Run Flex VRA from your audiometer’s VRA keys. The included integration cable works with the GSI AudioStar Pro, GSI Audiosol and Interacoustics EVO. Flex VRA Audiometer Integration Cable Audiometer integration for the GSI AudioStar Pro, GSI Audiosol and Interacoustics EVO Integration cable user guide (PDF) Works With Your Audiometer GSI AudioStar Pro Run up to six reinforcers straight from the audiometer’s Left, Center and Right VRA keys, just above the right attenuator dial. The Flex remote toggles between video and toy reinforcement. GSI Audiosol The Flex integration cable works directly in the GSI Audiosol software, with no extra integration modules. Interacoustics EVO Control left and right video and toy reinforcement directly within Interacoustics Suite during VRA testing. Computer-based audiometers Using a computerized audiometer or the Otometrics Astera? Flex PC triggers reinforcement from your keyboard or directly from the Audiometer Control Panel. FAQ Does Flex VRA integration cable work with my audiometer? Yes. If you have a GSI AudioStar Pro , GSI Audiosol , or Interacoustics EVO , the integration cable will work directly from your audiometer. If you have a computerized audiometer or Otometrics Astera by Natus , visit Flex PC to see how Flex VRA can work with your audiometer. My audiometer isn’t listed. Can I still use Flex? Yes. Every system works from its wireless remotes, and you can contact sales about your model of audiometer to see if there are any alternate methods of activation. Is integration an extra cost? No. The cable and Flex PC are included with every system.

Peer-reviewed research and published literature referencing modern, software-enabled visual reinforcement audiometry approaches, including Flex VRA. Research and literature A reading list for audiologists on visual reinforcement audiometry and pediatric hearing testing, from the studies that defined VRA to current guidelines and courses. 31 resources in 7 topics Pick a topic below. Each link opens in a new window. Guidelines and protocols · 5 Foundations of VRA · 5 Reinforcers and attention · 5 Thresholds and technique · 7 Clinical populations · 5 Play audiometry and beyond · 2 Courses and learning · 2 Guidelines and protocols Guidelines and protocols Professional guidance on how to set up, run and interpret behavioral hearing tests with infants and young children. 2025 Recommended procedure: visual reinforcement audiometry Free British Society of Audiology. Version 1.2, June 2025. The BSA’s procedure for VRA: equipment and booth setup, conditioning, running the test and interpreting results. Open PDF ↗ 2020 Assessment of hearing in infants and young children Free American Academy of Audiology. Clinical guidance document. Covers the full pediatric test battery, including behavioral observation, VRA and conditioned play audiometry, alongside physiologic measures. Open PDF ↗ 2019 Year 2019 position statement: principles and guidelines for early hearing detection and intervention programs Free Joint Committee on Infant Hearing. Journal of Early Hearing Detection and Intervention , 4(2), 1–44. The JCIH guidance on screening, diagnosis and intervention timelines that pediatric audiology follow-up is built around. Read statement ↗ 2019 Audiometric assessment for children aged 6 to 60 months Free Ontario Infant Hearing Program. Scollie S, Pigeon M, Bagatto M, Witte J, Malandrino A. A detailed clinical protocol covering VRA, conditioned play audiometry and individualized reinforcement audiometry. Open PDF ↗ 2022 Quality standards in paediatric audiology Free British Academy of Audiology. Service-level quality standards for pediatric audiology departments, including diagnostic assessment. Open PDF ↗ Foundations of VRA Foundations of VRA The studies that established visual reinforcement as a reliable way to measure hearing in infants. 1975 Auditory localization of infants as a function of reinforcement conditions Moore JM, Thompson G, Thompson M. Journal of Speech and Hearing Disorders , 40(1), 29–34. The classic study showing that a visual reward for a head turn produces far more responses than social or no reinforcement. PubMed ↗ 1977 Visual reinforcement of head-turn responses in infants under 12 months of age Moore JM, Wilson WR, Thompson G. Journal of Speech and Hearing Disorders , 42(3), 328–334. Looks at how young an infant can be and still be conditioned for VRA. PubMed ↗ 1984 A comparison of two conditioning procedures in the use of visual reinforcement audiometry Thompson G, Folsom RC. Journal of Speech and Hearing Disorders , 49(3), 241–245. Compares two ways of teaching an infant the response at the start of a VRA session. PubMed ↗ 1985 Response strength of young children in operant audiometry Primus MA, Thompson G. Journal of Speech and Hearing Research , 28(4), 539–547. How many responses young children give before they lose interest, and what influences it. PubMed ↗ 1987 Response and reinforcement in operant audiometry Primus MA. Journal of Speech and Hearing Disorders , 52(3), 294–299. How the choice of response task and reinforcer shapes results in operant audiometry with young children. PubMed ↗ Reinforcers and attention Reinforcers and attention Research on what the child sees as a reward, from animated toys to video, and how it affects the number of responses. 2021 Visual reinforcers designed for children with developmental disabilities Free Bonino AY, Hemann A, Mood D, Kay E, Pancoast ES, Sommerfeldt KK. Journal of Early Hearing Detection and Intervention , 6(1), 69–76. Describes visual reinforcers built for children with developmental disabilities, who are often hard to engage with standard rewards. Free full text ↗ 2025 Optimisation of visual reinforcement audiometry: a scoping review Visram AS, Jackson IR, Almufarrij I, Stone MA, Munro KJ. International Journal of Audiology , 64(8), 773–783. Maps the research on factors that affect how well VRA works, and where evidence is still missing. Read review ↗ 2010 Animated toys versus video reinforcement in 16–24-month-old children in a clinical setting Karzon RK, Banerjee P. American Journal of Audiology , 19(2), 91–99. In 145 toddlers tested in a busy clinic, animated toy reinforcement produced more threshold estimates than video. PubMed ↗ 2009 A comparison of video versus conventional visual reinforcement in 7- to 16-month-old infants Lowery KJ, von Hapsburg D, Plyler EL, Johnstone P. Journal of Speech, Language, and Hearing Research , 52(3), 723–731. Found no significant difference in responses, consistency or false alarms between video and conventional reinforcement. PubMed ↗ 2003 Visual reinforcement audiometry using digital video disc and conventional reinforcers Schmida MJ, Peterson HJ, Tharpe AM. American Journal of Audiology , 12(1), 35–40. Two-year-olds gave more responses before habituating with video reinforcement (about 15) than with an animated toy (about 11). PubMed ↗ Thresholds and technique Thresholds and technique What a VRA response level tells you, how to get the most reliable one, and how to cross-check it. 2015 Hearing thresholds, minimum response levels, and cross-check measures in pediatric audiology Norrix LW. American Journal of Audiology , 24(2), 137–144. Explains the difference between a true threshold and a minimum response level, and why cross-checks matter. PubMed ↗ 2016 Efficacy of earphones for 12- to 24-month-old children during visual reinforcement audiometry Weiss AD, Karzon RK, Ead B, Lieu JE. International Journal of Audiology , 55(4), 248–253. Looks at how often toddlers accept earphones during VRA, for ear-specific results. PubMed ↗ 2003 Minimal response levels for visual reinforcement audiometry in infants Parry G, Hacking C, Bamford J, Day J. International Journal of Audiology , 42(7), 413–417. Normative minimal response levels with insert earphones in normal-hearing infants aged 33 to 50 weeks. PubMed ↗ 2003 Hearing levels in infants and young children in relation to testing technique, age group, and the presence or absence of middle-ear effusion Sabo DL, Paradise JL, Kurs-Lasky M, et al. Ear and Hearing , 24(1), 38–47. Compares hearing levels across behavioral techniques and ages in a large group of young children. PubMed ↗ 2001 A longitudinal investigation of infant auditory sensitivity Tharpe AM, Ashmead DH. American Journal of Audiology , 10(2), 104–112. Follows the same infants over their first year to track how response levels change with age. PubMed ↗ 1992 The role of localization in visual reinforcement audiometry Primus MA. Journal of Speech and Hearing Research , 35(5), 1137–1141. The VRA response doesn’t depend on localization, but localization cues still noticeably affect performance. PubMed ↗ 1992 Operant response in infants as a function of time interval following signal onset Primus MA. Journal of Speech and Hearing Research , 35(6), 1422–1425. Most infant responses come within the first 4 seconds of the signal; longer trials add little. PubMed ↗ Clinical populations Clinical populations VRA in newborn screening follow-up, in children with developmental differences and with cochlear implants. 2005 A multisite study to examine the efficacy of the OAE/automated ABR newborn hearing screening protocol: results of visual reinforcement audiometry Free Widen JE, Johnson JL, White KR, Gravel JS, et al. American Journal of Audiology , 14(2), S200–S216. VRA follow-up at 8 to 12 months for 973 infants who failed OAE but passed AABR screening, across seven sites. Open PDF ↗ 2000 Identification of neonatal hearing impairment: hearing status at 8 to 12 months corrected age using a visual reinforcement audiometry protocol Widen JE, Folsom RC, Cone-Wesson B, et al. Ear and Hearing , 21(5), 471–487. The VRA protocol and results from the large multicenter study of newborn hearing screening outcomes. PubMed ↗ 2018 Measuring sound-processor thresholds for pediatric cochlear implant recipients using visual reinforcement audiometry via telepractice Free Hughes ML, Goehring JL, Sevier JD, Choi S. Journal of Speech, Language, and Hearing Research , 61(8), 2115–2125. Compares VRA done remotely with VRA done in person for setting cochlear implant thresholds in young children. Free full text ↗ 1979 Application of visual reinforcement audiometry (VRA) to low-functioning children Thompson G, Wilson WR, Moore JM. Journal of Speech and Hearing Disorders , 44(1), 80–90. Applies VRA to children with developmental delays, looking at developmental age rather than chronological age. PubMed ↗ 1978 Visual reinforcement audiometry (VRA) with young Down’s syndrome children Greenberg DB, Wilson WR, Moore JM, Thompson G. Journal of Speech and Hearing Disorders , 43(4), 448–458. An early study of VRA with young children with Down syndrome. PubMed ↗ Play audiometry and beyond Play audiometry and beyond Moving from VRA to play-based testing as children grow. 2020 Interrater reliability for a two-interval, observer-based procedure for measuring hearing in young children Free Bonino AY, Wiens A, Nightengale EC, Vance EA. American Journal of Audiology , 29(4), 762–773. Three observers scoring 2- to 4-year-olds on a play-based procedure agreed closely, supporting its reliability. Free full text ↗ 1987 A longitudinal study comparing responses of hearing-impaired infants to pure tones using visual reinforcement and play audiometry Talbott CB. Ear and Hearing , 8(3), 175–179. Follows infants with hearing loss as they move from VRA to play audiometry. PubMed ↗ Courses and learning Courses and learning Continuing education and self-study for clinicians. CE New tools and strategies for visual reinforcement audiometry Flex VRA AudiologyOnline, course 39687. A presentation on the new tools and strategies for VRA available with Flex VRA. View course ↗ CE Audiological assessment and interpretation in LSL intervention Free Hearing First self-study. Presented by Jace Wolfe, PhD. An overview of pediatric assessment, with a module on behavioral testing including VRA and conditioned play audiometry. Free to join. View course ↗ Planning research with Flex VRA? If you’re conducting or planning research on visual reinforcement audiometry, conditioned play audiometry or operant control approaches, we’re glad to talk through resources and technical considerations. Email sales@flexvra.com Or call 512-777-0016 Know of a study that belongs here? Send it our way and we’ll consider adding it.

Download the latest Flex VRA software updates, installation guides, and release notes to keep your Visual Reinforcement Audiometry system running at its best. Flex VRA Software Version 4.0 Update Estimated update time: 10-15 minutes Download PDF Instructions What’s New in Version 4.0 Animated pediatric welcome videos Bubble Game Farm Game Ball in the Bucket Game Improved performance

Flex VRA combo systems combine video and toy reinforcement in a single pediatric audiology setup, offering flexible engagement options for visual reinforcement audiometry testing. The Perfect Pair One system. One remote. No added complexity. "We have a couple Flex VRA systems and find that they work really well with our kiddos!" Chelsea Blankenship, Au.D., PH.D., Cincinnati Children's Hospital Flex VRA Combo System Configurations R=Right L=Left C=Center FLEX-RLC-FLEXTOY-RLC Right, Left, and Center Monitor Right, Left, and Center Toy 2 Remote Controls Flex PC Audiometer Integration $9,900 Point of View Demonstration Point of View Demonstration FLEX-RLC-FLEXTOY-RL (most popular) Right, Left, and Center Monitor Right and Left Toy 2 Remote Controls Flex PC Audiometer Integration $9,200 FLEX-RL-FLEXTOY-RLC Right and Left Monitor Right, Left, and Center Toy 2 Remote Controls Flex PC Audiometer Integration $7,700 Point of View Demonstration FLEX-RL-FLEXTOY-C Right and Left Monitor Center Toy 2 Remote Controls Flex PC Audiometer Integration $6,000 Point of View Demonstration FLEX-C-FLEXTOY-RL Center Monitor Right and Left Toy 2 Remote Controls Flex PC Audiometer Integration $4,700 International customers: Prices shown are in USD and exclude shipping, duties, and taxes. Pricing does not include the cost of shipping, applicable taxes, and installation. Sold through authorized distributors . We believe pricing transparency saves clinicians time. You can read more about why we post prices online here. Point of View Demonstration Get a Quote Brochure Audiometer Integrations Included with every Flex VRA Combo System Audiometer Integration Cable Directly interfaces with the GSI Audiostar Pro and the Interacoustics EVO and wirelessly activate with the Flex VRA on the audiometer keys. Flex PC Control Flex VRA with hotkeys while performing audiometric testing on a computerized audiometer Brochure Learn More The Remote Two Remote Controls Included With Every Flex VRA Combo System TOY Toggles to physical toy mode so that only toys respond to activators DISTRACT Use the VRA monitor as a focal point to keep patients still during tympanometry, otoscopy, or OAE testing. LIGHTS ON/OFF Turn on (top button) and off (bottom button) the 360 degree LED light bar while playing video content. ACTIVATORS Left (Blue), Right (Red), and Center (Green) LIGHTS ONLY Activate the 360 degree light bar only while an activation button is pressed down. Toggles video mode on. VIDEO Display videos of cartoons of cartoons and live-animals while an activation button is held down. Toggles video on VOLUME CONTROL Volume up, down, and mute control of the VRA monitors. Custom content comes standard with preloaded Hey Bear Sensory content, but any content can be loaded by the end user. Toggles video on. CUSTOM New Features Targeted Content Targeted Content is a feature in Flex VRA that lets the clinician pre-select exactly what video or stimulus will play when a specific button is pressed, before the test even begins. Instead of choosing content on the fly and hoping it connects with the child, Targeted Content flips the model. The child comes first, and the stimulus is chosen specifically for them. House Rules House Rules is a software feature in Flex VRA that lets clinicians set fixed behavior rules for a VRA monitor, most commonly the center screen, so it behaves exactly the way the audiologist wants during testing regardless of what stimuli are changed on the left and right monitors. House Rules reflects how Flex VRA approaches software driven VRA design. Instead of forcing clinicians to adapt to the system, the system adapts to how clinicians choose to run the test. Conditioned Play Audiometry Games Included with every Flex VRA Combo System Bubble Game "When you hear a tone, pop a bubble on the screen and see a character appear!" Watch Demo Farm Game "Pick a fruit out and feed it to one of the animals when you hear the tone." Watch Demo Bucket Game "Listen for the tone and when you hear the beep, touch one of the colored balls and drag it over into the bucket!" Watch Demo Dynamic SRT Pictured Words Board An SRT board that moves and has sound in response to touch! Watch Demo Diagrams Application Display diagrams of the ear for counseling or upload your own images! Watch Demo Who is Hey Bear Sensory? Learn More About Hey Bear! Hey Bear Sensory designs sensory-based content for children. Hey Bear has quickly gained popularity on YouTube, and within the last 10 years has amassed over 3 million subscribers, boasts approximately 2.5 billion views, and has a constant audience of thousands watching live every day. Flex VRA entered into an exclusive content licensing agreement with Hey Bear Sensory to provide the default custom content that will ship with every Flex VRA system. By combining Hey Bear's insanely popular content with the Flex VRA, we can provide the most engaging and positive VRA experience to audiologists and their patients.

Flex VRA combination systems put video, toy and Halo reinforcers on one remote, so you can test any age and switch in one press. $4,840–$10,195. Combo Systems Brochure See prices "We have a couple Flex VRA systems and find that they work really well with our kiddos!" Chelsea Blankenship, Au.D., Ph.D., Cincinnati Children's Hospital, Cincinnati, OH Combination VRA Systems Toy or video? Both. Up to six reinforcers controlled from a single remote. Toy, video, or a mix of both. One ecosystem. One workflow. From $4,840 Some children respond to video. Some respond to toys. A combo system lets you switch in a single press. Get A Quote See it in the booth FLEX-RLC-FLEXTOY-RLC Flex Video Right, Left and Center Flex Toy Right, Left, and Center FLEX-RLC-FLEXTOY-RL Flex Video Right, Left and Center Flex Toy Right and Left About Flex VRA combo systems VRA for any age. Some children respond best to a toy, others to a video, and many change partway through a test. A combination system gives you both on the same remote, so you can switch the moment a child loses interest instead of losing the test. Pair up to 6 different reinforcers in one system. Choose one of seven standard combinations, add a Flex Halo hybrid, or ask us to configure a custom mix for your booth. Configurations and prices (2027 list, USD) • Flex Toy left and right, Flex VRA center (FLEX-C-FLEXTOY-RL): $4,840 • Flex VRA left and right, Flex Toy center (FLEX-RL-FLEXTOY-C): $6,180 • Flex Halo left and right, Flex Toy center (FLEXHALO-RL-FLEXTOY-C): $7,475 • Flex VRA + Flex Toy left and right, Flex Toy center (FLEX-RL-FLEXTOY-RLC): $7,930 • Flex Halo left and right, Flex VRA center (FLEXHALO-RL-FLEX-C): $9,220 • Flex VRA + Flex Toy left and right, Flex VRA center (FLEX-RLC-FLEXTOY-RL): $9,475 • Flex VRA + Flex Toy left, right and center (FLEX-RLC-FLEXTOY-RLC): $10,195 Every combination system includes two remote controls, an audiometer integration cable for the GSI AudioStar Pro or Interacoustics EVO , Flex PC , built-in conditioned play audiometry games and a 1-year warranty. FAQ What is a combination VRA system? A setup that mixes video and toy reinforcers in one booth, controlled from one remote. How many reinforcers can one remote control? Up to six. Can I start with one type and add the other later? Yes. You can add video, toy or Halo units as your clinic grows. Can my audiometer work with all of the reinforcers? Yes. All reinforcers are accessible directly from your audiometer or computer. Need a different mix? We'll configure it for your booth. Get a quote

Free conditioned play audiometry (CPA) games for Windows. Bubble, Farm, Ball and SRT games that keep children engaged during pediatric hearing tests. Free conditioned play audiometry (CPA) games Four free Windows games for conditioned play audiometry and speech testing. Each one turns a child’s response into play: hear the sound, then feed an animal, pop a bubble or drop a ball in a bucket. They were built for Flex VRA and run on any Windows PC with a mouse or touch screen. Free download · Windows PC What is conditioned play audiometry? Conditioned play audiometry (CPA) is a behavioral hearing test for young children. The child learns to do a simple play action every time they hear a sound, and the audiologist uses those responses to find the softest sounds they can hear. A game on a screen keeps the child engaged for the whole test, so you get more reliable thresholds before attention runs out. How to use the games in a CPA test 1 Condition the response Show the child the game, present a sound, and guide them through the play action together until they respond on their own. 2 Present the stimulus Present tones or speech as usual. The child waits for the sound before they feed the animal, pop a bubble or drop the ball. 3 Reward on screen The game answers right away with movement, sound and music, so each response feels worth making. Download the CPA games Each game is a free ZIP download for Windows. Unzip it and run it on the PC connected to your booth monitor or touch screen. Flex Farm Game Drag fruit to an animal to feed it. When the task is done, the animal moves and makes a noise as a reward. During play audiometry, the child feeds the animal of their choice each time they hear the sound. Download for Windows (ZIP) Bubble Game Bubbles float across the screen. When the child pops one with a touch or a mouse click, an animated cat appears and music plays as a reward. Download for Windows (ZIP) SRT Board A visually reinforced picture board for speech reception threshold (SRT) testing. Pictures move and play a sound when the patient makes a correct selection. Download for Windows (ZIP) Flex Ball Game A drop-the-ball-in-the-bucket game for play audiometry, played by drag and drop with a mouse or on a touch screen. Download for Windows (ZIP) CPA games built into Flex VRA 4.0 Flex VRA 4.0 puts the Bubble, Farm and Ball games right on the booth monitor. They open instantly and support several fingers at once, and Pictured Words adds full-screen pictures for speech testing. No separate PC needed. Try the Flex VRA 4.0 demo Conditioned play audiometry FAQ What is conditioned play audiometry (CPA)? CPA is a behavioral hearing test for young children. The child is taught to do a simple play action, like dropping a block in a bucket or feeding an animal on a screen, every time they hear a sound. The audiologist uses those responses to estimate hearing thresholds. What age is CPA used for? CPA is typically used with children from about 2½ to 5 years old, once they can follow a simple play task. Younger children are usually tested with visual reinforcement audiometry (VRA) . What is the difference between CPA and VRA? In VRA, the child turns their head toward a sound and is rewarded with a video or animated toy. In CPA, the child does a play action in response to the sound. Read more in VRA vs CPA in pediatric audiology and how to decide between CPA and VRA . Do the CPA games work without a Flex VRA system? Yes. Each game runs on any Windows PC, with a mouse or a touch screen. With Flex VRA 4.0, the Bubble, Farm and Ball games are also built into the booth monitor. Are the games free? Yes. All four games are free to download and use in your clinic.

Learn about VRA calibration, reinforcer placement, and how to best position visual reinforcement audiometry equipment for optimal performance. One of the most common questions in pediatric audiology is whether a VRA system needs to be calibrated. The answer depends on what the term “calibration” refers to. Audio Calibration VRA equipment itself does not generate calibrated sound. The audiometer is the device responsible for delivering calibrated signals. As long as the audiometer is calibrated according to ANSI standards, the audio portion of the VRA test remains accurate. The VRA system simply presents the visual reinforcement once the child responds. Visual Calibration There is no formal visual calibration standard in Visual Reinforcement Audiometry. However, consistency matters. Clinics should verify that: • The left and right reinforcers activate at the correct moment • The reinforcers are bright and visible from the child’s position • The timing of activation matches the audiologist’s expectations Modern software-based systems make this easier because they remove the mechanical delays found in older VRA boxes. Positioning and Setup Although VRA systems do not require calibration in the same way an audiometer does, proper setup is essential. • Reinforcers should be placed at roughly 45 degrees to the child minimum to 90 degrees maximum • The height should match eye level • The center reinforcer should help maintain attention without overpowering the side reinforcers New features like House Rules in Flex VRA allow clinics to keep the center screen simple and add consistency to the test. When to Recheck Your VRA Equipment You should review your VRA system if you notice: • Delayed activation • Dim or inconsistent displays • Loose mounts or shifted positions • Software not responding correctly These checks help maintain accurate and repeatable VRA sessions. Summary A VRA system does not require formal calibration, but proper setup, clean activation timing, and consistent visibility are essential for reliable Visual Reinforcement Audiometry. Using well designed VRA equipment ensures accurate responses and smooth pediatric hearing evaluations. Does a VRA System Need Calibration?

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