Cross-domain transfer effects between musical training and language processing are well documented and this finding has clinical implication for different  pathologies, such as dyslexia. Only few studies have examined the impact of musical training on linguistic abilities in cochlear-implanted children. The  present review investigates whether musical training facilitates language processing in cochlear-implanted children. Priming studies demonstrated that linguistic  processing can benefit from prior exposure to rhythmic musical sequences. This was found by combining rhythmic primes and linguistic exercises in short and  long-term paradigms. Other studies have compared musician and non-musician cochlear-implanted children, or have assessed several abilities before and  after a musical training. They revealed better performance in linguistic tasks for musically trained children. Although these studies differ in many characteristics,  they highlight the possibility of transfer effects from music training to language processing in cochlear-implanted children. These findings can be understood   frameworks: the Dynamic Attending Theory appears to be useful for the interpretation of priming, while the expanded OPERA  hypothesis and the auditory scaffolding hypothesis are relevant to understand training studies.

• Cochlear implant

• Children

• Musical training

• Language

• Transfer of learning

Canette LH, Spada D, Pineau M, Tillmann B, Bigand E (2016) Transfer Effects between Musical Training and Linguistic Skills in Deaf Children with Cochlear Implants. Ann Otolaryngol Rhinol 3(12): 1152.

CI: Cochlear Implant(ed); NH: Normal-Hearing

 Music is a pleasant activity that brings together numerous abilities in different domains, notably cognitive, motor, affective and social abilities. Recruiting these abilities with music could modify the brain and thus lead to positive transfers to non-musical domains [1]. For example, several studies have investigated transfer effects for language, motor abilities and motor rehabilitation, socialization of infants, or emotional regulation [2].

Music is a complex acoustic structure that evolves through time. It can be described at different levels of organization [3]. The basic characteristics of musical sounds deal with pitch, timbre (i.e., spectral structure), duration and loudness, but a critical aspect of musical structure lies in the way musical events are patterned through time. Higher levels of musical organization, such as melodic contour, musical phrase, and metrical structures, emerge from this patterning. It is worth noting that in most musical idioms, a very limited number of musical events (i.e., 12 pitch classes in Western tonal music) can generate an infinite number of different musical pieces. This highlights the importance of combinatory processes in music. Musical sounds thus have abstract syntactic-like functions that are strongly context-dependent [4].

Language shares various acoustic and structural characteristics with music [5]. Similarly to music, speech transmits information based on pitch, timbre, and temporal dimension (tempo, rhythm, metric). It also contains elements that are structurally organized and develops over time. At a cognitive level, both music and language processing require memory, attention and temporal integration in order to create a mental representation and form expectations for upcoming events [6].

Given these shared characteristics, numerous studies have demonstrated some transfer between music and language in normal-hearing (NH) adults and children by comparing musically trained and untrained participants (for a review, see [7]). This comparison however, does not allow to conclude whether observed differences are caused by musical training or by differences existing before musical training. Longitudinal studies by contrast investigated the effects of a musical training in two random groups of non-musicians; one group followed a musical training program and the other followed a stimulating non-musical activity. Longitudinal studies confirm that musical training can improve different linguistic skills, such as phonological awareness [8], speech segmentation [9], reading skills and pitch discrimination in speech [10], as well as speechin-noise perception [11]. Interestingly, Degé & Schwarzer’s study [8] reported comparable effects of training on phonological awareness, whether the program was specific speech-based (phonological skills program) or non-specific (music program).

Musical training has further been used as a therapeutic tool for speech rehabilitation in different pathologies. In dyslexic children, a musical training program was found to improve phonological awareness and reading skills, by enhancing temporal processing and rhythmic skills [12]. Other studies demonstrated an enhancement of auditory syntactic processing (grammatical judgments) after listening to a musical rhythmic prime versus a non-rhythmical prime or environmental sounds in children with dyslexia and specific language impairment [13,14].This same musical priming approach applied to children with developmental language disorders had positive effects on reading performance (i.e., reading words and pseudo-words with two syllables) [15]. In addition, rhythmic priming paradigm has been used to restore a physiological marker of syntactic error perception in patients suffering from Parkinson’s disease and patients with basal ganglia lesions [16,17].

To what extent similar finding could be observed with deaf children with cochlear implants (CI)?

Developed for severely to profoundly deaf individuals, the implanted devices are constituted by electrodes that directly stimulate a limited number of areas of the basilar membrane. This sparse sampling of the place code, necessarily leads to an impoverished spectral resolution. By contrast, the temporal information of the signals at slower scales (the envelope of the bandpass signal) are relatively well preserved and transmitted as train of pulses to the auditory nerve. This sparse information allows for speech perception. When using vocoded speech (i.e. a simulation of the perception via CI), it has been shown that only a few bands are necessary to preserve intelligibility of speech in quiet [18]. As pitch plays an important role in segregating target speech from background noise, the loss in pitch resolution due to the CI has a direct impact on speech perception in presence of background noise [19].

Language acquisition in CI children is delayed and depends on different external factors. Earlier age at implantation has been shown to be associated with better language acquisition [20]. Children implanted before the age of 18 months show significantly higher rates of comprehension and expression than children implanted after 18 months [21]. Nevertheless, the majority of early implanted children do not perform as well as NH children when tested for language understanding and for receptive and active vocabulary [22]. Furthermore, other factors account for language acquisition: residual hearing before implantation and wearing of hearing aids before 6 months, parent-child interactions, socioeconomic status [21, 22]. Consequently, an important variability is observed across children, even with early implantation.

Children experience specific difficulties in speech-in-noise perception (e.g., [23]), prosody perception (e.g., [24]) and speech comprehension on the phone [25]. The CI remains also limited for music perception [26]. In comparison to NH listeners, pediatric CI users experience difficulties in various aspects of music perception [27]: pitch ranking [28], song identification and recognition [29-31], timbre discrimination [27], and rhythm discrimination [27]. Nevertheless, some studies have provided encouraging evidence that music could be used in rehabilitation programs to stimulate auditory perception, notably reaching beneficial effects on the perception of musical material (in children: [32]).

The transfer of learning effects from music training to language processing in CI users has been poorly studied with experimental designs up to now. In CI adults, two studies [33,34] using a melodic contour training program demonstrated improved melodic contour identification, which was directly trained, as well as improvement for various aspects of speech perception (not trained). In a pilot study with two patients using a sensorimotor training (i.e., patients had to produce the auditory patterns on a keyboard), Patel [33] measured positive effects on speech perception in noise and on prosody perception. Testing a larger sample of CI adults with a training protocol that was only perceptual, Lo et al., [34] did not show beneficial effects for the perception of speech in noise, but showed improved perception of prosody and of consonants in quiet.

This review focuses on training of CI children with two types of interventions, depending on the involved time scale: (1) short-term exposure to musical material with rhythmic priming paradigms, and (2) long-term exposure to music in a study comparing children who were musically trained and children who were not (that is, musician and non-musicians based on musical training in a specialized institution), and in studies using a specific musical training program and measuring linguistic skill performance before and after. We will then discuss three theoretical frameworks that might account for the experimental results.

Cason et al., [35] studied exposure to auditory rhythmic primes before language processing in deaf children with hearing device and children with CI. Children listened to a rhythmic prime sequence (played with percussion sounds) followed by a sentence that could metrically match or mismatch the metrical structure of the musical prime. The children had to vocally reproduce the rhythmic prime and had to repeat the heard sentence. A baseline condition, without prime, was also part of the experiment. Adding a baseline condition aimed for better understanding of matching/mismatching condition effects by controlling a possible cognitive cost due to the mismatching. Phonological accuracy was assessed in terms of percentage of correct production for vowels, consonants, syllables and words. Children showed greater accuracy in the matching condition than in both the mismatching and baseline conditions for syllables and consonants, and in the matching condition compared to baseline condition for vowel and word accuracy. There was no significant difference between the mismatching condition and the baseline condition. Listening to a matching rhythmic prime thus enhances subsequent phonological perception and the production of spoken sentences. Importantly, this result pattern also depends on children’s hearing aids: only CI users benefited from rhythmic priming. It is interesting to note that the experimental procedure asked children to reproduce the prime sequence and thus perform a vocal action in relation with the perceived auditory information, aiming to tap into processes linked to auditorymotor coupling. This allowed to strengthen the perceptual effect and to familiarize children with the motor act required for speech production. Adding the reproduction task was based on results of another study testing NH adults [36], which demonstrated better phonological processing in the group who performed vocal audio-motor training to the primes than in the group who didn’t perform this training. Audio-motor training thus increases auditory priming effects.

subsequent phonological perception and the production of spoken sentences. Importantly, this result pattern also depends on children’s hearing aids: only CI users benefited from rhythmic priming. It is interesting to note that the experimental procedure asked children to reproduce the prime sequence and thus perform a vocal action in relation with the perceived auditory information, aiming to tap into processes linked to auditorymotor coupling. This allowed to strengthen the perceptual effect and to familiarize children with the motor act required for speech production. Adding the reproduction task was based on results of another study testing NH adults [36], which demonstrated better phonological processing in the group who performed vocal audio-motor training to the primes than in the group who didn’t perform this training. Audio-motor training thus increases auditory priming effects.

To evaluate musical training effects in CI users, two types of studies have been conducted; either by comparing musicians versus non-musicians [38], or by designing an experimental musical training program and assessing abilities before and after training using longitudinal paradigms [39-41].

Comparing musician and non-musician CI children: A cross sectional study

Rochette et al., [38] compared two groups of profoundly deaf children (with hearing aids or hearing aid with CI) recruited in a specialized institute for children with hearing impairment. One group (14 children) performed weekly music lessons for a period of 1.5 to 4 years, and the other group (14 children) did not receive musical training. All children received standard rehabilitation programs. Musically trained children performed better than nonmusically trained children in auditory scene analyses, working memory and phonetic discrimination. Musical training can thus have effects on auditory cognition (auditory working memory) and on a linguistic skill (phonetic discrimination). For the latter, additional analyses taking into account the influence of music lessons, chronological age, duration of deafness, length of device use, perceptual threshold, and type of device they use, revealed that only music lessons accounted for the observed group differences, suggesting a transfer effect of musical training to this linguistic skill.

Musical trainings: longitudinal studies

Torppa et al., [39] examined prosody perception by collecting two measures over 16 months in early CI children practicing musical or non-musical activities. Children were between 4 and 13 years old. Two groups of CI children participated in the study: one group practiced dance or music lessons (N=8) whereas the other group was engaged in non-musical activities (N=13). In addition, a group of NH children matched for age, gender and musical/non-musical activities to the CI children (N=21) was included. The main result was that the CI music group performed better than the other CI group in prosody perception tasks. For word stress perception, musical activity was the strongest predictor, taking into account F0, intensity and duration perception, digit span, performance intelligence quotient and music group. For sentence stress perception, the performance of the CI music group and the NH group were similar, whereas that of the CI non-music group was lower than that of the NH group. The authors highlighted links between prosody perception tasks and auditory tasks: firstly, a link between intensity discrimination and word stress perception; secondly F0 discrimination was the strongest contributor for sentence stress perception. This result is coherent with the observation that intensity discrimination and F0 discrimination were equivalent between the NH group and the CI music group, whereas the CI group without music training showed lower performance than these two groups. Finally, this result is also observed for forward digit span, and further, in this task, the CI music group improved between the two measurements, whereas the CI non-music group did not improve.

Two other studies set up a specific musical training program, and evaluated different abilities before and after the program in order to measure potential improvements due to the program.

Yucel et al., [40] studied whether a musical training program based on pitch and rhythm perception (discrimination) can affect speech perception. It was a family centered program, using a take-home electric keyboard, with different levels of difficulty. Eighteen profoundly hearing-impaired children with unilateral cochlear implantation participated in the study, 9 in the music group and 9 in the control group. Assessment of speech perception occurred at pre-implant and 1,3,6,12,24 months post switch-on. Assessment focused on sound and word identification tests, comprehension of verbal instructions and sentence repetition. Furthermore, parents completed report scales about musical perception, behavior related to auditory perception and to speech production. No differences were found between the two groups concerning speech perception tasks at the different evaluation times, except at 3 months. Although the performances of the music group improved more rapidly, only one difference appeared between the two groups at 3 months post switch-on, notably for the comprehension of verbal instructions test. This might reveal a positive effect of music training on speech perception development at the beginning of the implant. The results obtained from questionnaires indicated positive effects of musical training on daily listening attitudes: on the basis of parent’s reports, children in the music group were more interested in listening to music, more attentive to musical and rhythmical changes, more able to follow the melody of songs, and differed in terms of emotional reactions to music. The authors interpreted the lack of effects on speech perception by the absence of contralateral hearing aids. Pitch perception is indeed better with this type of device used in conjunction with CI than with CI alone, and using both types of devices would promote music perception [42,43] and thus musical training. Another interpretation can be proposed. The musical training of this study was based on perceptual discrimination but children did not produce music. Based on previous findings (see [44] for a comparison between active and passive music classes in infancy), we can postulate a greater effect when musical training engages children in audio-motor actions such as playing instruments, singing or dancing with the beat.

Roman et al., [41] used an auditory training program based on environmental and abstract sounds, voices and music. Beyond testing trained and untrained abilities, they aimed to assess whether the auditory training can transfer to a nontrained linguistic ability, in particular phonetic discrimination. The authors compared a trained group (experimental group) to an untrained group (control group). The experimental group performed 20 individual weekly sessions of 30 minutes. Each group was assessed two times, before and after training, regarding their performance in identification, discrimination, auditory scene analysis, auditory memory and phonetic discrimination. Children in the experimental group showed a significant improvement of directly trained auditory abilities (identification, discrimination and auditory memory), as well as in the non-trained phonetic discrimination ability, whereas the control group did not show any significant improvement. These results revealed a transfer effect from auditory training to a linguistic skill. Improved auditory abilities might permit phonetic discrimination enhancement. Furthermore, this improvement in phonetic discrimination was stronger in younger children: age was the best predictor for phonetic discrimination improvement. This result highlights the importance of early training intervention.

The link between music and language processing can be traced back to infancy. Infants possess early receptive musical skills [45] and can entrain to musical rhythms [46]. Moreover they show preferences to the melody of speech, singing and music, and they move in rhythm and manifest interest and happiness [47, 48]. Musicality plays an important part in early motherinfant communication: infants synchronize their responses to their mother with rhythmic patterns of vocalization, body movements and gestures [47,48]. In these proto-conversations, infants adjust, for example, own arm movements to the syllabic rhythm of adult speech [49], and the role of rhythmic tactile communication has been shown for children with sensory loss, including deafness [50]. A proto-musical competence, coupling manual and vocal rhythmic gestures, leads to a proto-language, by engaging overlapping processes in the brain. The fundamental place of musicality in childhood and the contribution of music and rhythm processing for language and communication suggest the hypothesis of potential transfer effects of one trained ability on the processing of the other. To further explain transfer effects between musical training and language processing in particular, we focus on three theoretical frameworks based on empirical research conducted with children and adults. By stimulating perceptual and cognitive processes, also involved in language perception, music training can enhance these processes and therefore language ability.

The expanded OPERA hypothesis and the SEP hypothesis

According to the original OPERA hypothesis [51,52], adaptive plasticity in speech processing networks is induced by musical training when 5 conditions are gathered: (1) Overlap of brain networks that processes music and speech, (2) Precision: music places greater requirements on these networks than speech, (3) Emotion: pleasantness of music, (4) Repetition: frequent repetition of actions related to several sessions of music practice, and (5) Attention: focused attention is required during the musical activity. When these conditions are combined, the speech processing networks function with higher precision and this plasticity profits to speech processing. Whereas the original OPERA hypothesis focuses on the fact that music training requires enhanced sensory processing, the expanded OPERA hypothesis [33] goes further by also considering the demands that music training places on cognitive processing. Indeed, the expanded OPERA hypothesis unifies the OPERA hypothesis – centered on sensory processing – with Strait and Kraus [53] and Besson et al., [7] studies. According to these authors, music and speech involve both auditory working memory and auditory attention with overlapping brain networks. By enhancing these skills, music training can have an impact on speech processing. In sum, the expanded hypothesis suggests that music training can elicit plasticity in speech processing networks. Music training enhances speech processing when it involves greater requirements than speech on shared sensory or cognitive processes, in the context of emotion, repetition and attention.

Fuji and Wan [54] developed a rhythm-specific extension of the OPERA hypothesis named SEP hypothesis. This framework adds two components to Patel’s framework to explain how and why musical rhythm can benefit speech and language processing: (1) Sound Envelope Processing and (2) Synchronization and Entrainment to a Pulse. The hypothesis is based on the observation of overlapping brain resources for rhythm perception and production in music and speech. A rhythm-based training program may thus stimulate brain networks underlying communication via sound envelope processing as well as synchronization and entrainment to a pulse.

The auditory scaffolding hypothesis

The auditory scaffolding hypothesis, proposed by Conway, Pisoni and Kronenberger [55], proposes a link between sound and cognitive sequencing abilities. Because sound is a temporal and sequential signal, hearing sounds exposes to serially ordered events, and by this way supports the development of general cognitive sequencing abilities. According to this hypothesis, in deaf children, because of a lack of early auditory stimulation, cognitive sequencing abilities are affected. The authors demonstrated impaired motor sequencing skills (fingertip tapping task) and visual sequential learning in children with CI compared to age-matched NH children. A period of early auditory deprivation thus affects non-auditory sequencing abilities, which impacts spoken language.

In this context, by taking into account that musical training boosts sequencing skills, it might be possible to improve these skills in CI children using music, and as a consequence enhance language skills because sequencing is also involved in language perception [56].

The Dynamic Attending Theory

According to the Dynamic Attending Theory (DAT) [57- 59], attention is not distributed equally over time but develops in cycles, and tends to synchronize with regularities in environmental sounds (music, speech, etc.). Attentional resource distribution might depend on cerebral rhythm synchronization with external temporal structures. This synchronization, by modulating the attentional rhythm, might allow listeners to develop expectations about when incoming events will occur, to make more attentional resources available at specific time points, and as a consequence improve processing. This framework, initially proposed for music, also applies to speech [60-62].

Priming studies can be understood within Jones’ framework. Exposure to an auditory rhythm providing predictable cues induces temporal expectancies: by entraining internal oscillators, the regular events of the prime orient attention over time. This phenomenon then facilitates sequencing and temporal segmentation of speech, and thus benefits syntax processing. Speech is indeed tied to time and require temporal processing and cognitive sequencing [62]. In patients, an impaired temporal processing affects speech processing. Because music has as clear metrical structure (and more clearly established than in language), the impaired temporal processing can benefit from the musical stimuli in order to boost speech processing. This priming effect can occur with a matching rhythmic prime [35], but also without this direct and strict agreement between the prime and the subsequent sentence [13,14,16,17]. In this case, the rhythmic prime is designed to boost internal oscillators at an appropriate rhythm for speech processing (stressed syllables occurrence [63]).

The studies presented here suggest that different language abilities can benefit from music training in CI children. The results highlight the cross-domain impact of musical training on language processing. According to the here reviewed theoretical frameworks, transfer effects from musical training to language processing might occur thanks to shared sensory and cognitive abilities between these two domains. By boosting these abilities, musical training should lead to speech enhancements. The expanded OPERA hypothesis highlights both sensory and cognitive processing, with auditory working memory and auditory attention, whereas the auditory scaffolding hypothesis focuses on cognitive sequencing abilities. Furthermore, the expanded OPERA hypothesis emphasizes the role of cerebral plasticity in speech perception networks due to musical training. This is in line with studies indicating that language and music recruit shared neural resources [5,64].

While some results suggest that enhancing speech abilities by musical training is possible in CI children, the direct comparison of these results is difficult because the studies differ by numerous characteristics. These differences highlight the complexity of this research domain (for a review about music training, see Gfeller [65]).

(1) Characteristics of the children participants: types of hearing aids (unilateral or bilateral CI, contralateral hearing device), age, age at implantation, duration of CI use.

Regarding hearing devices, four studies [37,39-41] included only CI children, whereas the two other studies [35, 38] included not only CI children but also children with hearing aids. Cason et al., [35] did not obtain the same results in CI users and in hearing device users, showing the importance of distinguishing these two populations.

For age range, in Torppa et al., [39], it was very large (4 to 13 years old), thus including children with different language levels and different durations of implantation, whereas age range was more reduced in Rochette et al., [38]: 8; 6 years in average (SD=1).

For duration of CI use, Yucel et al., [40] followed children after switch-on whereas other studies assessed children several years after implantation. Taking into account duration of CI use is important because perception is very different just after switchon than after many years of CI use.

(2) About experimental design: cross-sectional studies or longitudinal studies with specific musical training, duration and frequency of the training, person who take charge of the training (professor, parents), type of group control (CI children, NH children, type of activity completed by the control group).

Studies are very different in terms of duration of exposure to music: 1) Cason et al., [35] studied short term effects with a priming paradigm, 2) Bedoin et al., [37] combined short-term priming impact and speech rehabilitation, 3) the other studies [38-41] measured long-term trainings, from some months to one or more years. Data from priming studies suggest an effect on subsequent language processing and potential long-term effects on language when it is used within a language rehabilitation program. Data from training studies suggest long-term effects on language processing.

Most of studies included a control group, who was not musically trained [38,40,41] or performed non-musical activities [39]. It is indeed crucial to include a control group to disentangle developmental effects from training effects in long-term studies. Including a control group that follows a non-musical activity such as painting seems to be also important for controlling motivational effects (e.g., [12]) Moreover, one study included NH children as a control group [39]. Finally, Bedoin et al., [37] did a cross-over design. This design allows counterbalancing the order of the two trainings across patients and to hold each training condition as the effect of an intra-individual factor.

(3) About musical training: active or passive training, musical characteristics targeted, and pedagogy.

Each study used a different training approach. Studies used different training exercises (discrimination in Yucel et al., [40]; interacting with instruments, sensorimotor activities, memory and analyzing emotional value of musical pieces in Rochette et al., [38]). Most of the long-term studies used active trainings that engaged not only perception but also demanded the child to be active, except in Yucel et al., [40]. In NH infants, Gerry et al., [44] have demonstrated that an active musical training is more effective than a passive training on the development of prelinguistic communicative gestures and social behavior. In addition, audio-motor training influences rhythm perception in music [66]. In this context, and also suggested by Cason et al., [35,36] in a priming approach, using audio-motor activities in musical training appear relevant in order to maximize training effects.

An important question is: what does “music training” refer to? Some studies target one or several aspects of basic musical characteristics and connect them to the assessed language skills. Priming studies [35,37] focused on rhythm (in line with the DAT) in link with sentence perception and segmentation, while Yucel et al., [40] proposed training based on pitch and rhythm perception and assessed prosody perception. Other studies [38,39] did not target a specific musical characteristic, but the training was based on musical lessons in which several musical characteristics were manipulated via different activities (playing instruments, singing, dancing). Roman et al., [41] integrated music sound training with more general sound training (combined with action).

(4) About measures: linguistic domains assessed and tools used to measure speech performances (experimental quantified tests, questionnaires).

Different speech abilities were studied. Two studies investigated phonetic discrimination, one with a retrospective approach [38] and the other with a longitudinal approach using pre- and post-tests [41]. Torppa et al., [39] focused on prosody perception (using perceptual tests), Yucel et al., [40] assessed other aspects of speech perception (sound and word identification tests, comprehension of verbal instructions and sentence repetition) and speech production using questionnaires, and Bedoin et al., [37] studied morpho-syntactic processing. These observations raise questions about what kind of speech abilities can benefit from musical training, and future studies should systematically manipulate the different aspects and levels involved in speech perception and production.

Furthermore, it is important to consider the initial degree of hearing loss and the hearing threshold achieved with the CI, and information about speech discrimination and language development. By providing a clinical picture of children, these information’s could allow for a better understanding of measured effects. In addition, measures about sensory and cognitive abilities, thought to be important for transfer effects according to the different theoretical frameworks presented above, should also be acquired in order to better understand potential transfer effects with its extensions and limitations. In sum, the use of music as a rehabilitation tool with CI children seems to be promising, but the domain needs further studies. Much more remains to be done in order to determine exactly which speech abilities can benefit or not from music training, by which means (e.g., shared sensory vs. cognitive processing) this effect takes place, and what kind of music training is the most appropriate to produce this effect. Future studies could thus allow creating and improving music rehabilitation programs, and musical training could be a complementary tool to classic language rehabilitation.

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