JCPSLP Vol 18 No. 1Mar 2016

CL/P and to investigate the relationship between phonological awareness, and language skills, speech production, middle ear function, and velopharyngeal function. Although there was no significant relationship between phonological awareness and speech production, middle ear function, and velopharyngeal function for the children with CL/P in this study, the results of the regression analysis demonstrated marginal evidence for an association between phonological awareness and language skills in this sample of 5-year-old children with CL/P. This finding supports previous research, which has highlighted the relationship between phonological awareness and language skills in both children with and without CL/P (e.g., Chapman, 2011; Roth, Speece, & Schatschneider, 2002; Cooper, Farrar, Ashwell, & Maag, 2005; Hardin-Jones & Chapman, 2011). This important relationship between phonological awareness and language skills may be attributed to the nature of the underlying skills required for oral language development, including attending to the semantic, morphological, and syntactic components of the linguistic environment (Cooper et al., 2002). Phonological awareness also requires a child to attend to their linguistic environment, but at a different level, involving the sound units of language (Farrar et al., 2005). Wagensveld, van Alphen, Segers, and Verhoeven (2012) found children who have not received formal literacy instruction use both global and analytical strategies in phonological awareness tasks. As some of the children in the current study had not yet received any formal literacy instruction, this may have had an impact on their performance; thus further research is needed to explore the relationship between phonological awareness and language, with specific exploration of the different aspects of phonological awareness. The results of this study do not support the research hypotheses that speech production, velopharyngeal function, and middle ear function in children with CL/P would be related to phonological awareness. Findings regarding the relationship between speech production and phonological awareness skills in children with speech sound disorders (without CL/P) are inconsistent throughout the literature. Some research has highlighted the difficulties experienced by children with speech sound disorders in phonological awareness tasks, particularly rhyme awareness (e.g., Mann & Foy, 2007; Preston, Hull, & Edwards, 2013). In contrast, other research has found no direct relationship between speech production and phonological awareness skills (Rvachew & Grawburg, 2006). These differing results may be a reflection of the complexity of phonological awareness tasks, and the importance of other underlying skills required for speech production, such as speech perception, which have been found to be associated with phonological awareness skills. For example, Rvachew and Grawburg (2006) found a significant relationship between speech perception and phonological awareness skills in young children with speech sound disorders without CL/P. Speech perception involves the transformation of an auditory signal into meaningful linguistic units through the interpretation of acoustic-phonetic and phonological representations of words (Rvachew & Grawburg, 2006). Speech perception thus plays an important role in the development of both speech production and phonological awareness. Given the important relationship between speech perception and phonological awareness skills, it would be important to investigate the impact of speech perception in children with CL/P on phonological awareness in future studies.

In relation to middle ear function, previous research has suggested that the presence of otitis media and subsequent middle ear dysfunction children with CL/P significantly impacts academic development, including phonological awareness performance (Schonweiler, Schonweiler, & Schmelzeisen, 1994; Winksel, 2006). Due to the retrospective nature of this study, the way in which middle ear function was categorised may not have captured the true nature of the relationship between middle ear function, and phonological awareness in this population. Further, the current study used tympanometry as a single measure of participant’s middle ear function. Given children with CL/P are known to have fluctuating middle ear function from birth to 5 years (Zeisel & Roberts, 2003), this measure did not account for the long-term nature of their middle ear function. Given these findings, it is also not surprising that no significant relationship between phonological awareness and velopharyngeal function was detected. It is recommended that future research further examine the relationship between phonological awareness and hearing and middle ear function using a variety of measures. Although this study only had a small sample size, the finding that there was only marginal evidence of interrelationships between phonological awareness and language skills may also suggest that other factors, not explored in this study, may be contributing to poorer phonological awareness skills of children with CL/P. Neumann and Romanath (2012) recently identified a core set of codes from the WHO International Classification of Functioning, Disability and Health-Child and Youth Version (ICF-CY; WHO, 2007), relevant to the CL/P population. By producing this core set, Neumann and Romanath (2012) emphasised the importance of considering the impact of environmental and personal factors on children with CL/P, to assist clinicians in providing holistic clinical management to this population. Indeed, research has highlighted a range of environmental and personal factors that may influence the development of phonological awareness in both children with and without CL/P, including cognition and socioeconomic status (e.g., Froelich, Petermann, & Metz, 2013; McDowell, Lonigan, & Goldstein, 2007; Zhang et al., 2013). As previous literature has highlighted that children with CL/P may have differences in their cognitive functioning (Roberts, Mathias, &Wheaton, 2012) and socioeconomic status (Durning, Chestnutt, Morgan, & Nester, 2006) compared to children without CL/P, further investigation of the impact of personal and environmental factors on phonological awareness in the CL/P population is warranted. Given that these factors were not included in the current study, further investigation into the impact of these factors on phonological awareness in the CL/P population is required. Limitations and future directions This study provides preliminary evidence regarding the potential relationship between language skills and phonological awareness in children with CL/P. However, due to the retrospective nature of this study, limitations must be considered. This study included a small number of participants, which may have limited the statistical power of the analysis, and therefore may not reflect the true nature of the relationship between phonological awareness and language, speech, middle ear function, and velopharyngeal function. Due to the data in this study being collected as part of standard clinical care, there were a range of

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JCPSLP Volume 18, Number 1 2016

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