Tonya R. Bergeson and Rachael Frush Holt
How does hearing loss affect perception and understanding of music? It is not as simple as turning down the volume on sound. Sensorineural hearing loss (with causes ranging from neurotoxic drugs to aging to genetics) involves damage to the inner ear and can result in different degrees and configurations of hearing loss. For example, when people age they might gradually lose high-frequency hearing but have no problem hearing low frequencies. Moreover, the technologies involved with assistive listening devices such as hearing aids and cochlear implants do not simply turn up the volume of sound. These aids can be programmed to process incoming sound in particular ways to amplify certain frequency bands. Hearing aids and cochlear implants were originally designed to benefit speech understanding, but engineers have begun to develop technologies to benefit music listening as well. Although tests of music perception are not included in routine examinations of hearing, clinicians are becoming more interested in how music can enhance quality of life. Finally, studying music perception in people with hearing loss can help answer questions regarding the effects of auditory deprivation on what some call the “universal language.”
The Centers for Disease Control and Prevention estimates that 2–3 per 1000 children are born with sensorineural hearing loss (CDC, 2010). Approximately 15% of people between 6 and 19 years of age have bilateral sensorineural hearing loss, and the ratio increases as age advances. Sensorineural hearing loss is a permanent condition caused by damage to structures located in the auditory periphery, typically the basilar membrane, which is located in the cochlea. Sensorineural hearing loss can, as the name suggests, be due to damage to the auditory nerve, but routine diagnostic testing does not distinguish between these two sites of lesion. The basilar membrane is organized tonotopically, meaning that it is maximally sensitive to sounds of different frequencies along its length: low frequencies are coded at the apex and high frequencies at the base. Sensorineural hearing loss can range from mild (inability to hear birds chirping, low-intensity, high-frequency sounds such as /f/ and /s/, or the sounds of a flute) to profound (inability to hear a loud motorcycle revving its engine, a rock band, and any speech sounds). Additionally, sensorineural hearing loss generally leads to reduced frequency selectivity because of damage to the cochlea. Specifically, the neural system’s ability to operate as a set of auditory filters, which are narrow to carefully analyze sound spectra, change with cochlear damage, becoming broader and less selective. This broadening can result in difficulties perceiving the harmonics in complex sounds, such as musical tones (Moore, 2008a). Moreover, frequencies that would normally stimulate an area of the cochlea that is no longer functional (i.e., “dead region”) can instead excite a different region of the cochlea, resulting in a different perception of pitch for those particular frequencies (Moore & Carlyon, 2005). Therefore, listeners with sensorineural hearing loss not only perceive input at reduced sensation levels (if at all), but the input is also distorted.
Deaf individuals often still enjoy music not only with the limited auditory signals they may receive, but also with visual and vibrotactile cues to the music (Good, Reed, & Russo, 2014). For example, famed percussionist Evelyn Glennie, who has had a profound high-frequency hearing loss since the age of 12 years, walks onstage with bare feet and lifts her head so that she can feel the sound vibrations from her feet and neck (Horowitz, 2012, pp. 134–138). Other individuals with hearing loss may choose assistive technologies to enhance the auditory signal. There are two basic categories of assistive devices that individuals with hearing loss can use to improve their auditory input: hearing aids and cochlear implants.
Hearing aids are recommended for hearing losses of all severities. Conventional analog aids amplify all sounds according to a pre-set frequency response that is based on an individual’s hearing loss. Some analog aids now also include the ability to program frequency responses according to various listening contexts, such as one-on-one conversation or a noisy cocktail party. Much more common, however, are digital aids, which convert sound into digital signals. Some digital hearing aids have the added benefit of noise reduction algorithms, which allow more control of acoustic feedback and loudness levels; additionally, some can self-adjust based on the acoustic environment. Nevertheless, no hearing aid provides “normal” hearing. And although hearing aids can be programmed to enhance music perception, there are still programming issues that remain, such as allowing listeners larger frequency and dynamic ranges to cover the demands of music, before delivering a normal-sounding musical signal (see Chasin & Russo, 2004 for a review). Finally, hearing aids do not completely ameliorate the reduced frequency selectivity due to sensorineural hearing loss. That is, the impaired ear distorts the sound signal, and the hearing aid effectively alters or distorts it even more (e.g., compression, expansion, etc.). The resulting distorted signal could be particularly problematic for music, where small pitch and timing differences are important in differentiating sequences, patterns, and songs.
Cochlear implants are auditory prostheses for listeners with the greatest degrees of hearing loss. They include an external microphone that converts sound into an electric signal, a sound processor that typically filters the electrical signal based on our understanding of speech perception, and a transmitter that passes the electrical signal to an internal receiver. This receiver sends the electrical signal to an array of electrodes surgically implanted in the cochlea that stimulate auditory nerve fibers. There is substantial variability in outcomes across cochlear implant recipients, but in general, cochlear implants transmit sound signals in a way that allows for speech and spoken language comprehension. On the other hand, cochlear implants were not designed to transmit suprasegmental information (e.g., pitch and timbre), leading to difficulty perceiving and producing music (Moore & Carlyon, 2005). One reason why cochlear implants are poor at transmitting pitch and timbre is that cochlear implant signal processing strategies have not traditionally conveyed fine spectral detail well, nor are listeners with sensorineural hearing loss able to process temporal fine structure cues well (Moore, 2008b). Another reason for cochlear implants’ difficulties with pitch and timbre is that the electrode array cannot be fully inserted into the cochlea. Instead, a typical electrode array will span (at best) 1½ of the possible 2½ turns of the cochlea, beginning at the base. Additionally, it is unlikely that the frequencies in the environment will be properly mapped to their correct respective regions on the tonotypically arranged basilar membrane. In effect, the electrical stimulation to the cochlea is frequency-compressed and frequency-shifted. Finally, there are a comparatively small number of electrodes (up to 24) that provide the stimulation that approximately 13,000 inner hair cells would typically provide in a normal-hearing ear, and adjacent electrodes often stimulate overlapping regions of the basilar membrane.
Despite the limitations of the assistive devices, hearing aid and cochlear implant users continue to report listening to and participating in music (e.g., Gfeller, Christ, Knutson, Witt, & Mehr, 2003). What do they hear when they listen to music?
The broad category of pitch perception includes a range of specific tasks such as pitch discrimination and melody recognition. In the following discussion, performance along particular dimensions of pitch perception for adults with hearing aids and/or cochlear implants is presented when available.
It is worth noting here that almost every study of music perception in listeners with hearing loss shows large individual variability. That is, even though the average performance might be poorer for listeners with hearing loss than normal-hearing listeners, there are often listeners with hearing loss who perform at levels similar to those of their normal-hearing peers.
When asked to discriminate two 1-second pure tones of different frequencies, normal-hearing adults displayed better discrimination abilities than adults with cochlear implants. Nevertheless, cochlear implant users could discriminate frequency differences less than one semitone (st), one of the building blocks of music (Gfeller et al., 2002). On the other hand, when tested on pitch discrimination for complex tones, normal-hearing adults had an average threshold of 1.1 st; adults with cochlear implants had an average threshold of 7.6 st.
In another study of pitch discrimination, a third group of adults was added: short-electrode cochlear implant users who receive low-frequency acoustic information from residual hearing in addition to the electric input from the cochlear implant (Gfeller et al., 2007). This group of cochlear implant users performed at levels of pitch discrimination similar to the group of normal-hearing adults when presented with low frequencies but not at a higher frequency range. Adults who have profound hearing loss but use hearing aids alone scored 75% correct on a 3-st pitch discrimination task whereas adults with cochlear implants performed at chance (Looi, McDermott, McKay, & Hickson, 2008).
In one study of melodic contour perception, Galvin, Fu, & Nogaki (2007) asked adults to identify nine melodic contours (e.g., rising, flat, falling, flat-rising) in five intonation conditions that varied in terms of number of semitones (1–5) between successive notes in each contour. Normal-hearing adults scored 95.8% correct, whereas adults with cochlear implants scored 53.3% correct across the conditions. Other researchers have used the Montreal Battery of Evaluation of Amusias, or MBEA (Peretz, Champod, & Hyde, 2003) to examine contour perception in adults with cochlear implants. In this task participants are presented with a pair of melodies in which one note of one of the melodies may be altered in such a way that it changes the musical contours in that melody. Normal-hearing adults score 84% correct on this test, whereas adults with cochlear implants only achieve 55–61% correct performance (Peterson & Bergeson, 2015; Wright & Uchanski, 2012). Moreover, normal-hearing adults listening to 4- and 6-channel cochlear implantation simulations perform at levels similar to adults who use cochlear implants (Cooper, Tobey, & Loizou, 2008). Finally, when cochlear implant users add a hearing aid, their contour perception performance improves to 73% correct, most likely due to the enhancement of the low frequency information in the signal (Peterson & Bergeson, 2015).
Although understanding of consonance (“pleasant” or “good”) and dissonance (“unpleasant” or “grating”) has been put to the test in normal-hearing listeners (e.g., Schellenberg & Trainor, 1996), perception of consonance and dissonance is less well understood in listeners with assistive devices. In one study of music perception with cochlear implants, listeners were asked to discriminate whether a sound selection was music or “noise” (Wright & Uchanski, 2012). Normal-hearing adults scored 100% and those with cochlear implants performed slightly worse (92.8%), but still well above chance. This is not a surprising result because cochlear implants are essentially “noise vocoders” that process incoming frequency bands of sound and transmit the amplitude-envelope, via noise bands that match those frequency bands, to the internal electrodes of the implant. The result is a “noisy” signal. However, very little is known about whether listeners can still distinguish consonant and dissonant music under the noisy conditions of a cochlear implant.
The little that is known about the perception of scale structure and musical key in adults with hearing loss suggests that adults with hearing loss perform poorly in these areas. Researchers have examined perception of note changes that violate musical scale in pairs of melodies on the MBEA, and found that normal-hearing adults achieve an average score of 91% correct, whereas adults with cochlear implants (with and without hearing aids) as well as normal-hearing adults listening to 4- and 6-channel cochlear implant simulations perform at or near chance levels (Cooper et al., 2008; Peterson & Bergeson, 2015; Wright & Uchanski, 2012).
The area of music perception that has been most extensively studied in adults with hearing loss is the perception and recognition of melody. In comparisons of melody recognition without lyrics across different timbres, performance for normal-hearing adults is consistently better than that of adults with cochlear implants (Dorman, Gifford, Spahr, & McKarns, 2008; Drennan et al., 2015). When note durations are equalized so that melodies are isochronous (i.e., no rhythm cues) performance remains near ceiling for normal-hearing adults but range from 12% to 52% for cochlear implants users (Dorman et al., 2008; Drennan et al., 2015; Kong, Stickney, & Zeng, 2005; Wright & Uchanski, 2012). Melody identification with original rhythm cues is better for listeners with hearing aids (91% correct) and listeners with cochlear implants plus hearing aids (57%) than for listeners with cochlear implants alone (17–52% correct) (Looi et al., 2008; Peterson & Bergeson, 2015). Finally, isochronous melody recognition improves for listeners with severe to profound hearing loss when using a hearing aid (average scores range from 45% to 71% correct) or when using a hearing aid in combination with a cochlear implant (average scores range from 55% to 71% correct) (Dorman et al., 2008; Kong et al., 2005). As expected, the more residual hearing a listener has access to (e.g., with a contralateral-side hearing aid, a hybrid device, or a soft-surgical approach that preserves neural structures, etc.), the more that listener can use spectral cues to recognize melodies stripped of temporal and rhythmic cues.
In one of the first studies of music perception in adult cochlear implant recipients, Gfeller and Lansing (1991) asked postlingually deafened adults to complete the Musical Instrument Quality Rating task, which assesses perceived quality (e.g., beautiful versus ugly) of melodies played on nine acoustic instruments. There was a wide range in ratings, with approximately 15–85% of participants labeling the instruments “beautiful” or “pleasant.” Listeners identified the correct instrument only 13.5% of the time (although the majority were not musically trained and may not have known instrument names or sounds). Several researchers have examined timbre recognition on closed-set tests of 8–9 instruments, with performance for listeners with cochlear implants averaging 37–70% correct (above chance levels) and normal-hearing adults averaging around 82–87% correct (Brockmeier et al., 2011; Drennan et al., 2015; Wright & Uchanski, 2012). Other studies have examined listeners’ abilities to differentiate among several instruments playing simultaneously. For example, Brockmeier and colleagues (2011) found that normal-hearing listeners could differentiate up to four instruments, whereas cochlear implant users could differentiate only two instruments and often had the perception of a fused timbre when more than one instrument was playing. Finally, Looi et al. (2008) examined perception of timbre in adults with severe-profound hearing loss who used either hearing aids or cochlear implants. Listeners in both groups performed similarly in an instrument recognition test (HA = 69%, CI = 61%) and an ensemble recognition test (HA = 47%, CI = 43%).
In general, adults with cochlear implants and hearing aids perform better on tasks involving perception of timing (tempo, rhythm, meter) compared to those involving pitch and timbre, with comparable performance to that of normal-hearing listeners (Brockmeier et al., 2011; Gfeller & Lansing, 1991; Looi et al., 2008; Peterson & Bergeson, 2015; Wright & Uchanski, 2012).
Very little is known about the perception of emotion in music by listeners with hearing loss. In one study, adults rated the emotions of several pieces of music on a scale of one (very sad) to ten (very happy) (Brockmeier et al., 2011). Normal-hearing listeners and those with cochlear implants gave similar emotion ratings, and these ratings were highly correlated with tempo (e.g., faster tempo related to higher rating of happiness). Nevertheless, emotions in music are much more complex than simply happy and sad, involving cues such as tempo, rhythm, pitch interval, mode, melody, and amplitude that result in emotional responses ranging from joy and triumph to nostalgia to hostility (see Timmers, this volume; Juslin, & Sloboda, 2011). Future studies are necessary to determine the musical properties that lead to an emotional response in listeners with hearing loss.
In a study examining ratings of liking and complexity of classical, country, and pop music, Gfeller and colleagues (2003) found that adults with cochlear implants did not prefer any of the three genres, whereas normal-hearing listeners liked classical music more than pop, and pop more than country. Moreover, normal-hearing listeners, but not listeners with implants, rated familiar items as more likeable than unfamiliar items. Both groups of listeners rated classical music as most complex and country music as least complex. Finally, Gfeller et al. found a positive correlation between liking and complexity for normal-hearing listeners, but a negative correlation for listeners with cochlear implants.
Wright and Uchanski (2012) asked listeners to rate the same musical selections as used in Gfeller et al. (2003). They found that cochlear implant users rated music as more pleasant sounding than their normal-hearing peers listening to cochlear implant simulations. However, both groups rated music as less pleasant sounding than normal-hearing listeners. It is quite possible that if the normal-hearing listeners had more time to accommodate to the simulation they would also find the simulation less harsh and more pleasant.
Although listening to music with hearing aids as opposed to cochlear implants enables better pitch perception (Looi et al., 2008) and melody recognition (Looi et al., 2008; Peterson & Bergeson, 2015), adults who have severe-to-profound hearing loss and use cochlear implants rate music as more pleasant sounding than adults with similar levels of hearing loss who use hearing aids (Looi, McDermott, McKay, & Hickson, 2007). Similar to Gfeller et al. (2003), both groups of listeners rate music with multiple instruments (i.e., more complex) as sounding less pleasant than music with a single instrument (i.e., less complex) (Looi et al., 2007).
Importantly, music perception and music appraisal are distinguishable outcomes following cochlear implantation (Gfeller et al., 2008). Factors such as music listening experience after implantation and performance on a visual cognitive task predicted preferences for instrumental music, whereas music listening experience prior to implantation, use of bilateral implants or a cochlear implant plus a hearing aid, and performance on speech perception in noise predicted preference for music with lyrics. To date, researchers have found no correlation between performance on various music perception tests and music enjoyment in cochlear implant users (Brockmeier et al., 2011; Drennan et al., 2015; Wright & Uchanski, 2012).
Adults with post-lingual hearing loss have had the opportunity to build their internal representations and understandings of music over years of experience listening to, participating in, and learning music. Children with pre-lingual hearing loss, however, must develop their understanding of aural music using a different set of cues received through hearing aids or cochlear implants. How do children hear music after receiving hearing aids or cochlear implants following congenital and pre-lingual hearing loss? We turn now to an examination of these matters.
Even though prelingually deafened children have not had the opportunity to develop internal representations of music prior to receiving a cochlear implant, they still show some patterns of music perception similar to adult cochlear implant recipients (Bergeson, Chin, Anderson, Simpson, & Kuhns, 2010; Houston et al., 2012; Nakata, Trehub, Mitani, & Kanda, 2006). Like adult cochlear implant recipients, there is significant variability in children’s pitch perception performance, ranging from 9.5% to 92.5% on a pitch discrimination and ranking task (Chen et al., 2010). In studies of pitch discrimination, children with and without hearing loss were asked to determine whether the second in a pair of notes was higher or lower than the first. Normal-hearing children were able to discriminate pairs of tones that were separated by 7 semitones, whereas children with cochlear implants discriminated tones separated by 14 semitones (See, Driscoll, Gfeller, Kliethermes, & Oleson, 2013). Jung et al. (2012) found even better pitch direction discrimination of 3-tone complexes (3 semitones) in children with cochlear implants. When asked to determine whether two tones were different in pitch (regardless of direction), children with cochlear implants can discriminate tones separated by only 0.5 semitones (Vongpaisal, Trehub, & Schellenberg, 2006).
See et al. (2013) presented 5- to 10-year-olds with spoken and sung sentences and asked them to determine whether the sentences were statements (falling contour) or questions (rising contour). Normal-hearing children performed better than children with cochlear implants (83% vs. 63% correct). In another study, Bergeson and colleagues (2010) asked children ages 5–15 years to listen to four vocal pitch contours (rising, falling, rising-falling, falling-rising) and then recorded their vocal imitations. Normal-hearing children produced more accurate contours (75% correct) than children with cochlear implants (63% correct), although the latter group still performed recognizable contours for three out of the four contours. Both groups of children performed best for the rising contour, followed by the falling and rising-falling contours, and finally the falling-rising contour.
In a study of music recognition, children with cochlear implants identified pop songs just as well as normal-hearing children (Vongpaisal, Trehub, Schellenberg, & Papsin, 2004). When the vocals were removed from the stimuli by using a karaoke version the children with cochlear implants could still identify the songs but were less accurate than normal-hearing children. Their performance dropped significantly as compared to normal-hearing children when the pop songs were presented as piano melodies with no additional cues. Similarly, when other researchers presented young listeners with isochronous melodies, children with cochlear implants achieved only 11% correct performance (Jung et al., 2012).
As of yet, the perception of consonance and dissonance, scale structure, and musical key have not been rigorously studied in children with hearing loss who use cochlear implants and hearing aids.
Jung and colleagues (2012) asked children with cochlear implants to identify musical instruments in a closed-set task. They found that children performed higher than chance level (34% correct). They performed most accurately for the guitar timbre, and often confused flute and violin timbres.
Most studies have been conducted on pitch and melody perception rather than timing. However, Nakata, et al. (2006) examined timing in songs of children with and without hearing loss, and found the two groups’ timing of performances to be similar to one another.
Volkova and colleagues (2013) presented children with and without hearing loss with “happy” (major mode, rapid tempo) and “sad” (minor mode, slow tempo) piano pieces and asked the children to point to a picture of a child laughing or crying. Normal-hearing children performed at ceiling (98%). Children with cochlear implants performed more poorly (80%) but still above chance levels.
Although children with cochlear implants perform more poorly than normal-hearing children on a number of music perception tasks, they still participate in music lessons and activities and rate music favorably (e.g., Trehub, Vongpaisal, & Nakata, 2009).
Although we now know quite a lot about perception of the various components of music by listeners who use hearing aids and cochlear implants, it turns out that there is little to no relationship between the perception of music’s component parts and ratings of music enjoyment (Brockmeier et al., 2011; Drennan et al., 2015; Wright & Uchanski, 2012). It is possible that the areas in which there is very little research, such as musical tonality and melodic expectancies, are the “glue” which “holds the parts together” to give a sense of the larger music picture. Further research is needed to determine the role these musical features play in music perception in listeners with assistive hearing devices.
It is also possible that general cognitive skills play a large role in music perception in listeners with hearing loss. Deficits in cognitive skills such as attention, working memory, and executive function, may be a byproduct of a period of auditory deprivation (e.g., AuBuchon, Pisoni, & Kronenberger, 2015; Houston et al., 2012). Indeed, there is evidence that performance on music perception tasks is related to cognitive skills in listeners with hearing loss (Gfeller et al., 2008; Vongpaisal et al., 2004). For example, children with cochlear implants have better pitch discrimination skills in tasks that compare pairs of tones alone rather than in the context of melodies (Vongpaisal et al., 2006). In a study of children’s song production, Bergeson et al. (2010) found that children with cochlear implants could sing the beginning of the song “Happy Birthday” with accuracy similar to that of normal-hearing children, but their pitch accuracy decreased after the first phrase. It is possible that the cognitive demands of keeping in mind simultaneously the melody, rhythm, lyrics, and motoric output outpaced the children’s cognitive abilities. In fact, music and speech therapists have used music as an integral part of speech therapy for children with hearing loss who use assistive devices (Barton & Robbins, 2015). It is possible that training cognitive skills such as attention, sequence learning, and working memory through music, which has high levels of enjoyment for children, might transfer to other areas such as speech and hearing (e.g., Tierney, Krizman, Skoe, Johnston, & Kraus, 2013).
If perception of the component parts of music and music enjoyment are independent for listeners with hearing loss what is the value of measuring music perception in clinical assessments? Measuring individual features of music is consistent with typical testing of hearing, which isolates frequencies and amplitudes, and testing of speech, which traditionally focuses in on perception of parts of words (e.g., minimal pairs), words, or sentences in quiet or in noise. Most tests of hearing and speech perception do not examine perception of natural conversation with multiple participants, which is more complex and difficult to interpret. It follows, then, that music batteries developed for use in the clinic might focus on the component pieces of music rather than on judgments of larger works of music. Listeners with hearing loss participate in and enjoy music regardless of their relatively poorer performance on music perception tests such as pitch, melody, and timbre. It could be argued that enjoyment of and participation in music are the most clinically relevant aspects of music for listeners with hearing loss.
There has been a wave of research and literature breaking down the ways in which music training benefits us in various ways, such as helping to ameliorate the deleterious effects of aging and degraded speech in noise perception (Slater et al., 2015). For the most part, the research on music cognition in listeners with hearing loss follows this line of reasoning. If there are benefits of music for normal-hearing listeners, we should understand how listeners with hearing loss perceive and understand music to determine the comparative benefits. However, this line of reasoning ignores the larger question of music enjoyment. Although there have been some studies that have examined ratings of music appraisal among listeners with hearing loss we still know very little about how music makes listeners with hearing loss feel. This spans the range of complex emotions normal-hearing listeners experience while listening to music to the feelings of identifying with lyrics to fitting into a social community. And, of course, we know even less about how all listeners with and without hearing loss, regardless of use of assistive listening devices, feel the physical features of music. As Evelyn Glennie noted, “Music is about communication . . . it isn’t just something that maybe physically sounds good or orally sounds interesting; it’s something far, far deeper than that” (Humphries, 2001).
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