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Learning Disabilities Research & Practice

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• Description
• Aims and Scope
• Editorial Board
• Abstracting / Indexing
• Submission Guidelines

Learning Disabilities Research & Practice (LDRP) publishes articles addressing the nature and characteristics of children and adults with, or with potential for, learning disabilities (specific learning disability; specific learning disorder) and/or attention deficits as they relate to practice, program development, assessment practices, and instruction - not limited to academic subjects. LDRP provides valuable information to professionals involved in a variety of different disciplines, including special education, school psychology, counseling, reading, and health sciences.

• Clarivate Analytics: Social Sciences Citation Index (SSCI)
• ERIC (Education Resources Information Center)

Manuscript Submission Guidelines: Please click here to submit your article: https://sage.atyponrex.com/journal/LDR

This Journal is a member of the Committee on Publication Ethics .

This Journal recommends that authors follow the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals formulated by the International Committee of Medical Journal Editors (ICMJE).

Sage disseminates high-quality research and engaged scholarship globally, and we are committed to diversity and inclusion in publishing. We encourage submissions from a diverse range of authors from across all countries and backgrounds.

There are no fees payable to submit or publish in this Journal. Open Access options are available - see section 3.3 below.

As part of the submission process you will be required to warrant that you are submitting your original work, that you have the rights in the work, and that you have obtained and can supply all necessary permissions for the reproduction of any copyright works not owned by you, that you are submitting the work for first publication in the Journal and that it is not being considered for publication elsewhere and has not already been published elsewhere. Please see our guidelines on prior publication and note that LDRP will consider submissions of papers that have been posted on preprint servers; please alert the Editorial Office when submitting (contact details are at the end of these guidelines) and include the DOI for the preprint in the designated field in the manuscript submission system. Authors should not post an updated version of their paper to a preprint server while it is being peer reviewed for possible publication in the Journal. If your paper is accepted, you will need to contact the preprint server to ensure the final published article link is attached to your preprint. Learn more about our preprint policy here .

If you have any questions about publishing with Sage, please visit the Sage Journal Solutions Portal .

What do we publish?

Aims & scope

Before submitting your manuscript to LDRP, please ensure you have read the Aims & Scope: Learning Disabilities Research & Practice (LDRP) publishes articles addressing the nature and characteristics of children and adults with, or with potential for, learning disabilities (specific learning disability; specific learning disorder) and/or attention deficits as they relate to practice, program development, assessment practices, and instruction-- not limited to academic subjects.  LDRP provides valuable information to professionals involved in a variety of different disciplines, including special education, school psychology, counselling, reading, and health sciences.

Because of the field of learning disabilities is multidisciplinary, LDRP publishes articles describing research, program development, and practices in teaching and assessment from a variety of disciplines as long as the focus is on learning disabilities and/or attention deficits. Unvalidated program descriptions, descriptions (without evaluation) of techniques or procedures, and personal accounts generally are not acceptable.

Each manuscript submitted is reviewed by the Editor, who will monitor it through the review process. Each paper undergoes blind review by experts in the area of its content. Submissions are judged on the following criteria:

• Importance of the topic addressed

• Soundness of conceptualization

• Clarity of purpose and goals

• Adequacy of the research

• Accuracy and validity of content

• Reliability of conclusions

• Contribution to professional literature

• Reader interest and appeal

Viewpoints expressed within LDRP are the author’s and do not necessarily reflect the individual or collective opinion of either the Editors, officers, review board, or members of DLD. Consequently, neither DLD nor LDRP can assume responsibility for statements made or opinions expressed by contributors.

Writing your paper

Visit the Sage Author Gateway for general advice on how to get published , plus links to further resources.

Sage Author Services also offers authors a variety of ways to improve and enhance your article including English language editing, plagiarism detection, and video abstract and infographic preparation.

Make your article discoverable

For information and guidance on how to make your article more discoverable, visit our Gateway page on How to Help Readers Find Your Article Online .

Manuscript Style. Manuscripts must be prepared according to the style recommendation in the Publication Manual of the American Psychological Association (7th ed., 2020). Manuscripts must be double-spaced, with wide margins throughout. Except under unusual circumstances, manuscripts should be no longer than 30 pages in length. The manuscript should contain the following elements:

Title page. The first page of the manuscript should include the title of the article and the complete names and institutional affiliations of all authors. As a separate item, indicate the name, postal and email address, and phone number of the corresponding author. Also provide a short title to be used as a running head.

Abstract. Each article should be prefaced by a brief abstract (100–150 words).

Biographical statement. Authors should include a short (40–60 words) biographical statement with the heading, About the Authors. If the manuscript is accepted and published this statement will be included at the end of the article.

Additional elements—tables, figures, acknowledgments, when included—should take the following form:

Tables. All tabulated data identified as tables should be given a table number and a descriptive title. Tables should be typed double-spaced on separate pages.

Figures. Figures should be numbered and labeled (first author’s name) in pencil on the reverse side. Brief captions to the figures should be listed on a separate page and numbered consecutively in correspondence to the figures. Upon acceptance of a manuscript for publication, the author should be prepared to supply line art as black on white glossy prints that are approximately twice the final size. Note: If symbols are used—especially many symbols on one graph (e.g., open squares, open diamonds, and closed circles)—they should be large enough to be clearly distinguished after reduction. Color photographs are acceptable, but reproduction thereof must be prepaid by the author.

Acknowledgments. Acknowledgments (e.g., of collaboration or support) may be included on a separate page. If the manuscript is accepted and published acknowledgements will appear at the end of the article before the reference section.

A note on manuscript style. Both sections of the journal publish only those articles judged to be of superior quality. Quality is judged on the basis of design, implementation, writing, and importance of the article to the field. However, different styles of writing are preferred in the two sections. Authors preparing manuscripts for the Research section should adhere to style guidelines generally observed in scientific journals. Care should be taken to describe subject selection criteria, subject characteristics, research procedures, data analysis employed, and the like. Discussion should emphasize the practical applications of the research findings, as well as theoretical interpretation of findings. Articles discussing issues of concern to researchers also are appropriate for this section of LDRP.

Authors preparing manuscripts for the Practice section should consider a more informal style with an emphasis on rich, detailed descriptions of programs and procedures, and implications. Discursive articles and reviews of literature on topics or issues of interest to practitioners are appropriate. In either case, the content must be grounded in research. Articles reporting original, practice-oriented research are also acceptable for this section, but the above stylistic guidelines should be considered.

Editorial policies

Peer review policy.

Sage does not permit the use of author-suggested (recommended) reviewers at any stage of the submission process, be that through the web-based submission system or other communication.

Reviewers should be experts in their fields and should be able to provide an objective assessment of the manuscript. Our policy is that reviewers should not be assigned to a paper if:

• The reviewer is based at the same institution as any of the co-authors.
• The reviewer is based at the funding body of the paper.
• The author has recommended the reviewer.
• The reviewer has provided a personal (e.g. Gmail/Yahoo/Hotmail) email account and an institutional email account cannot be found after performing a basic Google search (name, department and institution).

The journal’s policy is to have manuscripts reviewed by two expert reviewers. LDRP utilizes a double-anonymised peer review process in which the reviewer and authors’ names and information are withheld from the other. All manuscripts are reviewed as rapidly as possible, while maintaining rigor. Reviewers make comments to the author and recommendations to the Editor who then makes the final decision.

LDRP is committed to delivering high quality, fast peer-review for your paper, and as such has partnered with Web of Science (previously Publons). Web of Science is a third-party service that seeks to track, verify and give credit for peer review. Reviewers for LDRP can opt in to Web of Science in order to claim their reviews or have them automatically verified and added to their reviewer profile. Reviewers claiming credit for their review will be associated with the relevant journal, but the article name, reviewer’s decision and the content of their review is not published on the site. For more information visit the Web of Science website .

The Editor or members of the Editorial Board may occasionally submit their own manuscripts for possible publication in the Journal. In these cases, the peer review process will be managed by alternative members of the Board and the submitting Editor/Board member will have no involvement in the decision-making process.

Review Process.

The Editors will determine which section of the journal (i.e., Research or Practice) is the appropriate vehicle for the article submitted; author’s stipulations as included in the cover letter will generally be honored. The Editors will send the manuscript for blind review to Reviewers who will be selected on the basis of their expertise in the content area addressed or the methodology used. The review process normally takes 6 to 8 weeks, and, after all reviews are returned, the principal author will receive notification about the publication decision from the Editors. Authors may be requested to make revisions, ranging from minor to major, prior to final acceptance. The Editors reserve the right to make minor editorial changes that do not affect materially the meaning of the text.

All parties who have made a substantive contribution to the article should be listed as authors. Principal authorship, authorship order, and other publication credits should be based on the relative scientific or professional contributions of the individuals involved, regardless of their status. A student is usually listed as principal author on any multiple-authored publication that substantially derives from the student’s dissertation or thesis.

Please note that AI chatbots, for example ChatGPT, should not be listed as authors. For more information see the policy on Use of ChatGPT and generative AI tools .

Acknowledgements

All contributors who do not meet the criteria for authorship should be listed in an Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, or a department chair who provided only general support.

Please supply any personal acknowledgements separately to the main text to facilitate anonymous peer review.

Per ICMJE recommendations , it is best practice to obtain consent from non-author contributors who you are acknowledging in your paper.                            

Third party submissions Where an individual who is not listed as an author submits a manuscript on behalf of the author(s), a statement must be included in the Acknowledgements section of the manuscript and in the accompanying cover letter. The statements must:

• Disclose this type of editorial assistance – including the individual’s name, company and level of input
• Identify any entities that paid for this assistance
• Confirm that the listed authors have authorized the submission of their manuscript via third party and approved any statements or declarations, e.g. conflicting interests, funding, etc.

Where appropriate, Sage reserves the right to deny consideration to manuscripts submitted by a third party rather than by the authors themselves .

Declaration of conflicting interests

LDRP encourages authors to include a declaration of any conflicting interests and recommends you review the good practice guidelines on the Sage Journal Author Gateway .

If applicable, authors are required to state in the methods section whether participants provided informed consent.

Please also refer to the ICMJE Recommendations for the Protection of Research Participants .

Research data

The Journal is committed to facilitating openness, transparency and reproducibility of research, and has the following research data sharing policy. For more information, including FAQs please visit the Sage Research Data policy pages .

Subject to appropriate ethical and legal considerations, authors are encouraged to:

• Share your research data in a relevant public data repository
• Include a data availability statement linking to your data. If it is not possible to share your data, use the statement to confirm why it cannot be shared.
• Cite this data in your research

Peer reviewers may be asked to peer review the research data prior to publication.

• Peer reviewers may be asked to assess compliance with the research data policy
• Peer reviewers may be asked to assess research data files

If you need to anonymize your research data for peer review, please refer to our Research Data Sharing FAQs for guidance .  

Publishing policies

Publication ethics.

Sage is committed to upholding the integrity of the academic record. We encourage authors to refer to the Committee on Publication Ethics’ International Standards for Authors and view the Publication Ethics page on the Sage Author Gateway .

LDRP and Sage take issues of copyright infringement, plagiarism or other breaches of best practice in publication very seriously. We seek to protect the rights of our authors and we always investigate claims of plagiarism or misuse of published articles. Equally, we seek to protect the reputation of the Journal against malpractice. Submitted articles may be checked with duplication-checking software. Where an article, for example, is found to have plagiarized other work or included third-party copyright material without permission or with insufficient acknowledgement, or where the authorship of the article is contested, we reserve the right to take action including, but not limited to: publishing an erratum or corrigendum (correction); retracting the article; taking up the matter with the head of department or dean of the author's institution and/or relevant academic bodies or societies; or taking appropriate legal action.

Prior publication

If material has been previously published it is not generally acceptable for publication in a Sage journal. However, there are certain circumstances where previously published material can be considered for publication. Please refer to the guidance on the Sage Author Gateway or if in doubt, contact the Editor at the address given below.

Contributor’s publishing agreement            

Before publication, sage requires the author as the rights holder to sign a journal contributor’s publishing agreement. sage’s journal contributor’s publishing agreement is an exclusive licence agreement which means that the author retains copyright in the work but grants sage the sole and exclusive right and licence to publish for the full legal term of copyright. exceptions may exist where an assignment of copyright is required or preferred by a proprietor other than sage. in this case copyright in the work will be assigned from the author to the society. for more information, please visit the sage author gateway ., open access and author archiving.

LDRP offers optional open access publishing via the Sage Choice programme and Read and Publish agreements, where authors at participating institutions can publish open access with fees paid by the institution. Find out if your institution is participating by visiting Open Access Agreements at Sage . F or more information on Open Access publishing options at Sage please visit Sage Open Access . For information on funding body compliance, and depositing your article in repositories, please visit Sage’s Author Archiving and Re-Use Guidelines and Publishing Policies .

Preparing your manuscript for submission

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The preferred format for your manuscript is Word. LaTeX files are also accepted. A LaTex template is available on the Manuscript Submission Guidelines page of our Author Gateway.

Artwork, figures and other graphics

For guidance on the preparation of illustrations, pictures and graphs in electronic format, please visit Sage’s Manuscript Submission Guidelines .

Figures supplied in colour will appear in colour online regardless of whether or not these illustrations are reproduced in colour in the printed version. For specifically requested colour reproduction in print, you will receive information regarding the costs from Sage after receipt of your accepted article.

Identifiable information

Where a journal uses double-anonymised peer review, authors are required to submit:

• A version of the manuscript which has had any information that compromises the anonymity of the author(s) removed or anonymised. This version will be sent to the peer reviewers.
• A separate title page which includes any removed or anonymised material. This will not be sent to the peer reviewers.

Visit the Sage Author Gateway for detailed guidance on making an anonymous submission .

Supplemental material

This Journal is able to host additional materials online (e.g. datasets, podcasts, videos, images etc.) alongside the full-text of the article. For more information please refer to our guidelines on submitting supplemental files .

Reference style

LDRP adheres to the APA reference style. View the APA guidelines to ensure your manuscript conforms to this reference style.

English language editing services

Authors seeking assistance with English language editing, translation, or figure and manuscript formatting to fit the Journal’s specifications should consider using Sage Language Services . Visit Sage Language Services on our Journal Author Gateway for further information .

Submitting your manuscript

LDRP  is hosted on Sage Track, a web based online submission and peer review system powered by ScholarOne™ Manuscripts. Visit https://sage.atyponrex.com/journal/LDR t o login and submit your article online.

IMPORTANT: Please check whether you already have an account in the system before trying to create a new one. If you have reviewed or authored for the Journal in the past year it is likely that you will have had an account created.  For further guidance on submitting your manuscript online please visit ScholarOne Online Help .

As part of our commitment to ensuring an ethical, transparent and fair peer review process Sage is a supporting member of ORCID, the Open Researcher and Contributor ID . ORCID provides a unique and persistent digital identifier that distinguishes researchers from every other researcher, even those who share the same name, and, through integration in key research workflows such as manuscript and grant submission, supports automated linkages between researchers and their professional activities, ensuring that their work is recognized.

We encourage all authors and co-authors to link their ORCIDs to their accounts in our online peer review platforms. It takes seconds to do: click the link when prompted, sign into your ORCID account and our systems are automatically updated. We collect ORCID IDs during the manuscript submission process and your ORCID ID then becomes part of your accepted publication’s metadata, making your work attributable to you and only you. Your ORCID ID is published with your article so that fellow researchers reading your work can link to your ORCID profile and from there link to your other publications.

If you do not already have an ORCID ID please follow this link to create one or visit our ORCID homepage to learn more .

Information required for completing your submission

You will be asked to provide contact details and academic affiliations for all co-authors via the submission system and identify who is to be the corresponding author. These details must match what appears on your manuscript. The affiliation listed in the manuscript should be the institution where the research was conducted. If an author has moved to a new institution since completing the research, the new affiliation can be included in a manuscript note at the end of the paper. At this stage please ensure you have included all the required statements and declarations and uploaded any additional supplementary files (including reporting guidelines where relevant).

• Permissions

Please also ensure that you have obtained any necessary permission from copyright holders for reproducing any illustrations, tables, figures or lengthy quotations previously published elsewhere. For further information including guidance on fair dealing for criticism and review, please see the Copyright and Permissions page on the Sage Author Gateway .

O n acceptance and publication           , sage production.

Your Sage Production Editor will keep you informed as to your article’s progress throughout the production process. Proofs will be made available to the corresponding author via our editing portal Sage Edit or by email, and corrections should be made directly or notified to us promptly. Authors are reminded to check their proofs carefully to confirm that all author information, including names, affiliations, sequence and contact details are correct, and that Funding and Conflict of Interest statements, if any, are accurate.

Online First publication

Online First allows final articles (completed and approved articles awaiting assignment to a future issue) to be published online prior to their inclusion in a journal issue, which significantly reduces the lead time between submission and publication . Visit the Sage Journals help page for more details, including how to cite Online First articles.

Access to your published article

Sage provides authors with online access to their final article.

Promoting your article

Publication is not the end of the process! You can help disseminate your paper and ensure it is as widely read and cited as possible. The Sage Author Gateway has numerous resources to help you promote your work . Visit the Promote Your Article page on the Gateway for tips and advice.

Further information

Any correspondence, queries or additional requests for information on the manuscript submission process should be sent to the LDRP editorial office as follows: David Scanlon, E-mail:  [email protected] .

Appealing the publication decision

Editors have very broad discretion in determining whether an article is an appropriate fit for their journal. Many manuscripts are declined with a very general statement of the rejection decision. These decisions are not eligible for formal appeal unless the author believes the decision to reject the manuscript was based on an error in the review of the article, in which case the author may appeal the decision by providing the Editor with a detailed written description of the error they believe occurred.

If an author believes the decision regarding their manuscript was affected by a publication ethics breach, the author may contact the publisher with a detailed written description of their concern, and information supporting the concern, at [email protected]

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MINI REVIEW article

Psychological aspects of students with learning disabilities in e-environments: a mini review and future research directions.

• Department of Pedagogy, Psychology, Philosophy, University of Cagliari, Cagliari, Italy

What are the main learning difficulties or advantages encountered by students with learning disabilities (LDs) within e-environments? As a result of the Covid-19 emergency, e-learning is being increasingly used to support students’ learning processes. A number of countries closed their schools altogether, so face-to-face lessons were and have been replaced by distance lessons. A search of current literature via Scopus, Eric and Google Scholar electronic databases was conducted according to Prisma Guidelines. Other sources of literature were also considered, starting from the references in the full text of the articles consulted. We used the following search keywords: “LDs” combined with the “AND/OR” Boolean operator and “e-learning platforms,” “well-being,” “psychological factors,” “emotional distress,” and “self-regulation.” One body of literature highlights the lack of inclusive accessibility standards and a lack of attention to specific tools for addressing LDs, which causes students to develop high levels of stress/anxiety and emotional distress, in addition to low levels of well-being, self-esteem and self-efficacy. Another area of literature looks at how students can develop high levels of self-regulation and emotional awareness, as well as high levels of inclusion. Results are discussed in terms of the promotion of e-learning that focuses on the psychological well-being of students and teachers use of technological tools.

Introduction

The forced interruption of face-to-face teaching due to the worldwide outbreak of Covid-19, has significantly reactivated the debate on the concrete effectiveness and functionality of e-learning courses. Specifically, our goal was to better understand the psychological effects and efficacy of the current massive use of the e-environments on students with learning disabilities (LDs) ( Viner et al., 2020 ). Literature shows a variety of ways to define e-learning. For example, Cidral et al. (2018) define e-learning as a web-based learning system for the dissemination of information, communication, and knowledge for education and training. Until 2002, Eletti had affirmed that e-learning is a new type of training, a new teaching system that allows you to follow and above all personalize learning. The services and tools used allow for continuous contact with the “student”. In addition, a platform and an interface built ad hoc , adapting the contents, allows to model the teaching on the user’s needs ( Eletti, 2002 ). Thus, in light of the massive use of e-environments, there is a definite need to question how effective these tools are for students with LDs. According to international diagnostic criteria, LDs are an overarching group of neurodevelopmental disorders comprising different learning disorders that affect primary and/or secondary academic abilities and a child’s overall capabilities ( American Psychiatric Association, 2013 ; Schulte-Korne, 2014 ). Children with specific LDs are a rather heterogeneous group, both with regard to specific academic abilities such as listening, thinking, reading, speaking, writing, calculating, and spelling ( Sorrenti et al., 2019 ), as well as to their neuropsychological and functional profiles. For example, they may have impairments affecting different cognitive and neuropsychological abilities (working memory), long-term memory (implicit and explicit memory), attention (selective and sustained), and linguistic, praxis, visuospatial, problem solving, and/or executive abilities ( Petretto and Masala, 2017 ; Visser et al., 2020 ), etc. Moreover, there is general agreement on the association between LDs and other neurodevelopmental disorders (ADHD and specific language disorders); LDs typically occur in individuals of normal intelligence ( Sorrenti et al., 2019 ). A body of studies indicates a relationship between children’s LD and poor social relations in school ( Walker and Nabuzoka, 2007 ), this aspect is confirmed also in the University context ( Filippello et al., 2019 ). Literature shows a relationship between LDs and internalizing (depressive and anxiety disorders) and externalizing disorders (conduct disorders) ( Frith, 2013 ; Bonifacci et al., 2016 ; Panicker and Chelliah, 2016 ; Visser et al., 2020 ). If LDs are not adequately treated, they can evolve over time, potentially resulting in forms of psycho-social maladjustment ( Sorrenti et al., 2019 ). Regarding the use of e-learning, only a small number of studies have addressed these psychological factors and consequences, and there are few studies which have directly examined the quality of life of students with LDs, or the quality of interpersonal relationships (parents, teachers, and peers). In this mini-review and according to previous research in the field, we analyze these aspects and focus our attention to the following questions:

(1) What are the effects of the use of e-learning on psychological well-being?

(2) What are the effects of accessibility standards in promoting inclusion and in reducing stress, anxiety and emotional distress among students with LDs?

Methodology

A search of current literature using Scopus, Eric and Google Scholar electronic databases was conducted according to Prisma Guidelines ( Moher et al., 2015 ). Other sources of literature were also considered, starting from the references in the full texts of the articles examined. We used the following search keywords: “LDs” combined with the “AND/OR” Boolean operator and “e-learning platforms,” “well-being,” “psychological factors,” “emotional distress,” and “self-regulation”. Applying a systematic procedure, literature was then selected and results were charted and analyzed. The following inclusion criteria were established: papers on the use of e-learning with LD; on the relationship between e-learning platforms and related psychological aspects (self-esteem, emotional distress, and self-regulation); written in English and published from 2015 to 2020. The following exclusion criteria were applied: systematic reviews; papers on the use of e-learning without LD. On the basis of the research questions and the literature considered, we chose a minireview. For this reason the data will be presented as a narrative review.

Results and Discussion

In the first part of the search, two independent assessors found 53 articles. Applying our inclusion and exclusion criteria, after reading the abstract, 27 articles were considered. After reading the full texts, 4 further articles were excluded, thus a final group of 23 articles were considered ( Table 1 ). As expected, in literature, regarding the definition of “e-learning”, we found different systems and tools (platforms, devices, web materials/sites, Learning Content Management Systems, ICT, etc.). According to Bjekic et al. (2014) we categorized the different definitions in two groups. The first group refers to the use of Assistive Technology (AT) (hardware or software, used to increase, improve or maintain capabilities of persons with LDs aimed to support and/or increase learning). The second group of e-learning refers to a system of procedures, processes and instructional materials that supports learning. Moreover, we considered a difference between e-platforms and ICT tools ( Salehi et al., 2015 ; Table 2 ).

Table 1. Characteristics of papers which met the inclusion criteria.

Table 2. Papers which met the inclusion criteria in the school setting analyzed according to Bjekic et al. (2014) .

The papers showed a certain amount of heterogeneity in their definition of LDs. Some authors proposed a specific definition ( Chen et al., 2015 ; Richardson, 2015 ; Shonfeld and Ronen, 2015 ; Straub and Vasquez, 2015 ; Benmarrakchi et al., 2017 ; Sharabi et al., 2016 ; Adam and Tatnall, 2017 ; Vasalou et al., 2017 ; Lambert and Dryer, 2018 ; Lipka et al., 2019 ; Ziadat, 2019 ), while others proposed a general reference to Special Educational Needs or used the World Health Organization definition of Disability ( World Health Organization, 2001 ; Berizzi et al., 2017 ; Naumova et al., 2017 ; García-González et al., 2020 ). Some papers reported the definition of LD based on international diagnostic criteria, others described specific national law/s or references ( Sharabi et al., 2016 ). Moreover, with regard to sample recruitment, some authors chose samples consisting of different groups of students with other kinds of disabilities and then specified the number of students with LDs ( Richardson, 2015 , 2016 ; Shonfeld and Ronen, 2015 ; Terras et al., 2015 ; Benmarrakchi et al., 2017 ; Sharabi et al., 2016 ; Alamri and Tyler-Wood, 2017 ; Berizzi et al., 2017 ; Kent et al., 2018 ; Lipka et al., 2019 ; Ouherrou et al., 2019 ; García-González et al., 2020 ); while in other papers, the sample is made up only of students with LDs ( Chen et al., 2015 ; Straub and Vasquez, 2015 ; Vasalou et al., 2017 ; Lambert and Dryer, 2018 ). Regarding the level of schooling, about 1/2 of the studies focused on University environments ( Richardson, 2015 , 2016 ; Terras et al., 2015 ; Alamri and Tyler-Wood, 2017 ; Naumova et al., 2017 ; Kent et al., 2018 ; García-González et al., 2020 ) and the other 1/2 examined primary and secondary schools ( Chen et al., 2015 ; Straub and Vasquez, 2015 ; Benmarrakchi et al., 2017 ; Rice and Carter, 2016 ; Smith et al., 2016 ; Adam and Tatnall, 2017 ; Berizzi et al., 2017 ; Vasalou et al., 2017 ; Baharuddin and Dalle, 2019 ; Lipka et al., 2019 ; Ouherrou et al., 2019 ; Ziadat, 2019 ; Nieto-Márquez et al., 2020 ). One paper focused on the transition from school to university ( Sharabi et al., 2016 ). As expected, we also found a considerable heterogeneity in school settings, ranging from mainstream school/classrooms to special needs schools/classrooms, according to specific national and theoretical approaches and policies regarding the field of inclusion (see Table 2 ). Given that the countries in our sample ranged across Europe, United States, as well as Arab and Slavic countries, there was some diversity in the idea of inclusive policies for students with LDs. This is due to national differences regarding the issues of policies for students with LDs and, in general, for students with SEN. In some countries, there is an inclusion-based approach where students with LDs are placed in mainstream schools; in other countries there are special schools and special classrooms for them. In some countries, transition to complete inclusion is still ongoing ( Lindsay, 2016 ; Norwich, 2016 ; Petretto et al., 2019 ; Pilia, 2019 ). While one of the papers described a specific experience in two special needs classes ( Adam and Tatnall, 2017 ), other research papers concentrated on the use of specific e-learning approaches to designated groups of children with LDs or to all the children in the classroom in mainstream schools ( Straub and Vasquez, 2015 ; Vasalou et al., 2017 ).

The approaches employed range from the use of specific devices and/or platforms, to the use of specific “reasonable accommodations” (such as font quality and sizes in the learning materials on the web or the use of specific support technologies) ( Chen et al., 2015 ; Benmarrakchi et al., 2017 ; Rice and Carter, 2016 ; Alamri and Tyler-Wood, 2017 ; Berizzi et al., 2017 ; Ouherrou et al., 2019 ; García-González et al., 2020 ); or the use of software/games aimed to increase specific abilities in students with LDs ( Straub and Vasquez, 2015 ; Vasalou et al., 2017 ). For university settings, some articles describe the experiences of so-called “Open universities” that have been based on distance learning methods since they started. With the development of ICTs, in the past few decades these universities have started to use e-learning platforms to contact students and to promote learning and social connections ( Richardson, 2015 , 2016 ; Kent et al., 2018 ). Their ongoing experiences focus mainly on the attainment of students with LDs as well as on the need to increase access to information and learning. Other studies focus on the need for dedicated online courses to specific categories of students, aiming at reducing barriers and distances and providing specific accommodations ( Terras et al., 2015 ).

The age range in these university samples is very wide. From a positive perspective it can represent a sign of the wider opportunity for older people to access university courses. However, according to some studies, it could be also the sign of a lower and slower attainment of students with LDs in University ( Richardson, 2015 , 2016 ; Shonfeld and Ronen, 2015 ). The topics of attainment and achievement are interesting because even though some papers have discussed the risk of low achievement for students with LDs, other studies have demonstrated the positive effect of accommodations and have showed examples of unexpected achievement by LD students ( Shonfeld and Ronen, 2015 ). Another aspect is the fear of disclosure of their diagnosis by some students with LDs and the effects on their tendency to hide diagnoses rather than to communicate it, even when they should do so in order to define specific “reasonable accommodations” ( Richardson, 2015 , 2016 ; Terras et al., 2015 ). Although there may be increased student awareness of the need to disclose their diagnosis and the functional profiles that help to define a personalized approach that facilitates their access to learning and materials, some authors have highlighted the importance of further discussing the role of communication between teachers/instructors and students with LDs in the development of more comfortable learning environments and in the pursuit of shared learning and achievement aims ( Terras et al., 2015 ).

Focus on Psychological Well-Being

Few studies have directly examined the psychological aspects of students with LDs in e-environments. Some papers have focused on psychological consequences of the intensified use of Information and Communications Technologies (ICTs); other papers instead focused especially on adults, addressing some psychological effects of e-learning procedures adapted to students with LDs. In their study, Ouherrou et al. (2019) highlighted the fact that the integration of ICTs in special needs education may have a positive impact on the emotional states of children with LDs, because they may experience fewer negative emotions than findings of current literature would suggest with regard to the presence of higher levels of negative emotions in the classroom. Vasalou et al. (2017) argued that a socially constructed view of digital games-based learning provides new opportunities for the support of children with dyslexia. Children spontaneously engage in “game talk” regarding game performance, content, actions and they strategically use their individual game experiences to express their personality and interact with their peers. Also, such experiences can help improve the intra-individual function by enhancing a child’s self-esteem. The findings of Sharabi et al. (2016) supported earlier studies that assessed children and adolescents with LDs ( Sharabi and Margalit, 2014 ), showing that college students with LDs possess lower levels of personal resources (sense of coherence, hope and academic self-efficacy) and suffer higher levels of social distress and loneliness than their peers. The loneliness factor was predicted by measuring online avoidance coping, their amount of smartphone use and by examining their personal resources, the use of ICTs may provide additional environmental conditions to enable youngsters to meet their emotional needs. At the same time, these opportunities may also be misused as avoidance coping and thus may contribute to increased loneliness and lower academic self-efficacy. Coherently with previous studies, Lambert and Dryer (2018) highlighted that in high education the e-environment had a negative influence on the quality of life of students with increased stress and anxiety, the perception of feelings of inadequacy, a decrease in time available for other activities and personal relationships. The same authors also highlighted that for many students, the academic and emotional support provided by family and friends was a key factor in study success. Studies on the perception of the impact of e-learning on the development of academic skills and social interaction from the perspective of students and/or teachers showed that the quality of teacher-student relationships contribute to producing improvements in learning achievement ( Alamri and Tyler-Wood, 2017 ; Lipka et al., 2019 ; Ziadat, 2019 ). Only a small number of studies have considered the role of parents. Smith et al. (2016) investigated parents’ perceptions and experiences regarding exclusive online learning for their children with disabilities. The results showed that this experience altered parents’ previous roles and that many parents were not equipped to take a teaching role due to lack of training, time, and other constraints. A parent-as-teacher role can negatively affect parent–child dynamics, leading to frustration for parent and child but full online learning requires increased parent–teacher communication. This increased level of interaction and the positive outcomes associated with the shared information enhanced a collaborative parent–teacher relationship. The use of ICT and e-learning can improve the learning of students with LDs only where a supportive context is present. The support provided by family, teachers and peers can create a protective factor which improves the well-being of students with LDs.

Focus on the Accessibility Standards and Emotional Distress

Many of the difficulties in designing e-learning courses are due to accessibility issues that can affect successful engagement ( Draffan, 2012 ; Seale, 2013 ). The heterogeneity of the LD population entails great challenges to all parties involved in creating, managing and using e-learning content, tools and platforms with accessibility features ( Guenaga et al., 2004 ; Baharuddin and Dalle, 2019 ). Some papers described the risks of a design approach based on a general and average idea of students without LDs ( Kent et al., 2018 ). For Beacham and Alty (2006) the e-learning materials commonly employed were developed with the needs and capabilities of non-dyslexic learners in mind; clearly, resources do not generally take into consideration the individual learning approaches that these students manifest ( Alsobhi and Abeysinghe, 2013 ; Chen et al., 2015 ; Luongo, 2018 ). Chen et al. (2015) also underline this point, observing that empirically derived guidelines for designing accessible online learning environments for learners with dyslexia are still scarce. The problem of accessibility is fundamental in e-learning design, as it is strictly linked to certain psychological factors that will affect students, like willingness to focus on learning, management of emotions and behavior, learning motivation, interest and self-regulation ( Chen et al., 2015 ; Berizzi et al., 2017 ; Luongo, 2018 ). Existing literature provides clear evidence that text-based synchronous activities commonly used in education, like chat programs and videoconference, can create psychological and learning difficulties. However, only a small number of papers take into account the problems of students with LDs in collaborative environments ( Luongo, 2018 ). Some papers focus on the positive aspects of the use of e-learning platforms in increasing accessibility to information and learning materials ( Richardson, 2016 ), above all because participation in remote activities, like on-line forum discussions, improves the autonomy and self-regulation of students ( Berizzi et al., 2017 ). These aspects are reinforced by continuous support of tutors and peers, and reflection on what has been done, the goals to be achieved, and ultimately the strategies to be adopted. Other articles described the possible role of a “universal design for learning approach” in the design of websites, web materials and e-learning platforms ( Chen et al., 2015 ; Shonfeld and Ronen, 2015 ; Alamri and Tyler-Wood, 2017 ; Kent et al., 2018 ; Nieto-Márquez et al., 2020 ) in order to create environments that can be useful also for students with LDs.

This mini-review has attempted to analyze both the quality of life of students with LDs and their interpersonal relationships and the features of e-learning that can have positive and negative effects on them. The considerable heterogeneity of the articles we selected led us to the following reflections: we are aware that the heterogeneity could represent a limit but also an expected consequence of the chosen way of to explore a complex topic. Bearing in mind this issue, in a following article we will discuss the picture of the state of art that we derived from this minireview. In the near future, we will explore specific and more focused aspects, also with an attention on intervention aims. Two issues are emerged.

The first is how important online-support is to consolidate teacher-learner relationships, as it can affect a student’s well-being and learning achievement. We know that e-learning is a psychological process supported by e-technology, and learning is a social activity. Understanding that it is socially constructed should ensure that e-learning is organized to promote participation, allowing all students to take part in all activities, thus enhancing cooperative-learning.

The second consideration regards the fundamental role of accessibility and “reasonable accommodations”, which should lead to a reduction of emotional distress and promote positive psychological factors through full engagement with e-learning. In order to be effective, e-learning must go beyond simply digitizing books and ought to be designed carefully and appropriately for learners ( Penna and Stara, 2007 , 2010 ). What about the current and ongoing experience of the massive use of e-learning due to the COVID-19 outbreak? We agree with Al Lily et al. (2020) , who coined the term “Crisis Distance learning,” that the current ongoing experience is different from previous ones, and that caution is needed before making any kind of generalizations from previous experiences. Nevertheless, some general considerations can be drawn for future research. It is necessary to encourage and maintain cooperative approaches in all spheres, including in the use of e-learning in school and universities, with particular attention on the quality of the relationships between all the people involved (students-teachers-parents-peers) and with an even more specific focus on the psychological needs of students with LDs. The improvement of e-learning systems designed with attention to the care and quality of relationships can promote well-being among all parties involved in the learning process.

Author Contributions

All authors equally contributed to the design of the study. All authors have read and agreed to the published version of the manuscript.

This work was supported by ATS Sardinia: title project “ Profilo Neuro-Psicologico e Problematiche Emotive nei DSA: Una Proposta di Ricerca-Intervento” - – “Neuro-Psychological Profile and Emotional Problems in LDs: A Research-Intervention Proposal ” (November, 2019; June 2021).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords : e-learning, psychological well-being, emotional distress, self-regulation, learning disabilities

Citation: Cataudella S, Carta S, Mascia ML, Masala C, Petretto DR and Penna MP (2021) Psychological Aspects of Students With Learning Disabilities in E-Environments: A Mini Review and Future Research Directions. Front. Psychol. 11:611818. doi: 10.3389/fpsyg.2020.611818

Received: 29 September 2020; Accepted: 01 December 2020; Published: 07 January 2021.

Reviewed by:

Copyright © 2021 Cataudella, Carta, Mascia, Masala, Petretto and Penna. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Stefania Cataudella, [email protected]

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Factors associated with excess all-cause mortality in the first wave of the covid-19 pandemic in the uk: a time series analysis using the clinical practice research datalink.

Background Excess mortality captures the total effect of the Coronavirus Disease 2019 (COVID-19) pandemic on mortality and is not affected by misspecification of cause of death. We aimed to describe how health and demographic factors were associated with excess mortality during, compared to before, the pandemic. Methods and findings We analysed a time series dataset including 9,635,613 adults (≥40 years old) registered at United Kingdom general practices contributing to the Clinical Practice Research Datalink. We extracted weekly numbers of deaths and numbers at risk between March 2015 and July 2020, stratified by individual-level factors. Excess mortality during Wave 1 of the UK pandemic (5 March to 27 May 2020) compared to the prepandemic period was estimated using seasonally adjusted negative binomial regression models. Relative rates (RRs) of death for a range of factors were estimated before and during Wave 1 by including interaction terms. We found that all-cause mortality increased by 43% (95% CI 40% to 47%) during Wave 1 compared with prepandemic. Changes to the RR of death associated with most sociodemographic and clinical characteristics were small during Wave 1 compared with prepandemic. However, the mortality RR associated with dementia markedly increased (RR for dementia versus no dementia prepandemic: 3.5, 95% CI 3.4 to 3.5; RR during Wave 1: 5.1, 4.9 to 5.3); a similar pattern was seen for learning disabilities (RR prepandemic: 3.6, 3.4 to 3.5; during Wave 1: 4.8, 4.4 to 5.3), for black or South Asian ethnicity compared to white, and for London compared to other regions. Relative risks for morbidities were stable in multiple sensitivity analyses. However, a limitation of the study is that we cannot assume that the risks observed during Wave 1 would apply to other waves due to changes in population behaviour, virus transmission, and risk perception. Conclusions The first wave of the UK COVID-19 pandemic appeared to amplify baseline mortality risk to approximately the same relative degree for most population subgroups. However, disproportionate increases in mortality were seen for those with dementia, learning disabilities, non-white ethnicity, or living in London.

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• Research article
• Open access
• Published: 31 December 2019

Students with specific learning disabilities experiences of pre-registration physiotherapy education: a qualitative study

• M. Norris   ORCID: orcid.org/0000-0001-7779-5612 1 ,
• J. Hammond 2 ,
• A. Williams 3 &
• S. Walker 2  

BMC Medical Education volume  20 , Article number:  2 ( 2020 ) Cite this article

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Attainment gaps for students with disabilities have been noted in pre-registration physiotherapy courses in the UK. Previous research suggests disclosure, lack of staff knowledge and poor communication between University and placement sites may be relevant, but these are limited to small case studies with students with visual or physical disabilities. The purpose of this study was to explore disabled physiotherapy students’ experiences of their education in order to elucidate factors that may influence success.

Qualitative study drawing on phenomenological traditions. Four focus groups including 15 students with disabilities were conducted. Transcripts were analysed thematically. Procedures for transparency and rigour such as member checking and peer debriefing were implemented.

Three major themes were derived from data. “It was quite a relief” explores the personal and social implications of diagnosis. “They’re not natural” focuses on academic assessment and the specifics of adjustments made and not made within that context. “My dyslexia doesn’t switch off” explores the inaccessibility of the learning environment and dissects the contrast between the 24-h nature of having a specific learning condition and the somewhat piecemeal nature of adjustments during their education.

Conclusions

This study indicates that having a specific learning disability or anxiety creates a number of hurdles to success in physiotherapy education. Most were within the University setting and were perceived to result from staff ignorance or piecemeal approaches to inclusion. A lack of consistency alongside facilitated dialogue and acknowledgement of enhancements results in frustration, ambiguity towards disclosure and reinforcement of a deficit model. Such an approach belies the intention of the profession and the NHS and does not maximise the potential of widening participation.

Peer Review reports

There has been a specific focus on widening participation to higher education in the United Kingdom (UK) and worldwide since the beginning of the twenty-first century. Initial focus in the UK was on improving access and increasing participation for all [ 1 , 2 ]. However, in the last decade evidence has emerged of attainment inequalities [ 3 ]. Hence attention has been drawn to not only making higher education accessible to all, but also ensuring that those who enter successfully complete their course of studies. This has been bolstered by the Equality Act published in 2010 [ 4 ], and specific action to monitor metrics of learning gain through the Teaching Excellence Framework [ 5 ], practices to enable equal access and appropriate support for all.

Disability is one area where attainment inequalities have been found within higher education. This is of specific relevance to physiotherapy, as 12% of pre-registration students across all UK Higher Education Institutions (HEIs) declared a disability in 2016–17 on entry to their course [ 6 ], with the majority reporting dyslexia or other specific learning disabilities. This is equivalent to national data for all courses in 2016–17 [ 7 ]. The physiotherapy profession has a long history of including people with disability within education and the workforce, in particular people with visual impairment [ 8 ]. This is supported by the National Health Service (NHS) which has stated the aim of employing people with disability [ 9 ]. However, a number of issues have been raised within the literature.

First is a recent study which demonstrates an attainment gap exists for pre-registration physiotherapy students with a disability, particularly those studying on pre-registration MSc courses [ 10 ]. While this study in physiotherapy mirrors a pattern in medicine, dentistry and higher education more generally [ 11 ], it did not explore potential reasons for attainment inequalities; other related literature in physiotherapy may give some indications. Reluctance to disclose disability before, during and after clinical training has been highlighted as an issue due to concerns with negative judgement and prejudice [ 8 , 12 , 13 ]. Likewise, poor levels of staff knowledge and familiarity with specific disabilities, has been linked with reduced acceptability and unsupportive behaviour [ 14 ]. This has specifically been related to placements where communication between sites (clinical and academic personnel) has not been optimised [ 12 ].

Research in higher education in other clinical professions is more prolific and highlights additional concerns such as the construction of disability within education generally and the consequential focus on ‘adjustments’ in a concessionary structure [ 15 ]. Stigma, marginalization and discrimination have been noted, both directly in universities and with clinical staff but also indirectly through the regulatory frameworks related to fitness to practice [ 16 , 17 , 18 , 19 ]. In contrast, studies also highlight agency of students with disabilities with potential enhancement as a consequence of living with a disability [ 15 , 20 ]. To date it is not explicitly known how these relate to the broad experience of physiotherapy education, or disabilities such as dyslexia. Likewise, while there are a number of recommendations for inclusive education [ 21 ], it is not clear how these are being implemented and perceived in physiotherapy.

To complicate things further, the term disability itself is debated. We have approached this research with an awareness of current debates, but without a specific lens, remaining open to the various narratives of the participants. Given the literature on stigma and discrimination [ 8 , 12 , 13 , 16 , 17 ], we are mindful of the social model, where focus is directed towards barriers created by society [ 22 ]. However, in-keeping with critiques of this model we acknowledge that a focus on society should not detract from a need to consider the individual and their specific situation which is strongly supported in the limited physiotherapy literature [ 8 , 23 ]. Furthermore, recognizing the narratives on agency and enhancements [ 15 , 20 ] draws attention to the affirmative model in which the celebration of positive social identity and ownership of impairment is highlighted [ 24 ]. In contrast, Campbell’s [ 25 ] call for a more radical refocusing of disability studies that critiques the processes and practices that support and perpetuate ableism as homonormativity within society, requires a consideration of how those processes and practices may play out in physiotherapy education. This is in part reflected by Bryne [ 26 ] who reminds us to remain vigilant to the dominant discourse of ability in which ‘support’ and ‘adjustment’ are considered both as unfluctuating and as a concession which have to be earned through assessment and evidence.

Within this context, the purpose of this study was to explore disabled physiotherapy students’ experiences of their education in order to elucidate what factors might be relevant in student success. Due to the dearth of literature in physiotherapy it was impossible to predict which factors (social/environmental/individual) are more prominent in the lived experiences of physiotherapy students. Therefore, the study purposefully focused on the broad educational experience of the participants so that any factors relevant to them could be raised.

This was a qualitative study informed by phenomenological traditions [ 27 ], in-keeping with the focus on the students’ experiences of life as a student physiotherapist with a disability.

For practical reasons two HEI’s in the South East of England were chosen to conduct the study. The total pool of students studying BSc and MSc pre-registration courses was approximately 500, therefore there were approximately 60 potential participants based on the 12% prevalence estimate of physiotherapy students with a disability previously indicated [ 6 ]. Students at the two HEI’s were invited to participate in the study via a cohort wide email. Inclusion criteria included current students, who had completed both academic modules and clinical placement and who had a confirmed disability (self-declared but also documented in University records). To maximize inclusion further sampling restrictions were not included. This can be considered a convenience sample [ 28 ] of those with the relevant experience to respond to the study aims.

Focus groups were selected given their ability to support collective responses and increased depth often prompted through interaction. A focus group at the penultimate (MSc yr 1 and BSc yr 2) and final (MSc yr 2 and BSc yr3) year level were conducted at each HEI to explore the shared phenomenon of physiotherapy education. They followed a topic guide developed in relation to previous literature and discussed and agreed by the research team (Additional file  1 ). It included opportunities for participants to discuss their identity, positive and more challenging experiences in university and placement, garner their thoughts on the previous study that showed an attainment gap [ 10 ] and opportunities for enhancement. Open questions were intentionally used in order to avoid leading participants in particular apriori directions.

All focus groups were facilitated by experienced qualitative researchers from outside the host institution, and therefore were previously unknown to the participants, who were also physiotherapy faculty members (MN with AW as co-facilitator, JH with SW as co-facilitator). One had a disability which was shared with the participants in order to enhance an atmosphere of openness. The focus groups were audio-recorded and key points were noted on flip charts during the focus groups to aid in collective member checking of the data. This was deemed particularly important as all researchers are academic faculty and these checks served to highlight potential presuppositions of priority areas.

Audio-recordings were transcribed verbatim and anonymised. They were analysed thematically by one lead researcher [ 29 ]. This followed a process of familiarisation through reading of the transcripts, detailed inductive line coding and iterative development of categories and super-ordinate themes. An example of a thematic tree is given in Fig.  1 . Negative case analysis was conducted to check thematic development. Three co-researcher’s read the transcripts closely and engaged in critical discussions with the lead researcher to enhance depth of analysis and transparency. One of these researchers has a specific learning disability which offered the opportunity to consider a perspective from inside the community and to challenge potential emergence of ableist discourse.

Example thematic tree

The sample included 15 students (11 F, 4 M, 12 BSc, 3 MSc) with a range of predominantly specific learning disabilities including dyslexia, anxiety, dyspraxia, Attention Deficit Disorder -ADD and Attention Deficit Hyperactivity Disorder - ADHD (Table  1 ). While one student with physical disability volunteered, they were unable to attend the focus group. The focus groups lasted on average 92 min (range 83–99).

Three major themes were derived from the focus group data. The first theme “it was quite a relief” explores the personal and social implications of diagnosis on a bedrock of previous hard work and social ignorance. “They’re not natural” focuses on academic assessment and the specifics of adjustments made and not made within that context. The final theme “My dyslexia doesn’t switch off” highlights aspects of education delivery which are not ideal to access learning. Students noted that while these issues would resonate with most students, they had particular significance for those with specific learning conditions. These illustrate the contrast between the 24-h nature of having a specific learning condition and the somewhat piecemeal nature of adjustments during their education. This theme ends with a clear call for institutional practices to support rather than hinder the self-management strategies that the students own. On the basis of the experiences discussed in the focus groups, students suggested specific recommendations to education and practice. These are presented in the discussion.

“It was quite a relief”: the personal and social implications of diagnosis

As a starting point the students shared their own personal histories of struggle. Most had completed the majority of their earlier education without any formal diagnosis and therefore described how they had often felt isolated and somewhat confused by the difficulties they faced as this female participant describes:

“I was diagnosed with dyslexia when I was 19. Beforehand I’d struggled all the way through…so I was just average but working extremely hard to be average…I think if you don’t know …then you feel like you’re struggling by yourself…no one understands” F3 FG2

One student related how this lack of understanding of herself and her condition impacted on her emotionally resulting in a diagnosis of anxiety at an earlier age. Yet these are students that had succeeded in their education despite this lack of knowledge and support and the sense they were working harder than their peers in order to achieve resonated through all focus groups.

While diagnosis came late for the majority and the categorisation as having a disability itself was not unproblematic, when it came it was met with a degree of relief:

“I quite like it [diagnosis]…it was quite a relief…it justifies things…I could identify an issue” They later continue, “it’s kind of something to make me aware, I’ve got an idea of how I think and I’ve got some ideas of where I should go with it” M1 FG1

Diagnosis was usually accompanied with detailed reporting of their own specific condition. As the participant above indicates this knowledge led to understanding and a re-framing of their previous struggles. Participants talked about a sense of empowerment, awareness and insight which ultimately led to clearer ideas of personal action and acceptance which this example shows:

“once I understood it, it kind of made me feel a lot better about myself and just umm, those negative emotions and feeling they kind of dissipated a lot over time, it’s cos I understood better myself.” M2 FG1

The positive benefits of detailed reporting were noted particularly when they were accompanied by a clear and relevant introduction to strategies and how they could be implemented in real life. For one student this came through work alongside an Occupational Therapist, while another noted the usefulness of a report which specifically focused on physiotherapy related skills.

This reframing of their past history led to an increase in confidence but also appreciation of the positive traits. The students discussed their increased capacity to problem solve, be creative with ideas, look outside the box and have empathy with people who struggle, all skills which they saw as relevant additions to their future careers as therapists. This personal understanding was not present for all, influenced by the timing of their diagnosis, or the recent onset of new challenges such as placement. For those most recently diagnosed (within the last 12 months), their strategies were still developing and the work of re-understanding and reframing was still in progress.

The majority of the participants were not diagnosed until University (current or previous degree), which raised the issue of identification processes. The driver to seek testing came from a number of sources: previous work colleagues, medical personnel, personal tutors, a generic talk at induction, advice from other students and placement educators. While all were grateful for the prompt, and the awareness of role models within the profession was noted particularly favourably, the haphazard way in which it occurred was the source of concern for the participants. Students strongly expressed the need for early identification to maximise their capacity on the course which they indicated required more robust and reliable processes of identification.

“I suppose one of the really key things is just getting diagnosed like early, so you can get support in place, I suppose that's quite a major part” F10 FG4

Early identification and diagnosis, for many, lay in better awareness of the conditions. The students discussed many misconceptions they held prior to their own diagnosis, relating conditions such as dyslexia with lower intelligence. But while their own understanding developed, there were significant concerns raised about others in society, including in the academic arena. Some students reported not declaring their disability on their application for fear of judgement as a ‘problem’. This also extended to disclosure on placement through concerns of being treated differently or being supervised by staff who are “not gonna know where to start with you” F2 FG1. Mostly though, the students described positive experiences on placement with staff who were well informed or indeed had specific learning difficulties themselves. The majority of the issues raised were within the Universities themselves and specifics of this will be discussed in the following themes.

Overall this theme illustrates the complex journey students with disability have in relation to diagnosis and subsequent understanding of self. They highlight the importance of early and consistent identification which requires better awareness of conditions and signposting.

“They’re not natural”: the false glare of assessment

This theme unpacks the assessment process and how students perceive their disability within that specific context. While the participants on the whole were appreciative of adjustments made to exams, their insights draw on potential misconceptions about their conditions resulting in apparently random decisions on adjustments to assessment.

Of particular concern were practical exams and participants consistently raised their frustration and confusion over the lack of adjustment to these assessments. A key feature of this was a lack of adjustment in time. While it was inconsistent, most described additional time for reading components of practical exams but nothing for the actual delivery of the practical skill and discussion. For them, this separation between reading and oral/aural/practical components made little sense when they had recognised problems with processing and organising information. For them this was often harder in aural/oral form then in written, which led to high levels of anxiety about the questioning processes in such exams as this example demonstrates:

“I find it hard when they ask you questions on the spot and you don’t have a couple of minutes to process it…I find if I take a couple of minutes I can produce quite an outstanding answer, but if you want answer like that, which in the exam conditions you just kind of go blurgh” F3 FG2

The anticipation of facing these exams without additional time created a vicious circle for these students. Knowledge of their own challenges with processing and delivery, led to fear of not completing the exams on time. This created anxiety and pressure to speed up, which resulted in more errors and heightened awareness of their difficulties.

A further challenge was distraction within their exam. For written assessments they were often in a room with few students or on their own. However, with practical exams they were with other students with several exams happening simultaneously. While they appreciated the complexity of organising such exams, this format resulted in a mix of distraction and pressure. The noise of others speaking and moving disturbed their focus, already a recognised challenge for many, and as a result they had to regather their thoughts, ask for questions to be repeated or misunderstood what was being asked of them. All were seen to contribute to additional stress, loss of time, but also the potential of responding to what they thought they had been asked rather than the actual question/task.

“I’ve had to ask a number of times for them to repeat the question to me because I’m fixing on something else, or like I hear a beep or something’s happening and they’ve asked me a question and cos you’re under pressure and time, I’ve suddenly forgotten, I wasn’t even listening to the question and that, I then need to ask, “Oh sorry, can you repeat that again?” F1 FG1

The participants in these focus groups frequently commented that the problems they faced were common to all students, but highlighted that they were exacerbated when you had a specific learning difficulty.

Many had raised their concerns about the lack of adjustments with academic tutors and had been told that exams were designed to mimic the clinical environment. However, this contrasted with experiences on placement where they described a greater willingness of colleagues to consider adjustments as demonstrated here:

F10: “I asked about that first year for my bad auditory memory for practical exams and they said to me, it’s not like the actual setting of being on placement…but I got extra time for my initial assessments [on placement]…When you’re here (university) they’re sort of well that’s not how it’s gonna be in real life”

F8: “but you’re learning, there’s a difference…we’re learning at uni so we should get extra time…which is why we get extra time on placement” FG4

They highlighted numerous cases where exam conditions created problems which were never replicated on placement. Time was one factor, as students described a number of placements which considered additional time to be a holistic requirement not just for writing notes. Similarly, instructions and feedback were adjusted to be given on paper rather than verbally to assist with processing and retention. Likewise, students were encouraged to create templates as memory assistance while on placement, whereas in exams they were entirely reliant on immediate recall. Mostly though it was the pressure of exams and the intense time limited focus on the student. This restriction was not perceived in clinical practice leading the participants to conclude that the assessment process placed a false glare on their abilities.

“Again it’s not natural, when you do it you’re in a placement on a ward, it’s so natural you just do it whereas in an exam in the OSCEs [Objective Structured Clinical Examination] you, as I said, it just doesn’t feel…“F3 FG2

This theme highlights a clear perceived discrepancy between how practical assessments operate within the university environment, which are not replicated within the clinical field. The complex processing and problem solving required within case based practical exams appeared not to be considered, coupled with limitations placed on strategies participants were encouraged to develop when working clinically.

“My dyslexia doesn’t switch off”: inaccessible learning environments and piecemeal approaches to disability support

In the previous theme, an acceptance that some experiences may parallel those of non-disabled students became apparent. This next theme dissects the minutiae of the learning experience, unpacking features that create general inaccessibility, but which further impact on students with specific learning difficulties. This highlights a perceived piecemeal approach to support which contrasts with the 24 h experience of living with a disability.

Students consistently flagged the lecture arena as a complex minefield to navigate. While they acknowledged their lecturers were generally knowledgeable and engaging, the forum of the lecture, it’s structure, pace and density of material, as well as length were seen as a significant obstacle to learning. Students referred to ‘zoning out’ or metaphorically ‘leaving the room’ while remaining in it as words washed over them. The result was frustration, not only in their lack of understanding but also the awareness that they had lost time which they would have to compensate for later.

“I leave a lecture and I can hear some people being like “oh that’s really interesting” and I’m like you heard that? When was that mentioned 'cos I’ve not picked that up?...because to me it’s like someone throwing stuff at me, but in no particular order for me to actually contemplate or even put down on paper what they’ve said…it’s a bit of a set back for me ‘cos I feel like now I’ve got to go and do double the work to try and actually understand what that hour lecture was actually about” F2 FG1

A specific challenge was the necessity to write notes while listening and trying to understand. This was deemed essential as the students perceived many lecturers left slides minimally populated. This was matched with a perceived delay in posting slides prior to lectures so participants had inadequate time to familiarise themselves with the material to ease the complexity of the lecture format. Of particular note here was the participants understanding that the decision to have minimalist slides and late posting was a positive decision by lecturers based in part on pedagogical principles. This frustrated the students at a number of levels. First was the sense that their learning styles may be different to standard research as this participant describes:

“it was kind of like that kind of paternalism of “this is how you should learn”, which I think they can be really frustrating because it’s not actually, it might be the best way to learn in terms of research or whatever but we learn differently” M1 FG1

But it was not just a potential mismatch between their learning style with research, but also on perceived intention. The students in this research interpreted the lack of detail and delay as obstruction by lecturers, reinforced by a lack of change following requests. The consequence was they perceived a lack of flexibility for them to use their own style and strategies to maximise their learning and indeed take ownership of their learning.

Timely posting of material generally was raised in relation to Virtual Learning Environments (VLE’s), the online portals where most learning resources are stored. The students suggested that a key strategy for most of them was to organise themselves early, so they knew what they needed to attend to well in advance. This was rendered impossible when materials were not posted in good time. But they also commented on their frustration when the location of materials changed, different modules posted things in different, seemingly random places or indeed the VLE itself changed.

Other areas participants highlighted included class numbers and room layout, all perceived to impact on their ability to engage. These students were aware that ‘putting things together’ is often an area that they have to work hard to achieve. Rather than facilitating that process, the academic practices created further obstacles which they were forced to navigate. As this participant suggests:

“So I think here they just limit it, you’ve got dyslexia, great, we’ll help you if you need to. Here’s extra time in exams, but that’s it. They (staff) don’t think about things like, so the presentations and what they look like and how visually it can affect. They don’t think about room sizes or, you know, one to one sessions or smaller group sessions and I think that is, is a big thing”. F3 FG2

Other points raised were the perception that timetables and group changes were haphazard which limited capacity to plan ahead or work with the people who understood their learning styles. The participants suggested that changes came with a lack of adequate explanation as to why they had occurred or an appreciation that such changes were disproportionately disruptive to some students with disabilities. For the participants in this study, this rather piecemeal approach to their disability was frustrating. They sensed that support was inconsistently applied which was in direct contrast to their 24-h experience of living with a disability.

For many this was a result of perceived staff ignorance of their diagnosis. While examples were given on placement, more often participants discussed clinical educators who themselves had specific learning difficulties. They were mostly seen as allies. Consequently, the call for more education was firmly directed towards University based staff.

“Personally in the physio department there’s not a big awareness of specific learning difficulties I don’t think…. My educator, I’d be on placement for two weeks, said I think you maybe should consider going and get tested, I’d been at university for two or three years now and I know, I get on with the lecturers and I give them pieces of work to have a look at, none of them advised that I get a test or anything like that “F6 FG3

This sense of staff ignorance was not universal, but like the adjustments was seen as piecemeal. It was chance if you had a tutor who recognised signs, made the effort to signpost appropriately, and who made suggestions on how placement could be approached. And chance was considered a problem.

Cumulatively, this lack of awareness, lack of consideration of the on-going challenges of studying with a disability and adjustments that were only periodically considered had one overriding impact on the participants; an impedance to them managing their own situation. This disempowerment lay at odds with a clear sentiment across the participants in this study, that they were aware of their own dis/abilities and they were very willing to take ownership of their personal situation.

The narratives from this group of students with disabilities highlight a number of aspects which they associate with potentially impeding their success.

Early identification and orientation to the physiotherapy context facilitated recognition, understanding and development of strategies in order for these students to succeed as the independent professionals they aspired to be. When successful, these processes had the potential to shift the participants’ identity resulting in confirmation of their skills and capabilities. Clouder et al. [ 15 ] note that students with a disability often have strong agency and a desire to engage. This was also evident in this study as the participants demonstrated how an understanding of self, resulted in a desire to reject the deficit view of their disability and affirm their positive skills and attributes, possibly reflecting an emerging affirmation model [ 24 ]. The findings suggest that the process of transformation and the students’ confidence in engagement was hampered as a consequence of inadequate and inconsistently applied systems and staff ignorance. Therefore informed, proactive, timely and responsive systems that are equitably delivered to maximise the students’ potential for self-discovery and development are important and may impact positively on their successful progression in the course.

The further findings from this study illustrate some of the challenges of the learning environment and practices for students. Interestingly, issues identified were most frequently situated within the university arena rather than the clinical environment which is surprising, given that previous literature in the field has largely focused on the practice environment [ 8 , 12 , 13 , 18 , 19 , 23 ].

One issue relevant to the clinical and university settings was ambiguity in disclosure. Disclosure of their disability was rarely discussed by the participants in relation to potential prejudice as described by other authors [ 8 , 30 , 31 , 32 , 33 , 34 , 35 ]. Rather, in-line with Opie and Taylor [ 13 ] concern was situated once more in ignorance. On one side the students were unclear how their disability may impact on placement and as a consequence questioned the need for disclosure. On the other, the students perceived their educators both at university and on placement to be ignorant of specific disabilities and therefore disclosure may not be met with a supportive response. This insight suggests that the ambiguity around disclosure requires more nuanced examination and perhaps further exploration of qualified staff awareness of disability (particularly specific learning disabilities) is needed.

In relation to the university environment, numerous examples were highlighted by the participants indicating how their engagement and assessment potential were hampered. These raise some significant questions about what might be done to make the education experience more inclusive and what adjustments might be considered reasonable alongside the expectations of professional behaviour and competence. Understanding these opportunities may assist in facilitating engagement and subsequent assessment success.

One example noted by the students was the inaccessibility of the learning environments, whether through lecture format and notes, class sizes and structure or the virtual learning sites. A number of possible contributing factors were implied for this apparent lack of consideration of the wider features of education delivery such as: i) lack of familiarity of staff with principles of inclusive education (as described by Hockings [ 21 ]), ii) a lack of willingness to deliver on it or alternatively iii) a mismatch between the students’ expectations of specific delivery methods (e.g. introductory lectures) and the pedagogical considerations by the faculty. What was explicit in this study is that standardised and inflexible teaching and learning practices actively impede the students’ engagement, autonomy and management of self, a view supported by related literature and linked to success [ 20 , 26 , 36 , 37 ]. Furthermore, there appeared to be little opportunity for effective dialogue with academic staff to redress this.

A potentially more complex example was that of a lack of consideration and flexibility in practical examinations. The ability of these assessments to reflect clinical reality was questioned by the students who found the clinical environment to be more accommodating of alternative ways of processing and delivering information. This contradiction in experience raises some key questions about the purpose and process of practical assessments.

While personal fitness to practice was not expressly raised in this study, the implied necessity of clinical competence suggests the concept of ensuring students are fit to practice may influence faculty staff decision making about flexibility within practical assessment. For instance, extra time adjustments may be given for reading preparation but not within situations that apparently replicate a clinical encounter, which is similar to guidance for medical education [ 38 ]. However, this neither considers the iterative real time clinical reasoning processes that occur during practical examinations that were often described by the participants in this study. Nor does it potentially reflect many therapeutic clinical encounters in which the assumption of immediate and time restricted response (for purposes of safety) are not necessarily required. Discrepancy is also noted in students’ descriptions of proactive use of templates to support their organisation and decision-making while on placement which are explicitly not permitted within university assessments. Interestingly, alternative formats for students to respond to clinical questions, such as use of paper and diagrams, is recommended by the General Medical Council [ 38 ].

As a consequence, the very purpose of reasonable adjustments is questioned and a dilemma of prioritising safety over effectiveness is created (also reported in nursing education [ 39 ]). A focus on examination competence that does not reflect clinical need and competence suggests an approach to university assessment based on homonormativity and ableist processes. This limits students’ potential and autonomy, decreases their capacity to explore and be appropriately assessed on strategies they could use in practice, but also inappropriately homogenises all clinical situations. Eaterbrook et al. [ 20 ] and Bulk et al. [ 36 ] note that there needs to be greater clarity on necessary competencies and appropriate inflexibility alongside acceptance of where approaches and structures can be changed. A more considered approach to practical based assessments which involves closer dialogue with both clinical partners and students would result in an improved capacity to align assessment with clinical reality and assist visibility of decision making. This is particularly required given that currently the students perceive that the support they receive on placement is more appropriate and flexible and utilises their enhanced skill set rather than remaining in a deficit model.

A key aspect of these findings is that understanding these students’ experiences and the implication of education has broad relevance. Their narratives are a challenge not only to how education providers engage with students with disabilities, but how they engage with educating all students. Shakespeare [ 40 ] calls for a deconstruction of an assumed normality and in highlighting discontinuities in their experience, which they note impacts on all students, the students in this study echo that call.

The overall sense of these data is that these students are caught within a focus and indeed the language of deficit by a system that they perceive prioritises normalisation, while they indicate a desire to explore, affirm and express their able diversity. Adjustments for them were not seen as a concession to normalise but an opportunity to learn and perform to the best of their ability and reflected their experience in the clinical environment. This lay in contrast to what they perceive as the fractured institutional processes which appeared to remain in concessionary structure, but specifically one that only pertained to particular tasks, reading and written assessments. As a consequence, the inclusivity of the curricula and its delivery may be questioned, and the opportunities to celebrate able diversity need to be reconsidered.

This study has number of strengths and limitations which are important to consider. The limited representation of different disabilities, specifically physical and visual is acknowledged. Likewise, the specific locality of the study and its focus on two institutions may limit that relevance of the findings to a wider audience, however readers are encouraged to consider similarities to their own context. To counter some of these limitations a researcher with a disability was included during all stages, care was taken to encourage open conversations within the focus groups and the rigour of the analysis and the member checking of initial summaries gives strength to the depth and direction of the analysis.

These focus groups with physiotherapy students with a range of different specific learning difficulties and other long term mental health disorders, has demonstrated that studying physiotherapy involves complex dynamics, which the students have to learn to navigate. The students navigate factors that include ignorance of their conditions within the profession and educational institutions which results in often haphazard routes to diagnosis, ambiguity with disclosure, and critically, both a lack of continuity in the institutions approach to support and inadequate consideration of the impact of the learning environment, assessment and resources. While the students accepted that these concerns often relate to all students, they felt that they disproportionately impacted on those with disabilities.

As a result, the students felt somewhat disempowered by structures and processes throughout their course. These hurdles also impede use of their self-management strategies that they have worked hard to develop and wish to implement.

This was a small study based in a particular region of the UK. However, given the dearth of research to date within physiotherapy, it is an important step forward. Specifically, this study extends the literature in this area by highlighting the issues experienced within the university setting which have been under-reported in physiotherapy. This particularly relates to the concepts of and limitations to reasonable adjustments. It further highlights the ambiguity of disclosure, indicating a need for further exploration.

There is a need for more studies looking at the experience and attainment of students with disabilities nationally, with a focus on the factors that impact on their learning experience and successful strategies to facilitate that process. Specific focus on the transition from University to clinical environments is also warranted.

Implications

Students have a wealth of knowledge based on their experiences of living with a disability while undertaking pre-registration physiotherapy studies. The insights they raise pose a number of challenges to education providers both in academic and clinical environments. While caution is appropriately raised in regard to generalisations for what is a very heterogeneous group, some general considerations can be raised from this study. These include; consistent and accessible signposting to facilitate early self-understanding and recognition of strategies and skills; increase staff awareness of individual experiences of disability and how this can impact on learning in different environments; critical examination of the justifications for what is considered ‘reasonable’ in terms of adjustments; improved interaction between clinical and university based education providers to share understanding and expectations in relation to adjustments and clinical competence; and a reconsideration of inclusive education that creates opportunity to allow and celebrate able diversity.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Attention deficit disorder

Attention deficit hyperactive disorder

Higher education institutions

National Health Service

Objective structured clinical examination

United Kingdom

Virtual learning environment

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Acknowledgements

Thanks to the students who volunteered to participate in this study and offered to share their experiences.

The study was funded by Health Education England North West London, but the design of the study, data collection, analysis, interpretation and writing was entirely the responsibility of the authors.

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MN, JH, AW, SW conducted the focus groups. MN analysed the data. JH, AW, SW all reviewed the data and analysis and participated in critical discussions. MN drafted the article. JH, AW and SW made significant contributions to the final draft, which all authors have approved.

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Norris, M., Hammond, J., Williams, A. et al. Students with specific learning disabilities experiences of pre-registration physiotherapy education: a qualitative study. BMC Med Educ 20 , 2 (2020). https://doi.org/10.1186/s12909-019-1913-3

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Top 20 Principles for Students with Disabilities

Psychological science has much to contribute to enhancing teaching, learning, and well-being in the classroom. Psychology provides key insights on effective instruction; classroom environments that promote learning; and appropriate use of data, tests, and measurement.

We present here a document for listing and describing the top 20 psychological principles for use in the context of pre-K to 12 classroom teaching and learning, as well as the implications of each principle as applied to classroom practices for students with disabilities. These principles are categorized into five areas of psychological functioning:

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• Classroom management: How can the classroom best be managed?
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Specific Learning Disabilities: Issues that Remain Unanswered

Adarsh kohli.

Department of Psychiatry, PGIMER, Chandigarh, India

Samita Sharma

Susanta k. padhy, introduction.

Specific learning disabilities (SLDs) are defined as “heterogeneous group of conditions wherein there is a deficit in processing language, spoken or written, that may manifest itself as a difficulty to comprehend, speak, read, write, spell, or to do mathematical calculations and includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia and developmental aphasia.”[ 1 ]

DISTINCTION BETWEEN TERMINOLOGIES – DISORDER, DISABILITY, DIFFICULTY, AND SLOW LEARNER

The terms learning disorders, learning disability (LD), and learning difficulty are often used interchangeably but differ in many ways. Disorder refers to significant problems faced by children in academic areas, but this is not sufficient to warrant an official diagnosis. The word “disorder” is a medical term as mentioned in the Diagnostic and Statistical Manual of Mental Disorders,[ 2 ] and International Statistical Classification of Diseases and Related Health Problems,[ 3 ] both of which are considered authoritative guides for mental health professionals.

The word “disability” in SLDs is a legal term that is mentioned in the Right of Persons with Disabilities Act (RPWD Act, 2016),[ 4 ] notification issued by the Ministry of Social Justice and Empowerment (Department of Empowerment of Persons with Disabilities) and Individuals with Disabilities Education Act (United States federal law).[ 5 ] These federal laws protect the rights of students with disabilities. To receive special disability certificates and services under these acts, a student must be a “child with a disability.”[ 6 ] SLD is an official clinical diagnosis where the individual meets certain criteria as assessed by a professional (psychologist, pediatrician, etc.).

Children with “learning difficulties” underachieve academically for a wide range of reasons, including factors such as behavioral, psychological, and emotional issues; English being their second language and not their mother tongue; ineffective instruction; high absenteeism; or inadequate curricula. These children have the potential to achieve age-appropriate levels once they are provided support and evidence-based instruction.[ 7 ]

Students with below average cognitive abilities whom we cannot term as disabled are called “slow learners.” The slow learning child is not considered mentally retarded because he is capable of achieving a moderate degree of academic success even though at a slower rate than the average child.[ 8 ]

TYPES OF LEARNING DISABILITIES

Reading disability (also known as dyslexia) is the most common LD, accounting for at least 80% of all LDs.[ 9 ] Reading should be taught; it is not an innate entity. Reading requires the ability to understand the relationship between letters and the associated sound, which is known as phonetics. Dyslexia reflects a specific problem in processing individual speech sounds (e.g., the ssss sound, the mmm sound) in words (phonemes). There can also be problems with holding sounds in sequence in short-term memory (e.g., holding the sequence of sounds in a new word in mind long enough to recognize it). Children with a reading disability may also have difficulties with reading fluency, resulting in reading skills that are accurate but effortful and slow.[ 9 ]

Dyscalculia is generally characterized by difficulty in learning or understanding mathematical operations. A student with arithmetic disorder might have difficulty organizing problems on the page; following through on multiple step calculations such as long division; transposing numbers accurately on paper or on to a calculator, such as turning 89 into 98; distinguishing right from left; and using mathematical calculation signs. They may also be confused about basic operations and facts.[ 9 ]

Dysgraphia is generally characterized by distorted writing despite thorough instruction. A student with dysgraphia exhibits inconsistent and illegible writing, mixing upper and lowercase letters, and writing on a line and inside margins. He or she might have fine motor difficulties such as trouble holding the pencil correctly, inability to use scissors well, or coloring inside the lines.[ 9 ] Overall writing does not communicate at the same level as his or her other language skills.[ 9 ]

LDs are associated with psychological comorbidities.[ 10 , 11 ] Approximately 30% of children have behavioral and emotional problems.[ 12 ] Children with SLD are at an increased risk of hyperactivity. There is a strong relationship between inattentiveness and reading disabilities. The comorbidity of attention deficit hyperactivity disorder (ADHD) in children with LD varies from about 10% to as high as 60% depending on the sample taken.[ 13 , 14 ] Co-occurrence of major depressive disorder (MDD) and LDs was studied in 100 children age 9–12 years. It was seen that 62% of children with MDD had LD, whereas only 22% of children without depression had LD.[ 15 ] The comorbidity of LD with both internalizing and externalizing disorders implicates the need for cognitive and behavioral approaches in the remediation programs offered to dyslexic children. Diagnosis at an early age results in boosting self-confidence and social competency.[ 16 ]

LDs do not become evident till the child starts going to school. Many children do not exhibit any signs until they engage in tasks which require certain kind of cognitive processing which becomes apparent then.

A lot of research and efforts are being done in the field of LDs in the western world. However, in India, the experience and research are limited. The government and educational authorities are also progressing toward the betterment of education system. There are many gray areas in this field which need more efforts, clarity, understanding, and discussion.

TEACHERS' ATTITUDE, TEACHING METHODS, AND PRACTICES

Despite the fact that millions of people around the world suffer silently from SLD, there remains widespread confusion and misinformation with regard to identification of and interventions for SLDs. Due to this, children do not enjoy their school life and resist going to school. Some efforts have been made, like the one by National Council of Educational Research and Training in 2015, when a handbook on the inclusion of children with special needs was prepared. It was a very sincere effort in which a series of workshops were held in different parts of the country, involving regular school teachers, teacher educators, special educators, and experts from universities and nongovernmental and governmental organizations.[ 17 ] The handbook emphasized access and participation of children in the learning process, more than just placing them in schools. The question arises how far these efforts are being implemented successfully.

A study conducted in Haridwar, India (2015),[ 18 ] showed that 67% of teachers had no knowledge of LDs. Overall, teacher educators who participated in that study had a low level of knowledge about SLDs, irrespective of their gender or teaching experience. Another study conducted in Chandigarh on the perception of teachers about LDs showed some positive results. Approximately 67.5% teachers perceived that they do encounter children with LD in the school, 43.8% supported special schools for such children, and 36.3% were in favor of integrated education. About one-fifth of the teachers were ready to undergo special skill training for teaching students with learning disorders.[ 19 ] The level of awareness among teachers was explored in Puducherry (UT).[ 20 ] The study found that the teachers in the inclusive classroom require skill training to impart education to students with SLD. The data showed that in an inclusive education setup, the information regarding SLD is average. The authors recommended the Government of India to implement intensive and methodical training to fulfill the educational needs.[ 20 ] This is certainly important because when we talk about inclusive education, we must have means to support the idea to the fullest. Teachers should be sensitized and trained to screen for this problem at the primary school level itself so that remediation can be started at an early stage.

There is a huge difference in private and government school setups. In private schools, there is a counselor and special educator with a specialization in intervention for SLDs, but this facility is lacking in government schools. The students of private schools usually belong to middle and high socioeconomic status, paying hefty fees for education. These schools are better equipped to provide all the necessary services to the students. On the contrary, in government schools, the majority of the students are from lower socioeconomic status, with parents who are completely unaware of the concept of SLD. They are not able to avail these services and remain underprivileged. This is very disheartening because the teachers are also not keen to put in extra efforts to help these students. Many policies and rules are made only on paper, but implementation is missing.

In today's society, there are schools which are result-oriented and focus on producing “toppers.” They are not interested in keeping the so-called “slow child” in their classrooms. This attitude hinders the child's learning progress and results in worsening of prognosis of the problem. SLDs result in unexpected academic underachievement. Teaching authorities are demanding and lack patience for slow learners. The teacher certification programs in India are short of sufficient courses in special education to prepare general teachers for inclusive classrooms. Owing to the lack of proper training in the area and lack of familiarity with reading process and areas of reading skills which require assessment, creativity and “trial and error” are what guide the course of remediation.[ 21 ]

Teaching methods and styles adopted by the teachers differ from school to school and also have regional differences.[ 15 ] Some schools focus on phonetics and teach accordingly; some adopt the traditional rote learning pattern in which the child crams the alphabets without understanding their formation and sound. Rote learning methods focus on grades and good marks, ignoring the overall development of the child. Multisensory teaching aids, visual and auditory cues, computer software providing text-to-text and speech-to-text capabilities, and so on are restricted to only a few schools which can afford to provide such quality teaching practices.[ 22 ] It is very difficult to achieve this technological sophistication in all the classrooms in a developing country like India which suffers from wide economic disparity and fluctuating literacy rate. Resultantly, again the question arises whether the learning disorder is confounded by faulty teaching practices or due to the natural course of the problem. Sight word teaching, phonemic awareness difficulties, or specialized vision problems can also cause reading difficulty and are often mistaken for true organic dyslexia. Teaching methods such as sight words result in reading difficulty that mimic dyslexia. This method inhibits the development of left–right reading and eye jumps all around the word. According to the American Child Development Institute, “Children who have an average or above average IQ and are reading one and a half grades or more below grade level may be dyslexic.” “True dyslexia affects about 3%–6% of the population. Yet in some parts of the country, up to 50% of the students are not reading at grade level. The reason for most children not being able to read at grade level could be ineffective reading instruction. The child with dyslexia is often a victim of having SLD and is being exposed to ineffective instruction as well.”[ 23 ] In France, it was proved that schools that taught with whole word method produced more students with dyslexia than schools teaching with phonics. The brains of dyslexic students can be retrained with phonics.[ 24 ] In India, teachers are not trained enough to understand this and help the students in need. Traditional teaching methods such as spelling games and cursive writing exercises during vacations have almost disappeared. The expectations of parents and early induction of children into school have resulted in more damage than gains.

SHORTAGE OF SPECIAL EDUCATORS

Central Board of Secondary Education (CBSE) had made it mandatory for all the affiliated schools to appoint a special educator so that children with LDs could be assimilated with other students. It was ultimately seen that it was a big challenge for the schools to find qualified professionals in this area. According to school authorities, special educators are experienced in teaching physically challenged students; they lack theoretical and practical skills required for teaching learning disabled students. The teaching methods have to be tailor-made for these students since they have behavioral problems as well.[ 25 ]

In 2016, Special Educators' Forum of India had submitted a charter of demands to various education departments of every state. This was done because the government had not created a post of special educators or made it mandatory for the schools to appoint them.[ 26 ] In a recent report, it came to light that in Delhi, out of 927 posts of special educators, 432 are still vacant. This fault came into light when a mother of two sons with disability studying in a government school filed a complaint that her sons have not learned anything, instead they have become a source of entertainment for the students. Students and teachers bully them and authorities turn a deaf ear to them.[ 27 ] Special educators equipped with individualized educational program are the need of the hour to tackle the situation.

PROBLEMS WITH LANGUAGES

In the Oriental world, the LDs were considered a problem of English-speaking countries.[ 22 ] Due to lack of awareness and reportedly lower incidence rates in Asian countries like India and China, not many efforts were made in this field. Researchers in the Western world attributed this problem to the overcrowded classrooms and backward teaching strategies.[ 28 ] On the other hand, eastern researchers attribute it to the phonetic complexity of English language which resulted in problems in language adaptability.

Spelling–sound correspondence is direct in Hindi language, which means that we write what we speak. But in case of English, there are certain notorious traits of the language which makes it complex and it becomes necessary to remember the arbitrary spellings and words. For example, there are a lot of words in English language with silent letters which makes the language much more difficult, because here the person needs to remember formations such as psychology, pseudo, pneumonia, and walk. Those children having difficulty in process of learning find it difficult to comprehend. People reading and writing Hindi and other regional languages also do suffer from learning difficulties. It is seen equally in other languages as well. The child is unable to learn orthography, syntax, and phonetics of language because of which it becomes imperative for the teachers to adopt such teaching practices and for the school authorities to facilitate the learning process of these children.

LACK OF STANDARDIZED ASSESSMENT TOOLS

India is a multilingual country, so it is important to assess the problem of SLD in a child's mother tongue. There are numerous batteries used for the assessment of LDs, with their own merits and demerits. Some of the batteries are widely used for assessment, but there is a lack of well-established norms for all subtests, and these norms are based on a very small sample which makes generalization difficult like the AIIMS SLD: Comprehensive Diagnostic Battery and NIMHANS Index for Specific Learning Disabilities. Many batteries are prepared in regional languages (e.g., Marathi, Gujarati and Kannada) which lack nationwide applicability. Some batteries can only be administered on students of English medium schools like NIMHANS Index for Specific Learning Disabilities, whereas in India about 100.4 million students study in Hindi medium schools.[ 29 ] The content used in the batteries is not standardized. Existing batteries have not included all the age groups for assessment, which makes assessment difficult, especially when the student is to be assessed in tenth or twelfth board classes for the issuance of a certificate for availing benefits.

COMPLEXITY OF GRADATION IN LEARNING DIFFICULTY AND DISABILITY

According to standard assessment procedure for learning disorders, one class is taken as one standard deviation. So if a child is performing two classes below his actual standard/class, then he or she is diagnosed as LD, and if the performance is one class below, then it is diagnosed as learning difficulty not amounting to disability. Now, various education boards, including CBSE[ 30 ] The Indian Certificate of Secondary Education ICSE, Kerala Board, and Maharashtra Board, provide various concessions for students with LD; but there are no facilities for students with learning difficulty. The awareness among policy makers regarding this point of differentiation is limited. There is no provision for students with difficulties. Lack of support from school authorities and parents worsen the situation. Students are not able to avail relaxations and suffer silently. Pediatricians and psychiatrists rely on clinical psychologists to distinguish students with learning difficulty and disability. This confusion creates problems for the process of certification and intervention. The problems of students with learning difficulty not amounting to disability needs to be dealt with specialized techniques of intervention at early stages by a special educator and a parent together.

PROVISIONS FOR SPECIFIC LEARNING-DISABLED STUDENTS

After a series of consultation meetings and drafting process, the Rights of People with Disabilities Act, 2016 was passed by both the houses of the Parliament. It was notified on December 28, 2016 after receiving presidential assent. The list was expanded and it included SLDs in it. A bill was introduced in Rajya Sabha on March 24, 2017, entitled “The Children with Specific Learning Disabilities (Identification and Support in Education).” It highlighted the need for special facilities in educational institutions, setting up detection and remediation centers, guidelines for certification of children with SLDs, and so on.[ 31 ] On January 15, 2018, the Ministry of Social Justice and Empowerment (Department of Empowerment of Persons with Disabilities) issued a notification regarding the procedure to be followed while certifying people with disabilities. The Gazette laid emphasis on screening, diagnosis, and certification of SLD. Figure 1 gives the summary of standard operating procedure of certification for SLDs.[ 1 ]

The screening, diagnosis, and certification procedure for Specific learning disabilities

This effort by the Government of India deserves appreciation as it has highlighted the importance of certification and has tried to standardize it. Despite this step, there are certain issues which are a matter of concern. Psychiatrists have been excluded from the procedure of certification. Students with academic difficulties or scholastic decline are usually referred to Child and Adolescent Psychiatry clinics from the school. A team of psychologists and psychiatrists carry out the complete assessment of the students referred from schools. It is highly recommended that psychiatrists should also be included into the procedure along with pediatricians and psychologists because they have specialized training in mental health and developmental disorders of children and adolescents. Second, the Gazette mentions which tests shall be used for the assessment of IQ for uniformity, but in case of SLD assessment, it should be left to the discretion and experience of the psychologists. Instruments that are to be used should be latest and should have norms that can be generalized to the population concerned. The same tests cannot be used in the entire country because of a wide range of sociodemographic and regional differences which can influence test results.

Initiative steps have been taken by CBSE to provide a concession for LD students. These concessions are in the form of a scribe and complementary time, exemption from a third language, flexibility in choosing subjects, permission to use calculators in mathematics, and provision to read out question paper to a student with dyslexia. These students are also exempted from spelling errors and from writing answers in detail, and so on. According to the recent circular issued by CBSE, no school can deny admission to students with disabilities in mainstream education. It has also recommended regular in-service training of teachers in inclusive education at elementary and secondary level, as per CBSE guidelines.[ 30 ] Many other boards and state boards are also offering concessions, but there is no uniformity in rules for demanding certificates. Some boards demand only a certificate of SLD and some require a detailed report along with the certificate; some need renewal while some accept one-time certification.[ 32 ]

There are pros and cons of these provisions. Some parents have a mindset of demanding certificates even when their children do not have a, LD. They do not focus on remedial intervention. This leads to misuse of these provisions and certification. This is a sensitive issue which needs to be handled carefully. There are others who are not aware of these concessions, and the child keeps struggling with disability.

STIGMA AND LABELING

In India, acceptance of children suffering from LDs in schools largely depends on the capability of the schools to provide necessary services to the children and the attitude of the teachers to put some sincere efforts to help these children. Inclusion, therefore, has rather become selective inclusion of children with disabilities in the mainstream, especially in private schools.[ 33 ] These children suffer from many behavioral problems and certain comorbid conditions such as ADHD which is again not known to many. They are labeled as dull, lazy, mischievous, troublesome, and so on without knowing the actual reason behind this. Social attributes play a very important role in the overall course of illness. Acceptance from society, peers, teachers, and so on affect their successful inclusion.[ 34 ] The label of LD carries its own burden, baggage, and complications.

OVERLAP WITH SCHOOL DROPOUT

It is difficult to treat various students who drop out from the school as a homogeneous group. Dropping out from the school can be attributed to factors such as low socioeconomic status, behavioral issues, LDs, or intellectual disability. There is a lot of overlap between these categories. There are students who are first-generation learners. According to the National Policy on Education, 1986, these students should be allowed to set their own pace of learning and should be given remedial supplementary instructions.[ 35 ] Their slow pace of acquiring information may be due to their background which is not stimulating enough to induce learning, but these children can often be diagnosed with SLDs. This again creates confusion.

GOVERNMENT POLICIES AND APPLICABILITY

Sarva Shiksha Abhiyaan aimed at universalization of elementary education “in a time bound manner,” as mandated by the 86 th Amendment to the Constitution of India, making free and compulsory education to children between the ages of 6 and 14 years a fundamental right. It was decided under this scheme that no student shall be failed and will be promoted to the next class.[ 36 ] This is very important and necessary initiative; but because of this, LD remains undiagnosed and untreated for a longer period of time. Child's problems aggravate because parents do not bother until the child fails, and school authorities do not bother till the school result is affected. Since a child is promoted to next class without the need of minimum passing marks, parents and teachers become complacent and wake up only at secondary levels, and the child's problem remains unnoticed. Some parents try to get away with their child's problem by availing certificates of disability without any extra efforts which are actually required to be invested in.

Accommodations which are now being given to students with LDs in the classrooms are sometimes regarded as unfair by parents of students without SLD. It is important to make the parents aware of the fact that these concessions and accommodations are not unfair advantages to students. In fact, if appropriate and timely concessions are not used, students could be branded as having LDs, creating serious negative impact to their achievement and self-concept. The parents can be sensitized on the above issues through parent–teacher meetings and other awareness programs conducted in the school.

To understand LDs fully, it is necessary to examine the problem in black and white with all its shades of gray. These gray areas are the practical and experiential difficulties when dealing with these children in Child and Adolescent clinics. Constructing a standardized assessment battery, keeping in view of the diversity of Indian culture, is a mammoth task. Having a thorough insight into the overlapping areas can clear misconceptions and guide assessment, intervention, and welfare benefits to those children who genuinely deserve them.

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Future horizons: the potential role of artificial intelligence in cardiology.

1. Introduction

1.1. terminology, 1.1.1. machine learning (ml), 1.1.2. deep learning (dl), 1.1.3. artificial neural networks (anns), 1.1.4. convolutional neural networks (cnns), 2. materials and methods, 3.1. electrocardiography (ecg), 3.1.1. echocardiography.

• Assessing and monitoring the left ventricular systolic and diastolic function;
• Evaluation of the right ventricular function;
• Evaluation and quantification of the cardiac chamber size;
• Assessing the functional significance of a valvular lesion and the evaluation of the prosthetic valve structure and function;
• Identification of the cardiac source of embolism and the evaluation of the cardiac masses;
• Evaluation of pericardial diseases [ 58 ].

3.1.2. Coronary Angiography

3.1.3. cardiac computed angiography, 3.1.4. computed tomography, 3.1.5. cardiac mri, 4. discussions, 4.1. challenges in ai implementation, 4.2. limitations, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Patrascanu, O.S.; Tutunaru, D.; Musat, C.L.; Dragostin, O.M.; Fulga, A.; Nechita, L.; Ciubara, A.B.; Piraianu, A.I.; Stamate, E.; Poalelungi, D.G.; et al. Future Horizons: The Potential Role of Artificial Intelligence in Cardiology. J. Pers. Med. 2024 , 14 , 656. https://doi.org/10.3390/jpm14060656

Patrascanu OS, Tutunaru D, Musat CL, Dragostin OM, Fulga A, Nechita L, Ciubara AB, Piraianu AI, Stamate E, Poalelungi DG, et al. Future Horizons: The Potential Role of Artificial Intelligence in Cardiology. Journal of Personalized Medicine . 2024; 14(6):656. https://doi.org/10.3390/jpm14060656

Patrascanu, Octavian Stefan, Dana Tutunaru, Carmina Liana Musat, Oana Maria Dragostin, Ana Fulga, Luiza Nechita, Alexandru Bogdan Ciubara, Alin Ionut Piraianu, Elena Stamate, Diana Gina Poalelungi, and et al. 2024. "Future Horizons: The Potential Role of Artificial Intelligence in Cardiology" Journal of Personalized Medicine 14, no. 6: 656. https://doi.org/10.3390/jpm14060656

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