Autism in developing countries: lessons from iran

Needs and Coping during the COVID-19 Pandemic among Families of Children with Autism Spectrum Disorder in a Government Tertiary Hospital

Background

The COVID-19 pandemic has affected the well-being of children with Autism Spectrum Disorder (ASD) and their families. The core deficits of the condition and increased parental stress during this time made them more vulnerable.

Objectives

This study aims to explore how the pandemic has affected these families by identifying their needs and capabilities in order to provide support.

Methods

A total of 227 parents of children with ASD completed an online survey consisting of items on socio-demographics, family needs, and coping strategies. Descriptive statistics were used and t-test and ANOVA/Kruskal Wallis were used to determine the relationship between parent and child factors with needs and coping.

Results

Needs for Information, Community Services, and Finances are the top categories while the greatest identified need during this pandemic was for financial assistance. Religiosity, Problem-Solving, and Cognitive Reappraisal were the widely used coping strategies by the parents. Fathers, younger children, daughters with ASD, and having more than one child with ASD showed significant association with needs. Parents with primary and tertiary education were associated with use of the cognitive reappraisal strategy and those with jobs were associated with substance use.

Conclusion

Families of children with ASD have multiple needs during this pandemic, from autism-specific information and services, to more generic concerns such as financial assistance. Despite these challenges, these families have positive strategies in place to facilitate coping mechanisms.

Autism community priorities in diverse low-resource settings: A country-wide scoping exercise in India

LAY ABSTRACT

It is vital to directly engage with the autism community in order to develop better services and drive the research agenda. While some studies in high-income countries have mapped the priorities of the autism community, there is a severe dearth of such efforts in the global south. Five million autistic individuals are estimated to live in India alone, and there has been little effort to map their priorities. Moreover, studies in high-income countries focused largely on research priorities, and not so much on skills training and interventions. Keeping these needs in mind, we conducted an online survey followed by an in-depth conversation with parents of autistic children and autistic adults drawn from across India. We found that the respondents reported self-help skills to be the most important for training, as they considered it fundamental for every other aspect of life. Speech and language therapy was considered to be the highest intervention priority for this group, highlighting the importance of social communication. Mental health counselling was also considered to be a high priority, but several parents identified it as being more relevant for themselves rather than for their children. Within research, the topmost priority was to understand ways in which the community can better support autistic people. We hope that these findings will help researchers, policymakers and service providers to be able to make well-informed decisions, develop relevant services and shape future research.

Psychometric properties of the Turkish version of the parental competence scale for parents of children with autism

BACKGROUND

Parental competence is an important concept in increasing the quality of care provided to individuals with special needs and the quality of life of parents. This study was aimed to evaluate the psychometric properties of the Turkish version of the Parental Competence Scale designed for parents of children with autism spectrum disorders.

METHOD

This methodological study was conducted with 433 parents of children with autism between November 2021 and February 2023. Information Form, the Parental Competence Scale for Parents of Children with Autism, and the Parental Self-Efficacy Scale were used to collect the data. The data were assessed using content and construct validity, item analysis, confirmatory factor analysis, and internal consistency. Guidelines for reporting reliability and agreement studies (GRRAS) were adhered to in the study.

FINDINGS

The content validity index of the scale was 0.93. Item-total score correlation values ranged from 0.338 to 0.846. As a result of confirmatory factor analysis, the two-factor structure of the scale consisting of 19 items was confirmed. Factor loads were >0.30 and fit indices were >0.80. The Cronbach's alpha coefficient of the Turkish version of the scale was 0.85, and the Cronbach's alpha values of its sub-dimensions were 0.71 and 0.79.

CONCLUSION

The parental competence scale for parents of children with autism is a valid and reliable measurement tool for Turkey.

PRACTICE IMPLICATIONS

Pediatric nurses, all health professionals, special education professionals and teachers can use this scale in interventional studies aiming to evaluate or improve the competencies of parents with autistic children in the future.

Korean Immigrant Mothers and the Journey to Autism Diagnosis and Services for Their Child in the United States

Since autism diagnosis is directly linked to the availability of supportive services, identifying best practices for early diagnosis of autism has long been a concern of professionals and families. Meanwhile, studies show persistent racial disparities in autism diagnosis. Although numerous clinical diagnostic guidelines have been published, there is not enough discussion of diagnostic procedures through the lens of culturally diverse families.

PURPOSE

This study focuses on the autism diagnostic experiences that Korean immigrant mothers had with their children.

METHODS

Eleven first-generation Korean-American mothers of children with autism were included in the study. The data was collected using semi-structured interviews in Korean.

RESULTS

The main five factors (i.e., cultural beliefs and values, language barriers, complex emotions, immigration and navigating systems, and facilitators and assets) that mainly influence the diagnosis process were identified through thematic analysis.

CONCLUSION

Dynamics are interactive within and between the factors, influencing the entire diagnostic process by either delaying or facilitating the identification of a child's autism and the provision of treatment.

An Investigation on Cognitive and Behavioral Effects of Donepezil on Autistic Children in Winter 2020 in Gorgan's Taleghani Pediatric Hospital

Objectives

The present investigation has been done to study the behavioral effects of donepezil in autistic children, given that not much research has been carried out concerning using this drug for treating autism.

Materials & Methods

A cross-sectional and analytic-descriptive study was done on twenty patients with autism, aged 4-17, who visited the neurology clinic of Gorgan's Taleghani Pediatric Hospital and Yasha Pediatric Autism Clinic, Iran from 2019 to 2020. Demographic information, including sex, age, father's education, mother's education ,patient's education, family status, other problems, and ethnicity, were documented using a checklist, having been filled in during interviews with the parents. Before the trial, ABC cognitive and behavioral tests were taken to determine the children's current status. After the tests, these children received a daily dose of donepezil (10mg) before sleep for three months. At the end of the three months, the cognitive and behavioral tests were taken from the children once again. In order to analyze the effects of different factors on the studied variables, including irritability, lethargy, stereotypic behavior, hyperactivity, and inappropriate speech before and after the administration of donepezil in patients, a generalized linear model and to test the effects of donepezil on the studied variables, paired t-test was used.

Results

In this study, twenty patients were registered for the investigation, 12 (60%) male and eight (40%) female. Age groups 5-6 had the highest frequency, and age group 17 had the lowest. Regardingthe parents' education, the highest frequency was for bachelor's degrees, and the lowest was for less-than-high school education and master's degree. The highest frequency for the patients' education was kindergarten (60%), and then groups without education (20%) and elementary school-level education (15%). Most of the studied patients (80%) did not have other problems besides autism, and only 20% had other problems besides autism. The family status of 15% of the families was 'separated,' and ethnically, most patients (80%) were Fars, while the rest (20%) were Turkmen. None of the analyzed factors (age, sex, father's education, mother's education, patient's education, other problems, family status, and ethnicity) had a significant effect on the studied variables after the administration of donepezil. Among the studied variables prior to the administration of donepezil and among the analyzed factors, the father's education, the patient's education, other problems, and family status had only a significant effect on stereotypic behavior. The present research findings of the present research indicated that all the studied variables, including irritability, lethargy, stereotypic behavior, hyperactivity, and inappropriate speech, were significantly decreased toward the desired goal. The decreased amounts in irritability, lethargy, stereotypic behavior, hyperactivity, and inappropriate speech after the administration of donepezil were, respectively, 38%, 44%, 54%, 41%, and 54% and on average, these behaviors were reduced by 46%.

Conclusion

The present investigation has shown that all the studied variables, including irritability, lethargy, stereotypic behavior, hyperactivity, and inappropriate speech, were significantly decreased towards the desired goal by 46%. This significant decrease is indicative of the effectiveness of the treatment of autism patients with donepezil, and therefore, this drug can be placed as a prominent and essential part of the medical therapy of autism.

The Impact of Autism Spectrum Disorder on Parents in Arab Countries: A Systematic Literature Review

Background

Having a child with autism spectrum disorder can have significant psychological effects on parents. This systematic review summarizes the current state of literature underscoring the impact of autism spectrum disorder (ASD) on parents in Arab countries.

Methods

A systematic search of seven databases (PubMed, Scopus, ProQuest, Google Scholar, ERIC, Academic Search Complete, and PsycINFO) was performed, which identified 24 studies (20 quantitative studies and four qualitative studies) that included 3,299 parents or caregivers of children with ASD. These studies were conducted in 10 Arab countries (Saudi Arabia, Jordan, Egypt, Kuwait, Bahrain, Oman, Emirates, Palestine, Qatar, and Lebanon).

Results

The majority of the included studies found that ASD has a significant negative impact on the mental health and wellbeing of Arab parents. It was found that parents of children with ASD have a poor quality of life (QoL) and an increased risk of psychological disorders. These findings were in contrast to findings of parents of typically developing children and children with other developmental disorders. Challenges faced by parents of children with ASD were associated with several child- and parent-related factors. The most common coping strategy used by parents was religious coping.

Conclusion

The impact of ASD on parents has only recently gained traction among researchers in Arab countries. Despite several knowledge gaps, published studies have provided useful information outlining the impact of ASD on parents in some of these countries. Further research comprising larger random samples and using varied research and data-collection methods is required to understand the multifaceted challenges experienced by parents raising children with ASD in Arab countries.

“Iranian family caregivers of autistic children: the experience of stigma”

Purpose

Autistic children and their family caregivers are impacted widely by the social arrangements, which bring up a variety of problems and make their caregiving duties even more difficult. One of the main troubles family caregivers struggle with is the “Autism stigma” that eventually leads to social exclusion. This study aims to identify shreds of evidence of Autism stigma experienced by family caregivers of autistic children. The study also aims to present some general comparison between the findings in Iran and a few other countries’ available respective data to the “Autism stigma.”

Design/methodology/approach

This study is an inductive qualitative content analysis. Twelve family caregivers were purposefully selected. Data were gathered exercising semi-structured, in-depth interviews and scrutinized using content analysis method.

Findings

In the interviews with the participants, a new category called “Autism stigma” was discerned. This category includes three subcategories: “Diagnosis process,” “Lack of awareness” and “Presence in the society.”

Originality/value

In Iran, Autism is considered a kind of social stigma. It mainly happens due to a lack of public awareness about this psychological disorder. The family caregivers in the community suffer from the stigma of autism, which leads them to distance themselves from society. This paper aims to improve the social awareness in regard to the negative impacts of Autism stigma.

Characteristic Neuro-Linguistic Styles in Young Arabic Speaking Children Diagnosed with ASD

Evaluations of all Arabic speaking children age 3-9.0 years with significant speech delays or impairments, referred to a community based, child development center in the public health care system during a 5-year period were reviewed. Use of an inordinate degree of words and expressions in Fossha version of classical Arabic, mainly used in the media, children's literature and formalized venues, as well as in English, was highly associated with ASD, especially among those who were both more intelligent (IQ> 70), as well as older (greater than 4 years), (Pearson 7.29, Fisher 2-tailed test, p = 0.015). The use of "out of context" speech embedded in ordinary Arabic vernacular was associated with a higher degree of speech stereotypy (p < 0.001) among children with ASD, and unrelated statistically to the number of hours of screen viewing time, jargoning or associative speech. Idiosyncratic speech choices reflect neuro-linguistic mechanisms in social communication- impaired youngsters.

C1q/TNF-related protein-1: Potential biomarker for early diagnosis of autism spectrum disorder

INTRODUCTION

Autism spectrum disorders (ASDs) are neurodevelopmental diseases characterized by communication inabilities, social interaction impairment, repetitive behavior, as well as learning problems. Although the exact mechanism underlying this disease is still obscure, researchers believe that several factors play a significant role in its development and pathogenesis. Some authors have reported an association between adipokines family and autism. C1q/TNF-related protein-1 (CTRP1) is a member of the adipokines family, and we hypothesized that this adipokine might have an influential role in the pathogenesis of ASDs. Since there is no specific marker for screening the disease, we evaluated CTRP1 as a potential marker for achieving this purpose.

METHODS

Blood samples were collected from 82 (41 ASDs boys, 41 healthy boys as controls) children aged 5-7 years old. CTRP1 gene expression and CTRP1 serum level were measured by quantitative realtime-PCR and enzyme-linked immunosorbent assay methods, respectively.

RESULTS

It was found that CTRP1 is significantly elevated in autistic children in comparison to healthy controls, both at the gene expression level, as well as at the serum level; demonstrating a good diagnostic value with a good range of sensitivity and specificity for detecting ASDs.

CONCLUSION

CTRP1 expression is elevated in ASDs boys aged 5-7 years old, suggesting a role for this adipokine in ASDs pathophysiology. Also, receiver operating characteristic curve analyses revealed that this adipokine could be utilized as a diagnostic biomarker for differentiating ASDs patients from healthy individuals along with other recently proposed biomarkers.

The possible relation between stigma, parent psychiatric symptoms, quality of life and the disease burden in families of children with autism spectrum disorder in Egypt: a multicentre study

Background

Most autism spectrum disorder (ASD) interventions evaluated child outcomes and ignoring the role of parent and family factors on both the immediate- and long-term effects of therapy. The purpose of this study was to determine the relationship between stigma, parent mental health problems, and quality of life and burden in families of children with ASD in Egypt and its risk factors. Seventy parents of ASD children were recruited from two child intervention centers. Participants were divided into two groups based on burden scale: caregivers of moderate burden (n = 27) and caregivers of severe burden (n = 43). All parents were evaluated for demographic data, zarit Burden Interview, socioeconomic scale, symptom checklist–90 (SCL90), Explanatory Model Interview Catalogue Community Stigma Scale (EMIC-CSS), and the World Health Organization Quality of Life–BREF (WHOQOL-BREF).

Results

Half of the parents reported significant stigma, particularly caregivers with a severe burden. Caregivers with severe burden had more depression and about twice the frequency of sensitivity and somatization problems, lower QoL (20%) as compared with caregivers with moderate burden. Parents with ASD had many associate factors such as work, male autistic children and their caregiver, age of children and parents, the severity of the condition, and disease duration with burden, stigma, QoL, and mental health problems.

Conclusions

This study linked the interrelationships between increased burden and stigma, impaired quality of life, and parental mental health problems; the presence of one of these variables was found to increase the risk of other variables.

A space-time analysis of disparities in age at diagnosis of autism spectrum disorder: environmental and socioeconomic risk factors

INTRODUCTION

Early diagnosis of autism is a critical step for gaining early intervention. The earlier interventions begin, the greater chance to reduce symptoms of autism over the lifespan. Despite the improvement in early diagnosis, age at diagnosis varies by residential locations. In order to improve early screening services, this study aims to identify geographic clusters of early and late diagnosis of autism, in addition, it is aimed to compare cases inside the clusters with the rest of the province on characteristics and socioeconomic factors.

MATERIALS AND METHODS

Survey data were collected from 163 autistics born from 1996 to 2011 in Isfahan Province, Iran. As this study found diagnosis of autism occur at an earlier age among children, who on average every 2.5 months increased for each year of age, distance from regression line has been used to determine how early a case was diagnosed compared to other identified cases. After dividing cases into 5 classes based on their distances from the regression line, the ordinal based space-time scan statistic in SaTScan was used to identify geographic areas within specific time periods that have significantly elevated proportions of autistic children who received diagnosis at the earlier or later stages.

RESULTS

The space-time analysis identified two geographic areas that age of diagnosis was inconsistent with the overall study area, the first area has an early diagnosis in central part of Isfahan megacity between 1998 and 2006 (P = .001), the second area shows to have a late diagnosis centered by Najafabad from 2010 through 2015 (P = .007).

CONCLUSIONS

The result of our spatial analysis can be used to evaluate the performance of diagnosis services and additionally provide information to target specific at-risk population for further interventions.

The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond

In this paper we review the impact of DSM-III and its successors on the field of autism-both in terms of clinical work and research. We summarize the events leading up to the inclusion of autism as a "new" official diagnostic category in DSM-III, the subsequent revisions of the DSM, and the impact of the official recognition of autism on research. We discuss the uses of categorical vs. dimensional approaches and the continuing tensions around broad vs. narrow views of autism. We also note some areas of current controversy and directions for the future.

Intellectual Profile of Children with Autism Spectrum Disorder: Identification of verbal and nonverbal subscales predicting intelligence quotient

Objectives

This study aimed to explore the intelligence quotient (IQ) profile among children with autism spectrum disorder (ASD) and identify the most important subscales that predict the IQ. The analysis of an intellectual profile with age and gender differentials and the identification of a battery of subscales of intelligence are important for clinical management of ASD among children and for facilitating placement for remedial and educational services.

Methods

Data were collected through an exploratory study of 100 children aged between three and 13 years, who were referred to the department of child health and development in Sultan Qaboos University Hospital, a tertiary hospital, in Oman between June 2016 and June 2019.

Results

Among the 100 participants of this study, 79% were male, resulting in a male–female ratio of 4:1. The mean of full-scale IQ was found to be 68.6 ± 18.1. Furthermore, the mean of nonverbal IQ (73.5 ± 17.5) was significantly higher than that of verbal IQ (65.5 ± 17.6). Finally, more than half (61%) of the children were observed to have had mild to moderate impairment in their IQ levels.

Conclusions

Age and gender showed no significant association with IQ level. The regression analysis identified nonverbal fluid reasoning, nonverbal visual-spatial processing, nonverbal working memory and verbal knowledge as the significant predictors of total IQ. The crucial dimensions of verbal and nonverbal IQ identified in this study can be used to evaluate complicated cases.

Perceived stress among mothers of children with autism spectrum disorder in Egypt

Purpose

Children diagnosed with autism spectrum disorder (ASD) and their families especially their mothers face numerous and pervasive challenges. Difficulties to access quality care, financial burden, issues of adulthood and their child’s behaviors may produce significant stressors to mothers. This study aims to assess perceived stress among mothers of children with ASD in Egypt.

Design/methodology/approach

A cross-sectional study was conducted in Mansoura University Hospital, Egypt on 94 mothers of children with ASD using a structured questionnaire of the socio-demographic and clinical features of the studied mothers and their children and the perceived stress scale (PSS).

Findings

The mean total PSS score of mothers was 31.97 ± 12.39 and the level of autism had a statistically significant relation with stress perceived by the studied mothers.

Research limitations/implications

The findings in this study were based on caregivers’ self-reporting. As such, inaccurate reporting might have biased the findings. The main limitations of this study include non-participation and dropout. During data collection, some mothers declined to participate in the study. Also, the current study was conducted in one hospital. This represents a loss of valuable information and may weaken the generalizability of the current study findings. Another limitation is the use of a convenience sample in the study. With the use of convenience sampling, there is an increased risk of bias, as study participants may not accurately reflect the characteristics of the total population.

Practical implications

Caregivers’ education programs through media and press should be developed for mothers of children with ASD to help those who experience levels of stress by presenting knowledge about ASD and treatment and training on adaptive coping methods and teaching communication and problem-solving. Recognizing levels of stress and parent counseling may be a useful strategy. Regular periodic meetings should be conducted between mothers and hospital personnel to promote proper communication. One key policy implication, this paper can derive from this study is the need for cooperation between the Ministry of Health, social welfare and other relevant governmental and non-governmental organizations to provide support for families of individuals with ASD such as financial aids. It is also recommended that future study would benefit a larger sample to enhance external validity. As well, future qualitative research is recommended to more fully understand the lived experience of mothers of children with ASD.

Originality/value

This study provides evidence that mothers of children with ASD experienced high perceived stress. Caregivers’ education programs through media and press should be developed in Egypt for mothers of children with ASD.

The Use of Psychotropic Medication in Iranian Children with Developmental Disabilities

The use of psychotropic medication in children is increasing worldwide. Children with developmental disabilities seem to be prescribed these medications at a higher rate compared to their non-disabled peers. Little is known about prescribing in non-Western, middle-income studies. In Iran, the file records of 1133 children, aged 2 to 17 years, assessed as having autism spectrum disorder (ASD) or an intellectual disability (ID) in Tehran City and Province from 2005 to 2019 were collated, and information from parental reports of medications was extracted. Upwards of 80% of children with ASD and 56% of those with ID were prescribed a psychotropic medication with around one quarter in each group taking two or more medications. The rates were higher among male children showing difficult-to-manage behaviors such as hyperactivity, but less so for children of fathers with higher levels of education. The lack of alternative management strategies may be a significant driver for the use of psychotropic medications in Iran and other Low and Middle Income countries, despite their known side effects, and their failure to address the developmental needs of the children. Rather, multi-disciplinary, behavioral, therapeutic, and educational interventions are required, but these are not available widely in Iran, although a start has been made.

Grant Report on mCARE: Mobile-Based Care for Children with Autism Spectrum Disorder (ASD) for Low- and Middle-Income Countries (LMICs)

In low- and middle-income countries, especially in Bangladesh, Autism Spectrum Disorder (ASD) may be considered an anathema, and social-cultural-financial constraints mean that there are few facilities available for treatment for ASD children. The revolution in the use of the mobile phone (~80%) by the majority of people in Bangladesh in recent years has created an opportunity to improve the overall scenario in the treatment or remote monitoring process for children with ASD. In this grant project, we planned and developed a mobile phone-based system to remotely monitor children with ASD and help their treatment process both at the caregiver and care practitioner ends. In developing mCARE, we utilized a Remote Experience Sampling Method to design, build, deploy, and study the impact of mobile based monitoring and treatment of children with ASD in Bangladesh. We developed a mobile application using the Experience Sampling Method (ESM). A caregiver routinely reported the behavioral and milestone parameters of their children with ASD. The care practitioners monitored the longitudinal data that helped them in decision-making in a particular patient’s treatment process. The Value Sensitive Design (VSD) was used to make this mobile application more user friendly with consideration of the local economic, social, and cultural values in Bangladesh.

The effectiveness and adverse effects of D-cycloserine compared with placebo on social and communication skills in individuals with autism spectrum disorder

BACKGROUND

Symptoms of autism spectrum disorder (ASD) have been associated, in part, with the dysfunction of N-methyl-D-aspartate (NMDA) glutamate receptors at excitatory synapses and glutamate abnormalities. Medications related to glutamatergic neurotransmission, such as D-cycloserine - which is a partial agonist of the NMDA glutamate receptor - are potential treatment options for the core features of ASD. However, the potential effect of D-cycloserine on the social and communication skills deficits of individuals with ASD has not been thoroughly explored and no systematic reviews of the evidence have been conducted.

OBJECTIVES

To assess the efficacy and adverse effects of D-cycloserine compared with placebo for social and communication skills in individuals with ASD.

SEARCH METHODS

In November 2020, we searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers. We also searched the reference lists of relevant publications and contacted the authors of the included study, Minshawi 2016, to identify any additional studies. In addition, we contacted pharmaceutical companies, searched manufacturers' websites and sources of reports of adverse events.  SELECTION CRITERIA: All randomised controlled trials (RCTs) of any duration and dose of D-cycloserine, with or without adjunct treatment, compared to placebo in individuals with ASD.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted relevant data, assessed the risk of bias, graded the certainty of the evidence using the GRADE approach, and analysed and evaluated the data. We provide a narrative report of the findings as only one study is included in this review.

MAIN RESULTS

We included a single RCT (Minshawi 2016) funded by the United States Department of Defense. It was conducted at two sites in the USA: Indiana University School of Medicine and Cincinnati Children's Hospital Medical Centre. In the included study, 67 children with ASD aged between 5 and 11 years were randomised to receive either 10 weeks (10 doses) of (50 mg) D-cycloserine plus social skills training, or placebo plus social skills training. Randomisation was carried out 1:1 between D-cycloserine and placebo arms, and outcome measures were recorded at one-week post-treatment. The 'risk of bias' assessment for the included study was low for five domains and unclear for two domains. The study (67 participants) reported low certainty evidence of little to no difference between the two groups for all outcomes measured at one week post-treatment: social interaction impairment (mean difference (MD) 3.61 (assessed with the Social Responsiveness Scale), 95% confidence interval (CI) -5.60 to 12.82); social communication impairment (MD -1.08 (measured using the inappropriate speech subscale of the Aberrant Behavior Checklist (ABC)), 95% CI -2.34 to 0.18); restricted, repetitive, stereotyped patterns of behaviour (MD 0.12 (measured by the ABC stereotypy subscale), 95% CI -1.71 to 1.95); serious adverse events (risk ratio (RR) 1.11, 95% CI 0.94 to 1.31); non-core symptoms of ASD (RR 0.97 (measured by the Clinical Global Impression-Improvement scale), 95% CI 0.49 to 1.93); and tolerability of D-cycloserine (RR 0.32 (assessed by the number of dropouts), 95% CI 0.01 to 7.68).  AUTHORS' CONCLUSIONS: We are unable to conclude with certainty whether D-cycloserine is effective for individuals with ASD. This review included low certainty data from only one study with methodological issues and imprecision. The added value of this review compared to the included study is we assessed the risk of bias and evaluated the certainty of evidence using the GRADE approach. Moreover, if we find new trials in future updates of this review, we could potentially pool the data, which may either strengthen or decrease the evidence for our findings.

Children with Autism Spectrum Disorders in Low-Resource Settings: Reported Experiences and Needs of Parents in Mongolia

Although it is well-documented that families of children with autism in developed nations report hardships, few researchers have focused on families who live in less-developed, low-resource settings. Using five focus groups with 30 parents of children with autism in Mongolia, a low- resource setting, the purpose of this study was to provide detailed accounts of their experiences, challenges, and needs. Participants reported severe challenges related to raising their children with autism in their country. Parents shared barriers related to the limited availability of services and support, exacerbated financial burdens, and a lack of enforcement of relevant laws. Parents also shared their perceived needs including more services for their children, more sustainable training and coaching programs for parents, and parents' collective advocacy.

Using Hybrid Telepractice for Supporting Parents of Children with ASD during the COVID-19 Lockdown: A Feasibility Study in Iran

During the three-month closure of clinics and day centers in Iran due to the coronavirus disease 2019 (COVID-19) lockdown, parents of children with Autism Spectrum Disorder (ASD) became solely responsible for their care and education. Although centers maintained telephone contact, it quickly became evident that parents needed more detailed advice and guidance. Staff from 30 daycare centers volunteered to take part in a two-month online support and training course for 336 caregivers of children with ASD of different ages. In addition to the provision of visual and written information, synchronous video sessions were used to coach parents on the learning goals devised for the children. Both qualitative and quantitative data were collected to understand the acceptability of using telepractice and the outcomes achieved. A low dropout rate and positive feedback from parents indicated that they perceived telepractice sessions to be useful. The factors contributing to parents’ satisfaction were identified. Although the use of telepractice would be a good alternative for caregivers in any future lockdowns, it could also be used in conjunction with daycare center services to encourage greater parental participation, or with families living in areas with no day centers. Further studies are needed to compare telepractice to usual daycare face-to-face interventions, and to document its impact and cost-effectiveness for parents and children.

The effectiveness of sensory integration intervention on the emotional-behavioral problems of children with autism spectrum disorder

Purpose

Autism spectrum disorder is a kind of neurodevelopmental disorder characterized by persistent deficits in social communication and interaction across multiple contexts, and restricted, repetitive patterns of behavior, interests or activities. The purpose of this paper is to determine the effectiveness of sensory integration intervention on emotional-behavioral problems in children with autism spectrum disorder.

Design/methodology/approach

This research was conducted in a pretest-posttest design with control group. The participants were 30 children with autism spectrum disorder (6–11 years old) who were selected through convenience sampling from among children with autism spectrum disorder in Zeinab center of Isfahan and were randomly divided into two groups of 15 subjects. The children of the experimental group received 14 sessions of sensory integration intervention while the control group did not receive this intervention. To measure emotional-behavioral problems, the Behavior Assessment System for Children-Second Edition was used. To analyze the data, ANCOVA and MANCOVA tests were used.

Findings

The results showed that sensory integration intervention improves emotional-behavioral problems and its subscales (hyperactivity, aggression, behavioral problems, anxiety, depression, somatization, attention problems, learning difficulties, atypicality and withdrawal) in children with autism spectrum disorder.

Research limitations/implications

Therefore, it can be concluded that sensory integration intervention can be a suitable treatment for reducing sensory problems and improving emotional-behavioral problems in children with autism spectrum disorder.

Originality/value

The study of the effect of sensory integration on emotional-behavioral problems in children with autism spectrum disorder is necessary as a simple and non-side-effect educational and therapeutic method, both as a step to fill the research gap in this field, besides being a cheap and affordable way for improving the various skills of children with autism spectrum disorder for professionals, teachers, parents and educators.

Estimating the prevalence of autism spectrum disorder in Lebanon

This cross-sectional survey examines the prevalence rate of Autism spectrum disorder (ASD) in 818 children (16-48 months) across all Lebanese regions. Screening was done using the revised form of the Modified-Checklist for Autism in Toddlers. Based on the total score of items failed, children were classified into 3 categories of ASD risk (low, moderate and high). Phone calls follow-up interviews and clinical assessments for diagnosis ascertainment were conducted. Given the caregivers' reluctance to participate, the prevalence rate was estimated between 49 and 513 per 10,000 with a male predominance. Our prevalence estimation, even under restrictive assumptions, is higher than elsewhere in the Arab region. Anti- stigma interventions adapted to the socio-cultural context are needed prior to future research in the field.

Stigmatization among parents of autism spectrum disorder children in Riyadh, Saudi Arabia

BACKGROUND

Children diagnosed with autism spectrum disorder (ASD) have social and cognitive disabilities. For parents, these behaviors can lead to humiliation, social exclusion, and isolation. Stigma is a problem that not only may affect the individual with high functioning autism, but has the potential to extend to their family as well. Indeed, research indicates that the parents of children with disabilities (including ASD) commonly experience stigmatizing reactions from others.

AIM OF WORK

To determine the prevalence of self and enacted stigma among parents of ASD children from Riyadh, Saudi Arabia, and recognize possible risk factors and causes of stigmatization.

MATERIAL AND METHODS

An observational cross-sectional study involving the parents of ASD children from Riyadh, Saudi Arabia. About 163 participants were included from the Centre for Autism Research (CFAR) at King Faisal Specialist Hospital & Research Centre (KFSH & RC) in Riyadh. The primary material used for data collection was a five-point scale questionnaire developed by the investigator. The questionnaire consisted closed ended questions related to the participants' demographic data, autistic child, family life, resources, and social experiences as a parent. The collected data were analyzed using descriptive statistics and appropriate statistical analysis, using Statistical package for the social sciences (SPSS), version 22. The level of significance was P value < .05.

RESULTS

The findings of this work indicated that 55 (33.7%) of the parents scored more than 3 in answering questions related to felt stigma; 82 (50.3%) were fathers. On the other hand, 108 (66.3%) did not feel stigmatized being a parent of autistic child. Forty-two (25.8%) of the parents scored more than 3 in answering questions related to enacted stigma, whereas 121 (74.2%) did not face enacted stigmatization being a parent of autistic child. There was a strong tendency for mothers (41, 75%) to feel more self- and enacted stigmatized than fathers (P < .05). Moreover, the gender of the autistic child, consanguinity, severity of the ASD, and the monthly income of the family showed no significant difference in the parents who scored more than 3 for felt- or enacted stigmatization (P > .05).

CONCLUSION

Among participated parents of children with ASD in Riyadh, Saudi Arabia, 33.7% of them experienced stigmatization, and mothers felt more self- and enacted stigmatized when compared to fathers. Public awareness among people in Saudi Arabia have been increased and, thus, negative stigmatization has decreased among parents in the country. A high level of felt stigma suggests the need for psychological intervention for the family to help cope with this new situation. A higher level of enacted stigma suggests the need for their rights (individuals with ASD) and increased awareness in the society. It is recommended that further research is needed in different centers in Riyadh and other regions of Saudi Arabia to investigate the prevalence of stigma in parents of autistic children.

Culturally diverse families of young children with ASD in Sweden: Parental explanatory models

BACKGROUND

Research suggests that families' knowledge and cultural perceptions of autism spectrum disorder (ASD), and beliefs about its etiology and prognosis, can affect parents' recognition of the first signs of autism in their children and influence help seeking and treatment decisions.

OBJECTIVE

This study investigated explanatory models of autism among parents of young children with ASD in the multicultural context of Sweden.

METHOD

Seventeen parents from diverse cultural, ethnic and linguistic backgrounds participated in semi-structured interviews. A deductive approach to qualitative content analysis was used to analyze data. Five domains of the Explanatory Model supplementary module of the Cultural Formulation Interview (CFI) were used as coding categories, operationalized as 'Parents' understanding of autism'; 'Autism prototypes'; 'Causal explanations'; 'Course of autism', and 'Help seeking and treatment expectations'.

RESULTS

The results showed that parents' prior knowledge of autism and experience of young children's typical developmental trajectories, as well as the opinions of children's grandparents and preschool teachers, affected symptom recognition and help seeking. There were differences in parents' explanatory models before and after ASD diagnosis. Initial interpretations of the disorder included medical conditions and reaction to environmental influences, while genetic, supernatural/religious factors, and vaccinations were mentioned as definite causes after obtaining a clinical diagnosis. Parents also held multiple explanatory models, influenced by the views of family members and information obtained from media or from health care professionals. Parents' treatment decisions included use of available state-funded support services, and complementary and alternative treatments.

CONCLUSION

The results demonstrate the utility of the CFI's Explanatory Model supplementary module in autism research. Implications for clinical practice are discussed.

Explaining Age at Autism Spectrum Diagnosis in Children with Migrant and Non-Migrant Background in Austria

This study explored (i) differences in age at Autism Spectrum Disorder (ASD) diagnosis between children with and without a migrant background in the main diagnostic centre for ASD in Upper Austria (ii) factors related to the age at diagnosis and (iii) whether specific factors differed between the two groups. A retrospective chart analysis included all children who received their first diagnosis before the age of 10 years (n = 211) between 2013 and 2018. Children with a migrant background were diagnosed 13 months earlier than those without (r = 0.278, p < 0.001), and had more severe delays in language, more severe autism, no Asperger’s syndrome, lower parental educational level and more frequent referrals by paediatricians. For the total sample, expressive language delay, severity of restricted and repetitive behaviours, higher nonverbal development, and paediatric referrals explained earlier diagnoses. There was a stronger effect of parental education and weaker effect of language impairment on age at ASD diagnosis in children with a migrant background. In conclusion, no delay in diagnosing ASD in children with a migrant background in a country with universal health care and an established system of paediatric developmental surveillance was found. Awareness of ASD, including Asperger’s syndrome, should be raised among families and healthcare professionals.

Autism in Aotearoa

Abstract. Screening measures for autism spectrum disorder (ASD) are important tools for clinicians and researchers. However, where a measure developed and validated for one population is used with another, its performance in this new context must be carefully examined. The RAADS-14, a brief ASD screen developed in Sweden, was evaluated with a sample of New Zealand adults ( N = 387), 41 of whom self-reported a prior diagnosis of ASD. The convergent validity of the RAADS-14 (Hypothesis 2) was supported by a strong positive correlation with the AQ-10 (short version of the Autism Spectrum Quotient), r = .81. Discriminant validity (Hypothesis 3) was also supported by a strong negative correlation with the EQ-Short (short version of the Empathy Quotient), r = −.75. However, the measure did not meet inferential criteria for internal consistency (Hypothesis 1), and confirmatory factor analysis (CFA) found a poor fit of the proposed three-factor model (Hypothesis 4) to the data. A cut-off score of 14/42 provided adequate sensitivity (95%) to detect participants with self-reported ASD diagnoses, but not adequate specificity (70%), suggesting a very high rate of false positives should be expected if relying on RAADS-14 scores alone to interpret presence of ASD. In sum, our results do not provide sufficient evidence of reliability and validity to support the use of the RAADS-14 with the New Zealand population. We provide suggestions for refinement of the RAADS-14 that may lead to increased reliability and validity.

Feelings of hopelessness in mothers of children with neurodevelopmental disorders

The aim of the present study was to compare feelings of hopelessness in mothers of children with neurodevelopmental disorders. The statistical population of the study included all mothers of children with neurodevelopmental disorders in Shiraz, Iran. The sample consisted of 150 mothers of children with neurodevelopmental disorders, including 50 mothers of children with autism spectrum disorder (ASD), 50 mothers of children with intellectual disability (ID), and 50 mothers of children with specific learning disorder (SLD) and they were selected by convenience sampling method. The data were collected during the years 2015-2016. The Beck Hopelessness Scale (BHS; Beck et al.) was used for measuring the feelings of hopelessness. The one-way ANOVA and MANOVA tests were used for the data analysis. The results showed that the feelings of hopelessness and the two subscales of feelings of hopelessness, i.e. negative expectations of the future and the loss of motivation in association with the future, in mothers of children with ASD were significantly higher than those of the other two groups of mothers. It was also observed that mothers of children with ID, compared to mothers of children with SLD, had higher levels of feelings of hopelessness, negative expectations of the future, and negative feelings in association with the future. Additionally, the findings revealed that mothers of children with ASD, compared to mothers of children with SLD, had higher levels of negative feelings in association with the future. Therefore, adopting preventive and intervention programs which can help mothers of children with neurodevelopmental disorders, especially mothers of children with ASD, to overcome their feelings of hopelessness are of great importance.

Older adults' self-advocacy in patient safety: a cross-sectional study

BACKGROUND

patient advocacy is a major nursing role, which is linked to supporting, encouraging and reinforcing self-advocacy in patients. Patient safety is an important nursing outcome, especially in older adults.

AIMS

older adults' self-advocacy regarding patient safety behaviour and its relationship with some demographic characteristics were assessed.

METHODS

a valid older adult patients' self-advocacy questionnaire, which included subscales of behaviour, self-efficacy, attitude and outcome efficacy (range of scores=0-63), was used. In this cross-sectional study, 230 patients aged over 60 years were selected using a stratified sampling method.

FINDINGS

an association was found between total self-advocacy score (mean=40.16; SD=9.6) and rural living (β=-0.168; P=0.016) using multiple linear regression analysis. Similar findings were found between questionnaire subscales and sex, rural living, occupation and age.

CONCLUSION

older adults, especially women, those of advanced age and those in rural areas, may benefit from nursing interventions to improve their self-advocacy in patient safety.

Development of Parental Competence Scale in Parents of Children with Autism

PURPOSE

The purpose of this study is to develop and psychometrically of parental competence scale in parents of children with autism.

DESIGN & METHODS

This mixed-methods design with a sequential exploratory approach was conducted in May 2017 until June 2018 in the south of Iran. In the first phase, a conventional content analysis method was performed with the participation of 16 parents of children with autism. Interviews were held in the autism association offices in an urban area of Iran. In the second phase, validity and reliability of this instrument were assessed with 300 parents of children with autism.

RESULTS

During content validity testing, 12 items were deleted. Content validity ratio and index were 0.75 and 0.85, respectively. In face validity, impact scores for all items were reported as >1.5. Factor analysis led to the development of a 2-factor solution accounting for 71.4% of the observed variance. Reliability of the instrument using the calculation of the Cronbach's alpha coefficient was reported as 0.98 for the entire instrument. No statistically significant difference was reported between the pre and post-test scores of parental competence (p = 0.46). The parental competence scale demonstrated acceptable psychometric properties.

CONCLUSION

The parental competence scale demonstrated acceptable psychometric properties. Therefore, this scale can be used for assessing parental competence in parents of children with autism.

PRACTICE IMPLICATIONS

This scale can be used in future research and for educational and practical purposes with the aim of identifying parents' issues and improving the quality of life of parents of children with autism.

An Interpretative Phenomenological Analysis of Families Affected by Autism in Dubai

<b><i>Background:</i></b> The prevalence of autism spectrum disorders (ASD) in the Middle East region is suggested to be comparable with rates reported in the Western World; however, in the United Arab Emirates (UAE), autism is under-diagnosed and over-looked. <b><i>Objectives:</i></b> This qualitative study based in Dubai, UAE, aimed to explore personal experiences of autism and investigate the decision-making process of parents. A focus group interview with 6 UAE national mothers who have an autistic child was conducted; the semi-structured interview was audio-recorded and transcribed. <b><i>Method:</i></b> Interpretative phenomenological analysis was performed on the interview transcript and 3 main themes emerged: Education, Support and Social Stigma. <b><i>Results:</i></b> The research concluded that the majority of mothers are primary caregivers and the challenges faced by autistic families include: a lack of understanding and research; family reputation; stigma-associated discrimination; and maternal stress. <b><i>Conclusions:</i></b> Mothers with autistic children experience a number of stressors and would benefit from educational workshops, including ASD-specific training. A call for further investigation into the role and impact of maids as primary caregivers for autistic children in the UAE is advocated.

Assessment of knowledge about childhood autism spectrum disorder among healthcare workers in Makkah- Saudi Arabia

OBJECTIVE

To measure the knowledge of healthcare professionals about increasingly prevalent Autism Spectrum Disorder (ASD) along with perceptions around its management and prognosis and comparison across various specialties.

METHODS

This Cross sectional survey based comparative analysis took place at Maternity and Children Hospital and King Faisal Hospital Makkah from December 2017 to May 2018. The validated self-administered "Knowledge about childhood autism among health workers" questionnaire was used along with additional questions regarding perceptions about ASD. The mean and mean percent scores were calculated. Chi squared test and ANOVA were applied to find the association between quantitative and qualitative variables respectively.

RESULTS

Out of 162 participants, 153 returned the questionnaire and 147 were included in final analysis. Physicians constituted 81.6% (120) of participants. The mean score for participants was 9.80(S.E.M ±0.32) where non-physicians yielded higher mean score (11.2±4.41) as compared to physicians (9.6±3.28) (p=0.113). Psychiatrists had highest score of 16/19 while general physicians had lowest (6/19). Participants with more years of experience had higher mean scores (p-value = 0.01). About 72.10% (106) of participants opted for medication as a treatment option. Nearly 38.1% (56) of participants were skeptical about improvement of ASD with early interventions.

CONCLUSION

There is a lack of knowledge about ASD amongst healthcare professionals in Saudi Arabia. Experienced professionals working with ASD children can be utilized to deliver targeted trainings nationwide.

Lived experiences of caregivers of children with autism spectrum disorder in Kenya

Background

Autism spectrum disorder (ASD) is a global public health concern. In African countries such as Kenya, there is a greater need for establishing support services for developmental disorders such as ASD. The emotional, social and economic burden of ASD on caregivers is unknown because of a number of challenges. Citizens of Kenya have a unique view of disability and inclusion.

Objectives

To explore the perspectives of caregivers who are responsible for caring for both family and children living with ASD and to highlight the needs of children with ASD as well as the needs of their caregivers.

Method

A qualitative, descriptive phenomenological study utilising focus group discussions (FGDs) was conducted. Verbatim transcription was used. QSR N 'Vivo 10 was used to organise and analyse the data. Content analysis was used to identify important ideas and concepts.

Results

One theme, namely 'the burden of caring for children with ASD', was identified. Children with ASD and their caregivers experience isolation and stigmatisation.

Conclusion

Occupational therapists in Kenya should collaborate with the relevant national and global stakeholders for the promotion of the inclusion of children with ASD and their families. Responsive and context-appropriate occupational therapy interventions may begin to address service barriers.

Keywords

autism spectrum disorder; children; needs of caregivers; context-appropriate services.

Parents’ perceptions of raising children with autism spectrum disorders in the United States and Arab countries: A comparative review

Four databases were searched to identify studies published by Arab researchers on parents’ perceptions of autism spectrum disorder and studies conducted by US researchers and published in systematic reviews of this topic. The electronic search resulted in 14 studies published by Arab researchers and 55 studies published by US researchers. The results showed that autism spectrum disorder has many of the same effects on Arab and American families. Six major areas were identified in the results. Financial difficulties associated with raising children with autism spectrum disorder were mentioned more in Arab studies than in US studies. Arab studies had more emphasis on gender than US studies. The results related to quality of life of parents of children with autism spectrum disorder in Arab studies were equivocal. US studies included comparisons with families without a child with autism spectrum disorder, and addressed factors that were associated with quality of life indicators. More health, educational, and social services were available in United States than in Arab countries, but some frustration was reported by US parents in obtaining appropriate services in some studies. A higher percentage of Arab studies mentioned the role of religious faith than US studies. Finally, social stigma was evidenced in both cultures, but not much research was available.

Risk and Resilience Among Mothers and Fathers of Primary School Age Children With ASD in Malaysia: A Qualitative Constructive Grounded Theory Approach

Little is known about the coping and resilience experiences of parents of children with autism spectrum disorder (ASD) in the Malaysian cultural context. This study utilized a qualitative methodological approach adopting constructive grounded theory. The study sought to address the lack of research to date exploring the risk and protective experiences that contribute to parental stress and resilience for parents of primary school age children with ASD in the Malaysian setting. Twenty-two parents of children with ASD (13 mothers and 9 fathers) participated in semi-structured interviews. A strength of the study was the inclusion of both mother and father participant perspectives. The interviews lasted 50-80 min (mean: 67.5 min). The 22 parents had a total of 16 children (12 males; 4 females) formally diagnosed with ASD. Child age ranged between 5 and 12 years (mean age: 8.44). Overall, analysis of the 22 interviews revealed four prominent themes - "initial reaction to child's ASD symptoms and diagnosis," "family life affected by a child with ASD," "awareness about ASD in Malaysia," and "coping strategies, wellbeing, and becoming resilient." The first three themes revolved around stress and adversity, and, the adaptability and acceptance of the parents. These processes illustrated the risks experienced by the parents of children with ASD in Malaysia. The last theme especially highlighted the strengths and determination of the parents and illustrated the protective experiences and processes that helped parents to develop and enhance resilience. Overall, the findings revealed that resilience develops synergistically and dynamically from both risk and protective experiences across different levels - individual, family, community, society and government. The findings motivated the development of our theoretical model of resilience that can help health and education professionals tailor assessment and interventions for parents of children with ASD in the Malaysian context. Clinical, policy, and research suggestions were discussed.

Current Status of Health and Social Services for Children with Autism in Iran: Parents' Perspectives

Objective: The present study is a part of a larger study that aimed at developing a comprehensive model of service delivery for individuals with autism in Iran based on the local needs and characteristics. In this study, the status of the services provided to those with autism in Iran was investigated based on the perspectives of parents of children with autism. Method : A semi-structured interview was used to qualitatively investigate the status of the services with regards to autism in Iran based on the perspectives of parents of children with autism. Results: This study revealed several barriers, including shortness of eligible professionals, difficulty in access to care for families, high costs, and lack of formal and informal supports, in providing services to those with autism in Iran. Early detection and diagnosis are of prime importance. We also need to train our specialists to diagnose autism based on the standard protocols and tests. Conclusion: In sum, we need a comprehensive program that involves different sectors in charge of health and education in Iran.

Brief Report: Texas School District Autism Prevalence in Children from Non-English-Speaking Homes

Previous studies have implicated migration and ethnicity as possible risk factors for autism spectrum disorder (ASD) in developed countries. Using Texas education data, we calculated district-reported ASD prevalence stratified by geographic region, with reported home language as a proxy for immigration. Prevalence ratios were also stratified by race. Prevalence estimates were significantly lower for White children from homes speaking Spanish and other non-English languages compared to those from English-speaking homes. This is the first study, to our knowledge, that investigates ASD prevalence of children from non-English-speaking households in a large sample. Barriers in identification of children of immigrants with ASD indicate that the increased district-reported prevalence seen in our study may only be a small indicator of a potentially larger prevalence.

Internalizing and Externalizing Problems, Empathy Quotient, and Systemizing Quotient in 4 to 11 Years-Old Siblings of Children with Autistic Spectrum Disorder Compared to Control Group

Objective: This study was conducted to recognize the problems of living with a sibling with Autistic Spectrum Disorder (ASD) to improve their quality of life. Method : A total of 30 participants were selected among the 4-to11- year-old siblings of children who had referred to Tehran Psychiatric Institute due to autism spectrum disorder. For the control group, 30 children aged 4 to11years old who were the siblings of patients with chronic diseases referring to Pediatric Clinic of Rasoul-e Akram (PBUH) hospital were selected. Gilliam Autism Rating Scale-Second Edition (GARS-2) was filled out for patients and siblings participating in the study and Child Behavior Checklist was completed by their parents. Results: The mean age of the patients in this study was 4.46 ± 9.66 years (range: 1.5-22 years), and the mean age in the healthy children was 2.54 ± 8.18 years (range: 4-11 years). The mean scores of anxiety/depression, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, and rule-breaking behavior subscale of CBCL (Child Behavior Checklist) were not significantly different between groups. Aggressive behavior was the only subscale that showed such difference (p = 0.008). Externalizing problems in children who had siblings with ASD was higher than children who had siblings with physical illness. In a group in which a sibling had ASD, sisters were more anxious/ depressed than brothers. Conclusion: Due to various psychological and social problems that siblings of children with ASD experience throughout their life, studying their psychological problems to improve their quality of life seems to be of paramount importance.

Brief Report: Social Support and Coping Strategies of Mothers of Children Suffering from ASD in Kuwait

This cross-sectional study provides a general profile of mothers of children with ASDs in Kuwait and examines their use of social support resources and coping strategies (using the Brief COPE questionnaire). The majority of mothers reported decreased ability to perform social duties (62.4%) and take care of themselves (50.5%). Overall, 57.7% of mothers reported a decreased ability to enjoy life; this difference was more pronounced among non-Kuwaiti mothers compared to Kuwaiti mothers (p value = 0.03), and in mothers with a bachelor's degree or higher (p value = 0.011). There was a significant association between the mothers' ability to enjoy life and receiving support from the family (p value = 0.021) and support groups (p value = 0.003). "Religion", "Acceptance", and "Positive Reframing" were the 3 most common coping strategies.

Listening to Bedouin Mothers of Children with Autism

This article examines how Bedouin mothers in Israel describe, perceive, and interpret their experiences raising a child with autism. Data were collected using semi-structured ethnographic interviews with 18 Bedouin mothers of children with autism, aged 6-16, living in recognized and unrecognized settlements in the Negev. Analysis of the study findings shows how the subaltern status of Bedouin women, which includes their husbands' constant threats of divorce or taking a second wife, makes it difficult for them to be mobile and interact in the public sphere without the presence of a man and creates an experience unique to these mothers, which we call "Exclusion within Exclusion". The Bedouin mothers report not only stigmatization, a lack of social support and loneliness but also structural-cultural characteristics that prevent them from obtaining information and participating in decision-making about the child with autism and that restrict their agency in dealing with and coping with their child's autism. In light of this situation, the discussion highlights the unique connection between local cultural scripts and the phenomenology of autism.

Perceptions of disability, environmental risk factors and available services among local leaders and parents of young children with disabilities in West Timor, Indonesia

Purpose: As an underdeveloped region of Indonesia, West Timor faces a significant challenge of childhood disability compounded by environmental risk factors such as poverty, discrimination and stigma, and limited access to basic services. However, very little is currently known about how this important social issue is viewed from the perspective of parents and local leaders, who play an influential role in local society. This research aimed to explore the views of these groups, towards childhood disability, within an environmental risk context. Method: Data were collected via semi-structured interviews and photovoice with 23 parents and 15 local leaders such as a midwife, priest, headmaster and staff from international and local non-government organisations. Results: The results of the study suggest that local culture, including religion has a strong influence on the perceptions of disability and environmental risk factors, while available services are seen by parents as being inaccessible. Conclusions: Implications of the results are presented together with multi-sectoral recommendations for best supporting parents raising children with disabilities in rural areas in low-income jurisdictions such as West Timor. Implications for Rehabilitation Grass-root healthcare providers, such as community health centres in Indonesia should work with community leaders to improve health literacy and awareness on disability Initiatives like inclusive village might eliminate barriers to services such as stigma and distance to health centres Decision-makers should aim to empower religious and cultural figures to provide social support for parents of children with disabilities.

Characteristics of Agencies Providing Support Services for Children with Autism Spectrum Disorders in Vietnam

As in virtually all countries, in Vietnam there has been a general trend towards apparent increased rates of Autism Spectrum Disorder (ASD). To address the needs of families and children with ASD, many agencies providing support services have been opened throughout Vietnam over the last two decades. Although agencies in general appear to strive to provide good quality service, the actual quality of operations is unknown. The present article collected and analyzed secondary data from 68 agencies across Vietnam from different information sources, using the nine criteria published by Tran, Weiss, and Pham (in press) [1] and Nguyen, Hoang, Nguyen, Pham, and Tran (2017) [2] to evaluate agency quality. Results of this review suggest that a significant number of centers do not have appropriate legal status, are not following basic ethical standards, are using non-evidence based intervention methods, and are unclear in regards to the intervention procedures or intervention plans they use. Although the current study has a number of limitations, it provides important initial information regarding the current status of ASD services in Vietnam.

Environmental factors influencing the risk of autism

Autism is a developmental disability with age of onset in childhood (under 3 years old), which is characterized by definite impairments in social interactions, abnormalities in speech, and stereotyped pattern of behaviors. Due to the progress of autism in recent decades, a wide range of studies have been done to identify the etiological factors of autism. It has been found that genetic and environmental factors are both involved in autism pathogenesis. Hence, in this review article, a set of environmental factors involved in the occurrence of autism has been collected, and finally, some practical recommendations for reduction of the risk of this devastating disease in children are represented.

Vitamin D and Autism Spectrum Disorder: A Literature Review

Low vitamin D status in early development has been hypothesised as an environmental risk factor for Autism Spectrum Disorder (ASD), given the concurrent increase in the prevalence of these two conditions, and the association of vitamin D with many ASD-associated medical conditions. Identification of vitamin D-ASD factors may provide indications for primary and secondary prevention interventions. We systematically reviewed the literature for studies on vitamin D-ASD relationship, including potential mechanistic pathways. We identified seven specific areas, including: latitude, season of conception/birth, maternal migration/ethnicity, vitamin D status of mothers and ASD patients, and vitamin D intervention to prevent and treat ASD. Due to differences in the methodological procedures and inconsistent results, drawing conclusions from the first three areas is difficult. Using a more direct measure of vitamin D status—that is, serum 25(OH)D level during pregnancy or childhood—we found growing evidence for a relationship between vitamin D and ASD. These findings are supported by convincing evidence from experimental studies investigating the mechanistic pathways. However, with few primary and secondary prevention intervention trials, this relationship cannot be determined, unless randomised placebo-controlled trials of vitamin D as a preventive or disease-modifying measure in ASD patients are available.

Spiritual Journey in Mothers' Lived Experiences of Caring for Children With Autism Spectrum Disorders

INTRODUCTION

Helping mothers who have children with autism spectrum disorders requires understanding of their lived experiences. This study aims to uncover the spiritual journey as a main theme in Iranian mothers' experiences.

METHOD

This hermeneutic phenomenological study is a part of a larger study undertaken for partial fulfillment of the requirement for PhD dissertation in nursing. The main study was performed on 18 cases of Iranian mothers, with experience of caring for a child with an autism spectrum during 2011-2012. They were selected based on purposeful sampling method. Semi -structured interviews for data collection were used. Data analyses were done with the interpretative method.

RESULTS

Spiritual journey is one of the main themes of the phenomenon under study in the original project. It consists of three sub -themes each of which supported by a number of common meaning. The sub-themes and their common meanings in parenthesis are (1) Descent: wondering between what is and what will be (having sorrowful tale, unanswered question, escaping from reality, losing hope) (2) Connecting to deity: reflection on the failure in her struggle (gratefulness, surrendering to god, having the divine test) (3) Ascent: helping her child is becoming all of the mother's life (to rescue, being hopeful, listening to her inner voice)

CONCLUSION

This research concluded that caring for the autistic children led mothers' lives to raise spirituality and enabled them to help their children and themselves, to grow and be refined in this process.

Parental wellbeing of Iranian families with children who have developmental disabilities

To date, most research with families who have a child with developmental disabilities has been undertaken in English speaking countries. Poorer health, allied with increased levels of stress has been commonly reported for mothers but less is known about the impact on fathers and on overall family functioning. This study aimed to document the correlates of these parental impacts with Iranian mothers and fathers who had children with either intellectual disabilities (ID) or with autism spectrum disorders (ASD). In all 121 parents (69 mothers and 52 fathers from 94 families) who had a child with a diagnosis of ADS, along with 115 parents of children with ID (83 mothers and 32 fathers from 101 families) volunteered to take part in the study. Each participant completed through interview standardised rating scales of parenting stress, emotional well-being, family functioning and satisfaction with caring role along with demographic information and details of informal supports. Structural Equation Modeling identified that family functioning was much poorer in families whose child had ASD and both mothers and fathers reported higher levels of stress. Poorer emotional well-being contributed to higher stress and was more frequent among mothers, single parents and those whose children had behaviour problems. Having other dependents living at home and more sources of informal support improved the emotional wellbeing of parents but not their stress or family functioning. Parents who derived greater satisfaction from their caring role tended to have better emotional health and less stress. Although the impact on Iranian parents of having a child with developmental disabilities is broadly similar to those of parents in other cultures, there are indications that children with ASD present distinct challenges to these families. The model derived in this study is a useful guide both for further research as well as family-centred interventions.

The impact on Iranian mothers and fathers who have children with an autism spectrum disorder

BACKGROUND

To date, most research with families who have a child with autism spectrum disorder (ASD) has been undertaken in English-speaking countries. Increased levels of stress allied with poorer health have been commonly reported for mothers, with less attention paid to fathers. This study aimed to document the personal impact on Iranian mothers and fathers and identify the correlates of increased stress and poorer emotional well-being.

METHOD

In all, 103 parents (58 mothers and 45 fathers) from 74 families who had a child with ASD volunteered to take part in the study. Each participant completed through interview, standardised rating scales of parenting stress, emotional well-being and family functioning as well as rating their child's autistic symptoms, including stereotyped behaviours.

RESULTS

Mothers had significantly higher scores than fathers on measures of stress and emotional well-being. Although these variables were highly correlated, binary logistic regression identified that the poorer health was also associated with lower educational levels of the parents, more behavioural problems with the child and fewer autistic symptoms overall. A similar regression analysis of stress scores identified no gender differences but found that lower stress was associated with mothers and fathers who were joint caregivers and when the family lived with relatives.

CONCLUSIONS

Iranian parents experience broadly similar responses to parents in other countries, which suggests that the impact of ASD outweighs any cultural differences that might otherwise be present in parental responses to caring for children. In common with families internationally, these parents are likely to benefit from opportunities to become better informed about ASD and the management of their child at home allied with increased support from families and friends.