Toy + Video VRA: When Having Both Reinforcer Types May Make Sense

A combined toy and video Visual Reinforcement Audiometry (VRA) system may make sense when a clinic tests many children, sees a wide range of developmental needs, or wants a planned alternative ready the moment a first reward loses its pull. The research record supports reinforcer variety and individualized choice. It does not prove that a combined commercial system improves thresholds, test speed, completion rates, or accuracy, and any vendor who says otherwise is ahead of the evidence.

That distinction matters because the combined configuration is usually the larger purchase. This article covers what “toy plus video” means, what studies support, what remains unproven, and which clinic profiles get real value from both formats, with a decision grid to bring to a purchasing conversation.

What does a toy plus video VRA system mean?

A toy plus video VRA system gives the test room access to both physical animated toy reinforcers and screen-based video reinforcement, either as separate units mounted on each side of the booth or as a combined product. The Pehratek DualStim configuration provides both reinforcer formats in one system.

In practice, a toy reinforcer is a lighted, animated three-dimensional toy that activates when the child gives a correct head turn. The Pehratek XM-5000 Series 5 3D Toy system offers over 3800 combination possibilities across 10 sounds, 3 movements, and 5 colored LED patterns. A video reinforcer plays a short clip on a screen; the Pehratek VDS-3000 Series 3 HD Video system uses a 15.6 inch screen with articulating arm brackets included. A combined setup puts both options within reach of the same remote during the same session.

What does the evidence support?

Peer-reviewed research supports reinforcer variety, complexity, and novelty rather than one winning format. A 2025 scoping review of 59 studies found that more varied and complex visual reinforcers improved response behavior, and the largest direct toy versus video comparison recommended that practices testing large numbers of children keep both reinforcer types available.

The three direct format comparisons point in different directions, which is itself the finding. Schmida, Peterson, and Tharpe (2003) tested 40 two-year-olds and reported about 15 head turns before habituation with video against about 11 with a conventional toy. Lowery and colleagues (2009) found no significant differences between the two formats in 7 to 16 month old infants. Karzon and Banerjee (2010), the largest of the three with 145 children ages 16 to 24 months in a clinical setting, reported about 5.5 threshold estimates per session with animated toys against about 3.5 with video, and concluded that practices testing large numbers of children should have both types of reinforcement available to match the individual child.

Around those comparisons sits a consistent theme. Primus and Thompson (1985) reported that introducing a novel reinforcer renewed responding in 2-year-olds. Thompson, Thompson, and McCall (1992) found that using two reinforcers produced more responses than one. The 2025 scoping review by Visram and colleagues synthesized this literature and tied better response behavior to reinforcer variety and complexity, short reinforcer durations, and breaks.

What has not been proven?

No published trial has tested a combined commercial toy plus video system against a single-format system. There is therefore no evidence base for claims that a combined system improves thresholds, shortens test time, raises completion rates, or works better for a specific diagnosis. Buyers should treat any such claim, from any vendor, as unproven.

That includes the Pehratek DualStim. The studies above tested reinforcer formats and strategies in general, not this product, and the same scoping review that supports variety also states that further evidence is needed on the benefits of different reinforcers (Visram et al., 2025). What a combined system demonstrably gives a clinician is a second format on hand, in the same session, without rescheduling. Whether that changes a given clinic’s outcomes has not been measured, and this page will not pretend it has.

Which clinic profiles may value both formats?

Clinics most likely to value both formats test a high pediatric volume, see a broad developmental range, work with children who have strong specific interests, or want a planned alternative ready when the first reinforcer loses value. These are practical fit factors drawn from the research context, not evidence of a clinical outcome.

The developmental-range point deserves the most weight. Bonino, Mood, and Dietrich (2025) reviewed records of about 131,800 children across three hospitals and found that roughly 24 percent of children with developmental disabilities, versus about 9 percent of other children, had no completed diagnostic hearing assessment (audiogram or auditory brainstem response) in the study window. Separately, Bonino and colleagues (2021) built an openly licensed library of 45 reinforcer sets around commonly reported interests of children with developmental disabilities, noting that clinical effectiveness still needs study. Neither paper tested Pehratek equipment or proved that any reinforcer format closes those gaps. They do show why clinics serving these caseloads often want more ways to reach a child.

When may one format be enough?

One format is often enough for clinics with lower pediatric volume, a known reinforcer preference, a tighter budget, or limited booth wall space. A clinic already satisfied with its reinforcer plan does not need a second format, particularly when the platform allows adding equipment later instead of buying everything on day one.

Here is the decision grid in one place.

Factor	One format may be enough	Both formats may fit	Claim limit
Pediatric volume	Occasional VRA sessions	Daily VRA caseload	Karzon and Banerjee (2010) recommended both formats for high-volume practices; no trial has tested a combined commercial system
Developmental range	Mostly typically developing children	Frequent developmental disability or specialist-interest caseload	Access studies show assessment gaps; no study proves a format closes them
Habituation plan	Variety within one system (the XM-5000 3D Toy offers over 3800 combinations)	A ready mid-session switch to a second format	Novelty and variety improve response behavior in studies; outcomes for combined products are unmeasured
Room and mounting	Limited wall space beside the booth window	Space for toy and screen positions on each side	Site survey question, not a clinical one
Budget and timing	Tighter budget; start with one format	Budget for the full configuration now	No study justifies calling the combined purchase clinically necessary
Upgrade path	Add the second format later if the platform permits	Both installed and controlled from one remote on day one	Confirm upgrade options with the manufacturer before ordering

How should buyers compare combined systems?

Compare combined systems on reinforcers per side, independent control of each unit, how content and combinations change, control over light, motion, and sound, centering options, remote control path, mounting hardware, total cost of ownership, service terms, and upgrade path. A structured checklist keeps the decision grounded in the test room rather than the brochure.

On the control path, ask whether one remote runs everything. The Pehratek SMART remote uses eight buttons to control all units, including centering units, and is available in RF (four channels, omni-directional) and IR (line-of-sight) versions. Centering units matter more in a two-format room because they reorient the child’s attention back to a neutral starting position between presentations, whichever side rewards next. Ask about installation load as well: Pehratek systems are plug and play, with no computer, no software, and no calibration required. Finally, weigh the risk terms; Pehratek backs all orders with a 90 day trial and a 3 year warranty on US orders. For the full walkthrough, see our guide on how to choose a VRA system, and for the underlying studies, the companion posts on what toy versus video research shows, toy VRA strengths, and video VRA strengths.

Frequently asked questions

Is a combined VRA system better than toy-only or video-only?

Not as a matter of evidence. Studies support reinforcer variety and matching the reinforcer to the child, and the largest toy versus video comparison recommended access to both formats for high-volume practices. No trial has shown that a combined commercial system produces better thresholds, faster tests, or higher completion rates.

Can the clinician switch from toy to video during testing?

That depends on the system’s control design, so confirm it before buying. On Pehratek systems, the SMART remote controls all units from one handset, which lets the clinician move between toy, video, and centering units within a session. Ask any vendor to demonstrate a mid-session switch.

Who may benefit from access to both formats?

Clinics with a high pediatric caseload, a broad developmental range, or frequent visits from children with strong specific interests tend to value a second format most. These are practical fit factors, not proof of a clinical outcome, so weigh them against budget, room space, and your current reinforcer plan.

Does DualStim prevent habituation?

No product can claim that. Research links reinforcer variety, novelty, short reinforcer durations, and breaks to more responses before habituation, and the Pehratek DualStim provides both toy and video reinforcer formats in one system. Whether that changes habituation in a given clinic has not been tested in a published trial.

Can a clinic start with one format and add the other later?

Often yes, and it is a reasonable path for a lower-volume clinic or a tighter budget cycle. Confirm the upgrade route with the manufacturer before the first order, including mounting, remote compatibility, and whether existing units keep working alongside the added format.

Can schools buy a combined VRA system through a purchasing cooperative?

Pehratek VRA systems are available through BuyBoard Contract 804-26, with Inspiration Medical Technology as the awarded vendor. That path lets school districts and other public-sector buyers purchase through an already-competed contract, which typically shortens procurement review. Contact Pehratek to confirm the configuration before requesting a quote.

Pehratek has been making VRA systems since 1979, and the honest answer on the combined configuration is that it fits some clinics and not others. Compare the Pehratek Toy, Video, and DualStim configurations side by side, or write to info@pehratek.com with your caseload and room details and we will tell you plainly which setup we would put in your booth. School and public-sector buyers can purchase through BuyBoard Contract 804-26.

This article is educational content for hearing-care and procurement professionals. It is not medical advice. Product availability and specifications can change; confirm current details at pehratek.com.

References

• Visram AS, Jackson IR, Almufarrij I, Stone MA, Munro KJ. Optimisation of visual reinforcement audiometry: a scoping review. International Journal of Audiology. 2025;64(8):773-783. https://doi.org/10.1080/14992027.2024.2397716
• Schmida MJ, Peterson HJ, Tharpe AM. Visual reinforcement audiometry using digital video disc and conventional reinforcers. American Journal of Audiology. 2003;12(1):35-40. https://doi.org/10.1044/1059-0889(2003/008)
• Lowery KJ, von Hapsburg D, Plyler EL, Johnstone P. A comparison of video versus conventional visual reinforcement in 7- to 16-month-old infants. Journal of Speech, Language, and Hearing Research. 2009;52(3):723-731. https://doi.org/10.1044/1092-4388(2008/07-0270)
• Karzon RK, Banerjee P. Animated toys versus video reinforcement in 16-24-month-old children in a clinical setting. American Journal of Audiology. 2010;19(2):91-99. https://doi.org/10.1044/1059-0889(2010/10-0009)
• Primus MA, Thompson G. Response strength of young children in operant audiometry. Journal of Speech and Hearing Research. 1985;28(4):539-547. https://doi.org/10.1044/jshr.2804.539
• Thompson G, Thompson M, McCall A. Strategies for increasing response behavior of 1- and 2-year-old children during VRA. Ear and Hearing. 1992;13(4):236-240. https://doi.org/10.1097/00003446-199208000-00005
• Bonino AY, Hemann A, Mood D, Kay E, Pancoast ES, Sommerfeldt KK. Visual reinforcers designed for children with developmental disabilities. Journal of Early Hearing Detection and Intervention. 2021;6(1):69-76. https://pmc.ncbi.nlm.nih.gov/articles/PMC8061901/
• Bonino AY, Mood D, Dietrich MS. Rethinking the accessibility of hearing assessments for children with developmental disabilities. Journal of Autism and Developmental Disorders. 2025;55(10):3711-3721. https://doi.org/10.1007/s10803-024-06461-9