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Learn how to select a reliable, flexible VRA system for pediatric audiology. Flex VRA supports integration, visual reinforcers, & seamless clinic workflows. Not all VRA systems are designed the same. As pediatric hearing evaluations have evolved, the expectations for VRA equipment have changed, as well. Clinics now look for systems that are reliable, flexible, and easy to use while supporting consistent patient responses. Here are the key factors to consider when selecting a VRA system. 1. Reliability and Timing A VRA system must respond instantly when the clinician triggers a reinforcer. Any lag or delay makes the test harder and can disrupt the child’s attention. Software driven systems tend to offer faster activation times compared to older mechanical VRA boxes. For instance, Flex VRA utilizes a paired zoned 433 MHz radio frequency wireless transmission protocol to send signal from the remote control to the reinforcer. This means that the lag time between button press to activation would be similar to that of a lag time of a wireless keyboard to your computer...instantaneous. Moreover, because each system's transmission is zoned between paired reinforcers, there is no overlap from other systems or interference from any higher frequency RF signals. 2. Quality of Visual Reinforcers Children respond best to bright, engaging, but not overstimulating content. Look for a VRA system that allows you to customize content and adjust how exciting the reinforcer should present. Features like House Rules in Flex VRA let you control how the center monitor behaves so you get clearer head turns, and more focus on the left and right reinforcers. 3. Integration With Audiology Equipment The best VRA equipment connects smoothly with your audiometer, remote, or clinic workflow. Consider whether the system supports: • Remote control activation • Audiometer integration (GSI Audiostar Pro, Interacoustics EVO and Affinity) • PC or software-based triggering (Madsen Astera by Natus, MedRx Avant, Inventis) Seamless integration allows clinicians to stay focused on the patient instead of the equipment. And Flex VRA includes all three of those options with every Flex VRA shipped at no extra cost . 4. Durability and Build Quality VRA equipment is used daily in pediatric settings. Look for a system designed to withstand constant use, movement between rooms, and long clinical schedules. 5. Versatility and Future Features Clinics benefit from VRA systems that grow with them. Software based systems often release updates, new reinforcers, and feature improvements that extend the life of the system without requiring new hardware. 6. Support and Service Make sure the company behind your VRA system offers reliable support. Pediatric audiology depends on smooth daily operation, so access to fast assistance matters. By evaluating these factors, clinics can choose VRA equipment that improves workflow, supports accurate Visual Reinforcement Audiometry, and creates a better experience for both the child and family. Choosing the Right VRA System for Your Clinic

Flex VRA ® is the only VRA system that directly integrates simultaneous video reinforcement and traditional toy reinforcement with the GSI AudioStar Pro and Interacoustics EVO audiometers . Simultaneous Video And Toy Control Included with Every Flex VRA® System No additional integration modules required Why This Matters Most audiometers only provide a limited number of VRA control buttons. Flex VRA® is the only platform that combines both video and toy reinforcement into a single audiometer-controlled workflow. Clinicians can instantly transition between reinforcement types using remote toggling, allowing greater flexibility based on patient attention and testing needs. GSI (Grason-Stadler) Audiostar Pro Flex VRA® enables direct control of both video reinforcement and toy reinforcement simultaneously with remote toggling. Using the dedicated VRA control buttons above the attenuator dial and a remote control, clinicians can operate up to six reinforcers directly from the audiometer, creating a seamless pediatric testing workflow. This exclusive Flex VRA® integration was designed specifically for modern pediatric audiology workflows using the GSI AudioStar Pro. Interacoustics EVO Flex VRA® directly integrates with Interacoustics EVO, providing native control of simultaneous video and toy reinforcement during VRA testing through the use of remote toggling. Clinicians can operate left and right toy and video reinforcement configurations directly within Interacoustics Suite, allowing a fully integrated pediatric audiology workflow. Only Flex VRA® combines simultaneous video VRA and traditional toy VRA into a single integrated audiometer-controlled platform.

The site exists to show Flex VRA customers how to select the appropriate boot device on older Flex VRA systems. Flex VRA Tech Note: Not booting to proper boot device Download Tech Note Overview Issue Flex VRA turning on to a black screen that says the VRA cannot find the proper boot device. Cause The VRA is not booting to the correct boot device and it cannot find the correct Solid State Drive to launch the operating system. Resolution Confirm the user is using a Generation 2 remote control by having them identify the QR code on the bottom of the remote. Have them turn the device off by pressing the silver power button under the left-hand side of the screen behind the screen bezel. Find the “Toy” button on the remote control (the VRA sees this button as an ESC key). Press the power button again to turn the monitor on and immediately start tapping the “Toy” button until they see a blue and gray BIOS screen. Use the red right arrow on the remote control to navigate to “Boot” in the menu. Use the lights off button (icon on the bottom of the white circle on the remote control) to arrow down to “Boot Option 1”. Press the center green circle on the remote control (ENTER) to see your boot options and scroll to the “Windows Boot Manager” device and press the green circle again. Arrow over to Save and Exit and press the green circle button on the remote control to reboot. Note: If you do not see an option for “Boot Manager Device”, there is an issue with SSD card and it would need to be replaced. Please contact Flex VRA directly to coordinate a resolution.

Enhance VRA testing with the Flex Screen—Flex VRA's remote-controlled privacy screen for distraction-free audiology sessions. Custom sizes available. Block distractions. Improve results. Better visual control for more consistent pediatric testing. Get the Brochure Installation Guide Flex Cover configurations FLEX-WINDOWCOVER Electric rolling cover 3 ft x 3 ft Magnetic mounts Wireless remote control USB C charging cable $800 USD FLEX-DOORCOVER Electric rolling cover 6 ft x 18 in Magnetic mounts Wireless remote control USB C charging cable $800 USD 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. Includes Includes Operator's Side Patient Side Be heard, not seen. Visual control during pediatric testing. Battery-powered window cover for placement anywhere No tools required — install in seconds Custom sizing for individual booths Rechargeable motor for long-term, hassle-free use Wireless control from anywhere in the booth Simple Installation Specifications Wireless Communication Protocol 433 MHz Radio Frequency Power Internal Battery Battery Life 6-12 Months depending on use Charging Power USB C Dimensions Window: 3ft x 3ft, Door: 5 ft x 18 in Warranty Period 2 years

Discover Flex VRA — a modern Visual Reinforcement Audiometry system designed for pediatric clinics. Flexible, clinician-led, and trusted in 1000+ clinics worldwide. Flex Halo For years, pediatric audiologists had to choose. Toy? Video? Both? Now the choice is clear. Literally. Starting at $3,750 USD See it in action "I absolutely LOVE Flex VRA! Complete game-changer." Kelly Jobe, Au.D., Stephen F. Austin University Designed and assembled in Austin, Texas • Distributed worldwide • Prices shown in USD. International pricing will vary based on shipping, duties, taxes, and local installation fees. Flex VRA Dynamic Video VRA Starting at $2,450 USD Discover Flex VRA Flex Toy Toy VRA thoughtfully updated Starting at $1,250 USD Discover Flex Toy Flex Toy Flex Halo Flex VRA Which VRA system is right for you? Compare Flex VRA platforms Good Traditional Toy Reinforcement Better Video, Lights, and Custom Reinforcement Best All reinforcement modes in one system Video, 3D toy, lights, and custom content Static reinforcer with changing LED light patterns on each activation Ideal for clinics seeing a low amount of pediatric patients Ideal for any booth size Starting at $1,250 USD See it in action Videos of animals, cartoons, toys and custom content with LED light bar Ideal for a mix of pediatric and non-pediatric patients Ideal for any booth size or mobile Starting at $2,450 USD See it in action High-contrast video, lifelike changing 3D toy, custom content and LED lightbar Ideal for high volume or exclusively pediatric patients Ideal for booths 6' x 6' or larger Starting at $3,750 USD See it in action Not sure which VRA system is right for you? You can mix up different reinforcers to accommodate your specific booth space and budget. Unsure what would be best for your clinic? Request a quick demo or Contact us to discuss . Flex Window Cover Visual control for sound booths. Keeps the visual environment controlled during testing. $800 USD Discover Flex Window Cover Accurate sound where it matters. Flex Speaker A reliable speaker option commonly used in VRA testing environments. $650 USD Discover Flex Speaker Trusted by 1000+ pediatric clinics worldwide

Flex Speaker is a passive audiology sound field speaker designed for pediatric hearing testing, VRA, and audiometer-based sound booth environments. Compatible with leading audiometers. Audiology Sound Field Speakers for VRA and Audiometers Flex Speaker is a high-performance passive speaker system designed for sound field testing and sized to match the Flex VRA systems . Brochure Installation Guide $650 USD a pair 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. High-Performance Audiology Sound Field Speakers Flex Speaker is a passive audiology sound field speaker designed specifically for pediatric hearing testing, visual reinforcement audiometry (VRA) , and audiometer-based sound booth environments. Unlike general-purpose speakers, Flex Speaker is purpose-built for clean installation, repeatable placement, and compatibility with common clinical audiometers including GSI Audiostar Pro and Interacoustics EVO . Features include: Passive sound field speakers for clinical audiology Optional external amplifier (part number FLEX-AMP, $500) Magnetic backing for fast booth installation Includes audiometer speaker adapters Includes tape measure for consistent speaker positioning Low-profile mounting with no brackets required Compatible with amplified audiometers Designed for corner or flat-wall placement Mount. Secure. Align. Wire. Connect. Install cleanly and maintain consistent speaker positioning across audiology testing environments. Audiology Sound Field Speaker Installation Walkthrough Seamless Audiometer Integration Includes speaker adapters for common clinical audiometers used in pediatric audiology and sound field testing. Interacoustics EVO Speaker Adapter (2 1/4" mono to terminal) GSI Audiostar Pro Speaker Adapter (5 pin DIN to terminal) Designed for Pediatric Audiology & Sound Field Testing Purpose-built for pediatric sound booths, VRA testing , and clean audiometer speaker integration. Integrated pediatric VRA setup Side-profile, flush-mounted Front view, clean clinical install Frequently Asked Questions What are sound field speakers used for in audiology? Sound field speakers are used in pediatric audiology and hearing testing environments to present tones, speech, or stimuli through speakers rather than headphones or insert earphones. They are commonly used for visual reinforcement audiometry (VRA) and other pediatric sound field testing procedures. Which audiometers are compatible with Flex Speaker? Flex Speaker is a passive audiology sound field speaker compatible with amplified audiometers that support wired speaker connections, including systems like the Interacoustics Equinox and Otometrics Astera. Included adapters support the GSI Audiostar Pro and Interacoustics EVO. If your audiometer does not have an internal amplifier for sound field testing, a dedicated amplifier can be purchased from Flex VRA through your local distributor . Not sure if your audiometer needs amplification? Ask us! Does the Flex Speaker have to be magnetically mounted? No. In fact, we recommend that at least one screw is used to secure the speaker to the soundbooth wall for long term placement. Each Flex speaker has up to 4 predrilled mounting holes in the cabinet to allow for low-profile and secure mounting. Does the Flex Speaker require calibration? Yes. Calibration by a certified audiometric technician (such as e3 Diagnostics) is recommended to ensure accurate sound field testing performance within your clinical environment. What are the dimensions of the Flex Speaker? 13.5 inches (W) x 5 inches (W) x 15 inches (H)

Read the Flex VRA Privacy Policy and learn how we collect, use, and protect your information. Privacy Policy Flex VRA (“Flex VRA,” “we,” “us,” or “our”) values your privacy. This Privacy Policy explains what information we collect when you visit our website (the “Site”), contact us, or purchase our products and services, how we use it, and the choices you have. If you have questions, contact us at sales@flexvra.com . 1) Information We Collect Information you provide to us We may collect information you choose to share, including: Contact details (name, email, phone number, organization, job title) Inquiry details (messages submitted through forms, emails, or chat) Order and shipping details (billing/shipping address, purchase history) Support details (device information you share with support, troubleshooting notes, photos/videos you provide, and related communications) Marketing preferences (newsletter signups, communication preferences) Information collected automatically When you use the Site, we may automatically collect: Device and browser data (IP address, browser type, operating system, device identifiers) Usage data (pages visited, time on site, referring page, clicks) Approximate location (derived from IP address) Cookies and similar technologies We use cookies and similar technologies to operate the Site and understand usage. 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You can opt out of certain interest-based advertising through industry opt-out tools (availability varies by region). 5) Email and Marketing Preferences You can opt out of marketing emails at any time by using the unsubscribe link in the email or by contacting us at [privacy@flexvra.com ]. Even if you opt out of marketing, we may still send non-promotional messages, such as order updates or support communications. 6) Data Retention We keep personal information as long as needed for the purposes described in this Policy, including to provide services, comply with legal obligations, resolve disputes, and enforce agreements. Retention periods vary depending on the type of information and why we collected it. 7) Security We use reasonable administrative, technical, and physical safeguards designed to protect personal information. No method of transmission or storage is 100% secure, and we cannot guarantee absolute security. 8) Children’s Privacy The Site is intended for a general audience and is not directed to children under 13. We do not knowingly collect personal information from children under 13. If you believe a child has provided personal information to us, contact us and we will take appropriate steps to delete it. 9) Your Privacy Rights Depending on where you live, you may have rights regarding your personal information, such as: Accessing the personal information we hold about you Requesting correction of inaccurate information Requesting deletion of certain information Objecting to or restricting certain processing Withdrawing consent (where processing is based on consent) To make a request, contact [privacy@flexvra.com ]. We may need to verify your identity before fulfilling certain requests. “Do Not Track” Some browsers offer “Do Not Track” signals. Because there is no consistent industry standard, our Site may not respond to these signals. 10) International Visitors If you access the Site from outside the United States, your information may be processed in the United States or other locations where we or our service providers operate. These locations may have different data protection laws than your jurisdiction. 11) Third-Party Links The Site may link to third-party websites or services. This Privacy Policy does not apply to those third parties. We encourage you to review their privacy policies. 12) Changes to This Policy We may update this Privacy Policy from time to time. The “Last updated” date above shows when it was last revised. Changes take effect when posted on this page. 13) Contact Us Flex VRA 100 E. Whitestone Blvd., #160 Cedar Park, TX 78613 Email: sales@flexvra.com Phone: 512-254-9953

Learn how to prepare your child for a pediatric hearing test with simple tips that improve comfort, participation, and testing success. Preparing Your Child for a Hearing Test Top 5 Parenting Tips for a Successful Pediatric Hearing Test A pediatric hearing test can feel unfamiliar for both parents and children. This guide explains what to expect during a Visual Reinforcement Audiometry (VRA) appointment and how to help your child stay calm, engaged, and ready for a successful visit. Tip #1: Pediatric Hearing Tests Are Designed to Be Comfortable A visit to a clinic can be anxiety-inducing for both children and adults. Pediatric hearing tests, including Visual Reinforcement Audiometry (VRA) , are designed to feel more like a fun game than a medical procedure. While your child plays and responds to sounds, the audiologist gathers valuable hearing information. In most pediatric hearing tests, you also will not be separated from your child during testing. In many cases, testing can be completed with you in the room or even holding your infant or toddler on your lap. Important Parent Tip: If you are able to be with your child during the test, it's extremely important you don't participate in any way during these games. Even a head turn or gentle nudge during the test can compromise the accuracy of a result. Your job is to be a steady and uninvolved presence during the test unless the audiologist specifically asks you to intervene. Tip #2: Rested, Fed, and Relieved The length of a pediatric hearing evaluation is heavily dependent on the cooperation of the child. In order to reduce as many factors as possible that may interfere with your child’s cooperation, make sure your child is not coming into the appointment hungry, tired, or possibly needing to potty mid-way through the test. If your child has a comfort object (stuffed animal, blanket, small toy), it's also a good idea to bring it along to increase the chance of success during the hearing evaluation. Important Parent Tip: If timing of your appointment is flexible, try not to schedule during nap time. Ideally, plan for a time right after nap time with a snack right before the appointment so that they are primed to be comfortable during the visit. Tip #3: Avoid Screen Time and Overstimulation Before the Appointment Testing your child’s hearing depends heavily on engagement and attention. Pediatric audiologists use Visual Reinforcement Audiometry (VRA) , toys, games , lights, and videos to help children remain interested throughout the evaluation. To help make the transition easier, try to avoid highly stimulating screen time immediately before the appointment. Children who are focused on returning to a favorite show or device may initially have more difficulty engaging during testing. Important Parent Tip: If your child has specific shows or interests that will better engage them during the test, let your audiologist know prior to your visit. They may have a VRA system that allows them pre-load content specifically for your child so that they are as excited about the hearing test as they would be watching at home. Tip #4: Bring Your Enthusiasm Pediatric audiologists work hard to create positive reinforcement and an encouraging environment during testing. While they are experts in evaluating hearing, parents still play an important emotional role throughout the appointment. Encouragement from a trusted parent can help children feel more confident, engaged, and willing to participate during testing. The goal of the appointment is not for your child to perform every task perfectly, but to help the audiologist understand how they respond during testing. The more encouraged they feel, the more likely they are to give it their best effort. Important Parent Tip: Encouragement and coaching are different during a hearing test. Praising your child after they complete a task is very different from helping guide them toward a response during testing. Tip #5: After the Visit, Focus on the Positive Hearing evaluations for children are not always a one-time visit. Especially if a follow up visit is warranted, you want to make sure your child associates hearing tests as fun, and just as importantly, trusts that their audiologist is not a scary doctor to visit. This can make follow-up appointments even more effective as your child learns who the audiologist is, what is involved in a visit and that there is nothing to be afraid of. Your positive reinforcement of the experience after the visit can be just as valuable as the tools the audiologist utilizes during the test if a follow-up visit is required. Important Parent Tip: Even if the appointment was difficult or your child did not immediately connect with the audiologist, try to emphasize the positive parts of the experience afterward. This can help prevent anxiety or fear from carrying over into future hearing evaluations. Final Thought Pediatric hearing evaluations work best when children feel comfortable, engaged, and supported throughout the process. A little preparation before the appointment can make a major difference in helping your child have a successful experience. If you and your child would like to learn more about what to expect during a hearing evaluation, check out our Flex Dog animated introductory videos to learn more about the process in a fun and child-centric way. Flex Dog Videos

Free videos to help children prepare for hearing tests. Improve cooperation for VRA and CPA. Download and use in your clinic instantly. Knowing What To Expect Makes Hearing Tests Easier Flex Dog videos help kids understand what to expect at hearing tests so they can arrive more comfortable, confident, and ready to participate. Used in audiology clinics. Built into every Flex VRA. No Captions What Happens At A Child's Hearing Test Helps children understand exactly what will happen during a pediatric hearing test, reducing fear and improving cooperation during audiology appointments. Get Video File Want more free videos like this? Click here to give this video a Like on YouTube so we can track what content is most useful in clinics and create more of it. Captions No Captions The Listening Game (VRA) Introduces the listening game so children are ready to respond during Visual Reinforcement Audiometry (VRA) testing. Get Video File Want more free videos like this? Click here to give this video a Like on YouTube so we can track what content is most useful in clinics and create more of it. Captions No Captions Toy in the Bucket Game (CPA) Prepares children for Conditioned Play Audiometry (CPA) by showing the exact task they’ll perform during testing. Get Video File Want more free videos like this? Click here to give this video a Like on YouTube so we can track what content is most useful in clinics and create more of it. Captions No Captions Picture Game (SRT/WRS) Prepares children for pediatric speech hearing tests . Perfect for preparing children (and parents!) for audiology appointments. Get Video File Want more free videos like this? Click here to give this video a Like on YouTube so we can track what content is most useful in clinics and create more of it. Captions No Captions Oakley Get's His First Hearing Aid Introduces children to the experience of getting a hearing aid and the importance of consistent daily use. Inspired by Dr. Lisa Rylant, Au.D's children's book, Oakley Gets a Hearing Aid. Learn more about Oakley and the child-friendly resources she provides for pediatric patients at meetoakly.com . Get Video File Want more free videos like this? Click here to give this video a Like on YouTube so we can track what content is most useful in clinics and create more of it. Captions Why Preparing Children for Hearing Tests Matters A pediatric hearing test can be unfamiliar and sometimes overwhelming for young children. When a child doesn't know what's going to happen, it can lead to hesitation, inconsistent responses, or an incomplete test. When children know what to expect, they participate more readily, respond more consistently, and stay engaged throughout the appointment. For Visual Reinforcement Audiometry (VRA) and Conditioned Play Audiometry (CPA) especially, a child's responses directly impact the accuracy of the results. A few minutes of preparation can mean fewer delays, a smoother session, and clearer answers for everyone involved. These videos are used in audiology clinics, and built directly into Flex VRA. Download a clinic-ready poster patients can scan to watch these videos

Peer-reviewed research and published literature referencing modern, software-enabled visual reinforcement audiometry approaches, including Flex VRA. Relevant Research and Literature If you are conducting or planning research related to visual reinforcement audiometry, conditioned play audiometry, or operant control approaches, and would like to discuss resources or technical considerations, you are welcome to get in touch . Concepts related to modern, software-enabled visual reinforcement audiometry have been referenced in published research, including: Bonino AY, Hemann A, Mood D, Kay E, Pancoast ES, Sommerfeldt KK. Visual reinforcers designed for children with developmental disabilities. Journal of Early Hearing Detection and Intervention. 2021 Apr 22;6(1):69–76. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC8061901/ This scoping review examines factors that influence the effectiveness and optimization of visual reinforcement audiometry in pediatric hearing assessment. Visram, A., Jackson, I., Almufarrij, I., Stone, M., & Munro, K. (2024). Optimisation of visual reinforcement audiometry: a scoping review. International Journal of Audiology. Optimisation of visual reinforcement audiometry: a scoping review This document presents the British Society of Audiology’s recommended procedure for visual reinforcement audiometry, outlining clinical standards for test setup, execution, and interpretation. British Society of Audiology. Recommended Procedure: Visual Reinforcement Audiometry. Visual Reinforcement Audiometry RP by the BSA, January 2024. https://www.thebsa.org.uk/wp-content/uploads/2024/01/OD104-37-BSA-RP-Visual-Reinforcement-Audiometry-v2.pdf This presentation hosted by Audiology Online covers the new tools and strategies for Visual Reinforcement Audiometry available from Flex VRA. New Tools and Strategies for Visual Reinforcement Audiometry | 39687 Course 39687

Learn how Flex VRA was built to improve pediatric audiology testing through clinician collaboration, real-world feedback, and modern reinforcement methods. Steve Smith with his two assistant (to the) regional managers. We build solutions for the parents of the child being tested. If we provide tools for audiologists that help give those parents answers about their child’s hearing, we’ll always have a customer. Steve Smith, Founder About Flex VRA Listening to clinicians from the start Flex VRA was built to support how pediatric audiology is practiced today, not how it was practiced years ago. From the beginning, our focus has been on helping audiologists maintain attention, reduce distraction, and adapt testing environments to the needs of each child. Founded in 2018 by Steve Smith, Flex VRA began as a response to a simple question from the field: Is there a better way to control what appears on a VRA screen during testing? That question led to a prototype that allowed clinicians to tailor content and environment in real time to improve engagement and test efficiency. The positive response from audiologists shaped what Flex would become. Each request from clinicians became an opportunity to improve. Features like user-uploaded content, audiometer integration, and expanded testing modes were added in direct response to real-world use. That approach continues to guide how Flex VRA is designed today. Built through collaboration with clinicians Today, Flex VRA supports hearing tests in over 1,000 clinics. That growth has been driven by close collaboration with audiologists and a commitment to listening, adapting, and improving. Each feature added to Flex VRA reflects real-world feedback from clinicians working with pediatric patients every day. By focusing on usability, flexibility, and engagement, Flex VRA has evolved alongside the needs of the clinics it serves. Questions about Flex VRA? If you’d like to learn more or discuss how Flex VRA fits into your clinic, we’re happy to help. Contact Flex VRA

Learn about what Visual Reinforcement is and why it is so important in audologic testing. 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. 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: Animated or video-based displays Mechanical or illuminated toys 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. 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.