Performing visual reinforcement audiometry (VRA) with one tester

Performing visual reinforcement audiometry (VRA) with two testers is best practice for this type of test and recommended by the British Society of Audiology. However, there are examples seen in clinics around the world where VRA is performed with one tester.

Scenario 1: Clinician seated close to the child

In this first scenario, the clinician is seated close to the child with the audiometer controls to hand but hidden from view of the child (Figure 1).

In this scenario, the clinician is using the Touch Keyboard with the Equinox Evo audiometer, which integrates the VRA reinforcer controls alongside the audiometer controls. This provides a very convenient method of bringing the controls closer to the child while eliminating the need for multiple systems.

This is particularly advantageous in a one-tester VRA setup as it simplifies the testing setup, with the portability of the Touch Keyboard providing flexibility. By being able to bring the controls closer to the child and by only having one piece of equipment, the tester can concentrate their efforts and focus on engaging with the child, which is a vital component of the VRA test.

Scenario 2: Clinician seated separately from the child

In the second scenario, the clinician is seated separately from the child, either in the observation room or away from the child within the testing booth but screened from view.

The advantage here is that the child is not able to see the audiometer controls being used by the clinician. This will reduce the chances of them being cued to the presentation of the stimuli, which can lead to false-positive responses and inaccurate results being obtained.

Challenges when sitting separately

The challenge with this example is that the child is seated on their own with no engagement toys and is therefore more likely to look around to check for the visual reinforcer, which can also present as a false-positive response if such a check coincides with a stimulus presentation.

Some clinics may provide some toys for the child to play with, but this is much less engaging than when a second tester is playing with them. The child is also likely to grow bored with the toys and discard them, and they are without a second tester to retrieve the toys or supply a change of toys.

Some clinics may ask the parent to play with the child. This should be avoided as it comes with a significant risk of cueing and insufficient engagement from the parent.

Another option for this scenario is to use a third screen or toy reinforcer which is placed in front of the child. This can be activated in between stimulus presentations in place of a second tester to return the child’s attention back to the front / center line. This comes with its own risks:

• The child may become confused by the different reinforcers and lose conditioning.
• The child may develop a preference for the center/front screen and stop performing a head turn.
• The child may not find the center/front screen sufficiently engaging, which can result in false-positive responses or the child growing disinterested with the test.
• The child may grow upset at being on their own with nobody in front of them. The parent should be seated behind. Without another person to engage with the child, they may seek out the parent behind them and be unwilling to stay in the required position for the test.

Which scenario is best?

A two-tester VRA setup should always be the preferred scenario to support reliable and accurate result acquisition.

If a one-tester VRA setup is required, the first scenario detailed here is far preferable to the second scenario as there are fewer risks and less likelihood of false positives due to there being face-to-face engagement with the child.

To learn more about the Equinox Evo and Touch Keyboard combination, which allows you to bring the integrated audiometer and visual reinforcer controls into the booth and be close to the child, please visit the Equinox Evo.