What Age Is Visual Reinforcement Audiometry Used For?

Visual Reinforcement Audiometry (VRA) is commonly used with infants and toddlers at a developmental age of about 6 to 24 months. The ASHA Practice Portal describes VRA as a method of choice for developmental ages of approximately 6 through 24 months, the 2025 BSA recommended procedure covers a minimum developmental age of 6 to 7 months up to around 30 months, and the American Academy of Audiology’s 2020 guidance frames the range as approximately 5 to 24 months developmental age.

The operative word in every one of those documents is developmental. A child also needs head control, stable sitting, and enough attention to learn the conditioned head-turn task, and older children whose abilities fit the task can still be good VRA candidates. Here is how the current guidance breaks down.

Why is developmental age more useful than calendar age?

Developmental age predicts whether a child can do the VRA task; calendar age does not. Both the American Academy of Audiology and ASHA direct clinicians to select behavioral methods based on each child’s developmental abilities, because Visual Reinforcement Audiometry depends on specific motor and attention skills rather than on a birth date.

The AAA guidance states that the most appropriate protocol is individualized for each child based on developmental and/or chronological age and other relevant factors. ASHA describes the skill set directly: the child must have the developmental ability to respond to conditioned procedures, sit, maintain head control, and turn the head.

In practice, the conditioned head-turn task asks a child to:

  1. Sit unsupported, or with minimal support, on a caregiver’s lap or in a high chair.
  2. Hold the head steady at a neutral midline position.
  3. Turn the head toward a sound source when a stimulus is presented.
  4. Learn, through conditioning trials, that a correct head turn is followed by a visual reward such as a lighted animated toy or a video display.
  5. Keep doing it long enough to yield usable minimum response levels.

A 20-month-old with significant motor delay may not yet have these skills; a 3-year-old with a developmental disability may fit the task well. That is why every range below is stated in developmental age.

What do current guidelines say about the VRA age range?

Current guidance converges on roughly the same window with small differences at the edges. ASHA cites a developmental age of approximately 6 through 24 months, the 2025 BSA recommended procedure spans a minimum of 6 to 7 months up to around 30 months, and AAA gives approximately 5 to 24 months developmental age.

The table below compares the stated ranges. Note that these are guides for test selection, not eligibility rules.

Source Year Stated VRA range (developmental age) Notes
ASHA Practice Portal, Hearing Loss in Children Current Approximately 6 through 24 months Called a method of choice for infants and toddlers in this window
BSA Recommended Procedure: VRA June 2025 Minimum 6 to 7 months, to around 30 months Requires sitting with minimal support and head turns to each side
AAA Clinical Guidance Document 2020 Approximately 5 to 24 months Protocol individualized to each child’s development
Visram et al., scoping review, International Journal of Audiology 2025 Works for most infants around 7 to 24 months Synthesis of 59 original articles on VRA optimization

The practical reading for a clinic: plan for VRA as the workhorse behavioral method from the middle of the first year through the second year of life, and let readiness, not the birthday, make the call at either edge.

Can VRA work before six months?

Sometimes, but no major guideline makes early VRA the norm. The AAA guidance places the lower edge at approximately 5 months developmental age, while the 2025 scoping review reports that VRA works for most infants at a developmental age of around 7 to 24 months. Below that floor, head and trunk control usually limit the task.

The reason the floor sits where it does is motor and attentional, not audiological. The BSA procedure requires an infant who can sit with minimal support and turn the head to each side, and most infants consolidate those skills around the middle of the first year.

For younger infants, behavioral testing does not carry the load alone. The AAA guidance notes that electrophysiologic testing can be performed at earlier ages than behavioral measures, so electrophysiological results may need to stand alone for a period of time. A clinic seeing infants under about 6 months should expect physiologic and electrophysiologic measures to anchor the battery, with VRA joining as readiness arrives.

What changes near the upper end of VRA use?

Toward the top of the range, children respond less and habituate faster. The 2025 scoping review reports more responses from younger infants, around 12 months, than from older infants at around 18 to 24 months. The BSA procedure ties the endpoint to attention control: once a child can set their own attention and inhibit head turns, consider play audiometry.

Two findings are worth building into session planning. The Visram et al. review found response counts decline with age within the VRA window, so test-order efficiency matters more with a 22-month-old than with a 12-month-old. And the BSA procedure cites evidence that a 10 minute break can significantly increase the responses obtainable after initial habituation.

Managing attention between trials is also an equipment question. Pehratek centering units reorient the patient’s attention back to a neutral starting position, which supports the midline-to-head-turn cycle that VRA scoring depends on.

For session-level tactics on this problem, see the related posts on habituation and test-session fatigue and what to do when conditioning fails.

Can older children use VRA?

Yes, when their developmental abilities fit the task. The AAA guidance discusses team-based VRA as helpful when testing children with developmental delays, and reinforcer materials have been designed specifically for children with developmental disabilities. Age and diagnosis do not select the method; the child’s current skills do.

The AAA guidance names a team testing approach for VRA as helpful in circumstances such as testing children who have developmental delays. Bonino and colleagues (2021) developed visual reinforcers built around interests commonly reported for children with developmental disabilities; the authors state that future research is needed to determine the effectiveness of these materials in clinical settings, so treat them as a design direction rather than a proven outcome.

Two cautions keep this section honest. A diagnosis by itself does not assign a child to VRA; a 4-year-old with a developmental disability may do better with conditioned play audiometry or adapted materials. And chronological age by itself does not rule VRA out; the method follows the readiness skills listed earlier. See the related post on VRA for children with developmental disabilities.

What comes before and after VRA?

In ASHA’s developmental framing, behavioral observation audiometry covers infants up to about 6 months, usually alongside electrophysiologic measures. Visual Reinforcement Audiometry takes over at a developmental age of about 6 through 24 months, and conditioned play audiometry fits developmental ages of about 2 through 4 years.

The timeline below summarizes the ASHA Practice Portal sequence for behavioral methods.

Method Typical developmental age What the child does Notes from the guidance
Behavioral observation audiometry (BOA) Birth to about 6 months Unconditioned responses observed Used with electrophysiologic assessment to screen or predict hearing ability
Visual Reinforcement Audiometry (VRA) About 6 through 24 months Conditioned head turn rewarded by a visual reinforcer Called a method of choice for this window
Conditioned play audiometry (CPA) About 2 through 4 years Play task, such as a block in a bucket, on hearing a sound May also be used with older children needing frequent or additional measures

Ranges guide test selection; clinician judgment and developmental ability decide. Every source in this article states its range in developmental age and expects the audiologist to individualize. For room and equipment planning across this sequence, start with the VRA practical guide and the post on matching reinforcer choice to age.

Frequently asked questions

Can a five-month-old complete VRA?

Occasionally, but it is not the expectation. The AAA guidance places the lower edge at approximately 5 months developmental age, while the BSA procedure sets a minimum of 6 to 7 months and the recent scoping review describes reliable performance from around 7 months. For infants this young, guidance keeps electrophysiologic measures central to the battery.

Can a three-year-old use VRA?

Yes, when the child’s developmental abilities fit the conditioned head-turn task, which is most common for children with developmental delays or disabilities. Guidance supports adaptations such as team testing in these cases. For typically developing 3-year-olds, conditioned play audiometry is usually the better match.

Is VRA based on age or development?

Development. ASHA, the BSA, and the AAA all state their VRA ranges in developmental age, and all require specific skills: sitting with minimal support, head control, a reliable head turn, and the ability to be conditioned. Chronological age is only a rough starting guess for whether those skills are present.

When should a clinic move from VRA to CPA?

The BSA procedure ties the switch to attention control rather than a birthday. Once a child can set their own attention before each trial, they can also inhibit head turns, and play audiometry should be considered. In ASHA’s framing this transition typically lands around a developmental age of 2 years.

What does a child need to be able to do for VRA?

Four things, per the ASHA and BSA descriptions: sit unsupported or with minimal support, hold the head at midline, turn the head toward a sound to each side, and learn the conditioned link between the sound and the visual reward. A child with those skills is a candidate at almost any age.

If you are planning or refreshing a VRA room for this age range, Pehratek has made VRA systems since 1979 and builds both reinforcer formats used across it: the HD Video VRA (VDS-3000 Series 3) with a 15.6 inch screen, and the 3D Toy VRA (XM-5000 Series 5), along with centering units that reorient attention back to a neutral starting position between trials. Compare systems at pehratek.com or write info@pehratek.com. School districts and other public-sector buyers can purchase through BuyBoard Contract 804-26 (Inspiration Medical Technology, awarded vendor).

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

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