JCPSLP Vol 18 No. 1Mar 2016

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JCPSLP Volume 18, Number 1 2016 38
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
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.