Play Audiometry: A Complete Guide

Table of contents

• What is play audiometry?
• Who is play audiometry for?
• Room setup and equipment required
• Assessing whether the child is ready for play audiometry
• Preparation for play audiometry
• Best practice guidelines
• Phases of play audiometry
• Aided play audiometry

What is play audiometry?

Play audiometry is a behavioral method of performing a hearing test, which is ideal for young children, or other older individuals who may have complex or additional needs that prevent them from being able to perform traditional pure tone audiometry.

Play audiometry involves teaching or encouraging the patient to play a game, whereby they perform an action of the game in response to the sound stimulus present. In this way, the action is the response, instead of pressing a button as we know from pure tone audiometry.

You can use a variety of games. Typically, it is useful to have a game that has several components to extend the test as long as possible. Commonly used games include:

• Building towers
• Rings on a stick
• Men in the boat
• Pegs on a board
• Throwing toys into a bucket

The type of game that you can use is limited only by your imagination! You can turn almost any game into a play audiometry task.

Terminology

Play audiometry is also referred to by other terms:

• Performance audiometry
• Conditioned play audiometry

These terms are often used to describe slightly different variations of the test but you can use them interchangeably.

Conditioned play audiometry

Conditioned play audiometry is sometimes used to describe the test when it is performed by demonstrating the task to condition the child that when they hear the sound, they must perform the action of the game, as opposed to direct instruction where they are told what to do. This is often the method used to teach the patient what they need to do when the patient is at a younger age of the age range.

Performance audiometry

Performance audiometry often refers to this type of test when it is performed in the sound field, sometimes via a handheld warbler, and again tends to encompass the conditioned element of the game.

Regardless of the terminology used, the test method is essentially the same. For the purposes of this article, we will use the term ‘play audiometry’ to describe all variations of this test.

Who is play audiometry for?

Most children are ready for play audiometry when visual reinforcement audiometry is no longer effective. This is generally due to the conditioning effect not lasting long enough to perform a complete hearing test.

It is usually noticeable that the child displays limited interest in the visual reinforcers and has more interest in playing with the engagement toys. This transition generally occurs around two and a half years of age. However, for some children, it may be at a younger age, and for others it may be older.

Theoretically, play audiometry has no upper age limit. Anybody, including adults, can be instructed to perform a game-like task for audiometric purposes. However, most children reach a point where they find the game concept too young for them and can feel patronized by the experience.

At this point, it is wise to transition them to pure tone audiometry, which is generally a faster test to perform and therefore more efficient. The age at which this occurs can vary widely. Some 5-year-olds may be ready for pure tone audiometry. For other children, they may prefer to perform play audiometry until the age of 7 or older.

It can be useful to combine pure tone audiometry and play audiometry within the same assessment. If a child finds one method boring or grows disinterested, switching to the other method can help to revive their interest and attention span. For some children, pure tone audiometry can be performed in a ‘play-like’ manner whereby the story is told that the button is like a computer game where the child needs to “catch / zap all the sounds”, for instance.

Room setup and equipment required

Below, we’ll discuss the room setup and equipment requirements.

Sound field testing

You should perform play audiometry in a sound-proofed booth. For older children, sound field testing may not be necessary. However, for younger children, it is important to have a sound field setup where the stimuli can be presented via speakers. A calibrated point should identify where the child should be seated.

Transducers

You can perform play audiometry using all available transducers:

• Headphones
• Via sound field
• Insert earphones
• Bone conduction

You can also perform play audiometry via the sound field in the aided condition to assess the child’s access to speech sounds via their hearing instruments.

Audiometer

You need an audiometer to deliver the stimulus presentations. If there is no calibrated sound field speaker setup, you can use a handheld warbler such as the PA5 to present the stimuli as an alternative. This is particularly useful for conditioning as it can be helpful for the child to ‘see’ where the sounds are coming from.

You can establish thresholds using handheld warblers. However, be mindful of the appropriate distance to hold the warbler from the child and perform sound level meter measurements to confirm the exact stimulus level at the child’s ear.

Tester setups

You can perform play audiometry via a one or two-tester setup.

Two-tester setup

A two-tester setup is like that used for visual reinforcement audiometry, typically involving the audiometer controlled by tester 1 in an observation room. It is also possible to have both clinicians in the same room, with tester 1 controlling the audiometer away from the child (ideally screened from view to avoid distracting and cueing the child).

If you use two rooms, there should be a two-way communication system in place – such as that available with the Equinox Evo – that allows both testers to communicate and be able to hear the stimuli being presented.

One-tester setup

In a one-tester setup, the clinician is responsible for playing with the child, monitoring their responses, and presenting the stimuli from the audiometer controls. It is important that the audiometer controls are not visible to the child to avoid cueing.

Many audiometers are hardwired and in fixed positions, which can make it challenging to present stimuli and focus on the child simultaneously, whilst also leading to sub-optimal ergonomics for clinicians.

You can bring a wireless handheld device such as the Touch Keyboard close to the child. The touch-sensitive controls make it easier to hide stimulus presentations from the child and the small footprint of the device allows for it to be discreetly placed out of sight.

Toys for play audiometry

A plentiful supply of toys should be available. Ideally, you should keep these in a lockable cupboard to ensure they are out of view of the child until required. It is important to have different types of games as some children may find certain types easier to play with and more engaging for the task.

Games with a definitive end point

For some children, a game with a definitive end point, such as placing the rings onto the stick as shown below, works effectively because they can see the conclusion of the game and that encourages them to complete the game.

However, once one game is over, some children may not be willing to repeat that game, and it may be necessary to accept that and move on to a different toy. Many children are willing to repeat the same game or do it backwards (e.g. take the rings off the stick).

When changing game, it may be necessary to re-condition or re-instruct so that the child knows to continue with the same listening / playing task.

Games with an ongoing feel

For other children, games and toys which have an ongoing feel to them, with no clear conclusion, may work more effectively as this sort of task can encourage them to keep going with the game and testing for a longer period.

Not having to change toys so readily also means that re-instruction is likely required. The sorts of toys that can work well here are toys with a selection of characters (trains, animals, well-known cartoon figures) that the child can line up or throw into a bucket.

Assessing whether the child is ready for play audiometry

There are two skills that the child needs to display for play audiometry to be suitable and effective:

• Dexterity skills (manual handling)
• Waiting skills

Dexterity skills

For younger children who are on the cusp of being ready for play audiometry, spending a few moments at the start of the session to gauge their readiness for the task is important.

Using a simple shape puzzle like the one below can help to assess whether their dexterity skills are sufficient to be able to perform the types of tasks required for play audiometry.

If they cannot manipulate the toys and don’t demonstrate the understanding of placing the shape into the puzzle board, then they are probably too young for play audiometry.

Waiting skills

It can be helpful to let parents know what the task involves before they attend their appointment and to encourage them to practice waiting tasks like “ready, steady, go!” games at home.

You can use the same shape puzzle above to play a simple ready, steady, go game with the child before beginning testing. By leaving a pause between “steady” and “go”, you will soon be able to judge whether they understand the concept of waiting for the “go” word before performing the action.

If the child is not quite there with their waiting skills, it can still be helpful to teach them about play audiometry and demonstrate the task. They may learn, with some practice, what to do during the session. If they do not, it may be necessary to revert to visual reinforcement audiometry.

If you cannot obtain a full set of results, the patient will need to return for further assessment when they are a little older and more likely to have developed the waiting skills required for play audiometry. Time spent practicing and teaching this during their first attempt will help to prepare them and demonstrate to the parents what they can practice at home in the interim.

Preparation for play audiometry

As mentioned previously, it can be helpful to explain to parents / carers what the play audiometry task involves before attending their appointment. Interacoustics has developed the short, animated video below which you can share with families to watch together with their children to prepare them for the hearing test experience.

It can also be helpful to provide a ‘social story’ or booklet which contains photos and steps of the specific clinic or hospital department that they will be attending.

Example from Evelina Hospital in London, UK: I’m having my hearing checked at the hospital

Best practice guidelines

There are currently no specific play audiometry guidelines from the British Society of Audiology. Clinicians may wish to refer to guidance found in national protocols from Canada (Ontario Ministry of Children, Community, and Social Services Infant Hearing Program, 2019), the United States of America (ASHA, 2004), and New Zealand (Ministry of Health, 2016).

Much of the guidance for play audiometry combines clinical and best practice elements of pure tone audiometry with the pediatric elements of visual reinforcement audiometry. If no national guidelines are available, individual clinics may be advised to develop their own protocol for performing play audiometry to help ensure the standardization of care across all staff and patients.

Phases of play audiometry

There are two main phases of play audiometry:

• The first phase includes teaching, conditioning, and instruction.
• Followed by the testing phase.

Teaching, conditioning, and instruction phase

In play audiometry, it is important to spend some time either explaining or demonstrating and then practicing the task that the child must do for the test. For older children, it may be sufficient to instruct them as follows:

“When you hear the sound, place the man in the boat. Keep doing this for every sound that you hear, even the very quietest.”

For younger children, a more playful version of the same instructions may be required. For example:

“We’re going to listen really, really hard. When the sound comes, the man jumps in the boat! Can you do that for me? Let’s practice together!”

This should then be followed by several stimulus presentations at a clearly supra-threshold level. For each presentation, the clinician can hold the toy together with the child and give encouraging hints on when the sound has been presented and that this means they need to perform the action.

Storytelling is particularly helpful. Instead of the child listening to the sound, the clinician can tell the story that the characters within the game are listening. For example:

“This man needs to jump into the boat. But he’s not allowed in until he hears the sound. Are you ready? Let’s make him listen to sound… Here it comes!”

For younger children, those lacking language skills, or even those with significant hearing losses who may not be able to hear the clinician’s instructions, the game can be taught through demonstration and hand signals.

This makes use of more of a conditioning philosophy, whereby the sound stimulus is linked to the action of the game. Sometimes by simply listening to the sound and demonstrating and then guiding the action, the child will learn to associate that the task follows on from the sound presentation.

Testing phase

Below, we’ll discuss several components of the testing phase.

Independent responses

Following the above phase, there should be opportunity provided for the child to perform some independent responses to stimuli presentations. In visual reinforcement audiometry, it is recommended that two independent responses to the conditioning stimulus are seen to confirm successful conditioning before moving onto the testing phase. You should adopt a similar approach for play audiometry.

Step sizes

Once it is established that the child reliably understands the task, testing should proceed to finding threshold. Using a 20 dB down, 10 dB up thresholding technique is common in play audiometry, as in visual reinforcement audiometry, to maximize the patient’s attention span. You may use smaller step sizes around the threshold.

Threshold criterion

You should accept two out of three ascending responses as the threshold, as in visual reinforcement audiometry and pure tone audiometry. It is possible to perform a screening play audiometry, whereby you perform testing down to normal levels (e.g. 25 dB HL in the sound field or 20 dB for other transducers). And if you obtain repeatable responses at the determined level, further testing within the normal range to establish ascending thresholds can be skipped to maximize time and efficiency.

Testing strategy

Clinicians should determine a testing strategy based on the child’s history and any known results from previous assessments or other tests performed before play audiometry. It is important to acknowledge that it may not be possible to obtain a full audiogram from a child and therefore the full assessment may take more than one attempt. The testing strategy should also consider this, and steps should be taken to obtain the most important clinical information.

For example, in pure tone audiometry, one ear is tested across the full frequency range and then testing moves over to the opposite ear. In play audiometry, it may be more prudent to switch between ears after one or two frequencies and then switch back to complete the full range.

It also may be appropriate to test in the sound field first (as some children may not tolerate ear-specific transducers). If the sound field results are raised, then you may need to perform bone conduction next before ear-specific air conduction, as this will provide information on the nature of the hearing loss.

Assessing response reliability

As play audiometry is dealing with a behavioral response from a cohort of patients who may not be easy to communicate directly with, it is important to assess the reliability of responses, and that only reliable responses contribute towards the determination of threshold.

Spending sufficient time at the teaching phase is vital to ensure a robust response will be performed by the child. If the child produces hesitant or uncertain responses, such as:

• Hovering the toy over the end goal
• Looking toward the clinician for assurance
• Picking the toy up but not completing the placement action

Then it may be advisable to return to the teaching phase to build more confidence in the task.

No-sound trials

The use of no-sound trials can help to judge when the child is producing false-positive responses, where they perform the game task, but not directly in response to the sound presentation. This can happen when the child does not fully understand the requirement to wait, or the link between the sound and the response.

Further time spent in the teaching phase may be required, or a different type of game may help to slow their pace. Using no-sound trials can help to identify how prevalent these false positives are within the assessment. Excessive false-positive responses should result in a change of tactic to improve reliability.

Stimuli

You can use a range of stimuli for play audiometry, including:

• PED noise
• Warble tones
• Narrowband noise
• Frequency-filtered sounds

You can use pure tones via headphones, insert earphones or bone conductor but not in the free field due to standing waves. Warble tones are typically preferred over pure tones as warble tones are more interesting to the child and more likely to capture their attention.

You can use narrowband noise if warble tones are not effective. However, narrowband noise lacks frequency specificity and risks off-frequency listening. A more frequency-specific option is PED noise.

A range of frequency-filtered sounds are available on the Equinox Evo audiometer. These can help capture the patient’s interest and attention if traditional stimuli are not effective. These are also suitable for aided testing.

Included in the Equinox Evo audiometer are the LING-6 sounds, the ManU-IRU stimuli, and the HD sounds. These three sets of stimuli are also available on the Interacoustics Eclipse for aided cortical testing, allowing for continuity of test results across different age groups/stages and test types.

Aided play audiometry

You can use play audiometry as a technique to perform aided testing. In other words, the same technique as described above is used with the patient wearing their hearing instruments in-situ and switched on.

Goal of aided play audiometry

The goal of this type of testing is to establish how well the patient can hear via their hearing aids. The results obtained from this type of testing can be useful in identifying whether the patient’s hearing aid amplification is providing them with the desired benefit.

If the results of aided play audiometry are not satisfactory, then adjustments to the hearing instrument settings may be warranted to improve the patient’s aided access to speech sounds. This is a particularly important step in the patient pathway for young children, as they are at a crucial age for speech and language development.

If they are not receiving the appropriate amplification, they may not be able to access the important speech sounds around them, which are vital for them to hear to develop their own speech and language skills.

Stimuli for aided play audiometry

It is a common misconception that you can perform aided testing in the same way as unaided audiometry, using warble tones. This is sometimes called ‘functional gain testing’ as it allows for a direct comparison of the aided vs unaided testing condition using the same stimuli.

However, the use of functional gain assessments is not recommended by the British Society of Audiology (2024) for several reasons. Instead, it is preferable to perform aided testing using speech-like stimuli. Utilizing these stimuli provides a few benefits:

• Hearing aids are primarily designed to improve the audibility of speech.
• Hearing aid verification such as REM or RECD uses the ISTS signal, which is representative of the long-term average speech spectrum.
• With young children, the main clinical question is generally focused on whether they can access speech sounds sufficiently to support their speech and language development.
• If you require a direct comparison of the two conditions, then you can test with these stimuli unaided as well as aided.

There are a range of speech-like stimuli available for aided (and unaided) play audiometry testing. The Equinox Evo audiometer includes the following frequency-filtered sounds for such a purpose:

• HD sounds
• LING-6 sounds
• ManU-IRU stimuli

The LING-6 sounds have been well established for some time (Scollie et al, 2012; Glista et al, 2014).

The ManU-IRU stimuli (Stone et al, 2019) were developed for aided cortical testing (available on the Interacoustics Eclipse) but were validated via different types of hearing aids in both a cortical setup and a visual reinforcement audiometry setup. These stimuli were further used for aided testing by Visram et al (2023) during a large-scale study of over 100 infant hearing aid wearers.

References

American Speech-Language-Hearing Association. (2004). Guidelines for the audiologic assessment of children from birth to 5 years of age [Guidelines].

British Society of Audiology. (2024). Practice guidance: The acoustics of sound field audiometry in clinical audiological applications. Retrieved February 27, 2025.

British Society of Audiology. (2024). Recommended procedure: Visual reinforcement audiometry. Retrieved February 25, 2025.

Glista, D., Scollie, S., Moodie, S., Easwar, V., & Network of Pediatric Audiologists of Canada (2014). The Ling 6(HL) test: typical pediatric performance data and clinical use evaluation.

Ministry of Health. (2016). Universal newborn hearing screening and early intervention programme: National policy and quality standards: Diagnostic and amplification protocols. Wellington: Ministry of Health.

Ontario Ministry of Children, Community, and Social Services. (2019). Audiometric assessment for children aged 6 to 60 months. Infant Hearing Program. Retrieved March 14, 2025.

Scollie, S., Glista, D., Tenhaaf, J., Dunn, A., Malandrino, A., Keene, K., & Folkeard, P. (2012). Stimuli and normative data for detection of Ling-6 sounds in hearing level. American journal of audiology, 21(2), 232–241.

Stone, M. A., Visram, A., Harte, J. M., & Munro, K. J. (2019). A Set of Time-and-Frequency-Localized Short-Duration Speech-Like Stimuli for Assessing Hearing-Aid Performance via Cortical Auditory-Evoked Potentials. Trends in hearing, 23, 2331216519885568.

Visram, A. S., Stone, M. A., Purdy, S. C., Bell, S. L., Brooks, J., Bruce, I. A., Chesnaye, M. A., Dillon, H., Harte, J. M., Hudson, C. L., Laugesen, S., Morgan, R. E., O'Driscoll, M., Roberts, S. A., Roughley, A. J., Simpson, D., & Munro, K. J. (2023). Aided cortical auditory evoked potentials in infants with frequency-specific synthetic speech stimuli: Sensitivity, repeatability, and feasibility. Ear and Hearing, 44(5), 1157-1172.