# Status of prosody in the practices of speech-language pathologists in France: A survey on theoretical and clinical dimensions

A. Petitpain, J. Brabant-Thery, Cédric Patin, Laurent Ott, Anahita Basirat

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## To cite this version:

A. Petitpain, J. Brabant-Thery, Cédric Patin, Laurent Ott, Anahita Basirat. Status of prosody in the practices of speech-language pathologists in France: A survey on theoretical and clinical dimensions. Journal of Communication Disorders, 2023, Journal of Communication Disorders, 107, p.106404. 10.1016/j.jcomdis.2023.106404. hal-04453528

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# Status of prosody in the practices of speech-language pathologists in France: a survey on theoretical and clinical dimensions

Aline Petitpain¹, Juliette Brabant-Thery¹,², Cédric Patin³, Laurent Ott⁴, Anahita Basirat⁴*

1. Department of Speech and Language Therapy, Faculty of Medicine, UFR3S, F-59000 Lille, France

2. Department of Neurology, Roger Salengro Hospital, CHU Lille, F-59000 Lille, France

3. Univ. Lille, CNRS, UMR 8163 - STL - Savoirs, Textes, Langage, F-59000, Lille, France

4. Univ. Lille, CNRS, UMR 9193 - SCALab - Sciences Cognitives et Sciences Affectives, F-59000 Lille, France

Address correspondence to:

Laboratoire SCALab UMR CNRS 9193

Université de Lille

Rue du barreau

BP 60149

59653 Villeneuve d'Ascq Cedex

France

Email: anahita.basirat@univ-lille.fr

This is the author accepted manuscript version of the following article:

Petitpain, A., Brabant-Thery, J., Patin, C., Ott, L., & Basirat, A. (2024). Status of prosody in the practices of speech-language pathologists in France: A survey on theoretical and clinical dimensions. *Journal of Communication Disorders*, 107, 106404.

<footnote>*: Corresponding author</footnote>
**Abstract**

**Purpose:** Many populations in the scope of speech and language pathologists (SLPs) are at risk of prosodic disorders that can impact communicative ability. While a few studies have examined the importance of prosody in the clinical practice of English-speaking SLPs, there is a lack of similar research in non-English-speaking countries. The current study aimed to establish an overview of the situation in France and to determine factors that might be associated with assessing and treating prosody.

**Method:** We collected data about the theoretical and clinical dimensions related to prosody from SLPs in France using an online survey.

**Results:** One hundred and twenty-eight valid responses were analyzed. Results suggest that both emotional and linguistic prosodies are examined by SLPs. Some aspects of prosody seem to be mastered better than others. While they are aware of the major prosodic difficulties in various pathologies and their negative impact, most SLPs in France rarely or never assess prosody. They feel more uncomfortable with it than with other speech-language domains and often do not consider it as a therapeutic target. Importantly, the perception of prosody as a therapeutic tool is associated with the frequency of assessing and addressing prosodic impairment.

**Conclusions:** Further studies should focus on identifying the factors that could improve practices and developing comprehensive assessment tools and evidence-based intervention methods in French. Providing better training in prosody and setting up more collaborations between SLPs and researchers in linguistics and psycholinguistics would be keys in developing this field.

**Key-words:** prosody; clinical practice; speech and language pathology; France
Introduction

Prosody is an umbrella term which designates the characteristics of speech which goes beyond
segments. Although prosody is considered as one of the essential features of effective interaction
(Levinson & Toni, 2019), it is reportedly a difficult subject for speech-language pathologists (SLPs)
(Peppé, 2009). This is a crucial issue as it may affect how prosody impairments are diagnosed and
managed by SLPs. The aim of the current study was to investigate the status of prosody in the
clinical practice of French SLPs.

Various definitions of prosody have been suggested in the literature (e.g., Crystal, 2008; Beckman & Venditti, 2011). Wagner & Watson (2010) provided definitions, one focusing on the functions of prosody and the other on its form. Prosody, defined by its functions, refers to "those phonetic and phonological properties of speech that are crucially not due to the choice of lexical items, but rather depend on other factors such as how these items relate to each other semantically and/or syntactically, how they are grouped rhythmically, where the speaker places emphasis, what kind of speech act the utterance encodes, whether turn taking in conversation is being negotiated, and they can reflect the attitude and emotional state of the speaker" (p. 906). Based on its form, prosody is defined as the "properties such as syllable structure, intonation, and reflexes of prosodic structure, which are acoustically reflected in fundamental frequency, duration, and intensity" (907).

Prosody thus refers to the phenomena such as stress, tone, rhythm, phrasing, and intonation.

Prosody is expressed through various phonetic parameters such as duration, amplitude, and
fundamental frequency (F0). For instance, the sentence "Ramona's a lawyer" will end with a sharp
rising of the F0 when spoken as an echo question, while it will end with a lowering of the F0 when
spoken as a neutral declarative (Ladd 2008). Importantly, these same parameters are also used to
convey paralinguistic information such as emotions. This may account for the use of two separate
terms in the literature. 'Linguistic prosody' refers to the linguistic functions of prosody, while
‘emotional prosody’ refers to the expression of emotion and affect. It is therefore important to
differentiate between the linguistic aspects of prosody and its phonetic expression, as well as
between the linguistic and paralinguistic uses of these phonetic parameters (Arvaniti, 2020).

Prosody and speech and language pathology

The perception and production of prosodic cues may be impaired in various disorders and pathologies which are treated by SLPs, such as speech disorders of neurological origin (e.g., apraxia of speech, dysarthria), fluency disorders, hearing impairments, and developmental disorders such as Autism Spectrum Disorders (ASD). Various aspects of prosody can be affected. Examples of prosodic changes are monotony of F0 in Parkinson's disease (e.g., Basirat et al., 2018), poorer perception of contrastive stress in adults with hearing loss (Kalathottukaren et al., 2017), and poorer imitation of intonation in children with ASD (Peppé et al., 2011) (for more details about the ways in which prosody can be impaired in different populations, see Peppé, 2009; Hawthorne & Fischer, 2020; Van Lancker Sidtis & Yang, 2021; Paul et al., 2021). Owing to their repercussions on communicative and social skills (Paul et al., 2005; Palmer et al., 2019), prosodic disorders need to be assessed and treated by SLPs when appropriate.

Recently, Hawthorne and Fischer (2020) conducted a survey on the status of prosody in the practice of American SLPs. They found that prosody is never assessed by the majority of SLPs and only rarely or occasionally treated by most SLPs. To our knowledge, no study to date has examined the importance of prosody in the clinical practice of non-English-speaking SLPs. The current study aimed at filling this gap by investigating whether and how French SLPs target prosody in their practice. Differences in educational and health systems, clinical tools and the scope of practice of SLPs across countries may mean that prosody has a different status in France. For instance, French SLPs do not work on issues such as accent reduction or business communication (American Speech-Language-Hearing Association, 2016). They cannot work directly in childcare facilities or in
schools, and they can only intervene on a very occasional basis, under legal conditions related to
the children's disability status. It is also noteworthy that the prosodic systems of French and
English share many properties (Gussenhoven 2004). However, there is a notable exception that
French does not exhibit lexical accent (Delais-Roussarie et al. 2015). All these issues may lead to
the prosody having different statuses in the two countries.

Prosody impairments in French-speaking patients have been investigated in various pathologies (e.g., Basirat et al., 2018; De Looze et al., 2019). Few clinical assessment tools exist in French and most concern neurological pathologies, such as the Batterie d'Évaluation Clinique de la Dysarthrie (BECD) (Auzou & Rolland-Monnoury, 2019), MonPaGe (Laganaro et al., 2021), DIADOLAB (Menin-Sicard & Sicard, 2019) and the Protocole Montréal d'Évaluation de la Communication (MEC) protocol (Joanette et al., 2004). Importantly, these tools focus on expressive skills, except the MEC (Joanette et al., 2004), which addresses both receptive and expressive skills. No tool assesses prosody in all its aspects (form, function). One of the rare French-language treatments based on prosody is the Thérapie Mélodique et Rythmée (TMR) (Eeckhout & Allichon, 1978), which is an adaptation of the Melodic Intonation Therapy (MIT) for aphasia (Sparks & Holland, 1976). While TMR takes advantage of prosody during the intervention, it does not specifically target prosody. A few studies have examined how SLPs use prosody in their clinical practice (e.g., the study of Patin and Macchi (2021) on the use of prosody as a tool in the context of SLP-child interactions). Despite these efforts, the status of prosody in the clinical practice of French SLPs remains elusive and the potential barriers to prosody treatment and assessment require detailed investigation.

Potential barriers for prosody assessment and treatment

Several types of barriers to optimal clinical practices have been described in the literature.

Cochrane et al. (2007) pointed to professional, patient, system and process barriers and those embedded in the guidelines, evidence support or resources. In the field of speech and language
pathology, some difficulties may not be addressed because they are not considered a priority by
professionals. For instance, after a stroke, SLPs may treat dysphagia before aphasia in an acute
hospital setting (Foster et al., 2013). In addition, working on language difficulties may be prevented
by other associated deficits. Another important factor influencing the clinical practices of SLPs is
suggested to be clinical self-efficiency (i.e., individual confidence in performing tasks related to
speech and language assessment and treatment, Pasupathy & Bogschutz, 2013) (see also,
McBride, 2022). Of specific interest to this work, Hawthorne and Fischer (2020) reported that the
likelihood of assessing and treating prosody increased with the confidence of SLPs in their ability to
do so. Little research has been dedicated to describing the barriers to the clinical practices of SLPs
in non-English-speaking populations. In France or other French-speaking countries, some of the
invoked limitations are the lack of time and skills in searching for evidence and evaluating scientific
information in English (Maillart & Martinez-Perez, 2017; Durieux et al., 2016) and the lack of
standardization of measures and assessment tools (Pommée et al., 2021) (see also Macoir et al.
(2021) and Tyler et al. (2022) for other barriers).

Regarding prosody assessment and treatment, several impediments have been specifically
highlighted in the literature, one of which being the complexity of ‘normal’ prosodic practice. As
pointed out by Van Lancker Sidtis and Yang (2021), prosody is not always tracked consciously by
listeners while attending to the verbal content. There are also many functional prosodic features
that vary within and between healthy speakers. The difficulty to describe prosodic phenomena in
general and to define what is considered ‘normal’ may be some of the reasons for a lack in
evaluation materials and treatment tools. In addition, there is no prosodic transcription system
equivalent to the International Phonetic Alphabet which is widely accepted and used (Delais-
Roussarie & Yoo, 2011). ToBI (Tones and Break Indices) is a well-known annotation system for
prosody, which is available in multiple languages and makes it possible to transcribe prosody at the
level of phonology (Silverman et al., 1992). Although it is a powerful transcription system and a
valuable tool for conducting research on prosody, ToBI is known to be labor-intensive and requires
significant training and theoretical knowledge (Jun, 2022). In clinical contexts, Peppé (2009)
pointed to the lack of precise vocabulary and common representations to describe prosody
impairments, and the difficulty for SLPs to identify whether it is prosody or another aspect that is
impaired. Other issues are the lack of formal training and practice and that of evidence-based
interventions targeting prosody (Hawthorne & Fischer, 2020; Diehl & Paul, 2009). In sum,
understanding, assessing and treating prosody have been found to be challenging for SLPs.

Current study

The present study aimed to investigate the status of prosody in the clinical practice of SLPs in France. To this end, we collected data from French SLPs using an online survey. Our primary objective was to establish an overview of the situation in France, while our second objective was to determine factors that might be associated with clinical practices related to prosody. Based on the literature reviewed above, we had the following hypotheses. We hypothesized that when faced with suspected prosody issues, SLPs in France assess and treat prosody infrequently. We also hypothesized that the theoretical knowledge of prosody presents challenges for SLPs. Moreover, we posited that the frequency of assessment and treatment is associated with the following aspects: the importance given to prosody in clinical practices, the estimated impact of prosodic difficulties on communicative abilities, and the level of self-efficiency, in terms of knowledge and skills.

Methods

Participants

Since several aspects investigated in this study were may be influenced by national context, our
target population consisted of SLPs who had both graduated and were working in France. Eligibility
was determined by self-reporting: we included the participants who completed the questionnaire
until the final section. There were no incentives for participation.

Survey design and data collection

The survey was implemented using LimeSurvey (LimeSurvey Project Team & Carsten Schmitz, 2012). A welcome page indicated the aim of the study, the inclusion criteria, the number of sections, the estimated completion time and the guarantee that no identifying data would be collected. We used the survey of Hawthorne and Fischer (2020) as a basis, regarding clinical practices related to prosody, training and resources, and we adapted it to the French context. Furthermore, we developed a new series of questions to explore conceptual knowledge of prosody (e.g., its definition, its acoustic correlates, its functions) and opinions on the importance of prosody within the field of speech-language pathology, as these aspects remained unaddressed in the original survey. A translated version of the survey in English is available in Supplementary Material 1.

In summary, to achieve our primary and secondary objectives and to examine our hypotheses, the
survey gathered information on the following aspects: the demographics and professional
backgrounds of the participants, their knowledge and attitudes towards the role of prosody in
clinical practice, their typical assessment and treatment practices, and the perceived obstacles to
integrating prosody into their work. The survey included 31 questions, six of which were
conditional and appeared only depending on the previous answers. Only 12 questions were
mandatory. We limited the number of the latter to facilitate the completion of the survey until the
last section. There was no filter question, as no question was designed to exclude participants from
answering certain subsequent questions based on their current answer. Question formatting
included a combination of single-choice items (n = 9), multiple-selection responses (n = 6), Likert
rating scales (n = 10) and open-ended items (n = 6). Participants were able to navigate backwards
through questions and modify their answers. The questionnaire was designed in accordance with
the Survey Checklist (Manifesto), which establishes criteria regarding item formulation, response
options as well as formatting and organizing (Gehlbach & Artino, 2018). The questionnaire was
developed by the first author (A. P.) and reviewed by the second, third and the last authors (J. B.-T.,
C. P. and A. B.). The first version of the survey was tested by a qualified SLP and two SLP students in
their fourth and fifth year of training. It was submitted to the local Data Protection Officer of the
University of [XXX], who issue an exemption from reporting under the General Data Protection
Regulation.

Data was collected anonymously between January 2023 and April 2023. The survey link was
distributed via e-mail to the regional SLP unions (Fédération des Orthophonistes de France, and
Fédération Nationale des Orthophonistes), to the authors' professional network and to relevant
national mailing lists. It was also posted on various Facebook group pages dedicated to SLPs. The
answer rate could not be calculated, as we could not trace how many recipients the survey link
was delivered to.

Data analyses

Responses were exported from the LimeSurvey platform and analyzed using the R software (R Core
Team, 2022). We excluded participants who had graduated outside of France and those who did
not complete the questionnaire until the final section. To establish an overview of the status of
prosody in French SLPs (i.e., our primary objective) and test our first and second hypotheses (i.e.,
the infrequent assessment and treatment of prosody by SLPs in France and the challenges faced by
SLPs in grasping the theoretical aspects of prosody), we performed descriptive analyses. For
questions with multiple choices, we calculated the number and percentage of responses for each
response option. The questions on the definition of prosody and the most frequent
disorders/diagnoses were open-ended items. For these questions, we used a conventional
qualitative content analysis as described by Hsieh and Shannon (2005) to classify answers into a few categories. We then calculated the number and percentage of answers in each category. Regarding the definition of prosody, the third and last authors (C. P. and A. B.) classified all responses independently. Disagreements were resolved by discussion. The classifications of disorders or diagnoses were suggested by the first author (A. P.) and reviewed by the second, who is a practicing SLP (J. B.-T.).

Our second objective was to explore factors that might be associated with clinical practices related to prosody. We hypothesized that the frequency of assessment and treatment is associated with the following aspects: the importance given to prosody in clinical practices, the estimated impact of prosodic difficulties on communicative abilities, and self-efficiency, in terms of knowledge and skills. To test these hypotheses, we used Kendall rank correlations to examine the association between the frequency of prosody assessment and treatment, and the clinical perception of prosody, the estimated negative impact of prosodic difficulties, the feeling of being comfortable with theoretical notions, assessment and treatment of prosody and the feeling of being clinically qualified in prosodic issues. Detailed information about the questions used in our correlation analyses are provided below.

Regarding the frequency of prosody assessment and treatment, the participants were asked to answer ‘never’, ‘rarely’, ‘sometimes’ or ‘always’. Participants who answered “*I have never had a patient with prosodic impairment*” were excluded from the association analyses involving this variable. We used ‘clinical perception of prosody’ to refer to the way participants consider prosody from clinical perspectives. Six aspects were included in our study: prosody as a support tool, as a rehabilitation tool, as a means of compensation, as a main therapeutic target, as a therapeutic yet secondary target, and as a symptom of certain disorders when it is altered. Participants were asked to select a maximum of three items. They could provide an open-ended response. Regarding the
estimated negative impact of prosodic difficulties, participants were asked to rate the following aspects, from 'no impact' to 'major impact': acquisition of spoken language, ability to understand one's interlocutor, intelligibility, ability to express oneself, interactions in daily life, and social image. A 5-level Likert scale was used. Regarding the feeling of being comfortable with prosody compared to other domains, three aspects were included: theoretical notions of prosody, prosody assessment, and prosody treatment. Participants were asked to rate each item from 'much less comfortable' to 'much more comfortable' using a 5-level Likert scale. Finally, the question about the feeling of being qualified in prosodic difficulties was a 'yes-no' question. As all the items used in association analyses were items with no/yes or Likert-type responses, they were treated as ordinal in statistical analyses. We considered the association between two variables as significant when the p-value was lower than 0.05. To address the issue of multiple testing, we applied a Holm-Bonferroni correction to the correlation matrix including all examined correlations.

## Results

We collected 245 responses, of which 117 were excluded either because the questionnaire was left unfinished (n = 102) or because the SLPs had not been trained in France (n = 15). One hundred and twenty-eight participants were thus included in this report. The average response time was 16 minutes and 9 seconds. To align with the study's primary and secondary objectives and our hypotheses, we organized the results into the following sections: characteristics of participants, theoretical notions of prosody, importance of prosody in speech-language pathology, prosody-related clinical practices, and potential barriers for assessing and treating prosody.

### Characteristics of participants

This section provides an overview of the general characteristics of participants. It also includes information related to the clinical practice and experience of participants and their education, with a particular focus on prosody. For the sake of brevity, some details are not included in this section
but can be found in Supplementary Material 2. Table 1 shows a summary of the demographic characteristics of the participants. Participants graduated between 1972 and 2022, mostly between 2008 and 2022 (54%). About a third of the participants graduated after 2018, i.e., after SLP training became a five-year Masters in France. Participants were from 12 (out of 13) mainland regions of France (see Supplementary Material 2, Table 1). The mode of practice was reported to be predominantly private. Two participants did not answer the question about their place of practice and one about the mode of practice.

<table><caption>Table 1: Characteristics of participants. N and % represent the number and the percentage of participants.</caption><thead><tr><th></th><th>N</th><th>%</th></tr></thead><tbody><tr><td><strong>Year of certification</strong></td><td></td><td></td></tr><tr><td>1968-1977</td><td>1</td><td>1</td></tr><tr><td>1978-1987</td><td>10</td><td>8</td></tr><tr><td>1988-1997</td><td>17</td><td>13</td></tr><tr><td>1998-2007</td><td>31</td><td>24</td></tr><tr><td>2008-2017</td><td>32</td><td>25</td></tr><tr><td>2018-2022</td><td>37</td><td>29</td></tr><tr><td><strong>Mode of practice</strong></td><td></td><td></td></tr><tr><td>Private practice</td><td>72</td><td>56</td></tr><tr><td>Salaried</td><td>46</td><td>36</td></tr><tr><td>Mixed practice</td><td>9</td><td>7</td></tr><tr><td>Not answered</td><td>1</td><td>1</td></tr><tr><td><strong>Number of patients with prosodic difficulties per year</strong></td><td></td><td></td></tr><tr><td>0</td><td>5</td><td>4</td></tr><tr><td>Between 1 and 5</td><td>66</td><td>52</td></tr><tr><td>Between 6 and 20</td><td>40</td><td>31</td></tr></tbody></table>
<table><tr><td>Between 21 and 50</td><td>14</td><td>11</td></tr><tr><td>Over 50</td><td>3</td><td>2</td></tr></table>

Regarding the most frequent diagnoses for the participants' patients with prosodic difficulties, the most common responses were ASD (23% of the occurrences), neurodegenerative pathology (12%) and acquired brain injury (12%). When responses which explicitly indicated a neurological pathology were combined (i.e., acquired brain injury, neurodegenerative pathology, brain injury (unspecified) and neurological disorder), they accounted for 31% of the total. Regarding the frequency of being referred patients for prosodic difficulties, 62% of SLPs replied "never", 24% "rarely", 10% "sometimes", and only 3% "frequently". The level of clinical experience of participants per condition managed by SLPs was the highest for developmental language disorder and dyslexia, followed by acquired brain injury and neurodegenerative pathologies (for details, see Figure 1 in Supplementary Material 2). Most participants were little to not satisfied about their initial training in prosody in general (66%) and about prosody development (81%), assessment (80%) and treatment (80%) specifically (for details, see Figure 2 in Supplementary Material 2). Most participants (91%) stated there are not enough continuing education training opportunities in prosody for SLPs and 82% did not complete a continuing education session, either directly or indirectly related to prosody. Importantly, participants mostly attributed their acquired knowledge or experience about prosody, its development, assessment and/or treatment to professional experience with patients after certification (59%) (for details, see Figure 3 in Supplementary Material 2).

## Prosody in clinical practices
Our first hypothesis was that when faced with suspected prosody issues, SLPs in France assess and treat prosody infrequently. As shown in Figure 1, when a prosodic impairment is suspected, most participants never assess prosody while only 9% always assess it. The three most frequent assessment methods, reported by those who do assess prosody, are BECD (Auzou & Rolland-Monnoury, 2019), a non-standardized assessment method developed by themselves or by another professional (e.g., acoustic analysis, perceptual analysis...), and the MEC (Joanette et al., 2004). Regarding the frequency of prosody treatment, the most frequent response was 'sometimes' and only 16% of the participants always treat prosodic difficulties (Figure 1). Interestingly, the TMR (Eeckhout & Allichon, 1978) and Lee Silverman Voice Treatment (LSVT) (Sapir et al., 2011) were provided by participants as intervention methods in their open-ended responses. Regarding the nature of prosody impairments, the skills that are most often observed to be altered in the patients primarily concern conveying emotions, then conveying attitudes (e.g., irony, sarcasm...), perceiving emotions, perceiving attitudes, conveying and perceiving linguistic information (Figure 2).

<figure><img src="image_3.png" /><figcaption>Figure 1: Assessment and treatment frequencies</figcaption></figure>
<figure><img src="image_4.png" /><figcaption>Figure 2: Impaired prosodic skills observed in patients</figcaption></figure>

Regarding potential factors in clinical settings limiting prosody assessment and/or treatment, most participants mentioned that prosody assessment and/or treatment was either prevented or significantly limited by other impairments considered to be more important (e.g., swallowing disorders, other language disorders) or by other associated disorders (Figure 3). Most participants felt much less comfortable with prosody assessment and treatment than with other domains of language (Figure 4). They felt they did not have adequate prosody resources for transcription (86%), objective description (78%), rapid (73%), standardized (83%), and patient-specific (87%) assessment, and evidence-based intervention methods (92%). Only 12% of them felt sufficiently qualified to work with patients with prosodic difficulties. The others expressed the need to improve their prosodic knowledge and skills, mostly in terms of treatment and assessment methods (Figure 5).
<figure><img src="image_5.png" /><figcaption>Figure 3: Opinions on potential factors in clinical settings limiting prosody assessment and/or treatment</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>Figure 4: Comfort with prosody compared to other domains of language</figcaption></figure>
<figure><img src="image_7.png" /><figcaption>Figure 5: Dimensions on which SLPs felt they could improve their prosody-related skills</figcaption></figure>

Regarding how prosody was perceived from a clinical perspective among the six items suggested in the survey, the role of prosody as a support tool was estimated to be the most important (and thus more important than its role as a therapeutic target) (Figure 6). Regarding the 'other' responses provided by participants, the most common response highlighted the importance of prosody in facilitating understanding and communication. Interestingly, one participant reported modulating their prosody despite not specifically working on it, owing to managing children with severe disabilities. One participant considered prosody not to be a priority. Regarding estimated extent of prosodic challenges and the level of prioritization, prosody was estimated to be a priority target mainly in transgender voice transition, followed by fluency disorders and hearing loss (Figure 7). Prosodic difficulties were not estimated in neurodegenerative pathologies, as this item was missing in the survey owing to a technical problem. Participants also rated to what extent prosodic difficulties may impact different aspects of communication. The impact on 'social image', 'interactions in daily life', and 'ability to understand one's interlocutor' were estimated to be more important than other aspects (Figure 8).
<figure><img src="image_8.png" /><figcaption>Figure 6: Clinical perception of prosody</figcaption></figure>

<figure><img src="image_9.png" /><figcaption>Figure 7: Estimated extent of prosodic challenges in various populations at risk</figcaption></figure>
<figure><img src="image_10.png" /><figcaption>Figure 8: Estimated impact of prosodic impairment</figcaption></figure>

## Knowledge about prosody

Our second hypothesis was that the theoretical knowledge of prosody presents challenges for SLPs. Three questions probed this aspect. They concerned (1) the definition of prosody, (2) the participants' feeling of being comfortable with theoretical notions of prosody compared to other language aspects, and (3) various aspects of linguistic prosody. In a decreasing order from 26 to 10 occurrences, the most frequent keywords given by participants to define prosody were speech, rhythm, intonation, melody, voice, musicality, modulation, emotion, pitch, accentuation and variation (see Supplementary Material 3 for all the definitions). Most SLPs felt less comfortable with the theoretical notions of prosody compared to those of other language aspects (see Figure 4). Regarding the various aspects of linguistic prosody, participants indicated the extent to which they were comfortable with acoustic correlates, articulatory correlates, sentence types, focus, and word grouping (Figure 9). Overall, fewer than 10% of participants expressed complete comfort with these aspects. They found the acoustic and articulatory correlates to be particularly challenging.
<figure><img src="image_11.png" /><figcaption>Figure 9: Comfort with various aspects of linguistic prosody</figcaption></figure>

## Potential barriers for assessing and treating prosody

Our last three hypotheses were that the frequency of assessment and treatment is associated with the importance given to prosody in clinical practices, with the estimated impact of prosodic difficulties on communicative abilities, and with the level of self-efficiency, in terms of knowledge and skills, respectively. Table 2 shows significant correlations between the frequency of prosody assessment and treatment and the factors of interest related to these hypotheses (see Supplementary Material 4 for non-significant results). We observed positive correlations between the frequency of prosody assessment and the fact of considering “prosody as a main therapeutic target”, the feeling of being comfortable with theoretical notions and with the assessment and treatment of prosody, and the feeling of being qualified in prosodic difficulties. The frequency of prosody treatment was found to be positively correlated with considering “prosody as a main therapeutic target” and with the estimated negative impact of prosodic difficulties on the acquisition of a spoken language, intelligibility, expression ability and daily interactions. We also observed a positive correlation between the frequency of prosody treatment and the feeling of
being comfortable with theoretical notions and with the assessment and treatment of prosody, and the feeling of being qualified in prosodic difficulties.

<table><caption>Table 2: Correlation between frequency of prosody assessment and treatment and the factors of interest. Only significant correlations are shown.</caption><thead><tr><th></th><th>Tau</th><th>95% CI</th><th>z</th><th>P</th></tr></thead><tbody><tr><td>Clinical perception: "prosody as a main therapeutic target"</td><td>0.33</td><td>(0.23, 0.43)</td><td>4.04</td><td>&lt; .01</td></tr><tr><td>Feeling of being comfortable with theoretical notions</td><td>0.40</td><td>(0.30, 0.50)</td><td>5.00</td><td>&lt; .001</td></tr><tr><td>Assessment</td><td></td><td></td><td></td><td></td></tr><tr><td>Feeling of being comfortable with assessment</td><td>0.48</td><td>(0.39, 0.57)</td><td>5.94</td><td>&lt; .001</td></tr><tr><td>Feeling of being comfortable with treatment</td><td>0.34</td><td>(0.23, 0.44)</td><td>4.27</td><td>&lt; .001</td></tr><tr><td>Feeling of being qualified</td><td>0.26</td><td>(0.14, 0.36)</td><td>3.08</td><td>&lt; .05</td></tr><tr><td>Treatment</td><td></td><td></td><td></td><td></td></tr><tr><td>Clinical perception: "prosody as a main therapeutic target"</td><td>0.30</td><td>(0.19, 0.41)</td><td>3.65</td><td>&lt; .01</td></tr><tr><td>Impact of prosodic difficulties on acquisition of spoken language</td><td>0.24</td><td>(0.12, 0.35)</td><td>3.04</td><td>&lt; .05</td></tr><tr><td>Impact of prosodic difficulties on intelligibility</td><td>0.29</td><td>(0.17, 0.39)</td><td>3.68</td><td>&lt; .01</td></tr><tr><td>Impact of prosodic difficulties on ability to express oneself</td><td>0.25</td><td>(0.14, 0.36)</td><td>3.20</td><td>&lt; .05</td></tr></tbody></table>
<table><thead><tr><th></th><th>Tau</th><th>95% CI</th><th>z</th><th>P</th></tr></thead><tbody><tr><td>Impact of prosodic difficulties on interactions in daily life</td><td>0.29</td><td>(0.17, 0.39)</td><td>3.62</td><td>&lt; .01</td></tr><tr><td>Feeling of being comfortable with theoretical notions</td><td>0.33</td><td>(0.22, 0.44)</td><td>4.13</td><td>&lt; .001</td></tr><tr><td>Feeling of being comfortable with assessment</td><td>0.36</td><td>(0.25, 0.46)</td><td>4.46</td><td>&lt; .001</td></tr><tr><td>Feeling of being comfortable with treatment</td><td>0.44</td><td>(0.34, 0.53)</td><td>5.52</td><td>&lt; .001</td></tr><tr><td>Feeling of being qualified</td><td>0.32</td><td>(0.21, 0.42)</td><td>3.87</td><td>&lt; .01</td></tr></tbody></table>

Discussion

In most studies so far on the status of prosody in clinical practice, the focus was on English-speaking SLPs (e.g., Peppé, 2009, Hawthorne & Fischer, 2020). Data in non-English-speaking countries is limited. The present study gathered information from French SLPs regarding the theoretical notions of prosody, its importance in speech-language pathologies and related clinical practices. We aimed at establishing an overview of the situation in France and at determining factors that may be associated with assessing and treating prosody. We hypothesized that when faced with suspected prosody issues, SLPs in France assess and treat prosody infrequently and that the theoretical knowledge of prosody presents challenges for SLPs. In accordance with these hypotheses, our results suggest that the majority of SLPs do not always assess and treat prosody and that SLPs face challenges in grasping some theoretical aspects of prosody. We also posited that the frequency of assessment and treatment is associated with the following three aspects: the
importance given to prosody in clinical practices, the estimated impact of prosodic difficulties on communicative abilities, and the level of self-efficiency, in terms of knowledge and skills. The results suggest that the frequency of prosody assessment is associated with the importance given to prosody in clinical practices and to the feeling of being comfortable and qualified regarding prosodic issues. However, the association with the estimated impact of prosodic difficulties on communicative abilities was not significant. Consistent with our hypotheses, the results regarding treatment suggest that the frequency of prosody treatment is associated with all the three aspects mentioned above. These findings are discussed below.

## Prosody in clinical practices

One of the major findings of the current study concerns clinical practices. First, most SLPS in France never or rarely assess prosody when a prosodic impairment is suspected. In addition, referring patients to SLPs, for instance by physicians and teachers, to treat prosodic difficulties is uncommon in France, which may lead to a delay in addressing such issues. Second, regarding prosody treatment, most participants declared they sometimes or always address prosody in the event of prosodic impairment. In comparison to those who reported they sometimes or always assess prosodic difficulties, twice as many SLPs declared they sometimes or always treat these difficulties.

This difference may be linked to the lack of prosody assessment tools. Another explanation may be that SLPs do not feel the need to assess prosody before addressing it, or that they usually treat prosody among a set of other deficits regularly associated with a given disorder. These are crucial issues which should be investigated in future studies. Third, the results show that although SLPs observe prosodic issues in both reception and expression, they are more frequent in the ability to convey one's emotions (and to a lesser extent, regarding linguistic prosody). Fourth, French SLPs reported feeling less comfortable with prosody than with other language domains in terms of theoretical notions, assessment and intervention. This may be due to their impression of not
having sufficient initial training and continuing education opportunities related to prosody. Fifth, a lack of appropriate methods or tools to describe, transcribe and assessing prosody were reported to be limiting factors. Most SLPs believed that prosody assessment and/or treatment was either prevented or significantly limited by other impairments considered to be more important or by other associated disorders. Finally, they also expressed the need to improve their prosodic knowledge and skills, mostly in terms of assessment and treatment methods.

Regarding the clinical perception of prosody, our results suggest that the importance of prosodic difficulties and the need to address them are recognized by SLPs. They consider that such issues have a negative impact on various aspects of communicative abilities. However, they mostly perceive prosody as a tool to support remediation or as a sign of impairment rather than as a therapeutic target. In addition, the role of prosody as a means to compensate other impairments was perceived by only 11% participants, although prosodic cues such as intonation may be factors supporting intelligibility (Klopfenstein, 2009). These results suggest that the role of prosody in speech-language pathology may be perceived in a limited way by SLPs.

## Knowledge about prosody

The results regarding the definition of prosody show that ‘rhythm’, ‘intonation’ and ‘melody’ were the most frequent aspects of prosody reported by the participants. Speech rhythm is a complex notion which may be described from different perspectives (White & Malisz, 2021), one of which focuses on structural relations. This approach, which is influential in research in phonology of prosody, describes rhythm as the alternation of stronger and weaker elements (Nolan & Jeon, 2014), adopting a conception of rhythm as the product of prominence and patterning (Arvaniti, 2009). Our data do not specify what participants meant by ‘rhythm’. Whether the term refers to parameters such as speech rate and pause positions or whether it also refers to boundary cues is unclear (Jun & Fougeron, 2000; see also Daigmorte et al., 2022). Further studies are thus required
to determine what conceptions of rhythm were adopted by participants. As previously mentioned,
'intonation' and 'melody' were also among the most frequent definitions. This means that SLPs
may have primarily associated prosody with intonation. If confirmed, this would be a crucial issue
as it could impact the assessment and treatment of prosody. For instance, SLPs might assess the
production of prosody in marking sentence modality (e.g., statement vs. question), yet neglect
other functions such as phrasing or focus. The results also show that most SLPs define prosody
based on its underlying acoustic/perceptual properties (e.g., pitch, modulation/variation)
compared to articulatory correlates. Finally, emotion is one of the aspects of prosody most
frequently reported by the participants. This suggests that this dimension of prosody is considered
by SLPs.

Our findings also show that SLPs feel very uncomfortable with the theoretical notions of prosody
compared to other language domains. Regarding linguistic prosody, they seem to be comfortable
with the focus and grammatical functions of prosody, such as grouping and modality of sentences.
Although the questionnaire included a question on word grouping, we did not specifically
investigate prosodic phrasing. Since this aspect is less often studied in pathological populations
suffering from prosodic impairments (Frota et al., 2021), we might expect SLPs not to be
comfortable with such notions. They seemed to be more confident about the linguistic functions of
prosody than about the acoustic features conveying prosodic cues and the motor aspects which
underlie their production. The phonetic expression of prosody may thus be challenging for SLPs. In
sum, while they may be comfortable with some aspects of the theoretical notions of prosody,
others need to be further addressed.

Potential barriers for assessing and treating prosody

While our primary objective was to establish an overview of the situation in France, our second
objective was to determine the potential barriers to the clinical practices related to prosody. To do
so, we tested three hypotheses on the role of the clinical perception of prosody, the estimated impact of prosodic difficulties on communicative abilities, and the feeling of being comfortable and qualified in assessing and treating prosody. In line with our hypotheses, we observed that the frequency of assessing and treating prosody are associated with the perception of prosody and the feeling of being comfortable or qualified in it: SLPs who consider prosody as a main therapeutic target or have the feeling of being more comfortable or qualified in it tend to assess and treat prosody more frequently than their counterparts. Moreover, the frequency of prosody treatment was related to the estimated impact of prosody impairment on the acquisition of a spoken language, intelligibility, expression ability and daily interactions. This means that SLPs who consider prosodic impairments more disabling than others treat them more frequently. The awareness about the negative impacts of prosody impairment could thus be one of the factors promoting prosody treatment by SLPs.

Although the above-mentioned associations were statistically significant, their strength is also an important issue. Various conventions are available in the literature to interpret the magnitude of the coefficient of correlations and are used to decide whether the association between two variables is weak, moderate or strong (e.g., Akoglu, 2018). However, consensus lacks about how to determine the minimal threshold strength in medical research as it depends on clinical contexts (Kraemer, 2006). It has been argued that "*empirical guidelines for interpreting the magnitude of correlation coefficients are, to some extent, artificial*" (Hemphill, 2023, p. 79). Despite these limitations, if we use a 0.4 cutoff to identify moderate and strong associations, three associations could be considered at least moderate: the association between assessment frequency and the feeling of being comfortable with theoretical notions of prosody, the association between assessment frequency and the feeling of being comfortable with prosody assessment, and the association between treatment frequency and the feeling of being comfortable with prosody treatment. Overall, these results suggest that improving self-efficiency regarding prosody might be
one of the levers to improve clinical practice. This possibility could be examined in further investigations. Future studies could adopt a longitudinal approach, as in the study of McBride (2022), to better identify how the development of clinical self-efficiency in prosody assessment and treatment may lead to changes in clinical practices. However, merely enhancing comfort and self-efficiency, without a corresponding increase in knowledge, could lead to issues. Future studies on the status of prosody in clinical practice should also explore the relationship between these feelings of comfort and the necessity for knowledge.

## Comparison with the study of Hawthorne and Fischer (2020)

Many results obtained in our study were similar to those reported by Hawthorne and Fischer (2020) in their study on SLPs in the US, such as the frequency of prosody assessment and treatment. In both studies, over 80% of SLPs agreed that prosodic difficulties impact intelligibility, the ability to express oneself and social image. In addition, in both studies, most SLPs felt less comfortable with prosody than with other domains of language in terms of assessment and treatment. Finally, the associations between assessment frequency and comfort in assessing prosody, and between treatment frequency and comfort in treating prosody, were among the strongest in the study of Hawthorne & Fischer (2020), as they were in our investigation. Overall, both studies highlight the existence of strong barriers related to prosody that need to be investigated and overcome in future research. However, some differences need to be mentioned. One of the differences was the availability of continuing education opportunities related to prosody, which was estimated to be very low in our study compared to that of Hawthorne and Fischer (2020). A major difference between our study and the study of Hawthorne and Fischer (2020) on SLPs in the US concerns the properties of the two samples. 72% of the participants in the study of Hawthorne and Fischer (2020) were school-based SLPs. Probably related to this, the most common diagnosis in the study of Hawthorne and Fischer (2020) was ASD (55% in total, 61% in
school-based SLPs) while neurological pathologies were the most frequent in our study (ASD represented only 23% of responses). This implies that the responses from SLPs in the Hawthorne and Fischer (2020) study might be more reflective of characteristics associated with clinical practices for children, while our study may mirror those associated with adult practices.

## Limitations

The current study has a few limitations, some of which are related to our sample. Indeed, our results could be affected by a selection bias. The SLPs who decided to participate may differ in terms of knowledge, consideration and practices of prosody from those who did not complete the survey, as they may have felt less concerned and involved in addressing prosody. Other limitations are the relatively small number of participants in our sample and the over-representation of salaried SLPs (vs. private SLPs). Indeed, the percentage of responses we received from salaried pathologists (36%) was greater than what they actually represent in the French SLP population (less than 15%) (official governmental statistics: ADELI- Drees, 2022). There may also be limitations related to the collected data. The answers to the questions about clinical practices may have been impacted by a social desirability bias, as SLPs may have wanted to appear as good professionals and thus answered that they address prosody more than they actually do. However, this bias may have been minimized by guaranteeing that responses were anonymous. There may also have been a question order effect: the answers to the questions that appeared first in the survey may have influenced the answers to subsequent ones. In addition, there may be limitations related to the questions and items included in the survey. In several questions, expressive and receptive skills were merged. This was done to decrease the number of questions and increase the number of participants who completed the survey. However, merging these two aspects may have complicated the interpretation of questions for participants. Moreover, although important information about the profile of patients was collected, no question about their age was included.
This is a limitation as the goals and considerations when assessing and treating prosody may differ
in children and adults. This may result in varying levels of clinical priority given to prosody. Finally,
we did not investigate the factors which may facilitate addressing prosody in clinical practice.
While the focus on barriers seems consistent in the literature on the status of prosody in the field
of speech and language pathologies (e.g., Peppé, 2009; Diehl & Paul, 2009; Hawthorne & Fischer,
2020), the factors impacting the practice of health professionals can also operate positively
(Shrubsole et al., 2019; Duncan & Murray, 2012). Enabling factors should therefore also be
investigated in future studies.

Recommendations

Some recommendations could be made as a result of this study. First, there is an obvious need to
develop comprehensive assessment tools to evaluate both receptive and expressive skills in all
aspects of prosody (form, functions). Second, prosody should be considered as a therapeutic goal
to be addressed in the management of language disorders. The beneficial effects of prosody
treatment have been reported in a few studies (e.g. Ballard et al., 2010; Neumann et al., 2018;
Holbrook & Israelsen, 2020; Benedetti et al., 2022). In their review, Hargrove et al. (2009) deplore a
lack of publications about prosody interventions. However, to our knowledge, there is no French
treatment tool that targets prosody. Third, prosody could be used more formally by SLPs
themselves to improve the management of other impairments (Patin & Macchi, 2021). Fourth,
more studies should investigate factors which impact the related clinical practices. The importance
attached to prosody conceptually and the estimated negative impact of prosodic impairment on
communicative abilities are crucial issues to be taken into account. Finally, more information about
prosodic difficulties (how to detect them, what they can induce) could be provided to physicians
and teachers to improve screening. To implement these recommendations, we believe that
providing SLPs with better training about prosody is necessary. As a start, Box 1 provides a brief
summary regarding the definition of prosody, its functions, and its relevance in clinical practice.

This could be particularly useful for SLPs who may not feel comfortable with the concept of prosody. We also believe that the field of speech and language therapy may benefit from collaborations between SLPs and researchers in linguistics and psycholinguistics in order to develop prosody assessment and treatment tools. Access to the scientific literature could also be improved so that SLPs may keep updated about new tools and techniques. Future studies should investigate the factors which may lead SLPs to implement evidence-based practice regarding prosody assessment and intervention, both in terms of barriers and enablers.

**Box 1. Prosody and its importance in speech and language pathology**

This summary provides a brief overview of what prosody is and its clinical relevance for clinicians. It is based on Arvaniti (2020), Wagner & Watson (2010), and Hyman (2006) for theoretical aspects and on Van Lancker & Yang (2021), Paul et al. (2021), and Peppé (2009) for clinical aspects.

**What is prosody?**

Prosody is an umbrella term which designates the characteristics of speech which go beyond segments (i.e., vowels and consonants). Prosody refers to the characteristics of speech that depend on factors such as rhythmic grouping of words, placement of emphasis by the speaker, and type of speech act encoded by the utterance. In addition to linguistic functions, prosody also has paralinguistic functions and conveys the emotions and attitudes of the speakers. When prosody refers to the expression of emotion and affect, the term 'emotional prosody' is usually used in the literature.

The main prosodic phenomena are:

*   **Intonation:** Intonation corresponds to the systematic and language-specific changes of fundamental frequency which span utterances.

*   **Phrasing:** Words are grouped together into chunks, rather than being produced/perceived as separate and distinct elements. Chunks of words are organized in hierarchical prosodic structures.

*   **Rhythm:** The notion of rhythm in speech is complex. A common definition is the
perception of groups of similar and repetitive patterns of phrasal constituents, which are
themselves rhythmically organized. This operates both at the level of the word and the
phrase.

* Stress/accent: Stress/accent causes syllables to stand out compared to others. It allows contrast (e.g., 'object' as a noun versus 'object' as a verb) and delimitation (e.g., "black 'bird'" versus "blackbird").

* Tone: In a language with tone, an indication of pitch enters into the lexical realization of at least some morphemes.

These prosodic phenomena are not independent. For instance, intonation marks phrasal boundaries. To comprehend intonation, it is thus important to have an understanding of phrasing as well.

**How is prosody expressed?**

Prosody is mostly expressed through duration, amplitude, and fundamental frequency. These same phonetic parameters are used to convey linguistic and paralinguistic information. Although usually defined as 'suprasegmental', prosody does not work independently of segments at the phonetic level. For instance, English vowels are reduced in the unaccented position or the accent on the phrase-initial segment in Korean depends on whether the segment is aspirated or tense.

**Why should prosody be taken into account in speech and language pathology?**

Relying on its linguistic and paralinguistic functions, prosody plays a prominent role in communication by conveying attitudes, emotions, intentions and meanings. For instance, prosody alone enables us to distinguish questions from statements or to express irony. Moreover, it is crucial for language development and considered as one of the essential features of effective interaction.

**In which situations are people at risk of prosodic difficulties?**

Situations with a risk of prosodic difficulties frequently reported in the literature are genetic syndromes such as Down syndrome and Williams syndrome, hearing impairments, developmental disorders such as autism spectrum disorders and specific learning disorders, fluency disorders, developmental language disorder, transgender voice transition, voice disorders, ear, nose and throat pathologies, speech disorders of neurological origin (e.g., apraxia of speech, dysarthria), acquired brain injuries, and neurodegenerative pathologies (e.g., Alzheimer's disease, primary progressive apraxia of speech).
Each of these situations might have a different impact on prosody and therefore requires appropriate assessment and treatment. Namely, when addressing prosody issues, it is important to differentiate between the linguistic functions of prosody and their phonetic expression, as well as between the linguistic and paralinguistic uses of the phonetic parameters. Prosody can be altered both in form and in its linguistic or paralinguistic functions, at both receptive or expressive levels.

## Conclusions

This study presents an overview of the status of prosody in the practices of SLPs in France. Regarding theoretical notions, the results suggest that while SLPs are comfortable with some aspects of the theoretical notions of prosody, others need to be further addressed. Regarding clinical practice, most French SLPs never or rarely assess prosody, despite the awareness that major prosodic difficulties exist in various pathologies and that they have a negative impact. They also feel more uncomfortable with prosody than with other speech-language domains and often do not consider it as a therapeutic target. Importantly, this perception of prosody as a therapeutic target was found to be associated with the frequency of assessment and treatment of prosodic impairment. Further research should attempt to identify the factors which can improve practices as well as to develop comprehensive assessment tools and evidence-based intervention methods in French. To this end, providing better training in prosody and setting up more collaborations between SLPs and researchers in linguistics and psycholinguistics would reap great benefits.

## Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

## Acknowledgments
We are grateful to the participants and to those who helped distribute the survey. This work was supported by the [XXX].

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Supplementary Material 1

Please see the *table attached*.
Supplementary Material 2

<table><caption>Table 1: French region of practice of participants</caption><thead><tr><td>Region</td><td>N</td><td>%</td></tr></thead><tbody><tr><td>Auvergne-Rhône-Alpes</td><td>6</td><td>4.69</td></tr><tr><td>Bourgogne-Franche-Comté</td><td>6</td><td>4.69</td></tr><tr><td>Bretagne</td><td>3</td><td>2.34</td></tr><tr><td>Centre-Val de Loire</td><td>2</td><td>1.56</td></tr><tr><td>Corse</td><td>0</td><td>0.00</td></tr><tr><td>Grand Est</td><td>2</td><td>1.56</td></tr><tr><td>Hauts-de-France</td><td>51</td><td>39.84</td></tr><tr><td>Île-de-France</td><td>7</td><td>5.47</td></tr><tr><td>Normandie</td><td>7</td><td>5.47</td></tr><tr><td>Nouvelle-Aquitaine</td><td>10</td><td>7.81</td></tr><tr><td>Occitanie</td><td>10</td><td>7.81</td></tr><tr><td>Pays de la Loire</td><td>15</td><td>11.72</td></tr><tr><td>Provence-Alpes-Côte d'Azur</td><td>7</td><td>5.47</td></tr><tr><td>Régions françaises d'outre-mer</td><td>0</td><td>0.00</td></tr><tr><td>Not answered</td><td>2</td><td>1.56</td></tr></tbody></table>
<figure><img src="image_12.png" /><figcaption>Figure 1: Level of clinical experience of participants per condition managed by SLPs</figcaption></figure>

<figure><img src="image_13.png" /><figcaption>Figure 2: Level of satisfaction with initial training regarding prosody</figcaption></figure>
<figure><img src="image_14.png" /><figcaption>Figure 3: Means enabling SLPs to acquire knowledge or experience on prosody and its development, evaluation or treatment</figcaption></figure>
Supplementary Material 3

<table><thead><tr><td>Keywords in French</td><td>Keywords translated in English</td><td>Number of occurrences</td></tr></thead><tbody><tr><td>Parole</td><td>Speech</td><td>26</td></tr><tr><td>Rythme</td><td>Rhythm</td><td>22</td></tr><tr><td>Intonation</td><td>Intonation</td><td>21</td></tr><tr><td>Mélodie</td><td>Melody</td><td>21</td></tr><tr><td>Voix</td><td>Voice</td><td>17</td></tr><tr><td>musicalité</td><td>Musicality</td><td>14</td></tr><tr><td>modulation</td><td>Modulation</td><td>13</td></tr><tr><td>émotion</td><td>Emotion</td><td>11</td></tr><tr><td>hauteur</td><td>Pitch</td><td>11</td></tr><tr><td>accentuation</td><td>Accentuation</td><td>10</td></tr><tr><td>variation</td><td>Variation</td><td>10</td></tr><tr><td>débit</td><td>Rate</td><td>8</td></tr><tr><td>supra-segmental</td><td>supra-segmental</td><td>7</td></tr><tr><td>communication</td><td>Communication</td><td>6</td></tr><tr><td>information</td><td>Information</td><td>6</td></tr><tr><td>intensité</td><td>Intensity</td><td>6</td></tr><tr><td>phrase</td><td>Sentence</td><td>6</td></tr><tr><td>tonalité</td><td>Tonality</td><td>6</td></tr><tr><td>intention</td><td>Intention</td><td>5</td></tr><tr><td>pause</td><td>Pause</td><td>5</td></tr><tr><td>enveloppe</td><td>Envelope</td><td>4</td></tr><tr><td>expressivité</td><td>Expressiveness</td><td>4</td></tr><tr><td>langage</td><td>Language</td><td>4</td></tr><tr><td>linguistique</td><td>linguistic/linguistics</td><td>4</td></tr><tr><td>phrasé</td><td>Phrasing</td><td>4</td></tr></tbody></table>
<table>
  <tr>
    <td>pragmatique</td>
    <td>pragmatics</td>
    <td>4</td>
  </tr>
  <tr>
    <td>Sens</td>
    <td>Meaning</td>
    <td>4</td>
  </tr>
  <tr>
    <td>transmission</td>
    <td>Transmission</td>
    <td>4</td>
  </tr>
  <tr>
    <td>fréquence</td>
    <td>Frequency</td>
    <td>3</td>
  </tr>
  <tr>
    <td>infraverbal</td>
    <td>Infraverbal</td>
    <td>3</td>
  </tr>
  <tr>
    <td>langue</td>
    <td>Language</td>
    <td>3</td>
  </tr>
  <tr>
    <td>nuance</td>
    <td>Nuance</td>
    <td>3</td>
  </tr>
  <tr>
    <td>paraverbal</td>
    <td>Paraverbal</td>
    <td>3</td>
  </tr>
  <tr>
    <td>chant</td>
    <td>Singing</td>
    <td>2</td>
  </tr>
  <tr>
    <td>compréhension</td>
    <td>Understanding</td>
    <td>2</td>
  </tr>
  <tr>
    <td>courbe</td>
    <td>Curve</td>
    <td>2</td>
  </tr>
  <tr>
    <td>discours</td>
    <td>Discourse</td>
    <td>2</td>
  </tr>
  <tr>
    <td>énoncé</td>
    <td>Utterance</td>
    <td>2</td>
  </tr>
  <tr>
    <td>maintien</td>
    <td>Upholding</td>
    <td>2</td>
  </tr>
  <tr>
    <td>Mot</td>
    <td>Word</td>
    <td>2</td>
  </tr>
  <tr>
    <td>Oral</td>
    <td>Oral</td>
    <td>2</td>
  </tr>
  <tr>
    <td>renforcement</td>
    <td>Reinforcement</td>
    <td>2</td>
  </tr>
  <tr>
    <td>respiration</td>
    <td>Breathing</td>
    <td>2</td>
  </tr>
  <tr>
    <td>sentiment</td>
    <td>Feeling</td>
    <td>2</td>
  </tr>
  <tr>
    <td>timbre</td>
    <td>Timbre</td>
    <td>2</td>
  </tr>
  <tr>
    <td>Vie</td>
    <td>Life</td>
    <td>2</td>
  </tr>
  <tr>
    <td>acoustique</td>
    <td>acoustic/acoustics</td>
    <td>1</td>
  </tr>
  <tr>
    <td>amplitude</td>
    <td>Amplitude</td>
    <td>1</td>
  </tr>
  <tr>
    <td>apport</td>
    <td>Contribution</td>
    <td>1</td>
  </tr>
  <tr>
    <td>caractérisation</td>
    <td>Characterization</td>
    <td>1</td>
  </tr>
  <tr>
    <td>compétence</td>
    <td>Competence</td>
    <td>1</td>
  </tr>
  <tr>
    <td>confort</td>
    <td>Comfort</td>
    <td>1</td>
  </tr>
</table>
<table><tr><td>couleu</td><td>Color</td><td>1</td></tr><tr><td>culture</td><td>Culture</td><td>1</td></tr><tr><td>, exchange</td><td>Exchange</td><td>1</td></tr><tr><td>emphase</td><td>Emphasis</td><td>1</td></tr><tr><td>enchaînement</td><td>Sequence</td><td>1</td></tr><tr><td>fluence</td><td>Fluency</td><td>1</td></tr><tr><td>fondamental</td><td>Fundamental</td><td>1</td></tr><tr><td>forme</td><td>Form</td><td>1</td></tr><tr><td>indispensable</td><td>Indispensable</td><td>1</td></tr><tr><td>intelligibilité</td><td>Intelligibility</td><td>1</td></tr><tr><td>langage écrit</td><td>written language</td><td>1</td></tr><tr><td>langage oral</td><td>oral language</td><td>1</td></tr><tr><td>larynx</td><td>Larynx</td><td>1</td></tr><tr><td>longueur</td><td>Length</td><td>1</td></tr><tr><td>message</td><td>Message</td><td>1</td></tr><tr><td>modalité</td><td>Modality</td><td>1</td></tr><tr><td>modification</td><td>Modification</td><td>1</td></tr><tr><td>monotonie</td><td>Monotony</td><td>1</td></tr><tr><td>motricité</td><td>Motricity</td><td>1</td></tr><tr><td>non-verbal</td><td>non-verbal</td><td>1</td></tr><tr><td>Note</td><td>Note</td><td>1</td></tr><tr><td>patron</td><td>Pattern</td><td>1</td></tr><tr><td>phonétique</td><td>phonetic/phonetics</td><td>1</td></tr><tr><td>ponctuation</td><td>Punctuation</td><td>1</td></tr><tr><td>prosodie</td><td>Prosody</td><td>1</td></tr><tr><td>ralentissement</td><td>Slowing-down</td><td>1</td></tr><tr><td>région</td><td>Region</td><td>1</td></tr></table>
<table><tr><td>relief</td><td>Relief</td><td>1</td></tr><tr><td>scansion</td><td>Scansion</td><td>1</td></tr><tr><td>Son</td><td>Sound</td><td>1</td></tr><tr><td>souffle</td><td>Breath</td><td>1</td></tr><tr><td>spécificité</td><td>Specificity</td><td>1</td></tr><tr><td>syntaxe</td><td>Syntax</td><td>1</td></tr><tr><td>utilité</td><td>Usefulness</td><td>1</td></tr><tr><td>verbal</td><td>Verbal</td><td>1</td></tr><tr><td>vitesse</td><td>Speed</td><td>1</td></tr><tr><td>volume</td><td>Volume</td><td>1</td></tr></table>
Supplementary Material 4

Correlation between frequency of prosody assessment and treatment and the factors of interest.
(number of observations: 121-128).

<table><thead><tr><th>Variable 1</th><th>Variable 2</th><th>tau</th><th>95% CI</th><th>z</th><th>p</th></tr></thead><tbody><tr><td rowspan="10">Assessment</td><td>Clinical perception: prosody as support tool</td><td>-0.17</td><td>(-0.28, -0.06)</td><td>-2.08</td><td>0.602</td></tr><tr><td>Clinical perception: prosody as rehabilitation tool</td><td>0.07</td><td>(-0.05, 0.18)</td><td>0.80</td><td>&gt; .999</td></tr><tr><td>Clinical perception: prosody as means of compensation</td><td>0.06</td><td>(-0.06, 0.17)</td><td>0.69</td><td>&gt; .999</td></tr><tr><td>Clinical perception: prosody as main therapeutic target</td><td>0.33</td><td>(0.23, 0.43)</td><td>4.04</td><td>0.001</td></tr><tr><td>Clinical perception: prosody as therapeutic yet secondary target</td><td>0.07</td><td>(-0.04, 0.19)</td><td>0.90</td><td>&gt; .999</td></tr><tr><td>Clinical perception: prosody as a symptom of certain disorders when it is impaired</td><td>-0.06</td><td>(-0.17, 0.06)</td><td>-0.70</td><td>&gt; .999</td></tr><tr><td>Impact of prosodic difficulties on acquisition of spoken language</td><td>0.08</td><td>(-0.04, 0.19)</td><td>0.98</td><td>&gt; .999</td></tr><tr><td>Impact of prosodic difficulties on ability to understand one's interlocutor</td><td>0.01</td><td>(-0.10, 0.13)</td><td>0.17</td><td>&gt; .999</td></tr><tr><td>Impact of prosodic difficulties on intelligibility</td><td>0.15</td><td>(0.03, 0.26)</td><td>1.91</td><td>0.794</td></tr><tr><td>Impact of prosodic difficulties on ability to express oneself</td><td>0.09</td><td>(-0.03, 0.21)</td><td>1.17</td><td>&gt; .999</td></tr></tbody></table>
<table><thead><tr><th>Variable 1</th><th>Variable 2</th><th>tau</th><th>95% CI</th><th>z</th><th>p</th></tr></thead><tbody><tr><td></td><td>Impact of prosodic difficulties on interactions in daily life</td><td>0.11</td><td>(-9.87e-03, 0.22)</td><td>1.36</td><td>&gt; .999</td></tr><tr><td></td><td>Impact of prosodic difficulties on social image</td><td>0.06</td><td>(-0.05, 0.18)</td><td>0.81</td><td>&gt; .999</td></tr><tr><td></td><td>Feeling of being comfortable with theoretical notions</td><td>0.40</td><td>(0.30, 0.50)</td><td>5.00</td><td>&lt; .001</td></tr><tr><td></td><td>Feeling of being comfortable with assessment</td><td>0.48</td><td>(0.39, 0.57)</td><td>5.94</td><td>&lt; .001</td></tr><tr><td></td><td>Feeling of being comfortable with treatment</td><td>0.34</td><td>(0.23, 0.44)</td><td>4.27</td><td>&lt; .001</td></tr><tr><td></td><td>Feeling of being qualified</td><td>0.26</td><td>(0.14, 0.36)</td><td>3.08</td><td>0.042</td></tr><tr><td rowspan="7">Treatment</td><td>Clinical perception: prosody as support tool</td><td>-0.07</td><td>(-0.18, 0.05)</td><td>-0.81</td><td>&gt; .999</td></tr><tr><td>Clinical perception: prosody as rehabilitation tool</td><td>0.17</td><td>(0.05, 0.28)</td><td>2.03</td><td>0.628</td></tr><tr><td>Clinical perception: prosody as means of compensation</td><td>-0.01</td><td>(-0.13, 0.10)</td><td>-0.17</td><td>&gt; .999</td></tr><tr><td>Clinical perception: prosody as main therapeutic target</td><td>0.30</td><td>(0.19, 0.41)</td><td>3.65</td><td>0.006</td></tr><tr><td>Clinical perception: prosody as therapeutic yet secondary target</td><td>0.01</td><td>(-0.11, 0.13)</td><td>0.14</td><td>&gt; .999</td></tr><tr><td>Clinical perception: prosody as a symptom of certain disorders when it is impaired</td><td>-0.21</td><td>(-0.32, -0.10)</td><td>-2.55</td><td>0.181</td></tr><tr><td>Impact of prosodic difficulties on acquisition of spoken language</td><td>0.24</td><td>(0.12, 0.35)</td><td>3.04</td><td>0.044</td></tr></tbody></table>
<table><thead><tr><th>Variable 1</th><th>Variable 2</th><th>tau</th><th>95% CI</th><th>z</th><th>p</th></tr></thead><tbody><tr><td>Impact of prosodic difficulties on ability to understand one's interlocutor</td><td></td><td>0.09</td><td>(-0.02, 0.21)</td><td>1.21</td><td>&gt; .999</td></tr><tr><td>Impact of prosodic difficulties on intelligibility</td><td></td><td>0.29</td><td>(0.17, 0.39)</td><td>3.68</td><td>0.006</td></tr><tr><td>Impact of prosodic difficulties on ability to express oneself</td><td></td><td>0.25</td><td>(0.14, 0.36)</td><td>3.20</td><td>0.029</td></tr><tr><td>Impact of prosodic difficulties on interactions in daily life</td><td></td><td>0.29</td><td>(0.17, 0.39)</td><td>3.62</td><td>0.007</td></tr><tr><td>Impact of prosodic difficulties on social image</td><td></td><td>0.21</td><td>(0.09, 0.32)</td><td>2.59</td><td>0.172</td></tr><tr><td>Feeling of being comfortable with theoretical notions</td><td></td><td>0.33</td><td>(0.22, 0.44)</td><td>4.13</td><td>&lt; .001</td></tr><tr><td>Feeling of being comfortable with assessment</td><td></td><td>0.36</td><td>(0.25, 0.46)</td><td>4.46</td><td>&lt; .001</td></tr><tr><td>Feeling of being comfortable with treatment</td><td></td><td>0.44</td><td>(0.34, 0.53)</td><td>5.52</td><td>&lt; .001</td></tr><tr><td>Feeling of being qualified</td><td></td><td>0.32</td><td>(0.21, 0.42)</td><td>3.87</td><td>0.003</td></tr></tbody></table>