Toy VRA vs. Video VRA: What Does the Research Actually Show?

Current evidence in Visual Reinforcement Audiometry (VRA) does not establish one reinforcer format as best for every child. Three direct comparison studies reached different results: one favored video for head turns before habituation, one found no meaningful difference, and the largest, a clinical study of 145 children, favored animated toys for threshold estimates. The 2025 British Society of Audiology (BSA) recommended procedure describes that comparative evidence as mixed and inconclusive, and current guidance supports access to varied reinforcers rather than a single format. Here is what each study measured, why the results differ, and how to turn the evidence into a sound equipment decision.

What does reinforcement need to do in a VRA test?

In a VRA session, the reinforcer is not the hearing test. It is the reward that teaches a child of roughly 6 to 24 months developmental age to turn toward a sound. A reinforcer has three jobs: capture attention, keep conditioned head turns coming, and delay habituation for as long as the session needs.

VRA is a conditioned response procedure. The audiologist presents a sound, the child turns, and a visual reward follows, which strengthens the link between hearing the stimulus and turning toward it. The BSA recommended procedure describes the reward as the consequence that maintains that learned association, and the American Academy of Audiology (AAA) clinical guidance and the American Speech-Language-Hearing Association (ASHA) Practice Portal frame VRA the same way.

Three plain terms matter when reading the research. Attention is whether the child notices and values the reward. Response strength is how reliably the child keeps turning. Habituation is the fade in responding as the reward loses novelty. A 2025 scoping review of 59 VRA studies reported that greater variety and complexity in visual reinforcers, and short reinforcer durations, were among the factors associated with better response behavior (Visram et al., International Journal of Audiology).

What did the three direct comparison studies find?

Three peer-reviewed studies have directly compared toy and video reinforcement: Schmida, Peterson, and Tharpe in 2003, Lowery and colleagues in 2009, and Karzon and Banerjee in 2010. One favored video, one found no significant difference, and the largest favored animated toys. None of the three identified a universal winner across ages and settings.

Study	Sample and age	Setting	Outcome measured	Finding	Key limit
Schmida, Peterson, and Tharpe (2003)	40 children, age 2 years	Research setting	Head turns before habituation	About 15 head turns with video vs about 11 with an animated toy	Single toy comparator; one age group
Lowery, von Hapsburg, Plyler, and Johnstone (2009)	14 infants, 7 to 16 months	Laboratory, repeated measures	Head turns, hit rate, false alarms, sensitivity	No significant difference between formats	Small sample of normal-hearing infants
Karzon and Banerjee (2010)	145 children, 16 to 24 months	Busy clinical practice	Threshold estimates obtained	More with animated toys, 5.52 vs 3.47 on average	Older toddler range; reinforcer sets differed between conditions

Two details are easy to miss. Schmida and colleagues compared video against a single animated toy, and Karzon and Banerjee obtained their result in a fast-paced referral practice, with threshold estimates rather than head turns as the endpoint (Karzon and Banerjee, 2010).

Why do the results point in different directions?

The three studies differ in age range, sample size, setting, reinforcer libraries, and the outcome each one measured, and any of those differences could plausibly explain the different findings. A 14-infant laboratory study and a 145-child clinical study ask related but not identical questions, so their answers do not have to agree.

The specifics are worth listing, because they are the reasons the findings may differ, not proven causes:

1. Ages studied: 7 to 16 months (Lowery), 2 years (Schmida), and 16 to 24 months (Karzon and Banerjee). Reinforcer preferences can shift across that span.
2. Sample size: 14, 40, and 145 children. Larger samples detect smaller effects.
3. Setting: laboratory conditions versus a working referral clinic with time pressure.
4. Reinforcer libraries: Schmida compared video against one animated toy; Karzon and Banerjee posited that the number and relative strength of the reinforcers in each condition drove their result (Karzon and Banerjee, 2010).
5. Outcomes measured: head turns before habituation is not the same endpoint as threshold estimates completed in a clinical session.

The scoping review by Visram and colleagues reaches a consistent bottom line: VRA works well for most infants developmentally aged around 7 to 24 months, but further evidence is needed on the benefits of different reinforcers. We go deeper in why VRA studies disagree.

What do current clinical guidelines say?

No major guideline names a winning reinforcer format. The 2025 BSA recommended procedure describes the comparative evidence on animated toys versus video rewards as mixed and inconclusive. The AAA clinical guidance and the ASHA Practice Portal both list toys, lights, and video as acceptable reinforcers without ranking one above another.

The BSA recommended procedure (version 1.2, June 2025) is the most current detailed VRA procedure. On format, it concludes the literature is mixed and inconclusive, and on session management it advises switching or combining reward toys to extend a child’s interest in responding.

The AAA clinical guidance document lists animated toys in darkened enclosures, video systems, and simple illumination for children who find animation upsetting, and it emphasizes that what is rewarding to one child may not be rewarding to another. The ASHA Practice Portal likewise lists flashing lights, moving toys, or video clips with no format preference. For the procedure itself, see our practical guide to Visual Reinforcement Audiometry.

What should a clinic weigh when choosing a reinforcer format?

Because the research does not settle the choice, the decision comes down to your patient mix and your equipment. These are buying considerations, not clinical protocol, and most of them can be evaluated before anything is installed: reinforcer variety, content control, room layout, controls, cost of ownership, service, and training.

1. Patient mix: caseloads weighted toward young infants, older toddlers, or children who need extra attention management may respond differently to each format. No format should be prescribed by diagnosis.
2. Child preference on the day: AAA guidance treats the individual child’s reaction as the deciding factor, so flexibility matters.
3. Number of distinct reinforcers: variety helps delay habituation (Visram et al., 2025). As a product fact, the Pehratek 3D Toy system (XM-5000 Series 5) offers over 3800 combination possibilities from 10 sounds, 3 movements, and 5 colored LED patterns.
4. Ability to change content: the Pehratek HD Video system (VDS-3000 Series 3) presents reinforcement on a 15.6 inch screen, so the visual content can be varied between children.
5. Attention management: centering units reorient the patient’s attention back to a neutral starting position between presentations, which supports clean head-turn observations.
6. Room layout and controls: mounting positions, sightlines, and a remote the audiologist can operate without looking away all affect session flow.
7. Budget, warranty, and service: compare total cost of ownership, trial terms, and support response.
8. Training: a system the whole team can run consistently protects test efficiency.

Our guide to how to choose a VRA system works through these points.

When does access to both toy and video formats make sense?

Karzon and Banerjee recommended that practices testing large numbers of children keep both animated toy and video reinforcement available so the format can be matched to the individual child. For a high-volume pediatric clinic, hospital department, or school program, that is the one place the comparison research offers direct buying guidance.

That recommendation comes from the largest of the three studies (Karzon and Banerjee, 2010), and it fits the guideline focus on the individual child. As a product fact, the Pehratek DualStim provides both reinforcer formats in one system; toy plus video VRA systems covers dual-format setups.

The decision aid is short: no universal winner. Match the reinforcer to the child, and match the system to the clinic.

Frequently asked questions

Is video VRA better than toy VRA?

The research does not show that either format is better for every child. One study favored video for head turns before habituation, one found no significant difference, and the largest clinical study obtained more threshold estimates with animated toys. Current BSA guidance calls the comparative evidence mixed and inconclusive.

Do children habituate faster to toys or to video?

In one study of 40 two-year-olds, children gave about 15 head turns with video versus about 11 with a single animated toy before habituating. That result used one toy as the comparator, so it may reflect reinforcer variety rather than format. Reviews report that more varied and complex reinforcers help delay habituation.

Does age determine the best VRA reinforcer?

Not on current evidence. The study of 7 to 16 month olds found no difference between formats, while the study of 16 to 24 month olds favored animated toys, but the studies differed in more than age. Guidelines place VRA at roughly 6 to 24 months developmental age and let the individual child’s response guide the choice.

Should a pediatric clinic have both toy and video VRA?

The largest comparison study recommended that practices testing large numbers of children have both formats available so the reward can be matched to each child. For lower-volume clinics, the choice depends on patient mix, room layout, budget, and service considerations rather than on a proven clinical advantage.

What do clinical guidelines recommend for VRA reinforcers?

The 2025 BSA recommended procedure, the AAA clinical guidance, and the ASHA Practice Portal all list animated toys, lights, and video as acceptable reinforcers, and none ranks one format above another. BSA additionally advises varying or combining rewards during a session to extend the child’s interest in responding.

Can school districts buy VRA equipment through a purchasing cooperative?

Yes. Pehratek VRA systems are available through BuyBoard Contract 804-26. That route lets school districts and other public-sector buyers purchase through an already-competed contract instead of running a separate solicitation.

Ready to compare formats side by side? Review the Pehratek 3D Toy, HD Video, and DualStim VRA systems, or write to info@pehratek.com with your booth layout and caseload questions. School districts can purchase through BuyBoard Contract 804-26 (Inspiration Medical Technology, awarded vendor). Every order includes a 90 day trial, with a 3 year warranty on US orders.

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
• British Society of Audiology. Recommended Procedure: Visual Reinforcement Audiometry. Version 1.2, June 2025. PDF
• American Academy of Audiology. Clinical Guidance Document: Assessment of Hearing in Infants and Young Children. 2020. PDF
• American Speech-Language-Hearing Association. Hearing Loss in Children, Practice Portal. https://www.asha.org/practice-portal/clinical-topics/hearing-loss-in-children/
• 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)
• Pehratek Product Info: Pehratek VRA - Toy + Video. 2025. Internal product source.