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 Table of Contents  
Year : 2021  |  Volume : 28  |  Issue : 4  |  Page : 291-297

Developing a programme for training phonological awareness and assessment of its effectiveness on reading skills of elementary first graders with cochlear implant

1 Department of Speech and Language Pathology, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
2 Department of Rehabilitation Management, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
3 Department of Speech and Language Pathology, School of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran
4 Department of Gerontology, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran

Date of Submission23-Aug-2021
Date of Decision15-Sep-2021
Date of Acceptance20-Oct-2021
Date of Web Publication29-Nov-2021

Correspondence Address:
Dr. Farzad Weisi
Department of Speech and Language Pathology, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_648_21

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Background: The current study aimed to develop a comprehensive phonological awareness intervention to train all levels of phonological awareness skills and to investigate its effect on the reading abilities of cochlear implanted children. Materials and Methods: This study was the single-subject intervention. Phonological awareness intervention programme was developed and validated by experts' opinions. Six elementary first graders with cochlear implants and weak or delayed reading development, in 5–7-year-old range, were trained in phonological awareness skills. 'Auditory test of phonological awareness skills' was used to evaluate the subjects' phonological awareness skills. Nama reading test was also used to determine the level of reading performance. Results: The results showed that all six subjects with cochlear implants had improvements of both phonological awareness skills and reading skills after participating in the phonological awareness intervention programme. This improvement was not only observed immediately after intervention but was also preserved in follow-up. Conclusion: The findings of this study demonstrated the importance of planning an intervention programme about phonological awareness skills for elementary first graders with cochlear implant, and the important role of such an intervention programme in improving their performance in phonological awareness tasks, and then in reading tasks consequently. The importance of improvement in these skills could considerably affect these children's linguistic and psychological abilities, which may facilitate their education at higher grades.

Keywords: Cochlear implants, phonological awareness, programme, reading

How to cite this article:
Shavaki YA, Weisi F, Kamali M, Soleymani Z, Kashani ZA, Rashedi V. Developing a programme for training phonological awareness and assessment of its effectiveness on reading skills of elementary first graders with cochlear implant. Niger Postgrad Med J 2021;28:291-7

How to cite this URL:
Shavaki YA, Weisi F, Kamali M, Soleymani Z, Kashani ZA, Rashedi V. Developing a programme for training phonological awareness and assessment of its effectiveness on reading skills of elementary first graders with cochlear implant. Niger Postgrad Med J [serial online] 2021 [cited 2022 Aug 12];28:291-7. Available from: https://www.npmj.org/text.asp?2021/28/4/291/331534

  Introduction Top

Reading skill is one of the linguistic categories essential for children and plays an important role in educational activities, and in their employment in the future as well.[1],[2],[3] According to various studies, the deaf and children with hearing impairments obtain lower scores of reading skills in comparison with their peers at the same age with normal hearing.[4],[5],[6] Children with normal hearing use their lexical and grammatical awareness to read a text, but children with hearing impairments may have poor lexical and grammatical awareness to read a text.[7] Moreover, identifying and manipulating sounds of words is considered as the core prerequisite of successful reading in children with normal hearing.[8],[9] Studies reported that poor phonological performance in children with hearing impairments leading to problems in developing reading skills.[10],[11] The relationship between reading skills and the ability of identifying and manipulating sounds was analysed by two aspects of the reading ability, i.e. understanding text messages and pronouncing the letters. For acquiring of the reading ability, any reader need learning and using of phonological awareness skills. There are studies supporting the association between phonological awareness and the ability to read correctly.[12],[13]

A better perspective was emerged after the innovation of cochlear implantation. It was to develop reading abilities in cochlear implanted children. The reports revealed that early cochlear implantation allows the children to receive auditory stimuli and have appropriate and enough hearing experiences from the environment, leading to increased verbal comprehension and improved speech production and facilitated spoken language development.[14],[15],[16]

Marschark et al. showed that the children who use cochlear implants acquire reading skill due to improved or advanced language skills.[10] Therefore, it is claimed that cochlear implantation facilitates and develops reading skills by providing more access to the phonological aspects of language and words.[17],[18] In a study conducted in Iran, it was found that the reading ability of children with cochlear implants was weaker than their peers with normal hearing, and there was a significant association between the reading skills and age of the children at the time of surgery for cochlear implantation. This might indicate that children with cochlear implants showed poor reading skills owing to their delay in access to phonological awareness and Persian words.[19]

Various studies revealed that phonological awareness skills in persons with hearing impairments are significantly impaired. Lund and Spencer and Tomblin argued that despite developing phonological awareness skills in children with hard of hearing after cochlear implant, it is delayed as compared to normal-hearing children.[20],[21] Studies conducted in Iran reported that cochlear implanted children had significantly lower scores of phonological skills than their regular counterparts.[22],[23],[24] There are various strategies for enhancing phonological awareness of hearing-impaired children. Gilliver et al.[25] proposed two approaches to develop phonological and lexical awareness to improve preschool children's reading skills assigned to two groups of children with hearing impairments. They concluded that the improvement of these skills in the age understudy could be active in reading ability, and specific phonological awareness training and its impact on reading skills.

We found no comprehensive programme in the Persian language in our searches. Therefore, the present study was inspired by different existing phonological awareness intervention programmes in Persian and English languages which some of them used in different studies.[26],[27],[28],[29],[30],[31],[32],[33] Our comprehensive phonological awareness intervention programme was developed by using of suggested methods and materials of the Persian and English intervention programmes.

  Materials and Methods Top


This study was approved following the 1975 Declaration of Helsinki, and its later amendments approved the study protocol. All the parents of participants signed the written informed consent.


The present study was a single-subject design A-B-A type.[34] The primary purposes were designed in two parts of developing phonological awareness intervention programme and phonological awareness intervention. In this study, six 5–7-year-old children with cochlear implants and weak and delayed reading development were trained in phonological awareness. All hearing subjects studied in Tehran met the inclusion criteria. It should be noted that the study was conducted in the summer of 2020. It should be noted that our most important limitation was lacking of classified information from cochlear implants, which makes them very difficult to access. The inclusion criteria were considered as follows: (a) subjects completed the first grade of primary school, (b) subjects with monolingual Persian language, (c) subjects with the history of at least 3 years of experience after cochlear implant surgery, (d) subjects with congenital hearing loss, (e) children with a 22-channel Nucleus Freedom cochlear implant, (f) the required IQ for entering public schools (listed in the medical records of these children in school), (g) no defects in the structure and movements of the child's speech organs by using of 'Oral-Speech Motor Control Protocol in Farsi-speaking Children'.[35]


By using interviews and consulting experts in phonological awareness, as well as studying the available texts, in Iran and abroad on the existing intervention methods and programmes in phonological awareness skills, the tasks needed to improve the appropriate skills were collected. The tasks selected were compatible with the Persian culture, and the required changes were made to meet these tasks with the purposes of the study and match with the Persian language. Eventually, all tasks were provided in an integrated manner in the form of a single intervention programme. To measure the content validity, the required changes were made to the designed programme according to comments from the experts in this field.

After designing the training programme, according to the inclusion criteria of the study as well as considering the children's abilities before and after the intervention, the following evaluations were performed and recorded their data: The evaluation of the speech organs, the phonological awareness abilities and reading skills. Then, the children received phonological awareness therapy. In the first session, the project's implementation method was explained to the children's parents, and the written consent forms were obtained. The questionnaire forms were filled out for each participant, which contained the participant's personal information and conducted with the help of parents.

Finally, as the subjects met the inclusion criteria, the preparation, scheduling and coordinating stages were performed. Two baseline assessments were done before intervention by 1 week interval, and intervention sessions were done 6–7 weeks (3 sessions every week) for the six children with their different levels of abilities, and then, final and follow-up assessments were done within 1-month interval. Each subject was evaluated during the intervention, in terms of reading ability and their phonological awareness once every five sessions. All of the process including 27–30 sessions carried out during 10–11 weeks for each of the children. The duration of each session was 1 h.

Evaluating the phonological awareness skills

'Auditory test of phonological awareness skills' (Arani Kashani-Ghorbani, 'ASHA 5') was used to evaluate the subjects' phonological awareness skills.[36] This test is based on providing auditory stimuli. This test was performed in a two-part session, and each part lasted for 30 min. The interval between the two parts were considered to be 30 min. At the beginning of each part, the children were explained about the purpose and the way of implementing the test according to their understanding, and it was tried to reduce their anxiety about the test.

Evaluating reading skills

Nama reading test was also used to determine the level of reading performance.[37] The validity of this test was reported by Karami-Nouri and Moradi (2008). They reported the validity and normative data for Azari, Kurdish and Persian deaf and normal-hearing persons. Nama reading test has ten subtests, with a sum of scores as an index of reading ability. These subtests include word reading, chain word, rhyme, picture naming, word and text comprehension, phoneme deletion, non-word reading, letter fluency and category fluency. The norm data for the test was gathered from 1614 students (844 girls and 770 boys) of 5 grades during 5 years in three cities named Tabriz, Sanandaj and Tehran. After collection of data and statistical analysis, they reported raw and norm scores for studied grades in students of the cities. We used the total score of the Nama test for analyses of reading ability in our study with respect to norms of children in Tehran, but some details about any subtest are explained here.[19]

Word reading

There are three lists with different levels of frequency for evaluation of this skill. Each list contains 40 words. Children must pronounce or read these words correctly in 2 min.

Chain word task

There are some word chains in the task. Each chain has three or four words. Children must determine meaningful words. Children have 2 min for this subtest.

Rhyme task

There are twenty words for this part with three choices for each of them. Children must select one word as the correct rhyme. The limited duration of this part is 2 min.

Picture naming task

This part has twenty pictures. Children must name them during 1 min.

Text comprehension task

There are three texts in this part. Each grade has two special texts. The other text is for all. Children must read them and then answer the related questions.

Word comprehension task

There are 30 words in this part. Children select the answer from four written choices.

Phoneme deletion task

There are 30 words in this part. Children retell the words but delete the requested phoneme. The limited duration of this part is 2 min.

Non-word reading task

There are 40 words in this part. Children read the non-words. The limited duration of this part is 2 min.

Letter fluency task

There are three Persian high-frequency letters (A, N and M). Children must say words beginning with each letter during 1 min.

Category fluency task

There are six categories (fruits, colours and so on) in this part. Children must recall each category in 3 min.

In this study, the total score of the reading test is considered that this score is obtained from the total score of its subtests.


Phonological awareness programme

This programme was developed and designed according to the existing stages of Persian and English intervention programmes including a programme for enhancing of phonological awareness in Down Syndrome persons (in the Persian language) performed in the 'University of Social Welfare and Rehabilitation Sciences', 'plans, and strategies for the development of phonological awareness skills' in the 'University of Florida' 'the phonological awareness intervention programme' in the 'University of Texas', as well as the 'The Gillon phonological awareness-training programme.'[26],[27],[28],[29] The stages of this intervention programme are explained as following in:

The first stage (preparation and consideration)

Before beginning the intervention programme, some activities and games were designed to make the children familiar with some linguistic concepts such as similarity-difference, beginning/middle/ending, initial/final, the concept of numbers up to 4, and definition of word and sound in a word. The children needed to know about these concepts for responding to questions.

The second stage (training at the syllable-structure awareness level)

At this level, the child realised each syllable contains one vowel. Bentin explained the central vowel creates a peak of acoustic energy in each syllable. The auditory system enables the person to distinguish the syllables making a word.[32]

The third stage (training at the onset-rime awareness level)

Phonological awareness at the onset-rime units refers to the realisation of rhyme, beginning and final of words. At this level, the person can understand what sound or combination (consonant-vowel) starts or ends a word. Evaluating this skill requires the individual to know that the beginning is separated from the final.[32]

The fourth stage (training at phonemic awareness)

The final level of phonological awareness skills is considered as awareness of individual sounds (phonemic awareness). A phoneme is the smallest sound unit affecting the meaning of a word, i.e. the meaning of the word is changed when a phoneme in a word is deleted or replaced by another phoneme. While phonemes are the small units, the word is not heard by these small units but as an interconnected set of these units.[21]

The fifth stage (sound-symbol association (phoneme-letter knowledge)

This stage is aimed at training or improving the child's knowledge of the phoneme-letter relationship. In this part, games for sound-symbol association were used. The tasks in this stage included word naming and identifying the first and last sounds, identifying the order and number of sounds, manipulating initial and final target sounds in words, integrating the skill with speaking, reading and spelling goals.[29]

  Results Top

As mentioned, the primary purposes were designed in two parts of developing phonological awareness intervention programme, and application of the programme for enhancing reading ability. After designing the intervention programme, 6 subjects participated in this study and the data of each subject were analysed individually (the results obtained from the assessments in each child were compared with themselves) and graph and graphical analyses were used to demonstrate the scores obtained and effectiveness of the interventions. The descriptive and demographic information of the participants is presented in [Table 1].
Table 1: Descriptive and demographic information of the Participants.

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[Figure 1] presents the total score of 'Auditory test of phonological awareness skills' in different stages of assessments (baseline 1, baseline 2, final and follow-up). The findings related to the total score of the NAMA reading test are also shown in [Figure 2] at different stages of assessment (baseline 1, baseline 2, final and follow-up).

[Figure 1] and [Figure 2] show that the six subjects have slight differences of phonological awareness skills and reading skills, respectively, both in baseline (1 and 2) or in final and follow-up assessments. These differences appear more in the final and follow-up stages between different persons. On the other hand, before and after treatment, the scores of these people are clearly different from each other, but for tracking of changes in the phonological awareness of each person, we need linear graphs in [Figure 3] and [Figure 4].
Figure 1: Score of ‘Auditory test of phonological awareness skills’ in different stages

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Figure 2: Score of Nama reading test in different stages

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Figure 3: The effectiveness of the intervention on phonological awareness in different stages

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Figure 4: The effectiveness of the intervention on reading skills in different stages

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[Figure 3] and [Figure 4] show the effectiveness of the intervention on phonological awareness and reading skills in the 1st, 2nd, final and follow-up stages.

[Figure 3] and [Figure 4] show changes of scores of each person from the first till the last assessment. These figures show that each person had a considerable increase between baseline 2 and final assessment both in total phonological awareness score and in the total reading score. This considerable difference occurred between before and after intervention for all of the participants.

Changes of scores between two assessments before treatment and also between two assessments after treatment are interesting, because of the presence of different patterns in different persons. It is noteworthy that in [Figure 3], the amount of variation between the two baseline assessments was very small for 4 subjects. The same 4 subjects have made some progress between the final and follow-up assessments too. Moreover, more interestingly, in the case of 2 children, there was a slight improvement between the two baseline assessments, and these 2 individuals, unlike the other 4 children, had a slight regression in the follow-up stage; i.e. their follow-up scores were slightly lower than the final scores.

According to [Figure 4], for four persons there was slight increase between the two baseline assessments, all of them had a slight increase between final and follow-up assessments too. Other two persons had different patterns in these changes. We can say that changes before intervention are different in different persons, and changes after the intervention may be different in different persons too, but the changes are small before the intervention, and also after that.

According to the findings of the study, results showed that the used intervention programme helped to the improvement of phonological awareness skills which was worked on during 6–7 weeks, but the reading ability was improved too, which was not worked on.

  Discussion Top

The current investigation was aimed to develop a phonological awareness intervention programme as a comprehensive intervention programme to train the phonological awareness skills at all levels to study its effect on the reading abilities of cochlear implanted children. The results of this study showed that the used intervention programme related to the improvement of phonological awareness skills could contribute to improving and acquiring both phonological awareness skills and reading ability in children with cochlear implant.

The purpose of the current study was the development of a phonological awareness intervention programme according to Persian and English phonological awareness intervention programmes, as a comprehensive intervention to train phonological awareness skills. In line with one of the previous studies, all levels of phonological awareness skills were syllable-structure awareness, onset-rime awareness, phonemic awareness and finally phoneme-letter knowledge.[25] These levels were taught, respectively.

The tasks were presented based on a simple to complicated hierarchy, and attempts were made as much as possible to provide tasks with visual clues. As discussed in the previous studies, the person needs to keep the words in his/her working memory to perform the requested auditory tasks. Thus, if the subject cannot do this, may forget the stimulus.[38],[39],[40] However, in pictorial tasks, as compared to the only auditory tasks, the working memory is less involved, and the possibility of error in response is less. Other studies investigated this issue and confirmed it. Carroll and Breadmore[39] and Allen[40] reported a relationship between verbal short-term memory and the ability to learn the phonological form of new words. James et al.[41] and Ahmadi et al.[42] stated that the visual, tactile, and written stimuli facilitate training the phonological awareness skill. Ahmadi et al.[42] argued that the type of syllabic context and the deleted syllables' position in words affect the ability to delete the syllable. Visual clues were some toys, pictures, letters, some words and sentences which were not used in the reading test. It seems that the visual clues used in this study may be a reason for better performance in reading ability in children with cochlear implants.

Phonological awareness was evaluated by auditory methods before and after the intervention. However, the intervention method was based on both auditory practices and visual clues helped the participants to have a better performance in phonemic awareness tasks such as making combinations. It can be a result of more extensive mental representations of the pictures and the related written words. It seems that the improvements made in this part also had considerable effects on the participants' reading skills. Weisi et al.,[19] and Lederberg et al.[43] showed that more diverse mental representations of words and the combination of auditory inputs with visual inputs could positively affect reading performance in people with cochlear implants and people with hearing impairment.

The results of phonological awareness and reading measurements in the present study indicated that explicit phonological awareness training could considerably facilitate the development of phonological awareness and reading skills in people with cochlear implants. This result is consistent with those found by Gilliver et al.[25]

The results of reading test administration before the intervention showed that all children with cochlear implants had lower scores than the criterion score of the reading test, revealing their poor performance in these skills before the intervention. In the previous studies, Geers,[17] Weisi et al.,[19] and Guerzoni et al.[44] mentioned various causes for poor performance in these skills, including less access to phonological and lexical information than hearing subjects, poor phonological manifestations and phonological processing skills and low lexicon, leading to poor reading skills. The present study showed that improvement of phonological awareness skills could increase reading skills by increasing attention to details of the sound structure, improving the encoding of written words and decoding current information of the lexicon. Moreover, phonological awareness intervention might improve phonological awareness skills in children with cochlear implant. This improvement in phonological awareness can have some effects on the speech processing system lead to their sensitivity to the structure of uttered and heard words, resulting in improved reading skills.

Regarding the phonological awareness development and consistent with the results of the present study, Gilliver et al.[25] showed that sound blending skills could be developed earlier than the beginning and final sound matching. Therefore, it could be concluded that children with cochlear implant might acquire phonological awareness from the earlier levels of this skill, i.e. syllable-structure awareness and onset-rime awareness.

Gilliver et al.[25] reported lower performance in the phonemic level skills than the skills of rhyme. This result was in line with the present study results. Further, the current study showed that children with cochlear implant had specific problems in some tasks such as initial and final sound matching. For example, the participants in this study had better performance in tasks of sound blending of CVC than sound alliteration tasks. This result was consistent with the findings of Gilliver et al.[25] but different from those found by Cupples et al.,[45] who showed that most children had better performance in sound alliteration tasks than the sound blending tasks. It is usually suggested to use more tasks with more variety and more number of sessions in all levels of phonological awareness than syllable-structure awareness or onset-rime awareness levels to help the participants develop their phonological awareness more and easier.[25] In this study, it was attempted to design the practices and tasks based on the abovementioned suggestion. In addition, word selection in this study was according to the following features: Both simple and complex syllabic structures, frequency of words, objectiveness, length of the word, the words could be depicted.

Desjardin et al.[46] conducted the reading comprehension test Woodcock-Johnson-III on 16 elementary school children with cochlear implant. They reported that in the subtest of letter comprehension, the subjects' scores were slightly higher than the average. The subjects' performance in this subtest showed that children with cochlear implant have no problem in letter knowledge though they were taught how to read and write in school.

  Conclusion Top

The results of this study indicated the importance of intervention programmes for enhancing of phonological awareness of elementary first graders with cochlear implant, through which they could have better performance in phonological awareness tasks and, consequently, reading tasks. The importance of improving these skills could considerably facilitate these children's linguistic and psychological abilities which may facilitate their education at higher grades. Furthermore, the current study demonstrated the importance of training rhyme-based tasks before training the phoneme-based tasks, as in hearing children, which should be considered by the experts in education and research related to education. It is suggested that the intervention programmes performed in this study be executed on more samples of cochlear implanted children and can be done on cochlear implanted children compared to hearing aid users.


This study was a part of the PhD thesis of the second author in speech and language pathology and was supported by Iran University of Medical Sciences. We would like to thank the Iranian speech and language pathologists and all of the children with cochlear implants and their families who participated in this study.

Financial support and sponsorship

This research was funded by the Iran University of Medical Sciences, Tehran, Iran.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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