Introduction
The occurrence of reading problems among typical children is referred to as dyslexia or a special reading disorder. The prevalence of this disorder in different linguistic backgrounds has been reported to range between 1% and 11% [1]. Available statistics from Iran indicate a high prevalence of reading disorders (approximately 8% to 25%) among primary school students [2, 3]. This discrepancy can be attributed to the varying definitions and clinical markers of reading disorder across different societies [1]. In the clinical setting, ongoing efforts are being made for early diagnosis and intervention to ensure that children are assisted before adverse learning experiences and later literacy problems. The prevailing belief is that early diagnosis can be done by the teacher and through direct observation of the child’s behavior in the classroom [1]. However, research indicates that these problems can be predicted or detected even before elementary school.
The objective of speech-language pathology is to identify populations at risk of developing reading difficulties at the earliest possible stage for providing early intervention to prevent the emergence of long-term reading problems. Research has demonstrated that children with speech sound disorder (SSD) are among the groups at risk for long-term reading and academic problems, particularly if they co-occurred with language impairment (LI) or persisted speech disorder after entering school [4-6].
Children with SSD have the most referred disorders to clinical settings [4, 5, 7, 8, 9, 10] ranging between 1.3% and 22.9% [11, 12, 13, 14] worldwide and 6.5% and 13.8% in Iran [15, 16]. Simple deficits of speech and language at an early stage are typically discernible in preschool children by parents and teachers. Nevertheless, the diagnosis of underlying defects, such as difficulty in phonological processing or phonological awareness (PA) tasks, is most appropriately conducted by speech-language pathologists (SLPs) [17-19].
One of the key questions for SLPs is to identify which subgroups of SSD may be at risk of developing reading difficulties later in life. The SSD classification system, as established by the American Speech-Hearing Association (ASHA), is based on three categories: Phonological disorders, articulation disorders, and motor planning/programming disorders. This classification is based on the rationale that the subgroups present with different types of speech errors. Phonological disorders are identified through the analysis of rule-based errors, which are understood to have a cognitive-linguistic basis. In articulation disorders, distortions are typically manifested as isolated errors in children and sequencing errors can be attributed to deficiencies in motor planning/programming (e.g. childhood apraxia of speech) [20].
Speech error patterns can be described qualitatively in three categories: Typical, atypical, and delayed. Typical or developmental errors are those that occur more than 10% of the time in any age group. Delayed sound errors are seen in 10% of younger children, but not in the study population. Atypical or non-developmental errors do not occur in more than children of any age group [4, 19, 21]. 
There is evidence that children with phonological disorders have deficits in speech perception, phonological memory, PA, and other cognitive skills. On the other hand, children with reading difficulties have weaknesses in the phonological process. Accordingly, phonological representation is related to speech perception and PA [5]. The existing literature provides mounting evidence of the relationship between speech accuracy and reading development. In this context, speech precision analysis is proposed as a diagnostic approach for identifying risk factors associated with literacy problems in children with SSD.
Given that both written and spoken words are based on an underlying phonological representation, the accurate phonological representation is considered the most valuable criterion for investigating the relationship between the accuracy of speech and the subsequent development of reading [4]. Two key factors in determining the phonological representation are the identification of the type of speech error and the complexity of the speech stimulus concerning the nature of the error. This introduction outlines the interrelationship between the type of speech errors and PA or reading difficulties. It then delineates a systematic search conducted to ascertain the role of stimulus complexity in predicting PA/reading difficulties. The results are presented in the following section.
In a study by Leitão and Fletcher [22], they analyzed the error patterns of 36 children between the ages of five and six who exhibited signs of a phonological disorder. A reassessment of the PA, reading, and spelling skills was conducted at the age of 12–13 years. The participants who exhibited atypical error patterns demonstrated significantly lower scores on the measures of PA and reading comprehension than those who exhibited developmental errors. They identified factors that could facilitate the early identification of children who are at risk of developing reading difficulties [22]. 
In the study conducted by Rvachew and Grawburg (2006), a total of 95 children between the ages of 4 and 5 years were assessed on speech perception, articulation, receptive vocabulary, and early reading skills. Accordingly, articulation accuracy did not have a direct effect on PA. Instead, the results demonstrated that receptive language skills were the critical variable in PA [23]. Subsequently, Rvachew et al. (2007) conducted an additional study to ascertain any correlation between the types of speech errors and PA in children with SSD. The frequency and types of sound errors associated with PA were evaluated in 58 children with SSD during the prekindergarten period. At the end of the kindergarten year, children with lower scores in PA had a greater prevalence of atypical speech errors. In this study, low scores in articulation production and a high frequency of typical errors in syllable structure, as well as atypical errors in consonants, were identified as reliable indicators for predicting children’s performance in the PA test [24].
Perston and Edwards (2010) examined the relationship between speech errors and PA performance in 4- to 5-year-old children with SSD to determine which types of speech errors might predict PA performance. The results showed that 33% of the variance in PA was partially predicted by screening variables such as receptive vocabulary and age. Meanwhile, 6% of the additional variance was related to atypical sound errors. Since the children with more atypical errors did not respond well to the PA test, the association between poor PA with low frequency of receptive vocabulary and atypical speech errors was specified. In addition, the percentage of consonants correct (PCC), which is considered a measure of the severity of SSD, showed that it alone may not be an appropriate measure for predicting the child’s reading status. The analysis of errors and the specification of the type of errors provided more appropriate information for the prediction of the child’s reading ability [19]. 
Preston et al. (2013) repeated Leitão and Fletcher with a larger number of participants. They studied 25 children with SSD at 4 years and 6 months and followed up at 8 years and 3 months. To predict PA performance and later reading ability, the frequency of speech errors (distortions, typical and atypical errors) was analyzed. The results indicated that the type of speech error had a significant relationship with reading disorder. Children with atypical phonological errors scored lower on PA and reading tests, thereby confirming the results of previous studies [18].
In 2014, a similar study was conducted in Iran by Shakeri et al. They investigated the association between phonological skills (using the Persian version of the diagnostic evaluation of articulation and phonology [25]) and PA (using the PA test [26]) in 21 children with SSD aged between 5 and 6 years old. They reported that atypical phonological processes were significantly associated with components of the PA test. Poor PA in children with SSD is associated with atypical phonological processes, especially at the singleton level [27]. 
Hayiou-Thomas et al. (2017) reported delayed and disordered phonological errors with later reading skills. The 68 preschoolers with SSD were assessed on PA, reading, and spelling of single words at 5.5 years (before formal reading instruction) and 8 years. The results showed that having SSD at 3.5 years of age is associated with poor spelling and PA performance at 5.5 years and poor reading skills at the age of 8 years. Meanwhile, children with disordered speech errors had poorer word reading compared to children with delayed errors. Similar to the Preston and Edwards study, PCC was not related to reading outcomes, and concomitant LI was the strongest predictor of reading difficulties at age eight [28]. Macrae and Tyler (2014) showed that children with SSD co-occurring with LI had more omission errors and fewer distortions. They associated the occurrence of atypical errors and omissions with an increased risk of reading difficulties [4].
In a recent study, Boada et al. (2022) examined the relationship between speech error types, as defined by the ASHA, and reading skills over time. They showed that phonological errors at the age of five to six years can predict letter knowledge, PA, and reading ability at seven to nine years. Among the error types, sequencing errors had a strong association with PA (5-6 years) and reading (7-9 years) [29]. The aforementioned studies are presented in Table 1.


Based on the results of previous studies, it was concluded that even when controlling for language ability, some unique components of SSD (speech error types) may predict both prerequisite and reading skills. Recent findings on the relationship between speech accuracy and PA/reading ability suggest that it is imperative to find stronger stimuli for the underlying phonological representation. Therefore, this review study investigates the effect of speech stimulus complexity on phonological representation and reports on the relationship between polysyllabic word production (as a complex stimulus) and PA/reading. Using the results of the research, it is possible to report on the role of polysyllabic production accuracy in predicting later reading development and literacy problems and also to fill the knowledge gap in this area by designing appropriate studies.

Materials and Methods
This review was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines to ensure comprehensive information was gathered [30]. A systematic search was performed on March 3, 2023, across four databases pertinent to speech-language pathology: PubMed, Web of Science, Scopus, ProQuest, and Google Scholar. The keywords used were “polysyllable” and “multiyllable” As these terms are the most frequently used in the existing literature and no other terms are found in the medical subject headings (MeSH), they were used as the primary search terms to estimate the number of references. The number of references in each database was fewer than 1000, and the search was not limited by other words or time constraints. Since the total resources obtained from the search included all existing research, in the mentioned databases, no other keywords were used. A review of sources obtained between the years 1952 and 2023 was conducted. A manual search and review of additional sources did not yield any new articles. All of the obtained sources were imported into the Endnote software for subsequent analysis.

Inclusion and exclusion criteria
The following criteria were used to determine the inclusion of studies in this review: references about the production of real polysyllabic words; perceptually studies of polysyllabic production (acoustic or any brain imaging/neurophysiological studies were not included); population of children below 18 years old; having no restrictions on the methodology employed in the study, including the use of review articles; no limitation of the language of the references.
Meanwhile, the following references were excluded from the study: Articles or conference papers lacking full-text availability and not responded to by the authors; articles about the perception, visual recognition, reading, and spelling of polysyllabic words; references concerning the perception and production of polysyllabic nonwords; references not related to the relationship between polysyllabic real word production and reading skills.

Results
A total of 1736 references were identified through the search process. All references were exported to Endnote X9, and 730 duplicates were subsequently removed. The remaining articles (n=1006) were initially evaluated based on their title and abstract. The articles examining polysyllabic word production (n=72) were identified and subjected to full-text screening. The full-text screening of the 72 articles finally resulted in the inclusion of five articles that contained data describing the relationship between literacy/PA skills and polysyllabic word production. These articles were deemed eligible for entry into the final phase of the review and qualitative appraisal. A flow diagram of study selection is demonstrated in Figure 1. Lewis and Freebairn [31] examined 60 children with moderate to severe phonological disorders, aged between three and 8 years old, in the presence of their parents and siblings. The performance of the family members of these children in phonology, linguistics, reading, and spelling measures was described. Participants imitated 20 polysyllabic words, phrases, and sentences during an evaluation of production skills. As proposed, sibling and parent groups with no history of speech and language disorder demonstrated greater performance in reading compared to groups with a history of speech-language disorder. The sibling groups were significantly different. The group of siblings demonstrated a notable discrepancy in their production of polysyllabic words and the repetition of nonwords. However, the parent group exhibited difficulty only in repeating polysyllabic words. Subsequently, the use of polysyllabic real words could serve to differentiate between families with a history of speech disorders and those without such a history. Accordingly, polysyllabic production errors were not merely indicative of sound errors but may also serve as a predictor of subsequent reading and writing abilities [31]. 
Larrivee and Catts (1999) investigated the accuracy of polysyllabic word production and PA in a sample of 30 school-aged children with phonological disorders and 27 children with typical development. A year later, the children were given a reading test. Based on their reading scores, the children with phonological disorders were divided into two groups: Subjects with good scores and subjects with poor results. Children who were diagnosed with severe phonological disorder based on production accuracy and PCC of polysyllabic words showed diminished language abilities and PA compared to children who demonstrated proficiency in reading. The two variables that displayed the greatest variance in children’s reading progress during the first grade were the correct production of consonants in polysyllabic words and PA [17].
Sutherland and Gillon [32] examined the relationship between phonological representation and PA tasks in a sample of nine children with severe speech impairment (one girl and eight boys) and a comparison group of 17 children without speech disorders. The researchers devised both receptive and expressive tasks for phonological representation. In the expressive tasks, challenging tasks such as the repetition of polysyllabic real words, phrases, and sentences were designed to elicit speech errors, thus enabling the distinction between individuals with and without speech impairment. Accordingly, there is a correlation between an individual’s performance on PA, reading, and spelling tasks, and their language skills. The results of the receptive tasks suggested that the relationship between PA and non-word learning is more pronounced than the relationship between speech production tasks and PA performance. Consequently, the development of PA and subsequent reading skills is more dependent on the capacity to form precise and comprehensive phonological representations than on the accurate articulation of spoken words. In other words, children who are unable to achieve accurate phonological representations also encounter difficulties in the conscious manipulation of phonological components. This issue is likely to impact the early decoding of words, namely reading [32]. These findings prompted other researchers to examine the production of polysyllabic words and the errors made by children with SSD. This group of stimuli has been identified as a valuable source of information in this field of study.
Masso et al. [5] conducted a simultaneous evaluation of the production of polysyllabic words, phonological processing, expressive vocabulary, letter knowledge, and writing in 93 children with phonological disorders aged four to five and a half years old. The objective was to determine the potential relationship between the accuracy of polysyllabic word production and these skills [5]. Following the analysis of the test scores, children with SSD were classified into two distinct groups: one group exhibiting low accuracy in the production of polysyllabic words and a second group demonstrating average scores in the production of polysyllabic words. The two groups exhibited notable discrepancies in their performance on measures of PA, expressive vocabulary, rapid naming, and digit memory. Nevertheless, no significant discrepancy was observed between the two groups con
cerning matching sounds, letters, and print. The group with poor scores in written knowledge was identified as being at risk of developing reading problems. Among the two groups, there was a group at higher risk that, in addition to exhibiting poor performance in phonological processing, demonstrated a greater number of errors in the production of polysyllabic words. In this study, the severity of SSD, which was measured based on the accuracy of the production of polysyllabic words, was found to have a significant relationship with the performance of phonological processing tasks [5].
Brosseau-Lapréa and Roepke (2019) conducted a comparative analysis of the relationship between the types of speech errors produced and PA skills in two groups of children with SSD and children with normal speech development [33]. A total of 40 children aged 4- to 5 years (20 subjects with typical development and 20 subjects with SSD) completed a single-word production test comprising 1- to 5-syllable words following the administration of speech, language, and PA assessments. The number of errors committed by the typically developing children was found to be significantly lower than that of the children with SSD, with fewer instances of deletion, substitution, distortion, and developmental errors. However, no statistically significant difference was observed between the two groups in terms of the overall number of errors. The study revealed that children with typical development did not produce any non-developmental errors in monosyllabic words. However, the probability of these errors occurring in polysyllabic words was higher. Among the types of speech errors executed by children with SSD, only the omission and atypical errors in polysyllabic words were found to have a significant relationship with PA. Hence, the researchers concluded that these errors are indicative of underlying difficulty in phonological representation, which may serve as a potential marker for identifying reading difficulties [33]. Table 2 presents an overview of these studies.



Discussion 
This review investigated the role of complex stimuli, specifically polysyllabic words, in predicting reading disorders in children with SSD. This is a pertinent area of research given the numerous studies that have highlighted an increased risk of reading disorders in children with SSD. In the study conducted by Lewis and Freebairn in 1997, family members of children with SSD had poorer performance in both phonological representation and reading skills. The repetition of polysyllabic words proved an effective method of distinguishing between families of children with disabilities and those without SSD and was therefore introduced as a suitable task for predicting future reading problems [31]. The study conducted by Larrivee and Catts (1999) demonstrated that the PCC of polysyllabic words and PA played the greatest role in predicting the reading progress of the same children in their first year of school [17]. However, the findings of Sutherland and Gillon (2005) did not support these results, as they designed expressive and receptive tasks to investigate the relationship between phonological representation and PA in children with SSD [32]. The results revealed that receptive tasks and non-word learning posed a stronger correlation with PA tasks than speech production tasks. This finding aligns with the conclusions of Rvachew and Grawburg [23] and Preston and Edwards [19], who asserted that comprehension variables are a more robust predictor of later reading difficulties.
The two recent studies by Masso et al. [5] and Brosseau-Lapréa et al. [33], which employed only polysyllabic words as a production variable, demonstrated that the accuracy of producing polysyllabic words is significantly associated with the performance of phonological processing tasks. Among the various types of speech errors, only the omission and atypical errors demonstrated a statistically significant correlation with PA. These results corroborate those of previous studies conducted by Leitão and Fletcher [22], Preston et al. [18], and Hayiou-Thomas et al. [28]. The evidence indicated a direct correlation between the occurrence of atypical speech errors in children with SSD and an increased risk of developing reading disabilities. Furthermore, polysyllabic words serve as a remarkable stimulus for elucidating underlying phonological representation problems due to their greater number of phonemes. Atypical errors and omissions in these words can predict reading difficulties in children with SSD. It must be acknowledged that these studies were conducted solely in English and with a limited number of participants. Furthermore, the recent research by Boada et al. [29] has proposed the role of sequence errors in predicting reading disorders [29]. Consequently, further research is required to investigate this particular potential. It would be beneficial to conduct further research in different languages and societies. The substantial body of evidence indicating that phonological disorder is a significant early indicator of reading difficulties [5, 10, 29, 33] suggests that children with speech production problems should undergo more comprehensive and in-depth evaluation at the outset of their elementary school education, particularly in terms of fundamental phonological representation functions. 
The review demonstrated that to identify persistent phonological disorders and the potential for reading difficulties in elementary school-aged children, tests utilizing more complex stimuli, such as polysyllabic word production tests or production tests comprising a sufficient number of polysyllabic stimuli, are essential. It is also important for SLPs to consider qualitative indicators in addition to quantitative ones when evaluating production accuracy. These include error type analysis and an investigation of the role of phonological processes in the assessment procedure. It is likely that targeting and removing atypical errors in practices, with the use of phonological representation and PA tasks, can be an effective method of reducing the risk of later problems, including the persistence of speech disorders and later reading difficulties.
All the reviewed studies revealed a consistent finding that the production of polysyllabic words is associated with performance on PA tests. Hence, in addition to the standard tests used to diagnose SSD and identify error patterns, SLPs should also assess and evaluate phonemic awareness in children suspected of SSD. While survey studies have demonstrated that SLPs do not devote a significant amount of attention to PA skills and exhibit less concern for the potential for developing reading disorders during the preschool years [34, 35]. Unfortunately, the proportion of Iranian SLPs who have demonstrated an awareness of this issue is also lower than the global average. 

Conclusion
The literature review indicated that to ascertain whether phonological representation can be identified as an early risk indicator of reading disability, in addition to language ability, it would be beneficial to consider some unique components in SSD (i.e. the type of speech errors). The objective of this review was to investigate the impact of employing complex stimuli and the nature of production errors on reading difficulties. Despite the existence of a stronger relationship between cognitive variables and age with PA and subsequent reading problems, examining the number and type of speech errors in the production of polysyllabic words, especially atypical errors, and omissions in the production of preschool children, also can detect SSD and predict later reading problems. The use of polysyllabic words, which possess a greater degree of phonological information and feature greater similarity to continuous speech, renders them more suitable candidates for the identification of speech errors in children. However, given the reports of the low frequency of polysyllabic words in the continuous speech of children with SSD in comparison to children with typical development, it may be advantageous to integrate these words into single-word production tests and identify their speech errors as a means of more accurately gauging the accuracy of representation. Furthermore, the identification of these issues at an early age allows for the implementation of timely intervention, which may prevent the development of reading difficulties in the future. The evidence obtained from this review indicates that an evaluation package for children with SSD in preschool should include multisyllabic word production and a PA test.

Research limitations
The research was conducted with the limitation that the Scopus database was not accessible through the university. Consequently, an account had to be created from within another service. The process of obtaining sources and corresponding with the authors of the articles, as well as awaiting and incorporating their responses, was quite time-consuming. As all available sources about the article’s objective were in English, the review and conclusion were unproblematic.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Medical Ethics Committee of the University of Social welfare and Rehabilitation Sciences, Tehran, Iran (Code: IR.USWR.REC.1402.083).

Funding
This review study was taken from the PhD dissertation of Mersede Imani-Shakibayi, approved by the Department of Speech therapy, School of Rehabilitation, University of Social Welfare & Rehabilitation Sciences, Tehran, Iran. This study has been supported in the form of a thesis project by the Pediatric Neurorehabilitation Research Center of the University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
Conceptualization, methodology, review, analysis of sources, and writing the original draft: Mersede Imani-Shakibayi; Project supervision and management: Talieh Zarifian; Review and editing: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to express their gratitude to the Pediatric Neurorehabilitation Research Center for its financial support of this research project.


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