Health, Spirituality and Medical Ethics

Introduction

One of the largest groups of exceptional children currently enrolled in special education schools consists of children with learning disabilities (LD) [1]. In recent years, learning disorders have emerged as a controversial subject in education and psychiatry, attracting considerable attention from specialists [2]. According to the fifth edition of the diagnostic and statistical manual of mental disorders (DSM-5), a learning disorder is a neurodevelopmental disability of biological origin, rooted in cognitive processes, and its diagnosis requires observable difficulties in learning reading, writing, numerical skills, or mathematics for at least one academic year [3]. Its prevalence in different societies has been reported to be 4.58% [4]. In Iran, the prevalence of specific learning disorders has been reported to range from 13% to 17% in boys and 10% to 12% in girls among school-aged children [5, 6]. These children may also experience various psychological and mental health difficulties in addition to learning problems, making them particularly vulnerable to psychological disorders [7] and more prone to emotional and functional challenges [8]. Consequently, these issues may lead to frustration and hopelessness among parents, disrupt psychological functioning within the family—especially among mothers—and ultimately compromise their mental health as they struggle with numerous psychological challenges [9].

One of the most significant psychological consequences experienced by mothers of such children is a decline in their emotional adjustment when facing continuous educational and emotional stressors. Emotional adjustment is a key component of mental health, referring to an individual’s capacity to manage, regulate, and accept emotions across different life situations [10]. Individuals with higher emotional adjustment can effectively control negative emotions, such as anxiety, anger, or frustration, and demonstrate constructive and balanced responses in difficult situations [11]. Mothers of children with LD, due to ongoing engagement with their children’s academic and behavioral challenges, are exposed to greater psychological and emotional pressure than other mothers [12]. These pressures may weaken their ability to regulate emotions and result in reduced emotional adjustment, which not only threatens their mental health but may also negatively affect parent–child interactions, the quality of the parent-child relationship, and even the child’s improvement process [13]. Therefore, enhancing emotional adjustment in these mothers is considered an essential priority in psychological interventions.

In addition to emotional adjustment, another critical component in maintaining mental health and quality of life among mothers is their level of spiritual vitality. Spiritual vitality refers to a state of liveliness, hope, inner peace, and meaningful engagement with life that stems from an individual’s spiritual and religious beliefs, values, and experiences [14]. Unlike temporary happiness or superficial pleasure, spiritual vitality is rooted in a sense of connection with a higher power, purposefulness in life, and existential tranquility [15]. For mothers of children with learning disorders—who frequently face exhausting challenges, chronic psychological stress, and persistent worries—spiritual vitality can serve as a powerful internal resource that promotes endurance, psychological balance, and effective coping [16]. Increased spiritual vitality not only enhances resilience, hope, and meaning-making in difficult circumstances but may also positively affect family relationships, parenting practices, and overall life satisfaction [17]. Hence, exploring effective interventions to improve emotional adjustment and spiritual vitality among these mothers is crucial and necessary.

Given the importance and influence of emotional adjustment and spiritual vitality on mothers’ mental health, the use of spiritual–Islamic skills training can serve as an effective intervention for enhancing these two components. Spiritual–Islamic skills training is a structured set of therapeutic-educational sessions emphasizing core religious concepts, such as self-awareness, connection with God, prayer and supplication, forgiveness, trust in God, gratitude, acceptance, death awareness, altruism, spiritual self-care, and remembrance of death [18]. These skills are designed to strengthen spiritual insight, promote psychological calmness, increase self-awareness, and reduce internal conflicts, thereby helping mothers become more resilient in the face of parenting stressors and providing a foundation for inner growth, self-acceptance, and emotional reconstruction [19]. Spiritual skills training, as an approach rooted in positive psychology and spirituality to enhance self-awareness, meaning-seeking, hope, acceptance of circumstances, and deep connection with oneself, others, and a transcendent source, play an effective role in increasing resilience and mental health [20].

Despite the high prevalence of learning disorders among students and the extensive psychological consequences experienced by mothers of these children, there remains a gap in effective and culturally adapted interventions to enhance the mental health of this vulnerable group. Many existing interventions focus solely on cognitive or behavioral dimensions and overlook cultural, value-based, and spiritual capacities. Additionally, the lack of interventions grounded in Islamic spiritual components is evident, particularly in a society like Iran, where religion and spirituality play a foundational role in daily life. The innovation of the present study lies in implementing an educational package based on spiritual–Islamic skills, emphasizing Islamic sources, Iranian culture, and an integrative approach combining positive psychology and Islamic spirituality. This study also has practical significance because it may inform the development of mental health–promoting interventions for families of exceptional children and provide an effective model for policymakers, counselors, and mental health practitioners. Accordingly, this study aimed to determine the effectiveness of spiritual–Islamic skills training on enhancing spiritual vitality and emotional adjustment among mothers of children with LD.

Methods

This study employed a quasi-experimental research with a pre-test, post-test design and a control group. The statistical population consisted of mothers of children with LD (dyslexia, dysgraphia, and dyscalculia) in the cities of Zahedan and Zabol, located in the Sistan and Baluchestan Province, Iran. Purposive sampling was used among mothers who were willing to participate and met the inclusion criteria. A total of 50 mothers of children with specific learning disorders, aged 30 to 55 years, were selected and randomly assigned to the experimental and control groups (25 participants in each). To determine the sample size, and considering the nature of the study and comparison of two groups, prior studies [19, 20] with similar designs were consulted. Using G*Power software, version 3.1.9.4 and with statistical power of 0.80, a significance level of 0.05, and a medium effect size (0.5), a minimum of 25 participants was estimated for each group. Sampling sites included learning disorder centers, special education schools, and the comprehensive assessment, education, and rehabilitation center of Zahak county, all operating under the supervision of the Exceptional Education Organization.

The inclusion criteria included having a child with a primary learning disorder (dyslexia, dysgraphia, or dyscalculia), no substance addiction or major psychological disorder (self-reported), and not receiving other psychological interventions during the study. The exclusion criteria included missing more than two intervention sessions. After obtaining permission from the provincial education security office, sampling was conducted across four learning disorder centers and two special education schools in Zabol and Zahedan cities. These centers held official licenses for identifying and rehabilitating children with learning disorders. Mothers who expressed willingness to participate were contacted, and the inclusion criteria were explained. Then, a short structured interview was conducted with the children of these mothers to diagnose specific learning disorders (dyslexia, dysgraphia, and math disorder). In the next stage, 50 mothers were selected from among the mothers whose children met the diagnostic criteria and who themselves met other inclusion criteria and were then assigned to two experimental and control groups (25 each).

The experimental group received the 12 90-minute sessions of the Islamic spiritual therapy protocol revised by Galanter & Siegel [21], administered by the researcher, while the control group received no training. This package has been adapted in previous domestic studies, including the work of Nakhaei et al. [22], with established validity and content reliability. The intervention was conducted with official approval from the Zabol county education office and at the Zahak comprehensive developmental and educational intervention center. Post-tests were administered to both groups upon completing the final session. Data were analyzed using multivariate analysis of covariance (MANCOVA) in SPSS software, version 26. The study instruments are described below.

Spiritual vitality questionnaire (SVQ)

The SVQ, developed by Chirian and Afrooz in 2016, consists of 60 items across two dimensions (beliefs and feelings/behaviors) rated on a 4-point Likert scale (1=strongly disagree to 4=strongly agree) [23]. Chirian and Afrooz [23] first examined the content validity through experts in this field. To determine the validity, the correlation of the total score with each question of the questionnaire was used. The range of the correlation coefficient obtained was from 0.141 to 0.92, which was significant at the 1% error level. The content validity of this questionnaire has been confirmed under the supervision of several experts [23]. Also, in another study conducted by Kazemi et al. the reliability for the beliefs and feelings and behavior subscales using the cronbach’s α method was 0.86 and 0.89, respectively [24]. In the present study, the cronbach’s α coefficient of the SVQ to determine its reliability was 0.85.

Emotional adjustment questionnaire

Emotional adjustment was measured using the Farahbakhsh emotional adjustment scale (2011), containing 13 items on a 5-point Likert scale (1=very low to 5=very high). In Farahbakhsh’s study, the validity of this questionnaire was confirmed. The average Lavish coefficient for explaining the content validity of the entire test was 0.71, and for the subscales, it was 0.58 to 0.82. Also, the content and face validity of this tool were confirmed by 15 expert professors in the field of psychology [25]. In another study, the correlation of the total score of the test with the GHQ test was 0.58, which indicates the validity of the test. The internal reliability of the entire test was determined to be 0.94, and for the subscales, it was determined to be 0.73 to 0.81 [26]. In the present study, the cronbach’s α coefficient of the emotional adjustment questionnaire was obtained to determine its reliability as 0.81.

Spiritual skills training package/spiritual therapy

This training package, designed and validated by Galanter & Siegel [21], aims to teach spiritual and Islamic skills to adults experiencing psychological challenges. Table 1 presents a summary of the session content.

The information obtained was used solely for the scientific purposes of the study, and no mention was made of the names or personal characteristics of the mothers or their children in the analyses and final report. Also, to observe educational justice and the principles of professional ethics, after the end of the intervention sessions, a summary of the content of the training on Islamic-spiritual skills was also provided to the control group in the form of an educational booklet to ensure their relative benefit from the intervention.

Results

Initially, Table 2 presents the demographic information of the study. To describe the demographic characteristics, the research sample consisted of 50 mothers of children with LD. The age range of the participants was between 30 and 50 years, and the highest frequency was observed in the age group of 36 to 40 years. In terms of education level, the majority of the participants had a diploma to a bachelor’s degree.

Table 3 presents the descriptive statistics for the mean and standard deviation of the scores of spiritual vitality and emotional adjustment variables separately for the experimental and control groups in two measurement stages (pre-test and post-test). As can be seen, the scores of spiritual vitality and emotional adjustment in the experimental groups in the post-test had a significant increase compared to the pre-test. Considering the design of the present study, which was a quasi-experimental study with pre-test, post-test design with the control group, data analysis was performed using MANCOVA to carefully examine the effect of the intervention after controlling for the effect of the pre-test scores. Although the independent t-test is suitable for comparing the means of two groups, it is not able to control the pre-test scores as covariates and, as a result, cannot properly show the real difference caused by the intervention. Therefore, using MANCOVA was chosen as a more accurate and appropriate method for the research objective.

Before interpreting the results, it was examined whether there was a significant difference between the groups in the linear combination of the dependent variables using multivariate statistical tests, including Pillai’s effect, Wilks’ lambda, Hotling’s statistic, and largest square root. Before interpreting the results, it was examined whether there was a significant difference between the groups in the linear combination of the dependent variables using multivariate statistical tests, including Pillai’s effect, Wilks’ lambda, Hotling’s statistic, and largest square root. The results showed a significant overall difference between the experimental and control groups in the linear combination of the dependent variables (Pillai’s Trace=1.60, F(2, 45)= 41.22, P<0.001, η²=0.67). Therefore, it was justified to conduct univariate analyses to examine the differences in each of the dependent variables.

After the overall difference between the groups was confirmed, the results of the univariate analysis of covariance were examined separately for each of the variables of spiritual vitality and emotional adjustment. The results in the Table 4 show that the intervention was significantly effective on both variables.

According to the results obtained, it is observed that there is a significant difference between the experimental and control groups in all variables. In Table 5, the adjusted means are presented, meaning that the effect of the pre-test variable has been statistically eliminated.

The results of Table 5 show that the process of spiritual therapy is effective on the spiritual vitality and emotional adjustment of mothers of children with LD, even after controlling for the pre-test effect. In fact, the results of Table 5 show that after controlling for the pre-test effect, the adjusted mean of spiritual vitality scores in the experimental group (99.28) was significantly higher than that of the control group (79.34) (F(1,46)=117.35, P<0.001, η²=0.67). Also, the adjusted mean of emotional adjustment scores in the experimental group (30.47) was significantly higher than that of the control group (19.68) (F(1,46)=98.45, P<0.001, η²=0.62). These results show that training in Islamic spiritual skills had a positive and significant effect on increasing both dependent variables, namely spiritual vitality and emotional adjustment of mothers of children with LD.

Discussion

The present study was conducted to determine the effectiveness of training spiritual–Islamic skills on spiritual vitality and emotional adjustment among mothers of children with LD. Overall, the findings indicated that the training of spiritual–Islamic skills was effective in enhancing both spiritual vitality and emotional adjustment in these mothers. The following section elaborates on these findings and explains the mechanisms underlying their effectiveness.

The first finding revealed that training spiritual–Islamic skills significantly improved the emotional adjustment of mothers of children with LD. Specifically, the mean scores of emotional adjustment of mothers of children with LD increased significantly in the post-test compared to the pre-test. This finding is consistent with previous research conducted by Zarei et al. [19], Mazruei et al. [27], and Karaca et al. [28], with no contradictory evidence reported in this area. The effectiveness of this intervention can be explained by the fact that training spiritual–Islamic skills provides a foundation for spiritual self-awareness and emotional regulation, thereby enhancing the mothers’ emotional adjustment. Abbasi et al. [20] showed that the sessions included practical exercises encouraging mothers to reflect on their lived experiences, internal thoughts, and emotions, helping them reconstruct and make sense of these feelings within the framework of religious and spiritual beliefs. For instance, addressing concepts, such as self-knowledge, listening to one’s inner voice, accepting limitations, and overcoming guilt enabled mothers to identify and acknowledge psychological stressors instead of denying or suppressing them. In line with this, Karaca et al. [28]found that exercises, such as self-forgiveness, narrating spiritual experiences, and discussions on patience, trust in God, and divine wisdom, reduced recurring emotional pressures, such as frustration, helplessness, self-blame, or anger toward the child, fostering greater cognitive and emotional flexibility. Exposure to themes, such as spiritual responsibility, meaning-making in suffering, relaxation through prayer and remembrance, and feeling connected to a transcendent source, helped mothers regulate negative emotions in a more balanced, accepting, and calm manner. Similarly, Zarei et al. [19] demonstrated that this process not only prevented impulsive emotional reactions to behavioral difficulties but also enhanced tolerance, increased empathy, and strengthened the mother–child relationship. Mazruei et al. [27] likewise explained that the intervention encouraged mothers to use more adaptive coping strategies—such as cognitive reappraisal, acceptance, inner relaxation, and positive evaluation—in daily situations rather than resorting to emotional coping. Accordingly, in the present study, training spiritual–Islamic skills significantly enhanced mothers’ emotional adjustment by activating internal resources, improving emotional processing, and strengthening emotional regulation abilities.

The second major finding showed that spiritual–Islamic skills training significantly improved spiritual vitality among mothers of children with LD. The mean scores of spiritual vitality increased significantly from pre-test to post-test. This finding aligns with previous studies by Karaca et al. [28], Yilmaz [29], and Gur et al. [30], with no contradictory findings reported. The effectiveness of this intervention can be understood in terms of strengthening meaning-seeking, enhancing connection with a transcendent source, and restoring hope and inner peace. Karaca et al. [28] found that throughout the sessions, mothers were introduced to concepts, such as gratitude, supplication, prayer, acceptance of divine wisdom, self-awareness, contemplation of mortality, altruism, kindness, and reliance on God, which they practiced in their daily lives. These elements—especially among religious individuals—serve as essential sources of deep and enduring spiritual vitality. In the present study, practices, such as focusing on divine blessings, engaging in group spiritual activities, narrating spiritual experiences, and reflecting on life hardships from a theological perspective helped mothers reinterpret their challenging circumstances not as threats but as opportunities for growth, inner transformation, and spiritual closeness.

Gur et al. [30] found that for mothers who had long struggled with caregiving fatigue, feelings of inadequacy or failure, and chronic psychological stress, spiritual training fostered a form of psychological reconstruction. Similarly, Yilmaz [29] demonstrated that redefining life purpose, cultivating a sense of usefulness, enhancing meaning, and adopting a God-centered worldview enabled mothers to experience freedom from negative thoughts and despair. Abedi et al. [31] found that feeling connected to God, participating in group spiritual activities, and realizing that they were not alone in enduring hardships provided mothers with psychological peace, security, hope, and the motivation needed to continue their life journey. Therefore, spiritual–Islamic skills training strengthened the positive components of spirituality and meaning-making in daily life, increasing spiritual vitality and helping mothers adopt a more hopeful, illuminated, and spiritually oriented perspective despite parenting challenges.

Conclusion

The findings of this study demonstrated that spiritual–Islamic skills training significantly increased spiritual vitality and improved emotional adjustment among mothers of children with LD. By emphasizing the components of Islamic spirituality, this intervention effectively activated mothers’ internal coping resources and enhanced their mental well-being. Consequently, the use of spiritual skills training can serve as an effective and culturally appropriate psychological support approach for parents of exceptional children.

Limitations and suggestions

Despite intervention effectiveness, this study had several limitations. The most significant limitations were the relatively small sample size and the geographical restriction to the cities of Zahedan and Zabol, which reduced the generalizability of the findings. Additionally, the use of self-report instruments may have been influenced by response bias. The absence of long-term follow-up also limits the evaluation of the sustainability of the intervention’s effects. Future studies are recommended to use larger and more diverse samples across different regions and cultures to improve the generalizability of results. Employing random sampling methods and controlled designs could help reduce selection bias and enhance internal validity.

Using multi-method assessments—such as clinical observations, semi-structured interviews, or reports from teachers and spouses—alongside self-report measures would increase the accuracy and richness of the data. Furthermore, future research should incorporate long-term follow-up to assess the durability of intervention effects. Based on the present findings, it is also recommended that spiritual–Islamic skills training be implemented as an effective intervention in learning disability centers and special education schools for parents—especially mothers—to reduce parenting-related psychological burdens by enhancing spiritual vitality and emotional adjustment. Additionally, developing home-based practice booklets or spiritual training packages, including daily gratitude exercises, rewriting negative thoughts into spiritually positive forms, and incorporating prayer and remembrance, can help maintain long-term intervention outcomes and strengthen mothers’ psychological resilience.

Ethical Considerations

Compliance with ethical guidelines

This study was approved by the Department of Education Security Office of Zabol County and conducted at the Comprehensive Center for Assessment, Education, Rehabilitation, and Early Developmental Intervention of Zahak (Code: 14040416-201). All stages of the study—including manuscript preparation, psychological intervention, data collection, confidentiality, voluntary participation, data analysis, and accurate reporting—were conducted in accordance with the ethical principles of the 2008 revision of the Helsinki Declaration. The study was approved by the Provincial Department of Education Security Office and the Exceptional Education Administration of Sistan and Baluchestan Province, Iran.

Funding

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions

All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Conflict of interest

The authors declared no conflicts of interest.

Acknowledgments

The authors extend their sincere appreciation to all individuals who assisted in this research, especially the mothers of children with LD.