Quality of Life and Coping Strategies in Children with and Without Learning Disabilities from the Perspective of Their Parents and Caregivers

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a cross-sectional survey of 6- to 18-year-olds with and without learning disability (LD), comparing their quality of life, coping strategies, and looking at associations between these two sets of outcomes. The study appears to have been well-executed and was certainly very easy to read (only occasional corrections to the English are needed.) I have a number of recommendations and some queries. I believe that the authors will be able to address them.

TITLE

1.      I recommend changing the title from “Children with Learning Disabilities’ Quality of Life and Coping Strategies: A Case Control Study” to “Quality of life and coping strategies in children with and without learning disabilities” because:

(a)    I don’t think it’s a case-control study design (see point 9 below)

(b)    This would get rid of the awkward apostrophe on “disabilities” (it is the children’s QOL and coping strategies, not the disabilities’ QOL and coping strategies).

ABSTRACT

2.      Please change “A representative sample of learning disabled (N = 97) and normal pupil (N = 89)” to “A representative sample of 6- to 18-year-old children with (N = 97) and without (N = 89) LD”.

3.      Please change “COPE” to “Coping Orientation to Problems Experienced Inventory (Brief-COPE)”.

4.      Please change “p = 0.00” to “p<.01” or “p<.001” or whatever it is. P can’t be exactly zero.

5.      I think the following statement over-simplifies the results: “Even after controlling for important confounders like grade, family status, and monthly income, we find that social and mental health has an important association with LD.” When you DIDN’T control for sociodemographic variables, 6 of the coping strategies were significantly associated with LD/non-LD (Table 2), whereas when you DID control for sociodemographic variables, only 2 of the coping strategies were significantly associated with LD/non-LD (Table 5). That suggests that sociodemographics explain a portion of the group differences. You might not be able to find room in the Abstract to say all of that, but please be more cautious in interpreting this result, which isn’t as clearcut as this statement suggests.

6.      Please give the statistical results to support this statement: “The physical component summary score is significantly associated with denial and substance abuse, while the mental component summary is significantly associated with active coping, behavioral disengagement, and humor coping strategies.”

INTRODUCTION

7.      Definition of LD: Could you please define LD more precisely? In the US and many countries, LD refers to academic skills (e.g., reading, maths) being lower that would be expected for the child’s age, but the definition excludes intellectual disability (ID). Having social and emotional difficulties doesn’t determine whether they have a LD (although some children with LD do have social/emotional difficulties). But in the UK, LD includes ID. And ID includes not only intellectual limitations but also limitations in social and adaptive skills. The description of LD in the Introduction to the present paper seems to fit the UK definition better than the US definition. So does that fact that the children were recruited from Special Schools. However, the prevalence (5-15%) would be high for ID, and the authors refer to DSM-5, which aligns with the US definition (no ID). So could the authors please clarify what is meant by LD in this paper?

8.      The syntax of the following sentence needs correcting: “In order to understand the coping mechanism employed by children with learning disability is important for developing targeted intervention and support system that are tailored to their needs.” I suggest something like: “It is important to understand the coping mechanisms used by children with LD in order to develop targeted interventions and support systems that are tailored to their needs.”

METHODS

9.      I think this study is incorrect in describing this as a case-control study. “In a case-control study patients who have developed a disease are identified and their past exposure to suspected aetiological factors is compared with that of controls or referents who do not have the disease.” (https://www.bmj.com/about-bmj/resources-readers/publications/epidemiology-uninitiated/8-case-control-and-cross-sectional) This was not done in the present study. It could certainly be described as a “cross-sectional study”. I would call it a cross-sectional comparative group design, because it compared two groups: children with and without LD. It could also be called a cross-sectional survey.

10.  Study Design: Please move the statement “Participants were recruited from special education schools.” to the next subsection: Participants.

11.  Participants: Please explain how the children in the control group were recruited, and what steps were taken to ensure that they were as comparable as possible to the children with LD (e.g., siblings, living in same area).

12.  Sample calculation: The text in this section does not give any sample calculation, but only a justification for the sampling method used (convenience sampling). This belongs in the “Participants” paragraph. It would indeed be difficult to do a sample size calculation for this study, and it isn’t a randomized controlled trial, and so I think this heading could be removed without any comment on why sample size wasn’t calculated.

13.  Who completed the surveys? Section 2.4 says that the SF-12 is a “self-reported tool” and for the Brief COPE, it says “participants rated their use of each strategy”. This suggests that the children themselves completed the questionnaires. This would be a very demanding task for children with LD (possibly ID) as young as 6 years of age. (The first 2 items on the Brief COPE, for example, are “I've been turning to work or other activities to take my mind off things.” “I've been concentrating my efforts on doing something about the situation I'm in.”) Section 2.5 talks about interviews with the parents or guardians but doesn’t say that parents completed the questionnaires on behalf of their children—which would be difficult, because the SF-12 and especially the COPE contain questions about thoughts and feelings, which parents won’t necessarily know about their children. So my questions are:

(a)    Could you please specify who completed the questionnaires?

(b)    If the children completed the questionnaires, how was this managed? Was a children’s version available? Or did a person sit with each child and read it to them and help them understand it?

(c)    If the parents completed them, do you have any evidence that they are valid as parent proxy-report tools?

14.  Related to those questions, the English version of the brief-COPE is designed for adults (age 18+). If it was used for children in this study, what adaptations were made?

RESULTS

15.  It is unusual for all parents to agree to participate in a study. Did you have any decline? Please specify many in each group.

16.  The finding that substance abuse was higher in LD is alarming. In the English version of the brief-COPE, the substance abuse items are “I've been using addictive behaviors or substances to make myself feel better.” and “I've been using alcohol or other drugs to help me get through it.” These items are intended for adults and so it is very surprising to have children (or parents on behalf of their children) answer yes to either of them. Was these positive responses restricted the adolescent age range? Do you know how participants interpreted these questions? For example, could the participants have been thinking of prescribed medications?

17.  Please could you modify the heading to Table 5 to indicate that you controlled for demographic characteristics in this analysis? Something like: “Table 5. Impact of coping strategies on quality of life of children with learning disability, controlling for demographic characteristics (grade, family status, and monthly income).”

DISCUSSION

I think the Discussion is good, and very interesting to read, but I am going to query a few specific statements made in it.

18.  In the following sentence, should “healthy participants” be “children with LD”? “As expected, QOL using the SF-12 was poor in children with LD compared to healthy controls, which seems to be mostly consistent with previous findings in healthy participants [32,33,34,35].”

19.  The second sentence here doesn’t seem to follow logically from the first, because “substance use” and “religious coping strategies” are not a form of “problem-focussed coping”: “Those with learning disabilities reported a higher reliance on substance use and religious coping strategies. These findings partially align with previous research [45], which found that children with learning disabilities tend to use problem-focused coping by seeking help and emotion-focused coping by managing frustration and compartmentalizing their disability.”

20.  This section has a very interesting discussion of the differences in coping strategies between the two groups. A couple of further considerations might be included:

(a)     One is that when sociodemographic characteristics were controlled for, a lot of the differences between the groups disappeared, which suggests that the differences in coping strategies may be sociodemographic rather than LD-related.

(b)    The other thing I wonder is whether different kinds of coping strategies are used for different levels of stress. For example, if the LD group are trying to cope with more difficult situations than the non-LD group, might that (partly) account for the differences? Is there any literature evidence on different coping strategies being used for different kinds of stress or different severities of stress? (For example, I could use distraction when I have a mild headache, but I would need to use different and much more active coping strategies if I fractured a bone, got expelled from school, or couldn’t get any friends.)

21.  It might be going too far to say that, “this study provided a thorough understanding of the coping mechanisms that can enhance the quality of life of children with learning disability.” The study was useful in shedding light on coping mechanisms and QOL in children with LD, but more work is needed to gain a thorough understanding.

22.  I’m also not sure that it’s valid to claim that, “it also highlights the significance of promoting adaptive coping strategies and addressing maladaptive coping strategies to improve the quality of life of children with learning disability.” This was a cross-sectional design, and therefore unable to unravel cause and effect. It is reasonable to suggest that the kind of coping strategies used might affect QOL, but QOL might also affect the choice of coping strategies, or other factors (e.g. some of those sociodemographic variables) might enter into the equation.

23.  I don’t think it’s true that “the results indicated that elementary school children were at a high risk of LD”. To determine this, you would need to get a sample of elementary school children, and then test them all to find out how many had LD. Instead, you found that in your sample there were more elementary school children in the LD group than in the comparison group. That shows that the comparison group was not matched to the LD group in terms of grade level. But it doesn’t tell you anything about prevalence of LD among elementary school children.

24.  Among the limitations, please consider the non-equivalence of the two groups on sociodemographic variables and the suitability of the instruments for children. Also limitations of self-report or parent-proxy report (whichever was used) for these questionnaires.

 

Author Response

Children with Learning Disabilities’ Quality of Life and Coping Strategies: A Case Control Study

Response to Reviewer 1 Comments
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted in Yellow color in the re-submitted files

 

This is a cross-sectional survey of 6- to 18-year-olds with and without learning disability (LD), comparing their quality of life, coping strategies, and looking at associations between these two sets of outcomes. The study appears to have been well-executed and was certainly very easy to read (only occasional corrections to the English are needed.) I have a number of recommendations and some queries. I believe that the authors will be able to address them.

 

TITLE

 

1. I recommend changing the title from “Children with Learning Disabilities’ Quality of Life and Coping Strategies: A Case Control Study” to “Quality of life and coping strategies in children with and without learning disabilities” because:

 

(a)    I don’t think it’s a case-control study design (see point 9 below)

Response 1a: Agreed to change the title as follows based on both Reviewers’ comments:

“Quality of Life and Coping Strategies in Children with and without learning disabilities from the Perspective of Their Parents and Caregivers”

 

(b)    This would get rid of the awkward apostrophe on “disabilities” (it is the children’s QOL and coping strategies, not the disabilities’ QOL and coping strategies).

 

Response 1b: We really appreciated your valuable comments, and you suggested that change the title of the study. We modified the title; please see changes in the Title in the manuscript

 

 

 

ABSTRACT

 

2. Please change “A representative sample of learning disabled (N = 97) and normal pupil (N = 89)” to “A representative sample of 6- to 18-year-old children with (N = 97) and without (N = 89) LD”.

Response 2: Thanks for this point; Please refer to Page 1, line 15-17

 

 

3. Please change “COPE” to “Coping Orientation to Problems Experienced Inventory (Brief-COPE)”.

Response 3: Thanks; please refer to Page 1, line 18-19

 

4. Please change “p = 0.00” to “p<.01” or “p<.001” or whatever it is. P can’t be exactly zero.

Response 4: Agreed; Please refer to Page 1, line 29

 

5. I think the following statement over-simplifies the results: “Even after controlling for important confounders like grade, family status, and monthly income, we find that social and mental health has an important association with LD.” When you DIDN’T control for sociodemographic variables, 6 of the coping strategies were significantly associated with LD/non-LD (Table 2), whereas when you DID control for sociodemographic variables, only 2 of the coping strategies were significantly associated with LD/non-LD (Table 5). That suggests that sociodemographics explain a portion of the group differences. You might not be able to find room in the Abstract to say all of that, but please be more cautious in interpreting this result, which isn’t as clear-cut as this statement suggests.

Response 5: Thanks for this suggestion, we had modified the abstract and removed the unwanted content

 

6. Please give the statistical results to support this statement: “The physical component summary score is significantly associated with denial and substance abuse, while the mental component summary is significantly associated with active coping, behavioral disengagement, and humor coping strategies.”

Response 6: Thanks for this suggestion, Please see changes in page 1 Line 30-34

 

INTRODUCTION

 

7. Definition of LD: Could you please define LD more precisely? In the US and many countries, LD refers to academic skills (e.g., reading, maths) being lower that would be expected for the child’s age, but the definition excludes intellectual disability (ID). Having social and emotional difficulties doesn’t determine whether they have a LD (although some children with LD do have social/emotional difficulties). But in the UK, LD includes ID. And ID includes not only intellectual limitations but also limitations in social and adaptive skills. The description of LD in the Introduction to the present paper seems to fit the UK definition better than the US definition. So does that fact that the children were recruited from Special Schools. However, the prevalence (5-15%) would be high for ID, and the authors refer to DSM-5, which aligns with the US definition (no ID). So could the authors please clarify what is meant by LD in this paper?

 

Response 7: We thank the reviewer for his/her insightful comments on what constitutes Learning Disabilities (LD). In reply, we would like to clear the point about LD definition usage in our paper.

LD in this study refers to the diagnostic criteria of DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), which exclude intellectual disabilities (ID). Criteria for LD requires a child to have academic skills (e.g., reading, writing, arithmetic) that are substantially below the expected level and otherwise unexplained by an intellectual disability. Under this definition, social and emotional problems are not primary factors in terms of the identification of LD but certainly could be comorbid.

In the United Kingdom, however, the term "learning disabilities" is used more broadly to describe intellectual disabilities as well as social and adaptive impairments. In this paper, however, we adhere to the more conservative DSM-5 definition in order to align with diagnostic criteria worldwide that employ DSM-5 principles of clinical diagnosis in the U.S. and elsewhere. Consequently, the children were recruited from Special Schools; however, they did conform to DSM-5 defined criteria for LD (excluding those with intellectual disabilities (ID).

 

8. The syntax of the following sentence needs correcting: “In order to understand the coping mechanism employed by children with learning disability is important for developing targeted intervention and support system that are tailored to their needs.” I suggest something like: “It is important to understand the coping mechanisms used by children with LD in order to develop targeted interventions and support systems that are tailored to their needs.”

Response 8: Thanks for this suggestion, we have modified according to your recommendation, please see changes in page 2 line 72-74

 

METHODS

 

9. I think this study is incorrect in describing this as a case-control study. “In a case-control study patients who have developed a disease are identified and their past exposure to suspected etiological factors is compared with that of controls or referents who do not have the disease.” (https://www.bmj.com/about-bmj/resources-readers/publications/epidemiology-uninitiated/8-case-control-and-cross-sectional) This was not done in the present study. It could certainly be described as a “cross-sectional study”. I would call it a cross-sectional comparative group design, because it compared two groups: children with and without LD. It could also be called a cross-sectional survey.

 

Response 9: Agreed. We were unable to investigate the etiological factors, thus we decided that it could certainly be defined as a "cross-sectional study". We updated the method part on page 2 line 86 with the following explanation: "It is a cross-sectional comparative group design, because it compared two groups: children with and without LD".

 

 

10. Study Design: Please move the statement “Participants were recruited from special education schools.” to the next subsection: Participants.

 

Response 10: Agreed, Please refer to page 3 line 96

 

11. Participants: Please explain how the children in the control group were recruited, and what steps were taken to ensure that they were as comparable as possible to the children with LD (e.g., siblings, living in same area).

 

Response 11: Thanks for this insight; Actually, we match control group participants based on key demographic factors such as age, areas of residence and ethnicity. This helps to control for these variables and ensures that any differences observed are more likely due to the learning disability rather than these factors.

 

12. Sample calculation: The text in this section does not give any sample calculation, but only a justification for the sampling method used (convenience sampling). This belongs in the “Participants” paragraph. It would indeed be difficult to do a sample size calculation for this study, and it isn’t a randomized controlled trial, and so I think this heading could be removed without any comment on why sample size wasn’t calculated.

 

Response 12: Thanks for this insight, we have changed the heading as Sampling Method instead of Sample calculation

 

13. Who completed the surveys? Section 2.4 says that the SF-12 is a “self-reported tool” and for the Brief COPE, it says “participants rated their use of each strategy”. This suggests that the children themselves completed the questionnaires. This would be a very demanding task for children with LD (possibly ID) as young as 6 years of age. (The first 2 items on the Brief COPE, for example, are “I've been turning to work or other activities to take my mind off things.” “I've been concentrating my efforts on doing something about the situation I'm in.”) Section 2.5 talks about interviews with the parents or guardians but doesn’t say that parents completed the questionnaires on behalf of their children—which would be difficult, because the SF-12 and especially the COPE contain questions about thoughts and feelings, which parents won’t necessarily know about their children. So my questions are:

 

(a)    Could you please specify who completed the questionnaires?

Response 13a: We agree with the reviewer’s concern about questionnaires completion. These questionnaires are completed by parents or guardians on behalf of the children, with the children present during the process. We adopted this approach, as our participants were of relatively young age and to overcome cognitive challenges presented by their LD. The original design assumed that parents, as the main caregivers of their children, would have enough knowledge about how well they are able to cope and feel emotionally. We made this clear in the revised manuscript on page no. 3 line no. 115-122

 

 

(b)    If the children completed the questionnaires, how was this managed? Was a children’s version available? Or did a person sit with each child and read it to them and help them understand it?

Response 13b: No children completed questionnaires themselves, so there was no child version and also no need to clarify individual items were readable by children. Instead, questionnaires were completed by the child's parents or guardians (as described above) who responded based on their observations of the children's behavior and coping styles. We have added this clarification on page no 4 line 152-154

 

(c)    If the parents completed them, do you have any evidence that they are valid as parent proxy-report tools?

 

Response 13c: While the SF-12 and Brief COPE are standardly used as self-report instruments, some studies employed parent proxy-reports [1,2,3], especially in those targeting children with developmental or cognitive impairments. Although some bias may be present in parent-reported measures, using parent-reports is typical for pediatric research when children are too young or have cognitive impairments that prohibit reliable completion of self-report assessments. Research evidence [1, 2, 3] supporting the use of parent proxy-reports in similar contexts has been cited and reinforced within our revised manuscript on page no 3-line no. 115-122  

1. Jeanbert, E.; Baumann, C.; Todorović, A.; Tarquinio, C.; Rousseau, H.; Bourion-Bédès, S. Factors Associated with Discrepancy of Child-Adolescent/Parent Reported Quality of Life in the Era of COVID-19. Int. J. Environ. Res. Public Health 2022, 19, 14359.
2. Mack JW, McFatrich M, Withycombe JS, et al. Agreement Between Child Self-report and Caregiver-Proxy Report for Symptoms and Functioning of Children Undergoing Cancer Treatment. JAMA Pediatr. 2020;174(11):e202861.
3. Chang PC, Yeh CH. Agreement between child self-report and parent proxy-report to evaluate quality of life in children with cancer. Psychooncology. 2005 Feb;14(2):125-34.

 

 

14. Related to those questions, the English version of the brief-COPE is designed for adults (age 18+). If it was used for children in this study, what adaptations were made?

 

Response 14: In answer to a question of the reviewer about adaptations we can confirm that there was used not any special version of Brief COPE prepared for children under 18 years of age. But to apply the Brief COPE with children through parent proxy-reports [1,2], we targeted onto their concepts of how well they know what strategies and feelings come out from their child. This method had been previously validated through similar population surveys [3]. We have inserted a sentence in the methodology section indicating this modification on page no 3 line no. 115-122 

 

1. Mack JW, McFatrich M, Withycombe JS, et al. Agreement Between Child Self-report and Caregiver-Proxy Report for Symptoms and Functioning of Children Undergoing Cancer Treatment. JAMA Pediatr. 2020;174(11):e202861.
2. Chang PC, Yeh CH. Agreement between child self-report and parent proxy-report to evaluate quality of life in children with cancer. Psychooncology. 2005 Feb;14(2):125-34.
3. Alsaleem, SA, Al-qahtani^, AH, Al-qahtani^, EH, AlKhaldi, YM. Stressors and coping strategies among secondary school male students in Abha City, Saudi Arabia. Psychol., 2024, 15

 

RESULTS

 

15. It is unusual for all parents to agree to participate in a study. Did you have any decline? Please specify many in each group.

Response 15: Thanks, A total of 130 participants were agreed to participate in this study and 97 participants completed the survey with a 74.61% response rate. Missing data from 33 participants were not included in the study.

 

16. The finding that substance abuse was higher in LD is alarming. In the English version of the brief-COPE, the substance abuse items are “I've been using addictive behaviors or substances to make myself feel better.” and “I've been using alcohol or other drugs to help me get through it.” These items are intended for adults and so it is very surprising to have children (or parents on behalf of their children) answer yes to either of them. Was these positive responses restricted the adolescent age range? Do you know how participants interpreted these questions? For example, could the participants have been thinking of prescribed medications?

Response 16: We agreed with this insight, Actually data was collected in congenial atmosphere, and researchers made personal contacts with the families of these disabled children. Data was collected from the caregivers mostly parents and guardians along with their child. Response from children below 12 years of age was collected mostly from their parents and guardians. Children above 12 years responded most of the questions of the survey with the help of their guardian and researcher. Although, items related to substance abuse were asked/answered by the adolescents only as the participants interprets items related to substance abuse as normal medication

 

17. Please could you modify the heading to Table 5 to indicate that you controlled for demographic characteristics in this analysis? Something like: “Table 5. Impact of coping strategies on quality of life of children with learning disability, controlling for demographic characteristics (grade, family status, and monthly income).”

Response 17: thanks for this point, we had modified the heading of the table 5 as per your suggestion

 

DISCUSSION

 

I think the Discussion is good, and very interesting to read, but I am going to query a few specific statements made in it.

 

18. In the following sentence, should “healthy participants” be “children with LD”? “As expected, QOL using the SF-12 was poor in children with LD compared to healthy controls, which seems to be mostly consistent with previous findings in healthy participants [32,33,34,35].”

Response 18: Thanks, healthy participants in this study are normal children

 

19. The second sentence here doesn’t seem to follow logically from the first, because “substance use” and “religious coping strategies” are not a form of “problem-focused coping”: “Those with learning disabilities reported a higher reliance on substance use and religious coping strategies. These findings partially align with previous research [45], which found that children with learning disabilities tend to use problem-focused coping by seeking help and emotion-focused coping by managing frustration and compartmentalizing their disability.”

Response 19: Agreed, we apologize for this mistake, we had changed the sentence and reference, please see page 9, line 292-294 and reference 45

 

 

20. This section has a very interesting discussion of the differences in coping strategies between the two groups. A couple of further considerations might be included:

 

(a)     One is that when sociodemographic characteristics were controlled for, a lot of the differences between the groups disappeared, which suggests that the differences in coping strategies may be sociodemographic rather than LD-related.

Response 20a: We agreed that when sociodemographic characteristics were controlled for, and many differences between groups disappeared, it suggests that the variances in coping strategies might be more closely related to sociodemographic factors—such as age, gender, socioeconomic status, or cultural background—rather than the presence of learning disabilities (LD) themselves. Moreover, coping strategies employed by individuals can be significantly affected by their sociodemographic backgrounds. Factors like family income, education level, and social support can shape how individuals respond to stress, which means any observed differences in coping strategies may not be inherently linked to LD. If the differences in coping strategies are largely attributable to sociodemographic variables, interventions aimed at improving coping mechanisms might need to target these broader factors. Tailoring support and resources to address sociodemographic disparities could be beneficial for all individuals, including those with LD.

 

(b)    The other thing I wonder is whether different kinds of coping strategies are used for different levels of stress. For example, if the LD group are trying to cope with more difficult situations than the non-LD group, might that (partly) account for the differences? Is there any literature evidence on different coping strategies being used for different kinds of stress or different severities of stress? (For example, I could use distraction when I have a mild headache, but I would need to use different and much more active coping strategies if I fractured a bone, got expelled from school, or couldn’t get any friends.)

Response 20b: Agreed, yes, research indicates that different coping strategies are employed based on the type and severity of stress individuals experience. The literature often distinguishes between adaptive and maladaptive coping mechanisms and shows that individuals may choose different strategies based on their specific circumstances, including the intensity of the stressor and individual characteristics, such as learning disabilities (LD).

Studies have demonstrated that individuals facing high-severity stressors are more likely to use problem-focused coping strategies, such as seeking solutions, while those facing lower-severity stress may rely more on emotion-focused strategies, like avoidance or denial. For instance, Folkman and Moskowitz (2004) highlight the importance of context and suggest that individuals assess the relevance and impact of stress before selecting their coping strategies [1]. Other research indicates that individuals with learning disabilities may experience unique challenges that can influence their coping strategies. For example, they might face chronic academic stressors that require different coping mechanisms compared to their peers without learning disabilities. Previous research has indicated that seeking social support, problem-solving, physical activity, avoidance, engaging with social media, watching movies, and fostering relationships were common coping methods for psychological distress among people with disabilities [2, 3]

1. Folkman S, Moskowitz JT. Coping: pitfalls and promise. Annu Rev Psychol. 2004;55:745-74.
2. Deasy, C.; Coughlan, B.; Pironom, J.; Jourdan, D.; Mannix-McNamara, P. Psychological distress and coping amongst higher education students: a mixed method enquiry. PLoS ONE. 2014, 9(12), e115193.
3. Kim, J.; Han, A.; Piatt, J.A.; Kim, J. Investigating relationships among coping, personal growth, and life satisfaction among individuals with physical disabilities. Health Promot. Perspect. 2020, 10(4), 401-408

 

 

21. It might be going too far to say that, “this study provided a thorough understanding of the coping mechanisms that can enhance the quality of life of children with learning disability.” The study was useful in shedding light on coping mechanisms and QOL in children with LD, but more work is needed to gain a thorough understanding.

Response 22: Thanks, the statement that “this study provided a thorough understanding of the coping mechanisms that can enhance the quality of life of children with learning disabilities” may be considered an overstatement for several reasons:

While the study highlights important coping mechanisms and their impact on the quality of life (QOL) for children with learning disabilities (LD), the term "thorough understanding" implies a comprehensive exploration that typically requires extensive longitudinal studies or diverse methodologies. If the research is limited in scope, such as a small sample size or a singular approach, it may not capture the full complexity of the issue.

Learning disabilities are multifaceted, influenced by various factors including cognitive, emotional, social, and environmental aspects. Our study primarily focuses on a few coping mechanisms might overlook other significant variables that contribute to a child's overall quality of life. Thus, a "thorough understanding" would necessitate a more holistic exploration of these complexities. Moreover, the findings from a single study may not be applicable to all children with LD. Variability in individual experiences, types of learning disabilities, and social circumstances means that what works for one group might not be effective for another. Broadening the research to include diverse populations will strengthen the understanding of how coping mechanisms impact QOL. Furthermore, understanding coping mechanisms and their influence on QOL may benefit from interdisciplinary approaches that incorporate psychological, educational, and sociocultural perspectives. A study that does not engage with these different dimensions may present a limited view.

In summary, while the study provides valuable insights into coping mechanisms and their potential impacts on the quality of life for children with learning disabilities, the complexities of the topic and the need for further exploration prevent it from delivering a "thorough understanding." Recognizing these limitations fosters a more realistic view of the findings and encourages continued research in this important area.

 

22. I’m also not sure that it’s valid to claim that, “it also highlights the significance of promoting adaptive coping strategies and addressing maladaptive coping strategies to improve the quality of life of children with learning disability.” This was a cross-sectional design, and therefore unable to unravel cause and effect. It is reasonable to suggest that the kind of coping strategies used might affect QOL, but QOL might also affect the choice of coping strategies, or other factors (e.g. some of those sociodemographic variables) might enter into the equation.

Response 22: Your concerns about coping strategies and quality of life (QOL) in a cross-sectional study are valid. Here’s a justification for your points:

Cross-sectional studies capture data at a single point in time, which means they can identify associations but cannot establish causal relationships. While it's reasonable to suggest that adaptive coping strategies might improve QOL, the reverse could also be true—higher QOL might influence the adoption of more effective coping strategies. The relationship between coping strategies and QOL is likely bidirectional. For example, children with better QOL may naturally gravitate towards adaptive strategies, while those using maladaptive strategies may experience lower QOL. This interplay complicates any assertion of direct causation. Moreover, the influence of sociodemographic variables: age, gender, socioeconomic status, or cultural background can significantly impact both coping strategies and QOL. These sociodemographic variables might confound the relationship, making it essential to consider them when interpreting results.

To better understand how coping strategies affect QOL (and vice versa), longitudinal studies are needed. These studies can track changes over time and help clarify the directionality of the relationships involved.

 

23. I don’t think it’s true that “the results indicated that elementary school children were at a high risk of LD”. To determine this, you would need to get a sample of elementary school children, and then test them all to find out how many had LD. Instead, you found that in your sample there were more elementary school children in the LD group than in the comparison group. That shows that the comparison group was not matched to the LD group in terms of grade level. But it doesn’t tell you anything about prevalence of LD among elementary school children.

Response 23: Thank you for your comment regarding our findings. We agree that establishing prevalence requires a representative sample of elementary school children, which we did not explicitly conduct in this study. The observed difference in the number of children with learning disabilities (LD) between our groups does suggest a potential mismatch in grade levels, rather than a direct assessment of prevalence. To address this concern, we had clarify in our manuscript that our results reflect a comparison between groups rather than an assessment of overall prevalence in the elementary school population. We appreciate your insights and will ensure that our discussion accurately reflects the limitations of our current study while emphasizing the necessity for further investigation in this area.

 

 

24. Among the limitations, please consider the non-equivalence of the two groups on sociodemographic variables and the suitability of the instruments for children. Also limitations of self-report or parent-proxy report (whichever was used) for these questionnaires.

Response 24: Agreed. We already highlighted the issues of parents-proxy reporting in the limitations section. We attempted to match participants based on demographic criteria such as age, location, and ethnicity. However, we were unable to match siblings or family members, which may impact the results added to limitations. Added the explanation of the applicability of the instrument too (page no. 12, line 432-436).

 

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The subject of the article refers to an important issue, important both from the perspective of medicine and pedagogy. The authors emphasize that their research is pioneering in Saudi Arabia, which is worth emphasizing. In terms of methodology, the research was conducted correctly. The analysis of the results was also performed adequately to the obtained research material. The authors should also be praised for being aware of the limitations related to the implemented research project, which they write about in the final part of the "Discussion" section. Nevertheless, the article contains certain gaps and shortcomings that require correction and supplementation:

1. Due to the fact that the research was de facto conducted in a group of parents and caregivers of children with learning disabilities, the authors should signal this in the title of the article. Therefore, I propose the following title: "Quality of Life and Coping Strategies in Children with Learning Disabilities from the Perspective of Their Parents and Caregivers: A Case Control Study". In the proposed version, the title of the article would be more adequate to its content.

2. The age range of the children assessed seems to be too wide. It is not appropriate to classify 6-year-old children and 18-year-old adolescents into the same group, regardless of whether they have learning difficulties or not, because they attend different types of schools, which have different requirements and criteria for assessing academic performance. Therefore, the authors should provide more detailed justification for the criteria for inclusion in the research group.

3. On page 3 (lines 99-100) the authors stated that “The control group included 89 normative controls who satisfied the inclusion and exclusion criteria”, but these criteria were not formulated separately for them.

After making appropriate corrections and additions, I support the publication of the reviewed article.

Author Response

Children with Learning Disabilities’ Quality of Life and Coping Strategies: A Case Control Study

Response to Reviewer 2 Comments and Responses
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted in Green Colour in the re-submitted files

The subject of the article refers to an important issue, important both from the perspective of medicine and pedagogy. The authors emphasize that their research is pioneering in Saudi Arabia, which is worth emphasizing. In terms of methodology, the research was conducted correctly. The analysis of the results was also performed adequately to the obtained research material. The authors should also be praised for being aware of the limitations related to the implemented research project, which they write about in the final part of the "Discussion" section. Nevertheless, the article contains certain gaps and shortcomings that require correction and supplementation:

1. Due to the fact that the research was de facto conducted in a group of parents and caregivers of children with learning disabilities, the authors should signal this in the title of the article. Therefore, I propose the following title: "Quality of Life and Coping Strategies in Children with Learning Disabilities from the Perspective of Their Parents and Caregivers: A Case Control Study". In the proposed version, the title of the article would be more adequate to its content.

 

Response 1: Agreed to change the title as follows based on both Reviewers’ comments:

 

“Quality of Life and Coping Strategies in Children with and without learning disabilities from the Perspective of Their Parents and Caregivers”

 

 It is changed in the revised version, Please see the Title page

 

2. The age range of the children assessed seems to be too wide. It is not appropriate to classify 6-year-old children and 18-year-old adolescents into the same group, regardless of whether they have learning difficulties or not, because they attend different types of schools, which have different requirements and criteria for assessing academic performance. Therefore, the authors should provide more detailed justification for the criteria for inclusion in the research group.

Response 2: We agreed with this point

Inclusion Criteria

1. Age Range (6–18 years):
   • The study focuses on children diagnosed with learning disabilities (LD). The age range of 6 to 18 years is chosen because it corresponds to the typical school age during which learning disabilities are most commonly identified and have a substantial impact on academic performance and social development.
   • Justification: This age range encompasses a developmental period where children are engaged in formal education, making it easier to assess learning difficulties in structured environments. Children below 6 years may not have been formally assessed for LD, and those above 18 might be beyond school-based evaluations, making the sample more homogenous and relevant to the research question.

Exclusion Criteria

1. Organic and Functional Disorders:
   • Children with organic (e.g., brain injury) or functional disorders (e.g., psychiatric conditions) were excluded from the study.
   • Justification: Organic and functional disorders can affect cognitive functions and learning capabilities independently of learning disabilities. Including children with such conditions could introduce confounding variables, as their learning challenges may not stem from learning disabilities alone. Excluding them ensures that the study isolates the effects of LD and prevents dilution of results by other conditions that might affect learning outcomes.
2. Children Under the Age of 6 and Over the Age of 18:
   • Participants younger than 6 and older than 18 were excluded.
   • Justification: Children under 6 years may not yet exhibit clear signs of learning disabilities or have undergone formal education sufficient to assess LD accurately. On the other hand, those over 18 may have completed formal schooling and be less representative of the primary age group targeted by the research. This criterion helps to maintain a focus on school-age children where LD is most diagnostically relevant.

 

3. On page 3 (lines 99-100) the authors stated that “The control group included 89 normative controls who satisfied the inclusion and exclusion criteria”, but these criteria were not formulated separately for them.

 

Response 3: Agreed: The inclusion and exclusion criteria for the control group are designed to select a population of children who are age-matched from 6-18 years, free from learning disabilities, and without other cognitive or developmental impairments. This helps create a baseline normative group that can be compared to children with LD, ensuring that differences between the two groups are attributable to learning disabilities rather than other confounding variables. Added to the method section, please see page 3, line 98-103

After making appropriate corrections and additions, I support the publication of the reviewed article.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

This is the second round of review of a cross-sectional survey of children with learning disability (LD), comparing their quality of life and coping strategies with a comparison group.

In my first review, I commended the authors on the care with which they executed this study and on the readability of the paper. I made quite a lot of recommendations and the authors have addressed most of them. There are still a few outstanding queries, particularly in the Discussion, where the authors have apparently agreed with my suggestions but not made changes to the paper.

MY PREVIOUS POINT 7: LD – US OR UK DEFINITION?

Thank you for explaining that it’s the US definition. In that case, it would be helpful to say (under “Participants” that children with intellectual disability were excluded.

LAST SENTENCE OF THE PARTICIPANTS SECTION

“The children without disabilities were 89 also satisfied the inclusion and exclusion criteria.” Should this say something like: “The children without disabilities also satisfied the inclusion and exclusion criteria.”?

MATCHING OF THE COMPARISON GROUP

In your response to me, you explained that you matched the two groups on certain demographic factors. I think you should mention this in the Methods.

RESPONSE RATE

You mentioned in your answer to me that “A total of 130 participants were agreed to participate in this study and 97 participants completed the survey with a 74.61% response rate. Missing data from 33 participants were not included in the study.” I think this information should be included in the paper. Also, whatever was the response rate in the comparison group.

RESPONSES TO SUBSTANCE ABUSE ITEMS

I expressed surprise at the higher rates of substance abuse was among children with LD because, in the English version of the brief-COPE, the substance abuse items are “I've been using addictive behaviors or substances to make myself feel better.” and “I've been using alcohol or other drugs to help me get through it.” I can hardly imagine children doing this in any country, but particularly in a Muslim country, where alcohol abuse must be extremely low.

You answered that “items related to substance abuse were asked/answered by the adolescents only as the participants interprets items related to substance abuse as normal medication”. Do you mean that only adolescents gave positive responses to these questions? Can you provide an age breakdown? And do you have any evidence that they understood this question as referring to “normal medication”? Do you know what kinds of medications? The result is so surprising that I think there should be a more indepth analysis of it in the paper.

DISCUSSION OF WHETHER DIFFERENCES ARE DUE TO SOCIODEMOGRAPHIC FACTORS

I suggested that the differences in coping strategies may be sociodemographic rather than LD-related because they disappeared when sociodemographic characteristics were controlled for. You gave me a very good response (which I’ll paste below), but as far as I can see, none of this appears in the paper (at least it isn’t highlighted). I think at least some of this should appear in the Discussion.

“We agreed that when sociodemographic characteristics were controlled for, and many differences between groups disappeared, it suggests that the variances in coping strategies might be more closely related to sociodemographic factors—such as age, gender, socioeconomic status, or cultural background—rather than the presence of learning disabilities (LD) themselves. Moreover, coping strategies employed by individuals can be significantly affected by their sociodemographic backgrounds. Factors like family income, education level, and social support can shape how individuals respond to stress, which means any observed differences in coping strategies may not be inherently linked to LD. If the differences in coping strategies are largely attributable to sociodemographic variables, interventions aimed at improving coping mechanisms might need to target these broader factors. Tailoring support and resources to address sociodemographic disparities could be beneficial for all individuals, including those with LD.”

DISCUSSION OF DIFFERENT COPING STRATEGIES FOR DIFFERENT STRESSORS

I asked whether different kinds of coping strategies are used for different levels of stress. Again, you gave me an excellent response, but I cannot see this in the Discussion. I think you should include some of this in your Discussion (with the references you’ve given).

“Agreed, yes, research indicates that different coping strategies are employed based on the type and severity of stress individuals experience. The literature often distinguishes between adaptive and maladaptive coping mechanisms and shows that individuals may choose different strategies based on their specific circumstances, including the intensity of the stressor and individual characteristics, such as learning disabilities (LD).

Studies have demonstrated that individuals facing high-severity stressors are more likely to use problem-focused coping strategies, such as seeking solutions, while those facing lower-severity stress may rely more on emotion-focused strategies, like avoidance or denial. For instance, Folkman and Moskowitz (2004) highlight the importance of context and suggest that individuals assess the relevance and impact of stress before selecting their coping strategies [1]. Other research indicates that individuals with learning disabilities may experience unique challenges that can influence their coping strategies. For example, they might face chronic academic stressors that require different coping mechanisms compared to their peers without learning disabilities. Previous research has indicated that seeking social support, problem-solving, physical activity, avoidance, engaging with social media, watching movies, and fostering relationships were common coping methods for psychological distress among people with disabilities [2, 3]”

A THOROUGH UNDERSTANDING

I queried the statement that said the study provided a thorough understanding of the coping mechanisms that can enhance the quality of life of children with learning disability. In your response, you seem to agree with me, and yet the statement still appears in the paper. I think it should be moderated.

STATEMENT ABOUT CAUSE AND EFFECT

I queried the statement that said, “It also highlights the significance of promoting adaptive coping strategies and addressing maladaptive coping strategies to improve the quality of life of children with learning disability” on the grounds that this is a cross-sectional design which cannot be used to draw conclusions about cause and effect. Again, you seem to agree with me in your response to reviewer, but the statement is still in the Discussion.

ELEMENTARY CHILDREN AT HIGH RISK

Again, I queried the statement saying that “the results indicated that elementary school children were at a high risk of LD”. Again, you appear to agree with me in your response to reviewer, but the statement has not been removed or modified in the paper.

 

Author Response

Please find enclosed our responses to Reviewer - 1 comments for Round 2. 

Author Response File: Author Response.docx

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

This is the third round of review of this cross-sectional survey of children with learning disability (LD), comparing their quality of life and coping strategies with a comparison group without LD.

The authors have clarified all of my queries. My only remaining suggestion is to enlarge the discussion of the responses to the substance abuse items a little bit, as follows: (I will add my addition in CAPITAL LETTERS, as I can’t use tracking or highlighting here):

“A significant point here is that Saudi Arabia has relatively low rates of drug and alcohol usage. Although cultural attitudes may influence how these items are understood, SUBSEQUENT CONVERSATIONS WITH PARTICIPANTS INDICATED that some of the teenagers and their parents/caretakers in our study interpreted the Brief-COPE items on substance use in relation to PRESCRIBED AND OVER-THE-COUNTER medications rather than illegal substances. IT SHOULD ALSO BE NOTED THAT ALL CHILDREN BELOW 13 YEARS OF AGE SCORED ZERO FOR BOTH SUBSTANCE ABUSE ITEMS.”

I think it’s good you’ve added in the details about translation in the Methods. I should have asked you about that. The use of 2 translators and the back-translation shows how careful you were.

Author Response

Comments:

This is the third round of review of this cross-sectional survey of children with learning disability (LD), comparing their quality of life and coping strategies with a comparison group without LD.

The authors have clarified all of my queries. My only remaining suggestion is to enlarge the discussion of the responses to the substance abuse items a little bit, as follows: (I will add my addition in CAPITAL LETTERS, as I can’t use tracking or highlighting here):

“A significant point here is that Saudi Arabia has relatively low rates of drug and alcohol usage. Although cultural attitudes may influence how these items are understood, SUBSEQUENT CONVERSATIONS WITH PARTICIPANTS INDICATED that some of the teenagers and their parents/caretakers in our study interpreted the Brief-COPE items on substance use in relation to PRESCRIBED AND OVER-THE-COUNTER medications rather than illegal substances. IT SHOULD ALSO BE NOTED THAT ALL CHILDREN BELOW 13 YEARS OF AGE SCORED ZERO FOR BOTH SUBSTANCE ABUSE ITEMS.”

I think it’s good you’ve added in the details about translation in the Methods. I should have asked you about that. The use of 2 translators and the back-translation shows how careful you were.

Responses:

We appreciate you once more providing insightful feedback and suggestions for improving our manuscript. Added the suggested part on page no.09 and line no. 298 – 304 in light blue color.

Author Response File: Author Response.docx