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

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C H I L D R E N WITH A T Y P I C A L P H O N O L O G I C A L 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 H E A T H E R ERICKSON B.A., Simon Fraser University, 2005  A THESIS SUBMITTED IN P A R T I A L F U L F I L L M E N T OF THE REQUIREMENTS FOR THE D E G R E E 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.  ii  Table of Contents Abstract  ii  Table of Contents  iii  List of Tables  v  List of Figures  vi  Acknowledgements  ..  vii  1. INTRODUCTION 1.1 Overview of the thesis 1.2 Protracted Phonological Development 1.3 Attempts at identifying sub-types of PPD 1.4 Which variables are related to impairments in speech production (i.e. PPD)? 1.5 Phonological awareness skills of children with PPD 1.6 Designing an assessment battery 1.7 Prospective evaluation of children with PPD 1.8 Non-phonological factors in outcomes of speech intervention 1.9 The current study  1 1 2 3 6 7 8 9 12 13  2. M E T H O D 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 Edition (PPVT-III) 32 rd  3. RESULTS : 3.1 Summary of children's performance on the assessment tasks 3.2 Statistical analyses  iii  33 34 , 36  4. DISCUSSION 4.1 Summary of findings 4.1.1 Group changes from T1 to T2 4.1.2 Identifying types of PPD 4.1.3 Assessment performance, severity of PPD and predictors of change 4.1.4 Qualitative characteristics related to change in phonology 4.2 Implications 4.3 Limitations  42 42 42 46 49 52 53 56  References  59  Appendix A : T l and T2 CAPES transcriptions  65  Appendix B: Summary of CAPES measures  78  Appendix C: Parent S P A A - 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 B R E B 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 if 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 word2  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 subtypes: (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). A n 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-yearold 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., motorbased 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 M c G i 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 cognitivelinguistic 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). A n 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 subtypes 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). Nonphonological 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 & ContiRamsden, 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) Will 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. O f 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  th  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 P I , 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 if 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 atTl  Age atT2  Prenatal or Perinatal difficulties? 3  Ongoing Tx? a  PI  5;2  5;11  No  No  P2 P3 P4 P5  4;0 5;3 5;2 4;5  4;9 5;8 5;7 4;10  Yes Yes No Yes  P6  4;2  4;6  No No No Hypotonic; low initial Apgar score but average after 5 min. No  P7  4;3  4;7  Yes  P8  4;0  4;5  P9  4;2  4;6  P10  4;l  4;6  No 'Blocked tube' and 'stopped growing,' bed rest from 3 mos. gestation during pregnancy; emergency Caesarian delivery Bed-ridden at 6 mos.; Caesarian delivery at 39 weeks No  Pll PI 2 P13  4;0 4;8 4;5  4;5 5;1 4;9  No No No  Yes Yes Yes  Yes  Yes + phonics class lx/wk Yes  Yes  #ofTx sessions T l to T 2  Attention at Tl Ax b  a  0 8 mo. (weekly) Unknown 0 Unknown  Inattentive  6 sessions 1-2 sessions  15  34  Inattentive  16 (group sessions) Unknown 8 sessions Unknown  Inattentive  Note. T l = time of first assessment, T2 = time of second assessment; Tx = treatment, A x = assessment. Parent report on the study questionnaire Author impression during assessment process a  b  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 and youngest child in his family. Parents of P2, P3, th  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 audiorecorded 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  CAPES: Profile  CAPES: IPE Level 2  CAPES: Profile CAPES: IPE Level 2  Perceptual/Processing  SAILS: cat, lake, rat, Sue  Motor  PIPA  SAILS - rat, Sue  CDI: Parent Checklist  MRRtri  TOCS+: MRRmono, MRRtri Vocabulary  PPVT - III  Comprehension Note. CAPES = Computerized Articulation and Phonology Evaluation System SAILS = Speech Assessment and Interactive Learning System CDI = Child Development Inventory (gross andfinemotor subscales) TOCS+ = Test of Children's Speech + MRRmono = Maximum repetition rate, monosyllabic MRRtri = Maximum repetition rate, trisyllabice PPVT - III = Peabody Picture Vocabulary Test (3 Edition) rd  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 derivedfromthe 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. Interjudge 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, HardinJones, 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: matchmismatch 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, word22  medial and word-final consonants. A score for word shape (e.g. C V C ) 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 if 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 M P T 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 S P A A - 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 - 3 Edition (PPVT-III) rd  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 o f children with P P D , 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 o f concurrent and longitudinal analyses were performed across tasks. In order to determine whether the children's performance on any o f the initial assessment tasks at time 1 ( T l ) was related to their performance on any o f the other tasks at T l , a series o f bivariate Pearson correlations was performed across the group. Another series o f 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 o f paired samples t-tests was performed comparing the average performance o f 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 o f rate, consistency and accuracy o f M R R t r i . In order to examine whether performance on the assessment tasks could predict stability or rate o f change i n their phonological systems, a series o f bivariate Pearson correlations was run on T l variables and the change i n percent consonant match ( G a i n P C M ) and change in word shape match ( G a i n P W M ) . This analysis also assisted i n determining whether severity o f P P D (as indicated by a low T1PCM and/or T1PWM score) is a factor i n predicting P C M and P W M scores at the time o f 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 o f children patterned together on the assessment tasks and their subsequent scores o f phonological skill (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 T2tAge  13 13  48 53  63 71  53.31 58.62  5.65 6.21  13 13 13 13 13 13  24.12 28.14 10.47 34.88 -5.02 -7.13  80.40 80.90 86.05 82.56 24.51 47.67  54.30 61.91 59.38 68.58 7.61 9.20  16.48 16.72 22.38 13.96 8.96 13.63  12 12 12 12 11 12 11  2.67 2.42 2.45 6.00 19.00 4.00 4.00  4.21 4.66 3.96 35.00 36.00 11.00 12.00  3.52 3.55 3.09 20.08 25.18 7.67 9.73  .46 .72 .43 6.96 6.16 2.39 2.37  Phonology T1PCM T2PCM T1PWM T2PWM %GainPCM %GainWSM  Maximum Performance Tasks TIMPTavg TI MRRtri T2MRRtri TI MRRtriAcc T2MRRtriAcc TIMRRtriCons T2MRRtriCons  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 13 27.00 45.00 36.31 5.14 T2SAILSRatSue raw 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 T1 MRRtri-T2MRRtri T1 MRRtri Acc-T2MRRtri Acc T1 MRRtriCons-T2MRRtriCons TI SAILSratSue raw-T2SAILSratSueraw  13 12 12 12 13  -2.43 1.95 -2.08  0.032  -2.67 2.93  0.077 0.064 0.024 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 r  E  0.889**  0.010  0.607*  0.036  TIPCM-TlMPTavg  -0.599*  0.039  Tl%WSM-TlMPTavg  -0.587*  0.045  Factors TlPCm-Tl%WSM T1PCM-PIPA  T l M R R t r i p - T l 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, T 1 P C M 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, ztlMRRtri, ztlMRRtriAcc, ztl MRRtri Cons, ztl PIPA and ztlSAILS. 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.  ztlMhon  ztl MRRtrifl cc  ztiMRRtriCons  0)  5-0.5 < -1 Input, Output and Phonology Measures  Figure 2: T l Cluster 1: P2, P4, P5, P6, P7, P9  37  ztiPlPA  t1 SAILS  1.5  to 0) i  o o to c ro  0.5  Q_  o  t ro Q_  O  —,  0)  ztlPhon  O)  ro  1 | ztiMRRtri  '  1 ztlMRRtriAcc ztiM|RRtri(tons  ztiPlPA  zt1 SAILS  i  > < -0.5  -1  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: T 2 P C M and T 2 P W M (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  o  1  o  CO •  N  I  0.5  Q.  r  T  a. v  :t2Phor i  1  zt2MRRtri  1  zt2MRRtriAcc  1  zt2MRRtriCons  z t2SAIL 3  CO  2 <  -0.5  Input, Output and Phonology Measures  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 zt2Phon  a> a>  g>  2MRR ri  zt2MRRtriAcc  zt2MRRtriCons  -0.5  <  -1  Input, Output and Phonology Measures Figure 5: T2 Cluster 2: PI, P2, P7, P l l  39  zt2SAILS  (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  o  IO.OOH  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 S P A A - 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 35 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, A n 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 if 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, T 1 P C M 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 T 1 P C M 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 T 1 P C M 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 T 1 P C M 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 T 2 P W M 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 T 2 P W M scores, P9 who had a lower T 2 P C M score and PI0 who had lower T2PWM and T 2 P C M 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 subtyping 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 S P A A - 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 if 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, 1hour 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 speechlanguage 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 subtypes of the speech disorder. In addition, certain assessment measures may be predictive of later gains in phonology. Future research into the significance of these relationships would be helpful in determining the quantity and course of intervention that is most beneficial for children with PPD with differing degrees of severity. Finally, children with a similar speech impairment display very individual patterns of performance on assessment tasks; therefore, therapy goals 57  need to be tailored to each child's individual areas of strength and need. B y continuing to explore the factors contributing to the severity of children's PPD, we can refine intervention approaches for children with PPD in order to improve their speech outcomes and facilitate the linguistic and literacy success of this population.  58  References Almost, D., & Rosenbaum, P. (1998). Effectiveness of speech intervention for phonological disorders: A randomized controlled trial. Developmental Medicine and Child Neurology, 40, 319-325. A V A A Z Innovations. (1994). Speech Assessment and Interactive Learning System (Version 1.2)  [Computer Software]. London, Ontario, Canada: Author. Bird, J., Bishop, D . V . M . , & Freeman, N . H . (1995). Phonological awareness and literacy development in children with expressive phonological impairments. Journal of Speech and Hearing Research, 38, 446-462. Catts, H.W., & Kamhi, A . G . (1999). Causes of reading disabilities. In H.W. Catts and A . G . Kamhi (Eds.), Language and Reading Disabilities (pp.95-127). Boston: Allyn and Bacon. Dodd, B . (2005). Differential Diagnosis and Treatment of Children with Speech Disorders.  London: Whurr Publishers. Dodd, B., Crosbie, S., Mcintosh, B., Teitzel, T., & Ozanne, A . (2003). The Pre-Reading Inventory of Phonological Awareness. San Antonio: T X : The Psychological Corporation. Dodd, B., Holm, A., & Crosbie, S. (2006). Letters to the editor. Topics in Language Disorders: Dyslexia in the Current Context, 26(2), 172-174.  Dunn, L . M . , & Dunn, L . M . (1997). Peabody Picture Vocabulary Test [3 ed]. Circle Pines, M N : rd  American Guidance Service. Felsenfeld, S., Broen, P. A., & McGue, M . (1992). A 28-year follow-up of adults with a history of moderate phonological disorder: Linguistic and personality results. Journal of Speech and Hearing Research, 35(5), 1114-1125. Goldman, R., & Fristoe, M . (2000). Goldman-Fristoe Test ofArticulation [2 ed]. Circle Pines, nd  M N : American Guidance Service.  Gooch, J.L., Hardin-Jones, M . , Chapman, K . L . , Trost-Cardamone, J.E., & Sussman, J. (2001). Reliability of listener transcriptions of compensatory articulations. The Cleft PalateCraniofacial Journal, 38, 59-67.  Hall, B.J.C. (1991). Attitudes of fourth and sixth graders towards peers with mild articulation disorders. Language, Speech, and Hearing Services in Schools, 22, 334-340.  Hodge, M . M . & Daniels, J.D. (2004). TOCS + MPT Recorder ver. 1. [Computer Software]. University of Alberta, Edmonton, A B , Canada. Holm, A., & Crosbie, S. (2006). Introducing Jarrod: A child with a phonological impairment. Advances in Speech-Language Pathology, 8, 164-175.  Hua, Z., & Dodd, B. (2000). Development and change in the phonology of Putonghua-speaking children with speech difficulties. Clinical Linguistics & Phonetics, 14(5), 351-368. Ireton, H. (1992). Child Development Inventory. Minneapolis: Behavior Science Systems. Jacoby, G.P., Lee, L., Kummer, A.W., Levin, L., & Creaghead, N . A . (2002). The number of individual treatment units necessary to facilitate functional communication improvements in the speech and language of young children. American Journal of Speech-Language Pathology, 11, 370-380. Knox, E., & Conti-Ramsden, G. (2003). Bullying risks of 11-year-old children with specific language impairment (SLI): Does school placement matter? International Journal of Language and Communication Disorders, 38(1), 1-12.  Kwiatkowski, J., and Shriberg, L. D. (1998). The capability-focus treatment framework for child speech disorders. American Journal of Speech-Language Pathology, 7, 27-38.  Larrivee, L.S., & Catts, H.W. (1999). Early reading achievement in children with expressive phonological disorders. American Journal of Speech-Language Pathology, 8(2), 118-128.  60  Law, J., Boyle, J., Harris, F., Harkness, A., & Nye, C. (2000). Prevalence and natural history of primary speech and language delay: Findings from a systematic review of the literature. International Journal of Language & Communication Disorders, 35(2), 165-188.  Lewis, B.A., Freebairn, L.A., & Taylor, H.G. (2000). Academic outcomes in children with histories of speech sound disorders. Journal of Communication Disorders, 33(1), 11-30. Liberman, I., & Liberman, A. (1990). Whole language vs. code emphasis: Underlying assumption and their implications for reading instruction. Annals of Dyslexia, 40, 51-76. McLeod, S. (2004). Speech pathologists' application of the ICF to children with speech impairment. Advances in Speech-Language Pathology, 6(1), 75-81.  McLeod, S. (2006). A n holistic view of a child with unintelligible speech: Insights from the ICF and ICF-CY. Advances in Speech-Language Pathology, 8, 293-315. .  Major, E. & Bernhardt, B.H. (1998). Metaphonological skills of children with phonological disorders before and after phonological and metaphonological intervention. International Journal of Language and Communication Disorders, 33, 413-444. Masterson, J. & Bernhardt, B . M . (2001). Computerized Articulation and Phonology Evaluations  System. [Computer Software]. San Antonio, T X : The Psychological Corporation. Masterson, J J . , Bernhardt, B.H., Hofheinz, M . K . (2005). A comparison of single words and conversational speech in phonological evaluation. American Journal of Speech-Language Pathology, 14, 229-241. Morrison, J.A., & Shriberg, L.D. (1992). Articulation testing versus conversational speech sampling. Journal of Speech and Hearing Research, 35, 259-273.  Naglieri, J.A., & Pfeiffer, S.I. (1983). Stability, concurrent and predictive validity of the PPVTR. Journal of Clinical Psychology, 39, 965-967.  61  Raitano, N . A., Pennington, B. F., Tunick, R. A., Boada, R., & Shriberg, L. D. (2004). Preliteracy skills of subgroups of children with speech sound disorders. Journal of Child Psychology & Psychiatry, 45(4), 821-835.  Rvachew, S. (1994). Speech perception training can facilitate sound production learning. Journal of Speech and Hearing Research, 37, 346-357/  Rvachew, S. (2006). Longitudinal predictors of implicit phonological awareness skills. American Journal of Speech-Language Pathology, 15, 165-176.  Rvachew, S., & Grawburg, M . (2006). Correlates of phonological awareness in preschoolers with speech sound disorders. Journal of Speech, Language & Hearing Research, 49(\),  74-87. Rvachew, S., Hodge, M . , & Ohberg, A . (2005). Obtaining and interpreting maximum performance tasks from children: A tutorial. Journal of Speech-Language Pathology & Audiology, 29(4), 146-157.  Rvachew, S., Nowak, M . , & Cloutier, G. (2004). Effect of phonemic perception training on the speech production and phonological awareness skills of children with expressive phonological delay. American Journal of Speech-Language Pathology, 13(3), 250-263.  Rvachew, S., Ohberg, A., Grawburg, M . , & Heyding, J. (2003). Phonological awareness and phonemic perception in 4-year-old children with delayed expressive phonology skills. American Journal of Speech-Language Pathology, 12(4), 463.  Shaffer, D.R., Wood, E., & Willoughby, T. (2002). Cognitive development: Informationprocessing perspectives and connectionism. In Developmental Psychology: Childhood and Adolescence (1 Canadian ed., pp.264-310). Scarborough, ON: Thomson Nelson. st  Shriberg, L.D., Austin, D., Lewis, B.A., McSweeny, J.L., & Wilson, D.L. (1997). The speech disorders classification system (SDCS): Extensions and lifespan reference data. Journal of Speech, Language, and Hearing Research, 40, 723-740.  62  Shriberg. L.D., & Kwiatkowski, J. (1988). A follow-up study of children with phonologic disorders of unknown origin. Journal of Speech and Hearing Disorders, 53(2), 144-155. Shriberg, L.D. & Lof, G.L. (1991). Reliability studies in broad and narrow phonetic transcription. Clinical Linguistics and Phonetics, 5, 225-279. Shriberg, L.D., Tomblin, J.B., McSweeny, J.L. (1999). Prevalence of speech delay in 6-year-old children and comorbidity with language impairment. Journal of Speech, Language, and Hearing Research, 42(6), 1461 Silverman, F.H. (1992). Attitudes of teenagers toward peers who have a single articulation error. Language, Speech, and Hearing Services in Schools, 23, 187-188. Snowling, M . , & Nation, K. (1997). Language, phonology, and learning to read. In C. Hulme and M . Snowlings (Eds.), Dyslexia: Biology, cognition, and intervention (pp. 153-166). London: Whurr Publishers. Stackhouse, J., Pascoe, M . , & Gardner, H. (2006). Intervention for a child with persisting speech and literacy difficulties: A psycholinguistic approach. Advances in Speech-Language Pathology, 8, 231-244. Stackhouse, J., & Wells, B. (1997). How do speech and language problems affect literacy development? In C. Hulme and M . Snowlings (Eds.), Dyslexia: Biology, cognition, and intervention (pp. 182-211). London: Whurr Publishers. Thoonen, G., Maassen, B., Wit, J., Gabreels, F., & Schreuder, R. (1996). The integrated use of maximum performance tasks in differential diagnostic evaluations among children with motor speech disorders. Clinical Linguistics and Phonetics, 10(4), 311-336. Thoonen, G., Maassen, B., Gabreels, F., & Schreuder, R. (1999). Validity of maximum performance tasks to diagnose motor speech disorders in children. Clinical Linguistics and Phonetics, 13(1), 1-23.  63  Tyler, A A . , & Lewis, K.E. (2005). Relationships among consistency/variability and other phonological measures over time. Topics in Language Disorder: Clinical Perspectives on Speech Sound Disorders, 25(3), 243-253.  Tyler, A . A . , & Lewis, K.E. (2006). Letters to the editor. Topics in Language Disorders: Dyslexia in the Current Context, 26(2), 175-176.  Weiss, A . (2004). The child as agent for change in therapy for phonological disorders. Child Language Teaching and Therapy, 20, 221-244.  Williams, P, & Stackhouse, J. (2000). Rate, accuracy and consistency: Diadochokinetic performance of young, normally developing children. Clinical Linguistics and Phonetics, 14, 267-293. Wolk, L., & Meisler, A . (1998). Phonological assessment: A systematic comparison of conversation and picture naming. Journal of Communication Disorders, 31, 291-313. World Health Organization (WHO). (2006). International Classification ofFunctioning, 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  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  Profile Initial Assessment  Follow-Up Assessment  iP ig lt OU !t OUZ ,t Ab ,dAk  iP ig  iP ig  ima mi ijard  ima mi ijad  ,ma mi ,jod  igAm ,nouz  igAtn  ,gAm  ^auz  -fij  ,fi J"ir) !SOUp  ifij ifiajirj !S80Up  ,1-ious ifi;  ,haus iZi par  ,wi sa !haus izi pa  Ju  ,Jau  ^3311 l iiVi ^Jiakan iwatf  ,vaen t hvi  h  h  h  ,t au !t auz  h  h  h  ,t ou  h  !t OUS ,t Ab ,dAk  h  h  Ab  h  h  ,dAk  3  3  3  3  ifi Jirj ,soup 3  ,WI SO 3  3  3  ,haus ,zi po Ju ivaen t i,vi itji kan 3  3  h  2  ,wa tr9Z 3  ^333171  ^eids  h  h  2  2  Jiskan  3  !waj ^aajaz ,3aern ik ei3 ibuk  ,watf  ,wa tjaz 3  ^33901 ik ei3 ,buk  h  ,buk  p ei d3az ^sef ,n b9n tOAm ,t i9  h  ,p eid3 ,laef h  h  3  1  3  h  jbee\  ,fe 6ar ,star ,slaid ^wisinir) ^win ipre zant ,tri 3  3  -,laf iwi ban  iWiaban ,flAm  3  3  failAm  ,t if ,zaes ife va !Sta ,sklaid ,skwe mirj ^win h  3  3  ^weazant  ,Jkwi  2k a3rj geiru  gailAv a^aenaga^au  s^arr^pjuarar  3  iglAv  3  h  3  ,haand ak^nu 9igen aba^un 3  aga^igla ^Aafan  k a,pju ra ^ae^nd ak^nu aig en abA^aun h  3  3  gaiWi la ^A^an 3  3  ,t i0 ,6aet ife va !Star ^laid h  3  ,si min 3  ,kwin ipwe zant itfwi 3  iglAv  k aerj ga,wu k a,pju ra ,haend ak^nu 9igen baeilun go,?i la h  2  3  h  3  3  Target 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  3  2 3  3  imAafan  65  iP ik idag t^oum h  ,feis  ,fei3saz  IPE Level 2 Follow-Up Initial Assessment Assessment iP ik ,dag ,k oum h  ,p ik h  idag ,k aum h  h  ^eis ifei saz 3  ,k a fin h  3  ,sup  ,sup  ,tjer  ,J"kea  ,hors  !haus  ^bre Jart ^est  iZi bwa  ^aigVIt]  ,dai vir)  ,d3aeakit  ^seskit  ,bitf ^aatfirj id3Amp  ibij  3  Jaut  ^est 3  ,bn d3az ilif ^aegbit  1  ,gar bid3 i6iQ imau9 ,6is ,brA 6ar iglae siz Jelf !9au zand 3  3  3  3  ^laeriatirj ^iSapar  3  3  3  k aBtr ,bai ^oigdsaz ilif h  t  ^a'sbids  tmauf  ,mauf ,6is !bWA var ^laeasiz  ,6is ,bwA va ga,laa siz Jeuf ,fau zand ,plaen tir) ,wip sa 3  3  3  3  3  3  ,spaul  ,drae gan  3  ^ ^ b l t  3  3  ispul  3  Jo"t !ves ,dai vin ,d3ae kit  wa3 brt  ,kWAj"  h  iZiabwa  iga bi3 ^wirj  ikrAj ,ski ,sil ispei Jip ,blu iP i kal 2  3  isup itje: ,ho"s  3  i3Amp h  3  h  ,bitf ,wa tfir] id3Amp  ,k aej ibae^g ,bwi 3az Jif  ibaeg  ,feis ^eiasaz ,k a fir)  ,ksi iski ja Jpeijip 3  ,blau  iP i ka h  3  ^u^waeggan  ifi"  3  Jelf ^auazand iplaeristirj ^ISapo" ^WAj  ,ski ,sil ^peijip ,blu iP i ko h  3  ,d3ae gan 3  Subject 2 IPE Level 2  Profile Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41" 42 43 44 45 46  Initial Assessment  Follow-Up Assessment  iP ig !t OU  iP ig ,t ou  iP ig !t OU  !t OUZ  ,t oudz  ,t Ab  ,t Ab  ,dAk ^ciami  ,dAk  ,t ouz /Ab ,dAk ima3ini  h  h  h  h  h  h  h  h  h  h  h  iiria mi ,jad 3  ijard igAm ,nouz ,fij  ijad  ,dAm ^oudz  igAm inou  iditj  ,fij  ,fi Jm  idi tfin  3  3  !SOUp  ,doup ,wi tou  !SOUp  ^aut dzi po id3„u ^an t Hvi ,tji kan  !haus  ,wi sal  3  ^aus iZi par Ju 3  ,vaen  t i,vi h  2  1  3  ^aen  3  2  ,k eid3 h  ,buk '  p ei d3az Jaef ,ri3ban tOAm /iO  3  ^atf  wa tfaz ,d3aem ,c eid3 ,bauk 1  3  3  ^set  fE 6ar 3  ,star ^laid ^wiamirj  o  h  h  p ei dzaz h  1  t i,vi ^Jiakan ,watf ,watf h  h  twatj iwa. traz  1  ,zi pa Ju  3  2  itfiakan  1  3  3  ^aem  • ,k eid3 ibuk ,p ei d3az h  h  3  ,lael  ,laef  ^isban !t A m  ^isban ,fy\m /if ,daet ife va ,sta !slaid  ,t its ,daet ,dt du !taa ,l:aid ,tswi min h  3  3  3  ^wiainin  ^win ,pre zant ,tri  ^win ^WEadbant  ^win  !twi  itri  iglAV  ,glAt  k aen gairu s^am^jusrar  aga^ala  . k an d9,wu iplu ta !haend t a nu 3iden sba^un da,wi la  ,mA fan  ^ A ^ i n  3  h  3  2  ,haend  k a,nu aigen aba^un h  3  3  3  3  3  h  3  3  iglAv  h  h  2  ,pwE zant  1  3  3  3  k aen gaiwu s^em^juara ^aend k a,nu 3igen aba^un ga,wi la imA fan h  3  2  47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  h  3  3  3  ,dag  Initial Assessment iP ik idag  ik oum  ,k oum  ifeis  ^eitO ,tei ta6  Target  3  3  66  iP ik  h  h  h  ^eiasaz  ,k a firj ,sup h  3  ,tjer  ,hors !zi bra Jart ,vest ^aiaVirj ,d339 kit 3  ibitf ^aatfirj ^3 Amp  ^aetj ibaeg  3  ,t„ a tin h  3  itup itfea !hot !di bwa ,d3at ides. ^aisdin  ^aegkit ibitj iwa trin 3  ,d3Amp  3  ^laegSiz ijelf ^auazand  ^eis ,fei saz ik a fin ,sup itfee ^o^i izi ba Jet 3  h  3  3  ,V£S ,dai vin 3  ,d388 kit 3  ibitf ^aatfin ^Amp  ,maut  ,mauf  !dits !bwA da id>lae tit  ibiz ,bwA va'  3  h  3  iQirj ^auO ,6is !brA 6ar  k oum h  1  ,wae bit !da bid3 ipin  ibaeg ,bwi d3at !lit  ^arabids  ,dag  h  h  Jif ^ae^n  h  ,k aetj" ibaeg ,bwi d3az ilif ,wae bit !ga bidz ifirj  ,k 39tf  ^riadsaz  iP ik  h  3  3  Follow-Up Assessment  3  3  3  3  3  3  3  ^teaSIZ  Jelf ,t„au zand ^laeristin  ^auszand ^laenatin  ^iSapar ikrAj  iwi pu  ,wis pa  tkWAtJ  ^WAtf  ,ski ,sil ispei J"ip iblu iP i kal ,spul  iki ,ti o ipei tj"ip ,blu iP i kal ipul idwae gan  ,ski ,sil ,spei tfip ,blu iP i kal !spua idwae gan  iplaen tirj 3  2  h  3  ^raeagan  3  3  3  2  h  3  3  3  2  h  3  3  Subject 3  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  iP ig ,t ou ,t ouz /AD ,dAk imaami ijard igAm inouz ifxj h  Profile Initial Assessment iP ig ,hou ,t ous ,t Ab  ip ig ,t ou t ous  !dAk  tdAk ,ma mi ijad igAm !nouz ifij ifi Jirj ,soup  h  h  h  h  h  h  h  1  Ab  h  imam ,da igAm iROUZ !flS ifi sir) ,soup  3  3  iSOUp ^IaSel ,haus izi par Ju ,veen t i,vi h  r  3  h  h  3  3  h  ,fe 6ar ,star ,slaid ,swi mirj ,kwin ^reszant itri iglAv k aer) g9iru k 9mipju r9r thaend k a,nu 9igen abg^un gain la ^Asfan 3  3  h  3  h  3  3  3  3  h  n  2  3  3  h  3  h  iwatj ,wa t 9z ^aem !k eid3 ,buk ,p ei d39Z ,l39f ,n b9n ^Am ,t i9  3  3  !haus izi pa Ju ,baen t i vi ^Jiakan ^atj twaatfaz ,d3aem  2  $i ken  3  ,wi sal  !haus izi pa Ju ivaen t i,vi iti kan ,wats !wats idaam 3  2  2  3  ^I^SOU  3  Follow-Up Assessment  ,k eits h  ,buk p eids ,laef ,wi ban  !buk p ei d3az ,laef ,wi ban  ,9Am  ,9Am  ,t if !daet ife da !Sta ,slai iswi min ^wi" ^weazen ,twi iQAV k aer) ga wu k amipju ra !haen k a,nu 3igen sbajun ga,wi wa imA f9n  !t if !dae ife do tSta ,slaid ^wismirj !kwin ,pwe zant ,tfwi ,glAV 2k 3en g9 wu k am,pju ro ,haend k a,nu 9igen aba^un aga^iala ^Asfan  h  h  1  1  3  3  h  3  3  h  2  3  1  h  3  3  h  3 3  3  3  3  3  h  3  3  h  3  1  h  3  3  Target 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  h  3  3  67  iP ik idag k oum ,feis ,fei saz ik a fin ,sup itfer ihors izi bre ,/art !vest ,dai vir) ,d3ae kit ,bitf iwa tfirj !d3Amp ^aetf ibaeg ,bn d3az ilif ^aesbit ^arabids i9irj ,mau9 ,6is ,brA 6ar ,glae siz Jelf !9au zand ,plaen tir] iWis par ikrAj ,ski ,sil ,spei Jip ,blU iP i kal ,spul ^raeagan h  h  1  3  h  3  3  3  3  3  3  3  3  3  3  3  2  h  3  IPE Level 2 Initial Follow-Up Assessment Assessment iP ik ,dag !k oum !feis ,feis ,k a fir) isup ,tsew ,110s iZi bwa !sat ,ves ,dai vir) ^aeakrt ,bits ,wa tsin ,dzAmp ,k aets ibaeg ibwe dzaz ilif ^aesbit igo bid ,SIQ imauf idis ^WAarO tglaeasiz ,self ^auazan ^wasristir) iWis po !kWAS ,ski isia ispei sip ,blu iP i ko ,spuo ,dwae gan h  h  h  3  3  3  3  h  3  3  3  2  h  3  3  iP ik idag k oum ^eis ^ei^sgz ,k a firj isup itfes ^os izi ba Jet ,v est ^aiavir) ,d3ae kit ibitf gastrin id3Amp ,k aetf ibeg h  h  1  h  3  3  3  h  ,bwi d3az 3  ilif ^aeabit ,ga bid3 iSIQ iinauf !dis !bwA doa ,gae siz Jelf isau zand ^laengtir) ^ISapa 3  3  3  3  ^WAJ"  nSkf  !SiO ^paijip ibu ip i kal ,spul idwae g9n h  3  3  Subject 4 IPE Level 2  Profile Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  ip ig /ou ,t ouz h  h  ,t Ab ,dAk  Initial  Follow-Up  Assessment iP id ,t ou ,t ous lP AP  Assessment iP id  h  h  h  /OU  h  ,t ou _ h  ,dAt  ,t Ab ,dAk  ima mi ,jard  ^c^rni ,wad  ^a^mi ijad  igAm  ,dAm  ,dAm  !nouz ifij ifiajin, ,soup  ,nou  inouz ifi; ifi Jm  ,WI S9l !haus  !WI SO ,haus  !Wi sa  izi par Ju ,vaen  isi pa Ju iVaen  ,zi pa Ju ^aen  hhdi  !ti di  platan ,watf  itji tan  twatj  ,wa3trez  ,wa tj"az  ,d3aem. ,k eid3  tdaem  h  h  3  3  3  t i,vi h  2  ^Ji^an  h  ,buk ^eigdsaz ^aef  ifij  ifi J"in Joup 3  3  !SOUp  3  3  ,haus  3  3  2  2  3  !watj ,watj ,d3aem  3  iP eid3 ^aef ,wi ban  itfeiz !buk iP eid3 ,laea ^iaban  iSAttl ,t it  ,SAm /it  ^aet ife da  !daet ife da  !Sta ,saia  !Sta  it eid3 ,but h  h  h  3  ,0Am  ,t i9 ^aet ,f e 6ar h  3  ^tar  ,slaid ,swi mirj  h  h  3  3  iSi min  tsaia iSi min  ,kwin  ,t in  ,tsin  ^re^ant  iP e zan /i  iP e zan Ji  lbAV  igAbs  k aen da wu iP i da ^aent  t ae na wu ,pu da ,haen  3  itri ,glAV k aen,ageiru a^arrHpjUarar h  2  ,haend ak^nu 3  3igen  ba,lun sga^iala imA fan  3  3  3  3  h  h  h  3  3  h  2  3  1  h  3  k a,nu h  3  3 3  a,den ba,lun t a ni na h  3  1  3  tiriAspan  h  2  3  1  3  Target 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  ak^nu  a,den ba,lun ada^iswa ,mA fan  3  2  3  68  ,p ik ,dag ,k oum ,feis ^ei^sez ik a firj isup h  Initial  Follow-Up  Assessment iP it idad  Assessment iP it idad i^oun ifeis ifeis it a fin  h  h  h  3  itfer ,hors tziabra  Jert !vest  ^eis ^ei^sez ik a fin Jup ,t ea ihas izi ba Jet h  3  h  3  h  h  3  isup itfea  ,has izi ba Jit 3  !WEf ^aisVin  ibes  ,d3ae kit ibitf  ,dae di ibitf  ^aeakit ,bitf  ^aatjir) ^Amp ,k a3tj"  ^aa/in  ,wa J"in  ^Amp  ,d3Amp  it aej  ik aets ibaeg ibigdsaz  ^aisVirj 3  h  ibaeg ,bn d3az ,lif ,rae bit 3  3  ^arabids  i0irj ^auO ,61s ^rAa&ar ,glae siz Jdf i9au zand ^laeriatirj !Wis par 3  3  3  h  !beit . ^v/i^ez  ijif iWaeaVit ^Oabldj  ,dai vin 3  3  h  !Wif ^aeabit  ^in  ,ga bid i6ir)  ^aut  imaut  ,dis  ,6is  tbAara  igae siz Jef 3  ^auszan  h  3  ^Aada ^aeaSiz  Jef Jauazan iP^riatin  iski ,sil spei Jip ,blu iP i kal  ^aeriatin ^I^va /AJ ,sti ,sil ^peijip ,bu iP i te  ,spul  !Stua  iP I tlS ,stul  ^raesgan  ,dai dan  ,dr3e dan  3  ikrAj  1  2  h  3  h  3  3  ^ISapa  JAJ !Stit  ,sil ^peijip ,bu h  3  3  Subject 5  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  Profile Initial Assessment  Follow-Up Assessment  iP ig ,t ou t ouz ,t Ab  iP i: !t OU ,t ou ,t ou  iP ig ,t ou !t OUZ ,t Ab  ,dAk  ,gae:  igAk  h  h  h  h  h  h  h  h  1  h  h  h  h  itna mi  ima mi  ijard  ija  !dad  igAm  igAm  igAm  !nouz  ,nou  inous  ifij ifi Jirj  ,P i iP i ?i"  ,fis  tsoup  !hou  wx sa\  ,wi ?a wa  3  3  h  h  3  3  3  !haus ,zi per  3  ,hou  iP i ?a !hu !ba" t i,vi h  3  3  J u  ween t i,vi h  2  2  h  2  ifi ?in Joup 3  ^ i j o a ,haus  ivi ?a 3  t i,vi ,ki ka ni h  2  ttfiaken ,watj ,wa tf9z ^aem  ,ki ka" ,woi  !k eid3  ^ei  ,buk  !bu  !k eiz !buk  ,p ei d3ez  iP ei  1  ,laef  ^OU  ^ban ,0Am  ^iaba ,tsou  3  h  h  3  /ie  !wa ?a 3  ^38""  3  iStar ,slaid ,swi mirj 3  ,kwin ^reszant itri ^IAV k aerj gairu h  3  h  a^am^jusrar ihaand  3  k a!nu a,g£n  3  bailun  aga^igla imAafan  ,wats ,wa tsiz ^aem 3  p eiz ,?aef ^isban lS33m  ,t is h  ,daet  p 33 7a iga ,lai H  3  1  ,bi ?i 3  iki iP s ?a h  3  ,t i ,gou g3e~ ?33iwu h  3  if e tea 3  idoe !laid ,fi mirj 3  ,k in ^weaTant ^ia h  igAb  k 39" ?a wu ,fu ta ^aend 3k a!nu h  3  2  3  i\as~ 3  k a!nua  3  3ige"  h  3  3  h  ,t i ,d33  2  3  h  h  ,6aet ,fe 6ar  2  3  h  ilu 3  47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  h  3  3  iga ?a:  1  Target  3  aigen  ba,lun ga l9 3  iiDAsfan  69  IPE Level 2 Initial Follow-Up Assessment Assessment  iP ik  iP i  iP ik  idag  ik oum  !da k oum  ,dag ,t oum  ifeis ^eissaz  ,fei ,bei ?a  jeis  ,k a fir] isup ,tj£r  ik a ?i !t £  J e a  nhors  !hor  !zi bra Jart  i?i b£  ,V£St ^aiaVirj ^SSBaklt ibitj  ib£  ^os i?i wr !sat !V£S  ,d3Amp  idAtn  ,k 39tf ibaeg ^riadsaz  !k ae ,be  ibi 7a  ^aets ibaeg ^n^kes  ilif  ill  ilif  ^aeabit  iWaesba  ^aesbit  ,gar bid3 ,9ir]  igar ba  iga biz  itir] ,rri3u  isin  ,6is !brA 6ar  ,di  ,dis  ,bA ?8  ^A 3 t £ 3  ,glae siz  igae ?a ^E'  ^ae^is ,h£lf iSSUssan injaeriatin ^i^Ea !k AS  h  h  h  h  h  3  3  h  3  ,m3u9 3  3  Jelf  !9au zand 3  ^laeristirj ^iSspar  h  h  1  3  3  k a fin h  1  3  3  isup h  3  3  !h£r ,dai ?i" ,gae ?a 3  ,dai vin  3  idzaeskit  ,bi iWa  ,bits  h  3  3  3  3  1  3  3  ^ausha" ,lae" ti" 3  iwi pa 3  ,k A  ikrAj"  ife s9z  h  mau9  h  h  ,ski  igi  ^il spei /ip  ,hil  ,bei p i  ,sio spei piis  !blu  ilu  ,blu  1  2  h  2  1  2  iP i kal  iP i kal  ^igkoa  ,spul  !bu ?a  ^raesgan  ^aeaga"  ibua ^se^an  h  3  h  3  3  Subject 6  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  iP ig /ou  Profile Initial Assessment ,p ed  iP id  ,t ou  / O U  h  h  h  h  / o u z  Follow-Up  /outs  t ous h  1  Ab ,dAk ima mi  ,t Ab  ,t Ab  ,dAt  ,dAt  ,jard  ,djad  igAm  ,dAm  ijats ^AITI  !nouz  !noud  ^outs  ifi; ifiajin,  ifitj fiitfirj  ifltj ifi tfin  ,soup  ,soup  iSOUp  3  h  h  ima mi 3  3  h  ,wi sel  3  ,wi tsoa  3  3  ,haus  ihaut  ^auts  iZi per Ju ^aen t iiVi ,tfi kan  idi po  ^diapo  Ju ,waen t i,di ^Jiadan  Ju ,waen tsi,di itfi tan  walS  ^ a t j  ,watj  iwa tfad ^aem ,t eid3  twa^t/ad ,d3aem ,tjeid3  ,but  ,but  3  h  2  3  3  h  2  3  ^aem ,k eid3 h  ,buk  h  2  3  ,laef ^ban ^Am ,t i9 ,6aet  ^aet  !star  !StD  iP eid3 ,laet ,wi ban ,SAIII /i tad ,daet ^doa ,tsaa  ,slaid  ,sai  iSaid  iswi mir]  ,fi min.  femin.  ^win  /in  !tsin  p ei d38z h  1  3  p ei d3ad h  1  3  11  iWi ben 3  jAm ,t i tad ,daet ife ro  h  h  3  h  3  3  ^re^ant itri  3  p e dan  aga^iala  ^T^Wa  ^Asfan  tmAatan  1  3  3  ,tsi  3  h  h  ,dzAds  t ae naiwu iP u do ^aen k a,nu 3iden ,bun  3  p e dant  h  ,tsi  k aer) gairu a^am^jusrar ^aend k a nu aigen ba,lun 3  3  1  ,tAd  2  3  3  iglAV h  h  h  1  h  2  3  h  3  h  3 3  Target  Assessment  ztsaenada^u  atfopjugdos ,haend t a nu a,d en ba,dun da,di wa ,mA tin  47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  h  3  1  3  3 3  3  3  70  IPE Level 2 Initial Follow-Up Assessment Assessment  iP ik idag ,k oum ,feis ,fei saz ik a fin isup itfer ihors ,zi bra Jart ,vest idax vir)  ,p it  ,dai dit  ,dai din  ^aeakit  ,d3ae tit  ^aeatit  ibitf ^aatfirj  ibitf  ibitf  ^ A m p  ^ A m p  id3Amp  ts etj !baeid ^i^ad ,dit ,wae bit  /aetj"  h  h  3  h  3  3  3  h  ,dat  iP it idads h  h  h  it oum ,feit ifei ta /a/in. Jup  / o u m  itfee  itfeo  ,hot ,di ba Jot  ^ots  ,vet  , v et  h  ifeits ifei tsaz ,t a tin. Jup  3  3  h  3  izi ba Jot  3  3  3  2  3  ,wa ti"  ^dstin.  3  n  ibaeg ,bn d3az T 1 if ^Be^it ^arabids iSirj ^auO ,6is 3  3  ,baed  ,bi d3az 3  !dit ^aesbit  ,da bid3  ^cbbids  iSins  iSirj  ^auf" idH  imaut  3  idis ibA doa  h  ,brA 6ar  ,bA dou  ^laeaSiz  ,dae \i6  tdaeatsiz  i/elt  Jelt  3  Jelf i6au zand p\een tir)  3  3  h  3  h  h  !fau dand ^as^tin  ^auazan  tWiSapar  ,wi pou  ,WI tS0  ikrAj  itSAtf  ,sil  ,t At; isdi isi  ^peiz/ip  ^eizjip  ,blu iP i kal ,spul ^raesgan  ibu  3  3  iski  h  3  3  3  h  ,p i tal ,bu' h  3  ^aeiadan  p aen tir| h  1  3  3  id3i iS„i o 3  ibei^tfip ,bu iP i tal !bul ,d3ae dan h  3  3  Subject 7  Target  Profile Initial Assessment  Follow-Up Assessment  Target  IPE Level 2 Follow-Up Initial Assessment Assessment  iP ig ,t o:  47  iP ik  iP ik  iP ik  48  ,dag  idag  idag  ,t ous  49  ,k oum  1  ,t Ab  !t Ab  50  ^eis  idei  ,dAk  idAk  51  ifeissez  ,dei d3  imaaini  ima mi  52  ^aafirj  7  ima^ini ijard  ,jart  ijad  53  ,sup  idup  isup  8  igAm  igAm  igAm  54  ,tfer  ^Jew  itfee  9  ,nouz  ,nouz  inouz  55  !hors  ,hot  ihors  10  ifi;  ifij  56  izi bre  11  ifi jin  ifi Jit]  57  ,det  Jot  12  !SOUp  !SOUp  !SOUp  58  iZ\ bra Jsrt nvest  ,di ba3  ifi Jirj  ifij  13  ,wi sal  ,WI S9l  ^issal  59  ,dai virj  !dai virj  ,d3i virj  14  ^aus  nhaus  ,haus  60  ,d3ae kit  ^aeakit  ^aegki?  15  izi psr  iZi par  isi par  61  ibitf  ,bit  ibitj  16  Ju  iwa tj"ir)  ,wa ti  iwa tjirj  ,vaen  Ju ^aen  62  17  Ju ,baen  63  ,d3Amp  idap  id3Amp  18  atVi  t i bi  19  itfiakan  20  ,wat  1  ip ig  2  !t OU  /ou  3  /ouz  1  4  ,t Ab  5  ^Ak  6  ip ig  h  h  h  h  h  t ous  h  h  h  h  3  3  3  h  3  3  3  3  3  3  t i,bi  r  21  3  3  3  k oum h  h  1  ifeis 3  ifeis k a firj h  1  3  !b3  3  3  ,b£S 3  3  3  3  64  ,k a5tj"  1  65  ibaeg  ibaeg  ibaeg  iwatf nwatj  66  ^riadsez  ibi d3  67  ,lif  ,wif  ibnd3 ilif  h  2  ^Ji^an ,watj iwatj  k oum  h  3  h  ,tfi kan  h  2  h  h  n  3  h  k ae to h  3  3  ,k aetf h  22  ^aem  ,rae brt  ,k eid3  ,k eid3  ,d3aea ,k eid3  68  23  69  ^argbids  ,dar bi  ^arabicfc  ,buk  idirj  h  h  h  !rae bi?  3  3  3  24  ,buk  !buk  70  i9irj  25  ,p ei d38z  ,p ei d3az  iP eid3  71  nmauO  imau  ifin ^auf  26  ,laef  ,la3  jase  72  ^IS  iri ben  iir b3n  nITaben  73  ,6is ,brA 63r  ,diz  27  ibo d3  !bWA d3  28  ,9Am  ,fAm  ifAin  74  ,glae siz  igae di  ,glae siz  29  ,t if  /it  75  Jelf  ,del  J3lf  ^33 ^ e da  ndae?  76  ^ a u ^ e n d  ^auaden  ^auszand  31  ,t i9 ,6aet ^ e 58r  ,fe dar  77  ,plaen tirj  ^aeristin  ^laeriatirj  32  !Star  iStar  iStar  78  ,wis p3r  ^iSapar  33  ,slaid  iSlaid  ,slaid  iwi pe  79  ikrAj"  ,k At  ,kWAj  34  ^wistnirj  ,swi min  80  ,ski  isi  ,ski  35  ikwin  ,kwin  ,k in  81  ,sil  /il  36  ,pr£ zent  ,pw£ zan  82  37  itri  !twi  ^re^ant itri  83  ,blu  38  iglAv  ^IAV  iglAv  84  iP i k3l  39  a^aerjagatru  ^aerbga^u  k aerj g3iru  85  ,spul  40  ^arrHpjUsrar  3  sk^rrhpjuarer  86  ,drae g3n  41  ,haend  ihaens  42  3  43  3  44  3  45  ag^ixjla  igra la  46  imAsfen  (triAsfn  30  h  3  3  h  3  3  k 8inu  h  3  3  h  3  3  3  h  3  k am,pju rar h  3  k a!nu h  h  8igen ba,lun  h  3  igein 3  bailun  h  2  3  ^aend  ak^nu 3igen 3  sbejun  3  ^A^an  71  3  3  3  3  3  3  3  h  2  ibu 3  ^eisj.bij"  ,blu  iP i k3l lP U d3l idai go h  3  ,p i kal h  3  3  ,spua  3  idraeagan  h  3  3  ,sil  ibei dip h  3  Subject 8  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  Profile Initial Assessment  Follow-Up Assessment 47  ip ig ,t ou /ouz A b ,dAk  iP ig /oua ,t ouz A b  iP ig  idAg  idAk  ima mi ijard  ^Aatni ijard  ,ma mi ,jad  ,gAm  igAm  igAm  !nouz  inouz  ifi/ ifiajin. ,soup iWI sal !haus izi per  ifiji ifijin  inous if es  h  h  h  3  /ou  t ous ,t Ab.  h  ,d339m ,k eid3 ,buk ,p ei d39z Jaef ^iaban ,0Am ,t i9 ,633t ,f e Sar ,star ,slaid ^w^rmr] ,kwin ^re^ant ,tri iglAV ^aerfega^u k arriipju rar ,haend ak^nu h  h  3  h  3  h  3  9 i g en aba^un ga,n la 3  ^A^an  h  3  53 54 55 56 57  fesm ,soup ,wi sod ihaus izi par 1ZU  58 59 60 61  3  iZI pa ,su ^ae" swiibi ^iakan ,wats !wats tdzaem ,k eit ,buk p ei daz ,laef ,wi ban ,fAm /is ^aet . ,fe da isa isaid ^wistnin 2  2  3  h  3  Ju ,vaen t iiVi ^/i^kar) ^atf  3  h  ^IaSal !haus  3  48 49 50 51 52  1  iSOUp  3  3  h  h  Target  3  62 63 64  ,van t hvi ,tsi kan !was h  2  iP ik ,dag ,k oum ^eis ^eiasaz ik a firj isup ,tfer  IPE Level 2 Initial Follow-Up Assessment Assessment p ik"'  iP ik  ida gi ,k oum  idag ,k oum ,feis  h  h  h  1  3  h  if eis ^eiasaz ,k a fit  h  h  itSE  ifei saz k a fin isup ^sea  ^ors !zi bra Jart ,v£st idaiaVirj ^aeakit ibitf ^Oatfirj ,d3Amp ,k aetf ibaeg ^riadsaz ,lif !rae bit ^arsbids  ,hors izi ba  ihos ,zi bwa  ^at ,v est  ,sut ,vss ^aisVin  i9in ,mau0 ,61s !brA 6ar ^laeasiz ijelf ,9au zand tplaeriatirj  iSirj ^auf !dis ,bA ra ,d3e siz !self ^auazan ipae tin  h  3  3  h  h  3  isup  3  ^a^vm ^aeakit ibitj iwa tsin ^ZAimp ^aets ibaeg ibidz 3  3  h  1  3  3  ^ae^if ^its ^a^sm ,dzAmp ik aets ibaeg ^wisdzaz h  ^c^tses ^aem ,k eidz !buk p ei dzaz !laef !Wi bi ifAm /if ,dae ife du  65 66 67 68 69 70 71 72 73 74 75 76 77  ^ta^a islaid ^WlalTlin  78 79 80  !Wis par ikrAj !ski  ,wis pa ,kWAS iski  ,wis pu ,kWAS ^ki  ,kwin ^eszant  ikwin ^wEgZan  itswi  itswi iglAV  81 82 83 84  ,sil ^pei^sip ,blu iP i kal  isil ^pei^sip iblu ,p i koa  85  ,sil ,spei Jip ,blu iP i kal !spul  ,spua'  86  idrae gan  ,sul ^weiagan  h  h  h  3  1  3  3  ,gAV  k irj gaiwu h  2  3  t a pu ra ,haend ak^nu aigen h  3  1  3  3  ba,lun agaiWiala ^Asfin 3  3  h  h  3  1  3  3  kaen ga wu iP u ru ihaend ak^nu 3  2  1  h  3  ,gen ,blun gaiWi la 3  3  imA fan 3  72  3  3  3  3  2  h  3  3  ilif ,wae bit ,gar bidz 3  3  3  3  3  3  h  3  ^aeabit ida bidz i9in ^auf !dis !bA du iglae siz 3  3  3  iSElf  ^auazand ^laeristin 3  h  3  ,dzwae gan 3  Subject 9 Profile Initial Assessment  Follow-Up Assessment  iP ig  iP id  /ou  /ou  iP ig  /ouz /Ab ^Ak  /ous  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  h  h  h  /ou /oud  lP AP ima mi  /Ab idAk ^asmi  .wad  !?ad  h  ,dAt 3  ijard  idAm  igAtn !nouz  igAm ,noud ,dit  inou  ifij  ifij  ifisjirj !SOUp .WIsSal ,haus ,zi par  ifi Jm Joup  Ju .vaen  Ju .vaen hi di .ti^an  3  t i,vi h  2  tWOstfaz  ,d3aem ,k eid3 h  ,buk  p ei d3az ,laef h  3  1  it oup .wiatoa ,haut h  .WI^O .haus iSi pa  idi pu ,diu ,daen t i/i it i kan 3  3  h  1  2  .watj  .di^tm  3  2  h  3  .bwat pasted ,daea~ ,k eid ,buk  iwatj .wastfaz .daem  it eid3 ,but ,p eid3 h  h  ,p ei dad  h  h  3  .waea  ,0Am  .waef !Wi ban ,SAITI  /ie  /it  ,t it  .Saet ,f e oar .star  ,daet .fesda  ,dae  ,sta  ,dE du .daa  ,slaid  .saia  .daid  ,swi mirj ^win  .si^mm /in  .prEszant  ,p e zan  ,tri  /i  .di^mm ,k in !P e dant /i  ,ri ban 3  3  3  ,glAV  k aer) geiru h  2  3  ^arrHpjUsrar ihaend k a!nu 3  h  9igen b9ilun gein la imA fan  3  3  3  3  3  ,wi ban  3  3  idAm h  3  h  h  h  3  3  ,bAV k aen da wu  igAd  iP i da  iP u d„oa  .haent  ,haen  h  2  3  1  h  3  k a,nu ^ d en  h  3  3  k ae,nu e,g£n  3  biibun  h  3  sba^un  t aini na ^A^an h  3  3  Target 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  h  3  ga,wi lae .mA^in 3  3  73  IPE Level 2 Initial Follow-Up Assessment Assessment  iP ik idag ,k oum  iP it  .dad ,p oum  iP it idag ik oum  ifeis  .feis  .deit  ifei saz ,k a fi0 ,sup  !fei saz ik a fin Jup /ea ihas izi ba Jet  .dei tad .k a tin idup /ea .hot .di bwa  .WEf  .d£t  h  h  3  h  3  itfer ,hors .z^bra  Jart !vest i6ai vir) ^saeskit ibitf ,wa tj"irj ,d3Amp 3  3  ^aetf  h  h  h  3  h  3  3  .bai^m !dae di ibitf 3  ,wa Jm 3  ,bAmp it aej ,beit  ,lif ^aeabit  ,bwi d3az ijif 3  .waesVit  ,gar bid3 iQiQ ,mau0 i6is  ,ba bid3 .fin  .brAg&ar ^laeasiz  ,bA ra  3  Jelf .Gau^and iplaen tir) ,wis par 3  3  ikrAj" ,ski iSil 2  h  3  3  3  3  3  /ut  .dai vm 3  .dae kit bit 3  n  iwa tin 3  ,dAmp  ,k aet ibaeg .bi dad h  3  .wid  .wae bit 3  .da bld tin 3  n  ,maut  .maut  idis  idi ,bA du  3  ,gae siz Jef .sau zan iP aen tin .WI va lt Aj 3  3  h  3  3  h  ispei Jip ,blu iP i kal ispul ,drae gan  3  h  h  h  ibeeg .br^ez  h  iSti iSil .speijip  ,bu iP i ta .stua .dai dan h  3  3  3  .gaeadia  .del .dau zan 3  iP aen tin wi p a .k aet igi h  3  h  1  3  h  idil  bei dip .bu ,p i koa .bul idae dan 2  1  h  3  3  Subject 10  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  Profile Initial Assessment iP ig ,t OU /ouz /Ab idAk  ip ig ,t ou t ouz /AD  iP ig /ou ,t ouz  h  h  h  h  h  h  1  Follow-Up Assessment h  /Ab  ima mi ijard  jar  idAk itnaami ijard  igAm  ,gAm  ,gAm  ,nouz ifij ifl JlQ.  inouz ifij ifi Jirj  ,zouz ifij ifi Jin  !SOUp  !S0Up  !S0Up ^IaSOU  ,dAk 3  3  3  ^I^al !hau0 idi pa ,su  !haus izi par Ju ,vaen t iivi ^Ji^an ^atj iwa tjez ,d333m !k eid3 3  zt^bi ^ken  ihaus izi par Ju iVaen t hvi /i kan  •* * * * * * * *  * * * * * * * *  3  3  ween  h  2  3  h  ,buk  p ei d3az ,1331 ,n ban h  1  3  3  3  ^Atn  /ie ,633t  h  2  3  ifAm /is ^aet ife da ^tar islaid  ,fAm  itwjn ,p e z3n ,twi  /if ,dae if£ da iStar iSaid" iSwiatnin ikwin ,p £ zan ,twi  igwAV  ,gwAV  k ae ga wu ipa ?ar nhaend k Binu  k 3e ga wu iPJu rar ihaen  3  !Star !slaid ^wiamirj !kwin ,pre z3nt itri ^IAV k 33rj gairu k arriipju rar ^aend ak^nu aigen b3,lun age^iala imA f3n 3  h  3  2  h  3  3  3 3  3  3  1  h  3  h  3  2  3  h  3  3  3igen  ,bwu igwi la ^A^id 3  1  h  3  h  _  3  2  1  3  Target 47 48 49 50 51 52 . 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  iP ik idag k oum  IPE Level 2 Initial Follow-Up Assessment Assessment iP ik idag ,k ou ifeis ifeiasaz ,k a fin ,sup ,t £r ,hors !zi bwa Jert  iP ik idag ,k ou ifeis ifei saz ik a firj isup itfer ihors ,zi bwa Jar  !VES  ,VES  ^aeakit ibitf ,wa trirj  idsiavirj idaeakit ibij ,wa Jin  idai vin ^ae-jkit ibit;  ,d3Amp  ,dAmp  ,dzAmp  k aetT ibaeg ibrigdssz ,lif iraeabit ,gar bid3 iQirj tmsuG ,6is ibrAa&ar iglaessiz Jelf i9au zand iplaen tirj iWis par ikrAj ,ski iSil ispei Jip ,blu iP i kal ,spul ,drae gan  ,k aet ibaeg !bnd ilif ^aesbit ,gar bid i9lQ ,mauf ,6is ,bA ra ^laessiz Jelf ^auazan ipaen tin ,wis par ikrAj" ,ski ,sil ispeis ,blu iP i kal ,spul idrae gan  ik Ej  h  h  1  jeis  ifei saz ^aafirj isup ,tj£r thors tzi bra Jert !V£St 3  3  idaiaVirj  3  h  1  3  3  3  3  2  h  3  3  h  h  h  3  h  3  h  h  3  h  3  3  3  3  h  3  3  3  3  h  3  3  h  ibaeg ,bwi 33Z twif ^ae^st iga bid ifirj imauf 3  3  ,VIS  !bA dar igwae siz 3  3  j£f  ,fau zan ,pwaen tin 3  3  iWISspU ^WAJ"  iski ,siou ispeizjip  ,bu iP i kA tspuou idwaeagan h  3  ak^nu  ,g£n ,bun ,gwi wae 3  itriA f £n 3  * Both video and audio recordings o f these words failed. P C M and % P C M scores were adjusted accordingly.  74  Subject 11  Target 1 2 3 4 5. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  Profile Initial Assessment  Follow-Up Assessment  iP id  ,p ik  /ou ,t ouz /AD  /out /out  /ou /ouz  /Ab  /Ab  ,dAk .maaimi ijard ,gAm  ,dAt  ,dAk  mam ,lad  ^Osmi ijad igAm  iP ig  h  h  h  h  t  ,dAm  h  h  .nouz ifij ifi Jirj  inout ,fie  inouz  3  ifijin  ,fis ifi sin  ,soup  J'oup  ^'oup  !Wi tal  ^IgS'OU  ^aus idi pa Ju  ^aus idi pa ,su  ,vaen t hvi  ,vaen /hvi  itfi tan  ^^kan  !wat !wat  ^ats'  3  3  !haus  iZi par Ju 3  .vaen t i,vi itji ken ,watf ^agtfsz h  2  3  3  3  h  2  3  ^a^az ^aem  h  ^aem ^eids  /eid  /eid'  ,buk ,p ei d3az  !but  ,but  p eid Jaef ^aswan ifAm  ,p ai d3Z ,laef ^isban ^Am ^is'  h  3  ,laef  ^ban .OAITI /i9 ^aet  h  1  /i0 3  ,slaid .swismirj .kwin .preazent  itri ^IAV  !Slaid  h'in ip ae nat i9'i  1  h  3  ag^riala  ^A^an  ^Asfin  3  ^aend ak^nu 8igen ba,lun 3 3  h  2  ,dar iS'laid ^^min ^win ^WEsdant  itri iglAb  k aerj wu ipu ro ^aen t ainu aid£n iblun ili la  h  3  3  iglAV  k 3erj gBiru sk^rrHpjUsrar  2  h  ,d„ae ifs du  ,daet  if£ ro ida  .star  h  1  3  h  3  3  3  k aet] ?a ru p u dar ,haen sk^nu h  2  3  h  1  3  1  Target 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  igen tblun  ^ri^ae ^Asfan  75  iP ik idag  IPE Level 2 Initial Follow-Up Assessment Assessment iP it  h  ik oum h  h  1  ,feis  jei  ifei s3z  .teased it a fir) Jup J'ea ihoas  3  ik a firj h  3  ,sup itfsr  ihors !zi bra Jart  h  3  1  ,zi baa ikjart  3  iP ik idag h  h  ,dad t oum  3  ,k oun h  ifeis ^eiasaz k a fin h  1  3  is'up 1S er ihors ,dzi bwae Jert 1  3  !V£St  .bet  idai virj ,d3ae kit  .daisVirj  ibitf ^Oatfirj ^Amp i^aetf  ibitf ,wa tirj ,dAmp  ibits  /aet .baed  /aets ibaeg ^m^das' Jif  3  3  ibaeg ,bn d33z ,lif 3  ^aeabit ^arsbids  i6irj ^auO ,6is ibrA 6sr ,glae siz j£lf i6au zand  ,dae dit 3  !VES ^aisVin ^zaeatit  3  ,bid  ilif !wae bit !da bid 3  3  ^'in  tinau ,6is  ,dZAmp  ^ae^n  .da^bis' ^in ,mauf  !diae did  ,dis ,brA dar ,glae siz  p\3en \iq  j£l ^ausdant ,plaen ?in  ^auazan .plaeriatin  ^iSaper  iwi pa  ^iapar  ikrAj  ,kA  ,drAs'  iski ,sil ,spei Jip ,blu iP i k3l ,spul  /i  igi ,sil  3  3  3  3  2  h  3  ^raeagsn  ,bA ra  3  3  3  3  3  J'il ^eizjip  bairo iP i to ,bo ,d3ae dan  3  h  3  3  3  ^eij'ip  !blou ,p i tou !buou ^waeadan h  3  Subject 12 Profile Initial Assessment  Follow-Up Assessment  ip ig /ou /ouz  iP i di lt 0U /ou  iP id„ /OU lt OU  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  h  h  3  h  h  /Ab  / A d  / A V  !dAd  ,dAt  tmasmi ijard  imam  ,gAm  idAm !nou  ima mi ijad idAm ^ouf 3  ija  ,nouz  47  h  ^Ak  ifit ifi tin  ,haus izi par  ifi ifi ti Jou ^I^O ihau ,vi d9  Ju ivaen zt^vi  Ju ^aen t iidi  $i kan  it i ta /at /at ,s aem /ei !bu p ei da ^ae ^iada  Ju ^aen t iibi /i dia ^ae: ,wae t3 tdaem ,t ei  ifij ifi Jin !S0UP 3  3  3  3  h  3  3  h  h  1  3  ,t ie ,Saet h  h  /a /si isi ni  tri ,glAV z^aerjage^u k 3m,pju r3r ^aend jik^nu a3igen aba^un aga^iala ^Aafan  ttwi  3  /i"  iP e da h  3  h  3  3  3  h  /i  !Star ,slaid ^wismirj ^win ,pre zant n  3  /i  3  3  3  ^An  3  h  3  3  ibut„ p ei da ^ae: ,WL bZ ,fAm  h  1  ,dae iP e da  jt &ar  Joup ,wi tou ihau izi paa  2  h  ^atf ,wa tj8z ^aem ,k eid3 ,buk p ei d38z ,laef  3  h  2  3  ,dA  t ei na,wu h  2  3  p ei do ^aem ainu h  h  3  1  3  !dae ife ba ,t ad ^'ai ^IalTlin itwin ,pw£ de 3  h  3  ,twi ,dwAb t En da,wu h  3  2  iwa da  iP i dou ^aen t 3!nu ^en ,bwu d3,wi rA  ^AstS  ^ A ^ I  3  1  3  a,d£n ,bun 3  3  Target  j  3  48 49 50 51 52 53 54 55 56 57 58 59 60 61  h  3  ,k a fin isup h  3  itf er ihors !Zi br3 Jert ^est ,d3i vir) ,d33e kit ibitj 3  3  3  62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77  wa \[iq  78 79 80 81 82  iWis p3r ikrA/ ,ski ,sil ,spei Jip  83 84 85 86  ,blu iP i k3l !spul  h  3  3  iP ik idag ^oum ,feis ,fei s3z  3  76  3  id3Amp k aetf ibaeg ,bn d33z h  1  3  ilif ,rae bit ,gar bid3 3  3  10IQ  ^auQ  ,61s ^rAa&sr ^lae^iz Jelf ,Gau z3nd ^laeriatirj 3  3  2  h  3  ^raeagsn  IPE Level 2 Initial Follow-Up Assessment Assessment iP it ida ,t ou ,fei ,fei ,t a ti h  h  h  3  Ju itSE iho iti ba iSO 3  ,fe ,dae di it ae di ibi ,wa ti ihSAin /ae ibae ,bi d3 3  h  3  3  3  ibi ,wae da ^dc^de iflQ ^au ,di 3  ^A^g  /ae d9 itje ,fau da ^ae'ati" lWI d3 3  1  3  3  / A  /i  iP i idad /oun ^ei ifei t £ it a bi • ,(3Up ,tS'E3 ,hot iPi bae h  h  3  h  3  3  iP'3t 1VE  !dai bi ^iaesdi ibit ,wa ti ,dAm /aet ibei ,bwi d£ ,wi iWaesbi ^Ogbl ifin ,mauf idi ,bWA d3 ,dwae d3 3  3  3  3  3  j£ ^ au d E ,pwae ti lWI t£ !tWA w  3  3  3  /i  iSi do ,peizjit ,bu 3  ,p i tal iP u ^Jaegdsn h  3  h  !Siou ,p ei ;i ,bwu ^IatOU p u dou idwaegd E h  2  h  1  3  Subject 13  Target 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46  Profile Initial Assessment  Follow-Up Assessment  ip ig /ou /ouz /AD ,dAk ima mi ijard igAm ,nouz  iP ig /ou /ous ,t Ab ,dAp ima mi ijard igAm !nous  iP ik ,t ou /oUS /Ab idAk ima mi ijad igAm !nouz  ifij ifi J"irj ^oup ,wi sal ,haus iZi psr  ifej ,fi Jin ,6oup ,wi 9al ^auO izi par  Ju ^aen t i,vi ,tfi kan iwatf  Ju ^aen tsi,vi ,tfi kan .watf ,watf ^aem ,k eid ,buk p ei d3ad ,laef ,wi ban ifAm /if  ifij ,fi fin iSOUp lWI SOU !hau izi p3r Ju ,vaen t ei,vi Ji k3n iwatf ^Ost/SZ id3aem ik eidz ,buk ^^iadsaz ^'aef ,wi ban ^AITI /if  3  3  h  2  3  ,k eid3 ,buk ,p ei d3az h  h  3  ll33f  ,n ban ,0Am /i0 ^aet ife 6ar istar ,slaid ^wismirj ,kwin ,pre zant itri iglAV k aerj gairu a^arritpjusrar ,haend k a,nu aig en ba,lun ga,n la ^A^an 3  3  3  h  3  h  3  3  3  3  2  3  h  h  3  1  3  h  2  3  h  3  ^33  !fA var !sar ,sai ^vismirj ,k in ,p e zan itTri ,gAV k aer] ga,wu lPJU d3 ihsen ak^nu 3  h  h  3  h  3  2  3  3  3  3  3  3  3  3  3  3  3  3  3  h  h  3  2  h  h  h  3ig3n  3  2  3  h  3  3  2  47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86  h  3  3  b3iwun g3,wi b3 ilTlAsfsn  3  ife far idzar ,slaid ^ m i n ,ka win ,pre zan ,dri ^IAV k aen gairu ^^m^juadar ,haend k a,nu  Target  3 i g en  abA^un ga,wi wA ^Asfsn 3  3  77  ,p ik idag ,k oum h  h  ^SIsSSZ ,k a firj ,sup h  3  itfer !hors !zi bra Jart ,v est idai virj ^aegkit ibitf ,wa tfir] ^Amp ,k aetf ibaeg ,btr d3az 3  3  3  IPE Level 2 Follow-Up Initial Assessment Assessment iP ik idag !k ou" ^eis ,feis k a fin !tsup itfer ihars ,zi bwa Jart ,ves ^aiaVin ,d33eakit ibitf ,wa tfir)  iP i idag ,k oum ^eis ,fei sad ,k a fin isup itf ea !hers ^iabae Jort ,V£S ^aiaVin ^aeakit ibitf ^Oatfin  i3Amp  id3Amp ,k aetf ibag ^riadsaz  h  h  h  1  3  3  3  3  3  3  ,9ir) ,mau9  ,6is ,brA 6ar !glae siz Jelf ^auszand .plaeriatirj ^iSapar ikrAj" iski ,sil ispei Jip ,blu iP i kal ,spul ,drae gan 3  3  2  h  3  3  h  3  h  3  h  h  ilif ,rae bit ,gar bid3  h  ibaeg ,bir d3id !Wif ^ae^if ,gar bid3 ifirj ^auf ^IS ,bA var !gae siz Jelf ^auszan p aen tin ,wi psar ik Af itsi iSiO ipseijip ,bu 3  3  3  3  h  1  3  3  h  iP i ko iPSUl ^aeagah h  3  ilif ^aesbit ^arsbids ,firj ^auf .dis ,brA var ^laeasiz Jelf ^auazan ^laeristen ^iapar ikrAf ,tsi .siou .psei^fip ,blu p i kou ,psuou 3  h  1  3  idrae g3n 3  Appendix B: Summary of CAPES measures PWM  PCM  GainPCM  GainPWM  76.74  9.04  10.46  74.42  82.56  24.51  8.14  79.9  68.24  81.4  15.08  13.16  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  Time 1  Time 2  1  69.85  78.89  66.28  2  52.76  77.27  3  64.82  4  Child  Time 1  Time 2  78  Appendix C: Parent S P A A - 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 S P A A - C  Subject  Has your child's  Does your child get  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  Y Y 13 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  4/12  2/12  7  8  10  9  11  12  13  DNT 2/12  3/12  7/12  Rhyme Awareness Raw Score %ile Range  7/12  4/12  11/12 5/12  9/12  8/12 0/12  50-54 55-59 90-94 30-34 55-59 15-19 85-89 80-84 0-4  15-19 25-29 70-74  10/12 1/12  8/12  Syllable Segmentation Raw Score %ile Range  11/12 0/12  9/12  1/12  4/12  6/12  11/12 0/12  8/12  75-79 15-19 85-89 0-4  95-99 5-9  80-84 85-89 15-19  90-94 30-34 65-69  7/12  4/12  7/12  5/12  Alliteration Awareness Raw Score %ile Range  1/12  11/12 4/12  7/12  4/12  2/12  1/12  1/12  80-84 10-14 90-94 50-54 60-64 85-89 85-89 60-64 20-24  70-74 10-14 10-14  11/12 1/12  1/12  Sound Isolation Raw Score %ile Range  11/12 0/12  0/12  0/12  0/12  11/12 0/12  1/12  0/12  80-84 50-54 80-84 10-14 20-24 20-24 20-24 90-94 20-24  50-54 35-39 20-24  0/12  0/12  Sound Segmentation Raw Score %ile Range  0/12  4/12  0/12  0/12  0/12  0/12  0/12  0/12  0/12  0/12  20-24 40-44 80/84 20-24 40-44 40-44 40-44 40-44 40-44  70-74 25-29 40-44  27/32 3/32  4/32  Letter-to-Sound Knowledge Raw Score %ile Range  24/32 0/32  0/32  0/32  0/32  25/32 0/32  95-99 65-59 95-99 10-14 20-24 20-24 20/24 95-99 20-24  83  5/32 4/32  70-74 55-59 70-74  Appendix G: TOCS+ Raw T l data  1  2  3  4  5  6  Child 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 D N T 3.91 4.52  3.62  3.94 3.32  3.37  2 4.22 2.91 2.19 3.55 4.18  3.14 2.46  4.63  4  3 3.48 3.95 2.39 4.03 4.03 3.14 2.73 4.05 3.25 [ta] 1. 4.18 4.61 2.65 2.48 3.79 3.44 2.73 3.94 3.76 2 2.98 3.75  2.6 3.56. 4.35  3 3.85 3.81 2.42 4.29 [ka] 1. 3.76 2.95 2 2.98 3 [pataka] 1.  2.5  4.25  3.1  3.66 4.13 3.11 3.45 3.51 3.38 3.77 4.27 3.76 3.86  4.1 3.73  2.5 3.76 4.46 3.82 3.31 3.66 3.08  2.9  3.69 3.32  3.2  2.77  4.27  3.22  1.61 2.71 3.68 3.51 2.28 3.55 2.26  3.33  4.1  3.6  3.6 3.72  2 4.28  3.54 2.81  3  .4.11 3.02 2.84  4  3.66 2.55  4.1 3.05  3.43 3.25  3.8 4.33 2.75 3.08 2.84 3.57  2.53  2.9 3.21 2.49 4.9 4.28  4.18  3.46 3.62  3.72  3 4.26  3.86 1.75 3.68  3.47 2.33 3.97 2.89  3.49 4.21 2.65  4.29 2.91  4.43 3.86 3.86 4.13 4.68 3.93  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  84  2.74 3.93 3.24  3.66 4.21 3.51  Appendix H : TOCS+ Summary of T l and T2 MRRtri raw rate, consistency and accuracy Time 1  Child  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  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  DNT  *4/9 **2/6 Note. DNT = Did not test  85  Appendix I: Results of Child Development Index Gross and Fine Motor Tasks  Subtest  1  2  3  4  Participant 5 6 7  8  9  10  11  12  13  Gross Motor Raw Score Age Norm SD Fine Motor Raw Score Age Norm  29/3026/30 30/3 29/3 26/3 27/3 27/3 24/3 28/3 28/3 28/3 29/3029/30 0 0 0 0 0 0 0 0 0 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  0  0  0  0  -1.3  0  0  -1.5  0  0  0  0  0  -  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 0 .0 0 0 0 0 0 0 0 5;0*  4;3  5;0*  3;0  SD 0 0 0 >-2 Note.* Indicates a score at ceiling  4;4  3;3  4;4  4;0  3;3  2;10  4;9  N / A 3;3  0  -1.3  0  0  -1.5  -2  0  N / A -1.5  86  Appendix J: Results of PPVT-III (1997) Participant 1  ~2  3  4  5  6  7  8  9  10  Tl  12  13  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  Raw Score  Note. DNT = Did not test  87  

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