Boy playing with toys in nurseryVisual reinforcement audiometry (VRA) is a subjective test, carried out in children under 3 years of age, non-cooperating children and children who do not allow to wear headphones (eg. because of the sensitivity around the head).

The test is performed in an open field and is supported by selected visual stimulus.

What is VRA for?

The aim of the test is to determine the binaural hearing threshold for the given sound stimulus, in this case, a single frequency. Because of the need of maintaining child’s concentration and auditory attention test is performed mainly on four voice frequencies (500Hz, 1kHz, 2kHz, 4kHz). If the child’s concentration is sufficient the test may be extended with the extreme frequencies.

VRA is used as a complementary test, for objective hearing tests, such as ABR, OAE, and AI.

How is the VRA performed??

VRA test is completely non-invasive. The test is performed in an open field and is based on learning by the child the expected reaction to the sound stimulus.

Visual reinforcers such as lighted toys are placed 90-degrees to each side of the patient to „train” the child to look toward the direction of the sound. Examination of children under 1 year of age is carried out on the changing table, which is placed in a calibrated free-field. From the speakers, there are sounds at a specific frequency and volume played, while the researcher observes characteristics, scope, intensity, and frequency of the child’s responses. For older children, the test is carried out on the parent’s lap or unassisted on the chair / carriage / baby carrier.


The test result of VRA is an audiometric curve for air conduction, determined on the audiogram for both left and right ears (binaural test).

VRA in children:

Due to the nature of the test, VRA is typical for newborns, infants, children and non-cooperating children with head and ears hypersensitivity. It is a supporting test for the selection of hearing aids and allowing the evaluation of the benefits of the proposed hearing aid. It should be always performed after the objective hearing tests in order to verify and expand the diagnosis.

Visual reinforcement audiometry is completely non-invasive. It does not require the cooperation of a child, but it is important that the child is sated, well-rested and awake. It is not recommended to perform this test before the child’s sleep in which the child’s response can be reduced and diagnostically unreliable

Author: Aleksandra Stojak