VRA vs CPA in Pediatric Audiology: What Is the Difference?

In pediatric audiology, two of the most commonly used behavioral hearing tests are Visual Reinforcement Audiometry (VRA) and Conditioned Play Audiometry (CPA).

Although both tests are used to evaluate hearing in children, they are designed for different developmental stages and rely on different response behaviors. Understanding the difference between VRA and CPA testing helps audiologists choose the most appropriate method and obtain reliable hearing thresholds.

What Is Visual Reinforcement Audiometry (VRA)?

Visual Reinforcement Audiometry (VRA) is a behavioral hearing test used primarily with infants and young toddlers, typically between 6 months and 2.5 years of age.

During VRA testing:

• Sounds are presented through speakers or earphones

• The child is conditioned to turn toward the sound

• A visual reinforcer (video, light, or toy) is activated after a correct response

  
  

VRA testing relies on natural head-turn behavior rather than instructed responses as you can see in the video below.

Example of VRA testing being done with a Flex VRA version 1

When VRA is typically used

• Infants and toddlers under 3 years old

• Children who cannot follow verbal instructions

• Early behavioral hearing assessments

• Pediatric patients with short or variable attention spans

Visual Reinforcement Audiometry is most effective when the reinforcement is engaging but controlled, allowing the child to stay focused without distraction.

What Is Conditioned Play Audiometry (CPA)?

Conditioned Play Audiometry (CPA) is a behavioral hearing test commonly used with older toddlers and preschool-aged children, generally between 2.5 and 5 years of age, depending on developmental readiness.

During CPA testing:

• The child is taught a simple play task (such as placing a block in a container)

• The task is performed each time a sound is heard

• Responses are intentional and conditioned

CPA requires the child to understand instructions and complete a specific action in response to sound.

When CPA is typically used

• Preschool-aged children

• Children who can follow simple instructions

• Patients with longer attention spans

• Diagnostic or follow-up audiology evaluations

Conditioned Play Audiometry can produce reliable thresholds when the child is developmentally ready.

Key Differences Between VRA and CPA

Feature	VRA	CPA
Full name	Visual Reinforcement Audiometry	Conditioned Play Audiometry
Typical age range	6 months to ~2.5 years	~2.5 to 5 years
Response type	Head turn toward sound	Conditioned play action
Instruction required	Minimal	Moderate
Attention demands	Short and variable	Longer and sustained
Reinforcement	Visual stimulus	Play-based task
Clinical goal	Sound detection and early thresholds	Behavioral thresholds

Why Developmental Readiness Is Important

Choosing between VRA and CPA is not based on age alone.

A child may be chronologically old enough for CPA but not developmentally ready to:

• Understand instructions

• Perform a conditioned task consistently

• Maintain attention throughout testing

Using CPA too early can result in:

• Inconsistent responses

• Increased test time

• Unreliable thresholds

In these cases, Visual Reinforcement Audiometry may still be the more appropriate test method.

Transitioning From VRA to CPA

The transition from VRA to CPA often occurs gradually. Some children may move between methods during the same appointment depending on:

• Fatigue

• Engagement level

• Task understanding

Audiology clinics benefit from testing environments that allow flexibility between VRA and CPA, rather than forcing a single testing approach.

The Role of Flexible VRA Systems in Pediatric Audiology

Modern pediatric audiology clinics increasingly rely on VRA systems that support:

• Multiple reinforcement options

• Adjustable visual engagement

• Controlled test environments

• Smooth workflow transitions

These capabilities allow audiologists to adapt testing methods based on the child’s developmental stage rather than strictly following age-based guidelines.

Choosing Between VRA and CPA

There is no single “best” pediatric hearing test.

• Use VRA when the child responds best to visual reinforcement and natural head-turn behavior.

• Use CPA when the child can follow instructions and reliably complete a conditioned task.

The most accurate pediatric audiology evaluations are achieved when clinicians can adjust testing methods in real time. This includes possible utilizing a VRA system with an interactive button for VROCA testing.

Summary: VRA vs CPA

Visual Reinforcement Audiometry and Conditioned Play Audiometry serve different but complementary roles in pediatric hearing testing.

Understanding the difference between VRA and CPA allows audiologists to:

• Select the appropriate test method

• Reduce testing time

• Improve reliability of results

• Create a better experience for children and parents