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This article was downloaded by: [York University Libraries]On: 21 November 2014, At: 13:11Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
European Journal of Special NeedsEducationPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/rejs20
Parent stress and satisfaction withearly intervention services for childrenwith disabilities – a longitudinal studyfrom GermanyKlaus Sarimski a , Manfred Hintermair a & Markus Lang aa Institut für Sonderpädagogik, University of Education ,Heidelberg , GermanyPublished online: 22 May 2013.
To cite this article: Klaus Sarimski , Manfred Hintermair & Markus Lang (2013) Parent stressand satisfaction with early intervention services for children with disabilities – a longitudinalstudy from Germany, European Journal of Special Needs Education, 28:3, 362-373, DOI:10.1080/08856257.2013.797706
To link to this article: http://dx.doi.org/10.1080/08856257.2013.797706
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Parent stress and satisfaction with early intervention services forchildren with disabilities – a longitudinal study from Germany
Klaus Sarimski*, Manfred Hintermair and Markus Lang
Institut für Sonderpädagogik, University of Education, Heidelberg, Germany
(Received 26 February 2013; final version received 17 April 2013)
This study assessed parent–child and family-related stress at two points of timeand analysed relationships between stress, child and family characteristics andparent satisfaction with early intervention services. In Germany, 125 parents ofyoung children with intellectual disabilities, hearing impairment or visualimpairment responded to a questionnaire. Eighty-seven parents agreed to partici-pate in the second survey. Results indicated that (a) perceived parenting compe-tence is associated with general self-efficacy and satisfaction with professionalsupport, (b) parent–child interactional stress increased with time, specifically infamilies with children with intellectual disability or visual impairment, (c) thelevel of satisfaction with amount and quality of family support was low in aconsiderable subgroup of parents, (d) regression analyses support predictive rela-tionships among parent–child stress, family-related stress, perceived parentingcompetence and satisfaction with early intervention services.
Keywords: parent–child stress; family-related stress; satisfaction with earlyintervention
Parenting stress is an important variable to consider when providing early interven-tion services for children with disabilities and their families. The great demandsplaced on mothers and fathers who are rearing a child with special needs may con-tribute to high levels of parenting stress (Glidden 2012). However, results fromstudies with parents of children with different handicaps are inconclusive. Forexample, some studies with parents of deaf children report a level of stress that isnot higher than stress reported by parents of hearing children (Pipp-Siegel, Sedey,and Yoshinaga-Itano 2002). A growing body of evidence has shown that parentstress is associated not only with the type and level of child disability but with thedegree of behavioural problems that the child presents in daily family life (Bakeret al. 2002, 2003). Moreover, previous investigations have identified several parentand family characteristics as a potential buffer against stress, including perceivedcontrol over their life circumstances (Paczowski and Baker 2007; Glidden andNatcher 2009) and perceived social support which influence parents’ stress andwell-being (Asberg, Vogel, and Bowers 2008; Trivette, Dunst, and Hamby 2010),but the particular relationships between these protective factors deserve furtherstudy.
*Corresponding author. Email: [email protected]
European Journal of Special Needs Education, 2013Vol. 28, No. 3, 362–373, http://dx.doi.org/10.1080/08856257.2013.797706
� 2013 Taylor & Francis
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Furthermore, parent stress and child behaviour problems are not stable overtime. Baker et al. (2002, 2003) reported on parent stress and behaviour problems ina longitudinal study with 225 young children with and without disabilities. Theyreported a stable correlation between parent stress and behaviour problems andfound that behaviour problems were predictive for the course of parent stress duringthe following year. Gerstein et al. (2009) followed the same sample up to the ageof five. Maternal stress was significantly associated with the perceived quality ofspouse relationship. According to the results of another longitudinal study (EarlyIntervention Collaborative Study), stress in parent–child interaction (measured viathe Parenting Stress Index, PSI) increased from one to five years and familycohesion revealed as the main predictive variable (Erickson Warfield et al. 1999).
A second line of research supports the evidence of relationships betweenparental satisfaction with early intervention services and parental stress. Measuringparent satisfaction has long been a critical focus of early intervention programs inthe USA as well as in Europe (McNaughton 1994; Mahoney and Filer 1996; Lan-ners and Mombaerts 2000; Peterander 2000; Bailey et al. 2008). Although there isconsensus that it is essential in the evaluation of early intervention programmes,there is a paucity of satisfaction measures. Recently, Bailey et al. (2011) reportedon the development and psychometric validation of a short measure called ‘FamilyOutcomes Survey – Revised’. Another instrument is the ‘European Parent Satisfac-tion Scale about Early Intervention’ (EPASSEI; Lanners and Mombaerts 2000; Zivi-ani, Cuskelly, and Feeney 2010) which has been used in studies with mothers orchildren with physical handicaps or developmental disabilities, while experienceconcerning its reliability and validity in other samples (e.g. mothers of hearing orvisual impaired children) is still lacking.
Despite the common assumption that rearing a child with a disability such ashearing loss, visual impairment or intellectual disabilities may put strain on parents,so studies have shown that not all families are at risk, that is, some factors mayshield parents from the stress generated by their child. The complex relationshipsbetween characteristics of children, families and services, parenting competence, par-ent stress and well-being, parental control attributions and parental satisfaction withearly intervention services are not fully understood and information from a longitudi-nal perspective is lacking. The current study aims to contribute to the informationavailable regarding the longitudinal course of parent stress and satisfaction with earlyintervention services in a German sample including mothers of children with mentalretardation, hearing impairment or visual impairment. 125 families contributed to thedata of the survey. In order to analyse longitudinal relationships, they were asked tocomplete the questionnaire twice with a time interval of one year. Specifically, weanalysed the following hypotheses:
(1) There is a significant correlation between individual/social characteristics ofparents and children and perceived parent stress.
(2) Parent stress differs between parents of children with intellectual disabilities,hearing impairment or visual impairment.
(3) Parent stress and/or parent satisfaction with early intervention change duringa year of service.
(4) Parental satisfaction with services and parental self-efficacy as variablesobtained from the first survey predict the level of parent stress reported oneyear later.
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Methods
Participants
Participants at time 1 were 125 carers (mainly mothers, i.e. 92%) of children up tothe age of 3 years with intellectual disabilities, hearing or visual impairment. Meanage of the parents was 35.4 years (SD= 5.5 years). Parent’s education level was highin nearly half of the sample. Family income was reported as more than 3.000e in30.4%, 1.500–3.000e in 52.8% and lower than 1.500e in 9.6% (9 cases missing).56.8% of the parents came from a rural area. Most parents (96%) were married orlived with a partner. Participants were contacted via 15 early intervention centres inthe south of Germany.
Mean age of the children at time 1 was 30.9months (SD= 12.6months). Sixty-three of them were males. Sixty-seven children (53.2%) had intellectual disabilities,37 children (29.4%) had a hearing impairment and 22 children (17.5%) a visualimpairment. Additional impairments were reported in 41 cases (40.8%), for exam-ple, a combination of visual impairment and intellectual disabilities. In 18 children(14.4%), the health status was reported as unstable or low (no specific informationavailable). Early intervention had started in the first year of life in the majority ofcases (M= 11.2months; SD= 9.6months).
At time 2, 87 parents (69.6% of the original sample) agreed to contribute datato the second survey. The sample characteristics at both points of time do not differconcerning sociodemographic characteristics of the families or developmental statusof the children with the exception that there is a tendency that less parents with avisually impaired child contributed data to the follow-up in comparison with theother groups (χ² = 5.64; df = 2; p< .06).
The German system of early intervention offers home-based and centre-basedservices. Programme characteristics were reported as home-based in 63.2% and ascentre-based only in 31% of cases. The mixed form was chosen more often in theservices for hearing impaired children (χ² = 10.1, df= 2, p< .006). Sixty-four percent reported using the services once or twice in a week, 15.2% every fourteendays, 12.5% once in a month. In 17 families (13.6%), frequency of services wasless than once in a month.
Measures
Parent–child stress
As a measure for parent–child stress, we used 12 items on parent–child interactionfrom the ‘Parenting Stress Index – Short Form’ (PSI-SF; Abidin 1999). The PSI-SFhas been proved as a valid measure for parent stress in various international studieson this topic. The PSI-SF uses a five-point Likert-type scale for responses rangingfrom strongly disagree (1) to strongly agree (5). Examples of items are as follows:‘It takes a long time and it is very hard for my child to get used to new things.’ or‘Sometimes my child does things that bother me just to be mean’. Cronbach’s coef-ficient alpha was calculated as .83 in the current sample and is acceptable.
Family-related stress
As measure for family-related stress, we used the German version of the ‘FamilyImpact Scale’ (Ravens-Sieberer et al. 2001). The ‘Family Impact Scale’ is a 27-itemscale using a four-point Likert-type scale format, with higher scores indicating
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higher levels of family-related stress. Examples of items: ‘Nobody understands theburden I carry’ or ‘I live from day to day and do not plan for the future’. The itemsare grouped into four subscales: daily hassles and social disruptions, personal strain,financial strain and coping problems. Internal consistency was good in the currentsample (Cronbach’s α= .90).
General self-efficacy
As a measure for the individual’s perceptions of himself or herself as competent incoping with stress, a well-validated German questionnaire was used (‘AllgemeineSelbstwirksamkeitserwartung’, i.e. ‘general self-efficacy’; Schwarzer and Jerusalem1999). The instrument consists of ten items purporting to assess general optimismand internalised locus of control, that is, it is not specific for challenges in the lifeof parents of children with developmental disabilities, and Items are, for example,‘I am able to find a solution for every problem.’ ‘What ever may happen, I shallget along with it.’ Internal consistency in the current sample was acceptable(Cronbach’s α= .87). This instrument was administered in the first survey only,because general self-efficacy is seen as a rather stable individual characteristic.
Parenting competence
Additionally, four items of the ‘Early Intervention Parenting Self-Efficacy Scale’(EIPSES; Guimond, Wilcox, and Lamorey 2008) were administered in a Germanversion. An exploratory factor analysis suggested these four items as characteristicfor individually perceived competence in parenting a child with disabilities. Theitems were as follows: ‘If my child is having problems, I would be able to think ofsome ways to help my child.’ ‘When my child shows improvement, it is because Iam able to make a difference in my child’s development.’ ‘If my child learns some-thing quickly, it would probably be because I know how to help my child learnnew things.’ ‘Over the past year, I can see the progress that I have made in becom-ing a better parent.’ However, the internal consistency revealed to be low whichmay be caused by the short item list (Cronbach’s α= .55).
Social resources
As a measure for the parent satisfaction with social resources, we used a scale from aGerman questionnaire that was developed to reflect various coping styles of parentswith children with developmental disabilities (Krause and Petermann 1997). Thisscale consists of nine items reflecting satisfaction with support of spouse, relatives,friends and professionals. The items differentiate between practical and emotionalaspects of support. Internal consistency was acceptable (Cronbach’s α= .77).
Behaviour problems
Child behaviour problems were assessed using 12 items on social reactivity, persis-tence and impulsivity/hyperactivity. Higher scores reflect a higher level of problems.A general score was obtained from these items to cover behaviour problems.Reliability was in the moderate range (Cronbach’s α= .74). The scale measuringbehaviour problems – as well as the following scale measuring child competence –was constructed for this survey.
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Child competence
The parents were asked for information on developmental milestones in the follow-ing domains: motor development, play development, self-help skills and languagecompetence. The items were combined to a general score reflecting developmentallevel. Internal consistency for this scale was high in the current sample (Cronbach’sα= .94).
Parent satisfaction with early intervention services
In order to assess parent satisfaction with the quality of early intervention services,we translated 12 items from a national survey on first experiences with early inter-vention in the USA (Bailey et al. 2004). These items differentiated between per-ceived outcomes of early intervention and perceived satisfaction with services. Thisscale uses a four-point Likert-type scale (less satisfied, partially satisfied, rather sat-isfied, very satisfied). Specifically, the parents were asked to score their satisfactionwith the amount and quality of child-oriented therapy, with the amount and qualityof family support, with the number of professionals included and with the collabo-ration among the professionals. The internal consistency of the scale proved to begood in the current sample (Cronbach’s α= .94).
Results
Prediction of parent stress at time 1
A path analysis was conducted to examine the relationship between several inde-pendent variables and parent stress. Figure 1 provides the significant paths, onlywithout indicating the covariances between the independent variables. The model ishypothesis driven, that is, the paths between parenting competence to parent–childand family-related stress were set as well as the paths between general self-efficacyand parent satisfaction with early intervention services and parenting competence.The other relationships revealed as significant by running an exploratory analysis.
The statistics revealed a good model fit (CFI = .94; RMSEA 0.07); the factorsexplained 56% of the variance in family-related stress and 51% of the variance inparent–child stress. Perceived parenting competence was significantly and nega-tively related to family-related stress (�.18) and parent–child stress (�.24). Parentgeneral self-efficacy was associated with parent competence in supporting the devel-opment of child with a intellectual disability, that is, parents with a high level ofgeneral self-efficacy report a higher level of parenting competence (.29). Addition-ally, a higher level of parent satisfaction with early intervention services was relatedto the development of parenting competence (.18).
However, the results provided support for the hypothesis that other variables areequally or more important for the level of parent stress. For example, higher scoresfor child behaviour problems are related to parent–child stress (.56), while higherscores in child competence are related to less family-related stress (�.40). A satis-factory child health status is related to less family-related stress (�.27) and less par-ent–child stress (�.22). Among the other variables social support is negativelycorrelated with family-related stress (�.41), but not with parent–child stress. Finallyparent competence is significantly related to parent educational level. Parents with ahigher education level report lower scores in parent competence (�.23).
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Between-group differences
In order to analyse group differences between the three groups at time 1 (childrenwith intellectual disabilities, children with visual impairment and children with hear-ing impairment), an ANOVA was conducted (Table 1).
The analysis of variance revealed significant group differences in parent–childstress (p< .005) which are due to a higher level of stress reported by parents ofchildren with intellectual disabilities in comparison with parents of hearing impair-ments (Scheffe Test). Family-related stress was significantly different, too (p< .046).There is a tendency for higher daily stress levels reported by parents of childrenwith intellectual disabilities (p< .10) and for higher scores of financial stressreported by parents of children with intellectual disabilities and parents of childrenwith visual impairments in comparison to parents of children with hearing impair-ments (p< .10). Additionally, there are significant group differences regarding childbehaviour problems and child competencies: Children with hearing impairmentshow less behaviour problems and more competencies than children with intellec-tual disabilities (Scheffe’s test). There were no significant differences betweengroups in personal and social resources (general self-efficacy, parent competenceand social support) or parent satisfaction with early intervention services.
Change of parent characteristics between Time 1 and Time 2
In Table 2, mean scores and SD in parent–child stress, family-related stress, parentcompetence, social support and behaviour problems as well as parent satisfaction
Figure 1. Path analysis presenting relevant factors of parental coping with family andinteractional stress.
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with early intervention services are shown for time 1 and time 2. Parent–child stressis significantly elevated at time 2, while the other parent characteristics did notchange significantly. Specifically, parent–child stress of parents of children withhearing impairments tend to be lower than parent–child stress in the other groups(p< .09).
Parent satisfaction with early intervention services
Table 3 presents data concerning parent satisfaction with early intervention servicesat time 1 and time 2.
In general, a considerable subgroup of parents reports to be less or only partiallysatisfied with the amount and the quality of family support they received. Althoughthe number of parents reporting to be less or only partially satisfied decreased fromTime 1 to Time 2, more than 30% of the respondents reported that their programsdid not provide all the services, which the parents needed. Using the parents’ rat-ings as an ordinal scale and examining differences, the change of scores did notreveal as significant in most of the scales. However, there was a tendency to reporta lower level of satisfaction with the quality of the child-oriented therapy at time 2
Table 1. Group differences in parent and child characteristics between children withintellectual disabilities, visual and hearing impairments (n= 125).
Intellectualdisabilities
Hearingimpairment
Visualimpairment
M SD M SD M SD F
Parent–child stress (PSI) 24.77 7.71 19.89 6.51 22.23 6.42 5.58⁄⁄Family-related stress (FaBel) 2.13 .55 1.87 .45 1.97 .50 3.15⁄General self-efficacy (SWE) 3.05 .44 3.07 .42 3.00 .48 .14Social support (SOEBEK) 4.58 .69 4.54 .84 4.66 .77 .19Parenting competence (EIPSES) 3.57 .52 3.71 .57 3.70 .63 .94Child behaviour problems 1.76 .41 1.52 .28 1.72 .24 5.82⁄⁄Child competence 2.00 .60 2.39 .52 2.01 .79 5.06⁄⁄Parent satisfaction with early intervention 2.85 .78 2.88 .71 3.00 .77 .27
⁄⁄p< .01; ⁄p< .05.
Table 2. Change in parent characteristics between Time 1 and Time 2 (n= 87).
Scale
Time 1 Time 2
M SD M SD T
Parent–child stress (PSI) 23.58 7.39 26.29 6.81 �4.33⁄⁄⁄Daily hassles and social disruptions (FaBel) 2.16 .69 2.24 .72 �1.50Personal strains (FaBel) 2.38 .58 2.33 .70 1.72Financial strains (FaBel) 2.19 .76 2.36 .86 �1.33Problems with coping (FaBel) 1.59 .41 1.54 .53 .79Family-related stress (FaBel) 2.19 .58 2.22 .62 �1.00Social support (SOEBEK) 4.65 .73 4.58 .78 1.00Parenting competence (EIPSES) 3.66 .36 3.62 .46 .09Child behaviour problems 1.63 .36 1.68 .35 �1.80Parent satisfaction with early intervention 3.00 .76 2.96 .84 .90
⁄⁄⁄p < .001.
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(T= 1.90; df= .84; p< .06). Additionally, the satisfaction with the collaboration withprofessionals decreased significantly (T= 2.11; df= .80; p< .03).
Prediction of parent stress at Time 2
Two regression analyses were conducted to determine how relevant variablesobtained at time 1 predicted parent stress levels at time 2. The scores of parent–child stress and family-related stress were used as dependant variables. Parentalresources (general self-efficacy, parent competence, social support), child character-istics (behaviour problems, competence) and parent satisfaction with early interven-tion services were used as predictors.
The amount of variance explained by the independent variables was 64% forparent–child stress and 78% for family-related stress (we adjusted R square accord-ing to the sample). In both regression analyses, the level of stress obtained at time1 determined stress level at time 2. Additionally, parent–child stress at time 2 waspredicted by the parent’s satisfaction with early intervention services at time 1. Par-ents who reported a higher level of satisfaction reported a lower parent–child stressat time 2. For family-related stress parent competence obtained at time 1 revealedas a significant predictor for stress at time 2. Parents with higher perceived compe-tencies showed les family-related stress (Tables 4 and 5). Practical and emotionalsupport did not reveal as a significant predictor for change in parent stress levels.
Discussion
This study examined the parent–child interaction and family-related stress of 125parents of children with intellectual disabilities, hearing impairments and visualimpairments. Parents were interviewed via standardised questionnaires twice during
Table. 3. Parent satisfaction with early intervention services at Time 1 and Time 2 (in%;N= 87).
Time 1 Time 2
I am satisfied with …Low/
partiallyRather/very
Low/partially
Rather/very
Impact on child quality of life 28.7 71.3 29.8 68.9Impact on family quality of life 39.1 59.8 39.0 59.8Impact on child development 17.2 82.8 21.8 77.0Impact on parenting competence 43.7 54.0 42.5 56.3Impact on social support 52.9 44.8 57.4 39.1Impact on optimism 43.7 55.1 39.0 59.8Satisfaction with amount of child-orientedtherapy
17.2 81.6 19.5 78.2
Satisfaction with amount of familysupport
41.3 57.5 36.8 60.9
Satisfaction with quality of child-orientedtherapy
9.1 89.6 18.4 79.3T
Satisfaction with quality of family support 43.6 54.0 33.3 63.2Satisfaction with number of professionals 21.8 75.8 24.1 72.4Satisfaction with collaboration withprofessionals
14.9 82.8 21.8 72.4⁄
⁄p < .05; Tp< .10.
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a year. The data were analysed for relationships between stress level and severalchild and parent characteristics. Eighty-seven parents participated at time 2. Thesample consisted of young children with less than three years of age at time 1 inthe majority of cases.
Overall, the analyses of the relationships support the hypothesis that parentswho perceive a higher level of parenting competence report lower levels of dailyparent–child stress and general family-related stress. However, practical and emo-tional support was not related to change of parent stress during a year of early inter-vention. This finding is contrary to our expectations. Perceived parentingcompetence that is associated with general self-efficacy seems to be more important.Additionally, these parents report a higher level of satisfaction with the professional
Table 4. Multiple regression analyses of the relationship of child and family characteristicsto parent–child related stress at Time 2 (n = 87).
Predictors time 1
Parent–child stress (PSI) Time2
F (df 8,66) = 17.66⁄⁄⁄
β T
(constant) .92PSI Time 1 .67 7.20⁄⁄⁄General self-efficacy �.07 �.87Parenting competence .08 1.02Practical support �.00 .97Emotional support .19 1.83Child behaviour problems .12 1.32Child competence �.11 �1.43Satisfaction with early intervention services �.19 �2.62⁄
R= .83; R2 = .68; korr. R2 = .64
⁄p < .05; ⁄⁄⁄p < .001.
Table 5. Multiple regression analyses of the relationship of child and family characteristicsto family-related stress at Time 2 (n= 87).
Predictors Time 1
Family-related stress (FaBel)Time 2
F (df 8,61) = 31.55⁄⁄⁄
β T
(constant) .14FaBel Time 1 .91 9.84⁄⁄⁄General self-efficacy .01 .21Parenting competence �.12 �2.04⁄Practical support .06 .67Emotional support .06 .77Child behaviour problems �.01 �.16Child competence �.03 �.45Satisfaction with early intervention services .03 .51
R= .90; R2 = .80; korr. R2 = .78
⁄p < .05; ⁄⁄⁄p < .001.
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support they receive in early intervention services. These results suggest that inthese cases the professionals succeeded in involving parents in early interventionactivities and promoting their empowerment. Parent control attributions did notreveal as the dominant factor determining parent stress, however. Child behaviourproblems and child competence were equally or more important for the explanationof variance in parent stress scores. This finding is consistent with previous researchthat child characteristics have a significant impact on perceived parent stress (Bakeret al. 2002, 2003).
Analysing between-group differences, the results showed that parents of childrenwith hearing impairments perceive less parent–child interactional stress incomparison with parents of children with intellectual disabilities or visualimpairments. These finding supports some previous investigations with parents ofdeaf children (Pipp-Siegel, Sedey, and Yoshinaga-Itano 2002). We also found lowerscores for child behaviour problems in this group. Both relationships revealed asstable over time. That means that parent stress levels are determined by aheterogeneous group of variables including child disability itself.
The study has several limitations. First, the sample is self-selective, that is, thereis no way of knowing whether the parents who agreed to participate are representa-tive of individuals engaged in early intervention in general. Our procedure (askingservice providers to select typical parents from their caseload) likely resulted in anoverrepresentation of parents who were actively involved in their children’s serviceprogrammes. Second, the internal consistency of the items constructing the scale forparent competence proved as less than acceptable. For further studies, we intend todevelop a measure for perceived parenting competence which is more comprehen-sive and reliable than the four item set from the EIPSES questionnaire used in thissurvey. Third, all variables are assessed by parental report. Independent measure-ment of parenting competence and social support would be desirable.
In spite of these limitations, the results suggest that a considerable number ofparents did not rate the services they actually received as consistent with theirneeds. Specifically, they reported a low level of satisfaction with the amount andquality of family support, while the child-oriented therapies received higher ratings.These results persist for both points of time. Additionally, the satisfaction with thecollaboration with professionals decreased from time 1 to time 2. That means thatthe results of our study provide little support for a family-needs driven model inpractice.
These results may have implications for interventions with this population. Itseems that early intervention professionals (in Germany) should respond more tothe priorities and needs of families and should focus more specifically on promotingparenting competence as a major variable to reduce parent stress. To the extent thatour regression analyses were sensitive to factors contributing to important variablesdetermining family stress, it appeared that the parents’ satisfaction with early inter-vention services is predictive for parent–child stress and that the parents’ perceivedparenting competence is predictive for family-related stress one year later. Theseresults should be considered with caution regarding generalisability, however. Oursample consisted primarily of mothers and may not generalise, highlighting thatmore research into the experience of fathers is warranted. Additionally, futureresearch may want to investigate different models of early intervention servicescomparing systematically the effects of more family-driven services in comparisonwith child-driven models of early intervention. Finally, the use of independent
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measures of parenting competence and social support is desirable in order to ruleout the possibility that some of the results are influenced by rater effects as weapplied parental reports for measurement only.
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