Assistive Technology Research Institute
College Misericordia - Dallas, PA 18612
Founded and Sponsored by the Sisters of Mercy of Dallas


Auditory and Visual


A Test of the Effectiveness of a Protocol to Evaluate a Simultaneous Presentation of Visual and Auditory Information in Children with Learning Disabilities


Denis Anson, MS, OTR, Christine Breslin, OTS, Samantha Conzo, OTS, Stacey Sterner, OTS, Stephanie Viola, OTS, and Wendy Warner, OTS

Please address all correspondence regarding this paper to the first author. Email:


The purpose of this pilot study was to test a protocol for assessing the effectiveness of bimodal reading programs. A protocol for testing the ability of children to retain information presented using a bimodal approach of vision, hearing, or both was developed and tested. The pilot study utilized a computer program, WYNN, to present each mode by controlling which of the sensory channels was available to the subject. The participants were randomly assigned to one of three groups for story presentation: print only, voice only, or the combination of print and voice. After the story was presented, the participants were asked a series of nine questions. In order to test delayed recall of the reading material, the participants were asked the second series of questions one week later without review of the reading material. The pilot study demonstrated that the research protocol was able to present information at a consistent rate across the three delivery methods, and to assess both short term and delayed recall of the information presented. In addition, the pilot study indicated that there may be differences in delayed recall that are not in agreement with accepted theory. Based upon this information, the pilot study supports future research to determine the most effective method of teaching for children with learning disabilities. The weakness of the protocol was in recruitment, which may have been influenced by concerns about new federal legislation, and the enforcement of confidentiality within the school systems.


"The field of learning disabilities (LD) has probably the widest parameters of all the fields of special education" (Kirk & Elkins, 1975) . The definition of learning disabilities as adopted by the Learning Disabilities Association of Canada, on January 30, 2002 states:

Learning disabilities refer to a number of disorders which may affect the acquisition, organization, retention, understanding or use of verbal or non-verbal information. These disorders affect learning in individuals who otherwise demonstrate at least average abilities essential for thinking and/or reasoning, as such, learning disabilities are distinct from global intellectual deficits. Learning disabilities result from impairments in one or more processes related to perceiving, thinking, remembering or learning. These include, but are not limited to: language processing, phonological processing, visual spatial processing, processing speed, memory and attention, and executive functions (e.g. planning and decision-making).

Leaning disabilities range in severity and may interfere with the acquisition and use of one or more of the following: oral language (e.g. listening, speaking, understanding), reading (e.g. decoding, phonetic knowledge, word recognition,comprehension), written language (e.g. spelling and written expression), and mathematics (e.g. computation, problem solving). Learning disabilities may also involve difficulties with organizational skills, social perception, social interaction and perspective taking.

The two most common areas of difficulty involved with a learning disability are visual and auditory perception of language (The National Center for Learning Disabilities, 2003) . Learning includes the acquisition, storage and recall of new information, as well as the integration of new information with the old. Reading is a key method for the acquisition of new information. The child who cannot read fluently will fall behind in acquisition of new information, unless another means for acquiring information are found to replace or support reading. "Reading problems are among the most prevalent concerns for those who teach students with LD" (Rankhorn, England, Collins, Lockavitch, & Algozzine, 1998) .

Lyon (Lyon, 1977) asserts about 50 percent of our nation's children learn to read relatively easily once exposed to formal instruction. Unfortunately, it appears that for the rest, learning to read is a much more difficult challenge, and for at least 20 to 30 percent of these youngsters, reading is one of the most difficult tasks that they will have to master throughout their life. This is very unfortunate because, without the ability to read fluently, it will be much more challenging for an individual to acquire the information needed to manage daily life.

Reading skills serve as the major avenue to learning about subjects that must be mastered in school and in life. When children cannot read well, their general knowledge, their spelling and writing abilities, and their vocabulary development suffer as well. A student who lacks reading fluency, which serves as a major foundation for all school-based learning, has limited chances for academic and occupational success (Lyon, 1977) .

The National Institute of Child and Human Development (NICHD) studies showed that young students with poor reading skills are "largely doomed to . failure from the beginning" (Lyon, 1977) . Children who are not able to master reading skills and keep up with their age-mates by the end of first grade begin to experience decreases in their self-esteem, self-concept, and motivation to learn. As these children reach elementary and middle school grades, the deficits become worse because they cannot read grade-level textbooks. If they graduate from high school, they virtually never move on to college, which limits their occupational and vocational opportunities (Lyon, 1977) .

Children that have not profited from ordinary instruction (possibly due to reading difficulties) require "specialized" techniques of instruction for their development. '.[C]hildren with specific learning disabilities require "special education:" practices that are unique, uncommon, of unusual quality, and, in particular, supplement the organization and instructional procedures used with the majority of children' (Kirk & Elkins, 1975) .

Occupational Therapy is a "related service" that provides alternative approaches to learning when the traditional approach is not effective. According to the American Occupational Therapy Association, Inc. and the American Occupational Therapy Foundation (American Occupational Therapy Association Inc. & American Occupational Therapy Foundation, 2003) , the role of the occupational therapist in the school system is to "enhance the student's ability to fully access and be successful in the learning environment" which may include working on handwriting or fine motor skills so the child can complete written assignments, working with the teacher to modify the classroom and/or adapt learning materials to facilitate successful participation, and helping the child organize himself or herself physically and cognitively in the environment (including work space in and around the desk). The portion of the therapy program focusing on the child may seek to develop increased cognitive organization, which can include providing assistance with learning to read, learning to use memory and language by increasing skill development, modifying the task, and using alternative strategies. Whalen (Whalen, 2002) supports the belief that "occupational therapy programs enhance the student's ability to learn, and occupational therapists eliminate problems that interfere with a child's ability to profit from the instruction" (p.16).

In addition to working directly with the child, an occupational therapist may work to provide an environment that supports and enhances learning. Niehues, Bundy, Mattingly and Lawlor (Niehues, Bundy, Mattingly, & Lawlor, 1991) describe how "occupational therapists enable a more positive view of the student and provide a basis for developing new and more effective teaching and/or parenting strategies" (p. 202). As described by these studies, occupational therapy is effective in teaching new skills to the student, and in creating a learning environment and teaching strategies that support learning for the child with a learning disability.

One alternative approach to learning that may be used by occupational therapy is using multiple sensory channels to present material to be learned. This is intended to strengthen and unify the modalities. For example, when teaching letters to the child with a learning disability, the occupational therapist may provide textured letter forms. The child will see the forms, trace them with her finger, and say the letter out loud. The combination of visual, motor, and auditory cues will enhance a child's ability to remember the letter shape and name. Associative processes are used when the student associates (links) the name and sound of a letter with its printed symbol. (Guyer & Sabatino, 1989) .

One of the multisensory supporting approaches to teach children with learning disabilities the skill of reading is the Orton-Gillingham Approach. This approach to reading is language-based, utilizing phonetics and emphasizing visual and auditory learning styles. This multisensory approach is structured, sequential, cumulative and flexible (Academy of Orton Gillingham Practitioners and Educators, 2000) . In the Orton-Gillingham approach as described by Guyer & Sabatino (1989), learners move step by step from simple to complex materials in a sequential, logical manner that enables students to master important literacy skills, by fusing smaller units (letters, sounds, and syllables) into more complex whole (words).

While the Orton-Gillingham approach uses a highly structured approach to teaching language constructs, there are other, less prescriptive approaches that are offered to assist the learning disabled child to read. Computer programs such as Text Help and What You Need Now differ from Orton-Gillingham in that they begin with a whole- language approach for learning rather than the progressive process that Orton-Gilligham takes of using beginning letter sounds, advancing to whole sentences. While the Orton-Gillingham program has been demonstrated to provide improved reading skills, the evidence for the simplified approach offered by reading programs such as What You Need Now is less compelling.

This pilot study tested a protocol that could be used to answer the questions:

  1. Does the combination of visual and auditory presentation of written material provide improved acquisition as compared with visual presentation alone for students with learning disabilities?
  2. Does the combination of visual and auditory presentation of written material provide improved acquisition as compared with auditory presentation alone for students with learning disabilities?
  3. Does the combination of visual and auditory presentation of written material provide improved retention of information as compared with visual presentation alone for students with learning disabilities?
  4. Does the combination of visual and auditory presentation of written material provide improved retention of information as compared with auditory presentation alone for students with learning disabilities?


This protocol uses a quasi-experimental, group comparisons model.


Subjects in this pilot study were 6 children in the 4 th through 5 th grades, identified with a non-specific learning disability. They had a documented second grade reading level, were able to understand spoken English, and had little or no prior experience with a multisensory reading program.


A flyer describing the proposed study was developed and included: requirements for participation, a brief explanation of the proposed study, and a name and phone number of a researcher to contact regarding more information. A variety of school districts were contacted by telephone and given a brief description of the proposed study. The districts were then sent additional information for further explanation. Those school districts that were interested in participation were asked to develop a list of potential participants to send informational flyers home to. In order to assure student confidentiality the flyers were sent home by the schools, being either mailed from the school or sent home in the candidates' backpacks. This assured that the disclosure of any student's reading disability was solely at the discretion of the child's parents.

Any parents interested in having their child participate in the study contacted the researchers to further clarify the purpose of the study and receive a packet of materials needed to participate. Enclosed in the packet was a parental and participant consent form, stating the purpose and expectations of the study and subjects. It also provided an assurance of confidentiality. These items were reviewed separately with each individual who responded to the distributed flyer. In addition to obtaining the consent necessary for the testing, the nature of the learning disability as well as demographic information was obtained.


This protocol tests the ability of children with learning disabilities to acquire and recall information from a short story. The story that was used for the pilot was titled "A Peanut Butter Sandwich", and was at the second grade reading level. The story was approximately 40 sentences long, and was presented in 11 short paragraphs of three to five sentences. Following presentation of the story, the participants were asked a series of 9 questions, in one of two tests. There were a total of 18 questions used with this story, of which nine were supplied with the story and nine generated by the researchers. To control for differences in question difficulty, the supplied and researcher-generated questions were mixed to generate the two tests. The questions on the tests included fill in the blank and multiple choice formats. All multiple choice items provided 3 answers for the children to choose from. The order in which the two tests were presented was balanced to control possible differences in difficulty of the two forms. Half of the children completed form A immediately after reading and/or listening to the story, while the other half completed form B. One week later, each child completed the alternate form to test for retention.

The presentation modalities to be tested by this protocol were: (1) visual text only (subjects read the story off the computer screen with a yellow highlight moving at a rate of 150 words per minute), (2) auditory text only (the story was read to the participant by the computer program at a rate of 150 words per minute), and (3) both visual and auditory text combined (as the text was read aloud, a moving highlight followed on the screen at a rate of 150 words per minute).

For this study, the story was presented by the commercial computer program, WYNN, which is intended to provide bimodal presentation of reading material. (Note: this protocol is intended to test bi-modal presentation generally, not the WYNN program specifically.) For the children who received bimodal information, the participants were able to both see the screen of the computer and hear the voice output of the program. The sound was turned off for those that received visual information only, and the screen was closed for those that received auditory information only. WYNN was configures with the following settings to display the story: text was set for 14 point, Arial font; the background was white, with black text, highlighted in yellow. In order to equalize the exposure of the story to the children, the visual-only presentation used the WYNN program, with a moving highlight set for the same rate (150 WPM) that was used for auditory only and bimodal presentation. When the moving-highlight reached the end of the story, the screen was closed to limit the study time.

The laptop computers used in this study had a minimum Pentium 4 processor operating at 500 MHz, 256 MB of RAM, and 18.6 GB of hard drive. For visual only presentation, the sound volume of the computer was set to zero and the screen oriented to directly face the participant. For each presentation method involving sound, the participant children were asked if the volume was too loud or soft on a sample document, and it was adjusted to provide a comfortable listening level prior to presentation of the test story.


On the initial day of testing participants were escorted to the testing area, and randomly assigned to one of three story presentation modes. The testing was conducted in a room that had minimal visual/auditory distractions, and with only the participant and the researcher present. The computer was then configured to present the story in the appropriate format, and the participant exposed to the story in the selected format.

Immediately after the participant completed reading, being read to, or both, the computer screen was closed to minimize distraction and the immediate recall test was administered. The researcher read a series of nine multiple-choice/fill-in-the-blank questions related to the content of the story. The participant responded to the questions verbally, and the researcher recorded the responses. At no time in this process was the participants asked to control or touch the computer.

To evaluate retention of information, researchers met with the participant a second time one week later. At this second meeting, no reading material was provided to the participant. The researcher asked the participant if they remembered having heard/read a story a week previously to orient them to the task. Once oriented, the participant was asked a second series of nine mixed multiple-choice/fill in the blank questions, and again, the researcher recorded the responses. Each session took approximately 10-20 minutes.


Table 1. Immediate and delayed recall of items by subject


Immediate recall
(session 1)
(Correct of 9 questions)

Long term recall (session 2, one week later) (Correct of 9 questions)

Auditory 1



Auditory 2



Auditory 3



Visual 1



Visual 2



Auditory and Visual 1



Overall, the described protocol appeared to work well to evaluate immediate and delayed recall of presented information once subjects were recruited into the study. However, the researchers did have difficulty in the recruitment of participants from schools. School administrators were reluctant to participate for a number of reasons, including confidentiality policies and reduced time availability of the students and faculty. They were concerned about removing students from classroom schoolwork or from important breaks in the school day, such as recess, to participate in the study. The administrators also had reduced time availability because they had their own workload and were reluctant to commit to an additional project that might require additional time out of their workday. Another difficulty was that the flyers used may not have included sufficient details, as calls were received from parents with children that did not meet the inclusion criteria. Finally, considering there was a small group tested, the flyers may not have been attractive to the viewers' eyes therefore limiting the number of responses received.

Data Trends/Discussion

While no statistical analysis is possible in a pilot study, the preliminary data shows trends that support the need for a larger study. The number of correct responses immediately (after the first session) and one week later (after the second session) are shown below in the data table.

On examination of the data, the initial session shows no remarkable variance of the number of correct answers when using a single stimulus (auditory or visual). There does appear to be a slight improvement in immediate recall following a bi-modal presentation. This is in agreement with classroom observation: students appear to recall more of their reading when a bi-modal approach is used. The delayed recall scores, however, do not support the conventional wisdom in that most of the students showed retention of story information with only modest changes in performance. One student receiving visual presentation only performed most poorly on initial testing, but then performed best of all participants on the delayed recall. By contrast, the student who performed best on the initial testing, and who had received bi-modal presentation of the story, had the poorest recall of the details of the story on delayed recall.

Pilot studies are not designed to provide statistical evidence for such findings, but can indicate the need for further research, as this pilot study has done. It is possible that these changes reflect random variation of the very small sample used in this study. However, it is also possible that students with learning disabilities who struggle to interpret visual language continue to process that information after the initial presentation, and show improved delayed recall. It is likewise possible that the students who receive the story through both vision and sound are less engaged, or process the story differently, so that delayed recall is impeded.


This pilot study evaluated the utility of a protocol to test the effectiveness of multimedia presentation of information for children with learning disabilities. If adapted to include a better recruitment method, the protocol appears to offer the ability to provide objective measures of short and long-term recall of new material as well as to offer a means to objectively evaluate the use of multisensory reading material for children with learning disabilities.

The preliminary data collected using this protocol supports the conventional wisdom regarding learning disability and bi-modal presentation of information for immediate recall. Of the participants in the pilot study, the student with the best immediate recall received the story by both visual and auditory channel, and the student with the least immediate recall received visual stimuli only. However, the delayed recall demonstrated by the participants showed an unexpected reversal: the best delayed recall was seen in the student who had the poorest recall initially, with visual stimuli only, while the poorest delayed recall was demonstrated by the student who had received bimodal instruction.

In summary, this pilot study demonstrated that, with adjustments to the recruitment procedures, this protocol can be an effective tool to evaluate the short and long-term recall afforded by visual, auditory, and bi-modal instruction of students with learning disabilities. It also suggests that such a study must be done to determine if the results of the pilot represent actual learning outcomes, or are the results of statistical variation.


Academy of Orton Gillingham Practitioners and Educators. (2000, February 16, 2004). What is the Orton-Gillingham approach? Retrieved May 14, 2004, from

American Occupational Therapy Association Inc., & American Occupational Therapy Foundation. (2003). Parents ask about occupational therapy services in schools . Retrieved May 20, 2004, from

Guyer, B. P., & Sabatino, D. (1989). The effectiveness of a multisensory alphabetic phonetic approach with college students who are learning disabled. Journal of Learning Disabilities, 22 , 430-434.

Kirk, S. A., & Elkins, J. (1975). Characteristics of children enrolled in the child service demonstration centers. Journal of Learning Disabilities, 8 , 630-637.

Lyon, R. (1977, April 13, 2000). Language Tune-Up Kit Phonics: Report on Learning Disabilities Research . Retrieved May 15, 2004, from

Niehues, A. N., Bundy, A. C., Mattingly, C. F., & Lawlor, M. C. (1991). Making A Difference: Occupational Therapy in the Public Schools. The Occupational Therapy Journal of Research, 11 , 195-212.

Rankhorn, B., England, G., Collins, S. M., Lockavitch, J. F., & Algozzine, B. (1998). Effects of Failure Free Reading Program on Students with Severe Reading Disabilities. Journal of Learning Disabilities, 31 , 307-312.

The National Center for Learning Disabilities. (2003). Visual and Auditory Processing Disorders . Retrieved May 28, 2004, from

Whalen, S. (2002). How occupational therapy makes a difference in the school system: A summary of the literature. OT Now, May/June , 15-18.


More Read and Understand Stories and Activities, written by J.E. Moore. Published in 1999 by Evan-Moor Corporation. For additional information, call 1-800-777-4362 or check the website,