VRA Testing: The Role of the Second Tester

10 - 30 mins
21 December 2021


This video provides a discussion of the importance of the role of the second tester for visual reinforcement audiometry (VRA) testing, and explores how and why the second tester should interact with the child throughout the session. Find the full transcript below.


The importance of the role of the second tester is often underestimated when it comes to VRA testing. Although it is logical to see the first tester as the person leading the appointment, in actual fact, our second tester has a much more pivotal role when it comes to the cooperation of the child.

A happy child who is enjoying their VRA experience is one who is much more likely to produce results than a child who is upset, scared, or nervous. Whilst it is not always possible to ensure we have a happy patient on our hands, there is a great deal that the second tester can contribute towards this.


Building a relationship with the child

I would always encourage the second tester to be present in the testing room, sat in their position on the opposite side of the table before the child enters. Ideally, they should have a toy or two on the table and should welcome the child into the room in a friendly, warm, and inviting manner. This way, the child has a welcoming focal point to go towards as well as those all-exciting toys.

Wearing non-medical clothing can help the child to see this experience as not threatening. While tester one takes a history from the parents, tester two has an ideal opportunity to build a friendly rapport with the child. The more of a rapport that is built between the child and the second tester, the more cooperative the child is likely to be.

As it will be the second tester interacting with the child for the test itself, it is far more important that they – rather than the first tester – build this relationship with the child. Developing this rapport has a further benefit of helping the social reinforcement from the second tester to be more meaningful to the child. If the two are both enjoying the session and it is a shared experience, the child has every reason to remain content and engaged throughout testing for as long as possible.

Although it can be tempting for reasons of efficiency to call the second tester into the room just as the VRA test is about to begin, this can actually be quite risky. Introducing a new face and expecting the child to perform almost immediately can disrupt the flow and introduce a source of unknown which can feel daunting or scary to that child.


Observing the child’s behavior

These initial few moments where the second tester is playing with the child to help settle them in are a valuable opportunity to start reading and understanding the child.

Questions to consider:

  • Are they shy?
  • Are they over excited?
  • Are they upset, tired, or scared?
  • What toys do they look interested in?
  • Do they require more time to settle in?
  • What does their attention span seem like?
  • Is there something that can help relax them?
  • Would a more hands-off approach be better?
  • How are they likely to react to examination of their ears?
  • Are they age-appropriate for VRA or are they ready for play audiometry?
  • Are they discarding each toy after a very brief glance, or do they have good focus?
  • Do they need more time with their parent before coming further into the appointment?
  • Would it be sensible to start testing right away or do they need a bit more time to calm down?


Role during testing

During testing, our second tester has much closer contact with the child than tester one. It is this – combined with their closer rapport and better understanding of the child – that places them in the most pivotal role.

Tester one should be prepared to trust and accept guidance from tester two. They will be better placed to judge when to start testing and then how the child's progressing throughout testing in terms of:

  • Mood
  • Interest level
  • Attention span
  • Degree of enthusiasm and engagement

It is important that tester two recognizes the responsibility they have to feed back to tester one and is confident in contributing to the appointment. It is often the case that trained and experienced clinicians find this easier and more natural to do than assistants or students. Clinicians who work closely together on a regular basis will also find this communication easier.


Engagement vs distraction

Our understanding of child psychology can inform how the second tester plays and interacts with the child. There can be a tendency to assume that VRA is quite a complex task for the child and as clinicians, we are very aware of the importance of obtaining results and the pressure of the limited attention span of such young children.

Often, it follows that the second tester therefore interacts minimally with the child using only very basic play to distract them. However, young babies are actually capable of a lot more than we often give them credit for. A normally developing one-year-old child is quite capable of playing with a toy and simultaneously having their attention drawn away by the stimulus, providing the visual reinforcer is sufficiently motivating and that appropriate conditioning has been successful.

This is where the concept of engagement rather than distraction becomes relevant. Some VRA guidelines and advice will encourage the second tester to distract the child. I'm pleased to see that the British Society of Audiology's recommended procedure for visual reinforcement audiometry has adopted the importance of engagement, advising the second tester to engage the child in play rather than distract them.


Benefits of engagement

There are several reasons why the second tester should avoid simple distraction.


1. Keep appropriate focus

Firstly, if you wave a toy in front of the child without them being able to play with it themselves, the chances are that child will try to reach for the toy. The problem we have here is that that unobtainable object has now become their sole focus and they are going to be driven by the motivation of that toy rather than the visual reinforcers and the stimulus.

Allowing the child to play with the toy themselves means that their drive and their need to obtain the toy has been met. Their natural curiosity about what it does, how it feels and so on can be satisfied. This allows the stimulus and visual reinforcers to remain more motivating than the toy itself.

There is a balance to be struck in not giving the child too interesting or too complex a toy, or too many toys. This can be guided by their age as well as the second tester’s judgment of their developmental stage. For very young infants, waving a toy in front of them may be engagement enough but I would urge you to use social interaction as appropriate to ensure that it is engaging rather than uninteresting distraction.


2. Maintain rapport and interest

Secondly, if the child is engaged with play with the second tester, this continues to be an interesting and enjoyable experience for the child and further cements that rapport that the child and the second tester have developed before testing began.

If the second tester becomes distant as soon as testing starts, this could be upsetting and confusing for the child. And if the toys being used to distract them are not interesting, they will soon grow bored of the task and the appointment. Remember, the happier the child is and the more they enjoy the experience, the more attention span and testing time you will have available.


3. Reduce checking and false positives

Thirdly, employing engagement type play rather than distraction techniques is a powerful tool in reducing checking and false positives. The ongoing principle must be maintaining the correct balance of the stimulus and visual reinforcers being more motivating than the engagement toys. But not to such an extent that they hold the child's sole focus.

If the stimulus and visual reinforcers are significantly more motivating than the engagement toys, there is a higher risk of checking and false positives. The degree to which they will be motivating will vary for each child. But if such a scenario occurs, increasing the amount of engagement with tester two and the toys can help to rebalance the child's focus attention and motivation away from the stimulus and visual reinforcers.


4. Support social reinforcement

Lastly, engagement type play can help to support social reinforcement. The need for social reinforcement to supplement the visual reinforcers will vary according to each child. However, with the joint play that comes with engagement rather than distraction also comes a greater rapport and trust between the tester and the child.

If the second tester is excited and enthusiastic about the visual reinforcers, the child will absorb and imitate this reaction. If the child trusts the second tester and sees them as a new friend, the shared experience of the VRA test will be positive and enjoyable. If very uninteresting and dull distraction is used, this bond isn't being strengthened and the social reinforcement used could lack the influence and power it could otherwise have carried.



The role of the second tester is really important in VRA testing and often underestimated. By providing a welcoming environment, our second tester can help to build a rapport with the child. This allows them to be able to read the child and deliver important communication to tester one, which can shape the whole assessment.

Using engagement play rather than distraction play is vital to keeping the child in the appropriate state of attention, focus, and motivation. It can also add further weight to the social reinforcement they display alongside the visual reinforcers.


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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