Online use of Conditioned Play Audiometry

Conditioned Play Audiometry

While it is difficult for a child to sit still through traditional behavioral audiometric testing, playing a game to obtain results is well within the realm of possibility. In order to use play-based methods to obtain hearing thresholds, the child must be conditioned to associate a sound with an action.

What is CPA?

Does your doctor ask you to play a game in order to perform a check-up? Pediatric audiologists ask their patients to do so in order to assess their hearing, whether it is a routine evaluation or part of a diagnostic process. This appointment is often an enjoyable experience because the child perceives it as a simple game with a captive audience.

Conditioned Play Audiometry (CPA) is used with children ages 3-5 years old (cognitively) who have surpassed the need for simpler methods but cannot yet be tested in the same way as adults given their cognitive and/or attention span development (Sabo, 1999). The procedure involves hand-over-hand techniques, showing the child how to perform a designated activity every time they hear a tone.

Popular methods include stacking blocks or throwing toys into a bucket at the sound of a pure tone. CPA can be used for both air conduction (traditional sound) thresholds or bone conduction (sound vibration) thresholds. The child must be shown the action repeatedly until they are sufficiently conditioned to the task and can perform it themselves. Thus, CPA falls under the umbrella of Behavioral Psychology.

Traditionally, CPA is performed by one audiologist (or audiology assistant) playing with the child inside a sound booth and a second audiologist outside the booth administering the tones into headphones or insert earphones that the child is wearing. By varying the pitch and loudness of the tone, the audiologist administering the test can gain an accurate picture of the child’s hearing thresholds and can detect potential hearing loss.

Detecting hearing loss in childhood is essential to ensure that children are receiving proper speech input during the critical period of language development (Yeung et al., 2013). The field has begun to evolve to capture the interest of the modern child: technology they can play with.

Can CPA be performed using Labvanced?

In the aftermath of the global pandemic, many are still hesitant to leave their homes and especially to enter healthcare settings. Performing tests such as CPA online might be the answer to reaching people through telehealth.

There are several objects and features in Labvanced that can be used to create a Conditioned Play Audiometry study:

  • Multi User Studies:open in new window A licensed audiologist can administer a play-based listening task to a child participant from the comfort of home. Both parties can interact in real time.
  • Audio Object: Audio files can be added to the study and presented either by the audiologist or automatically via an in new window
  • Longitudinal Studies: Set your study to repeat in the future to track the child’s hearing across several months.
  • Eye Tracking/Video Recording: Some children are hesitant to participate in activities, so use eye tracking to catch subtle eye movements towards the desired target if a response is not given. Labvanced also offers video recording of participants that can be used to review the session during or after the participant has completed the task.

Collectively, these features can help drive CPA a step closer to the possibility of becoming fully remote.

What research is being conducted regarding CPA?

The field of audiology is only about 75 years old, but has seen an incredible amount of technological advances within that time.

Using Apps and Tablets

Researchers at Children’s Mercy Hospital in Kansas City are working to capitalize on the latest technology to introduce a new kind of conditioned play audiometry: The HearPlay™ in new window In this app, children and audiologists play games together on iPads to assess the child’s hearing. The audiologist conducts testing via an audiometer in the same way as traditional CPA, but instead of physical toys and the potential need for a second audiologist, the child is conditioned to play a game on the tablet. The app can help assess not only pure tone thresholds, but speech awareness and reception as well. While the functions of this app must be administered with at least one audiologist present in-person, it’s a huge step forward towards a more modern diagnostic procedure.

Using Telehealth to Reach Remote Patients

Telepractice is another advancement in the field that has become a viable option for many audiologists and their patients. This process of providing remote care allows patients in rural or underserved communities to be seen by their practitioner at a location that is more accessible. While this setup, described thoroughly in Hughes et al. 2018,open in new window still requires at least two trained individuals to administer, it is currently the closest method of remote CPA to be developed. In this setup, the audiologist remotely communicates with an assistant and patient at a different location. The assistant and audiologist conduct CPA to obtain hearing thresholds as normal, with the only difference being that the audiologist is controlling the stimuli remotely. This method has been shown to be just as accurate for certain audiometric processes as in-person methods.

Closing Remarks

While these advances certainly mean great things for the field of audiology, they are not without limitations. CPA must be conducted by trained individuals and cannot be taught to a parent or guardian during a telehealth appointment. Without an assistant present, this procedure cannot be counted as accurate data. Patients must also have a good internet connection in order to reduce lag times between sound presentation and the child’s response.

Despite these limitations, the digitization of CPA can provide healthcare services to patients in need of remote assistance. As technology continues to advance, we can expect to see more and more online services being offered.

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Hughes, M. L., Sevier, J. D., & Choi, S. (2018). Techniques for Remotely Programming Children With Cochlear Implants Using Pediatric Audiological Methods via Telepractice. American journal of audiology, 27(3S), 385–390.

Ralston, S. HearPlay App. HearPlay Audiometric Testing App from Children's Mercy | Children's Mercy Kansas City,

Sabo D. L. (1999). The audiologic assessment of the young pediatric patient: the clinic. Trends in amplification, 4(2), 51–60.

Yeung, J., Javidnia, H., Heley, S., Beauregard, Y., Champagne, S., & Bromwich, M. (2013). The new age of play audiometry: prospective validation testing of an iPad-based play audiometer. Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale, 42(1), 21.