Received: 22 November 2020 Accepted: 20 June 2022
DOI: 10.1111/1460-6984.12764
RESEARCH REPORT
Phonological processing skills in children with speech
sound disorder: A multiple case study approach
Sherine R. Tambyraja1
1 CraneCenter for Early Childhood
Research and Policy, The Ohio State
University, Columbus, OH, USA
2 School of Communication Science and
Disorders, Florida State University,
Tallahassee, FL, USA
Correspondence
Sherine R. Tambyraja, Ohio Department
of Education, 25 S. Front Street, 6th floor,
Columbus, OH 43215, USA.
Email: stambyraja@yahoo.com
Funding information
Institute of Education Sciences,
Grant/Award Number: R324A090012;
This research was supported by Grant,
Grant/Award Number: R324A090012; U.S.
Department of Education, Institute of
Education Sciences, awarded to Laura M.
Justice, and an internal seed grant from
The Crane Center for Early Childhood
Research and Policy, awarded to Sherine
R. Tambyraja
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language
Therapists.
Int J Lang Commun Disord. 2023;58:15–27.
Kelly Farquharson2 Laura M. Justice1
Abstract
Background: Children with speech sound disorder (SSD) are at increased risk
of reading difficulties due to poor phonological processing skills. However, the
extent to which children with SSD demonstrate weaknesses on specific or all
phonological processing tasks is not well understood.
Aims: To examine the phonological processing abilities of a clinically identified
sample of children with SSD, with and without reading difficulties. To determine
the extent to which the proportion of children with concomitant SSD and reading
difficulties exhibited weaknesses in specific areas of phonological processing, or
a more general phonological deficit.
Methods & Procedures: Data were obtained from 157 school-aged children
(Mage = 77 months, SD = 7.01) in receipt of school-based speech therapy. Approx-
imately 25% of the sample was identified as poor readers, based on a standardized
measure of word decoding. We compared the proportion of children who scored
at or below 1 SD below the mean, or the bottom 16th percentile, on measures
of phonological awareness, rapid automatized naming and verbal short-term
memory among those identified as poor readers and good readers.
Outcomes & Results: Children with SSD demonstrated a range of phonological
processing difficulties, particularly on the measure of verbal short-term memory.
No specific skill differentiated groups of children with SSD with and without
reading difficulties; however, those classified as poor readers on the word-
decoding measure exhibited more widespread difficulties, even after controlling
for language ability.
Conclusions & Implications: Results support a cumulative risk model such
that children with SSD and reading difficulties are likely to demonstrate
generally poor phonological processing abilities.
KEYWORDS
phonological processing, reading, speech sound disorder
wileyonlinelibrary.com/journal/jlcd 15
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16 PHONOLOGICAL PROCESSING SKILLS IN CHILDREN

What this paper adds

What is already known on the subject
∙ Children with SSD are at heightened risk of reading difficulties, particularly if
their SSD persists into school age. However, not all children with SSD experi-
ence reading problems. Research aimed at determining which children are at
the highest risk is mixed as to how best to identify which children with SSD
are most likely to experience reading difficulties.

What this paper adds to existing knowledge

∙ The study used a multiple case study approach to determine if performance
on phonological processing skills might differentiate children with SSD who
were poor readers from those who were good readers. As a group, children
with SSD exhibited poor verbal short-term memory but relatively intact rapid
automatized naming skills. No one phonological processing skill differentiated
children who were poor readers from good readers. However, children with
reading difficulties appeared to experience more general difficulties across
phonological processing tasks, even after controlling for language abilities.

What are the potential or actual clinical implications of this work?

∙ A single deficit (i.e., speech sound production) is not sufficient data to make a
complete diagnosis or treatment decisions. Multiple sources of data, including
several aspects of phonological processing, should be obtained to understand
reading risk in children with SSD.

INTRODUCTION
The diagnosis of speech sound disorder (SSD) is conferred
on children who exhibit a broad spectrum of difficulty with
speech sound production, and constitutes a heterogeneous
group with respect to the nature of their disorder, the types
of speech errors they produce and the severity of their
unintelligibility (Dodd, 2014; Macrae & Tyler, 2014; Pre-
ston & Edwards, 2010; Waring & Knight, 2013). Increasing
evidence suggests that regardless of the underlying cause,
children with SSD, including those with idiopathic SSD,
are at heightened risk of subsequent reading problems
(Cabbage et al., 2018; Lewis et al., 2011, 2015; Raitano et al.,
2004), particularly if their speech difficulties are present
at school entry, when formal reading instruction begins
(Burgoyne et al., 2019).
This is an especially salient issue for speech and lan-
guage pathologists (SLPs) serving school-age children,
who must often simultaneously support children’s speech,
language and reading skills within the context of therapy
(American Speech–Language–Hearing Association, 2001).
Research focused on determining the extent of reading dif-
ficulties for children with SSD has been somewhat mixed.
For example, although some studies suggest that risks for
reading difficulties are highest for children with SSD and
concomitant language impairment (LI) (Peterson et al.,
2009; Sices et al., 2007), recent evidence indicates that
variation in reading abilities among school-age children
with SSD may be more closely related to phonological
skills (e.g., Burgoyne et al., 2019; Tambyraja et al., 2020),
regardless of language ability. This explanation aligns with
prevailing theories of reading development in that strong
phonological skills are a prerequisite for the word decod-
ing process of reading (e.g., Gough & Tunmer, 1986), which
subsequently relates to reading comprehension. Linkages
between SSD and word decoding difficulties are also in
line with speech processing theories in that speech diffi-
culties are just one manifestation of a generally impaired
phonological system in children with SSD (e.g., Stack-
house & Wells, 1997), which extends to the word decoding
process of reading. Considered altogether, it might be
concluded that children with SSD, with and without LI,
are at risk of reading difficulties, but that children with
poor phonological processing skills are at highest risk.

TAMBYRAJA et al.
Thus, examining children’s phonological processing abil-
ities, regardless of diagnostic status, may be particularly
informative for identifying children with poor reading
skills.
To date, data concerning reading difficulties among
school-age children with SSD who receive speech–
language therapy are relatively sparse, thus limiting the
ability to understand the connections between phono-
logical processing and word decoding (hereafter used
interchangeably with reading), which has both theoretical
and clinical implications. Indeed, some studies have
supported the idea of the ‘critical age hypothesis’, and that
children whose SSD remains present at school entry are at
greatest risk of reading difficulties (e.g., Burgoyne et al.,
2019; Nathan et al., 2004), yet there is limited research
to guide clinical practice in identifying who will require
reading support. As such, the present study determines
the extent to which performance on three unique phono-
logical processing skills may help to ascertain which
clinically identified children with SSD are at increased
risk of reading difficulties.
Word decoding: Links to phonological
processing
Theories of reading acquisition converge on the notion
that learning to decode words is largely contingent on
children’s phonological processing abilities (e.g., Gough &
Tunmer, 1986; Wagner & Torgesen, 1987; Wagner et al.,
1994). According to the phonological processing theory of
reading (Wagner & Torgesen, 1987), for example, decoding
printed words requires three primary phonologically ori-
ented skills, namely: phonological awareness (PA), rapid
automatized naming (RAN) and verbal short-term mem-
ory (vSTM). The present study focuses on these three
phonological processing skills and examines the extent to
which performance on any one, or combination, differen-
tiates children with SSD who have reading difficulties from
those whose reading skills are within normal limits.
Phonological awareness (PA)
PA refers to an awareness of the sound structures of
language (Whitehurst & Lonigan, 1998). It, particularly
phoneme awareness, is positively associated with word
decoding ability (e.g., Lonigan et al., 2009; Schatschneider
et al., 2004; Strattman & Hodson, 2005) and the relation
appears to be causal (Castles & Coltheart, 2004; Ehri et al.,
2001, Wagner et al., 1994). Children with SSD perform
more poorly on measures of PA compared with typically
developing (TD) children (Rvachew & Grawburg, 2006;
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17
Sutherland & Gillon, 2007), even among older children
whose speech difficulties have resolved (e.g., Peterson
et al., 2009). Thus, although a large proportion of chil-
dren with SSD have poor PA which will subsequently
impact their reading ability (Burgoyne et al., 2019; Tam-
byraja et al., 2020), the extent to which difficulties in PA
specifically differentiates those with and without reading
difficulties remains unclear.
Rapid automatized naming (RAN)
Some studies suggest that RAN requires accessing and pro-
cessing stored phonological information from long-term
memory (Wagner & Torgesen, 1987). RAN tasks measure
the speed at which children retrieve and name the lexi-
cal codes associated with known items, such as colours,
objects or letters; thus, slow RAN times are thought to
reflect an inefficient timing process when children are
asked to quickly associate specific visual stimuli and
phonological codes (Wolf & Bowers, 1999). RAN is associ-
ated with word decoding skills in TD children (e.g., Clarke
et al., 2005; Manis et al., 1999), yet some research sug-
gests these connections are not evident in children with
LI and/or SSD (e.g., Burgoyne et al., 2019; Tambyraja
et al., 2015). Theoretical explanations for the relationship
between RAN and decoding differ, yet some empirical
evidence indicates that RAN accounts for significant and
unique variance in decoding ability above and beyond PA
(Clarke et al., 2005; Schatschneider et al., 2004). In con-
trast, Burgoyne et al. (2019) found that although children
with SSD had poorer PA and decoding skills compared
with TD children, there were no group differences on a
measure of RAN. However, given the relations between
RAN and decoding in TD children, and the available
evidence suggesting it is a relatively intact phonological
processing skill for children with SSD, it is possible that
RAN tasks may help identify which children with SSD are
likely to experience reading difficulties.
Verbal short-term memory (vSTM)
vSTM refers to the short-term memory storage of auditorily
presented information. It is the mechanism readers use to
maintain the memory of the sounds of decoded graphemes,
while continuing to decode later graphemes in a word (e.g.,
Gathercole et al., 1991). Thus, it is a phonological process-
ing skill that is independent from PA and RAN. However,
some studies indicate that measures of vSTM and PA tap
the same underlying phonological skill (e.g., Chow et al.,
2005) and do not individually account for unique vari-
ance in word decoding (Muter & Snowling, 1998). Previous

18
work has found that children with SSD have difficulties
with vSTM tasks (e.g., Couture & McCauley, 2000; Lewis
et al., 2011). An fMRI study similarly found that the neu-
ral regions activated during phonological memory tasks
are different in children with SSD compared with children
with typical speech production abilities (Tkach et al., 2011).
Overall, research generally indicates that children with
SSD exhibit poorer phonological processing skills com-
pared with TD children. However, there remain relatively
limited data to determine whether children with SSD who
experience reading difficulties demonstrate difficulties
across all phonological processing skills, or if difficulties
with one or more specific phonological processing skills
may be particularly associated with poor reading skills.
Even fewer studies have examined clinically representa-
tive samples to understand the rate of reading difficulties
among school-age children who meet criteria for SSD, and
are thus a heterogenous group, as they may have additional
diagnoses as well. This is an important clinical considera-
tion, as SLPs often have time and resource constraints to
meet the multiple needs of children on their caseloads.
To that end, this study seeks to determine the extent to
which specific phonological processing skills may be clin-
ically useful for identifying children with SSD at risk of
concomitant reading difficulties.
A multiple case study approach
Historically, researchers have used variable-centred
approaches (e.g., linear regression) to understand the
skills and characteristics significantly associated with
reading ability in children with SSD. These methods are
useful for identifying significant predictors of reading
ability, but do not account for individual variation within
heterogeneous groups (Murphy & Farquharson, 2016;
Tambyraja et al., 2015, 2018). In the present study, we take
a person-centred approach to expand our understanding
of the most prevalent types of phonological processing
difficulties in children with SSD, and the extent to which
difficulties in specific aspects of phonological processing
may differentiate children with SSD who have reading
difficulties from those who do not.
One method that has been used to understand which
skills areas underlie reading difficulties is a multiple case
study (e.g., Carroll et al., 2016; Ramus et al., 2003). Multiple
case study approaches apply a threshold (i.e., cut-point) on
measures to reflect a deficit (e.g., more than 1 SD (standard
deviation) below the mean) and determine the propor-
tion of individuals who exhibit difficulties on the selected
measures, or to identify patterns of difficulties within a
specified group of individuals. For example, Ramus et al.
(2003) administered an assessment battery to adults with
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PHONOLOGICAL PROCESSING SKILLS IN CHILDREN
dyslexia (n = 16) to determine whether their primary
weaknesses supported a phonological processing theory of
dyslexia, an auditory/visual theory or a cerebellar theory.
All adults with dyslexia exhibited phonological difficulties,
whereas only some exhibited auditory, visual and/or motor
deficits. Carroll et al. (2016) used a multiple case study
approach to determine how many children with dyslexia
might be classified as demonstrating deficits, based on
measure cut-points, on a battery of print, motor and
phonological tasks. There was no specific task on which
all children classified as poor readers met the criteria for
a deficit, rather they demonstrated a large constellation of
associated difficulties. The present study adopts the mul-
tiple case study approach to further our understanding of
how to differentiate children with SSD who exhibit read-
ing difficulties from those who do not, based on their
phonological processing abilities.
Purpose of the current study
To sum up, the present study contributes to a small but
growing body of literature focused on clarifying the asso-
ciations among SSD, phonological processing and reading.
Increasing evidence suggests that school-age children with
SSD are at heightened risk of reading difficulties, par-
ticularly decoding, but the extent to which that risk is
due to a generally impaired phonological system or can
be attributed to specific phonological processing skills
remains unclear. Further, the extent to which impairments
in one or multiple phonological processing skills may
relate to a child’s cumulative risk status is also of interest.
We address the following questions:
∙ What proportion of children with SSD experience diffi-
culties in PA, RAN and/or vSTM, and do those propor-
tions vary for children who are identified as poor or good
readers?
∙ What proportion of children in each reading subgroup
(poor readers, good readers) exhibit difficulties in mul-
tiple areas, and are there difficulties that cluster together
more frequently in either or both subgroups?
∙ To what extent is the number of phonological pro-
cessing difficulties associated with reading difficulties
in children with SSD when controlling for language
abilities?
METHODS
Participants
Participants were 157 children with SSD who were
receiving school-based speech–language therapy in public

TAMBYRAJA et al.
schools in the Midwest and Southeastern regions of the
United States. Participants were drawn from a subset of
children participating in a larger study examining cur-
rent practices in school-based speech–language therapy
sessions. Eligibility for the larger study required that
children: (1) were in kindergarten, first or second grade
(i.e., between the ages of 5 and 8); (2) were receiv-
ing school-based speech–language therapy; (3) did not
have hearing loss or a severe cognitive impairment that
would impact their ability to complete study tasks; and
(4) primarily communicated in English. For information
about the complete sample in the larger study, includ-
ing recruitment processes, see Tambyraja et al. (2015)
(year).
As part of the larger study, we obtained the individ-
ualized education plan (IEP) of each participating child.
The IEPs were coded according to the therapy targets
within goals (e.g., vocabulary, grammar, fluency, articu-
lation), which were then used to select children for the
current study. Therefore, we operationalized SSD to reflect
current clinical practice such that the children selected
for the current investigation had at least one IEP goal tar-
geting speech sound production, as determined by their
school-based SLP (e.g., Student will produce /s/ blends and
/l/ blends at the beginning of words when naming pictures
with 90% accuracy for two consecutive sessions) and had
completed the assessment of decoding in the beginning
of the academic year. Of note, the larger study primar-
ily focused on children with LI. Thus, the present sample
of 157 included a large proportion of children who had
both language and speech/articulation therapy goals (n
= 106), and a smaller proportion of children whose IEP
had only speech sound goals (n = 51). Despite this distinc-
tion related to therapy goals, analyses were conducted with
the entire sample as a whole in order to provide informa-
tion that directly reflects a representative clinical sample.
Furthermore, because of the larger study’s focus on exam-
ining services for children with LI, the testing protocol did
not include a standardized assessment of children’s speech
sound skills. Thus, further information about the specific
nature of children’s speech sound difficulties was also not
available. However, a narrative language sample for each
child was transcribed and the total per cent consonants cor-
rect (PCC) was calculated for all children selected for this
study. See Tambyraja et al. (2020) for a full description of
this process.
Table 1 includes additional descriptive data for predic-
tor variables, including information on children’s age, sex,
socio-economic status (SES), race and ethnicity. Descrip-
tive data regarding children’s language and PCC are shown
in Table 2.
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19
Procedures
Informed consent and all study procedures were approved
by the Institutional Review Board at The Ohio State Uni-
versity. Consented children participated in a battery of
standardized language and literacy assessments at the
beginning (timepoint 1) and end (timepoint 2) of the aca-
demic year. For the present investigation, only timepoint
1 measures are included. All assessments were adminis-
tered individually in a quiet room by trained field assessors.
Training for field assessors included: (1) a review of assess-
ment manual and procedures, (2) completion of an online
module about the measure and a score of 100% on an
administration quiz, (3) completion of a mock assess-
ment and (4) live observation of the assessor’s initial test
administration by the project manager.
Measures
Several measures were used to address the study’s main
research questions. In addition to the key outcome mea-
sures detailed below, children were also administered
the Core Language subtests of the Clinical Evaluation
and Language Fundamentals—Fourth Edition (CELF-4;
Semel et al., 2003) as an index of spoken language, and the
Matrices subtest of the Kaufman Brief Intelligence Test—
Second Edition (KBIT-2; Kaufman & Kaufman, 2004) as
an index of non-verbal intelligence. These measures were
used to characterize children’s overall language and non-
verbal intelligence abilities and used as control variables
in some analyses. Reliability coefficients for the Core Lan-
guage subtests of the CELF-4 range from 0.71 to 0.86 and
from 0.78 to 0.87 for the KBIT-2.
Word decoding
Children’s reading ability was measured with the Word
Attack (WA) subtest of the Woodcock–Johnson III Tests
of Achievement (Woodcock et al., 2001). The Word Attack
subtest includes lists of non-words that increase in com-
plexity; children were required to decode the non-words.
The number of non-words accurately decoded represented
the raw score; this was converted into a standard score,
which was used in analyses. Using the multiple case study
approach, children whose standard score was less than
85 (i.e., 1 SD or more below the mean) were classified as
poor readers. In the current sample, 44 children (28%) were
considered to be poor readers. Test–retest reliability for
children aged 4–7 years for the Word Attack subtest is 0.79.
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20 PHONOLOGICAL PROCESSING SKILLS IN CHILDREN

TA B L E 1 Participant characteristics and demographic information (n = 157)

Variable n %
Child age (months)
Mean 77.01
SD 7.77
Range 60–96
Grade
Kindergarten 49 31.2%
First grade 103 65.6%
Second grade 5 3.2%
Gender
Male 105 66.9%
Female 52 33.1%
Highest level of maternal education
Less than high school 13 8.3%
High school graduate 17 10.8
Some college 36 22.9%
Associates degree 19 12.1%
College graduate or higher 43 27.4%
Not reported 29 18.5%
Race/ethnicity
White/non-Hispanic Caucasian 93 59.2%
Hispanic 8 5.1%
Black/African-American 10 6.4%
Asian 3 1.8%
Other 8 5.1%
Not reported 35 22.3%
Note: SD, standard deviation.

RAN PA

RAN ability was tested using the Shapes and Colours sub-
test of CELF-4 (Semel et al., 2003). This subtest required
that children name visually presented shapes, colours
and shape–colour combinations as quickly as possible.
Although other types of RAN tasks (e.g., letters, digits)
are sometimes used, research suggests that all RAN tasks
require overall similar processing skills (Cummine et al.,
2014). Children were timed as they named the colours and
shapes (e.g., blue circle), presented on a 6 × 6 grid. The
total number of errors paired with time (s) is used to deter-
mine a score. Criterion scores from the publisher’s manual
(Semel et al., 2003) were used to rate performance as nor-
mal, non-normal and slower than normal. Children who
were classified with a performance level that was non-
normal or slower than normal were considered to have a
RAN deficit. Test–retest reliability for RAN naming time is
0.87.
The Catts Deletion Task was used to evaluate children’s
PA abilities (Catts et al., 2001). In this task, children are
presented with a target word and are asked to delete
phonological segments that vary in size (word, syllable,
phoneme; ‘say baseball without base’). This task was cho-
sen because it has been shown to be strongly predictive of
reading ability (e.g., Torgesen et al., 1994). A binary scor-
ing approach (i.e., correct/incorrect) was applied to all 21
items. Raw scores were used in the analyses. Children who
scored in the bottom 16% were classified as having a PA
deficit (Catts et al., 2005). Cronbach’s alpha for this sample
was 0.69.
vSTM
vSTM was assessed using the Number Repetition sub-
test from CELF-4 (Semel et al., 2003). This subtest was
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TAMBYRAJA et al. 21

administered as part of the full battery of assessments in

SS = standard score; Language = Core Language subtests of the Clinical Evaluation of Language Fundamentals—4th Edition (CELF-4); Non-verbal IQ = Kaufman Brief Intelligence Test—Second Edition (KBIT-2).
the larger study; previous research suggests this task is
associated is often used as a measure of vSTM and is signif-
Effect size icantly correlated with other memory tasks, such as those
involving non-word recall (Cain et al., 2004; Rispins &

0.43
1.05
0.69

0.27
0.73

0.75
0.21
Baker, 2012). In this subtest, children are auditorily pre-
sented with a list of digits, which increase by one as the
trials progress. Children are asked to repeat the list of digits
in forwarding order. Raw scores were converted to stan-
dard scores (M = 10, SD = 3), which were used in the
Descriptive statistics for phonological processing variables and effect sizes for differences between the poor reader and good reader subgroups

analyses. Consistent with using –1 SD from the mean as

Good readers (n = 113)

a cut score, children with standard scores below 7 were

determined to have a deficit in vSTM. Internal consistency
reliability for this subtest was 0.79. Descriptive statistics
78.59 (15.67)

92.71 (11.84)
108.11 (41.55)
75.56 (7.60)

8.39 (7.63)
Mean (SD)

5.37 (1.75)

for all variables, as well as their PCC, including the effect

86.78 (7.5)

size from mean score differences between good and poor

readers on all variables, are presented in Table 2.

RESULTS

Phonological processing skills in poor and

good readers
Poor readers (n = 44)

The first aim of this study was to determine the propor-

133.41 (72.66)
62.23 (15.41)

tion of children with SSD who experience difficulties in

80.72 (7.00)

4.30 (1.90)

84.34 (9.41)
Mean (SD)

3.23 (5.13)
85.17 (7.5)

PA, RAN and/or vSTM, and the extent to which those pro-
portions differed for children classified as good or poor
readers. As described above, cut scores were created for
each measure to identify children who exhibited difficulty
on each task, as determined by performing below to cut
score criterion. Descriptive data in Table 2 indicate large
differences in measures of interest between the groups of
poor and good readers. The proportion of children who
Total sample (n = 157)

performed poorly on each phonological processing vari-

able for the entire sample, as well as for the good and poor
reader subgroups, are presented in Table 3. Chi-square
115.20 (53.15)

90.36 (11.79)
74.01 (17.21)
Mean (SD)

6.94 (7.38)
77.01 (7.78)

5.07 (1.85)
86.33 (7.5)

analyses confirmed that the proportion of children who

exhibited deficits across all three phonological process-
ing measures was significantly greater in the poor readers
Notes: SD, standard deviation; Effect size, Hedges’ g.

subgroup. Also, as a group, children with SSD exhib-

ited notable difficulty with the vSTM task, according to
Verbal short-term memory (vSTM) (raw

age-standardized performance.
Rapid automatized naming (RAN)
Phonological awareness (PA) (raw

*p = 0.01, **p < 0.01, ***p < 0.001.

Per cent consonants correct

Children with multiple difficulties

Non-verbal IQ (ss)***

The second research question determined whether chil-

Language (ss)***

dren with SSD demonstrated difficulties in any one par-

Age (months)

(seconds)*
score)***

ticular area, or any specific combinations of, phonological

score)**
TA B L E 2

Variable

processing. As seen in Table 4, the total sample of clinically

identified children with SSD did not appear to demonstrate
difficulties on the RAN task; however, overall performance
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22 PHONOLOGICAL PROCESSING SKILLS IN CHILDREN

T A B L E 3 Chi-square analyses of the number (percentage) of children scoring below 1 SD from the mean on the PA and short-term
memory measures and below normal criterion on the RAN measure
Variable Total sample (n = 157) Poor readers (n = 44) Good readers (n = 113) χ2 p-value
Phonological awareness (PA) 79 (50%) 32 (73%) 47 (42%) 12.28 0.001
Rapid automatized naming (RAN) 33 (21%) 15 (34%) 18 (16%) 10.39 0.012
Verbal short-term memory (vSTM) 97 (62%) 36 (82%) 61 (54%) 6.29 0.001

T A B L E 4 Number (percentage) of children exhibiting deficits in each individual phonological processing area (and combinations
thereof) in the total sample, and among those who are (a) good readers and (b) poor readers
Phonological processing skill Total sample (n = 157) Poor readers (n = 44) Good readers (n = 113)
Phonological awareness (PA) 14 (9%) 3 (7%) 11 (10%)
Rapid automatized naming (RAN) 5 (3%) 1 (2.3%) 4 (3.5%)
Verbal short-term memory (vSTM) 31 (20%) 8 (18%) 23 (20.5%)
PA + RAN 4 (2.5%) 1 (2.3%) 3 (3%)
PA + vSTM 43 (27%) 16 (36%) 27 (24%)
RAN + vSTM 6 (4%) 1 (2.3%) 5 (4%)
All three 20 (13%) 14 (32%) 6 (5%)
No risk areas 34 (23.5%) 0 34 (30%)

on the PA and vSTM tasks were much poorer. However,
as Table 4 also shows, the subgroup of children classified
as poor readers were more likely to experience difficulties
in all three areas compared with those classified as good
readers. Furthermore, children classified as poor readers
demonstrated difficulties in at least one phonological pro-
cessing area, whereas 30% of children classified as good
readers did not exhibit difficulties in any of the three
phonological processing skills.
Predicting reading status from the number
of difficulties
Because data from the previous research question deter-
mined that this group of children with SSD did not appear
to have significant RAN deficits, but did demonstrate dif-
ficulties with PA and vSTM, it was of interest to know
whether the combination of deficits in two or three areas
would account for significant variance in poor reader sta-
tus. A hierarchical logistic regression, using SPSS software
(version 27.0), ascertained the extent to which the total
number of factors for which children exhibited deficits
(i.e., one, two or three) would be significantly associated
with classification as a poor reader, while controlling for
children’s language ability and non-verbal intelligence, as
this sample of children with SSD demonstrated a range of
language skills and non-verbal IQ. Although these vari-
ables were not included as control variables in earlier
analyses, the logistic regression approach allowed us to
do so and include language and non-verbal IQ as con-
tinuous variables, rather than further dichotomizing the
sample.
The initial model was significant, χ2 (3) = 36.75, p <
0.001, Nagelkerke R2 = 0.30; oral language ability (B =
–0.055, p < 0.001) and non-verbal IQ (B = –0.050, p
= 0.019) were significantly associated with poor reader
status. These results suggest that children with stronger
language skills and higher non-verbal IQ were less likely to
be categorized as poor readers. The number of phonologi-
cal processing difficulties that each child experienced was
added in the next step as a categorical variable (Table 5).
The final hierarchical logistic regression model, includ-
ing all variables was statistically significant, (χ2 = 42.23,
p < 0.001, –2 LL = 144.04). The final model explained
33.9% (Nagelkerke R2 ) of the variance in reading status
and correctly classified 80% of cases. The final model indi-
cated that children demonstrating difficulties in all three
phonological processing areas, based on cut-points, were
significantly more likely to be classified as poor readers
compared with children demonstrating difficulties in one
or two areas of phonological processing. Notably, these
results show that the number of phonological processing
abilities accounted for significant variance in poor reader
status above and beyond language skills.
DISCUSSION
This study contributes to our understanding of the types
of phonological processing difficulties that school-age chil-
dren with SSD, with and without reading problems, are

TAMBYRAJA et al.
TA B L E 5 Hierarchical logistic regression predicting poor readers from the number of phonological processing risk
Variable B Wald
Step 1
Language –0.055 16.049
Non-verbal IQ –0.050 5.486
Step 2
Language –0.048 8.786
Non-verbal IQ –0.046 4.552
1 PP difficulty –1.649 3.411
2 PP difficulties –1.185 3.015
3 PP difficulties –1.339 4.396
Constant 7.633 14.101
Note: Language = Core Language subtests of the Clinical Evaluation of Language Fundamentals—4th Edition (CELF-4); Non-verbal IQ = Matrices subtest of the
Kaufman Brief Intelligence Test—Second Edition (KBIT-2). PP = phonological processing.
likely to demonstrate. An important and novel aspect of
this work is that our sample was clinically identified and
included children who were currently in receipt of school-
based services for their SSD. Thus, although our results
largely align with previous literature, we offer a contempo-
rary and clinically impactful perspective on this population
of children. Specifically, (1) children with SSD are hetero-
geneous with respect to reading ability, (2) performance
on phonological processing measures may differentiate
good and poor readers, and (3) children with SSD and
reading difficulties experience more widespread difficul-
ties across phonological processing tasks compared with
children with SSD and age-appropriate reading abilities,
even after accounting for language skills.
First, our results support that children with SSDs are
heterogeneous with respect to their reading status, lan-
guage abilities and phonological processing skills (e.g.,
Dodd, 2014; Macrae & Tyler, 2014). Approximately one-
third of the participants in this study were identified as
being poor readers. Descriptive data suggested that chil-
dren with SSD who were poor readers were older, on
average, and had significantly lower scores on all mea-
sures of phonological processing compared with children
with SSD who were good readers. Further, although this
particular study included a large number of children with
therapy goals related to both language and speech, even
those who only had speech-related goals still demonstrated
relatively poor language skills. Thus, this sample is rep-
resentative of children receiving services in school-based
settings, making this investigation ecologically valid. Of
particular interest, however, children with SSD who were
poor readers did not exhibit significantly poorer speech
sound production abilities, as measured by PCC, com-
pared with those who were good readers. Given that this
data is taken from a clinically identified sample, this
indicates that many school-age children may not exhibit
‘simple’ articulation issues or ‘just’ articulation issues (Far-
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23
Exp(β) p-value R2 change
0.300
0.947 0.000
0.951 0.091
0.039
0.953 0.003
0.955 0.033
0.192 0.065
0.306 0.083
0.262 0.036
2066.08 0.000
quharson, 2019) and that greater consideration should be
given to assessing a wider array of phonological processing
abilities.
Similar heterogeneity in underlying phonological skills
is found in other children with communication disorders
as well. For example, Gray et al. (2019) administered a
battery of working memory tasks to four distinct groups
of second-graders: TD, dyslexia, developmental language
disorder, or both dyslexia and developmental language dis-
order. These researchers identified four unique working
memory profiles ranging from low to high abilities. Chil-
dren from all four diagnostic groups were present across
each of the four profiles. Thus, even children with dyslexia,
who are often identified on the basis of their weak phono-
logical processing skills, had variable working memory
abilities. The results from Gray et al. (2019) and from
the current investigation, when taken together, are rather
surprising: children with disorders that are largely classi-
fied by their ability to use or understand the phonological
system (i.e., dyslexia and SSD, respectively) do not have
consistently low performance on phonological processing
tasks. That is, their underlying phonological processing
abilities may not translate into the expected performance
for their diagnosis. In the present study, it is possible
that the observed heterogeneity in phonological process-
ing skills was in part due to the intervention they received.
As described above, all participants in the current study
were in current receipt of speech–language therapy, with
potentially variable therapy targets. However, these data,
in conjunction with previous work (e.g., Gray et al., 2019),
suggest that it can be difficult to ascertain which chil-
dren with SSD, with and without concomitant language
difficulties, may be at risk of reading difficulties based on
performance on one task.
Second, study results showed that PA and vSTM, but
not RAN, were particularly challenging tasks for children
with SSDs. Nearly 62% of children in our sample performed

24
poorly on the measure of vSTM, including some who had
age-appropriate decoding abilities. This result is somewhat
of a paradox, as poor vSTM is often a strong predictor of
poor reading abilities (e.g., Carroll et al., 2016). As such, it
was surprising to see that some children with SSDs exhib-
ited poor vSTM but age-appropriate word reading abilities.
Although our work is the first to make this explicit observa-
tion, it is possible that this result is due to the type of vSTM
task used (i.e., digit span recall) and that performance on
a non-word recall task, for example, would have been in
stronger alignment with word reading. Overall, however,
previous research has found that vSTM skills are markedly
weak in children with SSDs compared with their TD peers
(Adams & Gathercole, 1995; Couture & McCauley, 2000;
Farquharson et al., 2018), although these studies did not
include a parallel examination into reading abilities, or
control for language abilities, as in the present work. Our
results question the extent to which an SSD may magnify
an impairment in other aspects of the phonological system.
Identifying children with SSD who are likely to have read-
ing difficulties is not straightforward. For example, there
is the possibility that children who are subthreshold at
one time point may begin to experience more difficulties
as reading instruction becomes more complex and relies
more heavily on PA and/or vSTM skills. Therefore, it is
important to continue to assess the phonological process-
ing and reading skills of children with SSD to ensure their
reading skills are supported in later school years. This is
particularly true with respect to reading comprehension,
which becomes a more heavily tested and relied-upon skill
set as children progress through schooling. If phonologi-
cal processing skills are weak, this may lead to difficulties
with decoding more complex words, and eventually lead to
difficulties with reading comprehension.
The overall difficulties with the PA task were not unex-
pected, as research indicates that many children with SSD
experience difficulties specific to PA (e.g., Pi & Ha, 2020;
Raitano et al., 2004). The task selected for measuring
PA in this study was a deletion task that required chil-
dren to verbally respond to prompts requiring them to
state new words after deleting either a word, syllable or
phoneme. This is a highly sensitive task with respect to
manipulating different phonological units, but it does not
assess varying PA skills such as rhyming, blending, seg-
mentation, and initial/final sound awareness. Thus, it is
possible that other measure of PA might have revealed
more pronounced differences in the proportion of chil-
dren exhibiting PA difficulties in each subgroup (i.e., good
versus poor readers).
Although the generally poor performance on the vSTM
was widespread, we concede that only one measure was
included and thus may not have captured nuances in mem-
ory performance that other, or additional, measures might
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PHONOLOGICAL PROCESSING SKILLS IN CHILDREN
have. For example, although our measure of vSTM (i.e.,
number recall) was static, other types of working mem-
ory tasks are dynamic which may provide a more accurate
assessment of the ‘working’ part of working memory (Far-
quharson et al., 2018). Research certainly suggests that
children with SSD, particularly those with concomitant
language difficulties similar to those in the current study,
often demonstrate poor vSTM abilities (Farquharson et al.,
2018; Waring et al., 2017), it is critical to continue exam-
ining which types of memory tasks are most sensitive and
informative for children with SSD.
The overall stronger performance on RAN was not unex-
pected (Raitano et al., 2004). Previous investigations of
children with SSDs similarly found that RAN was not
predictive of reading risk (Tambyraja et al., 2020), and Bur-
goyne et al. (2019) also found that children with speech
difficulties performed comparably with TD children on
RAN. Our RAN results could also be explained by the
specific measure. Compton et al. (2002), for instance,
administered two different RAN tasks to a group of chil-
dren. The traditional RAN (RAN-T) task scored children’s
ability to name all alphanumeric items on a matrix; the
alternative RAN (RAN-A) scored children’s ability to name
as many alphanumeric items as possible within 15 s. The
RAN-A version accounted for more of the variance in word
recognition than did RAN-T. Previous studies indicating
RAN difficulties in children with SSD have used alphanu-
meric items (e.g., Anthony et al., 2011; Leitao et al., 1997).
As such, future work should explore alternative applica-
tions of RAN tasks to clarify the relation of this skill to
reading in children with SSDs.
Finally, although our results did not indicate that one
specific type of phonological processing skill differenti-
ated children who were poor or good readers, these data
do support that children clinically identified as having
SSD who are also poor readers experienced more global
difficulties compared with children with SSD who were
good readers, across phonological processing skills (e.g.,
Peterson et al., 2009). Further, even after controlling for
language and non-verbal intelligence, children with SSD
who were identified as demonstrating difficulties in all
three areas of phonological processing were more likely to
have a comorbid reading problem, indicating cumulative
risk as the number of impaired phonological process-
ing skills increases. This is certainly in line with the
double deficit hypothesis (Wolf & Bowers, 1999), which
suggests that children with dyslexia may have difficulty
with PA, RAN or both. These measures are considered to
be independent sources of reading impairment (but see
Schatschneider et al., 2002), thus, difficulty with both will
yield a more severe case of dyslexia. Badian (1997) extended
this theory to the triple deficit hypothesis, which included
an orthographic knowledge task. Similar to the current

TAMBYRAJA et al.
results, Badian (1997) reported that when two or three skill
areas were impaired, children were classified as poor read-
ers. Notably, children in our clinically identified sample
exhibited an additional area of impairment: speech sound
production. As such, these data support a more complex
hypothesis that considers multiple deficits across multiple
domains.
Pennington (2006) conceptualized such a hypothesis
when examining the relations between children with
dyslexia, attention deficit hyperactive disorder (ADHD),
and SSD in a review of decades of behavioural and genetic
work. Evidence suggested that a multiple cognitive deficit
model is consistent with the profiles seen in these groups
of children. Although our results can be interpreted within
the double-, triple- or multiple-deficit hypotheses to some
extent—an important conclusion is that a single deficit
(i.e., speech sound production) is not sufficient data to
make a complete diagnosis or treatment decisions. Mul-
tiple sources of data must be obtained to examine word
decoding and several aspects of phonological processing.
Our results support that multiple areas of the expressive
(speech sound) and receptive (decoding and phonological
processing) phonological system are likely to be impaired
in children with SSDs. It is important that next steps
build on this and develop profiles that could be applied
to assessment and treatment. Specifically, from a clini-
cal perspective, our results underscore the critical need to
evaluate multiple phonological processing skills for chil-
dren with SSD to understand which children might benefit
from additional reading supports. In the United States, for
instance, it is not commonplace to assess these or literacy
skills when determining eligibility for services for children
with SSD (Farquharson & Tambyraja, 2019).
Limitations and future directions
Our results provide unique and robust information regard-
ing the complexities of phonological processing as they
related to word decoding for children with SSDs. However,
there are several limitations, which relate to opportunities
for future research. First, these data are cross-sectional.
Longitudinal investigations are necessary to better under-
stand how phonological processing relates to long-term
reading outcomes for children with SSD. Related, we do
not have information regarding classroom performance,
classroom reading instruction, and/or receipt of supple-
mental reading instruction. Children in this study were in
early elementary school, and thus would have had read-
ing instruction by the time of the study; however, details
regarding classroom reading practices were not obtained.
Although our measures classified children as good and
poor readers, future studies should collect data regarding
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25
classroom performance to bolster the ecological validity of
the findings. In addition, although this work offers impor-
tant information about clinically identified children with
SSD, further subgrouping according to SSD subtype and
language ability was outside the scope of this study. Future
studies should more carefully investigate the extent to
which phonological profiles may differ for children meet-
ing varying SSD subclassifications. Finally, future research
should incorporate a variety of phonological processing
measures, particularly RAN tasks that require retrieval
of both alpha and numeric objects (Schatschneider et al.,
2002), vSTM tasks involving word span, and PA tasks that
measure abilities other than phonological deletion.
CONCLUSIONS
Children with SSD are heterogeneous and demonstrate
variable phonological processing abilities. The extent
to which these variations interact with their speech
sound production difficulties requires further investiga-
tion. However, the results of the present investigation
suggest that phonological processing skills underpin read-
ing abilities, and that vSTM, in particular is a sensitive
measure for children with SSDs. Clinically, it is crucial
to also note that these skills may very likely change over
time; children should be screened at least annually and
be comprehensive enough to capture potential multiple
phonological difficulties.
CONFLICT OF INTEREST
The authors have no relevant conflicts of interest.
D A T A AVA I L A B I L I T Y S T A T E M E N T
Research data are not shared.
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How to cite this article: Tambyraja, S.R.,
Farquharson, K. & Justice, L.M. (2023)
Phonological processing skills in children with
speech sound disorder: A multiple case study
approach. International Journal of Language &
Communication Disorders, 58, 15–27.
https://doi.org/10.1111/1460-6984.12764