Tone and sentence perception in young Mandarin-speaking children with cochlear implants

Lexical tone recognition in multi-talker babbles and steady-state noise by Mandarin-speaking children with unilateral cochlear implants or bimodal hearing

BACKGROUND AND OBJECTIVES

Lexical tone presents challenges to cochlear implant (CI) users especially in noise conditions. Bimodal hearing utilizes residual acoustic hearing in the contralateral side and may offer benefits for tone recognition in noise. The purpose of the present study was to evaluate tone recognition in both steady-state noise and multi-talker babbles by the prelingually-deafened, Mandarin-speaking children with unilateral CIs or bimodal hearing.

METHODS

Fifty-three prelingually-deafened, Mandarin-speaking children who received CIs participated in this study. Twenty-two of them were unilateral CI users and 31 wore a hearing aid (HA) in the contralateral ear (i.e., bimodal hearing). All subjects were tested for Mandarin tone recognition in quiet and in two types of maskers: speech-spectrum-shaped noise (SSN) and two-talker babbles (TTB) at four signal-to-noise ratios (-6, 0, +6, and +12 dB).

RESULTS

While no differences existed in tone recognition in quiet between the two groups, the Bimodal group outperformed the Unilateral CI group under noise conditions. The differences between the two groups were significant at SNRs of 0, +6, and +12 dB in the SSN conditions (all p < 0.05), and at SNRs of +6 and +12 dB of TTB conditions (both p < 0.01), but not significant at other conditions (p > 0.05). The TTB exerted a greater masking effect than the SSN for tone recognition in the Unilateral CI group as well as in the Bimodal group at all SNRs tested (all p < 0.05). Among demographic or audiometric variables, only age at implantation showed a weak but significant correlation with the mean tone recognition performance under the SSN conditions (r = -0.276, p = 0.045). However, when Bonferroni correction was applied to the correlation analysis results, the weak correlation became not significant.

CONCLUSION

Prelingually-deafened children with CIs face challenges in tone perception in noisy environments, especially when the noise is fluctuating in amplitude such as the multi-talker babbles. Wearing a HA on the contralateral side when residual hearing permits is beneficial for tone recognition in noise.

Tone perception development in Mandarin-speaking children with cochlear implants

OBJECTIVE

The purpose of this study was to examine the longer-term effects of cochlear implant (CI) use on tone perception by evaluating improvement in Mandarin tone recognition in children with CIs 2 and 3 years post CI activation, and to explore the effects of implant age, chronological age and duration of CI use on the development of tone perception.

METHODS

Tone perception was assessed in 29 bilateral profound hearing impaired children (mean chronological age = 4.6 years, SD = 0.7 years) with unilateral CIs at 24 and 36 months after CI activation using the tone perception subtest in the Mandarin Early Speech Perception (MESP-T) test.

RESULTS

Children's tone recognition for tone pairs and individual tones improved significantly between 2 and 3 years post CI use, showing an increase in average tone recognition score from 73.2% to 81.8%, which was significantly higher than chance level (i.e. 50%). There was no significant correlation between tone recognition ability and either implant age or chronological age at two evaluation points. Further analysis revealed that the tone recognition score for tone pair 2-3 was significantly lower than that for other tone pairs except for tone pair 2-4.

CONCLUSIONS

Longer CI experience can significantly improve tone recognition ability in CI children between 2 and 3 years post CI activation.

Quantifying the Influence of Factors on the Accuracy of Speech Perception in Mandarin-Speaking Cochlear Implant Patients

Rehabilitation of hearing perception in cochlear implant (CI) patients is a challenging process. A comprehensive analysis of the characteristics of hearing rehabilitation in Mandarin-speaking CI patients was conducted. We measured the aided hearing threshold (AHT) and the speech perception accuracy (SPA) and collected clinical data. A total of 49 CI patients were included. Significant linear relationships existed between the AHT and SPA. The SPA increased by about 5-7% when the AHT decreased by 5 dB. An apparent individual difference in the SPA was observed under the same AHT, which in some patients was lower than the reference value fitted by the regression model. The timing of both of cochlear implantation and rehabilitation training was found to lead to significant improvement in SPA. The SPA increases by 2.1-3.6% per year of cochlear implantation and 0.7-1.5% per year of rehabilitation training. The time of auditory deprivation can significantly reduce the SPA by about 1.0-1.6% per year. The SPA was still poor in some CI patients when the hearing compensation seemed satisfying. Early cochlear implantation and post-operative rehabilitation are essential for recovery of the patient's SPA if the indications for cochlear implantation are met.

Discrimination of consonants in quiet and in noise in Mandarin-speaking children with normal hearing

OBJECTIVE

Given the critical role of consonants in speech perception and the lack of knowledge on consonant perception in noise in Mandarin-speaking children, the current study aimed to investigate Mandarin consonant discrimination in normal-hearing children, in relation to the effects of age and signal-to-noise ratios (S/N).

DESIGN

A discrimination task consisting of 33 minimal pairs in monosyllabic words was designed to explore the development of consonant discrimination in five test conditions: 0, -5, -10, -15 dB S/Ns, and quiet.

STUDY SAMPLE

Forty Mandarin-speaking, normal-hearing children aged from 4;0 to 8;9 in one-year-age increment were recruited and their performance was compared to 10 adult listeners.

RESULTS

A significant main effect of age, test conditions, and an interaction effect between these variables was noted. Consonant discrimination in quiet and in noise improved as children became older. Consonants that were difficult to discriminate in quiet and in noise were mainly velar contrasts. Noise seemed to have less effect on the discrimination of affricates and fricatives, and plosives appeared to be to be more difficult to discriminate in noise than in quiet. Place contrasts between alveolar and palato-alveolar consonants were difficult in quiet.

CONCLUSIONS

The findings were the first to reveal typical perceptual development of Mandarin consonant discrimination in children and can serve as a reference for comparison with children with disordered perceptual development, such as those with hearing loss.

Pre-attentive fundamental frequency processing in Mandarin-speaking children with cochlear implants as revealed by the peak latency of positive mismatch response

Introduction

Fundamental frequency (F0) serves as the primary acoustic cue for Mandarin tone perception. Recent behavioral studies suggest that F0 information may be differently processed between Mandarin-speaking normal-hearing (NH) children and children with cochlear implants (CIs), which may partially explain the unsatisfactory outcome of lexical tone recognition using CIs with tonal language-oriented speech processing strategies. The aim of the current study was to provide neural evidence of F0 processing in Mandarin-speaking kindergarten-aged children with CIs compared with NH children.

Methods

Positive mismatch responses (p-MMRs) to the change of the two acoustic dimensions of F0 (F0 contour and F0 level) in Mandarin-speaking kindergarten-aged children with CIs (n = 19) and their age-matched NH peers (n = 21).

Results

The two groups of children did not show any significant difference on the mean amplitude of p-MMR to either F0 contour or F0 level change. While the CI group exhibited a significantly shorter peak latency of p-MMR to F0 contour change than to F0 level change, an opposite pattern was observed in the NH group.

Discussion

This study revealed a higher sensitivity to F0 contour change than to F0 level change in children with CIs, which was different from that in NH children. The neural evidence of discrepant F0 processing between children with CIs and NH children in this study was consistent with the previously reported behavioral findings and may serve as a reference for the development and improvement of tonal language-oriented speech processing strategies.

Is Cantonese lexical tone information important for sentence recognition accuracy in quiet and in noise?

In Chinese languages, tones are used to express the lexical meaning of words. It is therefore important to analyze the role of lexical tone in Chinese sentence recognition accuracy. There is a lack of research on the role of Cantonese lexical tones in sentence recognition accuracy. Therefore, this study examined the contribution of lexical tone information to Cantonese sentence recognition accuracy and its cognitive correlates in adults with normal hearing (NH). A text-to-speech synthesis engine was used to synthesize Cantonese daily-use sentences with each word carrying an original or a flat lexical tone, which were then presented to 97 participants in quiet, in speech-shaped noise (SSN), and in two-talker babble (TTB) noise conditions. Both target sentences and noises were presented at 65 dB binaurally via insert headphones. It was found that listeners with NH can almost perfectly recognize a daily-use Cantonese sentence with mismatched lexical tone information in quiet, while their sentence recognition decreases substantially in noise. The same finding was reported for Mandarin, which has a relatively simple tonal system, suggesting that the current results may be applicable to other tonal languages. In addition, working memory (WM) was significantly related to decline in sentence recognition score in the TTB but not in the SSN, when the lexical tones were mismatched. This finding can be explained using the Ease of Language Understanding model and suggests that those with higher WM are less likely to be affected by the degraded lexical information for perceiving daily-use sentences in the TTB.

Sociodemographic disparities in pediatric cochlear implantation outcomes: A systematic review

OBJECTIVES

To determine the impact of sociodemographic factors on post-operative performance outcomes among PCI recipients across the world.

METHODS

A qualitative systematic review of PubMed, Scopus, Web of Science, and Embase was undertaken for studies analyzing the association of sociodemographic factors with measures of PCI outcomes published before July 18, 2021. Study quality assessment tools from the National Institutes of Health (NIH) were used to assess for risk of bias.

RESULTS

Out of 887 unique abstracts initially retrieved, 45 papers were included in the final qualitative systematic review. Sociodemographic disparities in PCI outcomes from 4702 PCI recipients were studied in 19 countries, with 14 studies conducted in the United States of America, published within the years of 1999 to 2021. Parental education and socioeconomic status (e.g. income) were the most investigated disparities in PCI outcomes with 24 and 17 identified studies, respectively.

CONCLUSION

Socioeconomic status was a consistently reported determinant of PCI outcomes in the USA and elsewhere, and parental education, the most reported disparity, consistently impacted outcomes in countries outside the USA. This study is limited by our inability to perform a meta-analysis given the lack of standardization across measures of sociodemographic variables and assessment measures for PCI outcomes. Future studies should address the literature gap on racial and ethnic disparities among PCI outcomes and use standardized measures for sociodemographic variables and PCI outcomes to facilitate meta-analyses on the topic. Targeting the mechanisms of these disparities may mitigate the impact of the sociodemographic factors on PCI outcomes.

The Impact of Hearing Aids on Speech Perception in Mandarin-Speaking Children

Background. Severe hearing loss can affect speech perception in children, and hearing aids as a medical device may help improve speech perception in children. Objective. To explore the effects of fitting hearing aids (HAs) on speech perception in children with severe hearing loss (60–70 dB HL). Methods. Ninety-five children with bilateral severe hearing loss who were fitted bilaterally with HAs before the age of 3 years were followed up. The subjects were grouped according to their age at the time of fitting, i.e., <1, 1–2 , and 2–3 years groups. The Mandarin Early Speech Perception test was used to evaluate speech perception of Mandarin monosyllabic words at 12, 24, and 36 months after fitting. Results. There were significant improvements in vowel, consonant, and tone perception scores from 12 to 36 months after fitting HAs in the three age groups, and the mean score at 36 months after fitting was significantly improved at >85%. The mean speech pattern and spondee perception scores averaged at >90% at 12 months after fitting and were comparable to the scores of 2-year-old children with normal hearing. Conclusions. HA helps with speech perception in children with severe hearing loss.

The effect of lexical tone experience on English intonation perception in Mandarin-speaking cochlear-implanted children

To examine the effect of lexical tone experience on English intonation perception in Mandarin-speaking cochlear-implanted children during second language acquisition in Taiwan. A retrospective cohort study. A tertiary referred center. Fourteen children with cochlear implant (CI) in the experimental group, and 9 normal hearing children in the control group were enrolled in this study. Cochlear implantation and hearing rehabilitation. Two speech recognition accuracies were examined: (1) Lexical tone recognition (4-alternative forced choice, AFC), (2) English Sentence Intonation (2AFC). The overall accuracies for tone perception are 61.13% (standard deviation, SD = 10.84%) for CI group and 93.82% (SD = 1.80%) for normal hearing group. Tone 4 and Tone 1 were more easily to be recognized than tone 2 and tone 3 in the pediatric CI recipients (cCI) group. In English intonation perception, the overall accuracies are 61.82% (SD = 16.85%) for CI group, and 97.59% (SD = 4.73%) for normal hearing group. Significant high correlation (R = .919, P ≦ .000) between lexical tone perception and English intonation perception is noted. There is no significant difference for English intonation perception accuracies between Mandarin-speaking cCI (61.82%) and English-speaking cCI (70.13%, P = .11). Mandarin-speaking cochlear-implanted children showed significant deficits in perception of lexical tone and English intonation relative to normal hearing children. There was no tonal language benefit in Mandarin-speaking cochlear-implanted children's English intonation perception, compared to the English-speaking cochlear-implanted peers. For cochlear-implanted children, better lexical tone perception comes with better English intonation perception. Enhancing Mandarin prosodic perception for cochlear-implanted children may benefit their command of intonation in English.

Just-Noticeable Differences of Fundamental Frequency Change in Mandarin-Speaking Children with Cochlear Implants

Fundamental frequency (F0) provides the primary acoustic cue for lexical tone perception in tonal languages but remains poorly represented in cochlear implant (CI) systems. Currently, there is still a lack of understanding of sensitivity to F0 change in CI users who speak tonal languages. In the present study, just-noticeable differences (JNDs) of F0 contour and F0 level changes in Mandarin-speaking children with CIs were measured and compared with those in their age-matched normal-hearing (NH) peers. Results showed that children with CIs demonstrated significantly larger JND of F0 contour (JND-C) change and F0 level (JND-L) change compared to NH children. Further within-group comparison revealed that the JND-C change was significantly smaller than the JND-L change among children with CIs, whereas the opposite pattern was observed among NH children. No significant correlations were seen between JND-C change/JND-L change and age at implantation /duration of CI use. The contrast between children with CIs and NH children in sensitivity to F0 contour and F0 level change suggests different mechanisms of F0 processing in these two groups as a result of different hearing experiences.

A Review of Speech Perception of Mandarin-Speaking Children With Cochlear Implantation

Objective: This paper reviewed the literature on the development of and factors affecting speech perception of Mandarin-speaking children with cochlear implantation (CI). We also summarized speech outcome measures in standard Mandarin for evaluating auditory and speech perception of children with CI.

Method: A comprehensive search of Google Scholar and PubMed was conducted from March to June 2021. Search terms used were speech perception/lexical tone recognition/auditory perception AND cochlear implant AND Mandarin/Chinese.

Conclusion: Unilateral CI recipients demonstrated continuous improvements in auditory and speech perception for several years post-activation. Younger age at implantation and longer duration of CI use contribute to better speech perception. Having undergone a hearing aid trial before implantation and having caregivers whose educational level is higher may lead to better performance. While the findings that support the use of CI to improve speech perception continue to grow, much research is needed to validate the use of unilateral and bilateral implantation. Evidence to date, however, revealed bimodal benefits over CI-only conditions in lexical tone recognition and sentence perception in noise. Due to scarcity of research, conclusions on the benefits of bilateral CIs compared to unilateral CI or bimodal CI use cannot be drawn. Therefore, future research on bimodal and bilateral CIs is needed to guide evidence-based clinical practice.

Dialect Effects on Mandarin Tone Perception Development

This study aimed to characterize factors that influence early dialect development in a language environment with multiple dialects. Children were evaluated for these dialect effects compared with normal hearing referenced measures of speech and language development that are commonly implemented in hearing-impaired children. Dialect exposure and use were assessed longitudinally in Chinese children (2-6 years old) that were raised in a community where Putonghua (PTH) and Sichuanhua (SCH) Mandarin dialects were used. Lexical tones in these dialects are different. A total of 20 boys and 20 girls (2 years old at the beginning of the study) that attended the same nursery school were included in this study. SCH was used by the majority of subjects <4 years old. The majority of subjects >4 years old used either dialect, with a few users of both dialects at this age. PTH tone perception did not differ significantly as a function of dialect use. Tone recognition and discrimination were >90% accurate by 6 years old, in contrast to previous results for children with minimal exposure and use of PTH. Children with approximately ⩾50% PTH exposure might be accurately assessed with norm-referenced speech materials spoken in PTH, regardless of their preferred dialect. However, the current norm-referenced assessments of children with minimal PTH exposure and nonusers of the dialect might be inaccurate.

The Role of Lexical Tone Information in the Recognition of Mandarin Sentences in Listeners With Hearing Aids

OBJECTIVES

Lexical tone information provides redundant cues for the recognition of Mandarin sentences in listeners with normal hearing in quiet conditions. The contribution of lexical tones to Mandarin sentence recognition in listeners with hearing aids (HAs) is unclear. This study aimed to remove lexical tone information and examine the effects on Mandarin sentence intelligibility in HA users. The second objective was to investigate the contribution of cognitive abilities (i.e., general cognitive ability, working memory, and attention) on Mandarin sentence perception when the presentation of lexical tone information was mismatched.

DESIGN

A text-to-speech synthesis engine was used to manipulate Mandarin sentences into three test conditions: (1) a Normal Tone test condition, where no alterations were made to lexical tones within sentences; (2) a Flat Tone test condition, where lexical tones were all changed into tone 1 (i.e., the flat tone); and (3) a Random Tone test condition, where each word in test sentences was randomly assigned one of four Mandarin lexical tones. The manipulated sentence signals were presented to 32 listeners with HAs in both quiet and noisy environments at an 8 dB signal to noise ratio.

RESULTS

Speech intelligibility was reduced significantly (by approximately 40 percentage points) in the presence of mismatched lexical tone information in both quiet and noise. The difficulty in correctly identifying sentences with mismatched lexical tones among adults with hearing loss was significantly greater than that of adults with normal hearing. Cognitive function was not significantly related to a decline in speech recognition scores.

CONCLUSIONS

Contextual and other phonemic cues (i.e., consonants and vowels) are inadequate for HA users to perceive sentences with mismatched lexical tone contours in quiet or noise. Also, HA users with better cognitive function could not compensate for the loss of lexical tone information. These results highlight the importance of accurately representing lexical tone information for Mandarin speakers using HAs.

High-Variability Phonetic Training Benefits Lexical Tone Perception: An Investigation on Mandarin-Speaking Pediatric Cochlear Implant Users

Purpose Lexical tone perception is known to be persistently difficult for individuals with cochlear implants (CIs). The purpose of this study was to evaluate the efficacy of high-variability phonetic training (HVPT) in improving Mandarin tone perception for native-speaking children with CIs. Method A total of 28 Mandarin-speaking pediatric CI recipients participated in the study. Half of the children with CIs received a five-session HVPT within a period of 3 weeks. Identification and discrimination of lexical tones produced by familiar talkers (used during training) and novel talkers (not used during training) were measured before, immediately after, and 10 weeks after training termination. The other half untrained children served as control for the identical pre- and posttests. Results Lexical tone perception significantly improved in both trained identification task and untrained discrimination task for the trainees. There was also a significant effect in transfer of learning to perceiving tones produced by novel talkers. Moreover, training-induced gains were retained for up to 10 weeks after training. By comparison, no significant pre-post changes were observed in the control group. Conclusion The results provide the first systematical assessment for the efficacy of the HVPT protocol for Mandarin-speaking pediatric CI users with congenital hearing loss, which supports the clinical utility of intensive short-term HVPT in these children's rehabilitative regimens.

Bimodal Benefits Revealed by Categorical Perception of Lexical Tones in Mandarin-Speaking Kindergarteners With a Cochlear Implant and a Contralateral Hearing Aid

Purpose Pitch reception poses challenges for individuals with cochlear implants (CIs), and adding a hearing aid (HA) in the nonimplanted ear is potentially beneficial. The current study used fine-scale synthetic speech stimuli to investigate the bimodal benefit for lexical tone categorization in Mandarin-speaking kindergarteners using a CI and an HA in opposite ears. Method The data were collected from 16 participants who were required to complete two classical tasks for speech categorical perception (CP) with CI + HA device condition and CI alone condition. Linear mixed-effects models were constructed to evaluate the identification and discrimination scores across different device conditions. Results The bimodal kindergarteners showed CP for the continuum varying from Mandarin Tone 1 and Tone 2. Moreover, the additional acoustic information from the contralateral HA contributes to improved lexical tone categorization, with a steeper slope, a higher discrimination score of between-category stimuli pair, and an improved peakedness score (i.e., an increased benefit magnitude for discriminations of between-category over within-category pairs) for the CI + HA condition than the CI alone condition. The bimodal kindergarteners with better residual hearing thresholds at 250 Hz level in the nonimplanted ear could perceive lexical tones more categorically. Conclusion The enhanced CP results with bimodal listening provide clear evidence for the clinical practice to fit a contralateral HA in the nonimplanted ear in kindergarteners with unilateral CIs with direct benefits from the low-frequency acoustic hearing.

Effects of Fundamental Frequency Contours on Sentence Recognition in Mandarin-Speaking Children With Cochlear Implants

Purpose Fundamental frequency (F0) is the primary acoustic cue for lexical tone perception in tonal languages but is processed in a limited way in cochlear implant (CI) systems. The aim of this study was to evaluate the importance of F0 contours in sentence recognition in Mandarin-speaking children with CIs and find out whether it is similar to/different from that in age-matched normal-hearing (NH) peers. Method Age-appropriate sentences, with F0 contours manipulated to be either natural or flattened, were randomly presented to preschool children with CIs and their age-matched peers with NH under three test conditions: in quiet, in white noise, and with competing sentences at 0 dB signal-to-noise ratio. Results The neutralization of F0 contours resulted in a significant reduction in sentence recognition. While this was seen only in noise conditions among NH children, it was observed throughout all test conditions among children with CIs. Moreover, the F0 contour-induced accuracy reduction ratios (i.e., the reduction in sentence recognition resulting from the neutralization of F0 contours compared to the normal F0 condition) were significantly greater in children with CIs than in NH children in all test conditions. Conclusions F0 contours play a major role in sentence recognition in both quiet and noise among pediatric implantees, and the contribution of the F0 contour is even more salient than that in age-matched NH children. These results also suggest that there may be differences between children with CIs and NH children in how F0 contours are processed.

Translation and validation of parental perspective questionnaire for children with cochlear implant in persian language

Objective: Parental views about the outcomes of implantation on the child's quality of life are valuable sources of information for implantation specialists. The aim at this study was to validate the "Parental Perspectives" questionnaire in Persian language.Design: The original questionnaire was translated from English to Persian language; the final Persian version of questionnaire was prepared and evaluated for validity and reliability. The internal consistency of the questionnaire and test-retest reliability were respectively evaluated by Cronbach's alpha and ICC index. Factor analysis was used to determine the construct validity.Study Sample: The participants of this study were 370 parents of CI children.Results: Sampling adequacy for executing of factor analysis was confirmed by the results of Kaiser-Meyer-Olkin (=0.84) and Bartlett test (p < .05). Three factors were extracted from exploratory factor analysis. Confirmatory factor analysis confirmed the accuracy of the three-dimensional structures. Principal component analysis revealed the structural validity of three factors. Correlation between questionnaire items was good (r = 0.76). Reliability coefficient was calculated as 0.93.Conclusions: The Persian version of the questionnaire has good validity and reliability and can be used to examine the perspectives of the parents about CI.

Bimodal Benefits for Lexical Tone Recognition: An Investigation on Mandarin-speaking Preschoolers with a Cochlear Implant and a Contralateral Hearing Aid

Pitch perception is known to be difficult for individuals with cochlear implant (CI), and adding a hearing aid (HA) in the non-implanted ear is potentially beneficial. The current study aimed to investigate the bimodal benefit for lexical tone recognition in Mandarin-speaking preschoolers using a CI and an HA in opposite ears. The child participants were required to complete tone identification in quiet and in noise with CI + HA in comparison with CI alone. While the bimodal listeners showed confusion between Tone 2 and Tone 3 in recognition, the additional acoustic information from the contralateral HA alleviated confusion between these two tones in quiet. Moreover, significant improvement was demonstrated in the CI + HA condition over the CI alone condition in noise. The bimodal benefit for individual subjects could be predicted by the low-frequency hearing threshold of the non-implanted ear and the duration of bimodal use. The findings support the clinical practice to fit a contralateral HA in the non-implanted ear for the potential benefit in Mandarin tone recognition in CI children. The limitations call for further studies on auditory plasticity on an individual basis to gain insights on the contributing factors to the bimodal benefit or its absence.

Health-Related Quality of Life in Mandarin-Speaking Children With Cochlear Implants

OBJECTIVES

The primary aim of this study was to evaluate the health-related quality of life (HRQoL) of children with cochlear implants (CIs) from the parental perspective. The secondary objective was to explore possible relationships between demographic variables (such as age at assessment, gender, age at implantation, and duration of language rehabilitation) and the HRQoL. The third objective was to determine the developmental trajectories of HRQoL.

DESIGN

This study included parents of 123 children with CIs (mean age, 40.45 months; mean age of CI implantation, 24.74 months; mean device experience, 16.34 months). The time periods for follow-up were at 0, 1, 2, 3, 6, and 12-month intervals of CI use. The Mandarin Children with Cochlear Implants: Parental Perspectives questionnaire was employed to assess HRQoL.

RESULTS

Parents were satisfied with HRQoL, especially with the domain of social relations; however, education received a less positive rating. The duration of CI use was positively correlated with 5 domains, suggesting that children who used CIs for a longer time had higher HRQoL ratings. Children with longer language rehabilitation received more positive ratings in the domains of social relations and education (p < 0.05); children whose mothers had higher education levels received more positive ratings in the domain of general functioning (p < 0.05); children living in cities received more positive ratings in the domains of communication, general functioning and self-reliance (p < 0.05). Girls received more positive rating than boys in the domain of well-being (p < 0.05). No significant correlation was found between age at implantation, age at assessment, only child status, and HRQoL. All domains showed clear increases in the duration of CI use; the majority of the domains showed steeper progress over the first 3 months of CI use. Communication exhibited the most rapid progress, with education progressing at a slower rate.

CONCLUSIONS

Parents were satisfied with all domains of HRQoL. Almost all domains exhibited rapid progress over the first 3 months of CI use, with education progressing at a slower rate. This research underscores the importance of language rehabilitation by revealing that strengthening language rehabilitation could be an effective means of improving the HRQoL of children with CIs.

Restricted Speech Recognition in Noise and Quality of Life of Hearing-Impaired Children and Adolescents With Cochlear Implants - Need for Studies Addressing This Topic With Valid Pediatric Quality of Life Instruments

Cochlear implants (CI) support the development of oral language in hearing-impaired children. However, even with CI, speech recognition in noise (SRiN) is limited. This raised the question, whether these restrictions are related to the quality of life (QoL) of children and adolescents with CI and how SRiN and QoL are related to each other. As a result of a systematic literature research only three studies were found, indicating positive moderating effects between SRiN and QoL of young CI users. Thirty studies addressed the quality of life of children and adolescents with CI. Following the criteria of the World Health Organization (WHO) for pediatric health related quality of life HRQoL (1994) only a minority used validated child centered and age appropriate QoL instruments. Moreover, despite the consensus that usually children and adolescents are the most prominent informants of their own QoL (parent-reports complement the information of the children) only a minority of investigators used self-reports. Restricted SRiN may be a burden for the QoL of children and adolescents with CI. Up to now the CI community does not seem to have focused on a possible impairment of QoL in young CI users. Further studies addressing this topic are urgently needed, which is also relevant for parents, clinicians, therapists, teachers, and policy makers. Additionally investigators should use valid pediatric QoL instruments. Most of the young CI users are able to inform about their quality of life themselves.

Processing of Acoustic Information in Lexical Tone Production and Perception by Pediatric Cochlear Implant Recipients

Purpose: This study examined the utilization of multiple types of acoustic information in lexical tone production and perception by pediatric cochlear implant (CI) recipients who are native speakers of Mandarin Chinese. Methods: Lexical tones were recorded from CI recipients and their peers with normal hearing (NH). Each participant was asked to produce a disyllabic word, yan jing, with which the first syllable was pronounced as Tone 3 (a low dipping tone) while the second syllable was pronounced as Tone 1 (a high level tone, meaning "eyes") or as Tone 4 (a high falling tone, meaning "eyeglasses"). In addition, a parametric manipulation in fundamental frequency (F0) and duration of Tones 1 and 4 used in a lexical tone recognition task in Peng et al. (2017) was adopted to evaluate the perceptual reliance on each dimension. Results: Mixed-effect analyses of duration, intensity, and F0 cues revealed that NH children focused exclusively on marking distinct F0 contours, while CI participants shortened Tone 4 or prolonged Tone 1 to enhance their contrast. In line with these production strategies, NH children relied primarily on F0 cues to identify the two tones, whereas CI children showed greater reliance on duration cues. Moreover, CI participants who placed greater perceptual weight on duration cues also tended to exhibit smaller changes in their F0 production. Conclusion: Pediatric CI recipients appear to contrast the secondary acoustic dimension (duration) in addition to F0 contours for both lexical tone production and perception. These findings suggest that perception and production strategies of lexical tones are well coupled in this pediatric CI population.

Music Training Can Improve Music and Speech Perception in Pediatric Mandarin-Speaking Cochlear Implant Users

Due to limited spectral resolution, cochlear implants (CIs) do not convey pitch information very well. Pitch cues are important for perception of music and tonal language; it is possible that music training may improve performance in both listening tasks. In this study, we investigated music training outcomes in terms of perception of music, lexical tones, and sentences in 22 young (4.8 to 9.3 years old), prelingually deaf Mandarin-speaking CI users. Music perception was measured using a melodic contour identification (MCI) task. Speech perception was measured for lexical tones and sentences presented in quiet. Subjects received 8 weeks of MCI training using pitch ranges not used for testing. Music and speech perception were measured at 2, 4, and 8 weeks after training was begun; follow-up measures were made 4 weeks after training was stopped. Mean baseline performance was 33.2%, 76.9%, and 45.8% correct for MCI, lexical tone recognition, and sentence recognition, respectively. After 8 weeks of MCI training, mean performance significantly improved by 22.9, 14.4, and 14.5 percentage points for MCI, lexical tone recognition, and sentence recognition, respectively (p < .05 in all cases). Four weeks after training was stopped, there was no significant change in posttraining music and speech performance. The results suggest that music training can significantly improve pediatric Mandarin-speaking CI users’ music and speech perception.

Comparable Electrode Impedance and Speech Perception at 12 Months after Cochlear Implantation Using Round Window versus Cochleostomy: An Analysis of 40 Patients

OBJECTIVE

The objective of this study was to examine whether cochlear implantation using the round window (RW) route versus cochleostomy achieves comparable electrode impedance and hearing results.

METHODS

This retrospective analysis included 40 patients receiving a cochlear implant (REZ-1): 20 using the RW approach and the remaining 20 using cochleostomy. Electrode impedance and tone, vowel, consonant, disyllable and sentence perception were measured during and after the implantation.

RESULTS

Electrode impedance did not differ significantly between the 2 groups at any time points [F(1, 38) = 1.84; p = 0.184]: 1.87, 5.16, 6.47 and 6.70 kΩ in the RW group versus 2.86, 5.33, 6.92 and 8.16 kΩ in the cochleostomy group at 0, 1, 3 and 12 months, respectively. There was no significant difference between the RW and cochleostomy groups for tone (77.50 vs. 80.50%; p = 0.472), vowel (77.70 vs. 78.65%; p = 0.760), consonant (75.50 vs. 78.25%; p = 0.443), disyllable (78.60 vs. 81.50%; p = 0.317) and sentence (50.90 vs. 52.50%; p = 0.684) perception at 12 months.

CONCLUSION

The RW approach is comparable to cochleostomy in electrode placement as reflected by impedance and function as reflected by tone, vowel, consonant, disyllable and sentence perception.

Mandarin-Speaking, Kindergarten-Aged Children With Cochlear Implants Benefit From Natural F 0 Patterns in the Use of Semantic Context During Speech Recognition

PURPOSE

The purpose of this study was to investigate the extent to which semantic context and F0 contours affect speech recognition by Mandarin-speaking, kindergarten-aged children with cochlear implants (CIs).

METHOD

The experimental design manipulated two factors, that is, semantic context, by comparing the intelligibility of normal sentence versus word list, and F0 contours, by comparing the intelligibility of utterances with natural versus flat F0 patterns. Twenty-two children with CIs completed a speech recognition test.

RESULTS

Children with CIs could use both semantic context and F0 contours to assist speech recognition. Furthermore, natural F0 patterns provided extra benefit when semantic context was present than when it was absent.

CONCLUSION

Dynamic F0 contours play an important role in speech recognition by Mandarin-speaking children with CIs despite the well-known limitation of CI devices in extracting F0 information.

Efficacy of a Hearing Aid Noise Reduction Function

Noise reduction systems have been implemented in hearing aids to improve signal-to-noise ratio and listening comfort. The aim of this study was to evaluate the efficacy of hearing aid noise reduction for Mandarin speakers. The results showed a significant improvement in acceptable noise levels and speech reception thresholds with noise reduction turned on. Sound quality ratings also suggested that most listeners preferred having noise reduction turned on for listening effort, listening comfort, speech clarity, and overall sound quality. These results suggest that the noise reduction system used in this study might improve sentence perception in steady-state noise, noise tolerance, and sound quality, although not all listeners preferred aggressive noise reduction. However, due to large interindividual variation, clinical application of the results should be on an individual basis.

Assessing the Importance of Lexical Tone Contour to Sentence Perception in Mandarin-Speaking Children With Normal Hearing

PURPOSE

The aim of the present study was to evaluate the influence of lexical tone contour and age on sentence perception in quiet and in noise conditions in Mandarin-speaking children ages 7 to 11 years with normal hearing.

METHOD

Test materials were synthesized Mandarin sentences, each word with a manipulated lexical contour, that is, normal contour, flat contour, or a tone contour randomly selected from the four Mandarin lexical tone contours. A convenience sample of 75 Mandarin-speaking participants with normal hearing, ages 7, 9, and 11 years (25 participants in each age group), was selected. Participants were asked to repeat the synthesized speech in quiet and in speech spectrum-shaped noise at 0 dB signal-to-noise ratio.

RESULTS

In quiet, sentence recognition by the 11-year-old children was similar to that of adults, and misrepresented lexical tone contours did not have a detrimental effect. However, the performance of children ages 9 and 7 years was significantly poorer. The performance of all three age groups, especially the younger children, declined significantly in noise.

CONCLUSIONS

The present research suggests that lexical tone contour plays an important role in Mandarin sentence recognition, and misrepresented tone contours result in greater difficulty in sentence recognition in younger children. These results imply that maturation and/or language use experience play a role in the processing of tone contours for Mandarin speech understanding, particularly in noise.

Processing of Acoustic Cues in Lexical-Tone Identification by Pediatric Cochlear-Implant Recipients

PURPOSE

The objective was to investigate acoustic cue processing in lexical-tone recognition by pediatric cochlear-implant (CI) recipients who are native Mandarin speakers.

METHOD

Lexical-tone recognition was assessed in pediatric CI recipients and listeners with normal hearing (NH) in 2 tasks. In Task 1, participants identified naturally uttered words that were contrastive in lexical tones. For Task 2, a disyllabic word (yanjing) was manipulated orthogonally, varying in fundamental-frequency (F0) contours and duration patterns. Participants identified each token with the second syllable jing pronounced with Tone 1 (a high level tone) as eyes or with Tone 4 (a high falling tone) as eyeglasses.

RESULTS

CI participants' recognition accuracy was significantly lower than NH listeners' in Task 1. In Task 2, CI participants' reliance on F0 contours was significantly less than that of NH listeners; their reliance on duration patterns, however, was significantly higher than that of NH listeners. Both CI and NH listeners' performance in Task 1 was significantly correlated with their reliance on F0 contours in Task 2.

CONCLUSION

For pediatric CI recipients, lexical-tone recognition using naturally uttered words is primarily related to their reliance on F0 contours, although duration patterns may be used as an additional cue.

Vocabulary development in Mandarin-speaking children with cochlear implants and its relationship with speech perception abilities

BACKGROUND

China has the largest population of children with hearing impairments and cochlear implantation is gaining popularity there. However, the vocabulary development in this population is largely unexplored.

AIMS

This study examined early vocabulary outcomes, factors influencing early vocabulary development and the relationship between speech perception and vocabulary development in Mandarin-speaking children during the first year of cochlear implant use.

METHODS AND PROCEDURES

A battery of vocabulary tests was administered to 80 children before implantation and 3, 6, and 12 months after implantation. Demographic information was obtained to evaluate their relationships with vocabulary outcomes.

OUTCOMES AND RESULTS

The Mandarin-speaking children, who received their cochlear implants before 3 years of age, developed vocabulary at a rate faster than that of their same-aged peers with normal hearing. Better pre-implant hearing levels, younger age at implantation, and higher maternal education level contributed to the early vocabulary development. The trajectories of speech perception development highly correlated with those of vocabulary development during 3 to 12 months of CI use.

CONCLUSIONS

and Implications: These findings imply that the vocabulary development of children implanted before 3 years of age may catch up with that of their hearing peers.

Mandarin Tone Identification in Cochlear Implant Users Using Exaggerated Pitch Contours

OBJECTIVE

To determine whether exaggerating the variations in fundamental frequency (F0) contours of Mandarin-based pitch fluctuations could improve tone identification by cochlear implant (CI) users.

METHODS

Twelve normal-hearing (NH) listeners and 11 CI users were tested for their ability to recognize F0 contours modeled after Mandarin tones, in 4- or 5-alternatives forced-choice paradigms. Two types of stimuli were used: computer-generated complex tones and voice recordings. Four contours were tested with voice recordings: flat, rise, fall, and dip. A fifth contour, peak, was added for complex tones. The F0 range of each contour was varied in an adaptive manner. A maximum-likelihood technique was used to fit a psychometric function to the performance data and extract threshold at 70% accuracy.

RESULTS

As F0 range increased, performance in tone identification improved but did not reach 100% for some CI users, suggesting that confusions between contours could always be made even with extremely exaggerated contours. Compared with NH participants, CI users required substantially larger F0 ranges to identify tones, on the order of 9.3 versus 0.4 semitones. CI users achieved better performance for complex tones than for voice recordings, whereas the reverse was true for NH participants. Confusion matrices showed that the "flat" tone was often a default option when the tone contour's F0 range presented was too narrow for participants to respond correctly.

CONCLUSION

These results demonstrate markedly impaired ability for CI users to identify tonal contours, but suggest that the use of exaggerated pitch contours may be helpful for tonal language perception.

Lexical tone recognition in noise in normal-hearing children and prelingually deafened children with cochlear implants

OBJECTIVE

The purpose of the present study was to investigate Mandarin tone recognition in background noise in children with cochlear implants (CIs), and to examine the potential factors contributing to their performance.

DESIGN

Tone recognition was tested using a two-alternative forced-choice paradigm in various signal-to-noise ratio (SNR) conditions (i.e. quiet, +12, +6, 0, and -6 dB). Linear correlation analysis was performed to examine possible relationships between the tone-recognition performance of the CI children and the demographic factors.

STUDY SAMPLE

Sixty-six prelingually deafened children with CIs and 52 normal-hearing (NH) children as controls participated in the study.

RESULTS

Children with CIs showed an overall poorer tone-recognition performance and were more susceptible to noise than their NH peers. Tone confusions between Mandarin tone 2 and tone 3 were most prominent in both CI and NH children except for in the poorest SNR conditions. Age at implantation was significantly correlated with tone-recognition performance of the CI children in noise.

CONCLUSIONS

There is a marked deficit in tone recognition in prelingually deafened children with CIs, particularly in noise listening conditions. While factors that contribute to the large individual differences are still elusive, early implantation could be beneficial to tone development in pediatric CI users.

Validation of list equivalency for Mandarin speech materials to use with cochlear implant listeners

OBJECTIVES

Speech materials validated with normal-hearing listeners may not be appropriate for clinical assessment of cochlear implant (CI) users. The aim of this study was to validate list equivalency of the Mandarin Speech Perception (MSP) sentences, disyllables, and monosyllables in Mandarin-speaking CI patients.

DESIGN

Recognition of MSP sentences, disyllables, and monosyllables each were measured for all 10 lists.

STUDY SAMPLE

67 adult and 32 pediatric Mandarin-speaking CI users.

RESULTS

There was no significant difference between adult and pediatric subject groups for all test materials. Significant differences were observed among lists within each test. After removing one or two lists within each test, no significant differences were observed among the remaining lists. While there was equal variance among lists within a given test, the variance was larger for children than for adults, and increased from monosyllables to disyllables to sentences.

CONCLUSIONS

Some adjustment to test lists previously validated with CI simulations was needed to create perceptually equivalent lists for real CI users, suggesting that test materials should be validated in the targeted population. Differences in mean scores and variance across test materials suggest that CI users may differ in their ability to make use of contextual cues available in sentences and disyllables.

Current trends in outcome studies for children with hearing loss and the need to establish a comprehensive framework of measuring outcomes in children with hearing loss in China

Since the 1970s, outcome studies for children with hearing loss expanded from focusing on assessing auditory awareness and speech perception skills to evaluating language and speech development. Since the early 2000s, the multi-center large scale research systematically studied outcomes in the areas of auditory awareness, speech-perception, language development, speech development, educational achievements, cognitive development, and psychosocial development. These studies advocated the establishment of baseline and regular follow-up evaluations with a comprehensive framework centered on language development. Recent research interests also include understanding the vast differences in outcomes for children with hearing loss, understanding the relationships between neurocognitive development and language acquisition in children with hearing loss, and using outcome studies to guide evidence-based clinical practice. After the establishment of standardized Mandarin language assessments, outcomes research in Mainland China has the potential to expand beyond auditory awareness and speech perception studies.

Known-Groups and Concurrent Validity of the Mandarin Tone Identification Test (MTIT)

Objective

The Mandarin Tone Identification Test (MTIT) is a new test designed to assess the tone identification abilities of children with hearing impairment (HI). Evidence for reliability and sensitivity has been reported. The present study aimed to evaluate the known-groups and concurrent validity of the MTIT.

Design

The MTIT and Mandarin Pediatric Speech Intelligibility test (MPSI) were administered in quiet and in noise conditions. The known-groups validity was evaluated by comparing the performance of the MTIT on children with two different levels of HI. The MPSI was included to evaluate the concurrent validity of the MTIT.

Study sample

81 children with HI were recruited in the present study. They were Mandarin-speaking children with profound HI (mean age = 9; 0, n = 41) and with moderate to severe HI (mean age = 8; 9, n = 40).

Results

Scores on the MTIT differed between the two groups with different hearing levels suggesting good known-groups validity. A strong relationship between tone and sentence perception both in quiet and in noise provided preliminary evidence for concurrent validity.

Conclusions

The present study confirmed that the MTIT has good known-groups validity and provided preliminary evidence for concurrent validity. The MTIT could be used to evaluate tone identification ability in children with HI with confidence.

Early speech perception in Mandarin-speaking children at one-year post cochlear implantation

PURPOSE

The aim in this study was to examine early speech perception outcomes in Mandarin-speaking children during the first year of cochlear implant (CI) use.

METHOD

A hierarchical early speech perception battery was administered to 80 children before and 3, 6, and 12 months after implantation. Demographic information was obtained to evaluate its relationship with these outcomes.

RESULTS

Regardless of dialect exposure and whether a hearing aid was trialed before implantation, implant recipients were able to attain similar pre-lingual auditory skills after 12 months of CI use. Children speaking Mandarin developed early Mandarin speech perception faster than those with greater exposure to other Chinese dialects. In addition, children with better pre-implant hearing levels and younger age at implantation attained significantly better speech perception scores after 12 months of CI use. Better pre-implant hearing levels and higher maternal education level were also associated with a significantly steeper growth in early speech perception ability.

CONCLUSIONS

Mandarin-speaking children with CIs are able to attain early speech perception results comparable to those of their English-speaking counterparts. In addition, consistent single language input via CI probably enhances early speech perception development at least during the first-year of CI use.

A Structural Equation Modeling Approach to Examining Factors Influencing Outcomes with Cochlear Implant in Mandarin-Speaking Children

OBJECTIVE

To examine the direct and indirect effects of demographical factors on speech perception and vocabulary outcomes of Mandarin-speaking children with cochlear implants (CIs).

METHODS

115 participants implanted before the age of 5 and who had used CI before 1 to 3 years were evaluated using a battery of speech perception and vocabulary tests. Structural equation modeling was used to test the hypotheses proposed.

RESULTS

Early implantation significantly contributed to speech perception outcomes while having undergone a hearing aid trial (HAT) before implantation, maternal educational level (MEL), and having undergone universal newborn hearing screening (UNHS) before implantation had indirect effects on speech perception outcomes via their effects on age at implantation. In addition, both age at implantation and MEL had direct and indirect effects on vocabulary skills, while UNHS and HAT had indirect effects on vocabulary outcomes via their effects on age at implantation.

CONCLUSION

A number of factors had indirect and direct effects on speech perception and vocabulary outcomes in Mandarin-speaking children with CIs and these factors were not necessarily identical to those reported among their English-speaking counterparts.

Consonant discrimination by Mandarin-speaking children with prelingual hearing impairment

OBJECTIVES

Little is known about the consonant discrimination ability of Mandarin-speaking children with prelingual hearing impairment (HI) and fitted with hearing aids (HAs). The present study aimed to evaluate Mandarin consonant discrimination ability in children with HI, and explore the effects of unaided and aided hearing threshold, the age of first HA fitting and the duration of HA use on consonant discrimination ability.

METHODS

Subjects were Mandarin-speaking children aged 5;4-12;6 years with profound HI (n=41), children aged 6;1-12;4 years with severe HI (n=26), and children aged 5;0-11;9 years with moderate HI (n=9). The Mandarin Consonant Discrimination Test was administered in six test conditions: -10, -5, 0, 5 and 10dB signal to noise ratios (S/Ns) and quiet. HAs were in the usual user's settings, adjusted to match the manufacturer prescribed settings and individual preferences, and the volume was set to comfortable listening level.

RESULTS

The results revealed that /p(h)/-/t(h)/, /ts/-/tʂ/ and /ʐ/-/l/ were the most difficult and /p/-/p(h)/, /t/-/t(h)/, /tɕ/-/tɕ(h)/ and /k/-/k(h)/ were the easiest consonant minimal pairs to discriminate in quiet both for children with profound HI and those with moderate to severe HI. In noise, no significant difference in performance was found among all consonant minimal pairs. A backward elimination stepwise multiple linear regressions revealed that unaided hearing level accounted for 25.4% of the variance in consonant discrimination performance in noise at 10dB S/N and 30.4% in quiet. However, aided hearing threshold, the age of first HA fitting and the duration of HA use did not significantly predict consonant discrimination ability both in quiet and in noise.

CONCLUSIONS

Consonant discrimination performance of children with profound HI was poorer than those with moderate to severe HI. The ability to discriminate consonant pairs seems to depend on age of acquisition of the consonants. Although the age of first HA fitting and the duration of HA use were not correlated with consonant discrimination outcomes, this finding does not preclude the importance of early HA fitting.

Tone identification in Mandarin-speaking children with profound hearing impairment

OBJECTIVES

Little is known about the tone identification ability of Mandarin-speaking children with profound hearing impairment (HI) and fitted with hearing aids (HAs). The present study aimed to evaluate the Mandarin tone identification ability in children with profound HI and fitted with HAs, and explore the effects of hearing thresholds, the age of first HA fitting and the duration of HA use on Mandarin tone identification ability.

METHODS

Subjects were Mandarin-speaking children aged 5;4-12;6 years with profound HI (n=41). The Mandarin Tone Identification Test was administered in five test conditions: in -10, -5, 0 and 5dB signal-to-noise ratios (S/Ns) and quiet. Hearing aids were in the usual user's settings, optimized for the best speech reception, and the volume was set to comfortable listening level.

RESULTS

Two-way repeated measures ANOVA showed significant effects of test conditions and tone contrasts in Mandarin tone identification. Post-hoc pairwise comparisons showed significant difference in performance among the five test conditions. Results also indicated that, among the six tone contrasts, the Tone 1/Tone 2 and Tone 2/Tone 3 contrasts were the most difficult tone contrasts in quiet. No significant difference in performance was found among the six tone contrasts in noise. Pearson product-moment correlation showed that the age of first HA fitting, the duration of HA use, aided and unaided average thresholds as well as the aided hearing thresholds in the low frequency region were not significantly correlated with tone identification ability in the five test conditions.

CONCLUSIONS

Consistent with previous findings, the Tone 1/Tone 2 and Tone 2/Tone 3 contrasts were the most difficult to identify in quiet; but the presence of noise resulted in these tone contrasts being equally difficult. Findings also suggest that the tone identification ability of children with profound HI needs to be improved. Although the age of first HA fitting and the duration of HA use were not significantly correlated with tone identification performance in children with profound HI, this finding does not preclude the importance of early HA fitting.