Visual Reinforcement Audiometry (VRA)

What is it and how does it work?

Visual Reinforcement Audiometry (VRA) is a behavioral hearing test used to evaluate hearing sensitivity in infants and young children, typically between 6 months and 2–3 years of age, by conditioning a head-turn response to sound using visual reinforcement.

Rather than asking a child to respond verbally or press a button, VRA relies on a natural behavioral response. When a child hears a sound, they learn that turning toward it results in something visually interesting. Over time, that association allows clinicians to estimate hearing thresholds based on consistent responses.

VRA is most often used with children between approximately 6 months and 2 to 3 years of age, although developmental level is often a more important factor than age alone.

Flex Visual Reinforcement Audiometry Systems Conditioning

Why is VRA used in pediatric audiology ?

Standard hearing tests require cooperation, instruction following, and sustained attention. For very young children, that expectation simply is not realistic.

Visual Reinforcement Audiometry was developed to bridge that gap. By pairing sound with visual reinforcement, clinicians can collect meaningful hearing information during a critical window for speech and language development.

For many children, VRA provides the first reliable behavioral data in the diagnostic process.

How Visual Reinforcement Audiometry Works

At its core, VRA is a conditioning task.

A sound is presented, typically through speakers or earphones. When the child responds appropriately, a visual reinforcer is activated. Over repeated trials, the child learns that responding to sound leads to a visual reward.

From there, the clinician can adjust stimulus levels and frequencies to estimate hearing sensitivity.

VRA being performed at the University of North Carolina

A Typical VRA Session includes:

Presentation of calibrated auditory stimuli
Conditioning the child to associate sound with visual reinforcement
Observing head turns or eye movements toward the sound source
Reinforcing correct responses
Gradually reducing stimulus levels to identify response thresholds

The process is flexible and adapts to the child’s attention span and engagement on a given day.

Types of VRA Testing

Sound-field VRA

Sound-field testing uses speakers positioned to the left and right of the child. This approach measures the response of the better-hearing ear and is commonly used early in the evaluation process.

Ear-Specific VRA

When a child tolerates earphones or insert phones, ear-specific information can be obtained. This allows clinicians to evaluate each ear independently and is preferred whenever possible.

Below is a real-world example of visual reinforcement audiometry performed in a pediatric clinic.

Equipment used in Visual Reinforcement Audiometry

Visual reinforcement may take different forms:

Modern VRA systems often allow clinicians to choose or adjust reinforcement types based on the child’s age, preferences, or attention level. A VRA setup typically includes:

An audiometer
Speakers or earphones
Visual reinforcers positioned to the left and right
A control interface or remote
Appropriate cabling and accessories

Many newer systems use software-based control, allowing clinicians to customize how reinforcement behaves during a session rather than relying on fixed hardware responses.

Does VRA Require Calibration?

Yes and no. The actual VRA reinforcers do not require any formal calibration because they are not putting out any kind of calibrated stimuli utilized for testing hearing threshold. They are simply the reward stimulus for after the patient has heard oand recognized a calibrated stimuli from the audiometer. It is important to remember that although the VRA does not require acoustic calibration, consistent placement and predictable behavior are important to reliable testing.

With that said, in order to properly perform VRA testing, a calibrated audiometer is required to ensure accurate threshold detection.

Benefits of Visual Reinforcement Audiometery

VRA allows clinicians to:

Obtain behavioral hearing information in very young children
Perform testing in a non-invasive, child-friendly way
Estimate frequency-specific thresholds
Adapt testing strategies based on engagement and development

For many pediatric patients, VRA represents the most practical balance between accuracy and cooperation.

Limitations to keep in mind

Like all behavioral tests, VRA has limitations.

Results depend on the child’s attention, motivation, and conditioning. Sound-field testing does not provide ear-specific data, and fatigue or loss of interest can limit session length. For these reasons, clinicians often combine VRA with other test methods using combinations systems and emphasize flexible system design. For patients who struggle with traditional visual reinforcement audiometry, VROCA testing offers an operant, visually reinforced alternative.

Child reacting to Flex Visual Reinforcement Audiometry Monitor

When VRA is the preferred approach

Visual Reinforcement Audiometry is typically used when:

A child is too young for conditioned play audiometry
Behavioral observation alone is insufficient
Behavioral data is needed to cross-check objective results
Ear-specific thresholds are possible but not guaranteed

Professional organizations such as the American Academy of Audiology and the American Speech-Language-Hearing Association recognize VRA as a standard behavioral assessment method in pediatric audiology.

Choosing a VRA System

When evaluating VRA equipment, clinicians often look beyond basic functionality. Considerations commonly include:

Ease of setup and room integration
Flexibility of reinforcement options
Compatibility with existing audiometers
Consistency and reliability during testing
Ability to adapt to different patient behaviors

Systems that allow customization during the session can reduce frustration and improve efficiency for both clinicians and families.

In Summary

Visual Reinforcement Audiometry plays a critical role in pediatric hearing assessment. By pairing sound with visual reinforcement, VRA allows clinicians to collect meaningful behavioral data during early stages of development when traditional testing is not possible.

As VRA technology continues to evolve, modern systems increasingly focus on flexibility, adaptability, and clinician control, all with the goal of improving test reliability and the overall experience for children and parents alike.

FAQ Review

What age is visual reinforcement audiometry used for?

Visual reinforcement audiometry is typically used for infants and young children between approximately 6 months and 2.5 years of age. It is most effective once a child is developmentally able to localize sound and turn their head toward a visual stimulus. The exact age range may vary depending on the child’s developmental level and attention skills.

How does visual reinforcement audiometry work?

During visual reinforcement audiometry, a child is conditioned to turn toward a visual stimulus, such as a lighted display or animated image, when a sound is presented. When the child correctly responds to the sound, the visual reinforcement is activated as a reward. Clinicians observe these head-turn responses to determine hearing sensitivity across frequencies and ears.

Is visual reinforcement audiometry reliable?

Yes, visual reinforcement audiometry is considered a reliable and widely accepted behavioral hearing test when performed correctly. Reliability depends on factors such as patient engagement, clinician experience, and proper test setup. VRA is commonly used in pediatric audiology as part of comprehensive hearing assessment.

How long does a VRA hearing test take?

A typical visual reinforcement audiometry session lasts 15 to 30 minutes, depending on the child’s cooperation and the information being gathered. Testing may be shorter or longer based on attention span, age, and whether additional assessments are needed. Breaks are often incorporated to maintain engagement.

What is the difference between VRA and play audiometry?

Visual reinforcement audiometry is generally used for younger children and relies on head-turn responses reinforced by visual stimuli. Play audiometry is used for older toddlers and preschool-aged children who can perform a task, such as placing a block in a bucket, when they hear a sound. Both are behavioral tests, but they are matched to different developmental stages.