Recommended Procedure

Visual Reinforcement Audiometry

Date: June 2014

Due for review: June 2019
 Recommended Procedure
Visual Reinforcement Audiometry
BSA
2014

General foreword

This document presents a Recommended Procedure by the British Society of Audiology (BSA). A
Recommended Procedure provides a reference standard for the conduct of an audiological intervention
that represents, to the best knowledge of the BSA, the evidence-base and consensus on good practice
given the stated methodology and scope of the document and at the time of publication.

Although care has been taken in preparing this information, the BSA does not and cannot guarantee the
interpretation and application of it. The BSA cannot be held responsible for any errors or omissions, and
the BSA accepts no liability whatsoever for any loss or damage howsoever arising. This document
supersedes any previous recommended procedure by the BSA and stands until superseded or
withdrawn by the BSA.

Comments on this document are welcomed and should be sent to:

British Society of Audiology

Blackburn House,
Redhouse Road
Seafield,
Bathgate
EH47 7AQ
Tel: +44 (0)118 9660622
[email protected]
www.thebsa.org

Published by the British Society of Audiology

© British Society of Audiology, 2014

All rights reserved. This document may be freely reproduced in its entirety for educational and not-for-profit
purposes. No other reproduction is allowed without the written permission of the British Society of Audiology.
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1. Contents
2. Introduction ............................................................................................................................. 4
3. Scope ........................................................................................................................................ 4
4. Competency and skills .............................................................................................................. 5
5. Facilities and preparation......................................................................................................... 5
5.1 Test environment, set-up and equipment ................................................................ 5
5.2 Type of reinforcement: illuminated and animated toys ........................................... 7
5.3 Positioning of the loudspeakers ................................................................................ 7
5.4 Position of reinforcers ............................................................................................... 7
5.5 Positioning of child and tester .................................................................................. 8
5.6 Position of tester in observation room ..................................................................... 8
5.7 Communication between testers.............................................................................. 8
5.8 Hearing protection .................................................................................................... 8
6. Stimuli....................................................................................................................................... 9
6.1 Stimulus type............................................................................................................. 9
6.2 Stimulus delivery ....................................................................................................... 9
6.3 Precautions against cross infection......................................................................... 10
6.4 Calibration ............................................................................................................... 10
7. Test procedure ....................................................................................................................... 11
7.1 Subject preparation................................................................................................. 11
7.2 Procedure for measurement of minimum response levels .................................... 11
7.2.1 Initiation of test and role of Tester 2 ...................................................... 11
7.2.2 Familiarisation and conditioning ............................................................ 12
7.2.3 Testing..................................................................................................... 13
7.3 Tips for effective VRA testing .................................................................................. 14
7.4 The most common pitfalls of VRA testing ............................................................... 14
7.5 Testing children with vision disorders, with other disabilities or at an early age... 15
7.6 Sequence and objectives of assessment ................................................................. 16
8. Interpretation of results ......................................................................................................... 17
8.1 Sound-field .............................................................................................................. 17
8.2 Insert earphones ..................................................................................................... 18
8.3 Bone conduction ..................................................................................................... 19
9. Recording and reporting of results ........................................................................................ 19
10. References.............................................................................................................................. 21

Appendix A. Authors and acknowledgments ................................................................................. 23

Appendix B. Definitions.................................................................................................................. 24
Appendix C. Suggested single-room layout ................................................................................... 25
Appendix D. Symbols ..................................................................................................................... 26
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2. Introduction
This document is a revision of the protocol produced by the Newborn Hearing Screening Programme
(NHSP, 2008); the revision was conducted by the BSA Professional Practice Committee (see Appendix A).
As with NHSP’s version, the content here is guided by evidence where possible. However, there is
insufficient research in this area and recommendations in this document are based on the opinion or
reported practice of experts in the field. General references that have guided the content of this
document are provided and specific references have been stated where considered helpful. We
welcome further research in this area.

Visual reinforcement audiometry (VRA) is a key behavioural test for young children. It is central to
completion of the diagnostic process for those hearing-impaired infants identified by newborn
screening. Furthermore, contemporary paediatric amplification fitting methods rely on solid foundations
of measurement to ensure the validity and reliability of hearing aid fitting. It is hoped that the
standardised VRA technique described here will facilitate training of Audiologists and be of use in
research studies.

There are many points of debate relating to set-up and methodology for this test technique and it is
recognised that alternative approaches exist some aspects of the technique. However, a decision was
taken to adopt the particular approach described here for the purposes of standardisation. It is advised
that only experienced Audiologists (or those led by such colleagues) should consider deviating from this
protocol. Appendix B provides a definition of terms.

3. Scope
The document sets out to provide guidelines for testing babies with a minimum developmental age of
5–7 months. The test is suitable for infants who are able to sit unsupported or with minimal support and
able to turn their head side to side. It is assumed that the reader of this document is familiar will the
principles of VRA. This protocol covers only VRA, including the defining feature of one-sided
reinforcement (rather than two-sided reinforcement of the conditioned orientation response test). VRA
is the accepted standard audiological assessment method for children that can be conducted with
reliability from a developmental age of
8–9 months onwards (Day et al. 2000).

The document covers the technical procedure of carrying out a manual VRA test,
equipment/environment considerations, basic interpretation of the results, reporting and patient
handling procedures relevant to the test. This document should be read alongside BSA (2008) for
guidance on the more technical aspects of sound-field testing, and also BSA (2011a) for air-conduction
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(AC) and bone-conduction (BC) testing.

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The term ‘shall’ is used in this document to refer to essential practice, and ‘should’ is used to refer to
desirable practice.

4. Competency and skills

Staff engaged in performing VRA testing should have received specific training associated with
documented assessment to demonstrate their competency to perform this test. The level of
competency should be at least adequate for the role performed (whether supporting or leading the
assessment). Those leading the assessment should be competent in briefing/debriefing carers, use of
the equipment deployed, and the correct interpretation of results to ensure appropriate
recording/reporting of results for use by oneself and others. To ensure correct reporting of results for
interpretation by others, it is particularly important that the differences between minimal response
levels (MRLs) obtained by VRA and adult normative thresholds are recognised and understood.

5. Facilities and preparation

5.1 Test environment, set-up and equipment

The test should be performed in a room that is of adequate size to accommodate parent(s), child and
two testers comfortably. Following BSA (2008), minimum floor dimensions of 6 m  4 m are advised.
Note: this specification assumes that the room is dedicated to the behavioural hearing assessment of
children under 3 years of age. The room should have adequate ventilation and air conditioning for
patient comfort; babies who are uncomfortable are less likely to respond well to testing. The room
should offer minimal distraction to the child. It is advised that diffuse (down) lighting is used to prevent
shadows. These lights should be capable of being dimmed, in order to permit enhancement of
illuminated visual rewards/reinforcers; this is particularly useful for children who have a visual
impairment or for children with other complex additional needs. The table should have a soft, wipe able
surface to keep noise down to a minimum when engaging with the child, yet is still compliant with
infection control procedures.

It is recognised that a variety of test room arrangements can be employed for VRA. However, the test
protocol described here is the preferred test equipment and set-up, using two testers and two rooms,
see Figure 1. The two-speaker and two-reinforcement unit arrangement as described is the basis of the
test procedure presented below.

Control of stimuli and reward should be operated from a second (observation) room by Tester 1 while
Tester 2 engages the child (Figure 1). Such an arrangement allows for discreet
communication/instructions to the tester controlling the child’s attention, reduces the potential for
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distraction, and allows for optimum (frontal) observation of the child’s behavioural responses. The test
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and observation room should be separated by a one-way window (or alternative arrangements
provided, e.g. image on a monitor screen) such that the child is not distracted, yet allowing the observer
(Tester 1) a clear view of the child and ideally of the engager (Tester 2) as well. This arrangement is also
more useful for training purposes and for allowing other family members to observe the test discretely.
There should also be the facility for the Tester 1 to hear sounds made in the room (for communication
and appropriate timing of stimulus). The arrangement also allows Tester 1 to present live speech to the
patient through the sound-field speakers, via a microphone with presentation level controlled by the
audiometer intensity attenuator.

Figure 1
Recommended room layout. Note Tester 1 is positioned to one side of Tester 2 to allow for direct line of
sight of the subject. Reinforcer cabinets (and/or reward monitors) should be readily moveable (see Section
5.5).
Where an observation room is not available, another possibility is to use a monitor screen linked to a
camera positioned to observe the front of the child and ideally of Tester 2 as well. Tester 1 should be
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out of view of the child, perhaps behind a screen/curtain (see Appendix C).

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In exceptional circumstances, there may be a need to move Tester 2 away (e.g. when the child is shy). In
these cases, particular attention must be paid to instructions to parents remaining in the test room with
the child.
Recommendations for maximum permissible sound levels are in BSA (2008).

5.2 Type of reinforcement: illuminated and animated toys

Reinforcers should be located within a moveable cabinet obscured by smoked perspex screen such that
the toys are not visually attractive without illumination. A switch in the observation room should control
animation and bright illumination of the toys. Ideally, at least two independently controllable toys
should be provided for each side of testing. Alternatively, a variety of equivalent video images could be
used (although these might not be appropriate for some children, Karzon and Banerjee, 2010) and a
rotating light would be a useful additional reinforcer.

5.3 Positioning of the loudspeakers

Loudspeakers shall be positioned at 90° azimuth (reference equivalent threshold sound pressure levels,
RETSPLs, are only available for these angles of presentation) relative to, and at least 1 m from, the test
position to each side (BSA, 2008). The speakers should be approximately level with the child’s head;
such positioning provides the most efficient means for conditioning the behaviour and establishing MRL.

5.4 Position of reinforcers

Reinforcers should be positioned as close to 90° as possible; 90° azimuth is used in order to elicit the
clearest head turn. The reinforcers should be located approximately level with the child’s head at a
distance of 1−2 m. Close proximity between speaker and reinforcer is preferred in order to aid
conditioning when using soundfield stimuli; so in practice adjacent positioning of loudspeaker and
reinforcers is recommended. Facility should exist to move the reinforcers closer to the child to enhance
reinforcement (if their developmental and/or visual ability requires this) although care should be taken
to avoid interfering with the calibrated soundfield of the loudspeaker. Reinforcers positioned to both
sides allows children to be rewarded on their preferred side (e.g. useful when testing through insert
earphones or through bone conduction).
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5.5 Positioning of child and tester

A younger infant (age 5–12 months) should be seated on the parent’s knee, gently supported at the
waist and facing forward. In some cases, it may be useful for the child to be supported by the parent’s
hands underneath the arms around the side of the body and facing forward, the thumbs resting on the
shoulder blades and the remaining fingers on the child’s chest. Here, the parent’s hands actively support
the upright sitting of the body, thus enabling even the younger infant to spend their effort in turning
rather than maintain the body’s upright position. Alternatively, the infant may be placed in a secure
‘high chair’. An older child can be seated on a low chair, with parent seated on the opposite side to
reinforcement, and slightly behind. The child should be at a point determined and marked during
calibration of the soundfield. A table is placed in front of the child to provide a surface for the engaging
activity. Tester 2 is positioned on the opposite of the table facing the child. She/he has a concealed and
plentiful supply of suitable toys close at hand adequate for the duration of the assessment. The table
should be at a height comfortable for the child to see (and if required reach). If a child is not
developmentally ready for full head turn to a reinforcer at 90°, it may be appropriate to change the
angle of position of the reinforcer to achieve a lesser angle (possibly in association with a reduced
distance) from the child. Care should be taken to ensure that the calibration position is not
compromised when soundfield testing (e.g. avoid moving the reinforcer in front of the speakers).

5.6 Position of tester in observation room

Tester 1 should have a clear view of the child’s face and Tester 2’s activity. The audiometer, reinforcer
control box and recording materials should be within easy reach.

5.7 Communication between testers

Good two-way communication between testers is essential requirement for the test. Communication
from Tester 1 to Tester 2 should be direct and discreet so as to avoid auditory distractions for the
subject, for example the use of a wire-free system.

5.8 Hearing protection

Regulations stipulate daily personal noise exposure levels beyond which hearing protection should be
used (Health and Safety Executive, HSE, 2005). If daily noise exposure is above the first action level of 80
dB(A) but below the second action level of 85 dB(A), hearing protection should be available to the
employee. If daily noise exposure is beyond the second action level, or if any peak levels exceed 137 dB
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SPL then hearing protection must be used. Daily personal noise exposure level can be calculated from
knowledge of the level and duration of the stimuli.

Calculations for a VRA system with a maximum output of 115 dB(A) indicate that the second action level
could be exceeded when testing one child with severe or profound hearing loss. As well as this, some of
the sound levels used may be uncomfortable and for this reason also hearing protection (muffs and /or
plugs) shall be available for parents and observers as well as testers. The maximum output at each
frequency should be measured and this information used to calculate likely noise exposure levels
according to the methods described in the Regulations. This information can be used to specify local
hearing protection policy. (See also recommendations for determination of uncomfortable loudness
levels BSA, 2011b.)

6. Stimuli

6.1 Stimulus type

Frequency-modulated (a.k.a. warble) tones and/or narrow-band noise (NBN) or any other stimuli that
have reference equivalent threshold sound pressure (AC) or force (BC) levels should be employed (BSA,
2008; Shaw, 2004). If the child is unresponsive to one of the above stimulus types, the use of an
alternative should be considered. Important notes when using NBN:
1. NBN for estimating thresholds should be calibrated in dB HL not dB effective masking level (in
order to avoid under-estimating hearing loss by 5–10 dB)

2. Reference equivalent threshold sound pressure levels for calibrating NBN in dB HL are available
for presentation in the sound-field but not via other transducers

3. Conventional NBN is considerably less frequency specific than warble tones and can lead to the
substantial under-estimation of hearing loss in people with steeply sloping hearing loss.
Therefore, care should be taken in use of conventional NBN where it is suspected that the
patient has a steep audiometric slope or results suggest this. Alternative NBN that is more
frequency specific and provides more accurate estimation of thresholds with steeply sloping
hearing loss may be available on some audiometers (Rowan et al, 2012).

6.2 Stimulus delivery

There are advantages and disadvantages/limitations related to each method of stimulus delivery; these
will not be explored here but have been described elsewhere (e.g. BSA, 2011a). However, a
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comprehensive range of transducers should be available for use: supra-aural earphones (e.g. TDH49/50),
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insert earphones (e.g. EAR3A coupled with immittance tip, foam tip or earmould), speakers for sound-
field presentation and a bone vibrator. For children with hearing aids, where available, insert tips
should be inserted into the tubing of their ear-moulds, as this will be useful for prescribing amplification.

6.3 Precautions against cross infection

Local procedures should be adhered to. If insert ear phones are used, disposable single-use tips should
be used and be available for different ear canal sizes. Manufacturer’s guidelines must be followed and
local advice be sought regarding best practices for cross-infection control when using supra-aural
headphones or bone vibrators.

6.4 Calibration

Stimuli presented through headphones, bone vibrator or insert-earphones shall be calibrated in

accordance with the relevant international standards, preferably in dB HL in order to present a unified
documentation of the audiogram.

Calibration of stimuli presented in the sound-field by loudspeakers is less straightforward. Sound-field

calibration requires a considerable knowledge of the use and limitations of sound level meters and
sound-field acoustics. Most test environments do not provide the ideal anechoic condition and a
number of measures have to be taken to ensure that the sound level delivered to a child’s ear is
accurate and stable. It is recommended that expert help be sought from centres with experience in this
field. The reader is referred to the specific guidance provided on calibration in BSA (2008) particularly as
they relate to use of static systems as employed in VRA.

Whatever the range of stimuli, a daily visual examination and listening checks shall be carried out (Stage
A check). The checklist described for pure-tone audiometry (BSA 2011a) could be used with additional
checks of reinforcers and between-room communication systems. Such checks are particularly
important for VRA given the variety of stimuli and transducers typically employed and routing of signals
between rooms often via additional cable connections.

Aside from the requirement for initial and annual full calibration (Stage B) against the standards,
calibration should be carried out when any major changes are made (e.g. to room layout) or changes in
external noise levels occur. Following BSA (2008), the test environment should be clearly documented
with a defined layout of furniture, furnishings, equipment and positions for people in the room during
testing; marks should be provided to floors and ceilings to ensure that layout and positions remain
consistent as any deviation may compromise calibration. If sounds other than warble tones and NBN are
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to be used, a biological calibration will have to be carried out; this is outside the scope of this document.
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7. Test procedure

7.1 Subject preparation

Following equipment checks, parent(s) and child are brought into the room, seated and introductions
made. History taking provides an opportunity for the child to settle in an unfamiliar environment and for
the audiologist to make some preliminary observations about the child. It is advisable to ask at the
beginning about the level of alertness of the child and if this is likely to change during the consultation in
order to determine the best point of time of testing. If the child is becoming restless it may be
appropriate to cut the history short and begin testing.

The test procedure is explained to the parent with suitable cautions about cueing the child to the
presence of an auditory stimulus, and the need to minimize distracting noise. Information should be
obtained about the child’s developmental and visual status before starting the test. If there is any doubt
about the child’s ability to respond in the desired manner (i.e. with a head-turn) this can be discussed
with the parent. If necessary, head control and turning can be checked by having the child visually track
an object of interest through an arc of 180°. It is important to advise the parents about the best way to
hold / support the child (see Section 5.6).

Any others present are best invited to sit in the observation room (preferred) or directly behind parent
and child. Care shall be taken when positioning parent and child to ensure that sound-field calibration (if
relevant) is not compromised. Ear protection (e.g. ear muffs / plugs) shall be available for those
individuals present in the test room. The transducer should be fitted to the child. The fitting of insert
earphones should be preceded by otoscopy (BSA, 2010) or if it is not done this is on the basis of an
assessment of risk and benefit for individual subjects. A flexible headband (e.g. elasticated towelling
/neoprene) may be used to position the bone vibrator in place as a more comfortable alternative to a
conventional ‘Alice band’. There should be due consideration for infection control when using a flexible
headband, e.g. washing following each use. If the child is resistant to either method of placement the
bone vibrator could be held in place by the parent with clear instruction that the conductor is applied
with moderate force. Whatever the means of placement, Tester 2 should be alert to ensure that the
conductor remains appropriately placed throughout the test procedure.

7.2 Procedure for measurement of minimum response levels

7.2.1 Initiation of test and role of Tester 2

Tester 2 will choose a suitable table-top activity (e.g. playing with small toys). The toys selected and
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manner employed will be the minimum necessary to encourage the child to adopt a midline forward
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position (for head position in relation to the calibrated sound-field system) and maintain alertness (in

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order to be ready to respond when the acoustic signal is presented). Importantly for children with object
permanence (Plaget and Inhelder, 2000; Anderson 1955) Tester 2 shall provide no change in activity
linked to stimulus presentation that could serve as a cue for signal presentation (e.g. distinct and
rhythmical phasing shall be avoided). Very young children who have not yet reached the developmental
level of object permanence should therefore require coverage of the object. Tester 2 should avoid noisy
play, so as not to mask the signal, and refrain from engaging with the child too fully, particularly direct
eye contact as this can override the response to hearing the signal, save for praising a correct response.

7.2.2 Familiarisation and conditioning

Before testing it is essential to establish conditioning. Some children will give a clear and repeatable
head-turn to an auditory stimulus without any formal conditioning while others will require a number of
conditioning trials.

The following sequence is suggested:

1. A 2-kHz stimulus is presented at a level judged adequately supra-threshold. (As a guide, 60–70
dB HL is suitable for routine purposes, although consideration should be given to the type and
degree of hearing impairment anticipated.) Also, a different frequency may be selected if it is
judged that the child is likely to be more responsive (e.g. a lower initial frequency would be
appropriate if there is suspicion that the child has a high-frequency hearing loss). See Section
7.6.
If the child gives a clear head turn within 2–3 seconds of the stimulus presentation then visual
reinforcement is provided in combination with the sound for a further 2–3 seconds. If
repeatable, conditioning can be considered to be established and the test sequence begins.
2. If the child does not respond spontaneously with a head turn, a more formal conditioning
procedure is needed. Initially stimulus and reward are presented simultaneously and if
necessary the child’s attention directed towards the reward. A number of such paired
presentations may be required. When a head turn response is reliably elicited to the combined
stimulus conditioning is checked by presenting the auditory signal alone and presenting the
visual stimulus as a reward after the head turn response. Once the child is responding to sound
alone testing can begin.
3. If the child responds to the combined stimulus/reward but fails to demonstrate a response to
the stimulus alone it may be that the stimulus is insufficiently interesting or is not audible. The
assumption should be that it is not audible and the presentation level increased (e.g. by 10 dB).
If no response is observed at this higher level then differentiation between interest/inaudibility
can be assessed by changing the stimulus type (e.g. to NBN, although see Section 6.1) or
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changing the frequency of the stimulus. Using a vibrotactile stimulus generated from the bone
vibrator (such as around 40 dB HL at 250 Hz) with reconditioning using the paired presentation
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should show a response even in a deaf child. If the tone is still inaudible at 80 dB HL, then care
shall be taken to increase the level of the tone in 5-dB steps until a response is observed, while
continuing to monitor the child for discomfort (e.g. blinking, crying).
4. If the child is not responding to the stimulus/reward combination it may be that the reward is
insufficiently visible or interesting. This may be remedied by lowering the room lighting,
changing the reward, using two or more rewards in combination or moving the visual reward
closer to the child. Alternatively it may be that the child is not developmentally ready for the
procedure or is not sufficiently motivated by the reward in which case other test procedures will
be required.

7.2.3 Testing

When conditioning is secure (at least two consecutive correct responses), Tester 1 will proceed to the
test trials proper. Here sound only will be presented for 2–3 seconds. If Tester 1 judges that the child has
turned in response to the sound, then visual reinforcement will be presented for 1–2 seconds, with
overlap of the stimulus in order to continue a clear association between the two. The desired response
is a clear head-turn to view the reinforcer. Eye glances or small movements should be interpreted with
more caution and be reported as such.

False ‘checking’ responses will be managed by using variable inter-trial intervals, some of long duration,
and additionally use of deliberate no-sound control trials may be employed. Withholding the visual
reinforcer for a moment or two after the child turns also may help to distinguish checking glances, which
are often short-lived, from real responses.

Once responses have been established to the initial high level, the level should be dropped as rapidly as
possible (e.g. 20-dB steps) as long as responses are still observed. Tester 1 should determine
presentation level based upon age of the child, attention state, and other factors concerned with time.
However, around the estimated MRL, a ’10-dB down, 5-dB up’ rule (BSA 2011a) should be adopted. The
criterion for minimal response level will be the lowest level at which a response occurs at least 2 out of 3
of ascending trials (i.e. >50 %). False positive responses should be discounted from judgment against
the criterion defining a MRL. Minimum response level at one frequency should be defined before
moving to another frequency where possible.

The initial and subsequent test frequencies will vary for each patient, depending on the information
obtained by previous methods and the need to acquire further information. When changing stimulus
frequency, present the initial stimulus at a level judged to be at or above threshold. It may also be
helpful to present clear supra-threshold stimuli or re-condition a child who has become distracted. For a
child who is restless or bored, various techniques can be used to maintain interest, e.g. changing
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stimulus type and choice or reward. Where ear-specific information is sought, insert ear phones should
be used. This could be achieved for one or more frequencies in each ear following sound-field VRA. In
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instances where the child rejects the inserts, or has reduced interest/awareness, the child’s localisation
ability for NBN or voice (supra-threshold, up to 30 dB above the minimal response level) may be
assessed, using both low and high frequency NBN. It may be necessary to recondition the child using
loudspeakers on both sides. Difficulty with localisation may indicate an asymmetric hearing loss, and
may warrant the need for testing each ear individually using insert earphones. An ability to localise
successfully, however does not exclude the possibility of an asymmetric loss. Therefore, where medical
or parental history indicates the need to investigate for an asymmetric hearing loss, then ear-specific
information should be the goal.

The selection of transducer to use will not be covered in depth in this Recommended Procedure; as with
selection of frequencies for testing, this will depend upon the profile of information previously obtained
on the child and that required for further management. However, use of insert earphones is strongly
preferred for those suspected or known to have a permanent hearing loss, in order to obtain reliable
ear-specific information.

7.3 Tips for effective VRA testing

● The procedure relies on continued cooperation of the child, in particular their ability to stay in the
required test position and to maintain interest; time will therefore be limited. To avoid
delay/disruptions ensure that all required equipment is checked in advance (Stage A calibration
checks are completed, reward system operating and communications equipment ready for
immediate use).

● Some children may be upset by certain animated toys. If so, reward through simple illumination
rather than animation or switch to alternative toys.

● To extend interest in responding, switch reward toys and/or use in combination. Also be prepared
to take a break from testing and return to complete the assessment, or switch testers. The interest
of older children in particular may be extended by praise/encouragement of correct head turn,
provided by Tester 2.

● Towards the end of the test procedure, return to the first frequency tested and present at MRL (or
5 dB above that dial level); does the child still respond? This information will help the tester judge
validity of later responses.

7.4 The most common pitfalls of VRA testing

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● Inadequate test set-up and communication between testers

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● Attempting conditioning to sub-threshold stimuli

● Not establishing clear responses at supra-threshold levels before descending to threshold

● Incorrect scoring as true responses i.e. scoring of movement other than a clear head-turn, or false
positive (checking) responses

● Distinct and/or rhythmical phasing of attention by Tester 2 such that response cues are given to the
patient

● Use of toys or behaviour by Tester 2 (or parent) that provides too little or too much engagement for
the child and therefore inhibit responses

● Overemphasis on quantity of results (number of MRLs obtained) rather than quality (reliability) of
those MRLs obtained

● Not using time efficiently, often spending too long at high intensities

● Inaccurate interpretation and reporting of results due to inadequate consideration of differences in

infant MRLs compared to adult normative (threshold) values (see Section 8.1)

● Obtaining MRLs with speakers on right and left and interpreting these as providing ear-specific
information (which they do not)

● Cues from parents (e.g. parents moving when sound is presented)

● Tester response bias (e.g. tester believing or wishing that child’s hearing is normal) leading to lack
of objective interpretation of turns vs. checks.

7.5 Testing children with vision disorders, with other disabilities or at an early age

Visual disability may interfere with conditioning and responses. Consider bringing the reward closer to
the child. Alternatively use of more visually contrasting rewards (e.g. bright flashing light), or removal of
the smoked Perspex cover to the reinforcer unit should be considered. Dimming the room lights will also
increase the contrast. For the more severely visually impaired, or children with complex needs, use of
other sensory reinforcement such as air puffs, vibratory stimulation or music may be needed to bring
children under stimulus control.
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General developmental delay may not necessarily interfere with VRA. However, motor difficulties may
obscure head-turn responses. A more flexible approach to response reward and interpretation may be
appropriate. However, any deviations from the standard approach should be described when reporting.

Although VRA is generally reliable in assessment of normally developing children from age 30 weeks
(corrected age), some infants may be testable at younger ages, from age approximately 20–26 weeks.
Testing at this age may be required because of parental or professional concern and is of particular
value to early diagnosis and habilitation. However, when testing younger children who have not yet
achieved object permanence in their developmental stage (Piaget and Inhalder, 2000), it might be
required to stop and cover/hide the engagement activity. The child will otherwise be unable to respond
to a different stimulus (e.g. the acoustic signal presented) due to their inability to switch attention. It
should be recognised that a sequence of test appointments may be required to incrementally gain the
information required (e.g. a series of frequency and ear-specific MRLs).

For children with disabilities or where VRA is used speculatively at an early age, a realistic appraisal of
the likelihood of test success should be presented to parents/carers before testing. Testers should also
seek the advice of parents/carers in advance of assessment to determine the appropriate test strategy.
For more detailed information on conducting VRA for children with disabilities, clinicians are advised to
refer to Coninx and Lancioni (1995).

7.6 Sequence and objectives of assessment

The sequence of assessment should be adapted depending on the objectives of the Audiologist and the
status of the child. However, the testers must be aware that the cooperation/interest of the child may
fail at any time and this should be reflected in the sequence of assessment: the clinically more important
information should be obtained first. As a guide the following sequences are suggested for an initial
formal behavioural assessment commencing with stimuli presented in the sound-field:

2 kHz → 500 Hz → 4 kHz → 1 kHz or

1 kHz → 4 kHz → 500 Hz → 2 kHz

Sound-field testing could be followed by delivery of stimuli through insert earphones where ear specific
information will be of use (e.g. where the possibility of significant asymmetry is indicated by the history)
or where results will be used to guide amplification. Likewise, BC testing may be indicated, albeit with
awareness of increased likelihood of vibrotactile responses at the lower frequencies compared to adults
(see BSA, 2011a). If ear-specific MRLs are desired and use of insert earphones is contra-indicated (e.g.
due to wax) circumaural headphones could be considered (on headband or held over the ear).The
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timescale for acquisition of MRLs should be considered carefully. On the basis that quality of results
takes prominence over quantity (of MRLs) consideration should be given to arranging a sequence of
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appointments. This is particularly important where a large quantity of information is required and/or
where the child is only just at sufficient developmental age or has relevant disabilities. A duration of 30
minutes would be typical for an assessment appointment that included sound-field VRA.

8. Interpretation of results
The process described above provides calibration to adult norms for a conventional audiometric
technique. There are no specific international standards on the RETSPL values for stimuli used for VRA.
Audiologists should be mindful of the influence of age of subject and the test method employed when
interpreting and reporting results. Consideration should also be given to the use of MRL information,
whether to inform others (e.g. ENT medical colleagues) of hearing status or for use by the Audiologist to
guide effective amplification to a prescriptive target.

There are numerous factors contributing to the known difference between infant VRA MRLs and adult
normative thresholds. These include sensory and non-sensory factors (including ear canal size) and
other factors such as the effects of subject generated noise. The effect of these contributory elements is
complex and not fully understood. However, the sum of these effects is that normally hearing infants
performing VRA require a higher intensity stimulus to induce a response (e.g. a head turn) than that
required for normally hearing adults performing pure-tone audiometry. Although some studies have
investigated and reported on the difference between MRLs obtained by VRA in infants and adult
threshold normative data, the data set (relating to test frequency, age of subject and type of transducer)
is far from complete. Further studies are required to confirm and build upon this knowledge base before
we can endorse a series of specific correction factors for VRA (as is the case for auditory brainstem
response testing of newborn babies). With due consideration of the above, the materials presented
below (and in the references) represent current information on the scale of infant-adult correction
factors based upon the mode of stimulus delivery, stimulus type and age. Consequently, the correction
values indicated are provisional at this time.

8.1 Sound-field

Information available on the relationship between adult thresholds and MRLs for sound-field VRA,
indicate that normally hearing infants (ages 7–12 months) present mean thresholds at approximately
+10 dB relative to adult thresholds (from 0.5–4 kHz). An infant with an MRL at 45 dB HL, for example
could be considered to have equivalent hearing to an adult responding at 35 dB HL. Therefore, it is
suggested that when testing infants by VRA in the sound-field, hearing should be tested down to at least
25 dB HL (equivalent to adult 15 dB HL) and that responses at this level are accepted as indicative of
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hearing within normal limits. Such guidance should not discourage testing down to lower levels, for
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results should be mindful that sound-field assessment only indicates the hearing status of the better
hearing ear at each test frequency.

8.2 Insert earphones

For insert earphones, the frequency-specific correction factors are equivalent to the MRLs measured in
studies on normally hearing children, examples of which are presented in Table 1. The Parry et al (2002)
study employed a VRA protocol similar to that described here and was conducted on 8–12 month old
infants with normal hearing. The Nozza et al (1995, 1999) studies were conducted on infants in the age
range of 6–11 months.

Table 1
Comparison of MRLs in infants for insert earphone VRA studies, in children with normal hearing.
Studies Infant mean MRLs, dB HL (standard deviation)
500 Hz 1000 Hz 2000 Hz 4000 Hz
Nozza (1995) 14.1
Nozza and Henson (1999) 17.2 6.8
Parry et al (2002) 16.4 (5.9) 13.3 (6.1) 7.1 (5.5) 6.4 (6.2)

Recommended provisional 15 15 5 5
value

The normative values presented above may be used as correction factors by subtracting these values
from the MRLs to provide the estimated PTA hearing threshold levels. The resulting values may
therefore be more comparable to an adult audiogram and as such suitable for interpretation by non-
audiological colleagues.

For example, when an infant obtains an MRL of 30 dB HL at 500 Hz using inserts, the conversion to an
adult hearing threshold level would be 30–15 = 15 dB HL. For an MRL of 30 dB at 2 kHz, the conversion
to an adult hearing threshold would be 30–5 = 25 dB HL. However, as such studies have only been
carried out on normally hearing infants, it is possible that these correction factors do not apply to
children with sensorineural hearing impairment. In addition, clinicians should be aware that there are no
studies that investigate such MRLs in older children.
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Correction of raw MRLs obtained by insert earphone VRA may also be appropriate when estimating the
audiometric profile, for inputting to hearing aid prescription formulae.

8.3 Bone conduction

No studies have been identified that provide correction factors between bone conduction VRA MRLs
and sound-field thresholds in dB HL. In view of this, it is important to label results appropriately where
BC MRLs are presented alongside corrected AC MRLs.

9. Recording and reporting of results

Reporting of the results should fulfil two purposes: firstly to give the final result of the MRLs for the
frequencies tested and secondly to provide the information relevant to subsequent interpretation and
to guide further assessment. Additionally, given the concept of MRLs, care should be taken in reporting
results to other professionals who may be more familiar with interpreting thresholds rather than MRLs.
It may be useful to retain the recording form for audit purposes.

The records and reporting of results should be clearly accompanied by a description of the type of
transducer, and any comments on the reliability of responses or factors preventing completion of the
test. Also each audiogram record should indicate whether recorded levels are MRL or corrected to
provide estimated adult thresholds.

The criterion to determine an MRL should be responses to > 50 % of presentations with at least two
positive responses at the MRL. Occasional false positive responses (checking responses; where the child
turns without a sound presentation) are quite common to VRA testing. However if excessive they may
have the impact of lengthening the time taken to secure reliable MRLs, possibly preventing completion
of the assessment. Excessive false positive responses should be reported for future reference.

Other factors that may have impacted on the reliability of the test should be recorded/reported: the
alertness state of the child can range from drowsy /sleepy to overactive/overexcited, noisy breathing
may mask the sound presented and/or the observed responses may be less distinct than a full head turn
towards the reinforcer.

Recommended symbols for recording the results of sound-field testing are given in Appendix D. Symbols
for inserts or headphones shall follow the BSA (2012) procedure for recording PTA, with clear indication
of which transducer was used on the audiogram. When masking has not been used, and there is a risk of
cross-hearing, this shall be clearly indicated on the audiogram.
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If a child responds reliably to the lowest sound levels tested at a particular frequency, the result shall be
reported as less than or equal that level, e.g. tested down to 25 dB HL, but not below this level is
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reported as ‘≤ 25 dB HL’. To indicate this on an audiogram the following symbol shall be used: an arrow
pointing diagonally to the right top away from the test level. However, this symbol level shall NOT be
connected with a line to any neighbouring symbol (of whatever type).

Where recorded results represent the MRLs (dial settings), this should always be clearly indicated in the
narrative associated with each audiogram or reported numeric results. Similarly, the nature of any MRL
threshold corrections applied (to guide interpretation or to provide an estimated audiogram for the
purpose of prescription for amplification) should be indicated.

It is recognised that determination of individual clearly observed MRLs that meet the criterion (see
Section 6.2.3) may not always be secured, often associated with a paucity of other information to guide
patient management. In such circumstances estimations may be required based on incomplete data.
Such estimated MRLs/thresholds must be clearly recorded/labelled as such pending confirmation
through reliable assessment.

The Audiologist leading the VRA procedure should be responsible for ensuring that results are
appropriately documented and reported.

Finally, guidance on the matter of MRL to adult threshold corrections may change with the outcome of
further research. The use of this (standardised) VRA protocol in further research studies around VRA
MRLs is encouraged in order to enable the transfer of outcomes of research across test, and
collaboration between, centres.

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10. References
Anderson, J E. (1955). Review of the construction of reality in the child. Psychological Bulletin 52 (6):
526-528.

British Society of Audiology (2003) Procedure for processing documents. Reading: British Society of
Audiology.

British Society of Audiology (2008). Guidelines on the acoustics of sound field audiometry in clinical
audiological applications. British Society of Audiology, Reading.

British Society of Audiology (2010). Recommended Procedure. Ear examination. British Society of
Audiology, Reading.

British Society of Audiology (2011a). Recommended Procedure. Determination of uncomfortable

loudness levels. British Society of Audiology, Reading.

British Society of Audiology (2011b). Recommended Procedure. Pure-tone air-conduction and bone-
conduction threshold audiometry with and without masking. British Society of Audiology, Reading.

Coninx F, Lancioni GE (Eds) (1995). Hearing assessment and aural rehabilitation of multiply handicapped
deaf children. Scand Audiol 24: Suppl 41.

Day J, Bamford J, Parry G, Shepherd M, Quigley A (2000). Evidence on the efficacy of insert earphone
and sound-field VRA with young infants. Brit J Audiol 34: 329–334.

The Health and Safety Executive (2005) Controlling Noise at Work. The Control of Noise at Work
Regulations 2005. Guidance on Regulations. Crown.

ISO 8253-2 (1992). Acoustics - Audiometric test methods. Part 2 - Sound field audiometry with pure tone
and narrow band signals

Karzon RK, Banerjee P (2010). Animated toys versus video reinforcement in 16–24-month-old children in
a clinical setting. Am J Audiol 19: 91–99.

National Hearing Screening Programme Clinical Group (2008) Visual reinforcement audiometry testing
of infants: a recommended test protocol.

Nozza RJ (1995) Estimating the contribution of non-sensory factors to infant-adult differences in

behavioural thresholds. Hear Res 91: 72–78.
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Nozza RJ, Henson A (1999) Unmasked thresholds and minimum masking in infants and adults: separating
non-sensory contributions to infant-adult differences in behavioural thresholds. Ear Hear 20: 483–496.

Parry G, Hacking C, Bamford J, Day J. (2003). Minimum response levels for visual reinforcement
audiometry in infants. Int J Audiol 42: 413–417.

Piaget J, Inhelder B (2000) The Psychology of the Child. New York NY: Basic Books.

Rowan D, Gomez R, Holmes H, Lantz J (2013). FRESH noise. Presentation at British Society of Audiology
Paediatric Interest Group Conference, Sheffield, April.

Shaw P (2004) Visual reinforcement audiometry. In B McCormick (ed), Paediatric Audiology 0-5 years
(3rd ed), pp 108–150. London: Whurr.

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Appendix A. Authors and acknowledgments

This is a revised version of a document written by a small group (John Day editor, Roger Green, Kevin
Munro, Georgina Parry, Paul Shaw, Sally Wood, Ed Brown and Graham Sutton, 2008), which built on an
earlier document with contributions by John Bamford and Marianne Gliddon; the previous documents
were approved by the NHS Newborn Hearing Screening Programme (England) Clinical Group.

The ongoing review of the document was handed over to the BSA in 2011, the current document being
the first BSA version of the document. It was revised and processed by the Professional Practice
Committee, in collaboration with BSA’s Paediatric Interest Group and with John Day, between May 2011
and March 2014, in accordance with BSA Procedure for Processing Documents (2003).

The PPC thanks all involved with previous versions of this document and all who contributed to the
current review and consultation (Spring 2012). An electronic copy of the anonymised comments
received during this consultation, and the responses to these by the authors, is available from BSA on
request.

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Appendix B. Definitions
Azimuth. Direction of a sound source measured in angular degrees in a horizontal plane in relationship
to the listener. For example, 0° azimuth is directly in front of the listener and 180° is directly behind.

Corrected age. Used to describe the age of children under 2 years old who were born preterm and
represents the age of the child from their expected date of birth. For example, a 36-week-old who was
born at 28 weeks gestation (i.e. 12 weeks early) has a corrected age of 24 weeks.

Chronological age. Usually referred to as ‘age’; time since birth.

Developmental age. The age level at which the child is functioning relative to her/his developmental
abilities. This can be above or below the chronological age.

Distractor. This term should be avoided and ‘engager’ be used instead. This is because the aim of this
role is to maintain the attention of the child towards the front, without being too engrossed.

Engager. The tester in the room in front of the child who keeps the child engaged and keeps the child's
interest on the table in between them.

Minimal response level (MRL). The criterion for the MRL is the lowest level at which a child responds in
at least 2 out of 3 of ascending trials (i.e. >50 %) at that level for a given stimulus and method of
presentation. While this criterion is similar to that used for 'hearing threshold' on pure-tone audiometry
(BSA, 2011a), the interpretation may not be. The MRL may only be the lowest level at which the auditory
signal was sufficiently strong to overcome the child's attention to the engagement activity.
No-sound control trial. A point in time during hearing assessment that is designated to observe the
child’s reaction without sound presentation and with all other parameters exactly the same. This is in
order to evaluate the probability/likelihood of the child producing false-positive responses.

Object permanence. A stage in child development when the child is aware that an object continues to
exist even though it can no longer be observed. For example, when an object falls off the table such that
the child can no longer see or hear it, the stage of object permanence has been reached if the child is
aware that the object must still be in existence.
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Appendix C. Suggested single-room layout

Monitor linked to
camera L R
Audiometer Curtain CCTV
Screen Camera
Reinforcer 90°
Control Box T
Tester 1 Subject 0°
S T
Low Tester 2
P Table
Parent

Loudspeaker R
L Reinforcer
Double-walled test room Cabinet

Figure 2
Recommended layout of test area if using single-room format.

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Appendix D. Symbols
Table 2 presents the symbols suggested for recording the results of sound-field testing on the
audiogram (from ISO 8253-2). In the case of sound-field testing, MRLs will usually be bilateral. In the
case of monaural results, it shall be noted with the audiogram how this was achieved (e.g. by occluding
contralateral ear and with what occlusion). It is important to remember that any form of occlusion of
the non-test ear has only limited attenuation and that this attenuation is probably unknown for child
ears. Consequently, responses to sounds presented to the test ear can therefore reflect hearing from
the occluded, non-test ear if the level of the sound is sufficiently high, similarly to cross-hearing with
PTA. It should always be noted on the audiogram form whether symbols represent thresholds or
minimal response levels.

Table 2
Recommended audiogram symbols for sound-field. ‘Monaural’ results indicate that the possible
involvement non-test ear has been reduced, such as by occluding it; the specific method used to achieve
this shall be noted with the audiogram.
Test condition Symbol
Monaural, left ear X
Monaural, right ear O
Bilateral B

Monaural, left ear aided

Monaural, right ear aided

Bilateral, aided

An example of sound-field results plotted on an audiogram form is given in Figure 3. In this example, the
responses are assumed to reflect the right ear, such as by occluding the left ear and the method of
occlusion would be recorded with the audiogram. If there is reason to doubt that assumption (i.e. if it is
unclear which ear is involved in the response), such as with the unaided results above 500 Hz, then the
results would instead be indicated by a ‘B’ symbol on the audiogram. Note that if computer-generated
audiograms are being produced, these symbols may not be available; a key shall therefore be provided
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that clearly identifies the meaning of all symbols used.

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Figure 3
Example of sound-field symbols plotted on the audiogram. It also should also be noted how monaural
testing of the right was achieved (e.g. using an ear plug in the left, and which type of plug). The symbol B
would be used if it were unclear which ear was involved in the responses.

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