Exploring phonological awareness skills in Arabic-speaking children with borderline intellectual functioning and poor reading

Background Phonological awareness (PA) is the awareness of speech sounds and the ability to reflect on and manipulate the phonemic segments of speech. Research on PA skills in children with borderline intellectual functioning (BIF) is scarce. The objective of this study was to explore PA skills in Arabic-speaking children with BIF and poor reading in comparison to dyslexic children using a modified version of the Arabic PA test. Methods A sample of 98 Egyptian children in the age range 6 years and 6 months to 11 years and 5 months was subjected to assessment by the modified Arabic PA test. The sample included 50 typically developing children, 24 dyslexic children, and 24 children with BIF and poor reading. Results and conclusion Children with BIF and poor reading demonstrated poor PA skills. Their performance on the modified Arabic PA test was significantly lower than the performance of normal as well as dyslexic children in younger age groups (6 years and 6 months to 8 years). However, in the older age group (8 years and 1 month to 11 years and 5 months), the performance of BIF and dyslexic children was comparable and significantly lower than normal children. The modified Arabic PA test shows evidence for its validity and reliability and can be used for the assessment of PA skills of children with average intelligence as well as children with intellectual dysfunction.


Background
Phonological awareness (PA) is defined as "the ability to identify, isolate, and manipulate speech sounds in a language" [1].A child's phonological awareness develops during childhood, moving from syllable-level sensitivity through onset-rime sensitivity to phoneme sensitivity [2].Early acquisition of this fundamental skill is important since it is a good predictor of future reading proficiency [3].
Dyslexia is a specific learning disability characterized by difficulties with accurate or fluent reading and spelling, despite adequate educational opportunities, and otherwise normal cognitive and intellectual abilities [4,5].Dyslexia is neurobiological in origin and is largely inherited and greatly modified by environmental variables [5,6].Phonological processing deficit is believed to have a causal role in the majority of individuals with dyslexia [4].
Borderline intellectual functioning (BIF) is a condition characterized by diverse cognitive impairments, with a borderline IQ (between 71 and 85), and impairment in personal functioning disturbing daily and social activities [7].Its prevalence among the school-aged population is estimated to be around 7% [8].Borderline intellectual functioning children frequently exhibit some degree of motor ability limitations in addition to intellectual (e.g., learning, reasoning, and problem-solving) and adaptive skill challenges (age-inappropriate social, communicative, and daily living behaviors) [9].
Learning issues are more common in individuals with BIF than in their contemporaries with typical intellectual functioning [8].Such issues are due to their weak executive functions, and short-term and working memory, in both verbal and visuo-spatial components [10][11][12].Additionally, the BIF group read real words and pseudo-words more slowly and with worse accuracy than the norm [11].
Research on phonological awareness skills in children with borderline intellectual functioning is scarce.Also, assessing phonological awareness in these children is considered challenging.The aim of this study is to explore the phonological awareness skills in Arabicspeaking Egyptian children with BIF and poor reading in comparison to dyslexic children using a modified version of the Arabic phonological awareness test.This would allow identifying the specific PA deficits that would be targeted in reading interventions.

Subjects
This observational comparative cross-sectional study was carried out on 98 Egyptian children in the age range of 6 years and 6 months to 11 years and 5 months, during the period from October 2018 to October 2021.Participants were divided into three groups: • Group I: Composed of 50 typically developing children (27 males and 23 females) with average intelligence and average reading development.These children were collected from primary schools in Dakahlia Governorate and from children attending the phoniatrics outpatient clinic at Mansoura University Hospital with complaints other than learning problems.• Group II: Composed of 24 dyslexic children (19 males and 5 females) with average IQ (>85).• Group III: Composed of 24 children (16 males and 8 females) with borderline intellectual functioning (IQ 70-85) and poor reading.• Groups II and III children were selected from children attending the phoniatrics outpatient clinic at Mansoura University Hospital.
Each of the 3 studied groups was further divided into three age groups as follows: • Group A: including children in the age range 6 years and 6 months to 8 years.• Group B: including children in the age range 8 years and 1 month to 9 years and 5 months.
• Group C: including children in the age range 9 years and 6 months to 11 years and 5 months.
Inclusion criteria were children and parents were native Arabic speakers, normal hearing and visual abilities, and adequate language productivity.Children with attention deficit hyperactivity disorders were excluded.
The sample size was calculated online using www.dssre search.com, provided the following: 1) From the previous study (Dessemontet et al. [13]), the mean score in children with intellectual disability was 10.26 ± 9.37 , while the expected mean in this study is 9.1.
2) The alpha error level is 5%, and the confidence interval is 95%.
3) The beta error level is 20%, and the statistical power of the study is 80%.
So, the sample size would be 42 children at least.To compensate for non-responders and defaulters, the sample size was increased by 10%, reaching 48 children for groups II and III.

Methods
The whole studied sample (n= 98) was subjected to phonological awareness assessment.In addition, children in groups II and III were subjected to the following assessment protocol: 1. Elementary diagnostic procedures: These included parents' interview and history taking, general examination, and subjective language and speech evaluation.

Clinical diagnostic aids • Psychometric evaluation: through Stanford Binet
Intelligence Scale "4th Arabic version" [14] for determination of IQ and mental age and Vineland Social Maturity Scale [15] for determination of social age.• Language assessment: the preschool language scale-4 (Arabic Version) [16] was used for the determination of language age.• Audiological assessment: to exclude children with hearing loss.• Modified Arabic dyslexia screening test [17] for diagnosis of reading disability.• The Arabic phonological awareness test: The Arabic phonological awareness test [18,19] was used for the assessment of phonological awareness skills in the studied groups.However, modification of the test was done to suit the purpose of the present study.For testing blending tasks (including blending syllables, blending onsets and rimes, and blending phonemes), and substitution tasks (including substituting initial, middle, and final phonemes), pictures were presented as visual aids (prompts) to be used if the child found difficulty to respond to the task auditorily.The picture representing the true answer was presented together with three picture distractors.For example, when testing blending syllables into words using syllables /lae/ and /baen/, pictures of a cup of milk, a door, an elephant, and a pencil were presented to the child and he/she was asked to choose the correct picture and say the answer.
Accordingly, for each of the 6 items presented with pictures, the child was given a score of 2 if the child gave a correct response auditorily (without a visual prompt), a score of 1 if the child responded correctly with the use of visual prompt, and a score of zero if the child gave an incorrect response.Regarding segmenting sentences into words and segmenting words into syllables, the child was given a score of 2 if the child could segment the task completely, a score of 1 if the child partly segmented the task, and a score of 0 if the child gave an incorrect response.For the rest of the items, the child was given a score of 2 for correct response, and a score of 0 for incorrect response.A composite raw score of PA ability with a maximum score of 185 points was created by adding the scores of all tasks.
Therefore, the original Arabic PA test was supplemented with a picture booklet containing 52 pictures.Pictures were carefully selected from Google images with great resolution, and representing real objects, to be easily recognized by the child.
Participants were assessed individually in a noiseless room in their schools or in the phoniatric outpatient clinic.The time of administration of the PA test was about 40-45 min.Responses to the whole test items were recorded on a score sheet to get a total raw score.

Statistical analysis
Data were analyzed using IBM SPSS (Statistical Package for Social Science) version 25 for Windows.Numbers and percentages were used to present qualitative data, whereas mean ± standard deviation or median (minimum-maximum) was used for quantitative variables.
The association between categorical variables was verified by chi-square test.However, Fisher's exact test and Monte Carlo test were used instead when appropriate.In order to compare continuous variables in two independent groups, independent sample t test was used for normally distributed variables and Mann-Whitney U test was used for non-normally distributed ones.In order to compare continuous variables in more than two independent groups, the one-way analysis of variance (ANOVA) followed by post hoc tests was utilized for normally distributed variables whereas Kruskal-Wallis H test was utilized for non-normally distributed ones.
In all statistical tests, results were considered significant when P ≤ 0.05.

Demographic data
The present study was conducted on 98 children aged 6 years and 6 months to 11 years and 5 months.They included 62 males (63%) and 36 females (37%), organized into 3 groups: Twenty-four percent of the studied children were in the 3rd grade.The 3 studied groups were matched for age, sex, and school grades (Table 1).

Validity and reliability of the modified Arabic PA test Validity
The validity of the modified Arabic phonological awareness test was tested using content validity and contrasted group validity.Three experienced bilingual phoniatricians judged all items as being entirely relevant to the purpose of the PA assessment.The normal group showed significantly higher performance on the test when compared to the dyslexic and BIF groups.

Reliability
To verify the reliability of PA test, the Cronbach alpha (α) equation was used.The total Cronbach alpha (α) for the 18 questions was 0.79 which indicates that the test has an acceptable degree of reliability based on the Nunnally scale [20], which established 0.7 as the minimal stability degree.

Comparative statistics
Comparison between the three studied groups in each age group as regards performance in phonological awareness (PA) assessment: • Comparison between groups IA, IIA, and IIIA as regards their performance in phonological awareness (PA) assessment: Significant differences were observed between the three groups in the total score and individual items of the phonological awareness assessment (except for multisyllabic word production).The scores were consistently highest in the normal group and lowest in the borderline intellectual functioning (BIF) group (Table 2).Post hoc analysis showed significant differences between each of the two groups, demonstrating that the performance of the BIF group differs significantly from that of the dyslexic group (Table 3).• Comparison between groups IB, IIB, and IIIB children as regards their performance in phonological awareness (PA) assessment: Significant differences were found between the three groups in the total score and nearly all individual items of the phonological awareness assessment.The highest scores were observed in the normal group (Table 4).Post hoc analysis showed significant differences between the normal group and each of the dyslexic and BIF groups.However, the majority of items as well as the total score did not differ significantly between dyslexic and BIF groups, demonstrating that both groups were comparable as regards their performance on PA assessment (Table 5).• Comparison between groups IC, IIC, and IIIC children as regards their performance in phonological awareness (PA) assessment: Significant differences were observed between the three groups in the total score and nearly all individual items of the phonological awareness assessment.The highest scores were observed in the normal group (Table 6).Post hoc analysis showed significant differences between the normal groups and each of the dyslexic and BIF groups.However, the majority of items as well as the total score did not differ significantly between dyslexic and BIF groups, demonstrating that both groups were comparable as regards their performance on PA assessment (Table 7).

Scoring of the modified version of the Arabic phonological awareness test
Since the administration of the Arabic PA test in the present study involved the use of pictures as visual aids, a new scoring system was developed.Consequently, the calculation of the 5th percentile values of the PA subtests and total score was done for the 3 age groups of the normal children (Table 8).
This would allow for the use of this modified version of the Arabic PA test as a diagnostic tool especially for children with intellectual dysfunction.If a child's total score on the test was found to be lower than the 5th percentile

Discussion
Phonological awareness is one of the factors that most accurately predict a child's capacity to learn to read [21].In all languages thus far studied (such as English, German, and Swedish), studies have provided conclusive evidence that individual differences in reading are predicted by individual differences in phonological awareness [22].Additionally, numerous studies found that phonological awareness training assists in reading development [23,24].Much like other languages, the PA influence on reading proficiency was also acknowledged in Arabic [25][26][27][28].The current study aimed to explore the phonological awareness skills in Arabic-speaking Egyptian children with borderline intellectual functioning and poor reading in comparison to dyslexic children using a modified version of the Arabic phonological awareness test.This would allow identifying the specific PA deficits that would be targeted in reading interventions.Ninety-eight Egyptian children aged 6 years and 6 months to 11 years and 5 months were subjected to assessment by the Arabic phonological awareness test.The sample included 50 typically developing children, 24 dyslexic children, and 24 children with borderline intellectual functioning and poor reading.
The Arabic PA test [18,19] was supplemented with a picture booklet as pictures were used as visual aids for testing blending and substitution tasks and scoring was modified accordingly.The use of visual aids helped children to respond to tasks more easily and minimized memory demands which are generally poor in BIF children.Many researchers believe that individuals with BIF experience learning problems due to their weak executive functions, and poor short-term and working memory, as compared to typically developing (TD) peers particularly in verbal and visuo-spatial constituents [11,12].
Comparison between normal, BIF, and dyslexic children in the age range 6 years and 6 months to 8 years as regards their performance on the modified Arabic PA test revealed significant differences between the 3 groups with the highest scores in the normal group.The BIF group showed the lowest scores.The lower performance of the dyslexic group as compared to the normal group was in agreement with earlier studies (e.g., Thomas-Tate et al. [29] and Afsah [19]) which demonstrated that children in the dyslexic group scored worse than the non-dyslexic children on tests assessing PA.In contrast, Stanovich [30] proposed that individuals with dyslexia would have a more severe phonological core deficit when compared with garden-variety poor readers (i.e., poor readers with low cognitive performance).
On comparing the performance of normal, dyslexic, and BIF children at older ages (from 8 years and 1 month to 11 years and 5 months) on phonological awareness tests, significant differences were observed between the 3 groups where the highest scores were observed in the normal group.However, the majority of items as well as the total score did not differ significantly between dyslexic and BIF groups, demonstrating that both groups were comparable as regards their performance on PA assessment.Similar  [31] who did not discover any differences between poor readers with higher IQs and those with lower IQs in their phonological reading abilities.According to Kuppen et al. [32], the poor vocabulary abilities linked to having a lower IQ may be sufficient to account for the poor phonological development of low-IQ poor readers.
Many studies revealed a considerable and consistent gap in PA between typically developed readers and reading-disabled children across grades, signifying persistent phonological deficits in reading-disabled children across developmental stages [4,33].Dandache et al. [34] found that despite dyslexic children showing PA impairment across grades, they exhibited progress even on the more Table 4 Comparison between groups IB, IIB, and IIIB as regards their performance in phonological awareness (PA) assessment Data expressed as "mean ± SD" or "median (minimum-maximum)" Since the administration of the Arabic PA test in the present study involved the use of pictures as visual aids, a new scoring system was developed.Consequently, calculation of the 5th percentile values of the PA subtests and total score was done for the 3 age groups of the normal children.This would allow for the use of this modified version of the Arabic PA test as a diagnostic tool especially for children with intellectual dysfunction.
As noted from the 5th percentile values of PA test in the normal group, isolation of initial and final phonemes was the easiest task, a finding that was in line with Stahl and Murray [35] who found that isolation of phonemes was the easiest PA tasks and seem essential to reading, because almost all children who could not successfully accomplish this task also did not have pre-primer academic proficiency.Tibi [36] examined some PA tasks in the Arabic language and found that identifying the word's initial sound and rhyme oddity was considerably easier for children to perform than syllable omission and phoneme segmentation.
The current findings are consistent with those by Vloedgraven and Verhoeven [37], who showed that children appear to acquire rhyming, phoneme isolation, and phoneme blending abilities as PA begins to develop; children appear to acquire phoneme segmentation and phoneme deletion abilities as PA continues to develop.When Anthony et al. [2] looked into the development of PA, they found evidence for a quasi-parallel development of PA abilities in overlapping phases.Accordingly, the cognitive process required to accomplish tasks like phoneme segmentation and phoneme deletion is far more complex than the cognitive process required to perform rhyming, phoneme isolation, and phoneme blending [38].
In all age groups, the normal children in the current study got higher scores in isolation of initial and final phonemes than scores on tasks assessing word and syllable awareness.This finding could be attributed to the teaching method that is currently implemented in Egyptian schools which relies on teaching KG children the isolation of initial and final phonemes besides teaching the alphabet and early reading skills.According to McCormack and Pasquarelli's [39] research, sounds or phonemes must be specifically taught in order to be recognized in speech.If students are unable to deconstruct words verbally, they will not be able to distinguish between sounds and relate them to letters.They fail to decipher words when they are written down and will have a hard time learning to read.In agreement with the present results, Bdeir et al. [40] found that for the isolation of final phonemes, blending phonemes, and segmenting phonemes, students who received PA instructions significantly outperformed students who did not receive any instructions.Students who received direct training could also identify the initial phoneme of any word irrespective of their letter knowledge and whether they are familiar with that word or not.The modified Arabic PA test showed evidence for its validity and reliability as a diagnostic tool for PA deficit.If a child's total PA score was found to be lower than the 5th percentile of his age group, this would indicate PA deficit.By comparing the subtests' scores with their 5th percentile values, specific areas of deficit could be delineated and targeted in the intervention.

Conclusion
Children with borderline intellectual functioning (BIF) and poor reading demonstrated poor phonological awareness (PA) skills.Their performance on the modified   The modified Arabic PA test shows evidence for its validity and reliability.The supplementation of the Arabic PA test with pictures as visual aids for 6 of its tasks allows for the use of this modified version of the test for the assessment of PA skills of children with average intelligence as well as children with intellectual dysfunction.

Table 2
Comparison between groups IA, IIA, and IIIA as regards their performance in phonological awareness (PA) assessment

Table 3
Post hoc test for groups IA, IIA, and IIIA as regards their performance in phonological awareness (PA) assessment * Significant P ≤ 0.05 One-way ANOVA test, KW Kruskal-Wallis test * Significant, P ≤ 0.05 challenging PA abilities; however, typically developing children in their study already achieved ceiling at grade 3.

Table 5
Post hoc test for groups IB, IIB, and IIIB as regards their performance in phonological awareness (PA) assessment

Table 6
PA in group IC of normal children, group IIC of dyslexic children, and group IIIC of below-average children Arabic PA test was significantly lower than the performance of normal as well as dyslexic children in younger age groups (6 years and 6 months to 8 years).However, in the older age group (8 years and 1 month to 11 years and 5 months), the performance of BIF and dyslexic children was comparable and significantly lower than normal children.

Table 7
Post hoc test for groups IC, IIC, and IIIC as regards their performance in phonological awareness (PA) assessment * Significant, P ≤ 0.05

Table 8
Fifth percentile values of the PA test in group I (normal children), n= 50