PERFORMANCE IN PHONOLOGICAL AWARENESS OF CHILDREN WITH PHONOLOGICAL DISORDER : COMPARISON OF TWO INSTRUMENTS

(1) Speech-Language Pathologist and Audiologist; Student of the Clinical and Educational Audiology specialization course at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo. (2) Speech-Language Pathologist and Audiologist; Master’s Degree Student in Biological Sciences (Genetics) by the Institute of Biosciences of Botucatu at the State University of São Paulo, IBB-UNESP, Botucatu – SP, Brazil. (3) Speech-Language Pathologist and Audiologist; Professor at IESB-Preve; Therapist at the Criarte Clinical and Education School, Bauru-SP, Brazil.  INTRODUCTION

is described by several authors.These models improve the capacity of letters identification, phonologic analysis, global recognition of word, reading isolated words, literacy, among others, whether for prevention or intervention.Thus, they make easier the acquisition of alphabetic code, necessary to skill of reading and writing [6][7][8][9][10] .
Due to its frequency and its damage in the development of children, the phonologic disorder preoccupies the Speech Therapist, who has extending his actuation on the prevention and rehabilitation of these language alterations.Thereby, this project aims to analyze and compare the performance of the phonologic awareness in two groups of children presenting phonologic disorder, one undergoing speech therapy and the other without intervention, using two evaluation instruments.

METHOD
The study included 21 children of both sexes, group age about five years and six months to eight years and ten months, presenting phonologic disorder that was not part of a global picture of development delay.
The study was conducted at the Speech-Language therapy and Audiology Clinic of the Bauru School of Dentistry, University of São Paulo (FOB-USP).
Among the 21 children, 10 of them pertained to group 1 (G1) which refers to children who were not undergoing the speech therapy and 11 children pertained to group 2 (G2), in which were undergoing intervention by a period of minimum four months and maximum of eight months.The speech intervention aimed to reorganize the sound systems of children, focusing to generalization and improvement of the speech understanding.The therapy model used was the Modified Cycles Approach 11 .
As criteria for inclusion in groups, were considered able to participated in the research individuals who: were authorized by parents or they tutors to participate by assigning a Consent Form; presented phonologic disorder according to literature and were between five and eight years old.
The exclusion criteria were: evident alteration on the neurological, cognitive, psychological and/or emotional aspects, and also hearing alteration.
In table 1 is described the participants' features regarding the chronological age and the school level.
stages of matureness and depends on the environment in which he/she is inserted on due to the stimulus received.During the phonologic acquisition, simplification processes are normal in the child, however such processes are abandoned and more complex productions are adopted.When the phonologic acquisition do not occur as expected, the child presents an alteration in the phonologic system, which differs of what is considered normal in the adult pattern, it is called phonologic disorder 1 .
The phonologic disorder is the child's difficulty in uses the rules of the phonologic systems that include phonemes and its distribution, and also the types of syllabic structures related to language.Thus, it would be identified a child with phonologic disorder, by the speech of difficult understanding caused by presence of phonologic processes unexpected for her age.The cause of the phonologic disorder still is unknown and the speech's intelligibility is varied, that is why there are several studies which relate causes biological, psychosocial, environmental and the family aspect to this disorder 2 .
Since children with this pathology have alterations in the phonologic sensibility, they may have problems with learning reading and writing during alphabetization, making evident the importance in verifies the phonologic disorder in the pre-scholar phase 3 .
The phonologic awareness is part of the development of the phonological aspect of language and it is defined as the skill to manipulate, detect and distinguish the sound's structure of words from the substitution of a sound until its segmentation in smaller units.The alphabetization process comprises phonologic tasks such as analyze words and its components, i.e., significant and meaning (phoneme and grapheme) of word 4 .
The development of the phonologic awareness and of the work memory depends on the chronologic age and maturity of the individual.These skills are correlated and are extremely important in the beginning of the orthography acquisition 5 .
Different authors concluded in their studies4 that the phonologic awareness occurs parallel to the literacy development, although initially they do not have a great level of dependency.As the alphabetization gets improved, the phonologic awareness also gets structured and they progress together supporting the child on the improvement of her cognitive functions, reflecting on the whole construction process of learning.
The effectiveness of the therapeutics models that employs tasks of phonologic awareness the reading and writing performance and of great predictive value to the subsequent performances.

Phonological Abilities Profile (PAP)
This instrument is composed by items which identify and compose the phonologic skills of analysis, addiction, segmentation, subtraction, substitution, rhymes, sequential rhymes, syllabic reversion and articulatory image; and may be applied on children among five to 10 years old, although, the items that evaluate the phonemic level only are applied on children with age higher than 7.
At the beginning of each level there is an order and a pattern pre-established.In the pattern, the first two statements are utilized to demonstrate the task.Since the activity is understood, the child must answer the four items selected.
In the items initial analysis, lexical segmentation, rhymes reception, sequential rhyme and articulatory image, the scores totalize two points; while in the tests of final and mean course analysis, addiction and subtraction of syllables and phonemes, phrasal segmentation, syllabic substitution and reversion, the positive score it will be of one point.In case of error the value zero will be assigned.These scores are sum up at the end of each item and at the end Children were submitted to a formal evaluation by the following instruments: Phonological Awareness Test 12 and Phonological Ability Profile 13 .

Phonological Awareness Test (PAT)
The test aims to evaluate the phonologic skills under written language.It is composed by ten subtests: Syllabic Synthesis; Phonemic Synthesis; Rhyme; Alliteration; Syllabic Segmentation; Phonemic Segmentation; Syllabic Manipulation; Phonemic Manipulation; Syllabic Transposition; Phonemic Transposition.Each subtest is composed by four items and by two initial examples in which the researcher explained to the child what it is to be done and corrects its answer in case to be incorrect.
The results were analyzed by the percentage of scores, ranging from zero to 40 points and to standardization of these scores in different levels of school degree proposed by the Capovilla studies, Capovilla and Silveira 14  It is a classification instrument developed to gather data about the individual capacity in process the phonologic aspects of language 13 .
By means a research with normal children were established values that classify quantitatively their performance (Table 2) 13 .
of the application, aiming to obtain the total scores which are analyzed regarding the child age.
In case of the child presents difficulties working on the abstract hearing level, it is necessary to assist her with concrete tips (material used as visual instrument).The results were organized into a database to facilitate its analysis.In this condition, the statistical analysis respected the criteria procedures of the evaluator's manual of each instrument used.Also, were developed a relevant statistical analysis aiming the comparing between the categories of analysis.

Age
In this study were applied the following statistical tests: Exact Test of Fisher, McNemar Test and Mann-Whitney Test, with significance level of p<0.05.

RESULTS
Tables 3 and 4 presented the classification of G1 in the Phonologic Abilities Profile and the Phonological Awareness Test, respectively.
Tables 5 and 6 presented the classification of G2 in the Phonological Abilities Profile and the Phonological Awareness Test, respectively.
Table 7 shows the comparing of sensibility on results of the tests PAT and PAP in groups 1 and 2.  Comparing the PAP to the variables age and school degree, it was not observed difference statistically significant, with p=0.185 and p=0.161, respectively.Comparing the PAT to the variables, as can be observed in Table 8, it was proved difference statistically significant to age and school degree, with both tests resulting in p=0.04.Therefore, it is observed, that children with performance lower than expected presented higher age and school degree.

INDIVIDUAL
Aiming to compare the performance of G1 and G2 in the PAT and PAP, was developed the statistically analysis by the Exact Test of Fisher, verifying results with no significance as both to PPS (p=0.65944) and PCF (p=0.31078).
The agreement level between tests, PAT and PAP, was accomplished by the McNemar Test, describing agreement in 14 cases (66.7%), however, it was not observed difference statistically significant (p=0.44969).
Mann-Whitney Test was used to compare the results of PAT and PAP with variables of age and school degree.

DISCUSSION
It was observed that 85% of children in G1 and G2 presented inferior performance in at least one of the two tests, agreeing with findings of studies that have found difficulties in phonological skills of children with phonologic disorders [15][16][17] , regardless the therapy.
Several authors relates the phonologic processing development to the precocious skills of reading and writing, that is why a child with dysfunctions in its phonologic capacity may present difficulties on language and reading, in the last case, it is due to the deficits on integrating orthographic and phonological cortical level, making use of different routes to children without difficulties [18][19][20][21] .
Considering the capacity of the two instruments of detect alterations, it was verified that PAP presented phonologic awareness alteration in 13 (62%) individuals and the PAT in 16 (76%) individuals, besides, it had agreement between tests in 14 cases (66.7%), of the total of 21 individuals.
It is important to emphasize that even with adjacent percentages, the results in G2 differed in 45% of the sample, if analyzed on the global context, in other words, five children presented different performance when comparing the instruments; while in G1, 20% of results differed between themselves, i.e., in two individuals only.Literature do not relates studies in this context.
Considering the school degree, the age and the performance of individuals, it is evident that the most age of five years old presented varied results such in PAT as in PAP, that shows the sensibility in both instruments in follow the phonologic disorder and higher sensibility of PAT in detect a alteration of phonologic awareness in those children.
On the age of six years old, both instruments are sensible in the evaluating the detection of alterations, but to reassessments of following, the PAP presented itself as more sensible.At the age of seven years old the PAT and the PAP present the same sensibility of 100% to the evaluation moment and to the moment of following the therapeutic evolution.And at the age of eight years old, the PAT showed to be more sensible to the initial detection of alterations in phonologic awareness and to the following of cases in this age.
Therefore, the phonologic awareness may be seen as a hierarchy of processes based on complex levels of the phonologic system.A higher level of awareness requires a detailed analysis of the minor units of phonologic system, as, e.g., the phonemes; and a primordial level requires a superficial analysis of the higher units of sound, the syllables 9,23,31,32 .
Regarding the necessity of precise instruments to diagnosis and following of the phonologic disorder, the present study showed that the performance of children with phonologic disorder in both tests (PAT and PAP) were similar in the sample G1 and differ in most of the sample evaluated in G2.Also, it is emphasized that the exams provide important elements to choose the pattern of intervention which will be applied in each individual, since the phonologic awareness related to the hearing discrimination and the therapy of minimum contrast are therapies more popular to phonological issues, among United Kingdom therapists 33 .The speech therapy approach based on the hierarchy of distinctive traces and in the phonologic awareness also presented to be effective in the overcome of phonologic processes and in the development of children with phonologic disorder 27 .

CONCLUSION
It was concluded that the most of children of sample (85%), regardless the phonologic therapy, presented performance inferior to the expected to their age in one of the evaluation instruments of phonologic awareness, demonstrating the importance of phonologic intervention with emphasis in this aspect, since it will be reflected directly in the process of alphabetization of the individual.children of first and second grades of elementary school had inferior performance in the application of PAT with difference statistically significant; although considering the same parameters in PAP it was not find difference statistically significant.
Due to the most children with unsatisfactory performance on G1 and G2 are in the first and second grade of elementary school in process of alphabetization or already alphabetized, this results disagree with the findings of studies which assume a mutual relation between the phonologic awareness and learning on reading and writing 4,[22][23][24][25] .During the scholar development, children who present oral skills slight developed, as in the cases of phonologic disorders, are overwhelmed.This aspect denotes the importance of oral language to aspects of learning on written language, as the phonologic awareness is a skill to be integrated in the academic environment.
Analyzing all the phonologic skills in PAT and correlating to the education level, it is observed that all children had the expected score to their level in some skills, both in G1 and G2, even the children that was not alphabetized.That agrees with different studies 26,27 that assume that in some levels of phonologic awareness it is previous to the acquisition of the written language, while others are possibly one more result of this acquisition?
A study with pre-scholars, which received specialized training of phonologic awareness and of the perception in general, based on the stimulation of the phonologic awareness to the learning of reading and writing, showed this to be unnecessary, being the perceptual training enough 28 .Another author concluded in his study that, generally, the phonologic awareness develops during the learning of reading and writing, when it is correlated to these three variables between the first four years of the elementary school, reinforcing the idea of these skills development to children without disorders on the phonologic aspect 29 .Also, it is possible to observe that even after time superior to four months and the therapy focusing the aspects related to phonologic skills, on the case of group 2, still it is evident the difficulty in skills involved to phonologic awareness, which confirm a different study 30 that compared the performance on phonologic awareness skills of individuals with the history in phonologic disorder after its overcome, by a phonologic therapy with individuals in typical phonologic development, and demonstrated that even after phonologic intervention, the individuals with the cited dysfunction presented performance inferior in the phonologic awareness skills.

.
Different studies verified the Phonological Awareness Test, as an instrument sensible to the level of phonologic development of children, and the performance measured, highly correlated to

Table 2 -Group age values
This project had the previous approval conceded by the Committee of Ethics in Research with Humans of the Bauru School of Dentistry, University of São Paulo (FOB-USP), under protocol n o 121/2007.All legal concerns were respected as demand the Resolution 196/196 of the National Committee for Ethics in Research (CONEP).All individuals and their tutors were informed about the objectives and procedures of the study (information letter to the patient) and signed the Consent Term.