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Pediatric Visual Reinforcement Audiometry (VRA)



Visual reinforcement audiometry (VRA) is a test that allows an audiologist to assess hearing in infants and toddlers too young for normal tests. VRA relies on behavioral conditioning to train very young kids to respond to sounds. It is designed for children aged 6 months to around 2 to 3 years old. 

Expanded Overview

VRA uses a machine called an audiometer to test a child's hearing threshold levels. Standard pure tone audiometers use headphones and a feedback button, so they are not practical for young kids. VRA replaces the headphones with earphones (usually with foam tips) or sound field speakers. Visual reinforcers such as video animations or lighted toys are placed 90-degrees to each side of the patient to "train" the child to look toward the direction of the sound.

Tests and Diagnosis

Video reinforcement audiometry uses a machine called an audiometer to assess a child's hearing threshold levels. A standard pure tone audiometer uses headphones and a feedback button so a patient can respond to different sound levels. Because the device is too complex for very young children, VRA usually includes the following modifications:

  • Earphones: Young children don't respond well to normal headphones, so VRA relies on transducers inserted into the child's ears. They may have either foam tips or personal ear molds made for your child's ears. Earphones may also use bone conduction vibration for improved accuracy.
  • Sound field speakers: Like headphones, earphones may be uncomfortable for certain infants and toddlers. In some cases, the audiologist may rely on "surround sound" speakers to perform the tests. 
  • Visual reinforcers: Because very young children can't respond to sounds by clicking a button, VRA uses visual reinforcers instead. These can be video-based or made up of animated toys placed in dark Plexiglas boxes located 90-degrees to each side of the child. The boxes are lit to elicit a head turn associated with a sound source.
  • While the child sits upright on a parent or caregiver's lap in a soundproof room, the audiologist plays a tone or some other sound to one of the child's ears. At first, the audiologist lights up the boxes in conjunction with the sound. This "trains" the child to respond by shifting her eyes or turning her head toward the sound source. Once a child understands what to do, the audiologist can "reward" the child by briefly delaying the visual stimuli.

During the test, the audiologist reduces the intensity of both the sound and the stimuli until the child's minimum hearing threshold is reached. Tests continue using different frequencies until the audiologist has a complete set of data about your child's hearing in both ears.


Visual reinforcement audiology (VRA) measures hearing sensitivity in infants and young toddlers aged 6 months to 3 years. Rather than responding using a feedback button, very young children are "trained" to respond to sounds using visual stimuli.

How Visual Reinforcement Audiometry Works

The audiologist uses video animation or lights up a toy hidden in a dark Plexiglas box in conjunction with a sound. Once the child understands the test, this "reinforcer" acts as a reward when he shifts his eyes or turns his head toward the sound.

Visual reinforcers are located at eye level, 90 degrees to either side of the child's head. The audiologist reduces the intensity of both the sound and visual stimuli until she determines your child's minimum hearing threshold. She will continue using different frequencies in both ears until she has a complete set of data for your child.

What VRA Measures

An audiologist can use VRA to measure your child's hearing sensitivity. Hearing thresholds are usually plotted on a graph called an audiogram. An audiogram shows audible thresholds over different frequencies. The data from the audiogram can help the audiologist to determine both the degree and type of hearing loss your child has, if any.

What to Expect

In a perfect world, your child will respond well to VRA testing. Unfortunately, infants and very young kids can become easily distracted or bored. Frequent breaks are often needed to keep kids interested and on task. Kids who become bored by visual stimuli may cooperate longer if the parent provides social reinforcement instead. Social reinforcement might include clapping or cheering for correct responses.

Also, some kids won't be able to use the earphones. In those cases, the audiologist will rely on sound field speakers instead. With speakers, though, the audiologist won't be able to measure ear-specific thresholds.


What is visual reinforcement audiometry?

Visual reinforcement audiometry, or VRA, is a type of pure tone hearing test. It uses visual stimuli in conjunction with sounds to get the attention of young patients.

Who needs VRA?

Standard hearing tests that use headphones and feedback buttons are too complex for very young kids. VRA is used on infants and children aged 6 months to between 2 and 3 years.

Where does visual reinforcement audiometry take place?

Visual reinforcement audiometry requires specialized devices and a soundproof room. It is typically performed by an audiologist in an ear, nose and throat (ENT) clinic.

What equipment is used for VRA?

VRA uses a standard audiometer modified with earphones or sound field speakers. Visual reinforcers such as video animations or lighted toys are placed 90-degrees to each side of your child to "train" her to look toward the direction of a sound.

What does visual reinforcement audiometry test for?

An audiologist uses VRA to measure your child’s hearing thresholds over several frequencies. Children with hearing loss can be referred to an appropriate specialist.

What happens during VRA testing?

The child sits upright on a parent or caregiver’s lap in a soundproof room. The audiologist will trigger visual stimuli in conjunction with sounds to collect the data.

What if my child becomes distracted during the tests?

Young children often become distracted or bored during VRA testing and need frequent breaks. Sometimes, social reinforcement such as clapping or cheering can be used to complement visual reinforcers.

Are there drawbacks to visual reinforcement audiometry?

In addition to lacking attention spans, some kids won’t tolerate the earphones. In that case, the audiologist will rely on “sound field” testing, which isn’t ear-specific.


This page presents the entire spectrum of VRA testing in children.
The British Association of Teachers of the Deaf

This page has a very detailed presentation of hearing assessment guidelines.
American Academy of Audiology

For a general description of VRA in children, see
Center on Human Development and Disability, University of Washington

This page offers descriptions of hearing tests in children, including VRA
National Acoustic Laboratories

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