How to Decide Between Conditioned Play Audiometry (CPA) and Visual Reinforcement Audiometry (VRA)
- Jun 1
- 3 min read
How to Determine Whether a Child Is Ready for Conditioned Play Audiometry
One of the most common decisions in pediatric hearing testing is whether to begin with Conditioned Play Audiometry (CPA)Â or Visual Reinforcement Audiometry (VRA). Choosing the appropriate behavioral hearing assessment can improve test efficiency, reduce frustration, and help obtain reliable hearing thresholds more quickly. While age provides a general guideline, developmental readiness is often a better predictor of whether a child is ready for CPA testing or should begin with VRA testing.
We recently had the opportunity to attend a presentation by pediatric audiologist, Dr. Josephine Marriage, and she shared a simple observation that can help guide this decision...offer the child a simple inset puzzle at the beginning of the appointment and watch what happens.
What the Puzzle Reveals
The goal is not to evaluate puzzle-solving ability. Instead, the puzzle serves as a quick assessment of several skills that are important for successful CPA:
Are they able to engage with a tabletop activity?
Can they understand simple tasks?
Do they have the attention and concentration needed for CPA?
Are they willing to follow adult direction?
Successful Conditioned Play Audiometry requires a child to understand a simple conditioned response, maintain attention, and participate in a structured play task. Common CPA activities include placing a block in a bucket, stacking rings, or completing a simple game whenever a sound is heard (Examples of games can be found here). Children who readily engage with a puzzle often demonstrate many of the same developmental skills required for successful CPA testing.
If a child readily sits down, explores the puzzle, and begins placing pieces appropriately, they may be a good candidate for CPA. These behaviors suggest they can likely learn and perform a conditioned play task such as placing a block in a bucket or a peg in a board when a sound is heard.
On the other hand, if the child shows little interest in the puzzle, struggles to engage with the activity, or is unable to participate meaningfully, beginning with VRA may be the more efficient approach.
Visual Reinforcement Audiometry is often the preferred behavioral hearing test for younger children or children who are not yet developmentally ready for Conditioned Play Audiometry. During VRA testing, the child is conditioned to turn toward a sound source and receives visual reinforcement when a response is made. Beginning with VRA can often lead to more efficient testing when tabletop play tasks are not yet appropriate.
Why This Matters
Many clinicians have experienced spending valuable test time attempting CPA with a child who is not developmentally ready. By the time the decision is made to switch to VRA, attention and cooperation may already be declining.
A simple puzzle can provide useful information within seconds and help guide the initial testing strategy.
A Practical Clinical Tool
This observation highlights an important principle in pediatric audiology: successful testing starts with meeting the child where they are developmentally.
While no single activity can perfectly predict success with CPA or VRA, a quick puzzle assessment may help clinicians make a more informed decision and improve testing efficiency.
As always, clinical judgment, developmental history, language abilities, and previous testing experiences should all be considered when selecting the most appropriate behavioral test method.
Whether you are deciding between Conditioned Play Audiometry and Visual Reinforcement Audiometry, matching the testing method to the child's developmental abilities is often the key to obtaining reliable results. Simple observations, such as how a child interacts with a puzzle, can help guide the decision between CPA testing and VRA testing before the first stimulus is even presented.