Jm .di^tm 57 Jart Jet / u t 12 !SOUp Joup i t h oup 58 !vest .WEf .d£t 13 .WIsSal . W I ^ O .w ia toa 59 i6ai3vir) .ba i^m .dai 3vm 14 ,haus .haus ,haut 60 ^saeskit !dae3di .dae 3kit 15 , z i 3 p a r i S i 3 p a i d i 3 p u 61 ibitf ibitf nbit 16 J u J u ,diu 62 ,wa3tj"irj ,wa3Jm i w a 3 t i n 17 .vaen .vaen ,daen 63 ,d3Amp ,bAmp ,dAmp 18 2 t h i , v i 2hi 1di 2 t h i / i 64 ^ a e t f i t h a e j ,khaeth 19 .ti^an i t h i 3kan 65 ibeeg , be i t ibaeg 20 .watj iwa t j .bwat 66 . b r ^ e z ,bwi3d3az .bi3dad 21 tWOstfaz .was t faz p a s t e d 67 ,lif ijif .wid 22 ,d3aem .daem , d a e a ~ 68 ^aeabit . w a e s V i t .wae 3bit 23 ,k heid3 itheid3 , k h e i d 69 ,gar 3bid3 ,ba3bid3 .da3bld 24 , b u k ,but , b u k 70 iQiQ .fin ntin 25 1 p h ei 3 d3az ,pheid3 ,p h e i 3 dad 71 ,mau0 ,maut .maut 26 ,laef .waef . w a e a 72 i6is idis idi 27 , r i 3 b a n ! W i 3 b a n ,wi 3 ban 73 .b rAg&ar , bA 3 ra ,bA 3du 28 ,0Am ,SAITI i dAm 74 ^ l a e a s i z ,gae 3siz .gaeadia 29 / ie / i t ,thit 75 Jelf Jef .del 30 .Saet ,daet , d a e 76 .Gau^and .sau 3zan . d a u 3 z a n 31 ,f e3oar . fesda ,dE3du 77 iplaen3tir) iPhaen3tin iPhaen3tin 32 .star ,sta .daa 78 ,wis3par .WI 3va 1 wi 3 p h a 33 , s l a i d . s a i a . d a i d 79 i k r A j " l t h A j .khaet 34 ,swi 3 mirj .si^mm .di^mm 80 , s k i iSti igi 35 ^win / i n ,k h in 81 iSil iSil idil 36 .prEszant , p h e 3 z a n !Phe 3dant 82 i s p e i 2 J i p . s p e i j i p 1 b e i 2 d i p 37 ,tri / i / i 83 ,blu ,bu .bu 38 , g lAV , b A V i g A d 84 iP hi 3kal iP h i 3 ta ,p hi 3koa 39 2khaer)3geiru 2 k h aen 3 da 1 wu 85 ispul .stua .bul 40 ^ a r r H p j U s r a r iPhi3da iPhu3d„oa 86 ,drae3gan .dai3dan idae3dan 41 ihaend 3 k h a ! n u .haent ,haen 42 3k ha,nu 3khae,nu 43 3 9igen ^ d en 3e,g£n 44 3b9ilun sba^un 3 b i i b u n 45 3gein 3 la 3thaini 3na 3ga,wi3lae 46 imA 3fan ^ A ^ a n . m A ^ i n 73 Subject 10 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 i p h i g iPhig iPhig 47 iP h ik iPhik iP h ik 2 ,thou ,t h OU / o u 48 idag idag idag ,khou 3 1thouz / o u z ,thouz 49 1k houm ,k hou 4 /AD /Ab / A b 50 jeis ifeis ifeis 5 ,dAk idAk idAk 51 ifei3saz ifeiasaz ifei3saz 6 ima3mi itnaami 52 . ^aafir j ,k h a 3 f in i k h a 3 f i r j 7 ijard jar ijard 53 isup ,sup isup 8 i g A m ,gAm ,gAm 54 ,tj£r ,th£r itfer 9 ,nouz inouz ,zouz 55 thors ,hors ihors 10 i f i j i f i j i f i j 56 tzi3bra !zi3bwa ,zi3bwa 11 ifl 3JlQ. i f i 3Jirj i f i 3 Jin 57 Jert Jert Jar 12 !SOUp !S0Up !S0Up 58 !V£St !VES ,VES 13 ^ I ^ a l ^ I a S O U 59 i da i aVi r j idsiavirj idai 3vin 14 !haus !hau0 ihaus 60 ^aeakit idaeakit ^ae-jkit 15 izi3par idi 3pa izi3par 61 ibitf ibij ibit; 16 J u ,su J u 62 ,wa 3tr ir j , w a 3 J in 17 ,vaen ween iVaen 63 ,d3Amp ,dAmp ,dzAmp 18 2thiivi zt^bi 2thhvi / i 3 k a n 64 1khaetT ,khaet i k h E j 19 ^Ji^an ^ k e n 65 ibaeg ibaeg ibaeg 20 ^ a t j • * * 66 ibrigdssz !bnd ,bwi333Z 21 iwa3tjez * * 67 ,lif ilif twif 22 ,d333m * * 68 iraeabit ^aesbit ^ae^s t 23 !kheid3 * * 69 ,gar3bid3 ,gar3bid iga 3bid 24 ,buk * * 70 iQirj i9lQ ifirj 25 1phei3d3az * * 71 tmsuG ,mauf imauf 26 ,1331 * * 72 ,6is ,6is ,VIS 27 ,n3ban * * 73 ibrAa&ar ,bA 3 ra !bA3dar 28 ^ A t n ifAm ,fAm 74 iglaessiz ^laessiz igwae3siz 29 / i e / i s / i f 75 Jelf Jelf j £ f 30 ,633t ^aet ,dae 76 i9au3zand ^auazan ,fau3zan 31 ife3da if£3da 77 iplaen3tirj ipaen3tin ,pwaen3tin 32 !Star ^tar iStar 78 iWis3par ,wis3par iWISspU 33 !slaid islaid iSaid"1 79 ikrAj ikrAj" ^WAJ" 34 ^wiamirj iSwiatnin 80 ,ski ,ski iski 35 !kwin itwjn ikwin 81 iSil ,sil ,siou 36 ,pre 3z3nt ,ph e 3 z3n ,ph£3zan 82 ispei 2Jip ispeis i s p e i z j i p 37 itri ,twi ,twi 83 ,blu ,blu ,bu 38 I^AV igwAV ,gwAV 84 iPhi3kal iPhi3kal iP h i 3 kA 39 2k h33rj 3gairu 2khae3ga1wu 2 k h3e _ 3ga 1wu 85 ,spul ,spul tspuou 40 3kharriipju3rar ipa3?ar iPJu3rar 86 ,drae3gan idrae3gan idwaeagan 41 ^aend nhaend ihaen 42 a k ^ n u 3 k h B i n u a k ^ n u 43 3aigen 3 3 i g e n ,g£n 44 3b3,lun ,bwu ,bun 45 age^iala igwi3la ,gwi3wae 46 imA3f3n ^ A ^ i d itriA 3f £n * Both video and audio recordings of these words failed. P C M and % P C M scores were adjusted accordingly. 74 Subject 11 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 i P h i g i P h i d , p h i k h 47 iP h i k iP h i t iP h i k 2 / o u / o u t / o u 48 i d a g ,dad i d a g 3 ,thouz / o u t / o u z 49 ik houm 1thoum ,k houn 4 /AD / A b / A b , d A k h 50 , f e i s jei i f e i s 5 . ,dAk ,dAt 51 ifei3s3z .teased ^ e i a s a z 6 .maaimi tmam ^ O s m i 52 i k h a 3 f i r j itha 3fir) 1 k h a 3 f i n 7 i jard ,lad i jad 53 ,sup Jup is'up 8 ,gAm , d A m i gAm 54 i t f s r J'ea 1S1 er 9 .nouz inout inouz 55 ihors ihoas1 ihors 10 i f i j ,fie , f i s 56 !zi3bra , z i 3 b a a ,dzi3bwae 11 i f i 3 J i r j i f i j i n i f i 3 s i n 57 Jart ikjart Jert 12 , soup J'oup ^'oup 58 !V£St .bet !VES 13 !Wi 3 ta l ^ I g S ' O U 59 idai 3 vir j . d a i s V i r j ^ a i s V i n 14 !haus ^aus ^aus 60 ,d3ae3kit ,dae3dit ^zaea t i t 15 iZi 3 par i d i 3 pa i d i 3 pa 61 ibitf ib i t f ibits 16 J u J u ,su 62 ^ O a t f i r j ,wa 3 t i r j 17 .vaen ,vaen ,vaen 63 ^ A m p ,dAmp ,dZAmp 18 2 t h i , v i 2 t h h v i / h v i 64 i ^ a e t f /aet /aets 19 i t j i 3 k e n i tfi 3 tan ^ ^ k a n 65 ibaeg .baed ibaeg 20 ,wat f !wat ^ a t s ' 66 ,bn3d33z , b i d ^m^das' 21 ^ a g t f s z !wat h ^a^az 67 ,lif ilif Jif 22 ^aem ^aem 68 ^aeabit !wae3bit ^ae^n 23 ^ e i d s / e i d / e i d ' 69 ^ a r s b i d s !da 3 b id .da^bis' 24 ,buk !but ,buth 70 i6irj ^ ' i n ^in 25 ,p hei 3d3az 1 p h e i d , p h a i 3 d 3 Z 71 ^auO tinau ,mauf 26 ,laef Jaef ,laef 72 ,6is ,6is ,dis 27 ^ b a n ^ a s w a n ^ i s b a n 73 ibrA 36sr , bA 3 ra ,brA3dar 28 .OAITI ifAm ^ A m 74 ,glae 3siz !diae 3did ,glae3siz 29 / i 9 / i 0 ^ i s ' 75 j £ l f j £ l 30 ^aet ,daet ,d„ae 76 i6au3zand ^ausdant ^ a u a z a n 31 if£ 3ro i fs 3 du 77 p\3en3\iq , p l a e n 3 ? i n .plaeriatin 32 .star ida ,dar 78 ^ i S a p e r i w i 3 p a ^ i a p a r 33 , s l a i d ! S l a i d i S ' l a i d 79 i k r A j ,kA ,drAs' 34 . s w i s m i r j ^ ^ m i n 80 iski / i igi 35 .kwin 1h'in ^ w i n 81 ,sil J ' i l ,sil 36 .preazent iphae3nat ^ W E s d a n t 82 , s p e i 2 J i p ^ e i z j i p ^ e i j ' i p 37 itri i9'i itri 83 ,blu 3bairo !blou 38 ^IAV iglAV iglAb 84 iP h i 3 k3 l iP h i 3to , p h i 3 tou 39 2 k h 3 e r j 3 g B i r u 2khaerj1wu 2khaet]3?a1ru 1phu 3dar 85 ,spul ,bo !buou 40 sk^ r rHp jUs ra r ipu 3ro 86 ^ r a e a g s n ,d3ae3dan ^ w a e a d a n 41 ^aend a k ^ n u ^aen ,haen 42 3t hainu s k ^ n u 43 38igen 3aid£n i g e n 44 3ba,lun iblun tblun 45 a g ^ r i a l a i l i 3 l a ^ri^ae 46 ^A^an ^ A s f i n ^ A s f a n 75 Subject 12 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 ip h ig iPh i 3 d i iP hid„ 47 iP h ik iP h i t iP h i 2 / o u l t h 0 U / O U 48 i d a g i d a i d a d 3 / o u z / o u l t h OU 49 ^ o u m ,thou / o u n 4 / A b / A d / A V 50 , f e i s , f e i ^ e i 5 ^ A k ! d A d , d A t 51 , f e i 3 s 3 z , f e i i f e i 3 t h £ 6 tmasmi i m a m ima 3 mi 52 , k h a 3 f i n , t h a 3 t i i t h a 3 b i • 7 ijard i j a i jad 53 i sup J u ,(3Up 8 , g A m i d A m i dAm 54 itf er itSE , tS 'E3 9 ,nouz !nou ^ouf 55 ihors iho ,hot 10 i f i j i f i i f i t 56 !Zi 3 br3 iti 3ba iPi3bae 11 i f i 3 J i n i f i 3 t i i f i 3 t i n 57 Jert iSO iP '3t 12 !S0UP Jou Joup 58 ^ e s t ,fe 1VE 13 ^ I ^ O ,wi 3tou 59 , d 3 i 3 v i r ) ,dae3di ! d a i 3 b i 14 ,haus ihau ihau 60 ,d33e3kit i t h ae 3 di ^ i a e s d i 15 i z i 3 p a r , v i 3 d 9 izi3paa 61 ibitj ibi ibit 16 J u J u J u 62 wa3\[iq ,wa 3 t i , w a 3 t i 17 ivaen ^ a e n ^ a e n 63 id3Amp ihSAin ,dAm 18 zt^vi 2 t h i i d i 2 t h i i b i 64 1khaetf /ae /aet 19 $i3kan i t h i 3 ta / i 3 d i a 65 ibaeg ibae i b e i 20 ^ a t f / a t ^ae: 66 ,bn 3d33z , b i 3 d 3 , b w i 3 d £ 21 , w a 3 t j 8 z / a t , w a e 3 t 3 67 ilif ibi ,wi 22 ^aem ,shaem tdaem 68 , r a e 3 b i t ,wae3da iWaesbi 23 ,kheid3 / e i , t h e i 69 ,gar 3bid3 ^dc^de ^ O g b l 24 ,buk !bu ibut„ 70 1 0 I Q iflQ i f i n 25 1 p h ei 3 d38z 1 p h e i 3 d a 1 p h e i 3 d a 71 ^auQ ^ a u ,mauf 26 ,laef ^ a e ^ae: 72 ,61s ,di i d i 27 ^ i a d a ,WL3bZ 73 ^ r A a & s r ^ A ^ g , b W A 3 d 3 28 ^ A n ,fAm 74 ^ l a e ^ i z / a e 3 d 9 ,dwae3d3 29 ,thie / i / i 75 Jelf itje 1 j £ w 30 ,Saet ,dae !dae 76 ,Gau 3z3nd ,fau 3da ^ a u 3 d E 31 jt3&ar iPhe3da ife3ba 77 ^laeriatir j ^ae 'a t i" , p w a e 3 t i 32 !Star / a , t h a d 78 iWis 3 p3r l W I 3 d 3 l W I 3 t £ 33 , s l a i d / s i ^ 'a i 79 i k r A / / A !tWA 34 ^ w i s m i r j i s i 3 n i ^ I a l T l i n 80 ,ski / i / i 35 ^win / i " itwin 81 ,sil iSi 3do !Siou 36 , p r e 3 zan t iPhe3da ,pw£3de 82 , s p e i 2 J i p , p e i z j i t , p h e i 2 ; i 37 ntri ttwi ,twi 83 ,blu ,bu ,bwu 38 ,glAV , d A ,dwAb 84 i P h i 3 k 3 l , p h i 3 t a l ^ I a t O U 39 z^aerjage^u 2 t h e i 3 n a , w u 2t hEn 3da,wu 85 !spul iPhu 1p hu 3dou 40 3 k h 3m ,p ju 3 r3 r 1 p h e i 3 d o iP ji 3dou 86 ^ r a e a g s n ^Jaegdsn idwaegd E 41 ^ a e n d ^aem ^ a e n 42 j i k ^ n u 3 a i n u 3 t h 3 !nu 43 a 3 i g e n 3a,d£n ^ e n 44 aba^un ,bun ,bwu 45 a g a ^ i a l a iwa3da 3 d 3 , w i 3 r A 46 ^ A a f a n ^ A s t S ^ A ^ I 76 Subject 13 Profile IPE Level 2 Target Initial Assessment Follow-Up Assessment Target Initial Assessment Follow-Up Assessment 1 i p h i g i P h i g i Ph i k 4 7 , p h i k i P h i k i P h i 2 / o u / o u , t hou 4 8 idag idag idag 3 / o u z / o u s / o U S 4 9 ,k h oum !k h ou" ,k h oum 4 / A D , t h Ab / A b 5 0 ^e is ^e is 5 ,dAk ,dAp idAk 5 1 ^S I sSSZ ,feis , fei 3 sad 6 i m a 3 m i i m a 3 m i i m a 3 m i 5 2 , k h a 3 f i r j 1 kh a 3 f i n , k h a 3 f i n 7 ijard ijard ijad 5 3 ,sup !tsup i sup 8 igAm igAm igAm 5 4 itfer itfer itf ea 9 , nouz !nous !nouz 5 5 !hors ihars !hers 1 0 i f i j i f e j i f i j 5 6 !zi 3bra ,z i 3 bwa ^iabae 1 1 if i 3 J"ir j , f i 3 J i n , f i 3 f i n 5 7 J a r t Ja r t Jo r t 1 2 ^oup ,6oup iSOUp 5 8 ,v est ,ves , V £ S 1 3 , w i 3 sa l ,wi 39al l W I 3 S O U 5 9 ida i 3 v i r j ^ a i a V i n ^ a i a V i n 1 4 ,haus ^auO !hau 6 0 ^ a e g k i t ,d33eakit ^ a e a k i t 1 5 i Z i 3 p s r i z i 3 p a r izi 3p3r 6 1 ibitf ibitf ibitf 1 6 J u J u J u 6 2 ,wa 3 t f i r ] ,wa 3 t f i r ) ^ O a t f i n 1 7 ^ a e n ^ a e n ,vaen 6 3 ^ A m p i3Amp id3Amp 1 8 2 t h i , v i 2tsi,vi 2 t h e i , v i 6 4 ,khaetf ,khaetf 1 9 , t f i 3 kan , t f i 3 kan J i 3 k 3 n 6 5 ibaeg ibaeg ibag 2 0 iwatf .watf iwatf 6 6 ,btr3d3az ,bir 3 d3id ^ r i a d s a z 2 1 ,watf ^ O s t / S Z 6 7 ilif !Wif ilif 2 2 ^ a e m id3aem 6 8 ,rae3bit ^ a e ^ i f ^aesbi t 2 3 ,kheid3 , k h e i d i k h e i d z 6 9 ,gar3bid3 ,gar3bid3 ^arsbids 2 4 ,buk ,buk ,buk 7 0 ,9ir) ifirj ,firj 2 5 ,p hei 3d3az 1 p h ei 3 d3ad ^ ^ i a d s a z 71 ,mau9 ^ a u f ^ a u f 2 6 l l33f ,laef ^ ' a e f 7 2 ,6is ^ I S .dis 2 7 ,n 3 ban ,wi 3 ban ,wi 3 ban 7 3 ,brA36ar , bA 3 va r ,brA 3var 2 8 ,0Am ifAm ^AITI 7 4 !glae 3siz !gae 3siz ^ l a e a s i z 2 9 / i 0 / i f / i f 7 5 Je l f Je l f Je l f 3 0 ^aet ^ 3 3 7 6 ^ a u s z a n d ^ a u s z a n ^ a u a z a n 3 1 ife36ar !fA3var ife 3far 7 7 .plaeriatirj 1p haen 3tin ^laer i s ten 3 2 istar !sar idzar 7 8 ^ i S a p a r ,wi 3 psar ^ i a p a r 3 3 ,slaid ,sai ,slaid 7 9 ikrAj" i k h A f i k r A f 3 4 ^ w i s m i r j ^ v i s m i r j ^ m i n 8 0 i sk i itsi ,tsi 3 5 ,kwin ,k h in ,ka 2win 8 1 ,sil iSiO .siou 3 6 ,pre 3 zant , p h e 3 z a n ,p re 3 zan 8 2 i s p e i 2 J i p i p s e i j i p . p s e i ^ f i p 3 7 itri itTri ,dri 8 3 ,blu ,bu ,blu 3 8 iglAV ,gAV ^ I A V 8 4 i P h i 3 k a l i P h i 3 k o 1 p h i 3 k o u 3 9 2k haerj 3gairu 2 k h aer] 3 ga ,wu 2 k h aen 3 gai ru ^ ^ m ^ j u a d a r 8 5 ,spul iPSUl ,psuou 4 0 a^arri tpjusrar l P J U 3 d 3 8 6 ,drae3gan ^ a e a g a h idrae3g3n 4 1 ,haend ihsen ,haend 4 2 3 k h a , n u a k ^ n u 3 k h a , n u 4 3 3 aig en 3 3 i g 3 n 3 3 i g en 4 4 3ba,lun 3b3iwun a b A ^ u n 4 5 3 g a , n 3 l a 3 g 3 , w i 3 b 3 3 g a , w i 3 w A 4 6 ^ A ^ a n ilTlAsfsn ^ A s f s n 77 Appendix B: Summary of CAPES measures P C M P W M Child Time 1 Time 2 Time 1 Time 2 GainPCM GainPWM 1 69.85 78.89 66.28 76.74 9.04 10.46 2 52.76 77.27 74.42 82.56 24.51 8.14 3 64.82 79.9 68.24 81.4 15.08 13.16 4 47.74 55.28 61.63 59.3 7.54 -2.33 5 . 31.66 52.47 10.47 58.14 20.81 47.67 6 42.71 47.47 56.98 61.28 4.76 4.3 7 80.4 80.9 86.05 82.56 0.5 -3.49 8 64.82 64.32 69.77 75.58 -0.5 5.81 9 44.72 39.7 50 55.81 -5.02 5.81 10 70.77 67.34 79.22 72.09 -3.43 -7.13 11 47.24 59.8 58.14 73.26 12.56 15.12 12 24.12 28.14 17.44 34.88 4.02 • 17.44 13 64.32 73.37 73.26 77.91 9.05 4.65 78 Appendix C: Parent SPAA-C Questionnaire Preventing Literacy Deficits in Children with Articulation/Phonological Disorders A. Questions for Parents Your Child 1. What does your child like to do? 2. Who are all the people your child would speak to within a normal week? Your Child's Speech 4. Describe your child's speech: a) Before therapy b) Now 5. What differences do you notice about your child's speech now compared to his/her siblings and friends regarding: a) The amount of talking b) How well s/he is understood c) Contexts and people where s/he is comfortable talking 79 d) Contexts and people where s/he is uncomfortable talking e) Is this a change from your child's speech before receiving therapy? 6. When your child isn't understood now, what does your child do? b) Is this a change from before? The Impact of Your Child's Speech Difficulty 7. What has been the biggest impact of your child's speech difficulty at home and school? 9. How aware/frustrated is s/he about his/her speech difficulty? Does s/he get embarrassed about his/her speech? 10. What goals would you like to achieve with your child's communication skills? 80 Appendix D: Summary of information collected from the SPAA-C Has your child's Does your child get Subject speech improved? embarassed about his/her speech? 1 Y N 2 Y N 3 Y •N 4 Y N 5 Y Y 6 Y N 7 Y N 8 Y N 9 Y N 10 * 11 * 12 Y Y 13 Y Y Parents did not return completed forms 81 Appendix E: Raw SAILS scores T l SAILS scores Participant Module 1 2 3 4 5 6 7 8 9 10 11 12 13 cat - level 1 5 6 8 7 6 4 8 7 4 8 7 7 8 lake - level 1 8 8 10 8 9 6 6 9 5 8 9 8 10 rat - level 1 5 8 10 6 5 5 6 8 6 4 8 5 8 rat - level 2 5 6 9 7 5 5 6 7 5 7 7 5 7 Sue- level 1 9 9 8 7 8 7 7 9 8 8 7 8 9 Sue- level 2 7 5 8 5 8 5 5 5 6 5 8 6 6 Sue- level 3 9 3 6 7 6 7 6 4 6 6 9 6 7 T2 SAILS scores Participant Module 1 2 3 4 5 6 7 8 9 10 11 12 13 rat - level 1 8 6 9 6 6 4 8 6 10 6 8 6 9 rat - level 2 9 7 9 5 7 3 6 8 8 5 7 6 8 Sue- level 1 10 9 8 6 7 9 8 6 5 9 8 8 8 Sue- level 2 8 8 8 6 6 9 7 4 6 7 10 8 7 Sue- level 3 10 6 8 4 9 6 7 6 9 8 9 7 8 82 Appendix F: PIPA scores Subject (Age in brackets) Subtest: 1 2 3 4 5 6 7 8 9 10 11 12 13 Rhyme Awareness Raw Score 7/12 4/12 11/12 5/12 4/12 2/12 9/12 8/12 0/12 DNT 2/12 3/12 7/12 %ile Range 50-54 55-59 90-94 30-34 55-59 15-19 85-89 80-84 0-4 15-19 25-29 70-74 Syllable Segmentation Raw Score 10/12 1/12 11/12 0/12 11/12 0/12 8/12 9/12 1/12 8/12 4/12 6/12 %ile Range 75-79 15-19 85-89 0-4 95-99 5-9 80-84 85-89 15-19 90-94 30-34 65-69 Alliteration Awareness Raw Score 7/12 1/12 11/12 4/12 4/12 7/12 7/12 4/12 2/12 5/12 1/12 1/12 %ile Range 80-84 10-14 90-94 50-54 60-64 85-89 85-89 60-64 20-24 70-74 10-14 10-14 Sound Isolation Raw Score 11/12 1/12 11/12 0/12 0/12 0/12 0/12 11/12 0/12 1/12 1/12 0/12 %ile Range 80-84 50-54 80-84 10-14 20-24 20-24 20-24 90-94 20-24 50-54 35-39 20-24 Sound Segmentation Raw Score 0/12 0/12 4/12 0/12 0/12 0/12 0/12 0/12 0/12 0/12 0/12 0/12 %ile Range 20-24 40-44 80/84 20-24 40-44 40-44 40-44 40-44 40-44 70-74 25-29 40-44 Letter-to-Sound Knowledge Raw Score 27/32 3/32 24/32 0/32 0/32 0/32 0/32 25/32 0/32 4/32 5/32 4/32 %ile Range 95-99 65-59 95-99 10-14 20-24 20-24 20/24 95-99 20-24 70-74 55-59 70-74 83 Appendix G: TOCS+ Raw T l data Child 1 2 3 4 5 6 7 8 9 10 11 12 13 Maximum Repetition Rate (Syllables per [pa] 1. 3.6 2.95 2.24 3.75 4.27 3.76 3.41 4.22 3.85 DNT 3.91 4.52 3.62 2 4.22 2.91 2.19 3.55 4.18 3.14 2.46 4.63 4 3.94 3.32 3.37 3 3.48 3.95 2.39 4.03 4.03 3.14 2.73 4.05 3.25 3.72 3.43 3.25 [ta] 1. 4.18 4.61 2.65 2.48 3.79 3.44 2.73 3.94 3.76 3.66 4.13 3.11 2 2.98 3.75 2.6 3.56. 4.35 3.46 3.62 4.1 3.05 3.45 3.51 3.38 3 3.85 3.81 2.42 4.29 4.18 3.66 2.55 4.25 3.1 3.77 4.27 3.76 [ka] 1. 3.76 2.95 2.53 3.8 4.33 2.75 3.08 2.84 3.57 3.86 4.1 3.73 2 2.98 2.5 2.5 3.76 4.46 3.82 3.31 3.66 3.08 2.9 3.69 3.32 3 2.9 3.21 2.49 3.6 3.72 3.86 1.75 3.68 3.2 2.77 4.27 3.22 [pataka] 1. 4.9 4.28 1.61 2.71 3.68 3.51 2.28 3.55 2.26 3.33 4.1 3.6 2 4.28 3.54 2.81 3 4.26 3.47 2.33 3.97 2.89 4.43 3.86 3.86 3 .4.11 3.02 2.84 3.49 4.21 2.65 4.29 2.91 4.13 4.68 3.93 4 4 2.89 3.72 4.88 5 4.38 2.94 3.31 5.49 6 4.03 4.83 3.07 4.92 PreMPTavg 3.74 3.67 2.67 3.45 3.92 3.52 2.74 3.93 3.24 3.66 4.21 3.51 84 Appendix H: TOCS+ Summary of T l and T2 MRRtri raw rate, consistency and accuracy Child Time 1 Time 2 Accuracy Consistency Accuracy Consistency (x/36) (x/12) (x/36) (x/12) 1 4.23 35 11 4.21 36 12 2 3.98 21 8 2.99 36 12 3 3.02 28 5 3.08 19 4 4 2.85 19 11 3.01 * ** 5 3.59 17 9 3.08 21 10 6 3.73 6 7 3.96 24 11 7 2.42 16 9 2.45 29 10 8 3.94 20 6 3.27 26 9 9 2.69 21 10 3.51 21 7 10 DNT DNT 11 3.27 20 5 2.6 25 11 12 4.66 16 4 2.79 21 11 13 3.8 22 7 3.54 19 10 *4/9 **2/6 Note. DNT = Did not test 85 Appendix I: Results of Child Development Index Gross and Fine Motor Tasks Participant Subtest 1 2 3 4 5 6 7 8 9 10 11 12 13 Gross Motor Raw 29/3026/30 30/3 29/3 26/3 27/3 27/3 24/3 28/3 28/3 28/3 29/3029/30 Score 0 0 0 0 0 0 0 0 0 Age 4;6 3;4 6;0 4;6 3;4 4;3 4;3 3;0 4;3 4;3 4;3 4;6 4;9 Norm SD 0 0 0 0 -1.3 0 0 -1.5 0 0 0 0 0 Fine Motor -Raw 30/3027/30 30/3 21/3 28/3 23/3 28/3 25/3 23/3 19/3 29/3 22/23 23/30 Score 0 0 0 0 0 .0 0 0 0 Age 5;0* 4;3 5;0* 3;0 4;4 3;3 4;4 4;0 3;3 2;10 4;9 N / A 3;3 Norm SD 0 0 0 >-2 0 -1.3 0 0 -1.5 -2 0 N / A -1.5 Note.* Indicates a score at ceiling 86 Appendix J: Results of PPVT-III (1997) Participant 1 ~2 3 4 5 6 7 8 9 10 Tl 12 13 Raw Score DNT 81 92 69 75 69 73 71 51 55 76 74 107 Standard Score 116 113 97 111 109 112 112 94 99 117 107 137 Percentile Rank 86 81 42 77 73 79 79 34 47 87 68 99 Age Equivalent 6;1 6;11 5;3 5;8 5;3 5;7 5;5 4;0 4;4 5;9 5;8 8;1 Note. DNT = Did not test 87 

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