EVIDENCE VERDICT
Published studies do not identify one reinforcer that works best for every child, and the professional guidelines agree. The British Society of Audiology calls the toy-versus-video evidence "mixed and inconclusive." Patient response should drive the choice. DualStim gives the clinician both formats in one setup.
The short answer
Toy VRA and video VRA can both support effective testing. Direct comparison studies reached mixed results, and the guideline bodies read the evidence the same way: the BSA calls it "mixed and inconclusive," AAA lists animated-toy boxes and video systems as equivalent, ASHA lists lights, moving toys, and video clips without ranking them. For a clinic choosing equipment, the sound approach is simple: pick the format that fits most of your work, or keep both formats available when your patient mix makes flexibility worth the added cost.
What the direct studies found
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Video: more head turns in 2-year-olds
Schmida, Peterson, and Tharpe studied 40 2-year-olds. The video group averaged about 15 head turns before habituation vs about 11 with one conventional animated toy.
Limit: did not test every toy or video set, and measured head turns, not threshold data.
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Similar responses in younger infants
Lowery and colleagues tested 14 infants aged 7 to 16 months with both formats. No significant difference in head turns, hit rate, false alarms, or sensitivity.
Limit: small sample, normal-hearing infants only.
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Toys: more thresholds in clinical use
Karzon and Banerjee studied 145 children aged 16 to 24 months in a fast-paced practice. Animated toy VRA averaged 5.52 threshold estimates vs 3.47 for video.
Limit: the authors linked the difference to the number and strength of reinforcers, and recommended keeping both formats available.
Strengths and limits, format by format
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3D Toy VRA
Strengths
- Physical, three-dimensional reward with light and motion; animation alone more than doubled responses in one study
- Performed best in the largest direct clinical comparison (145 children, 16 to 24 months)
- Gains strength from multiple or novel toys
- Lower starting price in the Pehratek line
Limits
- Performance depends on the appeal and number of toys
- Changing the reward may require a physical toy change
- One study of 2-year-olds found more head turns with video
- Some children are frightened by an animated toy; reward with simple illumination when that happens
A practical fit: clinics that want a proven physical format, a lower entry cost, and a simple setup.
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HD Video VRA
Strengths
- Holds a library of different visual rewards in one system; evidence consistently favors variety and novelty
- Fast content changes and clinic-selected content
- More head turns than one conventional toy in a study of 2-year-olds
- Custom clips may help children with developmental disabilities and specialist interests (BSA)
Limits
- Fewer threshold estimates than animated toys in the largest clinical comparison
- Results may depend on clip choice, length, brightness, motion, and sound
- Screen familiarity may change novelty for some children
- Tailored-video outcomes for developmental disabilities are not yet proven
A practical fit: clinics that value a broad content library, quick changes, custom content, and a low-profile wall setup.
DualStim VRA: when both formats make sense
DualStim places toy and video reinforcers at the left and right test positions. The clinician can begin with either format and use the other based on the child's response. It follows the most defensible lessons in the literature: novelty, variety, and the strength of the reward affect response behavior, while the direct toy-versus-video evidence remains mixed.
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DualStim may fit when your clinic:
- Tests a high number of infants and toddlers
- Serves a broad range of developmental ages and patient needs
- Wants a second reinforcer format ready when the first loses value
- Expects to use custom video content and changeable physical toys
- Prefers one purchase and one installation plan for both formats
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A single-format system may fit when your clinic:
- Has a lower pediatric test volume
- Has a clear team preference based on past clinical use
- Needs the lowest starting cost
- Can add or change reinforcers without disrupting the room
DualStim gives access to both formats. No published trial has tested DualStim or shown that a combined system improves accuracy, increases completed thresholds, cuts test time, or prevents repeat visits.
Getting more from any reinforcer
The strongest evidence in this literature is not about format. It is about how reinforcement is used.
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Keep the reward brief
A 0.5-second reward produced more responses and slower habituation than a 4-second reward in 2-year-olds.
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Use more than one reinforcer
Two reinforcers produced more responses than one. The BSA recommends at least two per side.
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Save novelty for when you need it
Novel reinforcers restored responding after habituation. AAA advises holding some in reserve.
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Use breaks
A 10-minute break significantly increased the responses obtainable after habituation in 1-year-olds.
Compare Pehratek VRA systems
Every price below is a complete left + right system, with the 90-day trial and the 3-year warranty.
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HD VIDEOHD Video VRA
Bright video reinforcement with an included library and support for clinic-selected content. Available in IR and RF.
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Both formats, one systemDUALSTIM
DualStim VRA
Toy and video at both test positions, with center options to match the room and workflow.
Centering options
Centering units bring the patient's attention back to neutral between trials. All three work with your existing Pehratek VRA remote.
All centering units work with your existing Pehratek VRA remote
Still unsure?
Tell us about your patient mix, room, current setup, and budget. Pehratek will recommend a system and explain the tradeoffs.
Findings vary by age group, study design, reinforcer content, and outcome measured.