Creating Visual Reinforcers for VRA Testing

10 - 30 mins
21 December 2021


This video demonstrates how to create customised visual reinforcers for visual reinforcement audiometry (VRA) testing, which can be used to tailor the VRA session to the preferences of the individual child. Find the full transcript below.


So, I want to show you how we can make customized visual reinforcers for VRA testing. With me today I've got the VRA computer here and this is the USB stick that we load the visual reinforcers onto. And then this is our VRA screen that we can play them on to the child.

So I'm going to take this USB stick and plug it into my computer, and this is where we have the VRA Playlist Creator software (available with VRA Screen) that I'm going to be using to put the images onto that USB stick.

So, we can either use still images or moving images for making custom reinforcers. This is one of the real benefits of using a digital screen solution in that we've got almost endless possibilities.

See also: Comparing Toy and Screen VRA Systems


Still images

First of all, I want to show you how to make some still image reinforcers. For this, I’m just going to use some images that I’ve downloaded off the internet. In this instance, I’m going to make a list of Mickey Mouse images. Potentially, our child is really motivated by Mickey Mouse. That's their favorite thing and if you've got a stock of those images ready to present during your testing, it's really nice that you've got those available.

So, we are in the Playlist Creator on the computer here. First thing I need to do is go to ‘add new playlist’. And then when I scroll down to the bottom, you will see that we've got ‘new playlist 1’. I'm just going to rename that Mickey Mouse. And just to the right of that you can choose the time that each of the clips is displayed for.

So, next I need to navigate to where my images are saved on my computer. I've got a VRA media folder that is just saved on my desktop. That's what comes with the system and the default clips are included in there. But I've created some new folders within this folder, and you can see that I've got a Mickey Mouse folder here and there's a handful of images that I've saved earlier.

What I can do is just make sure that my new Mickey Mouse playlist is highlighted on the computer, and I just press ‘copy to playlist’ on each of these. We can see at the top of the screen that they're all copying over super quick. That's now done, so I can scroll down, and we can see at the bottom we've got our Mickey Mouse images all saved onto that playlist.

Then simply take that USB stick out of the computer, put it into the VRA computer, and then you just need to navigate to the correct playlist. And there we have Mickey Mouse and a handful of different Mickey Mouse images ready to go.


Moving videos

Okay, so that's how we can make some still image reinforcers personalized to:

  • What our child is interested in
  • What they're motivated by
  • What they'll respond to

But a lot of the time, the moving video files are much more engaging. So, I want to show you how you can make those as well. So we're going to pop our USB stick back into the computer where the Playlist Creator is. And my suggestion here is that you definitely need to do this in advance.

So, if you've got something that the child is particularly interested in – in this case I'm using a cartoon called Cocomelon based on input from the child’s parents – I can make sure that I get those particular video clips ready for them.

What you need to make your own videos is what's called screen recorder software. So this is freely available off the internet. There are loads of different types out there and what you don't want to do is use an enormous, long video file on the VRA USB stick. You want to get just short clips of each particular cartoon or film that you're interested in.

So, I've taken a long video of Cocomelon, and I've used my screen recording software to just record five seconds, three seconds here or there and I've saved those as mp4 files on my computer. Again, screen recording software will do all of this for you so it's actually really easy. And, as I say, there's free stuff out there that you can use.

What I want to do now is go to create a new playlist up at the top of the screen – ‘add new playlist’. There we go. Back down to the bottom, I'm going to call this one Cocomelon. Again, I've saved the mp4 files that I used that screen recording software for into my VRA media folder. They're all up here on the screen. I'm just going to take three or four of those and transfer those across.

Now, the time that's displayed for the videos is important for your VRA system. What you don't want is it to be quicker than the video clip that you've got. So, if you've got a video clip that is five seconds long and you want to show that for four or five seconds – if it's set only to three seconds, then it will cut off and restart back at the beginning.

So, I'm actually going to set these all to 10 seconds. Again, I can stop them at whatever point I want. So, when my child has turned, they're looking at the screen and then they turn back to engage with the toys, I can switch that image off straight away. So, it's not necessarily going to play for the full 10 seconds but it's nice to have that as an opportunity.

So, now I can see that I've got four mp4 files video files under my Cocomelon playlist. I can just take my USB stick out of there and put it back into the VRA computer. Then I need to navigate to my Cocomelon playlist, which is right there, and we can see some video files that have appeared on there.

So, to create moving videos with some simple screen recording software:

  1. Find a longer video that you want to use.
  2. Get those short snippets of it.
  3. Save them into the individual files on your computer.
  4. Create a playlist for them.


Homemade videos

Okay, so we've seen how we can make still images and we can add in mp4 files with short video recordings from other videos. One other option that I'd really like to tell you about is using familiar faces. So, kids of this age absolutely love faces. They're really motivated by them, and they'll be really motivated by photos of faces that they know – their own family members for example.

A lot of the time, they'll come in and the parents will say “oh you know, her grandma is just her favorite person in the world” or “she's absolutely obsessed with her big brother.” And a really nice option is to get some photos taken of those people and use those as loaded photos onto the VRA system.

You could also make videos and I've got a video of a colleague of mine just giving a little wave to the camera. I'll just show you how quickly and easy it is to get that loaded onto the system. So, I'm going to take this USB port back into my computer and get the Playlist Creator back.

One idea I really like is to make a people playlist so that if you know they're really interested in faces, you can put in a bank of different people's faces. A nice way of doing this is to use the people that are working in your clinic. For instance, if it's a child with a hearing loss who's going to be coming back for a lot of different VRA appointments, they’ll see lots of different clinicians. You can load those pictures up and say, “oh look it's Anna” and “oh look it's John,” and introduce them before they meet them. And then they'll remember them, and they will become familiar faces.

But you could also – as I say – use family members. If you are using family members or people that the child knows, I would recommend that you delete those as soon as their appointment is finished. We shouldn't be using those for other appointments.

So, I've made a people playlist here and I'm going to go and get that video of my colleague waving so that's saved into my VRA media folder. I'm just going to copy that over onto the playlist here. I think the video is about five or six seconds. Again, I'm going to increase the time on that, but you've got full control over how long it plays for. Let's take that out and move it over here.

This is something that the family members could do in advance. They could email you some photos. They could email you some videos. Things that you can get ready for that particular patient. So, a really good idea for those repeat patients who are going to be coming back quite regularly.

So, let's go and find our people playlist. There it is. We have Leigh waving on the screen. So, a nice big photo or video that the child is going to be super motivated by – particularly if it's their favorite person.


How to make your own graphics

Next up, I'd like to show you how you can make your own animations. So, we've been looking at using pre‑existing videos or photos so far, but it's actually really simple to make your own kind of cartoon style images. For this, we're going to be using PowerPoint. It's really simple. So, I'm just going to load that up.


High-contrast images

A nice example of a particular type of image that's useful to have on your system is high‑contrast images. These are really effective for the very young age end of the age range for VRA – six, seven, eight, nine‑month‑olds where the vision may not be as developed and the contrast between strong colors and black and white and very big images can be really effective.

So, this is really simple to do. We're just going to insert a black background. So, I'm just going to get a rectangle there and we're going to make that black. And then I'm just going to go to ‘insert a shape’. For instance, you could do some stars. There are some really big, bright stars. Let's make those white so that they stand out. And I'm just going to copy and paste that a few times so that we've got some stars like that lined up. And we'll do that down there, we'll have six stars. And that one over there.

So, there we've got six stars. What you can then do is just make that full screen. Do a print screen of your full screen, and then you can save that onto your playlist. So, let's do that quickly. We just go ‘print screen’ like that and then paste that on top of our image. We can save that as a picture directly into the VRA folder. So, I go to my VRA media folder, and I've already got a high contrast folder set up. So, I will just save this as ‘stars new’ and put that there.

We go back to our Playlist Creator, and I have a high contrast playlist here. So, I select that and then I can add my ‘stars new’ image over onto that. Really simple. So, that's how to make a very simple image in PowerPoint. As you can see on the screen, they've got lots of different types:

  • Suns
  • Stars
  • Squares
  • Smiley faces

Different things like that. But you can also turn these into video files. So, we can animate them and turn them into video files. Let me show you how we can do that.


High-contrast animations

Very simply, select our star. We go to ‘animation’ and let's make it flash. I think that could be quite nice. So we can go on to a ‘pulse’, and then we can copy that and add that onto all of our stars. And we just go to our animation pane. We can maybe make these flash a few more times. We go into ‘timing’, and we'll repeat that maybe five times. If I go into full screen, we see that one flashes there, then that one flashes, and that one flashes, and so on and so forth.

So, you can play around with the different timings. You could have them all flashing at once. You could have one after the other. And if you use that screen recording software when the PowerPoint is on your full screen, it will just record the full screen of what that flashing star image is doing and then that can be saved as an mp4 file and loaded onto your VRA system. So, a really simple way of making a very basic yet effective video file for your VRA system.


3D models

I really love high contrast. It's very effective for the young children. But I want to show you another trick that I have in PowerPoint. So, we're going to make a blank slide here and I want to introduce you to the 3D models in PowerPoint. So if you go to ‘stock 3d models’, there are some 3d models already loaded into PowerPoint that you can use. Some of them are animated and some of them aren't.

Let's say we've got a kid who's really interested in animals. Absolutely crazy about dogs for instance. So we could pick this little dog here and we'll insert him. And this is an animated 3D model. So I'm just going to make him a little bit bigger, so he fills the screen. And what's lovely is there's actually different animations already applied to him. You can see here he's just having a little look around. But if we go to this scene icon at the top of the screen, we could go to this one, and this is where he jumps in and walks towards the screen. And what kid wouldn't love that during their VRA session?

And we could have another one where he's, oh he's got a little suitcase, and so on and so forth. So again, what you can do is just make this full screen, use your screen recording software to record this very brief animation here, and then save that and load that into your VRA system. So that's just one example.


How to animate 3D models

There are some other 3D models that aren't animated, so I'd just like to show you quickly how you can animate those yourselves. So, we'll just take another blank page, and we will go to 3D models. Let’s say the child is really interested in dinosaurs, so we'll take this guy here. We're going to put him in. Again, I would suggest that you make it as big on the screen as you can. So, we'll just enlarge that slightly and this guy doesn't have a preset animation. But you can move him round into different angles, meaning you could just use this to make some very simple static images that don't need to be animated.

But what you can do here is go to animations. We could give him an ‘arrive’ animation, so he will sort of gently fade in and turn. Or we could add a ‘swing’ animation where he swings round. You can increase the strength of that swing including how far and how fast it goes. Let's make that strong. There you can see he's slightly more animated.

Again, what we would do then is make it full screen. Set up our screen recording software, click the animation to work, and your screen recording software is then turning that into a video file that you can then load into the VRA system itself.


Random playlists

My last suggestion is that you create a random playlist on the Playlist Creator where you actually put a whole different selection of all of the different types that I've shown you today.  I've made a Mickey Mouse playlist, but the kid might get slightly bored of Mickey Mouse after a few minutes. So, it's nice to mix them up. And that can become part of the game where the engager is talking to the child and going “what's going to come next I wonder?” “Who's going to appear on the screen next?” That can be quite exciting because it's a different type of image every time.

So, I've set up a random playlist here and I've got:

  • A car
  • A cat
  • A plane
  • Some high contrast
  • Some of my animations
  • Some cartoon characters

All sorts of different ones. You could put some different people's faces in there. This means when it clicks through on the playlist, there's always something surprising and different, which can be really engaging to help keep that child's attention going for longer. The longer we keep their attention, the more testing we can do and the more results we can get.

Also, it helps if they are going to have to come back again that they've had a positive, enjoyable experience. If they've enjoyed being at the hospital, seeing their favorite cartoon characters or their favorite people, it helps to make this a softer experience for them. A lot of children have quite an aversion to hospitals and clinical settings. So, by making this as friendly and as enjoyable as possible, you'll get the best cooperation out of them and the more results that we need for our testing.


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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