Perspectives of Speech-Language Pathologists on Prosodic Intervention in Children with Hearing Impairment

Abstract

Prosody is an essential component of speech naturalness and improves speech intelligibility. Prosodic deficits are notably prevalent among children with hearing impairment (CwHI). Speech Language Pathologists (SLPs) are service providers responsible for identification and intervention of disorders of prosody. So far, there are limited published reports on the awareness and competence of SLPs in prosody intervention. The present study aimed to understand the knowledge and perspectives on prosody of SLPs working among CwHI through an online survey. A 10-item questionnaire was developed and utilized for this purpose. Additionally, information on the clinical service delivery of the respondents was also collected. A total of 130 SLPs responded to the survey (response rate = 65%). Although most respondents (93.1%) agreed that prosodic impairment impacted speech intelligibility of CwHI, 76.2% never provided intervention for prosodic deficits in CwHI. Several respondents (74.6%) opined of not receiving adequate training on assessment and intervention of prosodic impairments in CwHI. 82.3% of respondents were unaware of prosody assessment or treatment materials for CwHI. More than half of respondents (56.9%) felt that prosody is usually a low priority when considering the speech and language needs for CwHI. Nevertheless, 73% of respondents believed that it is necessary to target prosody as early as possible along with conventional speech and language interventions. The findings from this survey identify a clinical area largely ignored by SLPs among CwHI. Addressing these could lead to more comprehensive clinical care for CwHI, ultimately improving speech intelligibility and communication outcomes.

Introduction

Intonation, stress and rhythm are the components of prosody in human speech. These prosodic components serve significant functions in communication and are particularly important as they acoustically highlight the information a speaker wants to convey to the listener [1]. Acoustically, prosody is manifested as variations in fundamental frequency, duration, and intensity. These variations indicate several grammatical and pragmatic distinctions and help to verbally convey the emotions. For example, intonation cues as to a statement is made or a question; stress helps to highlight key words of a sentence and rhythm corresponds to the overall flow and structure of speech. Together, these components of prosody improve the naturalness of speech and aid in enhancing the speech intelligibility of the speaker.

Overall, without these prosodic components, verbal communication would be more challenging and less effective. When the normal prosodic characteristics of speech are disturbed, an individual is said to have dysprosody or prosodic deficits. Individuals with communication disorders often demonstrate prosodic impairments [2]. Prosodic deficits are notably prevalent among children with hearing impairment, developmental apraxia of speech, autism and adults with dysarthria.

Speech Language Pathologists (SLPs) are service providers responsible for identification and intervention of disorders of prosody. So far, there are limited published reports on the awareness and competence of SLPs in administering the existing prosody assessments. Nevertheless, SLPs tend to ignore prosody, and consider prosodic intervention as a last stage of speech therapy [3] particularly for children with hearing impairment (CwHI), though it is a significant aspect contributing to speech intelligibility [4, 5].

Need of the Study

Early intervention in CwHI often address the language and articulation characteristics while prosody has not received much attention [6]. When targeted in the earlier stages, prosody intervention provides an additional benefit in improving speech intelligibility. Listeners often perceive higher variability in pitch, loudness, and duration among CwHI compared to typically developing children [7] which is not generally evaluated clinically. Individuals with hearing loss find it difficult to perceive fine changes in pitch, duration, and loudness [8]. Inaccurate perception of these acoustic cues is reflected as difficulties in recognizing different components of prosody, such as differentiating question from statement, vocal emotion recognition, distinguishing word/phrase boundaries, and word stress [9–11]. Words or phrases are unusually lengthy, and the pitch contour has been observed to be excessively high, monotonous, or simply ‘inappropriate’ in individuals with hearing impairment.

While many researchers [12–14] have called for greater attention to prosody in clinical practice, it is not known if SLPs regularly evaluate or treat prosody, let alone if they base their decisions on the best available research. Hawthorne and Fischer [2] addressed this gap by surveying SLPs on their clinical practices related to prosody, as well as potential barriers to assessment and treatment. They found that SLPs regard prosodic deficits as having minimal impact and/or being of low priority.

On similar lines, the present study attempts to address the awareness of prosody among SLPs working with CwHI to understand their knowledge and elicit perspectives related to prosody assessment and treatment. No prior research has determined SLPs’ perceptions concerning prosodic aspects particularly in CwHI in the Indian context. Such a study can highlight the need for including prosody within general clinical evaluation and encourage SLPs to work on developing materials for prosody assessment and intervention for CwHI or for any other communication disorders per se.

The present study aimed to understand the knowledge and perspectives on prosody of student clinicians and practicing SLPs working among children with hearing impairment through an online survey. The specific objectives of this study were to, (1) examine the awareness of Speech-Language Pathologists on prosodic deficits in children with hearing impairment; (2) determine the self-reported competency of Speech-Language Pathologists on assessing and managing prosodic deficits in children with hearing impairment; (3) understand the associations between respondent characteristics and the perspectives on the prosodic aspects relating to the speech of children with hearing impairment; (4) determine the current practices in intervention for prosodic deficits in children with hearing impairment; and (5) delineate the potential barriers that constrain Speech-Language Pathologists for an effective service delivery related to prosodic deficits in children with hearing impairment.

Method

Research Design

This study followed a non-experimental research design. Data was collected through an online questionnaire-based cross-sectional survey research. The Checklist for Reporting of Survey Studies (CROSS) [15] was used for reporting the methods and results of this study.

Development of the Survey Questionnaire and Its Validation

The first step of this research involved generation of appropriate questions for the online survey. Relevant sources such as books, journal articles and other grey literature reporting on the prosodic deficits in CwHI were consulted and authors derived a preliminary questionnaire with a total of 16 questions suitable for this survey research. This preliminary questionnaire was content validated by a panel of six experienced SLPs had a postgraduate degree in Speech-Language Pathology and were involved in clinical practice among CwHI for a minimum of two years. The SLPs commented on the relevance of each item to the measured domain, the familiarity of the concepts and about the presentation of the content within each item. Relevant questions deemed appropriate by the panel of raters were included in the final questionnaire. Content validity Index [16] of the final questionnaire was found to be 0.9, which is suggestive of good content validity for six raters. Thus, the final core questionnaire consisted of a total of ten questions. These questions are tabulated in Table 1.

Table 1.

The ten core questions used in this survey

Sl. No.	Type of Question	Question
1	5-point Likert Statement	Does prosodic impairment impact speech intelligibility in Hearing Impairment?
2	Binary Choice	Do you take up goals on prosody during intervention for children with Hearing Impairment?
3	Binary Choice	Did you receive adequate training on assessment and treatment of prosodic impairments in children with Hearing Impairment during your course work?
4	Binary Choice	Are you aware of any prosody assessment or treatment materials for children with Hearing Impairment? If Yes, Specify
5	5-point Likert Statement	Do you feel prosody is usually a low priority when considering the speech and language needs as a whole for a child with Hearing Impairment?
6	Binary Choice	Are you confident in assessing and treating prosody in children with Hearing Impairment as other aspects of speech and language?
7	5-point Likert Statement	Do you feel assessment or treatment of prosody is time consuming in children with Hearing Impairment?
8	5-point Likert Statement	Do you think it is necessary to target prosody as early as possible along with conventional speech and language interventions for children with Hearing Impairment?
9	Open ended Question	What strategies or approaches can be used for prosody treatment in children with HI?
10	Binary Choice	Have you provided intervention for prosodic deficits in children with Hearing Impairment?
10a	Open ended Question	If you have implemented prosody treatment for Hearing Impairment, what were the areas targeted?

A google form was created by the first author after the finalization of the questions and was divided into four sections. The first section of the google form provided information about the aim, purpose and need for this research, along with contact details of the investigators. In addition, the first section of the google form was also used to collect the consent of the respondents for participation in the survey along with their contact details and demographic details relating to their educational qualification, and years of experience. The second section of the google form collected information on the clinical service delivery of the respondents. The third section of the survey consisted of ten survey questions. These questions consisted of binary choice questions (Yes/No responses), 5-point Likert-style statements (responses of 1 to 5 with 1 being strongly disagree and 5 being strongly agree), and open-ended questions. The fourth section of the survey was optional and was dependent upon the response of the participants to the question 10 (Have you provided intervention for prosodic deficits in children with Hearing Impairment? ). If the response was Yes, the respondents had to specify the areas targeted for prosody intervention for CwHI in response to question 10a (If you have implemented prosody treatment for Hearing Impairment, what were the areas targeted? ). The respondents could add additional comments to supplement their answers for each question, however, it was not mandatory. Once the google form was prepared, it was subjected to pilot testing by three other SLPs. Based on pilot testing, the google form was slightly modified for improved ease of use and understanding of the respondents.

Sampling and Participants

A convenient sampling method was used to recruit participants for the study. Invitations to participate in this survey research along with the link to google form was sent to 200 prospective participants through personal communication (WhatsApp and E-mail) from mid-June 2023 to August 2023. Prospective participants were identified to be an SLP after having obtained a minimum of bachelor’s degree in audiology and speech-language pathology or its equivalent. For the purpose of this research, we considered students who were pursuing their master’s degree in Speech-Language Pathology, professionals practicing as SLPs in various clinical setups, research scholars, and faculty at different speech and hearing institutions. Responses from participants who were currently not working as SLPs or were involved in any other profession were not considered for further analysis.

Data Analysis

The data obtained from this survey was analyzed appropriately. For numerical data, SPSS version 26 was used for the analysis. Descriptive analysis was carried out along with frequency count and percentage of the data. Relationships between the different variables and the responses of the participants were examined using Pearson Chi-Square test of association. Further, responses obtained for open ended questions were analyzed qualitatively and barriers that constrain service delivery were identified.

Results

Respondent Characteristics

Complete responses to the survey were obtained from a total of 130 SLPs (response rate = 65%).

Out of the 130 participants (Mean age 26.22 ± 3.87 years), 72 (55.4%) were practicing professionals and 58 (44.6%) were pursuing postgraduate studies. The mean age of practicing professionals was 27.93 ± 4.28 years, whereas it was 24.09 ± 1.65 years for postgraduate students.

These respondents had diverse work setups, which included training institutions (72.3%), hospitals (12.3%) private clinics (10.8%) and special schools (4.6%). Years of experience in clinical care of CwHI ranged from less than one year to 22 years. Although all the respondents have dealt with CwHI at any point of time during their clinical practice, 86 respondents (66.2%) were involved in speech and language rehabilitation of children with HI during the participation in the study. However, there was a variation in the proportion of children with HI among the clients who availed the services of these SLPs. Among these 86 respondents, 42 (48.8%) reported 0–20% of their caseload being CwHI. Twenty-six respondents (20%) reported that 21–40% of their cases are CwHI, whereas 11 respondents (8.5%) had 41–60% of their cases are CwHI. Only a minor share of the respondents reported higher proportions of CwHI 61–80% (4 respondents [3.1%]) or 81–100% (3 respondents [2.3%]).

Responses to the Questions of the Survey

The majority of the respondents (n = 121, 93.1%) agreed that prosodic impairment impacted speech intelligibility of CwHI. In contrast, five respondents (3.8%) disagreed with the statement that prosodic agreement impacted speech intelligibility of CwHI, and four respondents (3.1%) did not have an opinion or were neutral. Intervention of prosody was not a part of rehabilitative goals of 75 respondents (57.7%). Ninety-Seven participants (74.6%) opined of not receiving adequate training on assessment and intervention of prosodic impairments in CwHI during their course work. Similarly, 107 respondents (82.3%) were unaware of any prosody assessment or treatment materials for CwHI. Predictably, 74 respondents (56.9%) felt that prosody is usually a low priority when considering the speech and language needs as a whole for CwHI. However, 34 respondents (26.2%) felt otherwise that prosody often prioritized when considering the speech and language needs as a whole for CwHI. A total of 22 respondents (16.9%) were of no opinion or neutral on this statement. Even though a preponderance of participants (n = 95, 73.1%) felt that assessment and management of prosodic disturbance among CwHI were not time consuming, a good percentage of respondents (n = 105, 80.8%) reported being incompetent for the same. Nevertheless, the majority of respondents (n = 95, 73%) believed that it is necessary to target prosody as early as possible along with conventional speech and language interventions. However, most of the respondents (n = 99, 76.2%) never provided intervention for prosodic deficits in CwHI. In response to the open-ended questions on strategies or approaches which can be used for prosody treatment in CwHI, a wide variety of responses were obtained. The response of the participants to the binary choice questions 2, 3, 4, 6, and 10 are depicted in Fig. 1.

Fig. 1.

Responses of the participants to binary choice questions

Association between the Participant Characteristics and Survey Responses

The responses were examined with a stratification of the respondents into practicing professionals and postgraduate students of Speech Language Pathology. Pearson Chi-Square test did not reveal an association of the study group with the responses to any of the questions involved in the current study. Hence, it can be inferred that there are no differences in perspectives of practicing clinicians and post graduate students of Speech Language Pathology on the prosodic aspects relating to the speech of children with hearing impairment. Similarly, there were no associations observed between work setup of the respondents or the proportion of CwHI cases seen and their responses to the survey questions. This suggests that these factors, do not influence the perspectives of SLPs on the prosodic aspects relating to the speech of children with hearing impairment.

However, significant associations were observed between participant groups and two respondent characteristics. These were interaction with CwHI and the involvement of respondents with CwHI during participation in the study. The results of these significant associations are provided in Table 2. Additionally, when the participant characteristics were associated with the responses to survey questions, some statistically significant associations were found (Table 3). These were for questions 6, 8 and 10 of the survey.

Table 2.

Significant associations between participant groups and respondent characteristics

	Respondent Characteristics	χ2	p-value	Finding
1.	Interaction with CwHI	17.235	0.004	Practicing professionals were observed to have a higher duration interaction with CwHI (5 + years)
2.	Involvement with CwHI during participation in study	10.357	0.001	Post graduate students of SLP were more involved in clinical practice with CwHI.

Table 3.

Significant associations between participant characteristics and survey questions

Question No.	Participant Characteristics	χ2	p-value	Finding
6. (self-reported confidence of the clinicians in assessing and treating prosody in CwHI)	Duration of Interaction with CwHI	11.387	0.004	Respondents with longer duration of interaction with CwHI demonstrated a higher self-reported confidence in assessing and treating prosody in CwHI
	Involvement with CwHI during participation in study	6.598	0.01	Respondents presently involved with CwHI in clinical practice demonstrated a higher self-reported confidence in assessing and treating prosodic disturbances in CwHI.
8. (perspective of the clinician on the necessity to target prosody as early as possible along with conventional speech and language interventions for CwHI	Duration of Interaction with CwHI	32.304	0.04	Respondents with longer duration of interaction with CwHI agreed better on the need for early intervention to target prosodic disturbances in CwHI.
	Involvement with CwHI during participation in study	11.472	0.022	Respondents presently involved in clinical practice with CwHI felt that early intervention is necessary to target prosodic disturbances in CwHI.
10. (whether the respondents had provided intervention for prosodic deficits in CwHI)	Duration of Interaction with CwHI	12.137	0.033	Respondents with longer duration of interaction with CwHI have often provided intervention for prosodic disturbances in CwHI.
	Involvement with CwHI during participation in study	5.707	0.017	Respondents presently involved in clinical practice with CwHI, have provided intervention for prosodic disturbances in CwHI.

Responses to Open Ended Questions

Responses from the open-ended questions yielded the identification of several strategies or approaches which are used for prosody treatment in CwHI. These strategies included improving the stress patterns, intonation, loudness, rhythm, inflections, pauses, tonal discrimination, rate of speech. Some SLPs reported working on pauses, frequency, duration, and intensity, as well as emotions in speech. Additionally, some respondents also reported on the use of different types of sentences (questions vs. statements).

Analysis of the open-ended questions have revealed two major barriers that constrain prosody service delivery. The first barrier was the lack of adequate training of SLPs in identifying and managing prosodic disturbances in CwHI. This is highlighted as most respondents (> 80%) were unaware of assessment or treatment materials for prosodic deficits in CwHI. The second barrier was clinical practice related concerns. Clinicians opined that targeting prosody is often of a low priority in daily clinical practice, even though it is not time consuming.

Discussion

The survey findings provide a comprehensive overview of the demographics and professional backgrounds of Speech-Language Pathologists (SLPs) involved in the clinical care of children with hearing impairment (CwHI). The response rate of 65% indicates a substantial level of engagement from the SLP community, which adds credibility to the data. The predominance of training institutions as the primary work setting for SLPs (72.3%) highlights the importance of academic environments in the development and dissemination of speech and language rehabilitation practices. The distribution across hospitals, private clinics, and special schools emphasizes the diverse contexts in which SLPs operate, potentially influencing their approach to treatment and care. However, such differences in the work settings were not found to influence the perspectives of SLPs on the prosodic aspects relating to the speech of children with hearing impairment.

The wide range of experience, from less than a year to over two decades, indicates a heterogenous study population. The fact that all respondents have dealt with CwHI at some point suggests a universal aspect of SLP training and practice, whilst 66.2% of respondents presently involved in rehabilitation points to a significant portion of the workforce actively engaged in this area.

The variation in the proportion of CwHI among clients served by the SLPs reflects the diverse needs and demands of their practices. A majority of SLPs reported that a smaller fraction (0–20%) of their caseload consists of CwHI, which may indicate either a lower prevalence of hearing impairment in their client base or a broader range of speech and language issues being addressed. The smaller percentages of SLPs with higher proportions of CwHI in their caseload could suggest specialized practices or regions with higher incidences of hearing impairment.

The survey results reveal a significant consensus among SLPs regarding the impact of prosodic impairment on the speech intelligibility of children with hearing impairment (CwHI), with a vast majority (93.1%) acknowledging its importance. Despite this recognition, there appears to be a gap in the integration of prosody into rehabilitative goals, as indicated by 57.7% of respondents. A concerning 74.6% of respondents reported inadequate training in the assessment and intervention of prosodic impairments, which is further compounded by 82.3% being unaware of any specific assessment or treatment materials for CwHI. This lack of preparedness and resources may contribute to the low prioritization of prosody in treatment plans, as reported by 56.9% of respondents.

While a majority (73.1%) did not find the assessment and management of prosodic disturbances time-consuming, an even larger percentage (80.8%) felt incompetent in these tasks. The self-reported incompetency of the SLPs in assessing and managing prosodic disturbances in CwHI could be because of the lack of clinical training. It is notable that, although the majority of SLPs (73%) believe in the necessity of targeting prosody early in conjunction with conventional interventions, 76.2% have never provided such intervention. This inconsistency highlights a critical area for improvement in clinical practice.

The survey’s stratified analysis offers valuable insights into the perspectives of SLPs regarding prosodic aspects in the speech of CwHI. The lack of association between the study groups (practicing professionals vs. postgraduate students) and their responses suggests that the approach of both the groups in assessing and managing the prosodic deficits in CwHI are similar. This calls for further attention in improvising clinical care targeting prosodic deficits in CwHI.

The significant association between the duration of interaction with CwHI and the responses to certain survey questions points to several important findings. It indicates that longer involvement with CwHI similar to any other clinical population, plays a pivotal role in shaping the confidence and perceived competence of clinicians [17, 18]. Clinicians with longer involvement are more likely to feel confident in assessing and treating prosodic disturbances, which could be attributed to increased exposure to a variety of cases and challenges over time. The fact that postgraduate students are more involved in clinical practice with CwHI than practicing professionals, suggests the need for comprehensive training that equips all SLPs with the skills and confidence to address prosodic impairments effectively.

The strong agreement among clinicians currently involved in clinical practice with CwHI and those with longer duration of interaction with CwHI on the necessity of targeting prosody early aligns with the broader literature advocating for early intervention in speech and language therapy. Early intervention is often associated with better outcomes in various developmental areas, including speech and language [19–21]. The survey findings reinforce this principle specifically for prosody in CwHI, suggesting that early and focused attention on prosodic features could be beneficial.

The association between the duration of interaction with CwHI and the likelihood of providing intervention for prosodic deficits is significant. Clinicians with a longer history of working with CwHI are more likely to have provided such interventions. This finding suggests that experience enhances not only the skillset but also the inclination to engage in more beneficial treatment approaches, focusing on the needs of the client [22, 23].

The wide variety of responses to open-ended questions about treatment strategies for prosody in CwHI indicates a rich field of potential approaches, yet also reflects the absence of a standardized protocol. These findings underscore the need for enhanced training programs and the development of specialized materials focused on prosody for CwHI. The disparity between the recognition of prosody’s importance and its implementation in therapy suggests that SLPs may benefit from additional support and education in this area. Barriers that constrain the service delivery in this domain were identified in consonance with a previous study [2]. The first barrier was the lack of adequate training of SLPs [24]. Majority of respondents (> 80%) were unaware of assessment or treatment materials for prosodic deficits in CwHI. The second barrier was clinical practice related concerns. Clinicians opined that targeting prosody is often of a low priority in daily clinical practice [12], even though it is not time consuming [7]. More often, language and functional communication targets were prioritized over speech goals [6, 25].

Summary and Conclusions

This study presents the results of a preliminary survey exploring the perspectives of practicing SLPs on the assessment and management of prosodic deficits in CwHI. Results of this survey highlight that prosody is often a low priority area in the speech and language rehabilitation of CwHI. Our findings suggest that, despite being aware of the potential role of prosody in speech intelligibility, clinicians feel incompetent to assess and manage prosodic deficits which call for clinical attention and warrants introspection. Further research should investigate the barriers to incorporating prosody into clinical practice and develop strategies to overcome them. Additionally, the creation and validation of assessment and intervention tools for prosody in CwHI could bridge the current gap in resources.

In summary, the survey indicates a clear recognition of the significance of targeting the perception and production of prosody in CwHI but also highlights a disconnect between this understanding and practical application among SLPs. Addressing the training and resource needs of SLPs could lead to more comprehensive care for CwHI, ultimately improving speech intelligibility and communication outcomes.

Implications

By understanding SLPs’ perspectives on prosody assessment and treatment for CwHI, this study can contribute to the development of evidence-based practices in the field. Additionally, it can provide insights into the specific challenges and needs of CwHI in the Indian context, helping to tailor interventions that are culturally and linguistically appropriate.

Author Contribution

Both the authors (AM and NS) contributed to the study conception and design. Material preparation, data collection and analysis were performed by AM. The first draft of the manuscript was written by AM and was revised by NS. Both the authors have read and approved the final manuscript.

Funding

This research was funded by All India Institute of Speech and Hearing Junior Research Fellowship awarded to the first author (2022 to 2025).

Declarations

Compliance with Ethical Standards

This study received ethical approval from the Institutional Review Board (AIISH ETHICAL COMMITTEE) of All India Institute of Speech and Hearing (SH/EC/PhD/SLP-2/2023-24). An informed consent (for participation in the study and for publication of the results) was obtained from all the individual participants included in the study.

Competing Interests

The authors report of no competing interests.