Preparation and Setup for VRA Testing

10 - 30 mins
12 May 2021


There are some specific considerations for the setup and preparation of visual reinforcement audiometry (VRA). In this video, we will explore how to ensure the appropriate test environment, equipment setup, which toys to use, and how to prepare the different people involved in the test.


Test environment

Having an appropriate and dedicated testing environment is conducive to being able to perform high‑quality VRA.


Room size

It is recommended that the testing room is large enough to comfortably accommodate:

  • Both testers
  • The child and their parent
  • Required equipment and furniture

The British Society of Audiology recommends minimum floor dimensions of six by four meters.



The room should be well ventilated with adjustable air conditioning to ensure the comfort of the child.



Adjustable lighting is important in case additional illumination of the visual reinforcers is required to assist in testing of children with visual impairments. Downlighting is recommended to avoid casting distracting shadows.



The testing room should have adequate soundproofing to facilitate sound field testing.


Environmental sounds

Distracting environmental sounds should be removed. Suggestions include:

  • Toys which make minimal noise
  • Using a soft, wipeable covering to the table
  • Keep accompanying family members to a minimum
  • Avoid any siblings who may make noise and be distracting
  • Computers within the testing room should be fitted with silent fans


Test room arrangement

Although many test room arrangements are used, the preferred setup is to use an observation room for testing. Tester one would be stationed in the observation room with the audiometer and VRA system controls. It is vital that tester one has full observation of the child, second tester, and preferably the parents as well via a one-way window or camera image. Neither option should provide any form of distraction to the child.


Two-way communication

Reliable, two-way communication between both testers is essential. There are many options available. This could be via wired or wireless headsets or a hearing aid with FM mic and receiver. It is vital for both testers to be fully aware of the test circumstances, timing of presentations, and to be able to communicate regarding any necessary changes to test strategy.



The testing environment should be as tidy and distraction-free as possible to keep the child focused on the important elements of the test, the visual reinforcers, and the second tester with engagement toys.


Single room pitfalls

If using a single room for testing in which both testers and the audiometer controls are located, there are a number of potential pitfalls to be aware of.

See also: How to Avoid Pitfalls in VRA Testing


1. Distraction from tester one

The presence of tester one can be a cause of distraction to the child, who is likely to be aware of their presence. Situating the tester behind the child is usually not enough to remove this source of distraction. It is recommended to use a curtain or screen to keep the tester out of view of the child.


2. Cueing by tester one

Using a screen may not completely remove all sources of cueing from the tester. In particular, keyboard, audiometer, or mouse clicks may be audible to the child. Using devices with silent switches can help reduce this risk.


3. Compromised view

Ideally, tester one should have a frontal view of the child and be able to see the second tester and the parents as well to be fully informed of the testing circumstances. If tester one is either situated behind the child to their side or screened out of view, they will have a significantly compromised view. Therefore, it is recommended to install a recording camera to capture the live session with a monitor screen positioned near to the tester to watch.


4. Ineffective communications

To reduce queuing and distraction, it is important to reduce communication between testers in a single room arrangement. If the child hears tester one talking, this could become a source of intrigue. This makes communication less effective and furthermore less discrete than if the testers can communicate via a headset type device, with tester one in an observation room. There is no easy solution to this challenge. However, experience and familiarity between clinicians can help to facilitate a smooth and intuitive workflow.


Furnishing the clinic room

Now that we have our room requirements, we can go ahead and furnish the room.


Tester positioning

We have our big, spacious clinic room with a separate observation room, where our first tester will be positioned with the audiometer during testing. Our second tester will be inside the room looking very friendly and welcoming so that our patient is put at ease.



We have dimmable lighting and air conditioning controls.


Patient positioning

It is strongly advisable to place a mark in the middle of the room where you want the patient to be sitting for testing. This should be where the sound field system has been calibrated to.


Sound field speakers

Our sound field speakers should be positioned one meter from the patient at 90 degrees azimuth. It is important to avoid any reflective surfaces near or around the speakers.


VRA system

Next, we require our visual reinforcement system which could be a toy box or a digital screen system.

See also: Comparing Toy and Screen VRA Systems


Visual reinforcers

Ideally, the visual reinforcers should be located as close as possible to the speakers and in line with the patient's head. This will elicit the strongest and clearest head turn and help with ongoing reinforcement. In the youngest VRA patients or in case there are any issues with vision development, a really nice option to have available is the ability to move the reinforcers closer to the patient. Mounting the reinforcers on movable brackets or a stand with wheels are two good options here.


Arrangement of transducer cables

With the audiometer being in a separate room, it will be necessary to patch transducer cables through to the main testing room. I strongly recommend you label the different ports to avoid any incorrect connections. Extra‑long transducer cables are also really important so that the cables can be positioned out of reach and out of the patient’s view as much as possible.


Seating considerations

Next, we need a low table of a suitable height for a child. In an ideal world, the table height should be adjustable to remain comfortable when different seating types are used, and children of different heights are being tested.

A horseshoe shaped table with the child seated in the gap in the center has the advantage of wrapping around the child. Combined with a good choice of chair, this can really help encourage the child to stay seated in the correct location.

A soft table covering can help reduce unwanted noise from any engagement toys that might get tapped on the table.

We also need a chair for the child to be seated on. It is good to have an option that the parent can be seated on if the child is going to be positioned on their lap for testing. However, the first preference should be for the child to be seated independently. This minimizes the risk of cueing from the parents which can be hard to detect.

A small captain's chair offers the same advantage as the horseshoe table by wrapping around the child. It can help to keep them seated in position and should be brought as close to the table as possible, preferably with the arms resting underneath for maximum benefit.

Another great option to have available is a highchair. This is something most children of VRA age will be familiar with and comes with the benefit of straps to help keep the child in place. If a standalone highchair isn't an option, it is also possible to get small, boosted chairs which can be securely strapped to a typical adult chair. Some come with their own tray table which the second tester can then place engagement toys on.


Engagement toys

Lastly, now that we have all our equipment and furniture in place, we need a plentiful supply of engagement toys. It's a wise idea to keep these in a box that can be hidden out of view behind or under the table. A lid can also help to keep these out of sight.


Toys for VRA and play audiometry

Let's talk toys in more detail.


Play audiometry toys

The chances are that your VRA room will also be used for play audiometry in older children. It's wise to have some play audiometry type toys in case your VRA‑aged patient happens to be ready to cross over into play audiometry.


Dedicated storage

I strongly recommend you have dedicated toy storage that is out of view of the child during testing. This should preferably be positioned behind them to minimize distractions. Furthermore, using a cupboard that has closable doors that are also lockable can be very beneficial if you have a curious patient.


Organizing your toys

Organizing your toys is well worth doing so that you can quickly and easily put your hands on what you want.


Selection of toys

In your VRA box of engagement toys, it's really important to have a wide range available. For the youngest of children, one ring, one cup, or one ball may be all that you need. However, for children that are more active, older, or have complex needs, being able to change toys quickly and having a ready supply of new toys available can be the trick that keeps your VRA session on track.


Favorite toys

If the child has a particular preference or interest in specific types of toys, it's good to have those available. Although, I would recommend using careful judgment to decide when to introduce those. You don't want the engagement toys to be too interesting such that the VRA reinforcers lose their appeal. On the other hand, if the child is upset, not interested in the engagement toys, or too interested in the VRA reinforcers, introducing their favorite toy type can save the day.


Sensory toys

Having a selection of sensory toys – in particular light-up toys – is valuable for any patients with complex needs and especially those with visual impairment who may not be able to benefit from the standard engagement toys. Dimming the lights in the room can help these toys to stand out further if required. These are also great toys for distracting any child during otoscopy, tympanometry, and OAE testing.


Peg puzzle toys

If you have a child who is possibly on the verge of growing out of VRA and being ready for play audiometry, observing them with a peg puzzle can help you judge what level they are at. Generally, if the child doesn't show any understanding of the purpose of the peg puzzle, they are unlikely to be ready for play audiometry.

Likewise, if they lack the motor control skills to perform the peg puzzle, they may struggle to perform the tasks required for play audiometry. Checking whether they understand and can do the puzzle is something the second tester could be doing by playing with them whilst the first tester takes a history from the parents.



Secondly, every pediatric audiologist should have a plentiful supply of bubbles available at all times. These are great at distracting from any upset. And for otoscopy, tympanometry, and OAE testing, these can also work brilliantly as a reward. However, I wouldn't recommend using them as a form of engagement during VRA testing itself. The direction of the bubbles can be quite unpredictable and uncontrollable, which can lead to the child looking around quite considerably when ideally, we want their attention focused quite specifically forwards.


People involved in the test

The final piece of preparation I'd like to talk about relates to the people involved in the test. Let’s say we have a scenario with our two testers, our patient, their parents, and a sibling who has joined the family for the appointment.


Minimize number of people

My first recommendation in this scenario would be to ask one of the parents to take the sibling out of the room during testing. It's perfectly understandable that both parents would want to be present for the appointment. However, to minimize distractions, it would be best to ask them to leave and rejoin once testing has been completed.


The role of testers one and two

The role of tester one is typically to lead the testing, which involves the presentation of the stimulus and visual reinforcers. Most often, we will see that tester one takes the history and debriefs the results to the family. The role of tester two is to engage the child. It is really important that tester two is seen as a friendly, approachable individual who builds a rapport with the child.

Remember, many children of this age are nervous of strangers and may well have an aversion to medical or clinical settings. I highly recommend that tester two is not dressed in a white laboratory coat, as this can be frightening to some children. Ideally, civilian clothes should be worn although it may not be possible to avoid uniform regulations.

Tester two should also be careful not to be the source of any distraction. For instance, noisy jewelry and overpowering perfume should be avoided. Testers one and two should be prepared to switch roles during testing should this be necessary.

See also: The Role of the Second Tester in VRA Testing


Instructing the parent

The parent who remains in the room with the child needs to be appropriately instructed. It is important to explain the test to them in easy‑to‑understand terms. If the child will be sitting independently, the parent should be prepared to stay quiet and still throughout testing, ideally situated directly behind the child.

Even small movements can be detected by the child, so instructions should be given to help the parent avoid cueing or distracting. Both testers should remain vigilant throughout testing as to the possibility of parental cueing.

If the child is to be seated on the parent's lap for the test, similar instructions should be given to the parent not to react to the stimulus or the reward. In certain cases, the parent can be encouraged to provide supplementary social reinforcement. The child should be supported around the waist and under their arms, with the parent holding them upright and with a gap between them and the child. It is important the child remains alert throughout testing and is not tempted to relax back against the parent.


Ensuring cooperation from the patient

The patient's ideal state should be:

  • Well rested
  • Not hungry
  • Not thirsty
  • Not in need of being changed

The cooperation of the patient is essential to the success of a VRA session. Therefore, any possible sources of upset, need, or distress should be avoided where possible. When booking the appointment, it is worth asking if there is a good time of day. Avoiding nap times is always advisable.

Asking the parents ahead of time or at the start of the appointment regarding any preferences the child may have in terms of toys or visual reinforcers can supply the testers with useful information. Likewise, if the child has any particular aversions, it can be helpful to be aware of these.

It is advisable to start testing at the optimum moment when the patient is in the best state. If they are particularly shy, it may be worth spending more time to allow tester two to build up a rapport and engage the child in the session. If they are very active or appear to have a short attention span, starting testing as soon as possible may be the best course of action. A full thorough history can always be completed after testing is finished.

It is also worth judging whether to perform otoscopy, tympanometry, and OAE testing before VRA testing or whether to leave it until afterwards. Any procedure that may upset the child can risk losing their compliance and cooperation for the VRA test itself.

See also: Preparation and Setup for VRA Testing


Key takeaways

I would urge you to review your VRA room arrangement. Or – if you are considering setting up a pediatric testing room – to assess how you can create the best setup and environment possible. The key is friendly, welcoming, distraction‑free, and practical to work in.

Make sure your VRA room is equipped and furnished appropriately. And remember, you can never have enough toys when it comes to testing. It is so important that everybody in the room knows and understands the role they have to play. VRA is a group effort and obtaining successful results is well worth this preparation.


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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