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Conditioned Play Audiometry: It Should Be All Fun and Games

Neumann, Sara AuD; Smith, Joanna MS; Wolfe, Jace PhD

doi: 10.1097/
Tot 10

Dr. Wolfe, left, is the director of audiology at Hearts for Hearing and an adjunct assistant professor at the University of Oklahoma Health Sciences Center and Salus University. Ms. Smith, center, is a founder and the executive director of Hearts for Hearing in Oklahoma City, where Dr. Neumann, right, is a clinical audiologist and deaf education consultant at Hearts for Hearing in Oklahoma City.

As hearing health professionals, we are often confined to the clinic all day, every day of the week, and can find ourselves longing for the opportunity to be outside to soak in some sun, stretch our legs, and get in a brisk run (at our age, though, it's probably far more accurate to call it a deliberate jog or even a glorified walk). To a busy clinician, these types of activities can certainly fall under the description of “play time.” With that in mind, we were recently amused when one of our teenaged patients, also a member on his school's cross-country team, bemoaned the fact that he had to run for 30 minutes during the fifth period of school each day. “Are you kidding me?” we thought. Who wouldn't love the opportunity to take a break from work in the middle of the day?

This just proves that what qualifies as “work” and “play” is all in the eye of the beholder.

To a 13-year-old who is required to run every day and who feels the pressure to crank out a competitive time, running becomes a chore, rather than an escape. In much the same way, children who use hearing aids and cochlear implants can quickly come to view conditioned “play” audiometry (CPA) as conditioned “work” audiometry—or, even worse, as a real pain in the posterior.

The key to keeping the play in CPA is for the pediatric audiologist to always provide a variety of activities that are fresh, innovative, and appealing to the child who is ready to play. In this month's installment of the Tot 10, your fearless columnists and one of the true “gurus of games,” Dr. Sara Neumann, provide 10 suggested activities to keep kids engaged in CPA. We are dedicating this column to Carol Flexer, Jane Madell, Richard Seewald, and Marion Downs, all pioneers of pediatric audiology who continually strived to develop child-friendly pediatric audiology practices.

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10. Gentleman, start your engines: Cars in a tube

For some children, moving planes, trains, and automobiles across a table is great fun. Even better is rolling those same forms of transportation down a tube whenever a stimulus is heard. This “go-to” activity is highly engaging—and all one needs is a plethora of Matchbox/Hot Wheels sized cars, a tube wide enough to fit the cars through without getting stuck, and a large plastic box to catch the cars. A long wrapping paper or mailing tube works well. It is wise to use two tubs or boxes so one can be used to store cars and the other can be used to catch the cars. If transportation items don't interest a child, other small toys such as puppies, clowns, or seasonal items like plastic hearts or Easter eggs are excellent substitutes. Typically, only about 15 to 20 stimulus items are needed, because once all the items have been dropped, a quick switch of the tube allows for those same objects to be dropped again and again until the testing or mapping is completed or a new activity is introduced.

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9. Stack'em up or knock ’em down

Games like Angry Birds, Topple, Jenga, basketball toss, and WEDGiTS can bring out the fun in the most unwilling children. Pieces from the Angry Birds game, which can be purchased at almost any store, are great motivators for children to listen if they know they can slingshot an Angry Bird to knock down stacked blocks. This activity is best used as a last resort for children with waning attention because it takes longer than some of the other conditioning activities. Jenga is self-explanatory, as is the basketball toss, but it might be wise to practice beforehand to catch those wayward basketballs. Topple requires lots of concentration and is highly motivating, not to mention leading to laughter and giggles over the stress of keeping the toy from toppling. WEDGiTS are geometric shapes that fit inside each other to make fun forms. This activity is a winner for older children and often is intriguing enough to keep the attention of a child for a complete audiological evaluation or mapping session.

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8. A sticky situation: Stickers on a page

This is probably one of the easiest activities—and who doesn't love stickers? A child can select a page of stickers, then place the sticker on a sheet of colorful paper when he or she hears a tone. Parents or therapists, as partners, help keep things moving quickly by peeling the sticker off the sheet and giving it to the child for the next turn, as a child who has to remove the stickers can easily become distracted and the session extended unnecessarily because of the time required to remove a sticker from a page. Keeping stickers of all types on hand makes it possible for a child to select a favorite and get right to work.

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7. Your father's CPA: Connect 4, Lite-Brite, Pop-Up Pirate, Blokus

These classic games, which have withstood the test of time, are still available but are updated and improved. Connect 4 and Connect 4 × 4 allow for a player to have disks of multiple colors and sizes so even more responses can be obtained from one round of the game. Because there are two slots, the audiologist or therapist can play against the child; often, this friendly competition garners more motivation and interest. Lite-Brite is another new and improved item. No longer the size of a tube TV, it comes in a smaller, flat version with lots of fun-shaped pieces to insert when a stimulus is heard. Best of all, the child gets to turn off the lights at the end of the session to see the creation in the dark! Games like Pop-Up Pirate are additional motivators and keep children involved because a sword is placed every time the child responds to the sound. Because the child does not know which sword will be the one that causes the pirate to pop up, it keeps the attention of younger children. Another benefit associated with this toy is that the game can continue without having to reset all the swords, thus allowing for more responses in a shorter amount of time. A new game that is similar to Pop-Up Pirate is the Jumping Jack game by Goliath Games, which involves pulling a carrot out when the stimulus is heard. The surprise factor is very effective for children aged 5 or 6 who are learning the rules of games and are entertained by the “surprise.”

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6. Happy birthday to you: Candles in playdough

Who doesn't love pretending to be celebrating a birthday? Who doesn't love playdough? This sensory listening experience is excellent for younger children aged 2 or 3 who are intrigued by repetition and love rolling, pushing, and pressing items in playdough. Pretending to celebrate a birthday and placing candles on the playdough cake is great fun. Even two-year-olds have the strength and the fine motor ability to push a candle into the dough. Candles frequently break but are inexpensive to purchase at a dollar store. With younger children who may reach for the earphone or attempt to remove technology, keeping a candle or a golf tee in a chubby hand in the ready position next to the ear is just enough distraction to keep their hands busy and away from the earphones or technology.

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5. Your Royal Highness: Every child loves a crown.

There's nothing better than being a king or queen for the day by wearing a crown that the child creates because he or she is listening well. There are kits on the market that can be purchased, but because we are all on tight budgets, it is easy to create felt crowns using the Burger King crown as a template and finding “jewels” that can be put on the crown with Velcro and placed on the child's head for a photo that can be displayed on a bulletin board or on the refrigerator at home. We've had great success by affirming children for their listening skills as they wear the crown through the clinic after completing a mapping or testing session.

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4. There's an app for that: Good iPad apps

There are many fun apps that can be used for conditioned play audiometry. One of the favorites is Bubble Wrap FREE, which simply involves popping “fake” bubble wrap bubbles. There are also apps similar to basketball tosses that encourage the child to “toss” the ball with a finger when the sound is heard. To ensure that the child does not become distracted by the app during the testing or mapping session, it is best to have the child hold up his or her hand until he or she hears the sound, then the child can swipe the ball.

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3. Big red button

No subtitle is needed here. Think of it as a giant “Easy” button; in our experience, it has been a game-changer when doing CPA. A computer screen linked to a laptop or computer with PowerPoint, a big button (a “Big Mac” Switch or any similar button like a Learning Resources Answer Buzzers will work) and PowerPoint slides of pictures from favorite TV shows and movies have dramatically changed the length of time that children can maintain attention in the booth (Frozen, Cars, and Superheroes characters are the most popular in our clinic). Add a black or white screen between each picture and get started. When a child hears a sound, he or she is coached to push the button, and the screen changes from a black screen to a picture of a favorite character. This one is very helpful for children who struggle with false positives, because the audiologist controls the button and nothing will happen if the button is pushed when a sound was not presented.

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2. Splish-splash

Using a jug of water to fill with small toys or figurines can be another fun game. Let the child pick the toys he or she wants to use (always keep a large supply of sea animals, vehicles, GI Joe soldiers, dinosaurs, clowns, and teddy bears) for the child to drop in when the stimulus is heard. Numerous variations to the activity can be used to keep the child engaged. Using the lid as a diving board is a variation most children love, but the clinician may end up wet. Tub Tints are another trick often used in our clinic to obtain a few more responses. We are often amazed at the colors that are created with combinations of tint colors.

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1. Sugar and spice and cash are nice

We have all seen children with whom when all else fails, bribery is the only solution. Although not our first “go-to,” to obtain a complete audiogram, we have been known to use the candy machine, pennies, M & Ms, goldfish or animal crackers, or cereal to get those last few responses. Sometimes, bribing a child might be the only way to get the job done. The only caveat is that parents must give permission ahead of time.

Our experience is that with more variety and the constant reminder that children learn through play, conditioned play audiometry should be fun. Play on, so your work is disguised as play and little ones with hearing loss look forward to their next visit!

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