case study of a child with learning difficulties

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Home > Books > Learning Disabilities - Neurological Bases, Clinical Features and Strategies of Intervention

The Child with Learning Difficulties and His Writing: A Study of Case

Submitted: 30 May 2019 Reviewed: 16 August 2019 Published: 20 November 2019

DOI: 10.5772/intechopen.89194

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The purpose of this paper is to present one child with learning difficulties writing process in multigrade rural elementary school in México. It presents Alejandro’s case. This boy lives in a rural area. He shows special educational needs about learning. He never had specialized attention because he lives in a marginalized rural area. He was integrated into regular school, but he faced some learning difficulties. He was always considered as a student who did not learn. He has coursed 2 years of preschool and 1 year of elementary school. Therefore, this text describes how child writes a list of words with and without image as support. Analysis consists to identify the child’s conceptualizations about writing, his ways of approaching, and difficulties or mistakes he makes. The results show that Alejandro identifies letters and number by using pseudo-letters and conventional letter. These letters are in an unconventional position. There is no relationship grapheme and phoneme yet, and he uses different writing rules. We consider his mistakes as indicators of the learning process.

• writing difficulties
• learning difficulties
• writing learning
• writing process
• special education

Author Information

Edgardo domitilo gerardo morales *.

• Faculty of Philosophy and Letters, National Autonomous University of Mexico, México City, México

*Address all correspondence to: [email protected]

1. Introduction

One of the purposes of Mexican education system is that students acquire conventional writing during first grades in elementary school [ 1 ]. This purpose consists of students to understand the alphabetical code, its meaning, and functionality. In this way, they can integrate into a discursive community.

The elementary school teacher teaches a heterogeneous group of children [ 1 ,  2 ]. Some students show different acquisition levels of the writing. This is due to literacy environment that the family and society provide. Thus, some children have had great opportunities to interact with reading and writing practices than others. Therefore, some students do not learn the alphabetical principle of writing at the end of the scholar year. They show characteristics of initial or intermediate acquisition level of the writing. In this way, it is difficult for children to acquire writing at the same time, at the term indicated by educational system or teachers.

In addition, there may be children with learning difficulties in the classroom. Department of Special Education teaches some children. Students with special educational needs show more difficulties to learn than their classmates [ 3 ]. They require more resources to achieve the educational objectives. These authors point out that special educational needs are relative. These needs arise between students’ personal characteristics and their environment. Therefore, any child may have special educational needs, even if he/she does not have any physical disability. However, some students with learning difficulties do not have a complete assessment about their special educational needs. On the one hand, their school is far from urban areas; on the other hand, there are not enough teachers of special education for every school. In consequence, school teachers do not know their students’ educational needs and teach in the same way. Thereby, students with learning difficulties do not have the necessary support in the classroom.

Learning difficulties of writing may be identified easily. Children with special educational needs do not learn the alphabetical principle of writing easily; that is, they do not relate phoneme with grapheme. Therefore, children show their conceptualizations about writing in different ways. Sometimes, teachers censor their students’ written productions because they do not write in a conventional way. Children with special educational needs are stigmatized in the classroom. They are considered as less favored. At the end of the scholar year, children do not pass.

Therefore, the purpose of this paper is to present one child with special educational needs writing process in a Mexican multigrade rural school. This text describes how the child writes a list of words with and without image as support. Analysis consists to identify the child’s conceptualizations about writing [ 4 ], his ways of approaching, and difficulties or mistakes he makes. These mistakes are the indicators of learning process [ 5 ].

This paper presents Alejandro’s case. This boy lives in a rural area. He shows special educational needs about learning. He never had specialized attention because he lives in a marginalized rural area. He was integrated into regular school, but he faced some learning difficulties. He was always considered as a student who does not learn. Therefore, this text describes Alejandro’s writing, what he does after 2 years of preschool and 1 year of elementary school.

2. Children with learning difficulties and their diagnosis

According to the National Institute for the Evaluation of Education [ 6 ], Mexican education system provides basic education (preschool, elementary, and secondary school) for students with special educational needs. There are two types of special attention: Center of Multiple Attention (CAM, in Spanish) and Units of Service and Support to Regular Education (USAER, in Spanish). In the first one, children with special educational needs go to this Center. These children receive attention according to basic education and their educational needs. In the second, specialized teachers on special education go to school and provide support to students. These teachers provide information to school teachers too. In this way, there is educational equity and inclusion in Mexican school [ 7 ].

Physical appearance : Teacher describes the child’s physical characteristics. These features indicate the type of food the student eats, care his or her person, the parents’ attention, among other elements.

Behavior observed during the assessment : In this section, the teacher should record the conditions in which the assessment was carried out: child’s attitude, behavior, and interest.

Child’s development history : This section presents conditions in which pregnancy developed, physical development (ages in which child held his/her head, sat, crawled, walked, etc.), language development (verbal response to sounds and voices, age in which said his/her first words and phrases, etc.), family (characteristics of their family and social environment, frequent activities, etc.), hetero-family history (vision, hearing, etc.), medical history (health conditions, diseases, etc.), and scholar history (age at which he/she started school, type of school, difficulties, etc.).

Present condition : In this, there are four aspects:

It refers to student’s general aspects: intellectual area (information processing, attention, memory, understanding, etc.), motor development area (functional skills to move, take objects, position of his/her body, etc.), communicative-linguistic area (phonological, semantic, syntactic and pragmatic levels), adaptation and social interaction area (the child’s skills to initiate or maintain relationships with others), and emotional area (the way of perceiving the world and people). In each one, it mentions the instruments he suggests, although there is not enough information about them [ 3 ].

The second aspect is the curricular competence level. Teacher identifies what the student is capable of doing in relation to established purposes and contents by official curriculum.

The third aspect is about the learning style and motivation to learn. It presents physical-environmental conditions where the child works, their interests, level attention, strategies to solve a task, and the incentives he receives.

The fourth aspect is information about the student’s environment: factors of the school, family, and social context that influence the child’s learning.

Psycho-pedagogical assessment allows to identify children’s general educational needs. In this way, the school teacher could have information about the students’ difficulties. However, it is a general assessment. It contains several aspects and does not go deeper into one.

Therefore, this paper does not propose a new assessment. It consists of presenting one child’s writing difficulties, his ways of conceptualizing writing, and some mistakes he gets to make.

3. Students with learning difficulties and their scholar integration

Since 1993, Mexican system education has tried to offer special education services to students with special educational needs in basic education [ 8 ]. The first step was to promote the integration of these children in regular education classrooms. However, only insertion of the student in the school was achieved. Therefore, the system of education searched for mechanisms to provide advice to teacher. In this way, student with learning difficulties can be attended at the same time in the classroom [ 8 ].

Educational integration has been directly associated with attention of students with learning difficulties, with or without physical disabilities [ 8 ]. However, this process implies a change in the school. For this, it is necessary to provide information and to create awareness to the educational community, permanent updating of teachers, joint work between teacher, family, and specialized teachers.

At present, Mexican education system looks at educational integration as process in which every student with learning difficulties is supported individually [ 9 ]. Adapting the curriculum to the child is the purpose of educational integration.

Curricular adequacy is one of the actions to support students with learning difficulties [ 10 , 11 ]. This is an individualized curriculum proposal. Its purpose is to attend the students’ special educational needs [ 3 ]. At present, Mexican education system indicates that there should be a curricular flexibility to promote learning processes. However, it is important to consider what the child knows about particular knowledge.

Regarding the subject of the acquisition of written language, it is necessary to know how the children build their knowledge about written. It is not possible to make a curricular adequacy if teachers do not have enough information about their students. However, children are considered as knowledge builders. Therefore, there are learning difficulties at the process.

4. Alejandro’s case

This section presents Alejandro’s personal information. We met him when we visited to his school for other research purposes. We focused on him because the boy was silent in class. He was always in a corner of the work table and did not do the activities. For this, we talked with his teacher and his mother to know more about him.

Alejandro is a student of an elementary multigrade rural school. He was 7 years old at the time of the study. He was in the second grade of the elementary school. His school is located in the region of the “Great Mountains” of the state of Veracruz, Mexico. It is a rural area, marginalized. To get to this town from the municipal head, it is necessary to take a rural taxi for half an hour. Then, you have to walk on a dirt road for approximately 50 min.

Alejandro’s family is integrated by six people. He is the third of the four sons. He lives with his parents. His house is made of wood. His father works in the field: farming of corn, beans, and raising of sheep. His mother is a housewife and also works in the field. They have a low economic income. Therefore, they receive a scholarship. One of his older brothers also showed learning difficulties at school. His mother says both children have a learning problem. But, they do not have any money for attending their sons’ learning difficulties. In addition, there are no special institutes near their house.

The boy has always shown learning difficulties. He went to preschool for 2 years. However, he did not develop the necessary skills at this level. At classes, this child was silent, without speaking. Preschool teachers believed that he was mute. Nevertheless, at scholar recess, he talked with his classmates. Alejandro was slow to communicate with words in the classroom.

When he started elementary school, Alejandro continued to show learning difficulties. At classes, he was silent too. He just watched what his classmates did. He did not do anything in the class. He took his notebook out of his backpack and just made some lines. Occasionally, he talked with his classmates. When the teacher asked him something, Alejandro did not answer. He looked down and did not answer. He just ducked his head and stayed for several minutes.

When Alejandro was in second grade, he did different activities than his classmates. His teacher drew some drawings for him and he painted these drawings. Other occasions, the teacher wrote some letters for him to paint. The child did every exercise during several hours. He did not finish his exercises quickly. Sometimes he painted some drawings during 2 h.

Although Alejandro requires specialized attention, he has not received it. He has not had a full psycho-pedagogical assessment at school by specialized teachers. His school does not have these teachers. Also, the child was not submitted to neurological structural examination or neurophysiological studies to exclude an organic origin of his learning difficulties. His parents do not have enough financial resources to do this type of study for him. In addition, one specialized institution that can do this type of study for free is in Mexico City. It is so far from child’s house. It would be expensive for the child’s parents. Therefore, he is only attended as a regular school student.

For this reason, this paper is interested in the boy’s writing process. This is because Alejandro coursed 2 years of preschool and 1 year of elementary school; however, he does not show a conventional writing yet. In this way, it is interesting to analyze his conceptualizations about writing and difficulties he experiences.

5. Methodology

The purpose of this paper is to know the child’s ways to approach writing spontaneously and his knowledge about the writing system. For this, the author used a clinical interview. He took into account the research interview guide “Analysis of Disturbances in the Learning Process of Reading and Writing” [ 12 ].

The clinical interview was conducted individually. We explored four points, but we only present two in this text: to write words and to write for image.

Interviewer took the child to the library room at school. There were no other students. First, the interviewer gave the child a sheet and asked to write his name. Alejandro wrote his name during long time. Interviewer only asked what it says there. He answered his name: “Alejandro.” Next, the interviewer asked the child to write some letters and numbers he knew. Alejandro wrote them. The interviewer asked about every letter and number. The child answered “letter” or “number,” and its name.

To write words : The interviewer asked the child to write a group of words from the same semantic field in Spanish (because Alejandro is from Mexico) and one sentence. Order of words was from highest to lowest number of syllables. In this case, interviewer used semantic field of animals. Therefore, he used following words: GATO (cat), MARIPOSA (butterfly), CABALLO (horse), PERRO (dog), and PEZ (fish). The sentence was: EL GATO BEBE LECHE (The cat drinks milk). The interviewer questioned every written word. He asked the child to show with his finger how he says in every written production.

To write for image : This task was divided into two parts. The first analyzed the size and second analyzed the number.

Interviewer used the following image cards: horse-bird and giraffe-worm ( Figure 1 ). Every pair of cards represents a large animal and a small animal.

Cards with large and small animals.

The purpose of this first task was to explore how the child writes when he looks at two images of animals with different size. The animal names have three syllables in Spanish: CA-BA-LLO (horse), PA-JA-RO (bird), etc. In this way, we can see how the child writes.

The interviewer used the following pair of cards for second task ( Figure 2 ).

Cards for singular and plural.

First card shows one animal (singular) and the second shows some animals (plural). In this way, we search to explore how the child produces his writings when he observes one or more objects, if there are similarities or differences to write.

The interviewer asked what was in every card. Next, he asked the child to write something. Alejandro wrote something in every picture. Afterward, the interviewer asked the child to read every word that he wrote. Child pointed with his finger what he wrote.

After, the interview was transcribed for analysis. We read the transcription. The author analyzed every written production. He identified the child’s conceptualizations about writing. He compared the written production and what the child said. In this way, the analysis did not only consist to identify the level of writing development. This text describes the child’s writing, the ways in which he conceptualizes the writing, the difficulties he experienced to write, and his interpretations about writing.

6. Alejandro’s writing

This section describes Alejandro’s writing process. As we already mentioned, Alejandro is 7 years old and he studies in the second grade of the elementary school. His teacher says the child should have a conventional writing, because he has already coursed 1 year of elementary school, but it is not like that. Most of his classmates write a conventional way, but he does not.

We organized this section in three parts. The first part presents how Alejandro wrote his name and how he identifies letters and numbers; the second part refers to the writing of words; and the third part is writing for picture.

6.1 Alejandro writes his name and some letters and numbers

The first part of the task consisted of Alejandro writing his name and some letters and numbers he knows. His name was requested for two reasons. The first reason is to identify the sheet, because the interviewer interviewed other children in the same school. Also, it was necessary to identify every written productions of the group of students. The second reason was to observe the way he wrote his name and how he identified letters and numbers.

The interviewer asked the child to write his name at the top of the sheet. When the interviewer said the instructions, Alejandro was thoughtful during a long time. He was not pressed or interrupted. He did not do anything for several seconds. The child looked at the sheet and looked at everywhere. After time, he took the pencil and wrote the following on the sheet ( Figure 3 ).

Alejandro’s name.

The interviewer looked at Alejandro’s writing. He asked if something was lacking. The interviewer was sure that Alejandro knew his name and his writing was not complete. However, Alejandro was thoughtful, and looked at the sheet for a long time. The interviewer asked if his name was already complete. The child answered “no.” The interviewer asked the child if he remembered his name. Alejandro denied with his head. So, they continued with another task.

Alejandro has built the notion of his name. We believe that he has had some opportunities to write his name. Perhaps, his teacher has asked him to write his name on his notebooks, as part of scholar work in the classroom. We observed that Alejandro used letters with conventional sound value. This is because he wrote three initial letters of his name: ALJ (Alejandro). The first two letters correspond to the beginning of his name. Then, he omits “E” (ALE-), and writes “J” (ALJ). However, Alejandro mentions that he does not remember the others. This may show that he has memorized his name, but at that moment he failed to remember the others, or, these letters are what he remembers.

Subsequently, the interviewer asked Alejandro to write some letters and numbers he knew. The sequence was: a letter, a number, a letter, another letter, and number. In every Alejandro’ writing, the interviewer asked the child what he wrote. In this way, Alejandro wrote the following ( Figure 4 ).

Letters and numbers written by Alejandro.

For this task, Alejandro wrote for a long time. He did not hurry to write. He looked at sheet and wrote. The child looked at the interviewer, looked at the sheet again and after a few seconds he wrote. The interviewer asked about every letter or number.

We can observe that Alejandro differentiates between letter and number. He wrote correctly in every indication. That is, when the interviewer asked him to write a letter or number, he did so, respectively. In this way, Alejandro knows what he needs to write a word and what is not, what is for reading and what is not.

Also, we can observe that the child shows a limited repertoire of letters. He did not write consonants. He used only vowels: A (capital and lower) and E (lower). It shows us that he differentiates between capital and lower letter. Also, he identifies what vowels and letters are because the child answered which they were when the interviewer asked about them.

6.2 Writing words from the same semantic field

Asking the child to write words spontaneously is a way to know what he knows or has built about the writing system [ 12 ]. Although we know Alejandro presents learning difficulties and has not consolidated a conventional writing, it is necessary to ask him to write some words. This is for observing and analyzing what he is capable of writing, what knowledge he has built, as well as the difficulties he experiences.

The next picture presents what Alejandro wrote ( Figure 5 ). We wrote the conventional form in Spanish next to every word. We wrote these words in English in the parentheses too.

List of words written by Alejandro.

At the beginning of the interview, Alejandro did not want to do the task. He was silent for several seconds. He did not write anything. He looked at the sheet and the window. The interviewer insisted several times and suspended the recording to encourage the child to write. Alejandro mentioned he could not write, because he did not know the letters and so he would not do it. However, the interviewer insisted him. After several minutes, Alejandro took the pencil and started to write.

Alejandro wrote every word for 1 or 2 min. He required more seconds or minutes sometimes. He looked at the sheet and his around. He was in silence and looking at the sheet other times. We identified that he needs time to write. This shows that he feels insecure and does not know something for writing. He feels insecure because he was afraid of being wrong and that he was punished by the interviewer for it. It may be that in class he is penalized when he makes a mistake. There is ignorance because he does not know some letters, and he has a low repertoire of the writing system. Thus, Alejandro needs to think about writing and look for representing it. Therefore, this is why the child needs more time to write.

We identified that the child does not establish a phoneme-grapheme relationship. He only shows with his finger from left to right when he read every word. He does not establish a relationship with the letters he used. In each word, there is no correspondence with the number of letters. The child also does not establish a constant because there is variation in number and variety of letters sometimes.

Alejandro used letters unrelated to the conventional writing of the words. For example, when he wrote GATO (cat), Alejandro used the following letters: inpnAS. It is possible to identify that no letter corresponds to the word. Perhaps, Alejandro wrote those letters because they are recognized or remembered by him.

Alejandro shows a limited repertoire of conventional letters. This is observed when he uses four vowels: A, E, I, O. The child used these vowels less frequently. There is one vowel in every word at least. When Alejandro wrote PEZ (fish), he used two vowels. We observed that he writes these vowels at the beginning or end of the word. However, we do not know why he places them that way. Maybe this is a differentiating principle by him.

There is qualitative and quantitative differentiation in Alejandro’s writing. That is, he did not write any words in the same way. All the words written by him are different. Every word has different number and variety of letters. When two words contain the same number of letter, they contain different letters.

When Alejandro wrote MARIPOSA (butterfly), he used five letters. The number of letters is less than what he used for GATO (cat). Maybe he wrote that because the interviewer said “butterfly is a small animal.” This is because the cat is bigger than the butterfly. Therefore, it may be possible that he used lesser letters for butterfly.

In Spanish, PERRO (dog) contains five letters. Alejandro wrote five letters. In this case, Alejandro’s writing corresponds to the necessary number of letters. However, it seems that there is no writing rules for him. This is for two reasons: first, because there is no correspondence with the animal size. Horse is larger than dog and Alejandro required lesser letters for horse than for dog. Second, CABALLO (horse) is composed by three syllables and PERRO (dog) by two. Alejandro used more letters to represent two syllables. In addition, it is observed that there is a pseudo-letter. It looks like an inverted F, as well as D and B, horizontally.

When Alejandro wrote PEZ (fish), the interviewer first asked how many letters he needed to write that word. The child did not answer. Interviewer asked for this again and student said that he did not know. Then, interviewer said to write PEZ (fish). For several minutes, Alejandro just looked the sheet and did not say anything. The interviewer questioned several times, but he did not answer. After several minutes, Alejandro wrote: E. The interviewer asked the child if he has finished. He denied with his head. After 1 min, he started to write. We observed that his writing contains six letters. Capital letters are predominated.

Alejandro used inverted letters in three words. They may be considered as pseudo-letters. However, if we observe carefully they are similar to conventional letters. The child has written them in different positions: inverted.

May be there is a writing rule by Alejandro. His words have a minimum of four letters and a maximum of six letters. This rule has been established by him. There is no relation to the length of orality or the object it represents.

We can identify that Alejandro shows a primitive writing [ 4 ]. He is still in writing system learning process. The phoneticization process is not present yet. The child has not achieved this level yet. He only uses letters without a conventional sound value. There is no correspondence to phoneme-grapheme, and he uses pseudo-letters sometimes.

6.3 To write for image

Write for image allows us to know what happens when the child writes something in front of an image [ 12 ]. It is identified if there is the same rules used by the child, number of letters, or if there is any change when he writes a new word. It may happen that the length of the words is related to the size of the image or the number of objects presented. In this way, we can identify the child’s knowledge and difficulties when he writes some words.

6.3.1 The image size variable

The first task is about observing how the child writes when he is in front of two different sized images. That is, we want to identify if the image size influences on his writings. Therefore, two pairs of cards were presented to Alejandro. Every pair of cards contained two animals, one small and one large. The interviewer asked Alejandro to write the name on each one ( Figure 6 ).

Horse and bird writing.

Based on the writing produced by Alejandro, we mentioned the following:

Alejandro delimits his space to write. When he wrote for first pair of words, the child drew a wide rectangle and he made an oval and several squares for the second pair of words. The child wrote some letters to fill those drawn spaces. It seems that Alejandro’s rule is to fill the space and not only represent the word.

When Alejandro writes the words, we identified that he presents difficulty in the conventional directionality of writing. He wrote most of words from left to right (conventional directionality), but he wrote some words from right to left (no conventional). For example, the child started to write the second word on the left. He wrote seven letters. He looked at the sheet for some seconds. After, he continued to write other letters on the right. He wrote and completed the space he had left, from right to left.

Alejandro shows two ways to write: left–right (conventional) and right–left (no conventional). When he wrote the last word, the child wrote one letter under another. There was no limited space on the sheet. Alejandro wrote it there. The child has not learned the writing directionality.

When we compared Alejandro’s writings, we identified that the number of letters used by him does not correspond to the image size. Although the images were present and he looked them when he wrote, the child took into account other rules to write. The six names of animals had three syllables in Spanish and Alejandro used nine letters for CABALLO (horse) and eleven for PÁJARO (bird). The letters used by him are similar to the conventional ones. However, these are in different positions. There are no phonetic correspondences with the words. The child shows a primitive writing. Alejandro has not started the level of relation between phoneme and grapheme yet. We can believe that the boy wrote some letters to cover the space on the sheet. Alejandro takes into account the card size instead of the image size.

After writing a list of words, the interviewer asked Alejandro to read and point out every word he wrote. The purpose of this task is to observe how the child relates his writing to the sound length of the word. When Alejandro read CABALLO (horse), he pointed out as follows ( Figure 7 ).

Alejandro reads “caballo” (horse).

Alejandro reads every word and points out what he reads. In this way, he justifies what he has written. In the previous example, Alejandro reads the first syllable and points out the first letter, second syllable with the second letter. At this moment, he gets in conflict when he tries to read the third syllable. It would correspond to the third letter. However, “there are more letters than he needs.” When he reads the word, he shows the beginning of phoneticization: relation between one syllable with one letter. This is the syllabic writing principle [ 4 ]. Nevertheless, he has written more letters. Therefore, Alejandro says “o” in the other letters. In this way, we can point out that Alejandro justifies every letters and there is a correspondence between what he reads and what he writes.

When Alejandro reads the second word, the child pointed out as follows ( Figure 8 ).

Alejandro reads “pájaro” (bird).

Alejandro makes a different correspondence syllable-letter than the first word. Although his writing was in two ways, his reading is only one direction: from left to right. The first syllable is related to first three letters he wrote. The second syllable is related to the fourth letter. But, he faces the same problem as in the previous word: “there are many letters.” So he justifies the other letters as follows. He reads the third syllable in relation to the sixth and seventh letter. And, reads “o” for the other letters.

When interviewer showed the next pair of cards, Alejandro wrote as following ( Figure 9 ).

Giraffe and worm writing by Alejandro.

When the interviewer shows the pair of cards to Alejandro, the child said “It’s a zebra.” So, the interviewer said “It’s a giraffe and it’s a worm” and pointed out every card. The interviewer asked Alejandro to write the name of every animal. First, the child draws a rectangle across the width of the sheet. Next, he started to write on the left side inside the rectangle. He said the first syllable “JI” while writing the first letter. After, he said “ra,” he wrote a hyphen. Then, he said “e” and wrote another letter. At that moment, he looked at the sheet and filled the space he left with some letters ( Figure 10 ).

Giraffe writing.

Alejandro shows different rules of writing. These rules are not the same as previous. He delimited the space to write and filled the space with some letters. The child tries to relate the syllable with one letter, but he writes others. There is a limited repertoire of letters too. In this case, it seems that he used the same letters: C capital and lower letter, A capital and lower letter, and O. We believe that he uses hyphens to separate every letter. However, when he wrote the first hyphen, it reads the second syllable. We do not know why he reads there. Alejandro had tried to use conventional letters. He uses signs without sound value. In addition, there is no relation phoneme and grapheme.

When Alejandro wrote GUSANO (worm), he drew a rectangle and divided it into three small squares. Then, he drew other squares below the previous ones. After, he began to write some letters inside the squares, as seen in the following picture ( Figure 11 ).

Worm writing.

Alejandro used other rules to write. They are different than the previous. Alejandro has written one or two letters into every box. At the end, he writes some letters under the last box. There is no correspondence between what he reads and writes. There are also no fixed rules of writing for him. Rather, it is intuited that he draws the boxes to delimit his space to write.

6.3.2 Singular and plural writing

The next task consists to write singular and plural. For this, the interviewer showed Alejandro the following images ( Figure 12 ).

Cards with one cat and four cats.

Alejandro drew an oval for first card. This oval is on the left half of the sheet. He wrote the following ( Figure 13 ).

Alejandro writes GATO (cat).

Next, the interviewer asked Alejandro to write for the second card, in plural. For this, Alejandro draws another oval from the middle of the sheet, on the right side. The child did not do anything for 1 h 30 min. After this time, he wrote some different letters inside the oval ( Figure 14 ). He wrote from right to left (unconventional direction).

Alejandro writes GATOS (cats).

Alejandro wrote in the opposite conventional direction: from right to left. He tried to cover the delimited space by him. His letters are similar to the conventional ones. Also, there are differences between the first and the second word. He used lesser letters for first word than the second. That is, there are lesser letters for singular and more letters for plural. Perhaps, the child took into account the number of objects in the card.

The writing directionality may have been influenced by the image of the animals: cats look at the left side. Alejandro could have thought he was going to write from right to left, as well as images of the cards. Therefore, it is necessary to research how he writes when objects look at the right side. In this way, we can know if this influences the directionality of Alejandro’s writing.

With the next pair of images ( Figure 15 ), the interviewer asked Alejandro to write CONEJO (rabbit) and CONEJOS (rabbits).

Cards with one rabbit and three rabbits.

Alejandro draws a rectangle in the middle of the sheet for the first card (rabbit). He said “cone” (rab-) and wrote the first letter on the left of the sheet. Then, he said “jo” (bit) and wrote the second letter. He said “jo” again and wrote the third letter. He was thoughtful for some seconds. He started to write other letters. His writing is as follows ( Figure 16 ).

Alejandro writes CONEJO (rabbit).

At the beginning, Alejandro tries to relate the syllables of the word with first two letters. However, he justifies the other letters when he read the word. There is no exact correspondence between the syllable and the letter. As well as his writing is to fill the space he delimited.

Alejandro takes into account other rules for plural writing. He drew a rectangle across the width of the sheet. Starting on the left, he said “CO” and wrote one letter. Then, he said “NE” and drew a vertical line. After, he said “JO” and wrote other letters. His writing is as follows ( Figure 17 ).

Alejandro writes CONEJOS (rabbits).

Alejandro writes both words differently. He reads CONEJO (rabbit) for first word and CONEJOS (rabbits) for the second. Both words are different from each other. But, he wrote them with different rules. This is confusing for us because there are vertical lines between every two letters in the second word. We believe that the child tried to represent every object, although he did not explain it.

In summary, Alejandro shows different writings. He used pseudo-letters and conventional letter. These letters are in unconventional positions. There is no relationship between grapheme and phoneme yet; and, he uses different writing rules.

7. Conclusions

We described Alejandro’s writing process. According to this description, we can note the following:

Alejandro is a student of an elementary regular school. He presents learning difficulties. He could not write “correctly.” However, he did not have a full assessment by specialized teachers. His school is so far from urban areas and his parents could not take him to a special institution. Therefore, he has not received special support. Also, there is not a favorable literacy environment in his home. His teacher teaches him like his classmates. Usually, he has been marginalized and stigmatized because “he does not know or work in class.”

We focused on Alejandro because he was a child who was always distracted in class. We did not want to show his writing mistakes as negative aspects, but as part of his learning process. Errors are indicators of a process [ 5 ]. They inform the person’s skills. They allow to identify the knowledge that is being used [ 13 ]. In this way, errors can be considered as elements with a didactic value.

Alejandro showed some knowledge and also some difficulties to write. The child identifies and distinguishes letters and numbers. We do not know if he conceptualizes their use in every one. When he wrote, he shows his knowledge: letters are for reading, because he did not use any number in the words.

The writing directionality is a difficulty for Alejandro. He writes from left to right and also from right to left. We do not know why he did that. We did not research his reasons. But, it is important to know if there are any factors that influence the child to write like this.

The student does not establish a phoneme-grapheme relationship yet. He is still in an initial level to writing acquisition. He uses conventional letters and pseudo-letters to write. There are no fixed rules to write: number and variety of letters. However, we observed student’s thought about writing. He justifies his writings when he reads them and invents letters to represent some words.

There is still a limited repertoire of letters. He used a few letters of the alphabet. Therefore, Alejandro needs to interact with different texts, rather than teaching him letter by letter. Even if “he does not know those letters.” In this way, he is going to appropriate other elements and resources of the writing system.

Time he takes to write is an important element for us. He refused to write for several minutes at the beginning. After, he wrote during 1 or 2 min every word. As we mentioned previously, we believe that Alejandro did not feel sure to do the task. Perhaps, he thought that the interviewer is going to penalize for his writing “incorrectly.” He felt unable to write. Therefore, it is important that children’s mistakes are not censored in the classroom. Mistakes let us to know the child’s knowledge and their learning needs.

We considered that class work was not favorable for Alejandro. He painted letters, drawings, among others. These were to keep him busy. Therefore, it is important for the child to participate in reading and writing practices. In this way, he can be integrated into the scholar activities and is not segregated by his classmates.

About children with learning difficulties, it is important that these children write as they believe. Do not censor their writings. They are not considered as people incapable. It is necessary to consider that learning is a slow process. Those children will require more time than their classmates.

Special education plays an important role in Mexico. However, rather than attending to the student with learning difficulties in isolation, it is necessary that the teacher should be provided with information and the presence of specialized teachers in the classroom. In this way, the student with learning difficulties can be integrated into class, scholar activities, and reading and writing practices.

We presented Alejandro’s writing process in this paper. Although he was considered as a child with learning difficulties, we identified he shows some difficulties, but he knows some elements of the writing system too.

Acknowledgments

I thank Alejandro, his parents, and his teacher for the information they provided to me about him.

Conflict of interest

The authors declare no conflict of interest.

• 1. SEP. Aprendizajes Clave Para la Educación Integral. Plan y Programas de Estudio Para la Educación Básica. México, D.F.: Secretaria de Educación Pública; 2017. ISBN: 970-57-0000-1
• 2. SEP. Propuesta Educativa Multigrado 2005. México: Secretaria de Educación Pública; 2005
• 3. García-Cedillo E, Escalante I, Escandón M, Fernández L, Mustre A, Puga I. La Integración Educativa en el Aula Regular. Principios, Finalidades y Estrategias. México: Secretaría de Educación Pública; 2000. ISBN: 978-607-8279-18-0
• 4. Ferreiro E, Teberosky A. Los Sistemas de Escritura en el Desarrollo del Niño. México, D.F.: Editorial Siglo XXI; 1979. ISBN 968-23-1578-6
• 5. Dolz J, Gagnon R, Vuillet Y. Production écrite et Difficultés D’apprentisage. Genève: Carnets des Sciences de L’education. Université de Genéve; 2011. ISBN: 2-940195-44-7
• 6. INEE. Panorama Educativo de México. Indicadores del Sistema Educativo Nacional 2017. Educación Básica y Media Superior. México: Instituto Nacional para la Evaluación de la Educación; 2018
• 7. SEP. Modelo Educativo: Equidad e Inclusión. México: Secretaria de Educación Pública; 2017. ISBN: 978-607-97644-4-9
• 8. SEP. Orientaciones Generales Para el Funcionamiento de los Servicios de Educación Especial. México: Secretaria de Educación Pública; 2016. ISBN: 970-57-0016-8
• 9. SEP. Estrategia de Equidad e Inclusión en la Educación Básica: Para Alumnos con Discapacidad, Aptitudes Sobresalientes y Dificultades Severas de Aprendizaje, Conducta o Comunicación. México, DF: Secretaria de Educación Pública; 2018
• 10. Durán M. Las Adecuaciones Curriculares Individuales: Hacia la Equidad en Educación Especial. México: Secretaría de Educación Pública; 2016. ISBN 968-9082-33-7
• 11. CONAFE. Discapacidad Intelectual. Guía Didáctica Para la Inclusión en Educación Inicial y Básica. México: Secretaria de Educación Pública; 2010
• 12. Ferreiro E, Gómez M. Análisis de las Perturbaciones en el Proceso de Aprendizaje de la Lecto-Escritura. Fascículo 1. México: SEP-DGEE; 1982
• 13. Vaca J. Así Leen (Textos) los Niños. Textos Universitarios. México: Universidad Veracruzana; 2006. ISBN: 968-834-753-1

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Case studies on disability and inclusion.

To document UNICEF’s work on disability and inclusion in Europe and Central Asia region, UNICEF Regional Office for Europe and Central Asia has developed a set of five case studies.

UNICEF takes a comprehensive approach to inclusion, working to ensure that all children have access to vital services and opportunities. When UNICEF speaks about “inclusion” this encompasses children with and without disabilities, marginalized and vulnerable children, and children from minority and hard-to-reach groups.

The case studies have a specific focus on children with disabilities and their families. However, many of the highlighted initiatives are designed for broad inclusion and benefit all children. In particular, this case study, covers such topics as: Inclusive Preschool, Assistive Technologies (AT), Early Childhood intervention (ECI), Deinstitutionalisation (DI).

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Case study 1: “Open source AAC in the ECA Region”

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Case study 2: “Inclusive Preschool in Bulgaria”

Case study 3: “Assistive technology in Armenia"

Case study 4: “Early childhood intervention in the ECA region”

Case study 5: “Deinstitutionalization in the ECA region”

Living with Learning Difficulties: Two Case Studies Exploring the Relationship Between Emotion and Performance in Students with Learning Difficulties

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• First Online: 07 September 2020
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• Styliani Siouli 13 ,
• Stylianos Makris 14 ,
• Evangelia Romanopoulou 15 &
• Panagiotis P. D. Bamidis 15  

Part of the book series: Lecture Notes in Computer Science ((LNISA,volume 12315))

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• European Conference on Technology Enhanced Learning

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Research demonstrates that positive emotions contribute to students’ greater engagement with the learning experience, while negative emotions may detract from the learning experience. The purpose of this study is to evaluate the effect of a computer-based training program on the emotional status and its effect on the performance of two students with learning difficulties: a second-grade student of a primary school with Simpson-Golabi-Behmel syndrome and a fourth-grade student of a primary school with learning difficulties. For the purpose of this study, the “BrainHQ” web-based cognitive training software and the mobile app “AffectLecture” were used. The former was used for measuring the affective state of the students before and after each intervention. The latter was used for improving students’ cognitive development, in order to evaluate the possible improvement of their initial emotional status after the intervention with “BrainHQ” program, the possible effect of positive/negative emotional status on their performance, as well as the possible effect of high/poor performance on their emotional status. The results of the study demonstrate that there is a positive effect of emotion on performance and vice versa and the positive effect of performance on the emotional status and vice versa. These findings suggest that the affective state of students should be taken into account by educators, scholars and policymakers.

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• Learning difficulties
• Cognitive training
• Emotional status
• AffectLecture
• Performance

1 Introduction

Educational policy has traditionally paid attention to the cognitive development of students without focusing on how emotions adjust their psychological state and how this affects their academic achievement. Emotions have a large influence over mental health, learning and cognitive functions. Students go through various emotional states during the education process [ 1 ] thus their mental state is considered to play a major role in obtaining internal motivation [ 2 , 3 , 4 ]. Existing research in the field of education has shown however that students’ cognitive processes were far more important than emotional processes [ 5 ]. Therefore, educational research should take into consideration the experience of people with disabilities, including those with learning difficulties [ 6 ].

The definition of ‘learning difficulties’ (LD) is commonly used to describe students with intellectual/learning disabilities. For further specification, this group may be considered as a sub-group of all those students who face several disabilities such as physical, sensory, and emotional-behavioral difficulties, as well as learning difficulties [ 7 ].

Learning difficulties are considered to be a developmental disorder that occurs more frequently in school years. It is commonly recognized as a “special” difficulty in writing, reading, spelling and mathematics affecting approximately 15% to 30% of students total [ 8 ]. The first signs of the disorder are most frequently diagnosed from preschool age, either within the variety of speech disorders or within the variety of visual disturbances.

Students with learning difficulties (LD) within the middle school years typically display slow and effortful performance of basic academic reading and arithmetic skills. This lack of ability in reading and calculating indicates incompetence in cognitive processes that have far-reaching connotations across learning, teaching, and affective domains [ 9 ].

When it comes to obtaining certain academic skills, the majority of students with LD during their middle school years achieve fewer benefits in learning and classroom performance. Therefore, it’s inevitable the fact that as the time goes by, the gap becomes wider year after year and their intellectual achievements are considered to be less than the ones made by their peers [ 10 , 11 , 12 ]. In addition to deficiencies in basic academic skills, many students with LD in the middle years of schooling may even have particular cognitive characteristics that slow the process of their learning, like reduced working memory capacity and also the use of unproductive procedures for managing the components of working memory. In conclusion, learners with LD require a more sufficient way of academic instruction [ 13 ].

Simpson-Golabi-Behmel syndrome (SGBS) is a rare, sex-linked (X) disorder with prenatal and postnatal overgrowth, physical development and multiple congenital abnormalities. The primary reference to the disorder was made by Simpson et al. [ 14 ]. The phenotype of the syndrome broad and includes typical countenance, macroglossia, organomegaly, Nephrolepis, herniation, broad arms and legs, skeletal abnormalities, supraventricular neck, conjunctivitis, more than two nipples and constructional dysfunctions [ 15 ]. In line with Neri et al. [ 16 ], men have an early mortality rate and an expanded possibility of developing neoplasms from fetal age. Women are asymptomatic carriers of the gene, who frequently present coarse external features in the face and mental incapacity [ 17 ].

The psychomotor development of patients with SGBS is diverse and ranges from normal intelligence to moderate and severe disorder that may be appeared at birth [ 18 , 19 , 20 ]. Speech delay occurs in 50% of cases and motor delay in 36% [ 18 ].

Moreover, speech difficulties were appeared in most affected people, which are partially justified by macroglossia and cleft lip or palate. Affected boys show mild cognitive disorders that are not always related to speech delay and walking. Moreover, they face difficulty in fine and gross motor development [ 20 ].

Learning difficulties are frequently related to behavioral problems and ambiguities, attention deficit disorder, hyperactivity, concentration and writing disorders [ 21 ]. However, there has been limited research about the behavioral phenotype and the problematic behavior that progress during puberty, as well as the behavioral difficulties during the school years, which need mental health support and therapy [ 22 ].

There is a wide range of syndrome characteristics, which have not been identified or examined yet. Every new case being studied, found not to have precisely the same characteristics as the previous one. As new cases of SGBS appear, the clinical picture of the syndrome is consistently expanding [ 23 ].

1.1 Related Work and Background

Research has shown that children’s and youngsters’ emotions are associated with their school performance. Typically, positive emotions such as enjoyment of learning present positive relations with performance, while negative emotions such as test anxiety show negative relations [ 24 , 25 , 26 ].

Related work in the field of education, has indicated that students’ learning is related to their emotional state. Thus, negative emotions decrease academic performance, while positive emotions increase it [ 27 , 28 ]. However, recent studies have been based on specific emotions, disregarding the possible presence of other emotions that may have a significant impact on motivation and/or school performance [ 29 ].

At this same educational level, Yeager et al. [ 30 ] investigated the possible negative correlation between boredom and math activities, while Na [ 31 ] observed a negative correlation between anxiety and English learning. Likewise, Pulido and Herrera [ 32 ] carried out a study with primary, secondary and university students which revealed that high levels of fear predict low academic performance, irrespective of the school subject.

In addition, Trigueros, Aguilar-Parra, Cangas, López-Liria and Álvarez [ 33 ] in their study with adolescents indicated that shame is negatively related to motivation, which negatively adversely impacts learning and therefore academic performance. Moreover, Siouli et al. carried out a study with primary students which showed that emotion influences academic performance in all class subjects and that the teaching process can induce an emotional change over a school week [ 34 ]. The results of the aforementioned studies confirm a strong relationship between academic performance and students’ emotional state.

Several research studies have examined the relationship between emotions and school performance. For students with syndromes and learning difficulties, however, the only data that occur from our case studies.

2.1 Cognitive Training Intervention

The Integrated Healthcare System Long Lasting Memories Care-LLM Care [ 35 ] was exploited in this study, as an ICT platform that combines cognitive exercises (BrainHQ) with physical activity (wFitForAll). LLM Care was initially exploited in order to offer the important training for enhancing the elderly’s cognitive and physical condition of their health [ 36 ], as well as the quality of life and autonomy of vulnerable people [ 37 ].

BrainHQ [ 38 ], as the cognitive component of LLM Care, it is a web-based training software developed by Posit Science. It is the sole software available in Greek being used to any portable computing device (tablet, cell phone, etc.) as an application either on Android or on IOS provided in various languages. Unquestionably, enhancement of brain performance can lead to multiple benefits to everyday life. Both research studies and the testimonials of users themselves show that BrainHQ offers benefits in enhancing thinking, memory and hearing, attention and vision, improving reaction speed, safer driving, self-confidence, quality discussion and good mood. BrainHQ includes 29 exercises divided into 6 categories: Attention, Speed, Memory, Skills, Intelligence and Navigation [ 38 ].

Students’ training intervention attempts to fill some of the identified gaps in research and practice concerning elementary school students with learning difficulties and syndromes. Specifically, it aims to produce an intensive intervention to provide students with the required skills in order to engage them more successfully with classroom instruction. This intervention was designed as a relatively long-term, yet cost-effective, program for students with poor performance in elementary school.

BrainHQ software has therefore been used as an effort to cognitively train students with genetic syndromes and complex medical cases with psychiatric problems that go beyond cognitive function [ 39 , 40 ]. An intervention using BrainHQ could be a promising approach for individuals with Simpson-Golabi-Behmel and individuals with Learning Difficulties.

2.2 The AffectLecture App

AffectLecture application (courtesy of the Laboratory of Medical Physics AUTH: accessible for download through the Google Play market place) was utilized to measure the students’ emotional status. It is a self-reporting, emotions-registering tool and it consists of a five-level Likert scale measuring a person’s emotional status ranging from 1 (very sad) to 5 (very happy) [ 41 ].

2.3 Participants

I.M. (Participant A) is an 8-year-old student with Simpson-Golabi-Behmel Syndrome, who completed the second grade of Elementary School in a rural area of Greece and S.D. (Participant B) is a 10-year-old student with Learning Difficulties who completed the fourth grade of Elementary School in a provincial area in Greece.

Participant A performed a 30-session cognitive training intervention applied during school time (3–4 sessions/week for 45 min each). Few interventions were also conducted at the student’s house in order to complete the cognitive intervention program.

Participant B attended a 40-session training intervention at school during school time and at the student’s house (3 sessions/week for 45 min each for 8 weeks and then everyday sessions for the last two weeks of the interventions).

The cognitive training interventions were performed in classrooms, meaning that both students were in their own school environments and they received an equivalent cognitive training, although they faced different learning difficulties

Prior to the beginning of this study, both students were informed about the use of AffectLecture app by exploiting their tablets, in which the app was installed. The students’ were urged to state how they felt by selecting an emoticon. The emotional status was being measured before the start and by the end of each training intervention, for the entire duration of the training sessions. In Fig.  1 the students had to choose between five emoticons and select the one that best expressed them at that moment.

AffectLecture Input

Teachers provided at the beginning of each training intervention a unique 4-digit PIN, which let the students have access to the session and vote before and after it, so they could state their emotional status.

2.4 Research Hypotheses

Hypothesis 1: Students’ positive emotional state will have a positive effect on their performance, while students’ negative emotional state will have a negative effect on their performance.

Hypothesis 2: High students’ performance will have a positive effect on their emotional status, while poor students’ performance will have a negative effect on their emotional status.

2.5 Data Collection Methods

Students’ performance was assessed by the online interactive BrainHQ program. The detailed session results of BrainHQ and the students’ emotional status as measured by the AffectLecture app before and after each intervention were used in order to collect crucial data for the purpose of the study.

2.6 Data Collection Procedure

Before the beginning of the study, students were informed about the use of BrainHQ and the AffectLecture app, and they were instructed to have their tablets with them. The AffectLecture app was installed in both students’ devices. Accommodated test scores in 6 categories (Attention, Speed, Memory, Skills, Intelligence and Navigation cognitive performance) were being measured by BrainHQ interactive program. During each session students were trained equally in all six categories starting with Attention and moving on to Memory, Brain Speed, People Skills, Intelligence, and Navigation in order to benefit the most. Training time was equally spaced. Each time students completed an exercise level, they earned “Stars” according to their performance and progress in order to understand how their brain is performing and improving. The students’ emotional status was being measured before the beginning and by the end of each cognitive training session, throughout the intervention period.

2.7 Evaluation Methodology

A non-parametric Wilcoxon Signed-rank test was conducted to compare within interventions’ differences in emotional status. The AffectLecture responses of each student, before and after every intervention with BrainHQ cognitive training interactive program, were used for this comparison. Following that, a Spearman rank test was conducted to discover the relation between performance and emotional status variables. The significance threshold was set to 0.01 for all tests.

Concerning intervention results revealed a statistically significant difference in the emotional status before and after the intervention for participant A (Wilcoxon Z = −3.000, p = 0.003 < 0.01), as well as for participant B (Wilcoxon Z = −3.382, p = 0.001 < 0.01) as shown in Table  1 .

Furthermore, correlation coefficient Spearman Rho was used to measure the intensity of the relationship between the performance indicator provided by cognitive training program BrainHQ (stars) and the emotional status of participant A and participant B. As hypothesized, the performance may have a correlation with the affective state of the students.

The scatter diagrams (see Fig.  2 ) suggest a strong positive correlation between emotional status before the intervention and performance (BrainHQ stars) for participant A (Spearman rho r = 0.77, p = 0.000 < 0.01), as well as for participant B (Spearman rho r = −0.255, p = 0.112 > 0.01). Following the 0.01 criteria, the interpretation of the results shows that positive emotional status before the intervention tends to increase students’ performance during the cognitive training. More specifically, these findings illustrate the importance of positive emotions in the performance and other outcomes in relation with achievement, meaning that cognitive training intervention positively influenced students’ experiences in the level of performance.

Scatter Diagrams for emotional status before the intervention and performance in BrainHQ cognitive training interactive program for Participant A and B.

The scatter diagrams (see Fig.  3 ) also suggest a strong positive correlation between performance (BrainHQ stars) and emotional status for participant A (Spearman rho r = 0.896, p = 0.000 < 0.01), as well as for participant B (Spearman rho r = 0.433, p = 0.005 < 0.01). Following the 0.01 criteria, the interpretation of the results show that high performance during interventions tends to increase students’ emotional status after the cognitive training. Data on positive and negative emotions were obtained by asking each student to report their final emotional status on AffectLecture. An increase in happiness and motivation, was also observed when students’ performance was increased, while totally different emotions were expressed and signs of demotivation were observed when students’ performance was poor. These findings identify the impact of general well-being and happiness on performance.

Scatter Diagrams for emotional status after the intervention and performance in BrainHQ cognitive training interactive program for Participant A and B.

The correlation values coefficients (between emotional status before/after the intervention and performance) and their corresponding p- are included in Tables  2 and 3 .

4 Discussion

The present study was designed to investigate the influence of emotional state on students’ performance, as well as to identify the relations between cognitive performance and emotion. Specifically, the affective state of two elementary school students with learning difficulties was measured for long periods of time, by the AffectLecture app, before and after intervention with BrainHQ. Additionally, cognitive performance was measured by the online interactive BrainHQ program at the end of each session.

As hypothesized students’ positive emotional state had a positive effect on their performance. By contrast, students’ negative emotional state had a negative effect on their performance. It can be also concluded that high students’ performance had a positive effect on their emotional status, while poor students’ performance had a negative effect on their emotional status. Repeated measures revealed a significant positive effect of emotion on performance and vice versa and a positive effect of performance on emotional status and vice versa.

The results imply that performance influences students’ emotions, suggesting that successful performance attainment and positive feedback can develop positive emotions, while failure can escalate negative emotions. This set of case studies adds to the small body of empirical data regarding the importance of emotions in children with learning difficulties and syndromes.

The findings are in agreement with previous studies reporting that achievement emotions can profoundly affect students’ learning and performance. Positive activating emotions can positively affect academic performance under most conditions. Conversely, negative deactivating emotions are posited to uniformly reduce motivation implying negative effects on performance [ 42 , 43 , 44 , 45 , 46 ]. Numerous research studies have explored the relationship between emotional state and academic achievement. However, for pupils with Simpson Golabi Behmel syndrome and learning difficulties, the only available data comes from our case studies.

The findings of this research in sequence with BrainHQ available data (collected stars) reveal the significant contribution of the online brain training program (BrainHQ) to the cognitive enhancement of both students. The results from cognitive exercises and assessments in addition to students’ daily observation indicate that intervention with the BrainHQ program had a positive impact on cognitive function mainly in the area of visual/working memory and the capacity to retrieve and process new information, processing speed affecting daily life activities, attention, and concentration. Besides that, cognitive training improved students’ performance in solving learning problems and in the area of Memory, Speed, Attention, Skills, Navigation, and Intelligence [ 47 ].

At this point it is important to identify possible limitations of the present study design. The measurements that were performed cannot cover the total range of affecting factors that possibly impact participants’ cognitive performance and emotional state. Some of those factors, which were not included, could be: the level of intellectual disability/difficulty, language proficiency, family’s socioeconomic background, living conditions, intelligence, skills, and learning style.

The limitations of this study also consist of the research method (case study) that has often been criticized for its lack of scientific generalizability. For this reason the results of this study must be treated with caution and contain bias toward verification. Larger-scale studies should be conducted to prove the effect of emotional state on the cognitive function of children with learning difficulties/disabilities. On the other hand, case study research provides great strength in investigating units consisting of multiple variables of importance and it allows researchers to retain a holistic view of real-life events, such as behavior and school performance [ 48 ].

At this point, we should take into account that students tend to present their emotions as ‘more socially acknowledged’ when they are being assessed. Furthering this thought consideration must be given as to whether students consequently and intentionally modified their emotions and behaviours due to the presence of an observer, introducing further bias to the study.

Moreover, the knowledge of being observed can modify emotions and behaviour. Such reactivity to being watched is sometimes referred to as the “Hawthorne Effect”. The Hawthorne Effect refers to a phenomenon in which people alter their behaviour as a result of being studied or observed [ 49 ]. They attempt to change or improve their behaviour simply because it is being evaluated or studied. The Hawthorne Effect is the intrinsic bias that must be taken into consideration when studying findings.

5 Conclusions

The current study provides evidences that learning difficulties can be ameliorated by intensive adaptive training and positive emotional states. The results of a strong positive correlation between affective state and cognitive performance on BrainHQ indicate that the better the affective state of the student, the higher the performance, which was the hypothesis set by the authors. However, the causal direction of this relationship requires further investigation by future studies.

Developing and sustaining an educational environment, which celebrates the diversity of all learners, is circumscribed by the particular political-social environment, as well as the capacity of school communities and individual teachers to confidently embed inclusive attitudes and practice into their everyday actions. In addition, identifying and accounting for the various dynamics which influence and impact the implementation of inclusive practice, is fundamentally bound to the diversity or disability encountered in the classroom.

At the same time, it would be useful and promising to perform further research over a long period of time to investigate the influence of positive, neutral and negative affective states on students’ with cognitive and learning difficulties performance. Also, the findings could have significant implications understanding the effect of positive or negative emotions on cognitive function and learning deficits of children with learning disabilities. These findings obtained from the children after adaptive training suggest that positive emotional status during computer cognitive training may indeed enhance and stimulate cognitive performance with generalized benefits in a wide range of activities. It is essential, that this research continues throughout the school years of both students to evaluate the learning benefits.

Ultimately, more research on the relation between emotion and performance is needed for better understanding students’ emotions and their relations with important school outcomes. Social and emotional skills are key components of the educational process to sustain students’ developmental process and conduct an effective instruction. These findings may also suggest guidelines for optimizing cognitive learning by strengthening students’ positive emotions and minimizing negative emotions and the need to be taken into consideration by educators, parents and school psychologists.

Pekrun, R., Goetz, T., Titz, W., Perry, R.P.: Academic emotions in students’ self-regulated learning and achievement: a program of qualitative and quantitative research. Educ. Psychol. 37 , 91–105 (2002)

Article   Google Scholar  

Bergin, D.A.: Influences on classroom interest. Educ. Psychol. 34 , 87–98 (1999)

Krapp, A.: Basic needs and the development of interest and intrinsic motivational orientations. Learn. Instr. 15 , 381–395 (2005)

Hidi, S., Renninger, K.A.: The four-phase-model of interest development. Educ. Psychol. 41 , 111–127 (2006)

Frenzel, A.C., Becker-Kurz, B., Pekrun, R., Goetz, T., Lüdtke, O.: Emotion transmission in the classroom revisited: a reciprocal effects model of teacher and student enjoyment. J. Educ. Psychol. 110 , 628–639 (2018)

Lambert, R., et al.: “My Dyslexia is Like a Bubble”: how insiders with learning disabilities describe their differences, strengths, and challenges. Learn. Disabil. Multidiscip. J. 24 , 1–18 (2019)

Woolfson, L., Brady, K.: An investigation of factors impacting on mainstream teachers’ beliefs about teaching students with learning difficulties. Educ. Psychol. 29 (2), 221–238 (2009). https://doi.org/10.1080/01443410802708895

Kaplan, H.I., Sadock, B.J.: Modern Synopsis of Comprehensive Textbook of Psychiatry, IV. Williams and Wilkins, Baltimore (1985)

Google Scholar  

Graham, L., et al.: QuickSmart: a basic academic skills intervention for middle school students with learning difficulties. J. Learn. Disabil. 40 (5), 410–419 (2007)

Hempenstall, K.J.: How might a stage model of reading development be helpful in the classroom? Aust. J. Learn. Disabil. 10 (3–4), 35–52 (2005)

Cawley, J.F., Fan Yan, W., Miller, J.H.: Arithmetic computation abilities of students with learning disabilities: implications for instruction. Learn. Disabil. Res. Pract. 11 , 230–237 (1996)

Swanson, H.L., Hoskyn, M.: Instructing adolescents with learning disabilities: a component and composite analysis. Learn. Disabil. Res. Pract. 16 , 109–119 (2001)

Westwood, P.: Mixed ability teaching: issues of personalization, inclusivity and effective instruction. Aust. J. Remedial Educ. 25 (2), 22–26 (1993)

Simpson, J.L., Landey, S., New, M., German, J.: A previously unrecognized X-linked syndrome of dysmorphia. Birth Defects Original Art. Ser. 11 (2), 18 (1975)

Neri, G., Marini, R., Cappa, M., Borrelli, P., Opitz, J.M.: Clinical and molecular aspects of the Simpson-Golabi-Behmel syndrome. Am. J. Med. Genet. Part A 30 (1–2), 279–283 (1998)

Gertsch, E., Kirmani, S., Ackerman, M.J., Babovic-Vuksanovic, D.: Transient QT interval prolongation in an infant with Simpson–Golabi–Behmel syndrome. Am. J. Med. Genet. Part A 152 (9), 2379–2382 (2010)

Golabi, M., Rosen, L., Opitz, J.M.: A new X-linked mental retardation-overgrowth syndrome. Am. J. Med. Genet. Part A 17 (1), 345–358 (1984)

Spencer, C., Fieggen, K., Vorster, A., Beighton, P.: A clinical and molecular investigation of two South African families with Simpson-Golabi-Behmel syndrome. S. Afr. Med. J. (SAMJ) 106 (3), 272–275 (2016)

Terespolsky, D., Farrell, S.A., Siegel-Bartelt, J., Weksberg, R.: Infantile lethal variant of Simpson-Golabi-Behmel syndrome associated with hydrops fetalis. Am. J. Med. Genet. Part A 59 (3), 329–333 (1995)

Hughes-Benzie, R.M., et al.: Simpson-Golabi-Behmel syndrome: genotype/phenotype analysis of 18 affected males from 7 unrelated families. Am. J. Med. Genet. Part A 66 (2), 227–234 (1996)

Cottereau, E., et al.: Phenotypic spectrum of Simpson–Golabi–Behmel syndrome in a series of 42 cases with a mutation in GPC3 and review of the literature. Am. J. Med. Genet. Part C Semin. Med. Genet. 163C (2), 92–105 (2013)

Article   MathSciNet   Google Scholar  

Behmel, A., Plöchl, E., Rosenkranz, W.: A new X-linked dysplasia gigantism syndrome: follow up in the first family and report on a second Austrian family. Am. J. Med. Genet. Part A 30 (1–2), 275–285 (1988)

Young, E.L., Wishnow, R., Nigro, M.A.: Expanding the clinical picture of Simpson-Golabi-Behmel syndrome. Pediatr. Neurol. 34 (2), 139–142 (2006)

Goetz, T., Bieg, M., Lüdtke, O., Pekrun, R., Hall, N.C.: Do girls really experience more anxiety in mathematics? Psychol. Sci. 24 (10), 2079–2087 (2013)

Pekrun, R., Linnenbrink-Garcia, L.: Introduction to emotions in education. In: International Handbook of Emotions in Education, pp. 11–20. Routledge (2014)

Zeidner, M.: Test Anxiety: The State of the Art. Springer, New York (1998). https://doi.org/10.1007/b109548

Book   Google Scholar  

García, C.A., Durán, N.C.: Revisiting the concept of self-efficacy as a language learning enhancer. Gist Educ. Learn. Res. J. 15 , 68–95 (2017)

García, M.D., Miller, R.: Disfemia y ansiedad en el aprendizaje de inglés como lengua extranjera. Rev. Española Discapac. 7 , 87–109 (2019)

Trigueros-Ramos, R., Gómez, N.N., Aguilar-Parra, J.M., León-Estrada, I.: Influencia del docente de Educación Física sobre la confianza, diversión, la motivación y la intención de ser físicamente activo en la adolescencia. Cuadernos de Psicología del Deporte 1 , 222–232 (2019)

Yeager, D.S., et al.: Boring but important: a self-transcendent purpose for learning fosters academic self-regulation. J. Personal. Soc. Psychol. 107 , 559 (2014)

Na, Z.: A study of high school students’ English learning anxiety. Asian EFL J. 9 , 22–34 (2007)

Pulido, F., Herrera, F.: La influencia de las emociones sobre el rendimiento académico. Cienc. Psicológicas 11 , 29–39 (2017)

Trigueros, R., Aguilar-Parra, J.M., Cangas, A., López-Liria, R., Álvarez, J.F.: Influence of physical education teachers on motivation, embarrassment and the intention of being physically active during adolescence. Int. J. Environ. Res. Public Health 16 , 22–95 (2019)

Siouli, S., Dratsiou, I., Tsitouridou, M., Kartsidis, P., Spachos, D., Bamidis, P.D.: Evaluating the AffectLecture mobile app within an elementary school class teaching process. In: 2017 IEEE 30th International Symposium on Computer-Based Medical Systems (CBMS), pp. 481–485. IEEE (2017)

LLM Care Homepage. www.llmcare.gr . Accessed 25 Apr 2020

Bamidis, P.D., et al.: Gains in cognition through combined cognitive and physical training: the role of training dosage and severity of neurocognitive disorder. Front. Aging Neurosci. 7 , 152 (2015)

Romanopoulou, E., Zilidou, V., Savvidis, T., Chatzisevastou-Loukidou, C., Bamidis, P.: Unmet needs of persons with down syndrome: how assistive technology and game-based training may fill the gap. Stud. Health Technol. Inform. 251 , 15–18 (2018)

BrainHQ Homepage. www.brainhq.com . Accessed 25 Apr 2020

Harrell, W., et al.: Feasibility and preliminary efficacy data from a computerized cognitive intervention in children with chromosome 22q11. 2 deletion syndrome. Res. Develop. Disabil. 34 (9), 2606–2613 (2013)

Siouli, S., Makris, S., Romanopoulou, E., Bamidis, P.D.: Cognitive computer training in children with cognitive and learning disabilities: two interesting case studies. In: 2018 2nd International Conference on Technology and Innovation in Sports, Health and Wellbeing (TISHW), pp. 1–6. IEEE (2018)

Antoniou, P.E., Spachos, D., Kartsidis, P., Konstantinidis, E.I., Bamidis, P.D.: Towards classroom affective analytics. Validating an affective state self-reporting tool for the medical classroom. MedEdPublish 28 , 6 (2017)

Lane, A.M., Whyte, G.P., Terry, P.C., Nevill, A.M.: Mood, self-set goals and examination performance: the moderating effect of depressed mood. Pers. Individ. Differ. 39 , 143–153 (2005)

Turner, J.E., Schallert, D.L.: Expectancy–value relationships of shame reactions and shame resiliency. J. Educ. Psychol. 93 , 320–329 (2001)

Boekaerts, M.: Anger in relation to school learning. Learn. Instr. 3 , 269–280 (1993)

Hembree, R.: Correlates, causes, effects, and treatment of test anxiety. Rev. Educ. Res. 58 , 47–77 (1988)

Pekrun, R.: The control-value theory of achievement emotions: assumptions, corollaries, and implications for educational research and practice. Educ. Psychol. Rev. 18 , 315–341 (2006)

Siouli, S., Makris, S., Romanopoulou, E., Bamidis, P.D.: Cognitive computer training in children with cognitive and learning disabilities: two interesting case studies. In: 2018 2nd International Conference on Technology and Innovation in Sports, Health and Wellbeing, pp. 1–6. IEEE (2018)

Kaufman, J., Yin, L.: What matters for Chinese girls; behaviour and performance in school: an investigation of co-educational and single-sex schooling for girls in urban China. In: Gender, Equality and Education from International and Comparative Perspectives, vol. 10, pp. 185–216 (2009)

McCambridge, J., Wilson, A., Attia, J., Weaver, N., Kypri, K.: Randomized trial seeking to induce the Hawthorne effect found no evidence for any effect on self-reported alcohol consumption online. J. Clin. Epidemiol. 108 , 102–109 (2019)

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Siouli, S., Makris, S., Romanopoulou, E., Bamidis, P.P.D. (2020). Living with Learning Difficulties: Two Case Studies Exploring the Relationship Between Emotion and Performance in Students with Learning Difficulties. In: Alario-Hoyos, C., Rodríguez-Triana, M.J., Scheffel, M., Arnedillo-Sánchez, I., Dennerlein, S.M. (eds) Addressing Global Challenges and Quality Education. EC-TEL 2020. Lecture Notes in Computer Science(), vol 12315. Springer, Cham. https://doi.org/10.1007/978-3-030-57717-9_10

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A CASE STUDY OF A CHILD WITH SPECIAL NEED/LEARNING DIFFICULTY Researcher

2018, INTERNATIONAL JOURNAL OF CREATIVE RESEARCH THOUGHTS(IJCRT)

The study has been conducted to investigate the levels and kind of difficulty the child/student is facing in learning things in or outside the classroom. It also examines the relationship between the school and home environment of the student with special needs who is facing difficulty in learning i.e. reading, writing listening or speaking. The case study was conducted by keen observations of the special needed child by involving and getting information directly from different reliable sources like,concerned teachers, peer groups from the school, parents, family members and peer groups of the child from the home environment. The tools used in the study were 1. Qustionnaire. 2. Direct observation. Etc.The study reveals the fact that the actually the child not having any slow learners like problem nor she is shy or un interested in learning by nature but she loves to read , learn , take part in different activities, she is having a creative mind by birth or nature but only the problem of her difficulties in learning is because of the depression she has laid in her mind of part of the home environment and improper treatment given to her by parents,family,teacher' s, elder' s in the school or at home.

Related Papers

The main purpose of this study was to find out the contributions and challenges of Sebeta Special School for the students with visual impairments. The research design used was qualitative case study method as this would enable the researcher to make in-depth study of the case from different perspectives. For responding to this main purpose of the study, purposive sampling was used and the subjects of the study were selected by purposive sampling technique as they were taught to have the necessary information for the problem under study. Accordingly, twelve teachers, (six males and six females), ten members of the support staff (five males and five females) and twelve students of grades five to eight (six males and six females) were selected for focus group discussions. Besides, interview was conducted with the director and vice-director of the school and two teachers (a male and a female) and two students of grades five to eight (a male and a female).Relevant documents and observation checklists were also used as data sources. Finally, the data collected were organized, thematically analyzed and presented. Regarding the contributions made, the findings revealed that the school has been serving the students as school to learn in and succeed, home to live in and family to leave with. There were also services being delivered for the students and different resources were also available in the special school. Findings displayed that challenges to the special school as manpower assignment was not need based and there were lack of skills necessary to run activities in the special school as reading and writing braille, inadequate budget and resources like student textbooks transcribed in to braille and wastages in usage of the available resources. Besides, there were conditions that violate the safety of students. The recommendations made included such things as alleviating the challenges the school encountered such as appropriate use of resource, availing the necessary resources as braille textbooks, budget and others.

CERN European Organization for Nuclear Research - Zenodo

Arpeeta Anand

IOSR Journals

" The ramification and still over effect of learning disability affect so much that education of school children find hard reality to attain its universal character. At the same time the problem continues to be the most baffling one for the state thriving for universalization of elementary education and ensuring right to education for all. Many interventions and policy measures although were initiated to increase the achievement level of students but at the Psycho-social level addressing the problem still remained attempted. Providing appropriate literacy and innumeracy learning opportunities especially, continues to be a challenge both for the teachers so also parents. Observing the gravity of the problem an earnest attempt has been made in this paper to understand the conflicting currents of the problem from a psycho-social perspective. A diagnosis also has been made to address the challenges of learning disability among school children, so that the objective of universalization of education could be well attained with.

Croatian Journal of Education - Hrvatski časopis za odgoj i obrazovanje

Jasna Kudek

Journal of emerging technologies and innovative research

Masrat Majeed

Learning Disorder is not single disorder but include disabilities in any of seven areas related to Reading, Language and Mathematics. These separate types of learning disabilities frequently co-occur with one-another and with Social Skill Deficits and Emotional or Behavioral Disorder. Approximately 7% of all school children under the age group of 3-6 years are identified as Learning Disability in the Composite Regional Centre (CRC) according the Survey done during the period of 2018. Using many tests and assessments, it was found that these children with LD are also attributed to other emotional or behavioral disorders. While learning disability, learning disorder and learning difficulty are often used interchangeably, they differ in many ways. Disorder refers to significant learning problems in an academic area. These problems, however, are not enough to warrant an official diagnosis. Learning disability, on the other hand, is an official clinical diagnosis, whereby the individual ...

SHODH SARITA

Arpeeta Anand , Mohd. Faijullah Khan (Asstt. Prof., IASE)

Specific Learning Disability (SLD) is a neurological problem which creates lots of challenges in the life of children. Academic challenges are the most significant one when it comes to SLD. Aims: To realize the academic challenges that children experienced with Specific Learning Disability. Setting and Design: Phenomenological method with purposive sampling technique was used to understand the perspective of children. Materials and Methods: Semi-structured Interview Schedule was administered on 10 SLD children who are already diagnosed by clinical psychologist studying in elementary grade i.e. 6th grade to 8th grade of private inclusive schools of Delhi. Analysis Used: Content Analysis was used to elicit the data from open-ended questions. Results: (i) Children with learning disability are not lazy & dumb, they perceive and process information in a different manner. (ii) They encounter difficulty in comprehending what they have read, experience making mistakes while reading, repeating the sentences, taking pause, trouble in remembering & mispronouncing same sounding words. (iii)Children doesn’t want to write because of the fright behind committing spelling mistakes. (iv) Many children experience problem of illegible writing, pain in hand, extra efforts & longer time for writing and trouble in expressing their own ideas & feelings in writing. (v)They struggle while comprehending & solving the word problems, issues of learning formulas, making things in order of operations, basic calculations, understanding time, directions, money related work and difficulty in keeping scores of games & matches. (vi) Have trouble in adjusting to new situations, take time to adapt new changes in their life, demand lots of coordination & organization, face problem in rote learning & remembering, comprehending meaning from text and thinking out of box (vii) Complained about inability to perform activities that require sequential order, meeting deadlines, following schedules, arranging things, setting priorities and managing time for themselves. (viii) Experience inability to interpret their own environment as a consequence react inappropriately, misunderstood situation and comprehend different meaning with incorrect interpretation. (ix) Trouble in understanding what they hear and making differences in sound, difficulty in comprehending meaning from sounds, require frequent repetition and struggle in remembering what they heard. (x) The foremost problem of misunderstanding in analyzing and synthesizing visually presented information. (xi)They experience inability to differentiate between same sounding words, struggle while copying from writing board, mispronouncing the words while reading, difficulty in comprehending meaning out of what they read and figuring out what is there in pictures & graphs. Conclusions: The present study has identified various challenges faced by children academically. Proper support & motivation of parents & teachers can help children in developing positive attitude towards learning. Keywords: Specific Learning Disability, Children, Education, Academic Challenges, Phenomenological Analysis

Science Park Research Organization & Counselling

This study aims to obtain problems encountered in special education in the direction of opinions of parents attending to Special Training and Rehabilitation Institution and develop solution suggestions compansating these problems. In the scope of study parents of 20 students were interviewed. Tha datas that were obtained as a result of qualitative semi-structured interview form, were analysed by descriptive analysis method. The participant parents were asked 7 questions about education period, physical conditions, difficulties they encountered regarding their children in the scope of relations of teachers with parents and managers and point of view of society. Most of the participants expressed problems such as most of the problems should be solved by top levels, training hours are insufficient and rejection of society.

Sara Sadiki , Fitore Bajrami

The qualitative method was the research method used in this study as the most appropriate to the purpose, objectives, and research questions of the study. The purpose of this study is to examine the experiences of parents during education of their children with special needs. The research question of this study was: What experiences have parents had during the education of their children with special needs? The sample in this paper consists of 13 respondents, citizens of Debar parents of children with special needs. The interviewed sample consisted of 10 mothers and 3 fathers. From the analyzes made, it appears that 99% of parents regarding the inclusion of children answered that it is very necessary, they hope that these laws and rules are respected in schools, that there are no differences and discriminations with children, but that everyone is equal in the classroom and have maximum care, especially children with special needs. 46% of the parents answered that they got enough help from the school, they were not underestimated by others, the teacher supported them and helped them adapt, showing that the children were calmer and more productive. While 53.8% of parents answered that the school does not have help with their child, they express dissatisfaction and non-fulfillment of the conditions for work with children with special needs. Based on the analyzes carried out, 75% of the parents answered that they had difficulties with their child's adaptation to school, and the parents were also forced to stay with them in the classroom for several months.

Dr. Muhammad Irfan Arif

Authors: Kafiat Ullah Khan Research Scholar Allama Iqbal Open University Islamabad E-mail: [email protected] Ameer Hasan MS(Management Sciences) Riphah International University Islamabad E-mail: [email protected] Muhammad Irfan Arif Ph.D Scholar University of Education Lahore E-mail: [email protected] "ABSTRACT The purpose of the study was to explore and measure the perception and satisfaction level of parents of special children about the role of special education institutes in the adjustment of special children in their families. The researcher used two self developed questionnaires to collect the data about the problem under investigation, one questionnaire to explore the perception of parents of special children about the role of special education school in the adjustment of special children in their families and the other questionnaire to measure the satisfaction level of parents. All special children of District Bhakkar were constituted as target population for the study. The special children of Special Education School Bhakkar were assessable population for the study. Parents of sixty special children from Special Education School Bhakkar conveniently selected as a sample for the study. Simple descriptive statistical techniques such as mean and percentages were used to analyze the collected data. After careful data analysis the researchers concluded that the special education schools may play very vital role in the adjustment of special children in their family but unfortunately due to lack of resources and infrastructure they are not fulfilling the needs of special children and there is also some lack in the awareness about the importance of social adjustment of special children in their families. The researcher identified very important needs, problems, self concept, and adjustment problems of special children through review of literature and research. Key Words: Special Education , Special Children , Family Adjustment "

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• A CASE STUDY ANALYSIS OF A CHILD WITH LEARNING...

A CASE STUDY ANALYSIS OF A CHILD WITH LEARNING DISABILITY/IES

The case study seeks to explore a child with a learning disorder that dropped out of his grade school, exploring the explicit factors that lead to that discussion and what he exactly went through. The case study will contain detailed information about the child starting from the point of birth, social, medical, and all other historical facts that are important in dissecting the learning disability in him. Historically, several children across the world struggle in school in certain circumstances of learning as monitored from time to time. Nevertheless, it has been noted that when a child struggles during learning in school with some skills for a period, it could be related to a learning disorder (O’Connell et al., 2019). The learning disorder has various definition depending on the prevailing parameters at that time. However, a learning disorder in a child can be defined as a scenario when a child exhibits some level of difficulty in one or more learning spheres.

Nastor, D. (2021). A CASE STUDY ANALYSIS OF A CHILD WITH LEARNING DISABILITY/IES. Afribary . Retrieved from https://afribary.com/works/a-case-study-analysis-of-a-child-with-learning-disability-ies

Nastor, Dan Paul "A CASE STUDY ANALYSIS OF A CHILD WITH LEARNING DISABILITY/IES" Afribary . Afribary, 05 Mar. 2021, https://afribary.com/works/a-case-study-analysis-of-a-child-with-learning-disability-ies. Accessed 29 May. 2024.

Nastor, Dan Paul . "A CASE STUDY ANALYSIS OF A CHILD WITH LEARNING DISABILITY/IES". Afribary , Afribary, 05 Mar. 2021. Web. 29 May. 2024. .

Nastor, Dan Paul . "A CASE STUDY ANALYSIS OF A CHILD WITH LEARNING DISABILITY/IES" Afribary (2021). Accessed May 29, 2024. https://afribary.com/works/a-case-study-analysis-of-a-child-with-learning-disability-ies

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Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

• Case Study Approach
• Case Study Method
• Enhancing the Quality of Case Studies in Health Services Research
• “We do things together” A case study of “couplehood” in dementia
• Using mixed methods for evaluating an integrative approach to cancer care: a case study

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Long-Term Outcomes for a Student with Severely Challenging Behavior in a Special Needs School for Intellectual Disabilities: A School Consultation Case Study

Masahiko inoue.

* Department of Clinical Psychology, Graduate School of Medical Sciences, Tottori University, Yonago 683-8503, Japan

Self-injurious, stereotyped, and aggressive/destructive behaviors exhibited by individuals with intellectual disabilities and autism spectrum disorders are called challenging behaviors (CBs). Severe CBs often require long-term treatment involving psychosocial approaches based on behavioral interventions and/or medication. A boy with severe CB enrolled in a special needs school, with diagnoses of autism and intellectual disability, was the client of the study. This case report describes the long-term outcomes of eight years of continuous school consultation. The student’s severe CB improved with environmental adjustments in the classroom, unified teacher involvement, instruction of leisure and communication skills, and medication. Long-term research on changes in CBs through school consultation is limited, and this case report provides important insights into the development of effective educational programs and curricula for severe CBs in school-aged children.

Recently, the term Challenging Behavior (CB) has been used in studies examining problematic behaviors associated with developmental disabilities such as autism spectrum disorder (ASD), attention deficit hyperactivity disorder, and intellectual developmental disorders (IDD). CB is not a diagnosis; rather, it is a term that emphasizes the issues arising from the interactions between individual and social factors. 1 Recent research has focused on persistence and long-term outcomes for CB in people with IDD and ASD, with several studies noting that severe CB, in particular, can persist for more than 10 years. 2 , 3 It has been shown that without an appropriate teaching environment, instructional system, and curriculum for CB, CB can become more severe throughout a child’s school years, even in special needs schools. 4 However, in the Japanese special needs education system, standard educational guidelines and functional assessments for severe CBs have not been institutionalized. School consultations with outside professional organizations for serious CB are important, 5 but many studies on this subject are short-lived and of limited effectiveness. 6 Long-term findings on school-age interventions and prognoses for severe CBs are useful for developing appropriate educational programs and curricula in schools. This case report presents the long-term outcome of one boy in a functional assessment-based school consultation for severe CB by Inoue and Oda. 6

PATIENT REPORT

The client in this case study was an 11-year-old boy diagnosed with IDD and ASD at age three, enrolled in the primary fifth grade at a special needs school for IDD. He was unable to take an intelligence test owing to CB. However, he could understand simple instructions, express himself using four-word sentences, and read some Kanji characters.

He lived with his parents and had been attending a special needs class at a local elementary school. However, by the third grade, the child continued to engage in aggressive behaviors such as biting, grabbing hair, and kicking at school and after-school facilities. Finally, partly owing to physical abuse by his parents, he was placed in a facility for IDD and transferred to a special needs school in that school district. In the Japanese education system, when a child has an IDD, and CB is severe, they are often educated in a special needs school for children with IDD in the school district rather than in a special needs class, and this was the case for this boy.

His parents regularly visited him at the facility and brought him sweets. He did not resist these visits, looked forward to the presents, and made no comments about wanting to go home. The consultant (author) was unable to assess the impact of the parental physical abuse because the school did not have detailed information about it. Upon admission to the facility, he showed strong resistance to new people and environments and demonstrated aggressive behaviors (hitting, kicking, biting, grabbing hair, and spitting). He also frequently engaged in self-injurious behaviors (hitting his head, biting his hand, and crying, among others). He also exhibited behavior such as defecating in places other than toilets, overturning school lunches, and throwing objects. At the facility, he wandered around at night, strangled children in other rooms, and engaged in various dangerous and aggressive behaviors.

School consultation

The author served as a consultant by visiting schools five to 11 times a year. Three to six consultations regarding students with CB were conducted during each visit to the school, including the student in this report. Each consultation lasted 15 to 20 minutes. The consultees were homeroom teachers, grade-level teachers, and facility staff. The school consultations were based on the functional assessment with applied behavior analysis approach, which is well-supported as an approach to CBs in individuals with IDD and ASD. 7 The consultation procedure was based on Inoue and Oda’s study. 6 The consultant (author) worked with the consultees (teachers/facility staff) using a strategy sheet 8 to determine antecedent control to prevent CB from occurring and teach appropriate alternative behaviors.

Antecedent control in the classroom environment

Owing to the severity of the CB, the teaching team was rotated so that there were two teachers. Group education was not possible, and individual education was provided. The following environmental adjustments were made as antecedent control procedures. A “private classroom” with cushioned walls was used as the classroom because of the student’s self-injurious behavior of hitting his head against the wall. The structure of the room is shown in Figure 1 . Classroom postings and educational materials were removed from classrooms to prevent disruptive behavior. Educational materials and leisure items were stored in the observation room across the hallway and only placed in the classroom as needed. The student’s desk and chair legs were fixed in place with thick plywood. Windows, on which he might bump his head, were boarded up in the lower half of the room. The room was partitioned to provide a cool-down space. A video camera was installed in the room so that if the student became unstable, the teacher could leave the classroom to allow him a cool-down period and monitor him from the observation room. A handover system was established at the end of each school year to ensure a consistent support policy based on the consultation with the author. The system ensured that at least one teacher familiar with the case would be included in the following year’s team.

 Environment around the classroom.

Appropriate alternative behaviors

School consultations focused on functional assessment for CB and teaching appropriate alternative behaviors. A functional assessment of the student’s CB was conducted through behavioral observation using the ABC chart. The ABC chart is a tool used to estimate the function of a behavior through direct observation, in the form of a sheet that records antecedents (A), behaviors (B), and consequences (C). As a result, there were different topographies of his CB, which included aggression, destruction, and self-injury; multiple functions, including communication (such as demands and avoidance) were inferred depending on the context; and sensory functions were estimated. Therefore, we taught leisure and communication skills, such as study time and recess, as appropriate alternative behaviors for each situation.

Leisure skills: For leisure skills, we initially introduced activities such as looking at advertisements and magazines, playing with a train toy, and using coloring books, which were considered to be the student’s favorite activities. However, he was unable to sustain performing these activities on his own. Also, regarding coloring books, he sometimes chewed, broke, and ate crayons and magic markers, which sometimes led to new CB.

For this reason, leisure activities were initially integrated into the assignment schedule with the goal of achieving independence in performing leisure skills. As a result, the student was able to work independently on several leisure activities. By the end of his junior year, he was able to engage in leisure activities alone for 10–30 minutes, including doing puzzles depicting his favorite characters, playing with building blocks, and coloring. In upper secondary school, he was able to request his teachers to use leisure activity picture cards. Additionally, he could go to the library to check out a DVD of his choice and return it after watching it.

Communication skills: When the student was in elementary school, several words in the teacher’s instructions triggered self-injurious behavior. And it was presumed that this behavior is a function of the escape. To address this, a list of these negative words was created, and the teachers were unified in their efforts to avoid using them. It became clear that the aggressive behaviors occurred when the child was crying, throwing things, or hitting his head against the floor or a wall, and when a teacher was nearby. When he began exhibiting these behaviors, the teacher did not forcibly stop him, but instead moved away and watched him.

The skill of requesting a particular choice among the leisure activity cards was taught as a target behavior. We also taught him the communication skill of refusal by introducing “I will not do it” cards. As a result, the student was less likely to act out during study time and was able to stay calm during recess.

Japanese version of the Aberrant Behavior Checklist score and medication

The Aberrant Behavior Checklist (ABC) 9 consists of 58 items, each scored on a 4-point Likert scale. It has five domains: irritability, lethargy/withdrawal, stereotypy, hyperactivity, and inappropriate speech. The Japanese version of the ABC (ABC-J) has been shown by Ono 10 to be as reliable and valid as the original. Figure 2 shows the ABC-J score trends and medication changes over eight years. The vertical axis shows scores, and the horizontal axis shows the evaluation time. The evaluation occurred twice every academic year, once in May and again 10 months later in March. May of the second year of high school was excluded owing to missing data.

 ABC-J score trends and medication changes over eight years. T1 (primary 5th grade, May), T2 (primary 5th grade, March), T3 (primary 6th grade, May), T4 (primary 6th grade, March), T5 (secondary 1st grade, May), T6 (secondary 1st grade, March), T7 (secondary 2nd grade, May), T8 (secondary 2nd grade, March), T9 (secondary 3rd grade, May), T10 (secondary 3rd grade, March), T11 (high school 1st grade, May), T12 (high school 1st grade, March), T13 (high school 2nd grade, March), T14 (high school 3rd grade, May).

The ABC-J score was 69 at T1, the beginning of the intervention (primary 5th grade, May), peaked at 155 at T3 (primary 6th grade, May), and remained between 64 and 108 until T9 (secondary 3rd grade, May). Scores then decreased to 46 points at T10 (secondary 3rd grade, March) and continued to decline progressively to 4 points at T14 (high school 3rd grade, May).

Medication was prescribed by medical providers independently of the school consultation and did not involve the authors. Initially, risperidone was prescribed. Biperiden hydrochloride and fluvoxamine maleate were started in junior high school. In upper secondary school, the patient began to feel unsteady while walking. Risperidone and fluvoxamine maleate were reduced.

Figure 3 shows the ABC-J sub-domain scores at T1 (primary 5th grade, May), when the support started, and at T11 (high school 1st grade, May) and T14 (high school 3rd grade, May) when CB improved significantly. At T1, lethargy and irritability were high (26 and 20 points, respectively). Hyperactivity scored 12 points, inappropriate speech 7 points, and stereotypy scored 4 points. The ratios of these scores remained similar until T10. Scores other than irritability decreased at T11. At T14, irritability also decreased to 2 points.

 Difference in ABC-J subscale and total scores by time. T1 (primary 5th grade, May), T11 (high school 1st grade, May), T14 (high school 3rd grade, May).

This case report describes the long-term outcome of school counseling based on functional assessment for a boy with ASD and IDD who was admitted to an institution owing to reported abuse at home and severe CB. For non-drug treatment of intense CB, elimination of excitatory stimuli and structuring of the classroom environment to provide the child with predictability are effective antecedent controls, making CB less likely to occur. 11

The consultant suggested to the school administration and teachers the creation of an instructional system and antecedent control for the prevention of CB. The consultant then advised the teachers regarding conducting functional assessments using ABC chart, selecting appropriate alternative behaviors, and choosing effective teaching methods.

The classroom environment and teacher assignments were developed through cooperation between school administrators and teachers. The teachers shared their ideas during the ongoing consultations. The ability to conduct consultations across academic years also played a critical role in effectively transitioning between grades and departments. The result of this long-term consultation case was the student’s acquisition of leisure and communication skills that substituted for CB functions in different situations that arose during his school life.

Long-term data on severe CB is limited. Few case reports describe specific approaches and improvements. The long-term changes in ABC-J scores in this report indicate that even as CBs decrease, they still show significant long-term fluctuation. Inoue et al. 4 analyzed long-term changes in severity of CB. This previous study suggested that changes in school age students were more likely to be observed for behavior groups such as hyperactivity. This case study supported this result, although the scale used was different.

In particular, in this case, a maximum dose of 5.7 mg of risperidone was administered at the peak severity of CB. The dosage of risperidone in childhood is not to exceed 3 mg (3 mL) for patients weighing 45 kg or more, and it is possible that the patient was oversedated at one point. In the UK, the national project STOMP is being promoted to stop over medication involving psychotropic medicines for people with IDD, ASD or both. 12 To successfully implement STOMP, stakeholders were required to be engaged in the process. 13 This case demonstrates the need for long-term collaboration with a patient’s healthcare provider to adjust the patient’s medication to accommodate changes as well as to consider side effects.

Both risperidone, an atypical antipsychotic drug, and function-based behavior-analytic interventions are widely used and empirically validated treatments for reducing CB in children with autism. 14 However, little is known about the interactions between the medication’s pharmacodynamics and behavioral function. 15 In this case, we did not control for the timing of the introduction of the behavioral interventions and pharmacotherapy, nor were we able to demonstrate functional changes in CB at each time point. Future research is needed to elucidate the long-term effects of both behavioral interventions and pharmacotherapy on aspects of behavioral topography and function.

Ethics statement

Written informed consent for the study and publication was obtained from the parents, school, and facility.

Acknowledgments

Acknowledgments: We thank the student, parents, school teachers, and facility staff. This work was supported by Grant-in-Aid for Scientific Research (B) Grant Number (JP17H02716) and Health and Labor Sciences Research Grant (22GC1019).

The authors declare no conflict of interest.

How family economic insecurity can hurt child mental health

Study examines cascading effects of covid-19 money issues.

Economic difficulty caused by the COVID-19 pandemic led to a cascade of connected problems for some parents -- resulting in mental health problems for their children, a new study suggests.

Researchers found that economic insecurity was linked to higher levels of depressive symptoms for parents, which was then associated with poorer relationship quality for the couples. That was linked with more harsh parenting and then to increased internalizing behaviors for their children.

"Pandemic-induced economic hardship had this downstream spillover effect that was ultimately linked negatively with their children's mental health," said Joyce Lee, lead author of the study and assistant professor of social work at The Ohio State University.

"Our findings parallel with other descriptive research showing that children's mental health plummeted during the pandemic."

The study was published online last week in the journal Child & Family Social Work .

The study involved 259 parents raising one or more children ages 12 years or younger who said they experienced at least one pandemic-related economic hardship. The longitudinal survey, which included participants from across the country, focused on two different points during the early weeks of the pandemic.

One of the strengths of this research is that it didn't just include middle-income families -- in 31% of the families studied, the parents' income was below $30,000.

Parents were asked about their depressive symptoms, relationship quality and harsh parenting practices. They were also asked about their children's internalizing behaviors such as complaining of loneliness, crying a lot, and being fearful or anxious.

The researchers found a clear connection between these issues, Lee said.

It started with the pandemic-induced economic insecurity. Those parents who reported higher levels of economic insecurity at the time of the first survey also had higher levels of depressive symptoms at the same time. And that was linked to a more negative relationship with their partner at the time of the second survey.

"They were reporting more disagreements and arguments and fights among themselves during the pandemic," Lee said.

That in turn was linked to reports of using more harsh parenting with their children. This included yelling, screaming and shouting at their child; and physical punishment such as spanking.

And finally, harsh parenting was linked to children who had internalizing behaviors such as frequent crying and loneliness. (Data from the study did not include externalizing behaviors, such as physical aggression and tantrums.)

"There are these cascading effects that begin with pandemic-initiated economic difficulties that all trickle down to children's mental health," Lee said.

While other studies have found that depressive symptoms in parents can be related to harsh parenting, one strength of this study is that it also included partner relationship quality, she said.

"Relationship quality is an important part of this. If you're not doing well with your partner, that speaks to a wider family dynamic that can spill over to how you deal with your children," Lee explained.

Findings also showed that there was not a significant gender difference in how mothers and fathers reacted when faced with economic problems during the pandemic. That was somewhat of a surprise since some reports said mothers took a larger hit to their careers because of COVID-19 and were more likely to take care of children at home when schools closed. That suggested mothers might do worse than fathers, but it wasn't found in this study.

Lee noted that this was a relatively small sample, so more research is needed to confirm gender differences in reactions to the pandemic.

While this study was done during the early weeks of the COVID-19 pandemic, Lee said that the findings could be relevant to other disasters or issues that lead to economic downturns.

One implication is the need for interventions that could help mothers and fathers who are struggling economically to stop the cascade of problems leading to child mental health issues, she said.

But it goes beyond that.

"We need a better social safety net to catch these parents early on before the economic pressures lead to these negative consequences," she said.

Co-authors on the study were Sehun Oh, Amy Xu and Angelise Radney of Ohio State; Shawna J. Lee of the University of Michigan; and Christina M. Rodriguez of Old Dominion University.

• Children's Health
• Child Psychology
• Child Development
• Poverty and Learning
• Public Health
• Early childhood education
• Lead poisoning
• Adult attention-deficit disorder
• Social inequality
• Cognitive psychology
• Intellectual giftedness
• Hyperactivity

Story Source:

Materials provided by Ohio State University . Original written by Jeff Grabmeier. Note: Content may be edited for style and length.

Journal Reference :

• Joyce Y. Lee, Shawna J. Lee, Sehun Oh, Amy Xu, Angelise Radney, Christina M. Rodriguez. Family Stress Processes Underlying COVID‐19–Related Economic Insecurity for Mothers and Fathers and Children's Internalizing Behaviour Problems . Child & Family Social Work , 2024; DOI: 10.1111/cfs.13188

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• Open access
• Published: 23 May 2024

Barriers and future improvements of workplace-based learning in Korean medicine clinical clerkship: perspectives of graduates

• Eunbyul Cho 1   na1 ,
• Do-Eun Lee 2   na1 ,
• Dongha Lee 3 &
• Hyun-Jong Jung 4  

BMC Medical Education volume  24 , Article number:  566 ( 2024 ) Cite this article

Metrics details

Workplace-based learning (WPBL) has emerged as an essential practice in healthcare education. However, WPBL is rarely implemented in Korean medicine (KM) due to the passive attitude of teachers and possible violation of medical laws that limit the participation of trainees in medical treatment. In this study, we implemented WPBL in the clinical clerkship of Acupuncture and Moxibustion Medicine at a single College of KM and explored the barriers and future improvements of WPBL.

The WPBL was implemented from January to July 2019. During the clerkship, each senior student was assigned an inpatient at the university hospital. WPBL was conducted as follows: patient presentation by the supervisor, interaction with the patient at the bedside, preparation of medical records, oral case presentation, and discussion with feedback. The student performed a physical examination and review of systems as a clinical task. In addition, six doctors of KM who are currently practicing after three years of WPBL were interviewed in September 2022 to investigate the real-world effects and unmet needs of WPBL in their workplaces.

Two major themes identified from the interview were: “the experience of novice doctors of KM with KM practice” and “Current state of KM clinical education.” The five subcategories were: “Clinical competency priorities vary according to the KM workplace,” “Difficulties faced by doctors of KM immediately after graduation,” “WPBL experience of the interviewees,” “Necessary but difficult to implement real patient learning,” and “Unmet needs for clinical clerkship in KM.”

It is essential to consider the unique characteristics of KM practice and the duties required in various workplaces for successful WPBL. We anticipate our study to be a starting point for improving the WPBL and addressing the unmet needs in KM clinical education.

Peer Review reports

Before the twentieth century, medical and Korean medicine (KM) education was mainly based on experience through apprenticeship [ 1 , 2 ]. Following the publication of the Flexner Report, medical education has shifted to a lecture-oriented form based on scientific theories and principles [ 2 , 3 ]. However, the need for workplace-based learning (WPBL) has arisen from concerns regarding the increasing disconnect between medical education and clinical practice [ 4 ]. WPBL refers to learning while performing practical tasks in the field [ 4 , 5 ]. WPBL enables trainees to develop skills pertaining to clinical tasks, communication, clinical reasoning, patient management, professionalism, and attitudes toward inpatients [ 6 ]. Direct observation by teachers in the workplace is an important assessment tool in competency-based education and is necessary for deliberate practice [ 7 ].

In South Korea, with the dual medical system, doctors of KM not only use the International Classification of Diseases (ICD) to diagnose like conventional medicine doctors, but also use the unique pattern recognition and systematic review of the body systems for diagnosis [ 8 ]. Doctors of KM exclusively use traditional treatments such as acupuncture and herbal medicine, and most of their services are reimbursed by the national health insurance [ 9 ]. KM education has gradually become competency-based since the publication of the secondary job analysis and competency modeling for doctor of KM [ 10 , 11 ]. Studies on the objective structured clinical examination (OSCE) [ 12 , 13 , 14 , 15 ] and the clinical performance examination (CPX) [ 16 , 17 , 18 ] for clinical practice education have been reported as Colleges of KM are required to use these assessment tools for clinical training [ 19 , 20 ]. However, a major limitation of using standardised patients is that their conditions are “simulated” according to a scenario. Moreover, they cannot represent pathological physical signs, are expensive, and require recruitment and training [ 17 , 21 ]. Therefore, the active participation of the trainees in clinical practice is encouraged by the new accreditation standards for Colleges of KM [ 22 ].

According to the Korean medical law, students in South Korea can conduct medical treatment related to their field of study under the guidance and supervision of an academic advisor. However, active participation of students in medical care during clinical clerkship has been reported to be limited due to the patients’ negative perceptions of students practicing in a clerkship setting; in addition, students cannot be paid for their medical practice [ 23 ]. Patient safety issues [ 24 ] and limited face-to-face contact with patients since COVID-19 [ 25 ] are also factors limiting experience with real patients. Due to these barriers, KM clinical clerkship is implemented passively at present, such as observing patient care or preparation of medical records [ 26 ]. However, future doctors of KM need sufficient practice with real patients before licensing, as only about 20% of graduates later become specialists through hospital training each year, and the vast majority are employed in primary healthcare institutions (PHIs) immediately after graduation [ 27 , 28 ]. However, studies have yet to be reported on the feasible methods and effects of implementing WPBL during the clinical clerkship of KM. We aimed to propose the implementation of WPBL at a single University KM hospital and explore the barriers to the implementation of WPBL and future improvements required in KM clinical clerkship by interviewing alumni.

This study was conducted as a qualitative case study. We used a qualitative thematic analysis method to obtain an in-depth understanding of the students’ experiences with WPBL in KM clinical clerkship and identify future improvements. Thematic analysis, a foundation of qualitative research methods, is an approach to identifying and analysing recurring patterns in qualitative data without being limited to a specific paradigmatic orientation [ 29 ].

Development and implementation of WPBL

Design of wpbl.

The learning objectives of WPBL were designed by one author (EC), who was a resident of the Department of Acupuncture and Moxibustion Medicine, the primary care physician for inpatients, and the supervisor of this WPBL, based on the competency modeling for doctor of KM [ 11 ] and were reviewed by the head professor of the department. Then, training contents were designed to accomplish the learning objectives. Patient presentation by the supervisor, interaction with a real patient at the bedside, case presentation, and writing medical records were set as four components of WPBL (Table 1). The Department of Acupuncture and Moxibustion Medicine has a special focus on patients with musculoskeletal or neurological disorders. We chose the department as the research field because musculoskeletal disorders, which are the department’s primary focus, account for the largest portion (74.8% in 2022 in South Korea) of KM treatment [ 30 ]. We aimed to provide adequate training for treating musculoskeletal disorders for future doctors of KM.

In order to ensure that the patients do not feel overwhelmed, we assigned a single student to each patient. Patient presentation by the supervisor was to help students efficiently learn their patients’ history (Competency [1]-1 History taking) and how to manage patients’ information and records (Competency [5]-1 Patient-care Management). After patient presentation, we aimed each student to suggest one musculoskeletal or neurological examination which could be useful to identify the patient’s condition. We intended to prevent errors by making the students perform the suggested physical examination on their supervisor with immediate feedback before interacting with the patient (Competency [1]-1 Physical examination). At the bedside, to demonstrate how to take a patient’s history, we let the supervisor to first identify the primary symptom for the students. The clinical tasks assigned to each student included one physical examination, review of system, and tongue and pulse diganosis. Tongue and pulse diagnosis are important examinations that must be performed for diagnosis in KM and require extensive clinical experience to gain proficiency [ 31 , 32 ]. We asked the students to diagnose the patients and develop treatment plans based on all the information gathered (Competency [1]-3 Integrative Care). The practice was also intended to let students communicate with patients and treat them with respect (Competency [2]-1 Physician-Patient Communication, [3]-2 Emphasis on Ethical Awareness). Writing medical records was included to help students organise what they had learned about the patient and document it in a fixed format. We also aimed for students to learn about the ICD codes and select an appropriate diagnosis, as doctors of KM must diagnose the patient after consultation and enter the appropriate ICD code in the chart [ 11 ], and the ICD codes are also included in the medical certificates issued by them (Competency [1]-2 Expertise Knowledge & Practical Skills). Since learning in the workplace is restricted to the clinical condition of the patient assigned to the student [ 4 ], we set a case presentation in which students described and shared their experiences to practice peer communication (Competency [2]-2 Standardized Communication in between Korean Medicine Doctors). Oral case presentation is the structured presentation of a clinical case to present important data, assessments, and plans. It is one of several methods used in workplace-based assessment [ 33 ].

Development of WPBL

The supervisor developed a portfolio form including the learning objectives, medical progress note, and doctor’s opinion form for the training was provided to students to record the contents of the training for a week. The learning objectives were presented in the portfolio to inform the students what they had to accomplish and promote learning [ 34 ]. The teaching materials of this WPBL were medical records, including the electronic medical records, prescriptions, and data from imaging tests.

Implementation

WPBL was conducted from January to July 2019 with the participation of 87 fourth-year students pursuing their clinical clerkship at the Wonkwang University, College of KM. Twenty-four groups comprising 3–4 students each participated in the training for five days. Each student was assigned a different patient. Inpatients who agreed to be examined by the students and were able to communicate on a daily basis participated in the WPBL. The WPBL process is presented in Fig.  1 .

Patient presentation by the supervisor

The supervisor explained the patient’s history and chief complaints; presented diagnostic images, such as radiographs using the Picture Archiving and Communication System (PACS); explained the findings; and provided instructions regarding history-taking and the preparation of medical records. Each student was instructed to suggest one physical examination that could be performed on the patient. The suggested physical examination was subsequently performed by the patient on the supervisor before interacting with the patient to prevent medical errors. If errors were noted during the examination, immediate feedback was given to perform the examination accurately. The students were instructed to select interview contents from various Review of System (ROS) items for performing pattern identification, a diagnostic method in KM. Although the supervisor did not suggest specific ROS items, students were required to perform tongue and pulse diagnosis. The students were informed that the patient’s information should not be disclosed and that students are responsible for disclosing personal information. The supervisor’s presentation was completed in 15–20 min.

Bedside interactions with real patients

After the discussion, the supervisor accompanied each student to the bedside. The supervisor initially asked the patient about the chief complaint, including pain intensity, pain characteristics, and aggravating factors. Subsequently, a physical examination, ROS assessment, and tongue and pulse diagnosis were performed on the patient by the student. The students were instructed to wash their hands thoroughly before and after patient contact. All procedures at the bedside were under the supervisor’s observation and supervision. After completing the task, the student returned to the office to review their practice. The same process was repeated for the next student and designated patient. Interaction with each patient was completed in 10–15 min by each student and a total of 40–60 min for the supervisor.

Preparation of medical records

Each student was instructed to prepare a medical record comprising the patient’s present illness, chief complaint, results of physical examination and ROS assessment, diagnosis, and treatment plan. The next day, the students received training for preparing medical certificates and doctors’ notes. A doctor’s note form was provided to the students to write the diagnosis using the ICD 10th edition codes, the date of onset, and future treatment opinions.

Oral case presentations and discussion

Each student prepared and delivered an oral case presentation on the patient’s present illness from existing medical records, chief complaints as determined by observing the supervisor, results of physical examination and ROS assessment performed by the student, the diagnosis made by the student, ICD code, and pattern identification by combining all information, and the treatment plan. After each presentation, all group members and supervisors discussed the patient, and the process was completed in approximately 1 h.

Explicit comments were minimised at the bedside, and simple feedback was provided in real time such that the student could revise the question or check items that were not performed. During the oral case presentation, feedback was provided primarily on the ROS, the students’ communication with the patient, the prepared medical record, and selected ICD codes.

Patient informed consent

We obtained informed consent from the patients to use their personal information for educational purposes. Additional verbal consent was obtained for participation in the WPBL process. None of the patients objected to or refused participation in the students’ training during the study period.

Conduct of qualitative research

Study population.

The graduates were set as the study population to explore the challenges faced by graduates when they started their job, whether WPBL was helpful for them in their workplace, and what aspects of WPBL need to be emphasized and improved. Additionally, the study aimed to identify the barriers to WPBL implementation and ways to improve the clinical clerkship by including university hospital residents currently responsible for clinical clerkship. In recruiting participants, purposeful sampling was applied to select study subjects from various types of workplace. This was due to the possibility of different opinions on WPBL depending on their work experience after graduation. Afterward, a snowball sampling was conducted by receiving recommendations to see if there were any doctors of KM with experience in other types of workplaces. The target of the initial purposive sampling was selected as a person who had experience as a student representative and was familiar with the work patterns of the graduates who experienced WPBL. The criteria for selecting study subjects were those who completed the WPBL and had been practicing KM for more than two years at the time of the interview.

Data collection

To determine whether the implementation of WPBL was beneficial to real-world clinical practice, interviews were conducted 3 years after the implementation of WPBL by a researcher (DL) with experience in qualitative studies who was not involved in the WPBL. As a doctor of KM and a specialist in KM Neuropsychiatry, the interviewer had an in-depth understanding of KM education and real-world practice. According to the purpose of the study, the researchers agreed that the main question was ‘Has WPBL helped clinical practice in the actual workplace?’ and set detailed interview question to this end. The key interview questions were: “What was the most challenging part in your workplace immediately after graduation?”, “Did WPBL help you in your clinical practice after graduation?”, “If you found WPBL helpful, what factors helped you? Do you have a specific experience that stood out to you?”, “If WPBL was not helpful, what could be improved?”, “With regard to your current workplace, what do you think you need to learn in your clerkship?”. In-depth one-on-one interviews, lasting approximately one hour per person, were conducted using an online conferencing platform and were recorded with the consent of the participants. During the interview, field notes were used to record observations, including nonverbal expressions. The WPBL supervisor (EC) transcribed the interview verbatim. The interview was continued until theoretical saturation was reached, at which point it was subjectively determined that the data collected and analysed was sufficient and no further data collection was necessary.

Data analysis

The interviews were analysed using a qualitative thematic analysis method. Microsoft Excel was used to analyse the transcribed raw data. There were two coders participating in concurrent data analysis. The transcribed data was reviewed repeatedly by the interviewer (DL) and subsequently summarised as meaning units. The meaning units were coded and categorised with categories and themes initially through constant comparison. The categorisation was then discussed and revised with another researcher (EC) to ensure objectivity in the analysis process and results. If opinions differed between researchers, advice was sought from an expert with experience in qualitative research unrelated to this study. Triangulation was applied to compare the field notes, transcription data, and audio recordings to ensure reliability and validity. Participants were asked to review the results obtained by the researchers through their interviews.

Ethical considerations

This study was reviewed and approved by the Institutional Review Board of the Wonkwang University (WKIRB-202,209-SB-070). The topic, purpose, methods of the study, and potential benefits of participating in the study were described in detail to the participants. Only doctors of KM who were willing to participate voluntarily in the study were included. The participants were informed that the results of the interviews would be published in a paper and that their responses would be anonymized. Written informed consent was obtained prior to participation. In addition, the participants were given a reward of 7$ immediately after the interview.

General characteristics of the interview participants

The study population consisted of six participants, including five males and one female. All but one of the six participants had experience as an intern. The specialties of participants D and E are Acupuncture and Moxibustion Medicine and KM Paediatrics, respectively. At the time of the interview, three participants were public health physicians, two participants were residents, and one participant was a self-employed doctor of KM (Table 2).

Perspectives from doctors of KM who have experienced WPBL

Meaningful units were extracted from the transcript. Twenty-eight codes were derived, which were categorised into five categories and two main themes (Table 3).

Theme 1: The experience of novice doctors of KM with KM practice

Category 1: clinical competency priorities vary according to the km workplace, patient needs and attitudes vary across healthcare organisations.

Participant F, who has worked as an intern, salaried physician, and self-employed physician since graduation, reported that the needs and attitudes of patients differed according to the type of KM institutions. Patients who visit KM clinics express various needs plainly to doctors of KM; therefore, Participant F “needed a period of time to realise the adequate compromise with patients” and determine “how much to accept.”

“I had to adjust to the needs of patients presenting to KM clinic, which are different from those of patients presenting to hospitals. In hospitals…patients do not ask this and that.” (Participant F).

Clinical skills required in workplaces

The perception of the participant regarding the types of clinical skills required in KM clinics and hospitals differed. Participant F stated that therapeutic skills are required in PHIs as he had to “insert acupuncture needles quickly, accurately, and completely,” as the clinic he worked for had more than 50 patients visiting per day, and acupuncture was used as a routine treatment for all patients. Thus, proficiency in acupuncture was a mandatory requirement. In contrast, participant E, who had been an intern, struggled with being “primarily assigned to managing inpatients,” which required her to perform various clinical procedures, such as intubation, L-tube placement, and auscultation of heart sounds.

Detailed testing and recording required in KM hospitals & limitations of detailed history-taking and examination

Another difference between KM clinics and hospitals is that hospitals require more thorough testing and completeness of medical records. Since interns have a set list of things to evaluate, Participant D reported that he “noticed he forgot to check something in the list after an interview with a patient was over and returned to the office to chart.” When Participant F was an intern at a hospital, he was required to “keep a thorough record” of the patient’s presenting illness, past medical history, physical examination, and imaging findings; however, he felt that there were interviews and examinations “that were not directly related to treatment.” Since Participant F is now self-employed in a KM clinic, he is more concerned about charting “patients involved in road traffic accidents,” whose records are particularly important, and documenting that he has fulfilled his obligation to “inform” patients. He also described the difficulty of performing detailed history-taking and physical examinations for patients who were seeking an immediate cure:

“Patients with a sprained ankle, for example, seek immediate pain relief, such as an ice pack, and to be able to walk better. They did not want me to perform a detailed history-taking or physical examination…” (Participant F).

Although differential diagnosis through specific history taking and examinations is required in KM hospitals, doctors of KM employed in KM clinics face varying patient needs and are requested to provide immediate treatment effects.

Category 2: Difficulties faced by doctors of KM immediately after graduation

Feeling “thrown” in front of the patient.

The participants reported feeling “embarrassed” and “thrown in front of patients” immediately after becoming a doctor of KM. They did not have sufficient experience with real patients during clinical clerkship or sufficient training in their workplaces after graduation.

“I did not have a lot of interaction with real patients; therefore, when I went to the clinical field and started seeing patients, I did not know what to say, what to ask. Moreover, I was not organised, so it was a bit difficult. I think I was nervous about performing clinical skills, such as acupuncture, as I did not have a lot of experience during clinical clerkship…” (Participant A). “I was only given a quick handover for two days before I started my job at the hospital, so I did not know what test to do…” (Participant D).

Participant C, who worked as a public health physician immediately after graduation, had learned about using the “charting program” from his predecessor but had not received any training for medical treatment. Participant B stated that he would have preferred to have “a lot more practice with real patients” as he felt there was “a gap between what he learned in the college and real practice” during his first clinical experience.

Tasks to be completed in limited time

The need to complete tasks in a limited amount of time was challenging for novice doctors of KM. The participants who had previously interned in hospitals expressed this difficulty.

“During the period of transition from internship to residency, we have to prepare a lot of medical reports, including the doctor’s note in our hospital. During that period, we learn in theory, but when a patient came and I tried to prepare the medical record, it sometimes took 10–15 minutes… In the hospital, I must finish the task related to one patient quickly and move on to the next patient, but I could not do that, so I think it was very hard.” (Participant D).

“When you are actually working in a hospital, it is more important to finish the task in a limited time, so I think it was harder to prepare medical records in a short amount of time.” (Participant F).

In addition, ‘ poor clinical skills ’, since novice doctors of KM lack experience, and ‘ difficulty deciding what to do with the patient ’, especially what to ask patients and what to examine were reported as difficulties. ‘ Low self-esteem ’ as a medical professional was due to not being respected by other medical staff during internship and performing assistive tasks immediately after graduation.

Theme 2: Current state of KM clinical education

Category 1: wpbl experience of the interviewees, wpbl not memorable.

Approximately three years after graduation, most of the participants could not recall the specifics of WPBL due to the passage of time; however, some participants recalled that they had interacted with real patients during the clerkship.

Beneficial procedure in WPBL

When asked to select the following four components of WPBL in order of importance: “Patient presentation by the supervisor,” “Interacting with a real patient at the bedside,” “Charting medical records,” and “Oral case presentation and discussion,” three of the current public health practitioners selected “Charting medical records” as the most important component.

Participant F, a self-employed physician, and Participant D, a resident, selected “Interacting with a real patient at the bedside” as the most important component. In contrast, Participant E, a resident, selected “Patient presentation by the supervisor” as the most important component. All participants mentioned the importance of having experience in preparing medical records, such as doctor’s notes.

“I think it is really important to have a lot of practice seeing patients and asking questions and charting, those activities have helped me treat patients in the clinic, and I wish I had more experience in charting.” (Participant A).

“When I was informed of the patient’s information by the supervisor, it was good to know what imaging tests they had undergone at other hospitals as I could get a sense of what kind of tests would be done for this condition.” (Participant E).

Insufficient feedback & indirectly related to treatment

Some participants reported that the feedback provided during WPBL was not sufficient and that “it would be nice to receive more in-depth feedback” (Participant F). Since the experiences of the participants with WPBL lacked direct relevance to the treatment, they required the supervisor’s explanations and feedback on how to use the information gathered to formulate a treatment plan.

“When you treat patients, you receive subjective and objective information and diagnose and formulate a treatment plan. Thus, just obtaining information is not the whole process…WPBL should not be limited to just taking history. Students need to understand how to use the information to treat. It is important to explain or give feedback on how to formulate a treatment plan based on the medical consultation.” (Participant F).

Lack of time for self-reflection and discussion

It was also reported that the schedule of having to interact with the patient immediately after being briefed about their condition did not give the participants sufficient time to consider how to interact with patients and that the discussion was not productive due to the different patient experiences. Since students are assigned different patients during WPBL and are not aware of the other patients’ conditions, they are less likely to understand the presentations of their peers and are less likely to ask questions.

“When I went to see the patient, I think I was pressed for time because I had to complete the assignment just after I got the patient’s information, and it would have been more memorable if I had taken more time to think about what to do with this patient.” (Participant B).

“Since the patient was known only to me and the supervisor, my colleagues could not question or agree with me…” (Participant D).

Category 2: Necessary but difficult to implement real patient learning

The importance and benefits of interaction with real patients.

Most participants expressed the need to practice on real patients as pathological symptoms and signs can only be observed in a real patient. The experience of examining real patients and observing pathologic signs was more productive and helped the participants in their practice after graduation.

“I recall performing sensory tests with my fingers on patients with herniated intervertebral discs. Considering that I do remember what I did during WPBL, at least vaguely, I think it is important. I used the test a few times as I learned when I was an intern at the hospital…” (Participant B).

“Physical examination training, such as manual motor tests, performed by trainees on each other seemed meaningless as we only observed normal findings in each other. In contrast, during WPBL, when I observed ‘zero’ or ‘trace’ in the patients during the examination, it really stuck in my head, and it remained in my memory when I came here and completed my internal medicine turn. I performed the test on critically ill patients and was able to understand the condition and differentiate the motor grade…” (Participant D).

The participants reported that detailed examinations and records are required in KM hospitals and that tasks must be completed by them within a limited time. The participants believed that interacting with real patients during clinical clerkship gives an opportunity to practice detailed consultations and examinations, and write complete records. In addition, experience with real patients gives students an opportunity to establish their professional identity.

“You know, we did not have the opportunity to take the time to really sit down with a patient and gather the information that we were looking for, especially counsel and examine to set treatment goals and plans. If you pursue an internship at a hospital, you might have that opportunity, but if you do not, I do not think you will… I think it is really important to have the opportunity to interact with patients at the beginning so that you feel that you are doing something as a healthcare provider and you remain motivated.” (Participant F).

Patient discomfort with care by student & lack of training staff

However, the two residents, who are currently responsible for clerkship in their workplace, disagreed on whether WPBL with real patients should be mandatory, considering both the pros and cons. Participant D, a resident in the Department of Acupuncture and Moxibustion Medicine, reported that implementing WPBL is difficult when patients feel uncomfortable with students; however, Participant D also stated that “it is definitely important to interact with and do something with the patients.” In contrast, Participant E, a resident in the Department of KM paediatrics, reported that the benefits of real patient learning are not worth the risk of patient dissatisfaction, which was based largely on her experience that paediatric patients and their protectors avoided trainees. Nevertheless, both residents agreed that limited availability of staff for clinical clerkship and barriers, such as “interruptions” and “inconsistencies” in clerkship due to urgent workloads for the residents in charge of training, was a problem.

“I am a KM paediatrician, so I heard kids saying “Why is the student here, please tell her to leave,” or patients who were always willing to come in will not come in because strangers are standing in the clinic… And some parents said, “Please tell us when students are not going to be here, and we will come then,” this is how I got rejection.” (Participant E).

Participant F, who has become a self-employed physician, emphasized that while trainees may be allowed to “just observe” at his clinic, it can be detrimental to the clinic if the patients feel uncomfortable and do not return. From the perspective of a physician running a clinic, he is concerned about receiving complaints from patients and is cautious about allowing trainees to observe.

Someone is opening the curtains and looking at me? Some aged people may allow it, but in general, it is not easy to convince patients…especially when it comes to counsel with patients for prescription of herbal medicine. Since the cost of herbal medicine is expensive, I do not think it would be easy for patients to allow those strangers (students) to look at them and note their information….

Category 3: Unmet needs for clinical clerkship in KM

Limitations of observation & bridging the gap between theory and practice.

Since “approximately 80% of current clinical practice is observation (Participant D),” just observing in the outpatient setting is “meaningless without patient information” (Participant E). Participant D was also refused the opportunity to observe by a professor who instructed him to “sit there like a sack of potatoes when there were no patients or leave when a patient came.” Thus, the participants lacked the opportunity to directly apply what they had learned in their previous five-year curriculum and observed a “gap between theory and practice.”

“I think it was very difficult for me to actually do what I had learned in theory. In terms of patient care and diagnosis, I think I have practiced a few times in some practical classes before, but I think it would be great if I experienced a lot more…” (Participant B).

Expanding engagement in real patient care

To close the gap between theory and practice, most participants suggested that students should be exposed to more practice with real patients. Further opportunities for patient consultation (Participant A) and experience of interacting with more than five real patients (Participants B and F) were suggested by the participants. Participant D, who is in charge of clinical clerkship, suggested that inpatients would most likely be targeted to increase the trainees’ learning in the workplace; however, since the opportunities may vary significantly due to different conditions of inpatients, it is important to balance practice with outpatients and inpatients.

Practice preparation of a medical record

Participant C suggested that trainees must be provided with more than two opportunities to perform the entire process of consultation and writing medical records on their own, and then receive feedback.

“Although I interned for a year, I realised that I am still not good at charting…” (Participant A).

“Just after graduation, I owe my ability to write medical records in the correct format to what the supervisor taught me during WPBL…” (Participant F).

Learning objectives and systemic design

The need to clarify the learning objectives of clinical practice in KM education and systematically design the practice curriculum was also mentioned by the participants. The participants had completed their overall clinical clerkship at three KM hospitals of a college. No learning objectives, such as knowledge, skills, and attitudes that students should be able to accomplish at the end of the training, were provided, and the content of the clerkship was organised inconsistently according to the decisions of the professors in each department. Furthermore, there was no list of core diseases, CPXs, or OSCEs that students were required to observe or perform before graduation.

“I felt the curriculum itself was very disorganised. Even if there had been some assigned tasks for each department, for instance, this department teaches A, and that department teaches B, I did not think that it was separated and organised when I was practicing…” (Participant B).

Experience with essential patient group & primary care-focused practice

Participant A proposed that undergraduates should interact with at least one patient with the primary disease of each of the eight clinical departments of KM. In contrast, Participant F, who has gained extensive experience at a local clinic, reported that although clinical training in KM curriculum focuses on inpatients in hospitals, many graduates are employed in KM clinics, and the characteristics of patients in KM clinics differ significantly from those of the patients in hospitals. Additionally, Participant C, who did not intern and only had experience working in public health, mentioned that he lacked training in identifying and referring emergency patients when performing his duties. He believed that students must be trained to determine when patients must be transferred from primary to tertiary care.

“Patients who come to KM hospitals usually bring their test results, so doctors of KM can identify at-risk patients. However, those in public health centres, who work in remote areas, cannot. I once wondered if I should transfer a patient with acute facial palsy due to the possibility of stroke. It would be better to provide more education on when to refer the patients to a higher level of care.” (Participant C).

Implementing further CPX & sufficient teaching of clinical skills and OSCE

Participant E, who had a negative attitude toward real patient learning due to patient dissatisfaction, believed that CPX is the most feasible way to improve competency level. Several CPXs are implemented with standardised patients at the hospital where Participant E is currently employed. Participant E emphasised the need to specify the required skills for each department and prepare sufficient models and infrastructure to practice various clinical skills. Clinical skill training and OSCE helped participants “apply the skills directly to clinical practice” (Participant B).

Further practice with medical device & education on finance & human resources management

The participants also emphasised the requirement for training on the use of medical devices, such as ultrasound and physical therapy devices, in clinical practice, as well as training on medical management and administration.

“I think it would be great if undergraduates could learn a little bit more broadly about the basics of tax or things about business management or human resource management, as a self-employed physician is also a person who runs a small company or a business.” (Participant F).

Principal findings

WPBL enables students to experience situations they will encounter as doctors of KM in the future [ 4 ]. Without any previous reference to WPBL in KM education, we designed and implemented a step-by-step WPBL process and evaluated its effectiveness through graduate interviews. Participants employed in various types of workplaces found it significantly beneficial to receive hands-on experience with real patients before graduation. We observed that the priorities of clinical competency and WPBL components vary according to the workplace. Despite some barriers to implementation, this study suggests that the WPBL model can be improved and utilized in KM clinical clerkships, thereby developing competent future doctors of KM.

Future improvements of the WPBL in KM education

The impact of WPBL was that students valued the experience of performing physical examinations and observing pathological signs in real patients and used them in their practice. This is particularly evident when taking into account the experiences of Participants B and D, who examined a patient with herniated intervertebral disc and a patient who had motor weakness. Most participants agreed that more opportunities are needed to interact with real patients. Nonetheless, we also identified some barriers and improvements of the WPBL model.

First of all, students need more detailed feedback and explanation regarding their performance and treatment plans. In the present study, although students were not graded on their work, we aimed to facilitate learning by observing, supervising, and providing specific and constructive feedback. However, some interviewees reported that the feedback was insufficient and that the students’ practice should be closely related to diagnosis and treatment during the discussion and feedback. The WPBL designed in this study focused on oral case presentations for just one hour on Day 4, resulting in limited time for feedback on the specifics of the treatment plans formulated by the students. It is necessary to allocate sufficient time for self-reflection and discussion, and provide high-quality supervision and feedback based on observation of students’ performance [ 35 ].

Secondly, training for the duties required in various workplaces after graudation is necessary. Our interviews showed that hospitals educate interns and residents by asking for well-structured medical records; however, this is not the case in primary care. All public health practitioners identified the preparation of medical records as the most important component of WPBL, despite the fact that two of them had internship experience. Even though meticulous charting was perceived as inconsistent with real-world practice by the participant who was self-employed in the local clinic, it is necessary for future doctors of KM to have a basic understanding of how to record their findings. In addition, one participant who did not intern, unlike other participants, mentioned that he needed more training for identifying and referring emergency patients. It is common for male doctors of KM to work as public health physicians for three years in rural underserved areas to fulfil their national defence obligations after receiving their license. Doctors of KM without internship experience may lack emergency patient experience and have difficulty performing examinations to rule out. Therefore, it is crucial to cover how to identify patients who require transfer to a higher level of care in WPBL.

Unique characteristics of WPBL in KM education

In South Korea, most doctors of KM are employed in PHIs after graduation rather than pursuing internships or residencies. A total of 744 graduates were licensed as doctors of KM in 2020; however, only 131 who had completed internship and residency programs were qualified as specialists [ 36 ]. Instead, doctors of KM can choose among several career paths after licensing, including employed physician, self-employed in KM clinics, or practicing as interns and residents in KM hospitals [ 37 ]. Therefore, we aimed to interview participants with experiences in these various workplaces. The interview suggests that current KM clinical teaching is mainly conducted in the setting of KM hospitals. However, since most doctors of KM work in clinics, future doctors of KM must practice communicating with more patients in clinics, who “express various needs plainly”, unlike patients in KM hospitals. Furthermore, “Finance & human resources management” in the competency modeling for doctors of KM [ 11 ], which represents understanding for insurance and effective manpower management, should be covered in clinical teaching since many doctors of KM are self-employed physicians and manage their own practice [ 37 ]. We also found that while teaching clinical skills is fundamentally important, proficiency in routine treatment skills is prioritized in primary care. In contrast, a variety of skills for inpatient care is required in KM hospitals.

Clinical reasoning is often the focus of WPBL in medical education [ 33 , 38 ]; however, we focused on the experience of interacting with real patients and performing physical examinations rather than clinical reasoning, as many doctors of KM encounter patients who have been examined and diagnosed in other hospitals. This is because many patients visit KM clinics as they wish to receive both Western and KM treatments [ 39 ]. Therefore, patient information, including medical history, chief complaint, and imaging test results of the patients, were presented to the students before they interacted with the patients to reflect the nature of KM practice. Instead of clinical reasoning, students were asked to conduct pattern identification, a unique diagnostic method in East Asian medicine, based on patients’ symptoms, students’ findings, and tongue and pulse diagnosis [ 40 ]. Moreover, the supervisor explained the results of the imaging and trained the students on the use of PACS. In South Korea, doctors of KM cannot order some diagnostic examinations, such as radiographs; however, they are required to have the ability to interpret the images and explain them to patients [ 41 ]. As clinical competency and simulation are currently emphasized in East Asian medicine education [ 20 , 42 ], this study provides insight into how to implement WPBL in East Asian medicine, which differs from conventional medicine in terms of diagnosis and treatment.

Strengths and limitations of this study

This is the first study to design and implement WPBL in KM education and assess the learners’ reactions through interviews. The graduates’ opinions on WPBL as well as clinical practice education and the unique characteristics of KM practice compared with those of Conventional medicine will serve as a reference for redesigning KM education to be competency-based. We also collected feedback from practitioners more than two years after graduation to assess the application of the training in the field. A limitation of this study is that the researcher who primarily conducted the interviews is a doctor of KM and the researcher who was responsible for the training participated in the study; thus, there may be experimental bias during participant recruitment, interviews, and data analysis. The responses of the participants may have been affected as they recognised that the interviewer was a doctor of KM. Although we conducted interviews until we reached theoretical saturation, we were only able to interview six participants. In addition, the lack of pre-interviews may have affected the quality of the study. Despite these limitations, this study is significant in that it provides an in-depth understanding of the impact of WPBL in real-world KM practice, the challenges faced by novice doctors of KM in clinical settings, and the unique characteristics of KM practice.

Implications for future research and education

As this study is the beginning of the research on WPBL in KM education, various studies on WPBL with real patients are urgently required. First, the patients’ and teachers’ perceptions of WPBL must be investigated. During our interviews, we learned that some patients did not want students to be involved in their care, which leads to residents having a negative attitude toward real patient learning. It is worth exploring whether there is a difference in patients’ attitudes and needs toward doctors of KM and how they perceive students’ participation in patient care in KM clinics and hospitals. Faculty and patient encouragement are beneficial factors in improving clinical skills [ 43 ]. However, even Participant F, who reported that WPBL was helpful and is important in KM education also had a negative attitude toward having students in his own clinic due to concerns regarding patient comfort and their possible decision to not return. It is unknown whether patients who visit KM institutions will dislike the increased participation of students. Further studies are required to gain an in-depth understanding of the challenges and unmet needs of clinical teachers to promote WPBL.

Second, assessment should be conducted to determine whether the intended learning objectives are achieved by utilising WPBL in KM clinical teaching. Learners’ positive reactions to mini-clinical evaluation exercise and direct observation of procedural skills have suggested the value of workplace-based assessment as a formative performance assessment [ 44 ]. Student performance may be assessed via direct observation by the instructor, as well as a written record or oral presentation by the student [ 5 ]. Further research is required to develop specific methods and assessment tools for workplace-based assessment that can be utilised appropriately in KM settings, in light of reliability and feasibility.

Third, as reported by the participants, clear objectives and a systematic curriculum of KM clinical teaching must be formulated for competency-based learning. The participants had practiced for 24 weeks at three teaching hospitals; however, they were not adequately trained to perform the expected tasks. Although competency modeling for doctors of KM has been defined, little information is available on how to implement competency-based education in individual KM courses [ 45 ]. The patients and tasks that students should experience in the clinical clerkship should be clearly defined.

Furthermore, the lack of clinical preceptors was noted as a barrier to implementing WPBL in this interview. Skilled preceptors who can prioritize teaching and supervision are needed to provide students with sufficient opportunity to perform tasks in the clinical field. While many residents now serve as preceptors for clerkship alongside faculty, residents are also the trainees. The teaching and communication skills of preceptors required for clinical education could be developed through existing faculty development programs [ 46 ].

The significance of the study is that it provides a specific report of WPBL that can be utilised in KM clinical teaching. This learning required up to 140 min of supervisor time per week, which we believe is acceptable in light of the authentic experience gained by the students. Thus, we expect the promotion of WPBL in KM education in the future and the introduction of various workplace-based assessments.

Promoting WPBL in KM education is crucial for enhancing various clinical competencies required in the KM workplaces. We implemented WPBL in the KM clinical clerkship and interviewed graduates three years later to explore the challenges they faced as novice doctors of KM and identify future improvements of WPBL. Patient discomfort with care by student and lack of training staff were identified as barriers to WPBL. Suggestions for improvement included providing sufficient feedback on student performance and discussion on synthesizing the information to set treatment plans. The findings of this study can contribute to improving the WPBL and addressing the identified unmet needs in KM clinical education.

Flow chart of workplace-based learning in the present study

Data availability

The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

• Workplace-based learning

Korean Medicine

Objective Structured Clinical Examination

Clinical Performance Examination

Primary healthcare institutions

Review of System

International Classification of Diseases

Picture Archiving and Communication System

Huang Y. A study on the Korean Medicine Education and the changes in the traditional Korean Medicine during the Japanese colonial era: focused on the Korean Medicine Training Schools. Korean J Med Hist. 2018;27:1–48.

Article   Google Scholar  

Flexner A. Medical education in the United States and Canada. Paju, Korea: Hangilsa; 2005.

Google Scholar  

Hong J, Kang Y. The implications of the Case of Medical Education in North America on Korean Medicine Education. J Korean Med Hist. 2018;31:91–101.

Harden RM, Laidlaw JM. Essential skills for a medical teacher: an introduction to teaching and learning in medicine. Paju(Korea): Academy; 2017.

Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide 31. Med Teach. 2007;29:855–71.

Dent JA, Harden RM. A Practical Guide for Medical Teachers. In: A Practical Guide for Medical Teachers. 2nd edition. Seoul: Academypress; 2008. p. 3–6,103–104.

Holmboe ES, Durning SJ, Hawkins RE. Practical guide to the evaluation of clinical competence. 2nd edition. Paju: Koonja Publish Co.; 2022. p. 62.

Kim T-H, Alraek T, Bian Z-X, Birch S, Bovey M, Lee J, et al. Clinical reasoning in traditional medicine exemplified by the clinical encounter of Korean medicine. Integr Med Res. 2021;10:100641.

Kim D, Shih C-C, Cheng H-C, Kwon S-H, Kim H, Lim B. A comparative study of the traditional medicine systems of South Korea and Taiwan: Focus on administration, education and license. Integr Med Res. 2021;10:100685.

Kim K, Kim J-H, Lim B-M, Shin B-C, Shin S-W, Kim G-W, et al. Secondary job analysis of doctors of Korean medicine. Seoul: Korea Health Personnel Licensing Examination Institute; 2013.

Lim C, Han H, Hong J, Kang Y. 2016 Competency Modeling for Doctor of Korean Medicine & Application Plans. J Korean Med. 2016;37:101–13.

Sim SB, Kweon JH, Kim HW, Hong JW, Shin SW. Student satisfaction study of clinical skills training in Korean medical education. J Korean Med. 2013;34:37–53.

Cho E, Lee J-H, Kwon OS, Hong J, Cho NG. Assessment of acupuncture and Moxibustion Medicine Clinical Practice using the Objective Structured Clinical Examination. J Acupunct Res. 2021;38:219–26.

Cho E, Han Y-M, Kang Y, Kim J-H, Shin M-S, Oh M, et al. Implementation of Objective Structured Clinical Examination on Diagnostic Musculoskeletal Ultrasonography Training in Undergraduate traditional Korean Medicine Education: an Action Research. Diagnostics. 2022;12:1707.

Cho E, Jeon H, Kwon OS, Hong J, Lee J, Jung E, et al. Training future Korean medicine doctors to perform bee venom acupuncture and obtain informed consent using an objective structured clinical examination. J Korean Med. 2022;43:6–17.

Kweon JH, Sim SB, Kim EJ, Hong JW, Shin SW. Evaluation of the implementation of clinical performance examination in Korean Medicine Education. J Physiol Pathol Korean Med. 2018;32:51–61.

Jo H-J, Park J-S, Roh JD, Sung HK. A survey on students’ perception of clinical performance examination (CPX) in College of Korean Medicine using student standardized patients. Soc Prev Korean Med. 2020;24:1–13.

Shin J, Go Y, Song C, Cho E, Leem J. Presentation on research trends and suggestion for further research and education on Objective Structured Clinical Examination and clinical performance examination in Korean Medicine education: scoping review. Soc Prev Korean Med. 2022;26:87–112.

Institute of Korean Medicine Education&Evaluation. The manual of 2nd cycle Korean medicine education evaluation and certification for College of Korean Medicine and Graduate School of Korean Medicine. Seoul: Karammunhwasa; 2017.

Han SY, Lee S-H, Chae H. Developing a best practice framework for clinical competency education in the traditional East-Asian medicine curriculum. BMC Med Educ. 2022;22:352.

Collins JP, Harden RM, AMEE Medical Education Guide No. 13: real patients, simulated patients and simulators in clinical examinations. Med Teach. 1998;20:508–21.

Institute of Korean Medicine Education and Evaluation. KAS2022 Korean medicine education evaluation certification manual and self-report method briefing session. Seoul; 2022.

Kang YS, Chae YB, Go HY, Kim HH, Kim HS, Hong JS, et al. A study for improvement of the national examination. Korea Health Personnel Licensing Examination Institute; 2017.

Yoon TY, Lee JK, Oh IH. Changes in the Clerkship in Korean Medical schools: the Prospect of a student internship. Korean Med Educ Rev.

Im S. Challenges and strategies in Medical Education in the COVID-19 pandemic. Korean Med Educ Rev. 2021;23:154–9.

Kim C-Y, Seo H-S, Lee M-E, Kwon K. Introduction of reflective journals and satisfaction evaluation for active clinical practice model of Colleges and the school of Korean Medicine. J Korean Med Ophthalmol Otolaryngol Dermatol. 2019;32:186–201.

Joo H. 156 doctors of Korean Medicine took the first round of the 23rd Korean Medical Specialist Qualification Exam and all passed. Akomnews. 2023. https://www.akomnews.com/bbs/board.php?bo_table=news_id=51897 . Accessed 5 Mar 2023.

Yearbook of traditional Korean Medicine Publications Committee. Yearbook of traditional Korean Medicine. Korea Institute of Oriental Medicine; 2020.

Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide 131. Med Teach. 2020;42:846–54.

Ministry of Health and Welfare. 2022 Korean Medicine Utilization Survey Report. Gyeongsan: National Institute for Korean Medicine Development; 2023. p. 34.

Anastasi JK, Currie LM, Kim GH, UNDERSTANDING. DIAGNOSTIC REASONING IN TCM PRACTICE: TONGUE DIAGNOSIS.

Kim H, Kim JY, Park Y-J, Park Y-B. Development of pulse diagnostic devices in Korea. Integr Med Res. 2013;2:7–17.

Daniel M, Rencic J, Durning SJ, Holmboe E, Santen SA, Lang V, et al. Clinical reasoning Assessment methods: a scoping review and practical Guidance. Acad Med. 2019;94:902–12.

Dornan T, Boshuizen H, King N, Scherpbier A. Experience-based learning: a model linking the processes and outcomes of medical students’ workplace learning. Med Educ. 2007;41:84–91.

Dornan T. Workplace learning. Perspect Med Educ. 2012;1:15–23.

Ministry of Health and Welfare. Healthcare workforce survey. Korean Statistical Information Service. 2022. https://kosis.kr/statHtml/statHtml.do?orgId=117&tblId=DT_117110_C004&vw_cd=MT_ZTITLE&list_id=F_007_003&scrId=&seqNo= ⟨ _mode=ko&obj_var_id=&itm_id=&conn_path=MT_ZTITLE&path=%252FstatisticsList%252FstatisticsListIndex.do.Accessed 2 May 2023.

Bak Y-H, Huang D-S, Shin H-K. A survey of the medical treatment environment in traditional Korean medicine clinics. J Korean Orient Med. 2011;32:25–36.

Ruczynski LI, Van De Pol MH, Schouwenberg BJ, Laan RF, Fluit CR. Learning clinical reasoning in the workplace: a student perspective. BMC Med Educ. 2022;22:19.

Seo Y, Kang S-H, Kim Y-H, Choi D-B, Shin H-K. Customers’ utilization and satisfaction in Oriental Medical clinics. J Korean Orient Med. 2010;31:124–36.

Korean Medicine Diagnostic Practice Compilation Committee. Diagnostics of Korean medicine. 2nd edition. Seoul: Koonja Publish Co.; 2017.

Kim J, Hwang B, Hwang M, Lee SK, Yi E, Leem J. Should Korean Medicine doctors use modern diagnostic medical devices? Survey result of public perspectives. J Korean Med. 2022;43:94–105.

Amitani M, Amitani H, Suzuki H, Kawazu S, Mizuma K, Yamaguchi K et al. Application of objective structured clinical examination (OSCE) for the evaluation of Kampo medicine training. BMC Med Educ. 2022;22.

Jamshaid F, Najjar A, Dost S, Kassam Z, Master B. Attempting technical skills on real patients: a London medical student perspective. Med Educ. 2018;52:1210–1210.

Miller A, Archer J. Impact of workplace based assessment on doctors’ education and performance: a systematic review. BMJ. 2010;341(sep24 1):c5064–5064.

Cho E, Hong J, Nam Y, Shin H, Kim J-H. Development of teaching and learning manual for competency-based practice for Meridian & acupuncture points class. Korean J Acupunct. 2022;39:184–90.

Alexandraki I, Rosasco RE, Mooradian AD. An Evaluation of Faculty Development Programs for Clinician–Educators: a scoping review. Acad Med. 2021;96:599–606.

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Acknowledgements

The authors appreciate the six interviewees for their voluntary participation in this study.

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Eunbyul Cho and Do-Eun Lee share the first authorship.

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KM Science Research Division, Korea Institute of Oriental Medicine, Yuseong-daero, Yuseong-gu, Daejeon, 1672, Republic of Korea

Eunbyul Cho

Department of Neuropsychiatry Medicine, College of Korean Medicine, Wonkwang University, Iksan, Republic of Korea

College of Korean Medicine, Wonkwang University, Iksan, Republic of Korea

Department of Diagnostics, College of Korean Medicine, Wonkwang University, Iksan, Republic of Korea

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Conceptualization and design of the study: Eunbyul Cho. Material preparation, data collection: all authors. Analysis: Eunbyul Cho, Do-Eun Lee. Writing– original draft: Eunbyul Cho. Writing– review and editing: all authors. All authors read and approved the final manuscript.

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This study was performed in accordance with the Declaration of Helsinki. This study was reviewed and approved by the Institutional Review Board of the Wonkwang University (WKIRB-202209-SB-070). The topic, purpose, methods of the study, and potential benefits of participating in the study were described in detail to the participants. Only doctors of KM who were willing to participate voluntarily in the study were included. The participants were informed that the results of the interviews would be published in a paper and that their responses would be anonymized. Written informed consent was obtained prior to participation.

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Cho, E., Lee, DE., Lee, D. et al. Barriers and future improvements of workplace-based learning in Korean medicine clinical clerkship: perspectives of graduates. BMC Med Educ 24 , 566 (2024). https://doi.org/10.1186/s12909-024-05288-3

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Received : 10 June 2023

Accepted : 11 March 2024

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DOI : https://doi.org/10.1186/s12909-024-05288-3

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