New Audiology Research for Enhancing Visual Reinforcement Audiometry (VRA) Systems with Evidence-Based Reinforcers
- Steve Smith
- Nov 11
- 2 min read
In pediatric audiology, achieving reliable behavioral thresholds is often the most critical step in diagnosing hearing loss. For infants and toddlers, the method of choice is visual reinforcement audiometry (VRA). Recently the study by Bonino et al. (2021) titled “Visual Reinforcers Designed for Children with Developmental Disabilities” has provided actionable insights for improving VRA system performance and outcomes.
Visual reinforcement audiometry is a behavioral hearing test technique typically used for children from ~6 months to ~2 years (and sometimes older) where a child is conditioned to turn toward a sound source and is rewarded via a visual stimulus (toy, video, light) when they respond. Reliable results depend on engagement and consistency.
The Challenge: Testing Children with Developmental Disabilities
Children with developmental disabilities (including autism spectrum disorder, intellectual disabilities, etc.) often face additional barriers: sensory sensitivities, limited attention shifts, restricted interests, atypical response behaviors, and difficulties with standard conditioning protocols. These factors reduce the likelihood of completing a full audiogram.
Breakthrough Study: Library of Visual Reinforcers
Bonino developed a library of 45 themed reinforcer sets (photos/videos) selected based on common interests of children with developmental disabilities. Each set contains 20-40 unique items and is formatted for commercial VRA systems and custom slideshow setups. The library is freely downloadable under Creative Commons licensing.
Key Findings & Take-aways for VRA Systems & Audiology Research
Reinforcers tailored to developmental interests may improve engagement, reduce the number of sessions, and improve data yield (though clinical validation is pending).
VRA systems that allow easy switching of content/themes—and custom uploads—are positioned to help overcome habituation and attention lapses.
Open-source, research-backed libraries democratize access to better reinforcement materials for audiology clinics of all sizes.
Future audiology research should quantify how tailored reinforcers impact completion rate, threshold reliability, session length, and cost reduction.
What This Means for Clinical VRA Testing
For audiologists and pediatric hearing centers:
Review the reinforcer content your VRA system uses. Does it include themes aligned to children with developmental disabilities?
If using a modern VRA system (such as Flex VRA), ensure the system allows custom video uploads and rapid reinforcer changes.
How Flex VRA Leverages the Research
Flex VRA supports both video-based and toy-based reinforcement, allows custom content uploads, and offers a modern touch interface for ease of use. This aligns directly with the Bonino study’s emphasis on reinforcer customization and engagement. By integrating research-backed libraries and making system configuration simple, Flex VRA positions your clinic to deliver better outcomes, particularly in populations that challenge standard VRA approaches.
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