Abstract
An examination was conducted to address issues concerning the assessment of students with learning disabilities (LD) in English speaking Canadian postsecondary institutions. These issues concern the nature of appropriate and evidence-based assessment and whether there is fair access to academic accommodations for students with LD. Access to academic accommodations is granted when an acceptable psycho-educational assessment provides an LD diagnosis, but what “acceptable” means appears very inconsistent across settings. This examination has ascertained that there is still no commonly accepted and empirically based procedure for the assessment of LD. Instead, a confusing variety of assessment practices exist, resulting in Canadian postsecondary accommodations practices being opaque and, therefore, discriminatory and vulnerable to legal challenges.
Over the last two decades, Canadian postsecondary institutions (universities, colleges, and technology institutes) have continuously improved their accessibility or more commonly termed disability services due to provincial and Canada-Wide Human Rights laws. Some institutions even post the equality rights provisions of the Canadian Charter of Rights and Freedoms and their provincial Human Rights Code on their websites. Many institutions also post their Policy on Academic Accommodations for Students With Disabilities or their accessibility service delivery model on their websites. These postings provide information to the general public regarding (a) the legal framework behind their service provision, (b) their definitions of various disabilities, (c) the responsibilities of the institutions and of the students requesting accommodation, (d) the processes for reaching accommodation and for appeal, (e) the components of acceptable documentation, and (f) the stages of service provision to those whose disabilities are identified only after registration. However, in the case of learning disabilities (LD: reading, writing, and mathematics disabilities), there seems to be a wide array of sometimes conflicting practices that postsecondary institutions use when determining whether the LD documentation of a student is acceptable and, consequently, whether or not the student can receive academic accommodations or financial aid for disability-related services or supports. This variation, unfortunately, may lead to Human Rights litigations based on accommodation criteria that indirectly exclude service provision to students with LD.
“Denial of access may be direct or indirect: it may result from refusal to accommodate students with disabilities, from admission criteria that indirectly exclude students with disabilities, or from barriers in funding programs” (Access Service, University of Ottawa, 2010). For example, students who cannot afford expensive psycho-educational reassessments may be denied access to accommodations.
Purpose
Our purpose was to conduct an examination of the criteria used by Canadian postsecondary English speaking universities for accepting LD diagnosis from their students who apply for academic accommodations based on a LD.
This examination was concerned with six questions:
psycho-educational assessment batteries whose results Canadian postsecondary institutions accept as valid and reliable;
the names of assessment measures whose results institutions do not accept as valid and reliable, and why;
the information that institutions consider to be crucial for LD diagnosis;
whether an IQ-achievement discrepancy is required for LD diagnosis;
the names of assessment instruments or interpretive processes that are accepted when an English as a Second Language (ESL) learner claims to have LD; and
the steps institutions take or any procedures they follow when an ESL learner is suspected of LD (for both domestic and international students).
Method
The examination is based on available web-based information regarding LD documentation requirements of postsecondary institutions in Canada, and because the web search did not yield all information sought, the accessibility offices of 130 postsecondary institutions were contacted by email for additional information. The initial data retrieval of the websites regarding LD or LD documentation requirements was conducted between May and July, 2010. Of the 133 publicly funded Canadian postsecondary institutions, only 7 did not have any information on their websites regarding LD or LD documentation requirements. Most others mentioned the term psycho-educational report or documented disability on the disability service provision site or on another institution site as part of the requirements for acceptable documentation. When the generic “student services” or “future students” prompts on the homepage of an institution did not lead to an accessibility/disability site, or when the disability/accessibility sites did not include the needed information, the following terms were used for an institution-wide online search: “learning disabilities,” “students with learning disabilities,” “psycho-educational assessment,” “documentation of learning disabilities,” and/or “documentation of disabilities.”
To obtain information regarding LD documentation that was not available on the website, we contacted the disability offices directly in early August 2010, and if no response arrived, once more in the beginning of September 2010. Forty-six institutions provided the requested information to all six questions by the beginning of October, 2010. The questions were those listed in the “Purpose” section of this article.
Findings and Commentary
Findings for Question 1: Reliable and Valid Assessment Batteries for LD Diagnosis
As Canadian postsecondary institutions require formal diagnoses from applicants in order to support the need for academic accommodations, several accessibility center websites list the names of batteries that include acceptable tests in four areas of functioning that are assessed when establishing a LD diagnosis.
This examination found that the supporting evidence for the diagnosis of LD is typically based on clinical observations, the data collected during a diagnostic interview, and an assessment battery relying on more than just one test or subtest of (a) aptitude, (b) achievement, (c) information processing, and (d) other assessment measures of personality. Because there is no explanation on any of the websites for the need to test all these four areas, there seems to be an expectation that they will be assessed. This is surprising, as there is no agreed-upon working definition of what an LD is and no agreed-upon empirically based diagnostic criteria that support the use of tests in the areas of aptitude, achievement, information processing, and personality. It is an assumption on our part that these areas would be assessed informed by the framework for LD diagnosis proposed by Flanagan, Ortiz, and Alfonso (2007), which is grounded in contemporary theory and psychometrically defensible research. However, this could only be ascertained by conducting an examination of the methods that professionals providing LD diagnosis follow.
The generic list of assessment batteries currently suggested by postsecondary institutions is listed in Table 1. As can be seen, there is a bewildering array of tests, and a significant number appear to have no direct relation to the diagnosis of a LD (Siegel & Ryan, 1984, 1988; Stanovich & Siegel, 1994). Note, too, that the institutions do not limit licensed practitioners from using other reliable and valid tests, nor do they require the use of all tests exhaustively in each of the four areas of psycho-educational testing. They only require that accepted tests be administered to sample certain areas of performance. In addition, some institutes do not list the name of specific batteries and tests as they leave it to the professional discretion of the licensed psychologist to choose their instruments and their method of arriving at a LD diagnosis.
Comprehensive Tests Accepted at Postsecondary Institutions.
The most detailed publicly available list of tests for assessing adults suspected of having LD are provided on the accessibility websites of Acadia University, Nova Scotia; Brandon University, Manitoba; Douglas College, British Columbia; Mount Allison University, New Brunswick; Queens University, Ontario; Ryerson University, Ontario; Seneca College of Applied Arts and Technology, Ontario; University of Prince Edward Island, Prince Edward Island; University of Victoria, British Columbia; and York University, Ontario.
Findings for Question 2: Tests Considered to Be Invalid and Unreliable
Several service providers and institution websites include the name of tests that are not considered acceptable when used on their own to make accommodation decisions. The names of these tests are listed in Table 2. It is not always clear why these tests are excluded. The Wide Range Achievement Test (WRAT) was noted on numerous sites and in emails as not recommended for diagnostic purposes. The reasons that were given were as follows: (a) The test poorly reflects the achievement pattern of the adult population and (b) it is not comprehensive enough. Siegel (1999), however, presents evidence that, though the WRAT has no pseudoword reading and reading comprehension tests, and so other tests should be used for these purposes, its spelling, reading, and arithmetic tests are valid and reliable as part of an LD assessment.
Tests Accepted Only for Screening Indicated by Number of Institutions.
Although not noted on these disability services websites, the validity of other achievement tests (in adult assessment batteries) has also been questioned. For instance, Doupe & Samuels (2007) note that there are problems around the validity of the Woodcock–Johnson Achievement Test (in the Psychoeducational Battery) as well as with the validity of the Wechsler Individual Achievement Test–II as the tasks in these tests do not always correspond to the academic tasks the students are expected to perform in a postsecondary setting.
Achievement tests commonly used with adults include the Wechsler Adult [sic] Achievement Test-II and the Woodcock Johnson Achievement Test. Validity may be a concern with both, as the results may not relate to how the student performs in school. For example, the student is required to hand write an essay for 15 minutes to assess written expression. Few students hand write these days (especially students with learning disabilities) and 15 minutes cannot reflect what it takes to write a research paper. Similarly, reading comprehension on a short passage may differ greatly from reading and understanding information in a textbook. (Doupe & Samuels, 2007, p. 9)
Conversely, it is argued that these tests measure some basic processes, such as basic decoding and word recognition skills, and are fundamental for higher level reading comprehension processes (Siegel, 1999). If there is a problem with the basic processes, then reading will be compromised. Therefore, it seems important to measure all of the basic skills that are relevant to reading or academic functioning before making a diagnosis of RD, a reading based LD.
Based on email correspondence with disability service providers, it seems that some provincial ministries of adult education (or their equivalent in name) can specify what measures/tests can or cannot be considered to be appropriate for use in a psycho-educational assessment for LD. This is the case, for example, in British Columbia and Nova Scotia. Because the provincial ministries of adult education hold a key to financial support, and therefore have influence on the range of accommodation options available at the postsecondary level in each province, it would be important to survey their personnel to find out what theoretical and empirical framework each ministry uses and what they expect their respective postsecondary institutes to follow for appropriate LD documentation.
Findings for Question 3: Crucial Tests for LD Diagnosis
Except for one respondent who named tests of reading decoding, spelling, and numerical operations as crucial for LD diagnosis, the recurrent answer from disability personnel was that for an LD diagnosis they require to see results from ability tests along with academic and information processing tests expect the tests used in the diagnostic report to validate that current symptoms substantially impair functions relevant to the requested academic accommodations. In addition, the test results must tie to specific recommendations that should include a detailed explanation of why an accommodation is needed to overcome educational barriers.
Findings for Question 4: IQ-Achievement Discrepancy Requirement
As of yet, theory and research do not provide a commonly agreed-upon LD definition and, consequently, agreed-upon guidelines for LD determination. In brief, some researchers advocate the use of achievement tests together with dynamic assessment for establishing or ruling out LD, while others are still entrenched in advocating for the use of a statistically dubious discrepancy between a student’s scores on intelligence (sometimes called cognitive abilities) tests and achievement tests. In view of the above, it was not a surprise to find varying expectations for acceptable documentation of LD when applying for academic accommodations at the postsecondary level.
Those institutions that provide an operational definition of LD, meaning they expect psycho-educational reports and assessment protocols to meet LD diagnostic criteria, typically use as their guideline either the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders 1 (DSM-IV; American Psychiatric Association, 1994), or guidelines developed by their province. 2 This examination found that several institutions expect to see LD diagnoses based on some kind of discrepancy in scores; that is a discrepancy between IQ and achievement scores and/or a discrepancy between IQ and information processing scores. In the case of DSM-IV diagnoses of Reading Disorder, Mathematics Disorder, or Disorder of Written Expression, the discrepancy between achievement and IQ required for diagnosis is 2 standard deviations (SD) or greater. 3 The only province where documentation needs to conform to the DSM-IV guidelines for students with LD to be eligible for provincial financial aid is British Columbia (StudentAidBC, 2009, p. 7).
In the case of provincial guidelines that do not follow DSM-IV criteria but which still employ a discrepancy definition, the diagnostic report is mostly expected to establish at least a 1 to 2 SD discrepancy, typically equal to or greater than 1.5 SDs.
In view of the different cut off scores, unfortunately, it seems possible then that at institutions where DSM-IV guidelines are followed, students whose diagnostic reports show a 1.5 SD, instead of 2, might not qualify to receive academic accommodations. Conversely, other institutions might accept a 1.5 or even 1SD discrepancy alone as indicating a LD, thus creating inequity between institutions regarding who is and who is not accommodated (see Sparks & Lovett, 2009).
On the other hand, there are institutions that are aware of this dichotomy and accept diagnosis following both DSM-IV and their provincial diagnostic guidelines. To complicate the picture, some institutions do not require an IQ-achievement discrepancy; however, they will accept diagnosis based on the DSM-IV definitions as well as ones based on nonoperational definitions such as those put forward by the Learning Disabilities Association of America or the National Joint Committee on Learning Disabilities. In other words, these latter institutions with their best intention to be inclusive accept LD diagnoses that stem from empirically (and theoretically) contradictory practices, and as such, the criteria for accommodations provision are confusing at best. In the larger Canadian postsecondary context, therefore, these contradictory practices may make certain institutions and/or all institutions of a certain province appear discriminatory.
A question that arises regarding use of the IQ discrepancy for provision of accommodations is that those institutions that require use of this discrepancy criterion might find themselves having to accommodate students when common sense would dictate it otherwise. This is possible due to the wording of provincial operational definitions that allow LD diagnosis even when an applicant’s academic achievement scores are in the normal or average range. More specifically, when a provincial operational definition states that LD diagnosis must be based on significant discrepancy between intelligence and level of achievement and/or 4 information processing related to learning, the accessibility service provider is forced into having to decide to provide accommodations to those students whose scores reflect academically average/normal achievement, average or above average IQ, but who have information processing 5 or achievement scores that are 1 to 2 standard scores below IQ.
One paradox here is that there is an almost infinite number of information processing measures, and a low score on one alone is not, in and of itself, diagnostic of any disorder. Can any of these justify the right for academic accommodations for students who otherwise achieve normal scores on timed and untimed achievement tests of reading, math, spelling, and writing? Conversely, this use of information processing alone in establishing whether a LD exists is also paradoxical when a student has poor achievement scores but good information processing. Is this student then, due to this kind of definition, not considered to have a LD?
One final issue regarding reliance on IQ scores for diagnosis of LD is that if an individual is a poor reader and shows no discrepancy between their IQ and their measured academic skill, then, based on the IQ—achievement discrepancy formula, the person is not considered learning disabled and is not eligible for academic accommodations. This is discriminatory in view of research that has “found no difference between the reading, spelling, phonological skills, and reading comprehension of individuals with dyslexia and poor readers on measures of processes most directly related to reading” (Siegel, 1999, p. 312). In other words, students who are appropriate candidates for academic accommodations do not get them in certain institutions or provinces where the IQ-achievement formula is one of the criteria in the establishment of accommodations.
These are real dilemmas that many disability providers need to face. Some disability centers circumnavigate the problem by providing an exclusionary clause to curtail normally achieving students’ claim for LD accommodations. Queens University, for example, provides the following clause in their LD documentation requirements: “Simply documenting low scores on tests of processing speed or working memory, in the absence of any academic impairment, is not sufficient to demonstrate the need for academic accommodations at Queen’s” (Queens University, n.d., p. 6). Those providers who are aware of the debate and concerns expressed around the usefulness of IQ discrepancy-based diagnosis might even take a step further and ignore their provincial diagnostic guidelines. For example, in Ontario some universities and colleges follow the 2001 LD definition originally endorsed by the Learning Disabilities Association of Ontario (LDAO), which does not refer to the use of “IQ discrepancy.” In other words, they do not follow the more recent (2003) recommended practices for diagnosing LD advocated by LDAO, which does require a clinically significant discrepancy between one or more of the psychological processes related to learning and average IQ. Besides Ontario, the present study found Alberta to be another province where accommodation service provision in postsecondary institutions is opaque and inconsistent. That is, in some institutions LD diagnosis is required based on an IQ discrepancy diagnosis of one sort, while in others, no IQ discrepancy is required. This is a surprising finding in view of the 2007 province-wide guidelines which state that IQ discrepancy analysis is outdated for LD diagnosis, and thus a two SD discrepancy criterion outlined in the DSM-IV should only be considered a guide (Doupe & Samuels, 2007, pp. 9, 12). If there are different requirements for LD diagnosis in postsecondary accessibility centers within and across provinces, and for the constituents of a psycho-educational report, one needs to ask again on what empirical data provinces and/or their individual institutions base their documentation requirements/guidelines. Table 3 provides the currently available information on the variety of acceptable documentation.
Types of LD Documentation Required by Canadian Postsecondary Institutions.
Findings for Question 5: Accepted Assessment Instruments or Interpretive Processes with ESL Learners Claiming to Have LD
Of the 133 postsecondary institution websites, 5 had reference to LD with regard to ESL speakers. 6 Some of the references justly caution readers that in the identification of a LD, cultural/ethnic background needs to be screened out; in other words, academically struggling ESL students do not necessarily have a LD. Two other sites refer to documentations that international students with any disabilities (which covers international ESL students with LD) need to provide to receive academic accommodations.
Unfortunately, Statistics Canada does not yet have information on the number of domestic ESL students working toward a postsecondary degree; however, in 2006, the number of international students was established at approximately 90,000 in full-time postsecondary programs and 13,000 in part-time programs (Association of Universities and Colleges of Canada, 2011). This number is expected to grow with the concerted effort on the part of institutions trying to find financial avenues to make up for the recent trend of decreasing government funding, and, as a result, the number of international students arriving with undiagnosed LDs might also increase.
ESL students with a Canadian citizenship or landed immigrant status, like all Canadian born students, receive publicly subsidized educational services including disability services, provided the diagnostic report they bring from their home countries or the diagnostic assessment they undergo in Canada conforms to the assessment requirements of the institution in which the student wishes to study. This means that in those provinces and institutions where IQ discrepancy must be established in a diagnostic report for the student to be able to apply for accommodation, ESL students with LD might just have generally average or low average scores on intelligence tests and low scores on achievement tests, and thus not qualify for an LD diagnostic label. This is because IQ and achievement measures are normed on the general English speaking adult population, and as such, they are culturally and linguistically biased (Gunderson & Siegel, 2001). More specifically, ESL students with a limited knowledge of certain cultural symbols and pragmatics—as well as with an English vocabulary and grammatical competency that are narrower than normally achieving native English speakers—may score lower on these tests. There was one college in Ontario, however, whose psychologist noted that when using IQ and aptitude measures (Wechsler Adult Intelligence Scale–4 [WAIS-4] and Woodcock–Johnson-III [WJ-III]), they check subtest scores for the degree of linguistic demands and cultural loading based on the recommendations found in Essentials of Cross-Battery Assessment (Flanagan, Ortiz, & Alfonso, 2007). Another disability provider emphasized the use of nonverbal intelligence measures as important for diagnosis in this population. It is not clear how often practitioners employ this strategy when assessing ESL students with a potential LD.
Another fundamental problem that assessors face is that they are assumed to know how to differentiate between generic errors stemming from the process of second language acquisition as opposed to a LD. 7 Despite this, several institutions noted that they would attempt to find a qualified assessor who has cultural and linguistic competence consistent with the background of the student in question, or that they believe their psychologists must have professional expertise working with culturally and linguistically diverse populations. As one respondent admitted, however, this might be naive. Certainly, assessing ESL students with uncommon language backgrounds can be an insurmountable challenge, as can geographical isolation (e.g., institutions in sparsely populated provinces sometimes may not even have access to psychologists within a 100 or more km radius for even their English as a first language speaker students).
Finding for Question 6: Steps or Procedures Followed When ESL Learners Suspected of LD
It is clear that having to decide whether a student with an ESL background, who has received instruction in English for a minimum of 4 to 5 years, has language learning difficulties related to their ESL status as opposed to a LD is confounded by other factors such as having possibly limited academic skills and/or a lack of effective study strategies. Those institutions that utilize the expertise of Academic Skills Coordinators with a background in ESL learners can refer an ESL student for LD assessment after the coordinator has screened the student’s reading, writing, and comprehension abilities. Fortunately, those institutions where disability personnel do not have a background in second language acquisition can use LD screening tools 8 whose results can suggest whether a student should be referred to a full psycho-educational assessment. For example, The Delta Screener (College Committee on Disability Issues, 2003) or the Learning Disability Screen (StudentAidBC, 2008) identify whether the ESL students have a history of academic difficulties in their first language, thus helping to differentiate between permanent learning problems and language learning difficulties.
International students pay full fees and receive disability services provided their psycho-educational reports from their home countries satisfy the conditions of the postsecondary institution to which they apply. However, if the students’ psycho-educational assessment is not acceptable according to the criteria employed by their institutions, then in theory they must pay for a Canadian psycho-educational assessment if they want to proceed with trying to ensure services. This is also the case for those international students who self-identify or are identified by their instructors as potentially having a LD. Because international students pay much higher student fees than their domestic counterparts, blocking them from publicly subsidized disability services seems to add a systemically discriminatory aspect to the current LD related accessibility service practices. However, there are exceptions. According to information provided by respondents in this survey, institutions that employ qualified professionals (e.g., psychologists or MEd specialists) are able to undertake informal in-house evaluations of students that may lead to provision of some academic accommodations. Alternatively, the international students may sometimes be screened for LD by certified postsecondary disability service providers or in some provinces (such as Saskatchewan) by the Learning Disability Association of the province in which they study, prior to being sent for a LD assessment.
Unexpected Findings
Although this examination did not concern itself with academic accommodation requirements with regard to the acceptable recency of LD documentation as well as to the professionals qualified for providing LD diagnosis, the substantial variations within and across provinces are worth mentioning. For example, if a student with an LD or their family would search through the sites for admission requirements, they would probably be surprised to discover that within one province their diagnosis would be considered out of date in one institution when applying for academic accommodations while in another it would be still up to date. It is true that many service providers note on their websites that on a case-by-case basis they will still evaluate the validity of a diagnosis made within a minimum of 2 years prior to application to a maximum of 5 years; nevertheless, the cut off dates across the country are varied enough to be considered inconsistent.
In addition, while LD diagnosis must come from members of an accredited professional body with the ability to diagnose LDs, across the provinces there is a variation as to who is deemed to be appropriate. For example, while in British Columbia, school psychologists are one type among the professionals who are considered to be eligible assessors, in Quebec, the same is true for speech therapists, and in Ontario, diagnosis from these types of professionals are not considered to be adequate at the postsecondary level. The question around a widely accepted empirical research that informs professional practice pops up again: Is it possible that these various types of professionals follow empirically contradictory diagnostic guidelines when providing a LD diagnosis?
Conclusion and Recommendations
In summary, this survey attempted to identify the standards currently used for accepting LD diagnosis from postsecondary students in Canada when applying for academic accommodations. The findings are not inclusive as detailed information provision for this survey was voluntary. Of the 133 publicly funded Canadian postsecondary institutions, only 46 yielded information to all six questions, the other institutions have partial information available on their websites, and thus we acknowledge limitations (see also Table 3). However, based on the responses and information collected from all the websites, it was clear to see that Canadian postsecondary students with LD, whether pursuing studies within their provinces or across provinces, encounter a bewildering variety of, and at times conflicting LD documentation requirements. To avoid the possibility of allegations of indirect discrimination with regard to academic accommodation provisions, accessibility/disability personnel and provincial ministries of adult/higher education need common criteria for acceptable LD documentation both for their English as first language speaker students and their ESL students. Those institutions that employ university faculty and psychologists with a background in psycho-educational assessment in their accessibility/disability centers need to take a lead in engaging in a dialogue within and across Canada’s provinces and territories to come to an agreement on an operational definition of LD, and in turn, streamline diagnostic guidelines both for English and ESL speakers, based on empirical evidence.
The discrepancy definition has been discredited (see Harrison & Holmes, 2012), and yet many postsecondary institutions appear to require this as a method of diagnosing LD. The lack of consistency in how LD must be diagnosed in order to receive accommodations exposes postsecondary institutions to possible legal or human rights challenges, as this may create situations in which there is real or perceived discrimination against some students depending on how they were diagnosed and in what province.
In the absence of a resolution of the issue of the definition, it seems reasonable to rely on a low achievement definition of LD (Siegel, 1999; Siegel & Ryan, 1984, 1988; Siegel & Smythe, 2008; Stanovich & Siegel, 1994). If a student, besides having a lifelong history of learning problems and in the absence of other reasonable explanations, has a low score (one or more SDs below the mean) in more than one of the following types of tests; word recognition, pseudoword reading, reading fluency, reading comprehension, computational arithmetic and mathematical problem solving, it would be appropriate to say that the student has LD (Siegel, 1999).
If a common, Canada-wide standard existed for the diagnosis of LD and such standards were employed when first diagnosing children, then there would be no need for costly psychological reassessment and updates throughout the life of the student. Rather, students transitioning to university or college who were diagnosed with such an agreed-upon definition would need only to demonstrate how their LD was currently having an impact on their academic performance. This analysis could be done inexpensively, perhaps even by staff at accessibility offices, who would also be in the best position to determine the most appropriate academic supports and services required for a student in their given program of study. Federal funding agencies that provide disability support grants to students with LD, too, could agree upon consistent and empirically grounded methods of determining eligibility for funding rather than relying on discredited methods of diagnosis, such as IQ-achievement discrepancy. Until then, students with LD have no guarantee that their documentation will allow them access to accommodations at the postsecondary level, and may be confused and frustrated to discover this only after being accepted into the school of their choice. Furthermore, students with legitimate LDs for whom English is not their first language will also face inconsistencies in whether their disorder is identified or accommodated, depending on where they study in Canada. Thus, the failure to adequately diagnose ESL students suspected of a LD, too, seems discriminatory and open to legal challenge.
Footnotes
Acknowledgements
The authors thank Allyson Harrison for her excellent comments on this article. Her insights and editorial suggestions were very valuable. The authors also thank the many access advisors, disability counselors, psychometrists, and psychologists (working in postsecondary accessibility/disability centers) who responded and sent additional information for this examination about their institution’s practices and to those who also used the questions in this study as an opportunity to develop their guidelines.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.