Comparing Toy and Screen VRA Systems

10 mins
09 June 2021


This video explores some of the recent technological advances in the field of visual reinforcement audiometry (VRA) and discusses the benefits of different types of visual reinforcer options. Find the full transcript below.


Traditional VRA systems

The original and classic VRA system involves using a box or series of boxes containing a puppet or toy (Figure 1).


Green toy frog behind smoked Perspex in a black box and illuminated with lights located inside the box.
Figure 1: VRA201 box.


This toy is screened behind smoked Perspex to make it invisible to the child in the clinic room. The tester has a switch, button, or foot pedal to illuminate the toy when required. The most advanced of these systems also have the option to animate the toy to make it more stimulating and rewarding to the child.


Drawbacks to VRA toy systems

There were and are some drawbacks to the VRA toy systems.


1. Limited selection of toys

Each system generally has a limited selection of one to three toys available, which can lose their effectiveness as the test duration goes on and the child grows used to seeing the same reinforcers each time.


2. Not interesting to older children

The toys are generally very effective for the younger end of the VRA age range but often insufficiently interesting to older children and for those with complex needs. Some clinics began to incorporate other forms of visual reinforcers such as flashing or spinning lights.


3. Old-fashioned

As the technological world has advanced and there is an increased number of screens accessible to young children through smartphones, tablets, and television, the toy system has begun to appear somewhat old‑fashioned. Many parents say that their children are more responsive to television and favored cartoons.


Modern VRA systems

To meet the increasingly obvious need for a visual reinforcer system that could meet the modern screen‑motivated child, a number of systems have been developed in recent years. Some early examples were quite basic, homemade systems. But these have now evolved into user-friendly devices perfect for clinical use such as the VRA Screen (Figure 2) and VRA Pure solutions from Interacoustics.


Young boy sat in a white chair on a blue cushion inside a booth. He’s looking and pointing toward a computer screen to his right that is showing a smiling animated lion. The VRA Screen computer and a speaker are located on each side of the computer screen.
Figure 2: VRA Screen.


A digital screen system typically involves software loaded onto either your audiometer PC or a standalone PC. The benefit of a standalone VRA PC is that it can work with a standalone audiometer or alongside a PC‑based audiometer, making it a very flexible solution.

TV or computer screens are used to display the visual reinforcer to the child via a control system such as a mouse or a keyboard. Digital VRA systems can also work alongside toy systems to provide both options as available reinforcers, which is useful in case certain children prefer and respond better to one type over the other.


Benefits of screen VRA systems

One of the advantages of using a digital screen VRA solution is the option to use both still and static images as well as moving video files. However, by far the most exciting advancement in the field of VRA, which is made possible by using a screen VRA system, is the option to customize the visual reinforcers. This allows almost endless possibilities as well as the opportunity to tailor the reinforcers used to the child's particular interests and motivations.


Combining both types

Some clinicians can be hesitant about how well screen reinforcers work for the younger end of the VRA age range. The ideal solution is to have a combined system that offers the option to select between screen reinforcers or toy reinforcers.

Using high‑contrast black and white images and videos has been found to be very effective in this younger age population. Having the possibility to move the screens closer to the child can also be beneficial for these younger children.


Important considerations

With a number of different screen VRA solutions on the market, I would encourage you to consider the important features that make for a good screen VRA system.


1. Is it fast and responsive?

One of the most important things is that the system must be fast and responsive. This is something you wouldn't necessarily notice if it works well, but a slow and unresponsive VRA system can ruin a good test.

To condition effectively and maintain the ongoing reinforcement between the visual reinforcer and the sound stimulus, it is imperative that the screen image is displayed immediately with no delay so that it can be displayed simultaneously with the sound stimulus.


2. Do you have total control?

A good screen VRA system should allow you to have full control over the available options. In particular, the duration of the presentation of the image. Look for a system that allows you to determine this duration. Ideally, you should be able to switch the image off as soon as the child has turned away from the reinforcer.

If the system only offers one predetermined presentation duration, you risk having the reinforcer on for too long or not long enough. Different children react differently to VRA, so being able to control and adjust according to each child is vital.


3. Does it offer two screens?

Although it is possible to perform VRA with reinforcers to one side of the child only, it is encouraged to have reinforcers on either side. The child will often – although not always – spontaneously turn to the new side if the stimulus side changes. Being able to recondition to the opposite side is helpful if the child is losing interest.

If you are considering a screen VRA solution, make sure it offers the possibility to connect two screens – one for either side of the child.


4. Is it customizable?

Most screen VRA systems will come with a selection of default images and/or video files loaded onto it. Make sure you are happy with this selection of images and explore what possibilities there are for customizing the image files. Is it possible to use moving videos as well as still images? How easy is it to load your own files into the system? Which file formats are compatible and how much file storage capacity is there?


Key takeaways

Advances in technology and also the increased use of screens in daily life have led to the development of digital screen reinforcers which display either a still or moving image on the screen. Screen VRA solutions offer a greater range of options and more flexibility than toy reinforcers.

However, the perfect scenario is using both together as complementary systems. This provides a setup that is suitable for all age ranges including the very young or older children with additional needs. Screen VRA systems can be customizable allowing you to tailor the VRA session to the child's particular interests and motivations.


A photo of Amanda Goodhew
Amanda Goodhew
Amanda holds a Master's degree in Audiology from the University of Southampton, where she now teaches as a Visiting Academic. She has extensive experience holding senior audiologist positions in numerous NHS hospitals and clinics, where her primary focus has been pediatric audiology. Her specific areas of interest include electrophysiology (in particular ABR, ASSR and cortical testing), neonatal diagnostics and amplification and the assessment and rehabilitation of patients with autism and complex needs. Amanda has a particular interest in pediatric behavioral assessment and has twice held the Chairperson position for the South London Visual Reinforcement Audiometry Peer Review Group, and is a member of the Reference Group for the British Society of Audiology Pediatric Audiology Interest Group. Amanda also works as an independent technical assessor, undertaking quality assessment for audiological services throughout the UK, and is a member of the expert reference group for the James Lind Alliance Priority Setting Partnership on Childhood Deafness and Hearing Loss.

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