The vestigial pinna-orienting system in humans briefly suppresses superior auricular muscle activity during reflexive orienting towards auditory stimuli.

The vestigial pinna-orienting system in humans is capable of increasing the activity of several auricular muscles in response to lateralized transient auditory stimuli. For example, transient increases in electromyographic activity in the posterior auricular muscle (PAM) to an attention-capturing stimulus have been documented. For the current study, surface electromyograms (EMGs) were recorded from the PAMs and superior auricular muscles (SAMs) of ten normal-hearing participants. During the experiments, lateralized transient auditory stimuli, such as, a crying baby, a shattering vase, or the participant's first names, were presented. These transient stimuli were either presented in silence, or when participants actively listened to a podcast. While ipsilateral PAM activity increased in response to transient stimuli, the SAM displayed the opposite behaviour, i.e., a brief, ipsilateral suppression of activity. This suppression of ipsilateral SAM activity was more frequent on the right (75%) than left side (35%), whereas an ipsilateral PAM increase was roughly equal in prevalence on the two sides (left: 90%, right: 95%). During the active listening task, SAM suppression on the right ear was significantly larger in response to ipsilateral stimuli, compared to contralateral ones (p = 0.002), whereas PAM activity increased significantly (p = 0.002). Overall, this study provides evidence of a systematic transient suppression of the SAM during exogenous attention. This could suggest a more complex system than previously assumed, as the presence of synchronized excitatory and inhibitory components in different auricular muscles points towards a coordinated attempt at reflexively orienting the pinna towards a sound.

Neural speech tracking shifts from the syllabic to the modulation rate of speech as intelligibility decreases.

The most prominent acoustic features in speech are intensity modulations, represented by the amplitude envelope of speech. Synchronization of neural activity with these modulations supports speech comprehension. As the acoustic modulation of speech is related to the production of syllables, investigations of neural speech tracking commonly do not distinguish between lower-level acoustic (envelope modulation) and higher-level linguistic (syllable rate) information. Here we manipulated speech intelligibility using noise-vocoded speech and investigated the spectral dynamics of neural speech processing, across two studies at cortical and subcortical levels of the auditory hierarchy, using magnetoencephalography. Overall, cortical regions mostly track the syllable rate, whereas subcortical regions track the acoustic envelope. Furthermore, with less intelligible speech, tracking of the modulation rate becomes more dominant. Our study highlights the importance of distinguishing between envelope modulation and syllable rate and provides novel possibilities to better understand differences between auditory processing and speech/language processing disorders.

EarGait: Estimation of Temporal Gait Parameters from Hearing Aid Integrated Inertial Sensors.

Wearable sensors are able to monitor physical health in a home environment and detect changes in gait patterns over time. To ensure long-term user engagement, wearable sensors need to be seamlessly integrated into the user's daily life, such as hearing aids or earbuds. Therefore, we present EarGait, an open-source Python toolbox for gait analysis using inertial sensors integrated into hearing aids. This work contributes a validation for gait event detection algorithms and the estimation of temporal parameters using ear-worn sensors. We perform a comparative analysis of two algorithms based on acceleration data and propose a modified version of one of the algorithms. We conducted a study with healthy young and elderly participants to record walking data using the hearing aid's integrated sensors and an optical motion capture system as a reference. All algorithms were able to detect gait events (initial and terminal contacts), and the improved algorithm performed best, detecting 99.8% of initial contacts and obtaining a mean stride time error of 12 ± 32 ms. The existing algorithms faced challenges in determining the laterality of gait events. To address this limitation, we propose modifications that enhance the determination of the step laterality (ipsi- or contralateral), resulting in a 50% reduction in stride time error. Moreover, the improved version is shown to be robust to different study populations and sampling frequencies but is sensitive to walking speed. This work establishes a solid foundation for a comprehensive gait analysis system integrated into hearing aids that will facilitate continuous and long-term home monitoring.

Interactive System for Similarity-Based Inspection and Assessment of the Well-Being of mHealth Users.

Recent digitization technologies empower mHealth users to conveniently record their Ecological Momentary Assessments (EMA) through web applications, smartphones, and wearable devices. These recordings can help clinicians understand how the users' condition changes, but appropriate learning and visualization mechanisms are required for this purpose. We propose a web-based visual analytics tool, which processes clinical data as well as EMAs that were recorded through a mHealth application. The goals we pursue are (1) to predict the condition of the user in the near and the far future, while also identifying the clinical data that mostly contribute to EMA predictions, (2) to identify users with outlier EMA, and (3) to show to what extent the EMAs of a user are in line with or diverge from those users similar to him/her. We report our findings based on a pilot study on patient empowerment, involving tinnitus patients who recorded EMAs with the mHealth app TinnitusTips. To validate our method, we also derived synthetic data from the same pilot study. Based on this setting, results for different use cases are reported.

Target enhancement but not distractor suppression in auditory neural tracking during continuous speech.

Selective attention modulates the neural tracking of speech in auditory cortical regions. It is unclear whether this attentional modulation is dominated by enhanced target tracking, or suppression of distraction. To settle this long-standing debate, we employed an augmented electroencephalography (EEG) speech-tracking paradigm with target, distractor, and neutral streams. Concurrent target speech and distractor (i.e., sometimes relevant) speech were juxtaposed with a third, never task-relevant speech stream serving as neutral baseline. Listeners had to detect short target repeats and committed more false alarms originating from the distractor than from the neutral stream. Speech tracking revealed target enhancement but no distractor suppression below the neutral baseline. Speech tracking of the target (not distractor or neutral speech) explained single-trial accuracy in repeat detection. In sum, the enhanced neural representation of target speech is specific to processes of attentional gain for behaviorally relevant target speech rather than neural suppression of distraction.

Assessment of Vestigial Auriculomotor Activity to Acoustic Stimuli Using Electrodes In and Around the Ear.

Recently, it has been demonstrated that electromyographic (EMG) activity of auricular muscles in humans, especially the postauricular muscle (PAM), depends on the spatial location of auditory stimuli. This observation has only been shown using wet electrodes placed directly on auricular muscles. To move towards a more applied, out-of-the-laboratory setting, this study aims to investigate if similar results can be obtained using electrodes placed in custom-fitted earpieces. Furthermore, with the exception of the ground electrode, only dry-contact electrodes were used to record EMG signals, which require little to no skin preparation and can therefore be applied extremely fast. In two experiments, auditory stimuli were presented to ten participants from different spatial directions. In experiment 1, stimuli were rapid onset naturalistic stimuli presented in silence, and in experiment 2, the corresponding participant's first name, presented in a "cocktail party" environment. In both experiments, ipsilateral responses were significantly larger than contralateral responses. Furthermore, machine learning models objectively decoded the direction of stimuli significantly above chance level on a single trial basis (PAM: ≈ 80%, in-ear: ≈ 69%). There were no significant differences when participants repeated the experiments after several weeks. This study provides evidence that auricular muscle responses can be recorded reliably using an almost entirely dry-contact in-ear electrode system. The location of the PAM, and the fact that in-ear electrodes can record comparable signals, would make hearing aids interesting devices to record these auricular EMG signals and potentially utilize them as control signals in the future.

Predicting Ecological Momentary Assessments in an App for Tinnitus by Learning From Each User's Stream With a Contextual Multi-Armed Bandit.

Ecological Momentary Assessments (EMA) deliver insights on how patients perceive tinnitus at different times and how they are affected by it. Moving to the next level, an mHealth app can support users more directly by predicting a user's next EMA and recommending personalized services based on these predictions. In this study, we analyzed the data of 21 users who were exposed to an mHealth app with non-personalized recommendations, and we investigate ways of predicting the next vector of EMA answers. We studied the potential of entity-centric predictors that learn for each user separately and neighborhood-based predictors that learn for each user separately but take also similar users into account, and we compared them to a predictor that learns from all past EMA indiscriminately, without considering which user delivered which data, i.e., to a "global model." Since users were exposed to two versions of the non-personalized recommendations app, we employed a Contextual Multi-Armed Bandit (CMAB), which chooses the best predictor for each user at each time point, taking each user's group into account. Our analysis showed that the combination of predictors into a CMAB achieves good performance throughout, since the global model was chosen at early time points and for users with few data, while the entity-centric, i.e., user-specific, predictors were used whenever the user had delivered enough data-the CMAB chose itself when the data were "enough." This flexible setting delivered insights on how user behavior can be predicted for personalization, as well as insights on the specific mHealth data. Our main findings are that for EMA prediction the entity-centric predictors should be preferred over a user-insensitive global model and that the choice of EMA items should be further investigated because some items are answered more rarely than others. Albeit our CMAB-based prediction workflow is robust to differences in exposition and interaction intensity, experimentators that design studies with mHealth apps should be prepared to quantify and closely monitor differences in the intensity of user-app interaction, since users with many interactions may have a disproportionate influence on global models.

Smartphone-Guided Educational Counseling and Self-Help for Chronic Tinnitus.

Tinnitus is an auditory phantom perception in the ears or head in the absence of a corresponding external stimulus. There is currently no effective treatment available that reliably reduces tinnitus. Educational counseling is a treatment approach that aims to educate patients and inform them about possible coping strategies. For this feasibility study, we implemented educational material and self-help advice in a smartphone app. Participants used the educational smartphone app unsupervised during their daily routine over a period of four months. Comparing the tinnitus outcome measures before and after smartphone-guided treatment, we measured changes in tinnitus-related distress, but not in tinnitus loudness. Improvements on the Tinnitus Severity numeric rating scale reached an effect size of 0.408, while the improvements on the Tinnitus Handicap Inventory (THI) were much smaller with an effect size of 0.168. An analysis of user behavior showed that frequent and intensive use of the app is a crucial factor for treatment success: participants that used the app more often and interacted with the app intensively reported a stronger improvement in the tinnitus. Between study allocation and final assessment, 26 of 52 participants dropped out of the study. Reasons for the dropouts and lessons for future studies are discussed in this paper.

Conventional versus notch filter amplification for the treatment of tinnitus in adults with mild-to-moderate hearing loss.

INTRODUCTION: Conventional hearing aids are commonly recommended for the treatment of tinnitus, though results of studies investigating the efficacy of hearing aid-based tinnitus treatments have been mixed. Recently, it has been suggested that the addition of a notch filter around the tinnitus frequency might enhance lateral inhibitory mechanisms and thereby improve tinnitus severity relative to traditional processing. The primary aim of this study was to compare the effects of conventional versus notch filter amplification strategies on subjective tinnitus severity in adults with mild-to-moderate hearing loss and no previous hearing aid experience. METHODS: Thirty-nine adults (mean age=53.6 years; SD=9.7 years) with bilateral, mild to moderate sensorineural hearing loss and an established clinical history of stable, tonal tinnitus participated in this double-blinded study. Each participant was randomly assigned to complete a 12-week hearing aid trial using either a conventional amplification strategy or a strategy which applied a notch filter at the given participant's tinnitus pitch match frequency. Tinnitus-related handicap and distress were assessed before and after the hearing aid trial via the Tinnitus Handicap Inventory (Newman et al., 1996) and the Tinnitus Questionnaire (Hallam et al., 1988). RESULTS: Average tinnitus severity did not differ significantly between the conventional and notch filter amplification groups following treatment. Moreover, average pre- to post-intervention change scores were relatively low for both groups, indicating minimal effect of either treatment on tinnitus symptoms. Participant age, high-frequency pure-tone average hearing threshold, average daily hearing aid usage, and pre-intervention tinnitus severity ratings were not predictive of treatment success or failure. DISCUSSION: Results of the present study suggest no significant effect of either conventional or notch filter amplification on average ratings of tinnitus severity following a 12-week hearing aid trial. However, as clinically meaningful changes in tinnitus severity were identified for some participants, future work is needed to better identify those individuals most likely to benefit, as well as optimal amplification characteristics.

Combining Mobile Crowdsensing and Ecological Momentary Assessments in the Healthcare Domain.

The increasing prevalence of smart mobile devices (e.g., smartphones) enables the combined use of mobile crowdsensing (MCS) and ecological momentary assessments (EMA) in the healthcare domain. By correlating qualitative longitudinal and ecologically valid EMA assessment data sets with sensor measurements in mobile apps, new valuable insights about patients (e.g., humans who suffer from chronic diseases) can be gained. However, there are numerous conceptual, architectural and technical, as well as legal challenges when implementing a respective software solution. Therefore, the work at hand (1) identifies these challenges, (2) derives respective recommendations, and (3) proposes a reference architecture for a MCS-EMA-platform addressing the defined recommendations. The required insights to propose the reference architecture were gained in several large-scale mHealth crowdsensing studies running for many years and different healthcare questions. To mention only two examples, we are running crowdsensing studies on questions for the tinnitus chronic disorder or psychological stress. We consider the proposed reference architecture and the identified challenges and recommendations as a contribution in two respects. First, they enable other researchers to align our practical studies with a baseline setting that can satisfy the variously revealed insights. Second, they are a proper basis to better compare data that was gathered using MCS and EMA. In addition, the combined use of MCS and EMA increasingly requires suitable architectures and associated digital solutions for the healthcare domain.

Vestigial auriculomotor activity indicates the direction of auditory attention in humans.

Unlike dogs and cats, people do not point their ears as they focus attention on novel, salient, or task-relevant stimuli. Our species may nevertheless have retained a vestigial pinna-orienting system that has persisted as a 'neural fossil' within in the brain for about 25 million years. Consistent with this hypothesis, we demonstrate that the direction of auditory attention is reflected in sustained electrical activity of muscles within the vestigial auriculomotor system. Surface electromyograms (EMGs) were taken from muscles that either move the pinna or alter its shape. To assess reflexive, stimulus-driven attention we presented novel sounds from speakers at four different lateral locations while the participants silently read a boring text in front of them. To test voluntary, goal-directed attention we instructed participants to listen to a short story coming from one of these speakers, while ignoring a competing story from the corresponding speaker on the opposite side. In both experiments, EMG recordings showed larger activity at the ear on the side of the attended stimulus, but with slightly different patterns. Upward movement (perking) differed according to the lateral focus of attention only during voluntary orienting; rearward folding of the pinna's upper-lateral edge exhibited such differences only during reflexive orienting. The existence of a pinna-orienting system in humans, one that is experimentally accessible, offers opportunities for basic as well as applied science.

Dogs, cats, monkeys and other animals perk their ears in the direction of sounds they are interested in. Humans and their closest ape relatives, however, appear to have lost this ability. Some humans are able to wiggle their ears, suggesting that some of the brain circuits and muscles that allow automatic ear movements towards sounds are still present. This may be a 'vestigial feature', an ability that is maintained even though it no longer serves its original purpose. Now, Strauss et al. show that vestigial movements of muscles around the ear indicate the direction of sounds a person is paying attention to. In the experiments, human volunteers tried to read a boring text while surprising sounds like a traffic jam, a baby crying, or footsteps played. During this exercise, Strauss et al. recorded the electrical activity in the muscles of their ears to see if they moved in response to the direction the sound came from. In a second set of experiments, the same electrical recordings were made as participants listened to a podcast while a second podcast was playing from a different direction. The individuals' ears were also recorded using high resolution video. Both sets of experiments revealed tiny involuntary movements in muscles surrounding the ear closest to the direction of a sound the person is listening to. When the participants tried to listen to one podcast and tune out another, they also made ear 'perking' movements in the direction of their preferred podcast. The results suggest that movements of the vestigial muscles in the human ear indicate the direction of sounds a person is paying attention to. These tiny movements could be used to develop better hearing aids that sense the electrical activity in the ear muscles and amplify sounds the person is trying to focus on, while minimizing other sounds.

Comparing Three Established Methods for Tinnitus Pitch Matching With Respect to Reliability, Matching Duration, and Subjective Satisfaction.

The pitch of tinnitus sound is a key characteristic that is of importance to research and sound therapies relying on exact tinnitus pitch matches. The identification of this tinnitus pitch is a challenging task as there is no objective measurement available. During the tinnitus pitch-matching procedure, the participant identifies an external sound that is most similar to the subjective perception of the tinnitus. Several methods have been developed to perform this pitch-matching procedure with tinnitus sufferers. In this study, we aimed to compare the method of adjustment, the two-alternative forced-choice (2AFC) method, and the likeness rating (LR) with respect to reliability, matching duration, and subjective satisfaction. Fifty-nine participants with chronic tinnitus were recruited and performed five consecutive runs of tinnitus matching. The participants were randomized to the three different pitch-matching methods. The intraclass correlation coefficients were .67 for method of adjustment, .63 for 2AFC, and .69 for LR, which can be interpreted as good reliability for all the three methods. However, the 2AFC method revealed significant larger within-subject variability than the other measures. Across the five runs and the three different methods, all participants learned to perform the pitch matching faster and with better self-rated accuracy. Comparing the three pitch-matching methods, LR is more time consuming and the participants were less satisfied with the 2AFC method. Overall, the three pitch-matching methods show good reliability. However, we identified differential aspects for improvement in all methods, which are discussed in this article.

Implementation and Long-Term Evaluation of a Hearing Aid Supported Tinnitus Treatment Using Notched Environmental Sounds.

Recent work has shown that sharp spectral edges in acoustic stimuli might have advantageous effects in the treatment of tonal tinnitus. In the course of this paper, we evaluate the long-term effects of spectrally notched hearing aids on the subjective tinnitus distress. By merging recent experimental work with a computational tinnitus model, we modified the commercially available behind-the-ear hearing aids so that a frequency band of 0.5 octaves, centered on the patient's individual tinnitus frequency, was blocked out. Those hearing aids employ a steep notch filter that filters environmental sounds to suppress the tinnitus-related changes in neural firing by lateral inhibition. The computational model reveals a renormalization of pathologically increased neural response reliability and synchrony in response to spectrally modified input. The target group, fitted with spectrally notched hearing aids, was matched with a comparable control group, fitted with standard hearing aids of the same type but without a notch filter. We analyze the subjective self-assessment by tinnitus questionnaires, and we monitor the objective distress correlates in auditory evoked response phase data. Both, subjective and objective results show a noticeable trend of a larger therapeutic benefit for notched hearing correction.

Neurodynamic evaluation of hearing aid features using EEG correlates of listening effort.

In this study, we propose a novel estimate of listening effort using electroencephalographic data. This method is a translation of our past findings, gained from the evoked electroencephalographic activity, to the oscillatory EEG activity. To test this technique, electroencephalographic data from experienced hearing aid users with moderate hearing loss were recorded, wearing hearing aids. The investigated hearing aid settings were: a directional microphone combined with a noise reduction algorithm in a medium and a strong setting, the noise reduction setting turned off, and a setting using omnidirectional microphones without any noise reduction. The results suggest that the electroencephalographic estimate of listening effort seems to be a useful tool to map the exerted effort of the participants. In addition, the results indicate that a directional processing mode can reduce the listening effort in multitalker listening situations.

Objective assessment of listening effort: effects of an increased task demand.

In demanding listening situations the individual has to exert an increased listening effort to process interesting auditory signals correctly. Especially people with hearing loss are particularly affected and require more effort to identify sounds compared to those with normal hearing. So far, a suitable objective estimate of listening effort is still not available. In previous studies, we presented an objective estimate of listening effort (OLEosc), which is based on the instantaneous phase distribution of the ongoing EEG activity. In the current study, the proposed measure was analyzed in detail. The task performance was taken into account, which indicates if the participants can solve the auditory task and exert effort or if they ceased solving the task. The EEG data was acquired from people with moderate hearing loss solving a listening task. During the experiment, hearing aid settings with different microphone configurations were tested. The results indicate that the OLEosc reflects the real exerted effort of the participants. Besides the reflection of different task demands related to the hearing aid settings, it was possible to show a decline of focused attention to the auditory stimuli related to an excessive task demand. Furthermore, the data indicate that the OLEosc is not directly correlated to the speech intelligibility presented in the word score data and is not subjectively biased like the results of the presented rating scale.

Towards the assessment of listening effort in real life situations: Mobile EEG recordings in a multimodal driving situation.

The EEG estimation of listening effort has been proven to efficiently map subjectively perceived effort on an objective scale. However, it has mostly been performed in controlled audiometric laboratory environments. In this study, we investigated the feasibility of the EEG listening effort assessment in a multisensory demanding environment. For this purpose, two mobile EEG acquisition systems were used to extract the objective listening effort of the ongoing oscillatory activity (OLEosc) while driving. As an auditory paradigm was presented to trigger listening effort, the simulated driving scenario served as a competing task responding to different modalities. The OLEosc was compared with a subjective rating of the expended listening effort and the task performance. Furthermore, we considered time resolved listening effort profiles over the duration of the paradigm. The results showed that the practical assessment of listening effort in a multimodal real life setting is viable. The OLEosc could be extracted and followed the subjective listening effort. Moreover, the analysis of the dynamic listening effort profiles unveiled further information such as "surrender effects", when the subjects ceased to solve the auditory task due to the intense multimodal load.

Impact of monaural frequency compression on binaural fusion at the brainstem level.

A classical objective measure for binaural fusion at the brainstem level is the so-called ß-wave of the binaural interaction component (BIC) in the auditory brainstem response (ABR). However, in some cases it appeared that a reliable detection of this component still remains a challenge. In this study, we investigate the wavelet phase synchronization stability (WPSS) of ABR data for the analysis of binaural fusion and compare it to the BIC. In particular, we examine the impact of monaural nonlinear frequency compression on binaural fusion. As the auditory system is tonotopically organized, an interaural frequency mismatch caused by monaural frequency compression could negatively effect binaural fusion. In this study, only few subjects showed a detectable ß-wave and in most cases only for low ITDs. However, we present a novel objective measure for binaural fusion that outperforms the current state-of-the-art technique (BIC): the WPSS analysis showed a significant difference between the phase stability of the sum of the monaurally evoked responses and the phase stability of the binaurally evoked ABR. This difference could be an indicator for binaural fusion in the brainstem. Furthermore, we observed that monaural frequency compression could indeed effect binaural fusion, as the WPSS results for this condition vary strongly from the results obtained without frequency compression.

Dysfunctional long term habituation to exogeneous tinnitus-matched sounds in patients with high tinnitus distress.

During the last years, the demand of accurate diagnostic tools for individualized tinnitus treatment gradually increased. Today several different psychometric instruments for the estimation of the patients degree of decompensation with clinical relevance have emerged. All of these tools are questionnaires for a subjective self-assessment and have deficits in comparability due to severe differences in their factor structure in the anamnesis. Those questionnaires thus they are only of limited value in the design of an individualized therapeutic approach. Objective diagnostic tools for the categorization of the patients' distress level are lacking in clinical routine. Scientific approaches yet demonstrated the feasibility of individual distress assessment by objective markers in the EEG. In this article we present the preliminary results of our study of a use of habituation correlates as objective indicator for the decompensation degree in high-distress tinnitus patients.

Objective assessment of listening effort in the oscillatory EEG: comparison of different hearing aid configurations.

An objective estimate of listening effort could support the hearing aid fitting procedure. Most of the digital hearing aids have already hearing aid settings which are supposed to reduce the listening effort, but the effects of these settings on the individual's listening effort remain unclear. In this study, we propose an objective estimate of listening effort using electroencephalographic data. The new method is based on the phase distribution of the ongoing oscillatory EEG activity. We hypothesize that for a non-effortful listening environment the phase is rather uniformly distributed on the unit circle than for a demanding condition. To prove if the phase is uniformly distributed around the unit circle, the Rayleigh Test was applied to the phase of the EEG. This method was tested in 14 hearing impaired subjects (moderate hearing loss, 65.64 ±7.93 yrs, 7 female). The tested hearing aid settings were a directional microphone combined with a noise reduction algorithm in a medium and a strong setting, the noise reduction setting turned off as well as a setting using omnidirectional microphones. Noise embedded sentences (Oldenburg Sentence Test, OlSa) were used as test materials. The task of the subject was to repeat each sentence. The results indicate that the objective estimate of listening effort maps the subjectively rated effort and for a listening situation like the presented one, the strong setting of the directional microphone requires the smallest effort.

Neural correlates of listening effort related factors: influence of age and hearing impairment.

In the last years, there has been a rising interest to find an objective method to estimate listening effort. Previously, we have shown that the wavelet phase synchronization stability (WPSS), gained from the instantaneous phase of auditory late responses (ALRs), could serve as a feasible measure for listening effort related factors. In the current study, we examined if the WPSS reflects the listening effort in young as well as middle-aged subjects and in persons with a different degree of hearing loss. To evoke ALR sequences, we generated syllabic paradigms with a different level of difficulty to evoke ALR sequences. We expected, due to the varying task demand, that the subjects require a measurable difference in the amount of effort to solve the paradigms. Additionally, a possible age and/or hearing loss related effect on the neural correlates of listening effort was investigated. The results indicate, that WPSS reflects the listening effort related factors needed to solve an auditory task. A further finding was that the reaction time data and the N1 wave amplitude information hardly yield any correlate of the invested listening effort. In addition, we noticed an age as well as hearing sensitivity related effect on the listening effort.