Introduction
The childs disability can profoundly affect the entire family, especially the parents. Parents typically expect the arrival of a healthy child. When developmental problems are diagnosed in their child, they may feel a great sense of guilt and responsibility for giving birth to a child with a disability [1, 2]. 
Disability is a broad concept that includes various physical, developmental, and emotional disorders [4]. One of the most common disorders in children is speech and language disorders, leading to multiple degrees of disability in children. Children with speech and language disorders have problems communicating with their environment [9]. Communication problems in these children can disrupt the acquisition of other skills and abilities, such as decision-making, self-confidence, self-esteem, independence, participation in social groups, and successful communication with peers [10]. 
Mothers are usually the primary caregivers of these children and are mostly affected psychologically. They bear the pressures and stresses of being responsible for these children [13, 14]. Mothers of children with developmental and psychological problems experience higher stress levels than mothers of typically developing children because the mother is the first person to communicate directly with the child. Feelings, such as guilt, fault, and deprivation stemming from the childs abnormality can result in the mothers isolation, depression, and disinterest in establishing a relationship with the environment; the outcomes are low self-esteem, depression, and jeopardy of mother›s mental health [15].
Rehabilitation services constitute an essential part of healthcare services for children with speech and language disorders. The process takes time and perseverance [28]. Given that rehabilitation results appear in the long term, the suitable mental conditions of parents, especially mothers, are of particular importance to continue and complete rehabilitation exercises. As such, the psychological well-being of children›s parents, particularly mothers, is a crucial sign that therapists should consider in providing treatment for children and families [14]. On the other hand, anxiety and depression are prominent symptoms that affect health-related QoL (HRQoL) [29].
Mothers play an essential role in the treatment process of their children; thus, their engagement in speech and language rehabilitation services and its resultant recovery over time can affect their stress levels, mental well-being, and quality of life (QoL) [23]. Hence, the duration of receiving rehabilitation interventions plays a vital role in the anxiety, depression, and QoL of mothers of children with speech and language disorders. Regrettably, this issue has not been addressed in previous studies.
Given the effectiveness of rehabilitation of speech and language disorders as well as the time-consuming nature of rehabilitation, we hypothesize that the level of stress, depression, and QoL in mothers of children with speech and language disorders will change over time (<1 month up to >1 year) after receiving rehabilitation services. Therefore, our study examined the relationship between anxiety, depression, and QoL in relation to the duration of receiving rehabilitation services. 

Materials and Methods
This study was a cross-sectional descriptive-analytical study. The mothers were selected by convenience sampling. A total of 185 mothers of children with speech and language disorders were selected from mothers of children who received rehabilitation services in speech therapy centers affiliated with Ahvaz Jundishapour University of Medical Sciences, Ahvaz City, Iran, based on the inclusion and exclusion criteria. The childs specific disorder was diagnosed by a psychiatrist, audiologist, and or speech therapist, depending on the type of speech and language disorder.
The inclusion criteria included having a child with a speech/language disorder, possessing the educational proficiency to read, understand, and complete the questionnaire, demonstrating willingness to cooperate and participate in the project, and being 20-45 years old. The exclusion criteria included multiple interruptions in receiving child rehabilitation services and multiple disability disorders in the child. Based on the duration of receiving rehabilitation services, mothers participating in this study were divided into four groups: Mothers whose children had received rehabilitation services for <1 month, mothers whose children had received rehabilitation services between 1 and 6 months, mothers whose children had received rehabilitation services between 7 and 11 months, and mothers whose children had received rehabilitation services for >12 months. Also, other factors, including the child’s disorder, the mother’s age, level of education, and job status, were considered for group comparisons.
Before filling out the questionnaires, the procedure and purpose of the study were fully explained to the mothers. They were assured that the information obtained would remain confidential. Then, they were asked to complete a written informed consent form. During this process, a researcher, responsible for collecting the questionnaires, was present at the site to solve the problems and answer the mothers’ questions. The mothers were invited to complete the questionnaire in one of the quiet rooms of the medical center.
In this study, we used the parental stress index short form (PSI-SF) to measure stress, the Beck depression inventory-2nd edition (BDI-II) to measure mothers’ depression, and the health background questionnaire (short form of 36 questions) (SF- 36) to measure the quality of life. PSI-SF is a 36-item self-report scale with three subscales: Parental distress, challenging child behavior, and dysfunctional parent-child interactions [34]. BDI-II is a 21-question questionnaire and one of the widely recognized and commonly used self-report measures of depression symptoms in people over 13. Answers are given using a 4-point scale from 0 to 3 [39]. Finally, the health assessment questionnaire is a short and multi-purpose health assessment questionnaire containing 36 questions. It consists of 8 subscales: Physical functioning, physical limitations, body pain, general health, vitality, social function, role-emotional problems, and mental health [44]. 

Statistical analysis 
In this study, we used the Shapiro-Wilk test to examine the normality of data distribution, Levene’s test for homogeneity of variances, and the M-box test to check the homogeneity of variance-covariance matrices. One-way analysis of variance (ANOVA) test and Tukey’s post hoc test were used to compare the groups based on the duration of receiving rehabilitation services. Also, to compare the QoL, the level of anxiety, and depression of mothers in study groups, we used the multivariate ANOVA test. This analysis considers the effect of four factors: Type of disorder, age, education level, employment of mothers, as well as their interactive effects. Data were analyzed using SPSS software, version 22 at a significance level of 0.05.

Results
Table 1 presents the demographic characteristics of the participants.


The Mean±SD age of mothers was 36.6±5.2 years. 
According to the results of the Shapiro-Wilk test, the significance levels of all research variables exceeded 0.05, so the data of all variables were normally distributed. Also, based on the level of significance obtained in Leven's test, the equality of variances was established (P<0.05). Therefore, this assumption was also confirmed. The results of the M-box test also indicated that the assumption of homogeneity of the variance-covariance matrices was established (P<0.05). 
The one-way ANOVA showed that the effect of the duration of receiving rehabilitation services on the average scores of PSI, BDI-II, and SF-36 was statistically significant. Specifically, mothers whose children received rehabilitation services for >12 months had the lowest score in PSI and BDI-II and the highest score in SF-36 compared to the other 3 groups (P<0.001) (Table 2). 


Also, the paired comparisons of Tukey’s post hoc test revealed that mothers whose children had received rehabilitation services for <1 month, compared to the other 3 groups had a lower QoL score and a higher level of stress and depression (P<0.001) (Table 3). 


Also, based on the results of the multivariate ANOVA test, the effect of the type of disorder on the average scores of PSI, BDI-II, and SF-36 was statistically significant (P<0.05). So, mothers with children with speech production disorder displayed the lowest level of stress and depression (46.79±12.08 and 9.11±3.07, respectively) and the highest level of QoL (78.81±9.95). However, mothers of children with autism had the highest level of stress and depression (74.12±26.47 and 9.11±3.07, respectively) and the lowest level of QoL (71.66±6.24). In examining the effect of the mother’s age and education factors on the mean scores of PSI, BDI-II, and SF-36, no single or interaction effect was found on the studied variables (P>0.05). Lastly, the interactive and combined impact of the two factors of disorder type and duration of receiving rehabilitation, as well as three factors of disorder type, duration of receiving rehabilitation, and mother’s occupation, on the results of the mean PSI scores of mothers were significant (P<0.05). In other words, mothers of children with autism who had received rehabilitation services for >1 month, had the highest level of stress (119.54±25.33), and mothers of children with voice disorder who had received rehabilitation services for >1 year, had the lowest level of stress (35.12±4.05). Also, household mothers of children with autism who had received rehabilitation services for <1 month, had the highest level of stress (121.37±22.09), and working mothers of children with speech production disorder who had received rehabilitation services for >1 year, had the lowest level of stress (29.00±3.46).

Discussion
This study investigated the effect of the duration of rehabilitation interventions on the psychological characteristics and QoL of mothers of children with speech and language disorders. Children with speech and language disorders need specialized medical and healthcare attention, and mothers usually assume a vital role in meeting these needs [47, 48].
Overall, our results showed that mothers whose children received rehabilitation services for a longer period exhibited lower levels of stress and depression and a higher QoL. Therefore, receiving ongoing rehabilitation services increases the QoL of mothers and reduces their stress and depression over time. One possible reason for this outcome is that mothers who have recently discovered their children's problems are at the beginning of the treatment process and may have doubts about the effect of educational programs, thus experiencing more anxiety. However, since the results of rehabilitation interventions are revealed over time, ie, the child's communication skills improve, and the behavioral problems are reduced, mothers who receive rehabilitation services for a longer period may see more improvement in their children. Also, they are better equipped with stress-coping strategies to deal with their child's condition, resulting in improved psychological well-being [49].
This result was consistent with a study conducted by Robertson and Wisemer, who concluded that intervention for children with language delays not only improved their language skills but also enhanced their social skills and reduced parental stress [50]. Also, Burger et al. showed that the stress level in mothers of hard-of-hearing children was very high after diagnosing their child's problem. However, their stress level decreased with the beginning of treatment sessions and over time [51]. In Lederberg's study, mothers of 22-month-old hard-of-hearing children were more concerned about their child's condition than mothers of normal-hearing children. Nevertheless, no significant difference was observed in the mean PSI of mothers of 3- and 4-year-old children. They found that this lack of difference in the preschool period may be due to the success of early intervention programs [52].
Among different speech and language disorders, mothers of children with autism disorders had higher stress and depression scores and lower QoL. This result is consistent with the study conducted by Burgis et al. and Islami et al [15, 53]. Their studies indicate that the QoL, hope, and meaning of life of mothers of children with autism are significantly lower than that of mothers with healthy children and mothers with deaf children or with intellectual learning problems [14 , 53]. Also, Ogeston et al. found that mothers of children with autism reported lower hope and more worry about the future than mothers with children with Down syndrome [54]. Lloyd et al. in a study, examined the relationship between hope and mental health in 198 mothers of children with mental retardation, autism, and Down syndrome and found that mothers of children with autism had a lower score on the hope and mental health scale compared to the other two groups [55]. In explaining the low level of hope observed in the mothers of children with autism compared to other mothers, we can attribute this difference to some of the characteristics of autism disorder compared to other disorders. These characteristics, such as language, communication, behavioral, and social abnormalities, create a lot of tension in the family and require special and continuous care, education, and treatment for children with autism [15]. 
Future studies are suggested to adopt a longitudinal approach, spanning an extended approach, and involve a larger sample size.

Conclusion 
The results of this study indicate that therapeutic interventions and the improvement of children’s communication skills are an opportunity to support mothers of children with speech and language disorders. By determining treatment goals and participating mothers in their child’s treatment and the consequent improvement, therapists can increase mothers’ satisfaction with their children’s recovery process and, as a result, reduce their stress and depression and increase their QoL. Therefore, it is suggested to hold educational and counseling classes to reduce the worries of mothers of children at the beginning of treatment and to increase their awareness about their child’s personality and communication characteristics. Also, forming mothers’ groups to share their experiences can provide a valuable platform for these families to receive support from each other and increase their hope. 

Ethical Considerations
Compliance with ethical guidelines
This study approved by the Ethics Committee of Jundishapur Ahvaz University of Medical Sciences (AJUMS) (Code: IR.AJUMS.REC.1399.291). Before the participants completed the questionnaires, the procedure and purpose of the study were fully explained to them. The participants were assured that the information obtained from the questionnaires would remain confidential, and written consent was obtained from the participants. In this study, they were allowed to exclude the study whenever they wanted.

Funding
This article was derived from a research project (No.: PHT-9910) under the auspices of the Research and Technology Vice-Chancellor of Jundishapur University of Medical Sciences. 

Authors' contributions
Conceptualization and methodology: Masoumeh Hosseini Bidokhti and Azadeh Abedinzadeh; Research and data collection: Fateme Shamal Nasab, Fatemeh Sotoudeh Lar, Emad Azhdari and Kobra Rajabi; Data analysis: Seyyed Mahmoud Latifi; Writing the initial draft and sourcing: Azadeh Abedinzadeh, Masoumeh Hosseini Bidkhti and Fatemeh Hosseini Bidkhti; Editing the paper and finalization: Masoumeh Hosseini Bidkhti, Azadeh Abedinzadeh, Seyed Mahmoud Latifi, Fatemeh Hosseini Bidkhti and Negin Moradi. 

Conflict of interest
The authors declared no conflict of interest. 

Acknowledgments
The authors express their gratitude to all the mothers who participated in this study, as well as the esteemed staff of the speech therapy department of the centers covered by Ahwaz Jundishapur University of Medical Sciences who cooperated in this study.

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