JSLHR

Research Article

Song Recognition by Young Children With Cochlear Implants: Comparison Between Unilateral, Bilateral, and Bimodal Users Tamar Bartova and Tova Mosta

Purpose: To examine song identification by preschoolers with normal hearing (NH) versus preschoolers with cochlear implants (CIs). Method: Participants included 45 children ages 3;8–7;3 (years;months): 12 with NH and 33 with CIs, including 10 with unilateral CI, 14 with bilateral CIs, and 9 bimodal users (CI-HA) with unilateral CI and contralateral hearing aid. Preschoolers were asked to identify children’s songs presented via 5 versions: (a) full (lyrics sung with piano accompaniment); (b) a cappella (only lyrics); (c) melodic (matching main melodic contour); (d) tonal (only pitch information); and (e) rhythmic (only song’s rhythm). Results: The NH group surpassed all CI groups at identifying songs via melodic and tonal versions, but no

significant differences emerged between the NH group and any CI group via full, a cappella, or rhythmic versions. Among the CI groups, no significant differences emerged via melodic or rhythmic versions, but bimodal users performed significantly better than bilateral users via the tonal version. Chronological age and duration of CI use correlated significantly with identification via the rhythmic version. Conclusion: Bimodal users showed an advantage in identifying songs in the tonal version through use of complementary information.

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rhythmic information alone), while comparing children with unilateral CI, bilateral CI, and bimodal CI-HA rehabilitation (CI with contralateral hearing aid).

he benefits of the cochlear implant (CI) are well documented for perception of spoken language (McDermott, 2004). In recent years, increasing research has begun to investigate the perception of music by adults and children who use CIs (Donnelly & Limb, 2009; McDermott, 2004). Music plays a large role in the activities of young children with CIs (Nakata et al., 2005; Olszewski, Gfeller, Forman, Stordahl, & Tomblin, 2005; Vongpaisal, Trehub, & Schellenberg, 2006), calling for examination of this population’s capacity to enjoy familiar music. Identification of specific musical features that foster song recognition could be effective in improving these young children’s subjective music experiences, thereby promoting their psychological and social functioning. In the current study, we explored young children’s ability to identify musical nursery rhymes on the basis of different musical characteristics, some assessed directly for the first time (such as

a

Tel Aviv University, Israel Correspondence to Tova Most: [email protected] Editor: Craig Champlin Associate Editor: Emily Tobey Received July 18, 2013 Revision received February 19, 2014 Accepted March 21, 2014 DOI: 10.1044/2014_JSLHR-H-13-0190

Key Words: cochlear implants, song recognition, children

Song Recognition by Adults and Children With CI on the Basis of Different Musical Characteristics In the normal auditory system, people perceive both major elements of music: rhythm and pitch. Pitch is fundamental to music perception in general and to melody perception in particular. It is one of the main dimensions along which sound varies in a musical piece (McDermott & Oxenham, 2008). For individuals with severe and profound hearing loss who use a CI, music perception remains a difficult task (McDermott, 2004). The difficulty stems from the fact that the CI provides limited information about pitch (Donnelly & Limb, 2009). Current sound processors provide more information about temporal-envelope modulations than about temporal fine-structure or spectral details (Loizou, 1998 and Rosen, 1992, both cited in Vongpaisal Trehub, & Schellenberg, 2009). One of those limitations causes a difficulty in pitch and timbre perception of the human voice and of musical sounds (Donnelly & Limb, 2009).

Disclosure: The authors have declared that no competing interests existed at the time of publication.

Journal of Speech, Language, and Hearing Research • Vol. 57 • 1929–1941 • October 2014 • © American Speech-Language-Hearing Association

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Studies have shown differences between adults with normal hearing and adults who use CIs in song and melody identification, in which the hearing adults were much more accurate (Galvin, Fu, & Nogaki, 2007; Gfeller, Jiang, Oleson, Driscoll, & Knutson, 2010; Gfeller et al., 2002; McDermott, 2004). Previous research investigating adult CI users revealed that the type of stimulus material had an effect on their ability to identify familiar songs. In particular, recognition was found to be easier when songs included the lyrics than when those same songs were presented in a melodic version—without words (Leal et al., 2003). Several studies examined the contribution of each musical element to melody identification (without words). In tasks that required the identification of familiar melodies, adults with CIs more easily identified melodies that included rhythmic characteristics than melodies in which rhythmic characteristics were excluded (Gfeller et al., 2002, 2005; Kong, Cruz, Jones, & Zeng, 2004). Research on song identification tasks performed by children with CIs likewise indicated the significant contribution of verbal information (Hsiao, 2008; Mitani et al., 2007; Nakata et al., 2005; Vongpaisal et al., 2006, 2009; Vongpaisal, Trehub, Schellenberg, & Papsin, 2004). Furthermore, findings for children with CIs resembled those of adults regarding identification of wordless songs. Both adults and children with CIs identified melodies with rhythmic and tonal characteristics better than melodies without rhythmic characteristics. It should be noted, however, that in only one of these studies did researchers test this in children with CIs (Hsiao, 2008). So far, the contribution of rhythmic information to song identification among adults and children alike has not been tested directly.

Unilateral, Bilateral, and Bimodal Music Perception by Adults Binaural rehabilitation has become a preferred choice in recent years, by means of either bilateral implantation or bimodal rehabilitation using a CI in one ear and a hearing aid (HA) on the opposite side (CI-HA; Ching, van Wanrooy, & Dillon, 2007). Many researchers reported the benefits of binaural and bimodal hearing in comparison to monaural hearing with one implant. Those advantages were evident in tasks of speech understanding in quiet and in noise, and also in sound localization tasks (Basura, Eapen, & Buchman, 2009; Ching et al., 2007; Galvin et al., 2007). Bimodal CI-HA rehabilitation provides an additional advantage—other than binaural hearing—as a result of the access to information obtained in the low frequencies via the HA. That information, combined with access to high frequencies through the CI, provides complementary information (Ching et al., 2007; Most, Gaon-Sivan, Shpak, & Luntz, 2011; Most, Harel, Shpak, & Luntz, 2011). Until now, the perception of music in general and song identification in particular was evaluated mainly among individuals with one implant (Veekmans, Ressel, Mueller, Vischer, & Brockmeier, 2009). Authors of one study showed that music perception benefitted from binaural hearing with two

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implants in comparison to monaural hearing with one implant (Veekmans et al., 2009). In that study, listeners reported better personal feelings while listening to music, higher subjective evaluation for detection of different musical elements, and more positive feelings about musical sound quality. A number of studies compared bimodal users with bilateral users regarding different music perception capabilities (Cullington & Zeng, 2011; Gfeller et al., 2008). Gfeller et al. (2008) tested melody identification with and without words among 209 adults with CIs, including 31 bimodal users and 25 bilateral users. The researchers found that success in identifying songs without lyrics was associated with HA use, among other factors. Thus, Gfeller et al. demonstrated that bimodal CI-HA users were better at identifying melodies without lyrics than bilateral CI users. Several studies focusing solely on bimodal users compared their melody identification in three conditions: bimodal, CI alone, and HA alone. A clear advantage emerged in the HA-only condition and in the bimodal CI-HA condition compared with the CI-only condition (Dorman, Gifford, Spahr, & McKarns, 2008; El Fata, James, Laborde, & Fraysse, 2009; Kong, Stickney, & Zeng, 2005; Sucher & McDermott, 2009). However, it is important to note that these comparisons were made only among adults. Song and melody identification has not yet been investigated to compare children who are unilateral, bilateral, and bimodal users.

Song and Melody Recognition in Children With CIs Several studies have investigated song and melody perception by children who use CIs. Two of these studies compared 8- to 18-year-olds with prelingual deafness who used CIs with their counterparts with normal hearing while attempting to identify songs presented instrumentally, without lyrics (Olszewski et al., 2005; Stordahl, 2002). Both studies revealed similar findings: Whereas the normally hearing children achieved almost perfect scores (~95%), the children with CIs only succeeded in identifying the songs about 40% of the time. Other studies on child CI users compared different versions presented for each song in order to explore the specific contribution of different musical components to song identification in this population (Hsiao, 2008; Mitani et al., 2007; Nakata et al., 2005; Vongpaisal et al., 2004, 2006, 2009). For example, Vongpaisal et al. (2009) examined identification of TV songs by young children with CIs (ages 4;7–11;7 [years;months]) with prelingual hearing loss. In this study, theme songs from popular children’s TV programs were presented in three versions: an original version, an instrumental version, and a melodic version (played with a synthesized flute). The children identified all versions at above-chance levels. However, recognition of the melodic and instrumental versions remained much lower than for the original version. Only one study among children included a tonal version, in which all rhythmic information was excluded

Journal of Speech, Language, and Hearing Research • Vol. 57 • 1929–1941 • October 2014

(Hsiao, 2008). Twenty children ages 7 to 15 years with prelingual deafness were asked to identify songs in three versions: an original version, a melodic version, and a tonal version. The original version included the lyrics, the melodic version included rhythmic and pitch information (without lyrics), and the tonal version was composed of a sequence of notes following the pitch pattern of the melody, without any rhythmic information. These children with CIs succeeded for 96% of the songs presented via the original version, 59% via the melodic version, and 39% via the tonal version. Hsiao’s (2008) findings showed that verbal information was most efficient for song identification by children with CIs, whereas pitch information remained less accessible. Therefore, pitch information alone was insufficient for song identification, and the inclusion of rhythmic patterns in the melodic version improved children’s accuracy. However, this ability to identify familiar songs by relying on rhythmic information alone has not yet been empirically tested among either children or adults. Also, as mentioned above, song and melody identification has not yet been compared among children who are unilateral, bilateral, and bimodal users. Moreover, possible interactions between groups and versions have not yet been tested in either child or adult CI users. Assessment of such interactions is important to obtain a more thorough understanding of each group’s capacity to perceive different types of musical information.

Current Study Objectives The purpose of the present study was to compare the ability to identify familiar children’s songs by young children with prelingual hearing loss who used CIs to that of young children with normal hearing. More specifically, song recognition was compared among three groups of preschoolers who used CIs: unilateral CI users versus bilateral CI users versus those who used unilateral CI-HA in the contralateral ear (bimodal users). We investigated the ability of these four groups of preschoolers’ to identify songs by presenting them with five different versions of each song: (a) full (lyrics sung with piano accompaniment); (b) a cappella (lyrics sung without instrumental accompaniment); (c) melodic (matching main melodic contour); (d) tonal (only pitch information); and (e) rhythmic (only song’s rhythm). This information can illuminate the children’s performance and the binaural and bimodal benefits in perception of acoustic signals with different musical characteristics. Notably, the differences between unilateral, bilateral, and bimodal users were not previously examined among children. Furthermore, the a cappella and rhythmic versions were tested in the current research for the first time. Research hypotheses were as follows: The normally hearing group will surpass all three CI groups for all five song versions. Ability to identify the melodic version (pitch and rhythm) will surpass ability to identify either rhythmic or tonal versions among all participants (normally hearing and CI users). All children with CI will perform better in

the full version and in the a cappella version compared with the other versions presented without lyrics. Bimodal users will surpass the other children with CI (unilateral and bilateral) in the tonal version. Due to the paucity of previous data on these five song recognition versions by young children using CI and particularly by unilateral, bilateral, and bimodal young users, we examined and compared the three CI groups’ song recognition hierarchy in different song versions.

Method Participants Participants comprised 45 Israeli preschoolers (18 boys and 27 girls) ages 3;8–7;3 (M = 5;5, SD = 0.98). Twelve children had normal hearing, and 33 children had prelingual sensorineural hearing loss and had been using at least one CI for a minimum of 1 year before data collection. All participants were native Hebrew speakers and used spoken Hebrew language at home and in school as their main mode of communication. All children were attending preschool or kindergarten at the time of data collection. The few outliers in terms of older age had remained in kindergarten for an extra year in consultation with audiologists and kindergarten teachers due to communicational immaturity related to their hearing loss. However, none of the children had additional difficulties other than the hearing loss. The children with CI were divided into three groups: users with unilateral CI, users with bilateral CI, and users with a CI in one ear and a HA in the contralateral ear. The individual details of all the children with hearing loss are presented in the Appendix. The effect of subject demographic characteristics is examined in the results section. Group with unilateral CI (n = 10; six boys, four girls). These children’s hearing loss was diagnosed during their first year of life (range: birth to 7 months, M = 2.5 months). Implantation occurred between 10 and 25 months (M = 14.3), with CI use duration at the time of data collection ranging from 31 to 66 months (M = 54.0 months). All but one of these unilateral users had a Nucleus with Freedom processor. One child used Advanced Bionics with Harmony processor. All children had used two HAs prior to implantation. All unilateral users attended inclusive classes with hearing children, either individually integrated into a standard preschool classroom in their local neighborhood with children with normal hearing (n = 5) or in groupinclusion settings where a small group of children with hearing loss was integrated into a standard preschool classroom (n = 5). Group with bilateral CIs (n = 14; five boys, nine girls). These children’s hearing loss was diagnosed between birth and 28 months (M = 7.5). Seven children were initially implanted with two CIs simultaneously, and the remaining children were implanted at two separate times. Children were implanted with their first CI(s) at 12 to 34 months (M = 19.8), and duration of use was 31 to 62 months

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(M = 42.0) at the time of data collection. Seven children were implanted with the second implant 2 to 28 months after the first implant (M = 15.0). Thus, these children had a Mage of 27 months at the time of the second implantation and had been using it for a M of 36 months at the time of data collection. The bilateral users had Nucleus with Freedom processor (n = 8), Advanced Bionics with Harmony or HiRes90K/Hi focus processor (n = 2), or MED-EL with OPUS2 processor (n = 4). All children had used two HAs prior to implantation, except one child who lost his hearing due to bacterial meningitis, was implanted immediately afterwards, and thus had no experience with HAs. All bilateral users attended inclusive preschools with hearing children: five in individual inclusion and nine in group-inclusion settings. Bimodal group (n = 9; one boy, eight girls). These children’s hearing loss was diagnosed between birth and 30 months (M = 9.5). Implantation occurred between 12 and 48 months (M = 28.89), with CI use duration at the time of data collection ranging from 19 to 66 months (M = 42). The bimodal users had Nucleus with Freedom processor (n = 2), Nucleus5 with CP810 processor (n = 3), Advanced Bionics with Clarion processor (n = 1), or MED-EL with OPUS2 processor (n = 3). All children had used two HAs prior to implantation. All bimodal users attended inclusive preschoolers with hearing children: three in individual inclusion and six in group-inclusion settings. All the children in this group used a digital HA in the contralateral ear. Mean unaided pure-tone average (PTA) in the HA ear was 93 dB HL. The mean unaided threshold at 250 Hz was 82.5 dB HL, and the mean unaided threshold at 500 Hz was 89 dB HL. Mean aided PTA in the HA ear was 48 dB HL. The mean aided threshold at 250 Hz was 44 dB HL, and the mean aided threshold at 500 Hz was 46 dB HL. Group with normal hearing (n = 12; six boys, six girls). These children had hearing in the normal range, with thresholds better than 15 dB HL in the frequency range of 500 Hz to 4000 Hz. These children had no history of speech, language, or hearing problems or any other disability.

Instruments Parents completed three instruments: a demographic questionnaire and a song familiarity checklist. Children completed a song recognition task. All questionnaires and song stimuli were developed for the purpose of this study. Questionnaires. The demographic questionnaire assessed children’s age, sex, educational setting, hearing loss, HA and CI history, and rehabilitation. The song familiarity checklist presented parents with a list of six familiar children’s songs and asked them to assess the degree of familiarity of each song (on a 5-point scale, with higher scores indicating higher familiarity) for their child. Song recognition task. We developed a set of 30 songs, comprising six nursery rhymes, all played by a professional

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musician on a synthesized piano. Five different versions were prepared for each of the six songs: 1.

Full version: Original vocal portions (lyrics) were sung by a woman, with harmonic instrumental accompaniment by a synthesized piano.

2.

A cappella version: Original vocal portions (lyrics) were sung by a woman, with no instrumental accompaniment.

3.

Melodic version: Original vocal portions (i.e., the sung melody) were replaced by a synthesized piano that matched the main melodic contour.

4.

Tonal version: The melody was presented as a stream of equal-duration notes (only pitch information), thereby removing the characteristic rhythmic patterns but preserving the exact melodic contour.

5.

Rhythmic version: The melody was presented by repeating only one note, thereby removing all pitch information but preserving the song’s original rhythmic patterns.

In a home recording studio, the full and a cappella versions for each song were recorded by a female singer, and all versions except the a cappella version were recorded by a professional musician playing on a synthesized piano. All 30 stimuli were presented in a pilot study to 20 children ages 4 to 7 years, including 10 children with CI and 10 children with normal hearing, using the task procedure described next. The stimuli and the task were found valid and appropriate. In the current study, each child listened to 20 song stimuli, comprising four songs each presented in five versions. The four-song playlist for each child was selected to include those four songs with which the child was most familiar on the basis of parents’ highest responses to the song familiarity checklist. Prior to commencing the 20-song task, a practice item was presented comprising all five versions of a demonstration song (not one of the six test songs), which was presented along with two illustrations: one visually representing the demonstration song and another visually representing a test song that was not on the child’s playlist (i.e., an illustration of a big green car to represent a song about a big green car; an illustration of a cake to represent a song about a cake). Once the child understood the task, he or she received four color illustrations, each depicting a song from that child’s playlist. The examiner assured the children that they were familiar with all of the songs to be presented and explained that they would be asked to point to the appropriate picture upon hearing each song. Item sequence was designed to prevent presentation of the same song or the same version twice consecutively. Each stimulus was presented only once, for 20 s, which included one verse and one chorus from the beginning of the song. After each stimulus, the child was asked to point to the appropriate illustration. Scoring comprised percent accurate identification for each of the versions.

Journal of Speech, Language, and Hearing Research • Vol. 57 • 1929–1941 • October 2014

Procedure Participants with CI were recruited via MICHA, an organization for the education and rehabilitation of preschool children with hearing loss and their families. Participants with normal hearing were recruited through personal acquaintance (relatives and friends). Signed consent forms were obtained from all parents. Each child was examined in a quiet room (at their preschool, at the MICHA center, or at their home), and children with CIs completed the song recognition task while using their own well-functioning and optimally fitted sensory aids (CI, HA). To check sensory aids’ functioning, at the beginning of the session, the examiner used a status clip for the HA or a signal checker for the CI, as well as Ling’s (1976, as cited in Baudhuin, Cadieux, Firszt, Reeder, & Maxson, 2012) six sounds test. The 20 items (four songs × five versions) were presented through a portable computer (MSI, U135DX) connected to two loudspeakers (Logitech Z120) located on both sides of the computer at a 45° angle 1 m from the participant’s seat. The child listened to the test items at 70 dB SPL from the participant’s seat through loudspeakers. This intensity level was measured at the child’s seat using a sound level meter. The loudspeakers’ frequency response was 20 Hz to 20 kHz.

Results Group Comparisons: Preschoolers With and Without Hearing Loss Each child received a percent accurate identification score for each of the five versions. To compare successful recognition of each of the five versions as a function of hearing loss and CI use, we compared the scores of the children with normal hearing with those of a combined group of all the children with hearing loss. One-way analysis of variance (ANOVA) for Group (normal hearing/hearing loss) with repeated measures on Version (full/a cappella/ melodic/tonal/rhythmic) was conducted using the mixed model. Table 1 presents the mean percent accurate identification score, SDs, and F values for each of the two groups. The analysis revealed a significant main effect for Group, F(1, 42) = 19.07, p < .001, a significant main effect for Version, F(4, 172) = 24.98, p < .001, and a significant Group ×

Version interaction, F(4, 172) = 13.77, p < .001. To examine the source of the interaction, comparisons between groups were performed for each version. These comparisons revealed a significant group difference for the melodic version, F(1, 172) = 9.72, p < .01, and for the tonal version, F(1, 172) = 66.67, p < .001. No significant group differences emerged for the other three versions. As can be seen from the table, children in both groups reached a ceiling effect and received perfect or near-perfect scores on the full version and the a cappella version. Both groups scored relatively low on the rhythmic version.

Group Comparisons: Unilateral CI Versus Bilateral CI Versus Bimodal CI-HA Users To compare successful recognition of each of the five versions as a function of type of sensory aid, we conducted one-way ANOVA for Group (unilateral/bilateral/ bimodal) with repeated measures for Version (full/a cappella/ melodic/tonal/rhythmic) and with age of implantation as a covariate, using a mixed model. Table 1 presents the mean percent accuracy score, SDs, and F values for each of the five versions for each of the three groups of preschoolers with CIs. The analysis revealed a significant main effect only for Version, F(4, 120) = 68.43, p < .001. No significant main effect emerged for Group, p > .05, and the Group × Version interaction neared significance, F(2, 37) = 1.89, p = .07. As can be seen from the table, all three groups received similarly high scores (reaching a ceiling effect with perfect or near-perfect scores) for the full version and the a cappella version. Scores for the melodic version were similarly medium high in all three groups, whereas scores for the rhythmic version were similarly low in all three groups. In order to examine the differences for the tonal version among the groups, t-test analyses were conducted. The analyses revealed significant difference only between the bimodal and the bilateral groups, t(21) = –2.6, p = .0166. Although the bimodal group seemed to perform better than the unilateral group, the analysis revealed that the difference was not significant. There was no significant difference between the unilateral group and the bilateral group for the tonal version (p > .05). Figure 1 presents the mean percent accuracy scores of each of the four study groups (unilateral CI, bilateral CI, bimodal CI-HA, and normal hearing) for

Table 1. Mean percent accurate song version identification scores, standard deviations, and F values for group comparisons. Percent identified accurately Song version

Percent identified accurately

Normal hearing: M (SD)

Hearing loss: M (SD)

Group F(1, 172)

Unilateral CI: M (SD)

Bilateral CI: M (SD)

Bimodal CI-HA: M (SD)

Group F(1, 120)

100 (0) 100 (0) 100 (0) 98 (7) 56 (25)

100 (0) 99 (4) 72 (27) 37 (29) 53 (23)

0.00 0.01 9.72* 66.67** 0.24

100 (0) 100 (0) 75 (34) 35 (30) 58 (16)

100 (0) 98 (6) 71 (23) 27 (22) 55 (25)

100 (0) 100 (0) 69 (23) 56 (28) 44 (23)

0.01 0.04 0.09 5.25* 0.78

Full A cappella Melodic Tonal Rhythmic *p < .01. **p < .001.

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Figure 1. Mean percent accurate song identification of each of the four study groups for the three wordless song versions.

the melodic, tonal, and rhythmic versions. Data for the full and the a cappella versions are not presented because all four groups received very high scores, precluding significant differences between versions.

Version Comparisons Multiple comparisons using the studentized maximum modulus adjustment (Hochberg, 1974) were conducted among the scores for the five versions. These comparisons revealed a significant difference between the full version and each of the following versions: the melodic version, t(120) = 5.99, p < .0001; the tonal version, t(120) = 13.01, p < .0001; and the rhythmic version, t(120) = 10.16, p < .0001. No significant difference was found between the full and the a cappella versions (p < .05). Significant differences were also found between the a cappella version and each of the following versions: the melodic version, t(120) = 5.86, p < .0001; the tonal version, t(120) = 12.88, p < .0001; and the rhythmic version, t(120) = 10.04, p < .0001. Significant differences were found between the melodic version and the tonal version, t(120) = 7.02, p < .0001; and between the melodic version and the rhythmic version, t(120) = 4.17, p < .0001. Significant difference was found between the tonal and the rhythmic version, t(120) = –2.85, p = .05.

Correlations With Demographic Variables Pearson correlations were conducted to examine the relations among various demographic variables in the combined group of children with hearing loss and song identification scores for the three wordless versions: melodic, tonal, and rhythmic. Correlations were not calculated for the full version or the a cappella version because of their ceiling effects, with perfect or near perfect scores for these versions across all groups. Table 2 presents the r and p values for the correlations between mean percent accurate song identification on the three wordless versions and children’s chronological age, age at implantation, and duration of CI for the combined

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group of preschoolers with hearing loss. Age at implantation and CI use duration refer to the first CI in the bilateral CI group. As can be seen from the table, children’s age correlated significantly with their recognition of songs presented via the rhythmic version. Older children scored better. Duration of CI use also correlated significantly with the rhythmic score. Longer duration correlated with a better score via the rhythmic version. The correlations between song identification scores on the three wordless versions and children’s aided and unaided PTA, 250 Hz, and 500 Hz thresholds in the HA ear of the bimodal group were also calculated. No significant correlations emerged, p > .05. Finally, we examined differences in song identification scores on the three wordless versions between children who were in individual inclusion (n = 13) and those who were in group inclusion (n = 20). A one-way ANOVA for each version revealed a significant difference between the two inclusion groups for recognition of songs via the melodic version, F(1, 29) = 5.1, p < .05, as well as via the rhythmic version, F(1, 29) = 10.89, p < .01. No significant difference emerged between the inclusion groups for the

Table 2. Pearson correlation coefficients between demographic characteristics and mean percent accurate song identification on the three wordless versions for the combined group of preschoolers with hearing loss. Version Variable

Melodic

Tonal

Rhythmic

.05 .78

.26 .14

.34 .05

–.15 .40

.30 .09

–.32 .07

.16 .38

.02 .91

.55 .00

Age r p Age at implantation r p Length of CI use r p

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tonal version, p > .05. Figure 2 presents the mean percent accuracy scores of the two inclusion groups for each of the three wordless versions.

Discussion The ability to recognize familiar songs plays a role in music enjoyment and is now more accessible to young children with CIs. Yet, this ability has not been sufficiently examined in the literature in comparison to young peers with normal hearing, nor have researchers investigated the challenges involved in recognizing different musical stimuli for this young population. The present study examined identification of five different song versions by users of unilateral CI, users of bilateral CI, bimodal users (CI on one ear and HA on the contralateral ear), and preschoolers with normal hearing. Two song versions included lyrics (i.e., the full and a cappella versions), and the other three: tonal, melodic, and rhythmic versions were wordless.

Performance of Children With and Without Hearing Loss The findings showed that the combined group of all of the children with hearing loss, regardless of sensory aid, resembled the group of children with normal hearing in their rates of identification for children’s songs presented in three of the five versions: high scores for the two versions that included lyrics and low scores for the wordless rhythmic version. In the worded versions—full and a cappella—the performance of the children in both groups was very high; in fact, they all showed a ceiling effect. Apparently, the good audibility of speech that is accessible through the CI (McDermott, 2004) and the relative ease of identifying worded songs enabled this very high performance. These results supported previous findings by Hsiao (2008), who examined the performance of children older than those in the current study and found that both children with normal hearing and children with CIs reported high Figure 2. Mean percent accurate song identification of each of the three wordless song versions among preschoolers from individual and group-inclusion settings.

identification of songs with words. In contrast, Vongpaisal et al. (2004, 2006, 2009) reported significantly better recognition of songs with words by children with normal hearing in comparison with children with CIs. Perhaps these inconsistent findings stemmed from the songs’ differing familiarity levels. In both the current study and Hsiao’s study, children were presented with popular and familiar songs, whereas in Vongpaisal et al.’s studies, the songs were probably not as familiar to the children because they were not exposed to them very frequently in everyday life. It will be interesting to examine the song familiarity variable in future controlled research. In contrast to the high scores found in the present study for identification of songs with words, the identification of songs based only on rhythmic information—without pitch or lyrics—resulted in relatively low performance among both children with normal hearing and those with CI. Notably, empirical examination of this rhythmic version was examined for the first time in the current study. The performance of the preschoolers with normal hearing in song identification using rhythmic information alone was the lowest in comparison with all the other versions, where recognition was almost perfect. Apparently, individuals with normal hearing mainly use tonal information in song identification (McDermott & Oxenham, 2008; Trainor, 2005). Future research would do well to further explore the ability to identify songs on the basis of rhythmic information along development, in children of various ages, adolescents, and adults, and by comparing those with and without hearing loss. For the remaining two song versions, tonal and melodic, the children with normal hearing significantly outperformed the combined group of children with CIs. These results support previous findings showing the disadvantage of children with CIs in their ability to identify melodies in comparison with children with normal hearing (Hsiao, 2008; Olszewski et al., 2005; Stordahl, 2002; Vongpaisal et al., 2004, 2006, 2009). Currently, CIs do not transmit sufficient auditory information on fine temporal and spectral changes of pitch that are necessary for music perception in general and melody perception in particular (Cullington & Zeng, 2011; Donnelly & Limb, 2009). Another explanation for the lower melodic and tonal perception by children with CI might be their experience of auditory deprivation during childhood. Pitch perception is a process that develops from birth over the years; hence, it is possible that exposure to different sounds varying in pitch is needed at young ages in order to develop normal pitch perception (Trainor, 2005).

Performance of Children With CIs (Unilateral, Bilateral, and Bimodal) As mentioned before, previous investigators of song and melody identification among children examined children with CI as a group. In light of the growing prevalence of binaural rehabilitation among children (bilateral CIs or bimodal CI-HA) in recent years, it is important to evaluate the relative contribution of each type of rehabilitation.

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This comparison may hold theoretical importance as well as clinical implications in order to facilitate better adaption of evaluation and rehabilitation programs for each group. Comparisons among the three groups of children with CIs (unilateral CI, bilateral CI, and bimodal CI-HA) in the present research showed no significant differences in the song identification performance of the groups on all the versions except for the tonal version. As mentioned above, in the two versions with lyrics, performance was very high among all the children with CIs. In the melodic version, the three CI groups performed similarly (at a M of 72% accuracy). No advantage was observed in melodic recognition as a result of the use of HA in addition to the CI, nor was an advantage pinpointed for bilateral-binaural hearing over unilateral. The current lack of a bimodal CI-HA advantage over the other two groups in song identification through the melodic version differed from previous findings on adults, which showed the benefit of HA use in the contralateral ear for melody recognition. For example, Gfeller et al. (2002) found that HA use contributed significantly to bimodal adult users’ greater success in identifying familiar melodies, in comparison with unilateral/bilateral CI users. The bimodal advantage for adults’ melody identification was also reported by Dorman et al. (2008) and Sucher and McDermott (2009), who investigated three listening conditions: CI alone, HA alone, and bimodal. Sucher and McDermott estimated that the added acoustic information in the low frequencies enabled better perception of the fine spectrotemporal elements. The difference between the present results in song identification through the melodic version and those of previous studies may stem from the study participants’ differences in age and onset of deafness. The current participants were young children with prelingual deafness, whereas the previous studies examined adults with postlingual deafness. Olszewski et al. (2005) reported that children with prelingual deafness, unlike postlingual adults, do not have the ability to compare signals to the normal acoustic representations of pitch because these young children did not experience them prior to implantation. Possibly, musical exposure prior to implantation in CI users who are postlingually deaf enables better usage of the HA (allowing acoustic hearing) compared with use of the CI in melody identification. Perhaps the young bimodal users in the present study did not have that advantage and therefore performed similarly to the other CI users. Another possible explanation for the different results in the present study regarding the identification through the melodic version may be the tasks’ difficulty levels. In Gfeller et al.’s (2008) study, participants were asked to identify 12 melodies in an open-set paradigm, whereas in the present study, children were asked to identify only four melodies presented in a closed-set paradigm. It is possible that the relatively easy current task was not sensitive enough to show differences between the groups in the melodic version. In future research, it may be interesting to explore the HA’s benefit for young bimodal users by comparing three

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listening conditions for a melody identification task: CI alone, HA alone, and bimodal. The rhythmic version, as well, did not yield differences among the three groups with CIs. As mentioned above, all of the participants (including the children with normal hearing) performed poorly with this version, with an average accuracy score of 54%. Interestingly, in a previous study, Cullington and Zeng (2011) did not find differences between bilateral and bimodal CI users either when the participants were required to discriminate between similar melodies that had different rhythmic patterns. It is recommended in future research to further explore the degree of benefit from HA use in this task by evaluating bimodal users in three listening conditions: CI alone, HA alone, and bimodal. Thus, all three CI groups performed similarly in recognizing songs via the full version, the a cappella version, the melodic version, and the rhythmic version. Only for the tonal version did a different pattern of success emerge among the groups of preschoolers with CIs. The unilateral and bilateral groups performed poorly, reaching low average scores (35% and 27%, respectively). That is to say, the participants in these groups were not able to successfully identify songs relying on pitch information alone. In contrast, the bimodal group reached an average of 56% in this version; hence, pitch information was more accessible to them. The difference between the groups was significant only between the bimodal and the bilateral groups. Thus, the contribution of the acoustic information provided by the HA was evident for the tonal version. This result supported previous findings by Kong et al. (2005), who reported a benefit from acoustic hearing to the identification of melodies with only pitch information. In that study, five bimodal adults were asked to identify melodies without rhythmic information in three listening conditions: CI alone, HA alone, and bimodal. Significant benefits emerged in the HA condition and the bimodal condition compared with the CI condition. Thus, in the current study, a complementary benefit was expressed when bimodal users were presented with the tonal version. The current results showed no significant differences between the bilateral and the unilateral CI users for any of the song versions. Interestingly, Veekmans et al. (2009) found that bilateral users reported that after their second implantation they experienced a subjective improvement in their ability to identify different musical elements and a more favorable subjective evaluation of music listening, compared with their prior unilateral use, before receiving a second implant. Furthermore, the unilateral users in Veekmans and colleagues’ research reported recognizing only rhythm, and they were generally less positive than the bilateral users about their music listening experiences. However, these results were for adults and reflected subjective indices rather than objective song identifications. In the current research, the lack of differences between the unilateral and bilateral groups may be due to the fact that the task that required song identification in quiet listening condition may not have been sensitive to the

Journal of Speech, Language, and Hearing Research • Vol. 57 • 1929–1941 • October 2014

bilateral-binaural benefit. It is known that binaural hearing provides better speech perception in noise, compared with monaural hearing (Ching et al., 2007). In future research, it is recommended to evaluate song recognition task in noise, to approximate children’s everyday life situations. This condition may reveal advantages of binaural hearing in music perception.

Comparisons Among Versions for Participants With Hearing Loss The effect of the song’s version on preschoolers’ performance in each of the three groups with CIs was examined as well. This comparison may add to knowledge about the different abilities of each group to correctly identify songs, depending on the type of acoustic information provided. We first compared two versions that included speech stimuli— the full version and the a cappella version—to assess whether piano accompaniment (in the full version) would act as noise and thereby detract from the CI users’ identification of the songs, as found for speech understanding in quiet versus noise (Berrettini, Passetti, Giannarelli, & Forli, 2010). However, none of the CI groups revealed a significant difference between the full version and the a cappella version. Indeed, for both of the versions that included lyrics, all three groups of CI users reached an almost perfect score. In future research, it may be interesting to investigate song recognition with different signal (a cappella) to noise (instrumental accompaniment) ratios. Our next comparison was between songs with lyrics and those without. As discussed above, all three groups of CI users showed significantly better identification of the songs that included words, thereby supporting previous studies on recognition of songs with lyrics compared with instrumental melodies (Hsiao, 2008; Mitani et al., 2007; Nakata et al., 2005; Olszewski et al., 2005; Vongpaisal et al., 2004, 2006, 2009). This difference between song identification with and without lyrics highlights the gap between speech and music perception by CI users (McDermott, 2004). Future research should further explore how younger CI users’ perceptions of prosodic and paralinguistic features in spoken language may be linked to the children’s identification of music that does not provide verbal information. The assessment of identifying melody from the tonal version may be especially valuable when considering candidacy for a second CI implantation, by enabling measurement of possible bimodal advantage (before the second implantation).

Correlations With Demographic Variables The current findings indicated that the ability to identify songs based only on rhythmic information correlated with age and with the child’s duration of experience in listening through a CI. Older children and those with a longer duration of CI usage were more successful in identifying songs that were presented only rhythmically. Perhaps greater experience in listening to music in general and in listening to stimuli through the CI in particular contributed

to these preschoolers’ development of musical cognition as expressed in this task. In future research, it may be of interest to examine a larger age range, from infancy to adulthood, and a larger range of length of implant use, in order to explore whether the ability to identify songs and melodies, especially in a rhythmic version, develops over the years with age, cognitive development, and experience using the CI. The nonsignificant correlations between preschoolers’ age and song identification for all the other versions (besides rhythmic) supported previous findings that evaluated children and adolescents ages 9 to 18 years (Olszewski et al., 2005) and children ages 4 to 11 years (Vongpaisal et al., 2009). Yet, Vongpaisal et al. (2004) reported a significant correlation between age and melody identification by older children with CI. In the latter study, Vongpaisal and colleagues assessed hit songs, to which children are probably exposed in adolescence; thus, that study’s significant correlation might have been a result of the stimulus materials. Likewise, the current lack of significant correlations between length of implant use and song identification in all the other versions (besides rhythmic) supported previous research that reported no correlation (Hsiao, 2008; Vongpaisal et al., 2009) or a weak correlation (Olszewski et al., 2005; Vongpaisal et al., 2004). The lack of a significant correlation between age at implantation and song identification in the current study supports previous research on children with prelingual deafness (Hsiao, 2008; Olszewski et al., 2005). Future studies should continue to explore whether children with prelingual versus postlingual deafness perform differently at identifying songs in the various versions. In the current study, severity of hearing loss in the bimodal users (hearing thresholds at 250 Hz, 500 Hz, and aided and unaided PTA in the nonimplanted ear) did not correlate with song identification for any of the versions. This finding differs from El Fata et al. (2009), who found a significant correlation between melody identification through the HA and hearing thresholds in the nonimplanted ear among bimodal adults with postlingual deafness. Differences in the hearing threshold range may explain the contrast between the two studies: the lowfrequency thresholds (at 250 Hz) in the current bimodal preschoolers ranged from 65 dB to no-response (except for one participant), whereas the range of thresholds was much wider (15 dB to 100 dB) and with more low-frequency residual hearing for the bimodal adults in the previous study. Future research should explore a larger sample of bimodal users, with a wide range of hearing thresholds in the nonimplanted ear. Preschoolers’ type of inclusive educational setting also appeared to play a role in song identification. The children with CI who were integrated individually with normally hearing peers (n = 13) significantly outperformed their counterparts who were integrated within a group of other children with hearing loss into a standard preschool (n = 20)—both for the melodic and the rhythmic versions. Perhaps this advantage for the individually included children related to a differing level and form of exposure to

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music in the two environments. It is possible that the presence of the group with hearing loss may have led the teacher to reduce children’s frequency and diversity of musical activity compared with the preschool where only one child with hearing loss was present. Another possibility is that other personal features that may have differentiated the children in the two inclusion programs (e.g., motivation), and not necessarily the program characteristics themselves, may have contributed to the differences in song identification by the children in these two programs. To clarify the validity of this conjecture, future researchers should attempt to measure music exposure in the educational environment, preferably through direct observation rather than subjective report. Moreover, further investigation should focus on the characteristics of music exposure in the educational environment and home. This analysis may have implications for planning and implementing rehabilitation programs through suitable music exposure in each of the educational environments. It should be noted that not all nursery rhymes are equal with respect to rhythm and pitch. The use of different songs across the individuals might have added error variance to the data set. Also, the sample size of the participants might have been a limitation of the current study. In conclusion, the present findings contribute uniquely to knowledge about preschoolers’ perception of different musical elements, which are necessary in order for young children to identify familiar children’s songs and to fully participate in social and educational activities in the preschool and home as well as to enjoy personal experiences with music. The comparison of song recognition among preschool-age children with normal hearing and children with unilateral CI, bilateral CI, or bimodal devices (CI-HA) yielded an important differentiation and perspective, and contributed to knowledge about each group’s ability to rely on different musical elements. The current inclusion of the novel rhythmic version enables confirmation of the assumption made in previous studies about the reliance of CI users on rhythmic information when performing a melody identification task. This confirmation was facilitated for the first time in the current study by directly measuring young children’s capability for identifying melodies based solely on rhythmic information, and comparing it with their results on melodic and tonal version identification. Finally, inasmuch as the tonal version offers key information on the benefit of complementary information, the song identification task using the tonal version can be incorporated into standard assessments for bimodal users when deciding whether to continue using the HA or to undergo a second implantation.

References Basura, G. J., Eapen, R., & Buchman, C. A. (2009). Bilateral cochlear implantation: Current concepts, indications, and results. Laryngoscope, 119, 2395–2401. Baudhuin, J., Cadieux, J., Firszt, J. B., Reeder, R. M., & Maxson, J. L. (2012). Optimization of programming parameters in

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children with the advanced bionics cochlear implant. Journal of American Academy of Audiology, 23, 302–312. Berrettini, S., Passetti, S., Giannarelli, M., & Forli, F. (2010). Benefit from bimodal hearing in a group of prelingually deafened adult cochlear implant users. American Journal of Otolaryngology: Head and Neck Medicine and Surgery, 31, 332–338. Ching, T. Y. C., van Wanrooy, E., & Dillon, H. (2007). Binauralbimodal fitting or bilateral implantation for managing severe to profound deafness: A review. Trends in Amplification, 11, 161–192. Cullington, H. E., & Zeng, F. G. (2011). Comparison of bimodal and bilateral cochlear implant users on speech recognition with competing talker, music perception, affective prosody discrimination, and talker identification. Ear and Hearing, 32, 16–30. Donnelly, P. J., & Limb, C. J. (2009). Music perception in cochlear implant users. In J. K. Niparko (Ed.), Cochlear implants: Principles and practices (2nd ed., pp. 223–228). Philadelphia, PA: Lippincott Williams & Wilkins. Dorman, M. F., Gifford, R. H., Spahr, A. J., & McKarns, S. A. (2008). The benefits of combining acoustic and electric stimulation for recognition of speech, voice and melodies. Audiology & Neurotology, 13, 105–112. El Fata, F., James, C. J., Laborde, M. L., & Fraysse, B. (2009). How much residual hearing is “useful” for music perception with cochlear implants? Audiology & Neurotology, 14(Suppl. 1), 14–21. Galvin, J. J., III, Fu, Q. J., & Nogaki, G. (2007). Melodic contour identification by cochlear implant listeners. Ear and Hearing, 28, 302–319. Gfeller, K., Jiang, D., Oleson, J. J., Driscoll, V., & Knutson, J. F. (2010). Temporal stability of music perception and appraisal scores of adult cochlear implant recipients. Journal of the American Academy of Audiology, 21, 28–34. Gfeller, K., Oleson, J., Knutson, J. F., Breheny, P., Driscoll, V., & Olszewski, C. (2008). Multivariate predictors of music perception and appraisal by adult cochlear implant users. Journal of American Academy of Audiology, 19, 120–134. Gfeller, K., Olszewski, C., Rychener, M., Sena, K., Knutson, J. F., Witt, S., & Macpherson, B. (2005). Recognition of “real-world” musical excerpts by cochlear implant recipients and normal-hearing adults. Ear and Hearing, 26, 237–250. Gfeller, K., Turner, C., Mehr, M., Woodworth, G., Fearn, R., Knutson, J., . . . Stordahl, J. (2002). Recognition of familiar melodies by adult cochlear implant recipients and normalhearing adults. Cochlear Implants International, 3, 29–53. Hochberg, Y. (1974). Some conservative generalizations of the T-method in simultaneous inference. Journal of Multivariate Analysis, 4, 224–234. Hsiao, F. (2008). Mandarin melody recognition by pediatric cochlear implant recipients. Journal of Music Therapy, 45, 390–404. Kong, Y. Y., Cruz, R., Jones, J. A., & Zeng, F. G. (2004). Music perception with temporal cues in acoustic and electric hearing. Ear and Hearing, 25, 173–185. Kong, Y. Y., Stickney, G. S., & Zeng, F. G. (2005). Speech and melody recognition in binaurally combined acoustic and electric hearing. The Journal of the Acoustical Society of America, 117, 1351–1361. Leal, M. C., Shin, Y. J., Laborde, M. L., Calmels, M. N., Verges, S., Lugardon, S., . . . Fraysse, B. (2003). Music perception in adult cochlear implant recipients. Acta Otolaryngology, 123, 826–835.

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McDermott, H. J. (2004). Music perception with cochlear implants: A review. Trends in Amplification, 8, 49–82. McDermott, H. J., & Oxenham, A. J. (2008). Music perception, pitch, and the auditory system. Current Opinion in Neurobiology, 18, 452–463. Mitani, C., Nakata, T., Trehub, S. E., Kanda, Y., Kumagami, H., Takasaki, K., . . . Takahashi, H. (2007). Music recognition, music listening, and word recognition by deaf children with cochlear implants. Ear and Hearing, 28(Suppl. 2), 29S–33S. Most, T., Gaon-Sivan, G., Shpak, T., & Luntz, M. (2011). Contribution of a contralateral hearing aid to perception of consonant voicing, intonation, and emotional state in adult cochlear implantees. Journal of Deaf Studies and Deaf Education, 17, 244–258. Most, T., Harel, T., Shpak, T., & Luntz, M. (2011). Perception of suprasegmental speech features via bimodal stimulation: Cochlear implant on one ear and hearing aid on the other. Journal of Speech, Language, and Hearing Research, 54, 668–678. Nakata, T., Trehub, S. E., Mitani, C., Kanda, Y., Shibasaki, A., & Schellenberg, E. G. (2005). Music recognition by Japanese children with cochlear implants. Journal of Physiological Anthropology and Applied Human Science, 24, 29–32. Olszewski, C., Gfeller, K., Forman, R., Stordahl, J., & Tomblin, B. (2005). Familiar melody recognition by children and adults

using cochlear implants and normal hearing children. Cochlear Implants International, 6, 123–140. Stordahl, J. (2002). Song recognition and appraisal: A comparison of children who use cochlear implants and normally hearing children. Journal of Music Therapy, 39, 2–19. Sucher, C. M., & McDermott, H. J. (2009). Bimodal stimulation: Benefits for music perception and sound quality. Cochlear Implants International, 10(Suppl. 1), 96–99. Trainor, L. J. (2005). Are there critical periods for musical development? Developmental Psychology, 46, 262–278. Veekmans, K., Ressel, L., Mueller, J., Vischer, M., & Brockmeier, S. J. (2009). Comparison of music perception in bilateral and unilateral cochlear implant users and normal-hearing subjects. Audiology & Neurotology, 14, 315–326. Vongpaisal, T., Trehub, S. E., & Schellenberg, E. G. (2006). Song recognition by children and adolescents with cochlear implants. Journal of Speech, Language, and Hearing Research, 49, 1091–1103. Vongpaisal, T., Trehub, S. E., & Schellenberg, E. G. (2009). Identification of TV tunes by children with cochlear implants. Music Perception, 27, 17–24. Vongpaisal, T., Trehub, S. E., Schellenberg, E. G., & Papsin, B. (2004). Music recognition by children with cochlear implants. International Congress Series, 1273, 193–196.

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Appendix (p. 1 of 2) Demographic Characteristics for the Four Study Groups Table A1. Participants with normal hearing (n = 12). No.

Sex

Age (years;months)

1 2 3 4 5 6 7 8 9 10 11 12

Female Female Female Female Female Male Male Male Male Male Female Male

5;6 5;6 5;1 4;8 3;11 6;1 5;5 4;2 4;6 4;1 6;6 5;10

Table A2. Participants with unilateral cochlear implant (CI) (n = 10).

Sex

Age (years;months)

Inclusion

CI type

1 2 3 4 5

Male Female Female Male Female

6;4 5;5 6;0 6;1 6;2

Individual Individual Individual Group Individual

6 7 8 9 10

Male Male Male Female Male

6;6 6;3 4;1 4;8 5;6

Individual Group Group Group Group

Nucleus Freedom Nucleus Freedom Nucleus Freedom Nucleus Freedom Advanced Bionics Harmony Nucleus Freedom Nucleus Freedom Nucleus Freedom Nucleus Freedom Nucleus Freedom

No.

Age at implantation (years;months)

Length of CI use (years;months)

Age of HL detection (years;months)

Age at rehabilitation (years;months)

1;0 1;0 0;10 1;3 1;0

5;4 4;5 5;2 4;10 5;2

0;7 0;0 0;0 0;0 0;7

0;9 0;6 0;7 0;4 0;7

1;0 1;9 1;1 2;1 0;11

5;6 4;6 3;0 2;7 4;7

0;3 1;6 0;0 0;3 0;2

0;6 1;8 0;7 1;7 0;5

Note. Age at rehabilitation relates to age at receiving hearing aids. HL = hearing loss.

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Journal of Speech, Language, and Hearing Research • Vol. 57 • 1929–1941 • October 2014

Appendix (p. 2 of 2) Demographic Characteristics for the Four Study Groups Table A3. Participants with bilateral CI (n = 14).

Bartov & Most: Song Recognition in Preschoolers With Cochlear Implants

No.

Sex

Age (years;months)

Inclusion

CI type

1 2 3 4 5

Female Female Male Female Female

4;9 5;10 4;6 3;8 4;9

Individual Group Group Group Group

6

Female

5;0

Individual

7 8 9 10 11 12 13 14

Male Female Male Female Female Female Male Male

6;6 6;9 6;6 6;3 3;11 6;0 6;1 4;5

Group Group Individual Individual Individual Group Group Group

Nucleus Freedom Medel Opus2 Nucleus Freedom Medel Opus2 Advanced Bionics Hires90k Advanced Bionics Harmony Nucleus Freedom Nucleus Freedom Medel Opus2 Nucleus Freedom Nucleus Freedom Nucleus Freedom Medel Opus2 Nucleus Freedom

Age at first implantation (years;months)

Length of first CI use (years;months)

Age at second implantation (years;months)

Length of bilateral CI use (years;months)

Age at HL detection (years;months)

Age at rehabilitation (years;months)

1;10 1;0 1;10 1;1 1;1

2;11 4;10 2;8 2;7 3;8

2;0 2;6 2;1 1;1 1;1

2;9 3;6 2;5 2;7 3;8

0;0 0;0 1;5 0;6 0;2

1;0 0;3 1;5 0;7 0;3

1;1

3;11

3;0

2;0

0;1

0;3

2;5 2;4 1;5 1;1 1;0 2;10 2;8 1;6

4;1 4;5 5;1 5;2 2;11 3;2 3;5 2;11

2;5 3;6 3;9 2;6 1;0 2;10 2;8 1;6

4;1 3;3 2;9 3;9 2;11 3;2 3;5 2;11

2;3 0;2 0;8 0;0 0;0 2;4 2;0 0;11

2;5 1;6 1;2 0;4 0;6 2;8 2;0 1;4

Note. Age at rehabilitation relates to age at receiving hearing aids.

Table A4. Participants with bimodal CI-HA (n = 9).

No.

Sex

Age (years;months) Inclusion

1 2 3

Female Female Female

3;9 5;10 5;9

4 5

Female Female

6 7 8 9

Female Female Male Female

CI type

Group Group Group

Age at Length Age at Age at PTA PTA 250 Hz 500 Hz implantation of CI use HL detection rehabilitation unaided aided unaided unaided (years;months) (years;months) (years;months) (years;months) (dB) (dB) (dB) (dB)

HA type

2;1 2;10 2;1

1;7 3;0 3;8

0;3 0;0 1;6

1;1 0;10 1;10

93 115 81

50 53 43

80 100 90

80 110 95

Phonak NaidaUPIII Oticon Sumo DM Phonak Naida UP

7;2 6;11

Nucleus-5 Nucleus Freedom Advanced Bionics Clarion Group Medel Opus2 Individual Nucleus Freedom

1;8 2;1

5;6 4;10

0;2 1;6

0;6 1;6

125 110

102 38

120 98

120 110

5;1 6;7 4;10 7;3

Group Individual Individual Group

2;11 4;0 1;0 3;0

2;2 2;7 3;10 4;3

0;0 2;6 0;6 0;3

0;11 2;6 0;6 0;5

88 81 72 70

45 28 42 32

80 30 65 75

85 50 75 75

Widex Senso P37 Starkey Destiny 1200 SP Phonak Naida SPIII Phonak Naida SPIII Siemens Aquaris Siemens Cielo P

Nucleus-5 Nucleus-5 Medel Opus2 Medel Opus2

1941

Note. Age at rehabilitation relates to age at receiving hearing aids (HAs). Hearing thresholds measured in the nonimplanted ear. CI-HA = CI with contralateral hearing aid; PTA = pure-tone average.

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