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Volume 11, Issue 4 (2023)
Health Educ Health Promot 2023, 11(4): 549-553 |
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Received: 2023/08/20 | Accepted: 2023/10/21 | Published: 2023/10/29
Received: 2023/08/20 | Accepted: 2023/10/21 | Published: 2023/10/29
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Sharif F, Johari Fard R, Borna M. The Effectiveness of Metacognitive Knowledge and Skills Program on Visual and Auditory Dyslexia in Students with Learning Disabilities. Health Educ Health Promot 2023; 11 (4) :549-553
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1- Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran
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Introduction
Learning disabilities are among neurodevelopmental disorders, including dyslexia or learning disorders characterized by reading difficulties [1]. Dyslexia refers to unexpected reading difficulties in individuals with cognitive abilities for better reading. It is mainly caused by challenges in processing phonemes, affecting an individual's speaking, reading, and spelling abilities [2]. Dyslexia is classified into different subtypes. The main subtypes include visual dyslexia and auditory dyslexia [3]. Visual dyslexia pertains to the condition where an individual can pronounce words, but he/she has difficulties in pronouncing words with different pronunciations from their written forms. In contrast, auditory dyslexia involves problems identifying vowel sounds within words and connecting letters to sounds [4, 5].
Structural ideas have influenced recent important innovations in reading and mathematics in elementary schools and have shed light on factors, like metacognition [6]. Metacognition refers to thinking about thinking and encompasses knowledge about the factors influencing task performance and awareness of strategies [7]. This includes metacognitive regulation processes, such as planning and monitoring task performance and evaluating the effectiveness of these strategies and monitoring processes [8]. Consequently, metacognitive processes are the aspect, through which students can significantly affect their learning process, allowing them to engage in multiple tasks simultaneously [9].
Metacognitive awareness is considered a crucial factor contributing to the success of students' learning [10]. One of the major challenges faced by dyslexic children is difficulty comprehending content due to their struggles in understanding words and sentences, necessitating the effective use of cognitive and self-regulatory (metacognitive) structures. Furthermore, research on reading and metacognition has shown that individuals with better reading abilities possess higher metacognitive knowledge than those with weaker reading skills [11]. Hence, various metacognitive programs and interventions have been designed for students, e.g., the Jager method [12].
Jager metacognition is the process, in which learners engage in thinking about their thinking and develop strategies for problem-solving. These processes encompass sub-constructs, such as planning, self-reflection, self-awareness, and cognitive strategies [13, 14]. Furthermore, cognitive and metacognitive strategies are goal-directed, consciously activated, and encourage students' efforts [15]. This educational program focuses on enhancing and correcting metacognitive knowledge and skills. It is believed that increasing metacognitive knowledge through simultaneous reading, providing self-feedback, and enhancing metacognitive skills, such as correcting predictions, attention control, identifying real problems, and defining them can improve learning difficulties and aid dyslexic children's progress [16]. These educational programs focus on supervisory and reflective skills for teaching metacognitive skills. The belief is that students will succeed when they have mastered extended cognitive and metacognitive strategies; otherwise, learning tasks will remain unresolved [17, 18].
Students are taught skills, such as thinking about the subject of study, revising their predictions, controlling their attention and focus, concentrating on the subject matter, identifying the actual problem, and defining and limiting it in metacognitive strategy instruction programs [19]. According to the literature, the Jager metacognitive approach effectively enhances neuropsychological performance among dyslexic students [20]. Sen [21] demonstrated that metacognitive strategy instruction improves and increases students' comprehension. Moreover, Schaeffner et al. [22] reported that employing such strategies for dyslexic children may improve their skills.
Considering the challenges of dyslexia, its slow progress among these students, and the resulting problems, it appears essential to adopt an instructional approach aligned with the fundamental needs of these children. Therefore, given the various significant challenges faced by dyslexic children, it is imperative to explore new methods to address dyslexia-related problems. Accordingly, the present study aimed to investigate the effectiveness of the Jager metacognitive knowledge and skills program on visual and auditory dyslexia in students with learning disabilities.
Materials and Methods
This study employed a semi-experimental design with a pre-test-post-test approach and a control group. Required data were collected through questionnaires. The study population consisted of all second- and third-grade elementary school students with learning disabilities in Tehran who were supervised in educational centers. A total of 30 students with dyslexia were selected by purposive sampling, of whom 15 cases were randomly assigned to the Jager method group and 15 to the control group. The sample size was selected using the G*Power software with a test power of 0.90, a significance level of 0.05, and an effect size of 0.76. The inclusion criteria were being second- and third-grade elementary students diagnosed with dyslexia, absence of intellectual and developmental disorders according to DSM-5, attending learning disability centers, not taking psychiatric medications, and parental consent to participate in the educational program. The exclusion criteria were simultaneous participation in other group educational programs or receiving concurrent treatments, initiation of psychiatric medication during the study period, being absent more than one session in the experimental group, and the lack of participation and cooperation in the training exercises of the sessions.
Procedure
The study was implemented in the following steps. After selecting participants and randomly assigning them to the experimental and control groups, a pre-test was administered to both groups. Subsequently, the Jager method was conducted for the experimental group over eight 45-minute sessions, with one session per week. However, the control group did not receive this program. After completing the intervention sessions for both groups, an individual post-test was administered, and the pre-test and post-test results were compared between the groups.
Educational intervention
The educational intervention in this study consisted of the Jager method delivered to the experimental group of students over eight 45-minute sessions. The control group participants only received regular classroom instruction during the intervention period. This program was designed to teach metacognitive knowledge and skills to elementary school students and included two phases executed collaboratively by the researcher and teachers. The educational program sessions are summarized as follows: In sessions one to five, questions were posed to assess the student's level of metacognitive knowledge. The questions for these sessions were as follows: Session one: What is the best thing to do before reading a text? Session two: What is the best thing to do while reading a text? Session three: What is the best thing to do after reading a text to assess whether you understood the text well? Session four: What is the best thing to do when you do not understand a sentence? Session five: What is the best thing to do when you do not understand a part of the text? Instruction and practice were provided for metacognitive skills in sessions six to eight. In the sixth session, the necessary metacognitive skills before reading a text were taught and practiced. In the seventh session, metacognitive skills required while reading a text were taught and practiced. Finally, in the eighth session, metacognitive skills needed after reading a text were taught and practiced.
Research tools
The Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV): The fourth edition of the WISC, developed in 2003, assesses the intelligence of children aged 6 to 16 and comprises four indices: verbal comprehension, perceptual reasoning, working memory, and processing speed. The overall IQ has a validity of 0.97, the verbal comprehension index has a validity of 0.85, and the perceptual reasoning index has a validity of 0.70 [23]. The verbal comprehension and perceptual reasoning indices were used in this study to assess visual dyslexia and auditory dyslexia, respectively.
Data analysis
Descriptive analysis was employed to calculate means and standard deviations, while inferential analysis using analysis of covariance (ANCOVA) was used to analyze the data at an inferential level. The Kolmogorov-Smirnov test was used to check the normality of data distribution, and Levene's test was used to check the equality of variances. Data were analyzed using SPSS 23 software.
Findings
As shown in Table 1, the mean scores of visual dyslexia and auditory dyslexia in the experimental group were lower than those in the control group. In other words, the Jager method reduced visual dyslexia in the experimental group.
Table 1. Mean and standard deviation of research variables in experimental and control groups
![src=./files/hehp/images/HTML_Publish/71175/71175-T_1.png]()
The results of the Kolmogorov–Smirnov test indicated that the assumption of normality of data distribution in visual dyslexia and auditory dyslexia was maintained in the experimental and control groups in the pre-test and post-test phases (p>0.05). The results of Levene's test showed that the assumption of equality of variances in both variables was confirmed in both stages of the research (p>0.05). Data were analyzed using ANCOVA, and the results are reported in Table 2. The findings of the multivariate ANCOVA revealed significant differences between the experimental and control groups in terms of dependent variables (p<0.001). Therefore, it can be stated that there was a significant difference between the two groups in at least one of the dependent variables (visual dyslexia and auditory dyslexia).
Considering the results of Table 2, it can be concluded that the Jager program effectively reduced visual dyslexia (F=33.18, p=0.027) and auditory dyslexia (F=56.16, p=0.001) in students with learning disabilities.
Table 2. The results of analysis of covariance on visual dyslexia and auditory dyslexia in the experimental and control groups
![src=./files/hehp/images/HTML_Publish/71175/71175-T_2.png]()
Discussion
This study aimed to investigate the effectiveness of the Jager method on visual and auditory dyslexia in students with learning disabilities. The results demonstrated that the Jager method reduced visual dyslexia and auditory dyslexia in the post-test phase in the experimental group compared to the control group. In other words, the Jager metacognitive program effectively enhanced the knowledge and skills of students with learning disabilities. Consistent with the results of the present study, Narimani et al. [14] reported that the Jager method had a positive effect on improving the reading performance of students with dyslexia. Moreover, Moradi and Mirbod [20] reported that the Jager method was effective in improving the neuropsychological performance of dyslexic students.
The deficiency in metacognitive knowledge and skills is one of the challenges faced by students with learning disabilities in reading [24]. The Jager method is designed in a way that first teaches metacognitive knowledge to students, then imparts metacognitive skills for reading, and finally, guides them to practice reading [12]. From another perspective, in the Jager method, students with learning disabilities learn to think about the text and its purpose before reading it. Then, they learn to monitor their understanding while reading a text (simultaneously monitor reading comprehension), and finally, they learn to provide self-feedback after reading [20]. Moradi and Mirbod [20] reported that metacognitive approaches can improve neuropsychological skills by organizing the brain, and the improvement of these skills will lead to an increase in academic skills, including reading. From this standpoint, it can be concluded that the Jager method effectively improves the metacognitive knowledge and skills and enhances the reading performance of students with learning disabilities. Reading is a complex cognitive process involving various skills, including comprehension, cognition, knowledge, and metacognitive skills. These skills will be effective when there is a balance between them [14]. Narimani et al. [14] reported that the Jager method increases metacognitive and cognitive skills in students with learning disabilities. Dyslexia is a problem related to information processing, and since the Jager method improves cognitive and metacognitive skills, it plays an effective role in the learning process [20]. Therefore, the Jager method can play a key role in providing effective strategies to solve their problems.
Cognitive deficit is one of the most significant factors contributing to the likelihood of developing reading difficulties. The Jager method can be applied to various aspects of reading, including eye movements, language processing, working memory, retrieval skills, and automatization [25]. Evidence suggests that dyslexia may result from multiple risk factors, and children with a wide range of cognitive and sensory-motor deficits are more susceptible to reading problems [26]. The Jager method is implicated in language and cognitive skill aspects, including specialized engagement in reading. The literature indicates that the Jager method promotes progress in skill acquisition, including reading [14]. The Jager method is effective in all cognitive processes and continues to capture attention in mental activities. Precision or attention is a fundamental mental activity that enables an individual to maintain an accurate cognitive and behavioral readiness in the face of a stimulus or prolonged activity, acquire necessary information, and provide the required response [20]. Narimani et al. [14] reported that the Jager method is designed in such a way that first the student is taught metacognitive knowledge, then metacognitive skills are taught in reading the text, and then the student practices reading the text. Therefore, the Jager method provides suitable opportunities for active engagement with various sensory inputs from the environment. Purposeful motor behaviors contribute to improving performance and lead to the enhancement of cognitive skills, including attention. Implementing such interventions can prevent the emergence of psychological issues like depression and anxiety resulting from adverse conditions and effectively address these problems [14].
One of our limitations was conducting the research only on the second- and third-grade students; thus, caution should be taken in generalizing the results to other grades. Also, it was not possible to measure the effect of each subject of therapeutic-educational sessions separately.
Conclusion
The Jager method is applicable for enhancing the reading performance of children with learning disabilities. Many reading difficulties among dyslexic students stem from a lack of attention because the process of developing accuracy and attention in dyslexic children is slow and delayed. Consequently, inadequate attention can render an individual's learning vulnerable. Therefore, educators in schools using the Jager method must address the necessary prerequisites of accuracy and attention for reading. It is recommended that the Jager method be implemented for all school students. Considering the limited awareness of teachers regarding the Jager method, a training course should be organized as part of in-service programs for teachers. Additionally, parent-teacher meetings should harness the potential of families to further enhance the effectiveness of the Jager method in this regard. Students with dyslexia should be identified at the beginning of their school attendance, and the Jager method should be implemented to address this deficiency.
Acknowledgments: This article was extracted from a part of the PhD dissertation of Mrs. Sharif at the Islamic Azad University, Ahvaz Branch, Iran. The authors would like to appreciate the collaboration of all students and their parents in the present study.
Ethical Permissions: The Ethics Review Board of Islamic Azad University, Ahvaz branch, approved the present study (code: IR.IAU.AHVAZ.REC.1400.158).
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Sharif F (First Author), Introduction Writer/Methodologist/Original Researcher/Discussion Writer/Statistical Analyst (35%); Johari Fard R (Second Author), Methodologist/Assistant Researcher/Discussion Writer (35%); Borna MR (Third Author), Assistant Researcher/Discussion Writer/Statistical Analyst (30%)
Funding/Support: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Learning disabilities are among neurodevelopmental disorders, including dyslexia or learning disorders characterized by reading difficulties [1]. Dyslexia refers to unexpected reading difficulties in individuals with cognitive abilities for better reading. It is mainly caused by challenges in processing phonemes, affecting an individual's speaking, reading, and spelling abilities [2]. Dyslexia is classified into different subtypes. The main subtypes include visual dyslexia and auditory dyslexia [3]. Visual dyslexia pertains to the condition where an individual can pronounce words, but he/she has difficulties in pronouncing words with different pronunciations from their written forms. In contrast, auditory dyslexia involves problems identifying vowel sounds within words and connecting letters to sounds [4, 5].
Structural ideas have influenced recent important innovations in reading and mathematics in elementary schools and have shed light on factors, like metacognition [6]. Metacognition refers to thinking about thinking and encompasses knowledge about the factors influencing task performance and awareness of strategies [7]. This includes metacognitive regulation processes, such as planning and monitoring task performance and evaluating the effectiveness of these strategies and monitoring processes [8]. Consequently, metacognitive processes are the aspect, through which students can significantly affect their learning process, allowing them to engage in multiple tasks simultaneously [9].
Metacognitive awareness is considered a crucial factor contributing to the success of students' learning [10]. One of the major challenges faced by dyslexic children is difficulty comprehending content due to their struggles in understanding words and sentences, necessitating the effective use of cognitive and self-regulatory (metacognitive) structures. Furthermore, research on reading and metacognition has shown that individuals with better reading abilities possess higher metacognitive knowledge than those with weaker reading skills [11]. Hence, various metacognitive programs and interventions have been designed for students, e.g., the Jager method [12].
Jager metacognition is the process, in which learners engage in thinking about their thinking and develop strategies for problem-solving. These processes encompass sub-constructs, such as planning, self-reflection, self-awareness, and cognitive strategies [13, 14]. Furthermore, cognitive and metacognitive strategies are goal-directed, consciously activated, and encourage students' efforts [15]. This educational program focuses on enhancing and correcting metacognitive knowledge and skills. It is believed that increasing metacognitive knowledge through simultaneous reading, providing self-feedback, and enhancing metacognitive skills, such as correcting predictions, attention control, identifying real problems, and defining them can improve learning difficulties and aid dyslexic children's progress [16]. These educational programs focus on supervisory and reflective skills for teaching metacognitive skills. The belief is that students will succeed when they have mastered extended cognitive and metacognitive strategies; otherwise, learning tasks will remain unresolved [17, 18].
Students are taught skills, such as thinking about the subject of study, revising their predictions, controlling their attention and focus, concentrating on the subject matter, identifying the actual problem, and defining and limiting it in metacognitive strategy instruction programs [19]. According to the literature, the Jager metacognitive approach effectively enhances neuropsychological performance among dyslexic students [20]. Sen [21] demonstrated that metacognitive strategy instruction improves and increases students' comprehension. Moreover, Schaeffner et al. [22] reported that employing such strategies for dyslexic children may improve their skills.
Considering the challenges of dyslexia, its slow progress among these students, and the resulting problems, it appears essential to adopt an instructional approach aligned with the fundamental needs of these children. Therefore, given the various significant challenges faced by dyslexic children, it is imperative to explore new methods to address dyslexia-related problems. Accordingly, the present study aimed to investigate the effectiveness of the Jager metacognitive knowledge and skills program on visual and auditory dyslexia in students with learning disabilities.
Materials and Methods
This study employed a semi-experimental design with a pre-test-post-test approach and a control group. Required data were collected through questionnaires. The study population consisted of all second- and third-grade elementary school students with learning disabilities in Tehran who were supervised in educational centers. A total of 30 students with dyslexia were selected by purposive sampling, of whom 15 cases were randomly assigned to the Jager method group and 15 to the control group. The sample size was selected using the G*Power software with a test power of 0.90, a significance level of 0.05, and an effect size of 0.76. The inclusion criteria were being second- and third-grade elementary students diagnosed with dyslexia, absence of intellectual and developmental disorders according to DSM-5, attending learning disability centers, not taking psychiatric medications, and parental consent to participate in the educational program. The exclusion criteria were simultaneous participation in other group educational programs or receiving concurrent treatments, initiation of psychiatric medication during the study period, being absent more than one session in the experimental group, and the lack of participation and cooperation in the training exercises of the sessions.
Procedure
The study was implemented in the following steps. After selecting participants and randomly assigning them to the experimental and control groups, a pre-test was administered to both groups. Subsequently, the Jager method was conducted for the experimental group over eight 45-minute sessions, with one session per week. However, the control group did not receive this program. After completing the intervention sessions for both groups, an individual post-test was administered, and the pre-test and post-test results were compared between the groups.
Educational intervention
The educational intervention in this study consisted of the Jager method delivered to the experimental group of students over eight 45-minute sessions. The control group participants only received regular classroom instruction during the intervention period. This program was designed to teach metacognitive knowledge and skills to elementary school students and included two phases executed collaboratively by the researcher and teachers. The educational program sessions are summarized as follows: In sessions one to five, questions were posed to assess the student's level of metacognitive knowledge. The questions for these sessions were as follows: Session one: What is the best thing to do before reading a text? Session two: What is the best thing to do while reading a text? Session three: What is the best thing to do after reading a text to assess whether you understood the text well? Session four: What is the best thing to do when you do not understand a sentence? Session five: What is the best thing to do when you do not understand a part of the text? Instruction and practice were provided for metacognitive skills in sessions six to eight. In the sixth session, the necessary metacognitive skills before reading a text were taught and practiced. In the seventh session, metacognitive skills required while reading a text were taught and practiced. Finally, in the eighth session, metacognitive skills needed after reading a text were taught and practiced.
Research tools
The Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV): The fourth edition of the WISC, developed in 2003, assesses the intelligence of children aged 6 to 16 and comprises four indices: verbal comprehension, perceptual reasoning, working memory, and processing speed. The overall IQ has a validity of 0.97, the verbal comprehension index has a validity of 0.85, and the perceptual reasoning index has a validity of 0.70 [23]. The verbal comprehension and perceptual reasoning indices were used in this study to assess visual dyslexia and auditory dyslexia, respectively.
Data analysis
Descriptive analysis was employed to calculate means and standard deviations, while inferential analysis using analysis of covariance (ANCOVA) was used to analyze the data at an inferential level. The Kolmogorov-Smirnov test was used to check the normality of data distribution, and Levene's test was used to check the equality of variances. Data were analyzed using SPSS 23 software.
Findings
As shown in Table 1, the mean scores of visual dyslexia and auditory dyslexia in the experimental group were lower than those in the control group. In other words, the Jager method reduced visual dyslexia in the experimental group.
Table 1. Mean and standard deviation of research variables in experimental and control groups
The results of the Kolmogorov–Smirnov test indicated that the assumption of normality of data distribution in visual dyslexia and auditory dyslexia was maintained in the experimental and control groups in the pre-test and post-test phases (p>0.05). The results of Levene's test showed that the assumption of equality of variances in both variables was confirmed in both stages of the research (p>0.05). Data were analyzed using ANCOVA, and the results are reported in Table 2. The findings of the multivariate ANCOVA revealed significant differences between the experimental and control groups in terms of dependent variables (p<0.001). Therefore, it can be stated that there was a significant difference between the two groups in at least one of the dependent variables (visual dyslexia and auditory dyslexia).
Considering the results of Table 2, it can be concluded that the Jager program effectively reduced visual dyslexia (F=33.18, p=0.027) and auditory dyslexia (F=56.16, p=0.001) in students with learning disabilities.
Table 2. The results of analysis of covariance on visual dyslexia and auditory dyslexia in the experimental and control groups
Discussion
This study aimed to investigate the effectiveness of the Jager method on visual and auditory dyslexia in students with learning disabilities. The results demonstrated that the Jager method reduced visual dyslexia and auditory dyslexia in the post-test phase in the experimental group compared to the control group. In other words, the Jager metacognitive program effectively enhanced the knowledge and skills of students with learning disabilities. Consistent with the results of the present study, Narimani et al. [14] reported that the Jager method had a positive effect on improving the reading performance of students with dyslexia. Moreover, Moradi and Mirbod [20] reported that the Jager method was effective in improving the neuropsychological performance of dyslexic students.
The deficiency in metacognitive knowledge and skills is one of the challenges faced by students with learning disabilities in reading [24]. The Jager method is designed in a way that first teaches metacognitive knowledge to students, then imparts metacognitive skills for reading, and finally, guides them to practice reading [12]. From another perspective, in the Jager method, students with learning disabilities learn to think about the text and its purpose before reading it. Then, they learn to monitor their understanding while reading a text (simultaneously monitor reading comprehension), and finally, they learn to provide self-feedback after reading [20]. Moradi and Mirbod [20] reported that metacognitive approaches can improve neuropsychological skills by organizing the brain, and the improvement of these skills will lead to an increase in academic skills, including reading. From this standpoint, it can be concluded that the Jager method effectively improves the metacognitive knowledge and skills and enhances the reading performance of students with learning disabilities. Reading is a complex cognitive process involving various skills, including comprehension, cognition, knowledge, and metacognitive skills. These skills will be effective when there is a balance between them [14]. Narimani et al. [14] reported that the Jager method increases metacognitive and cognitive skills in students with learning disabilities. Dyslexia is a problem related to information processing, and since the Jager method improves cognitive and metacognitive skills, it plays an effective role in the learning process [20]. Therefore, the Jager method can play a key role in providing effective strategies to solve their problems.
Cognitive deficit is one of the most significant factors contributing to the likelihood of developing reading difficulties. The Jager method can be applied to various aspects of reading, including eye movements, language processing, working memory, retrieval skills, and automatization [25]. Evidence suggests that dyslexia may result from multiple risk factors, and children with a wide range of cognitive and sensory-motor deficits are more susceptible to reading problems [26]. The Jager method is implicated in language and cognitive skill aspects, including specialized engagement in reading. The literature indicates that the Jager method promotes progress in skill acquisition, including reading [14]. The Jager method is effective in all cognitive processes and continues to capture attention in mental activities. Precision or attention is a fundamental mental activity that enables an individual to maintain an accurate cognitive and behavioral readiness in the face of a stimulus or prolonged activity, acquire necessary information, and provide the required response [20]. Narimani et al. [14] reported that the Jager method is designed in such a way that first the student is taught metacognitive knowledge, then metacognitive skills are taught in reading the text, and then the student practices reading the text. Therefore, the Jager method provides suitable opportunities for active engagement with various sensory inputs from the environment. Purposeful motor behaviors contribute to improving performance and lead to the enhancement of cognitive skills, including attention. Implementing such interventions can prevent the emergence of psychological issues like depression and anxiety resulting from adverse conditions and effectively address these problems [14].
One of our limitations was conducting the research only on the second- and third-grade students; thus, caution should be taken in generalizing the results to other grades. Also, it was not possible to measure the effect of each subject of therapeutic-educational sessions separately.
Conclusion
The Jager method is applicable for enhancing the reading performance of children with learning disabilities. Many reading difficulties among dyslexic students stem from a lack of attention because the process of developing accuracy and attention in dyslexic children is slow and delayed. Consequently, inadequate attention can render an individual's learning vulnerable. Therefore, educators in schools using the Jager method must address the necessary prerequisites of accuracy and attention for reading. It is recommended that the Jager method be implemented for all school students. Considering the limited awareness of teachers regarding the Jager method, a training course should be organized as part of in-service programs for teachers. Additionally, parent-teacher meetings should harness the potential of families to further enhance the effectiveness of the Jager method in this regard. Students with dyslexia should be identified at the beginning of their school attendance, and the Jager method should be implemented to address this deficiency.
Acknowledgments: This article was extracted from a part of the PhD dissertation of Mrs. Sharif at the Islamic Azad University, Ahvaz Branch, Iran. The authors would like to appreciate the collaboration of all students and their parents in the present study.
Ethical Permissions: The Ethics Review Board of Islamic Azad University, Ahvaz branch, approved the present study (code: IR.IAU.AHVAZ.REC.1400.158).
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Sharif F (First Author), Introduction Writer/Methodologist/Original Researcher/Discussion Writer/Statistical Analyst (35%); Johari Fard R (Second Author), Methodologist/Assistant Researcher/Discussion Writer (35%); Borna MR (Third Author), Assistant Researcher/Discussion Writer/Statistical Analyst (30%)
Funding/Support: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.