Coping strategies and education of parents of autistic children in Bangladesh

Objectives: Bangladesh is a country characterized by the shared cultures of different ethnic groups. Parents in different cultures demonstrate diverse psychological functioning when caring for a child with a chronic disability such as autistic disorder. Few investigations have been conducted in Bangladesh regarding the coping strategies used by parents of autistic children. Therefore, the purpose of this study was to examine the coping strategies of parents raising autistic children in Dhaka city. We also studied the relation between the coping strategies of parents with autistic children and the parents’ educational status. Materials and Methods: A total of 44 parents with autistic children participated in this survey and were randomly selected from a simple sample comprising parents of children attending special schools in Dhaka city, Bangladesh. Data were collected through questionnaires on coping strategies and were administered by an interviewer. A chi square test was conducted to determine the significance of the relation between education and different coping strategies. Results and Discussion: Eight groups of coping strategies were selected as follows: Confrontive coping, Distancing from problem, Seeking social support, Self-controlling, Accepting responsibility, Planful problem-solving, Escape-avoidance, and Positive reappraisal. A total of 34, 10, 26, 19, 17, 32, 6, and 35 parents chose “at least try,” “not overanalyzing,” “get professional help,” “separate own feelings,” “conduct self-evaluation” “apply more effort....;” “hand over...,” “fantasies for turn the....,” “wish for over the...,” and “change daily lifestyle”, respectively. Moreover, a significant relation was revealed between parents’ education and the strategy, “accepting responsibilities.” Conclusion: We concluded that parents of autistic children need more social support, counseling, and higher education to support their child’s special needs, as well as ensure their own physical and mental wellbeing.


Introduction:
A lack of social interaction, communication challenges, and repetitive behaviors are common in autistic children 1 . Both developmental delays and motor coordination difficulties negatively affect the children and limit their lifestyles. 2,3 Due to the stressful nature of the development process for children with this condition, parents experience significant challenges in their daily life as they endeavor to simultaneously manage both the needs of their children and their own 4 . Socio-economic conditions of parents of ASD children were stated in our previous study 5 . Little is known about the coping strategies of parents with autistic children.
Coping strategies comprise procedures in which individuals can manage undesirable events and simultaneously control the internal tension created by the resultant stress. Coping strategies fall into one of two categories: problem-or emotion-avoidantbased strategies. Problem-based strategies entail a recognition of the problem to manage them and emotion-avoidant based coping strategies are related to self-emotion; therefore they are related to the concept, intolerance of uncertainty (IU) 6 . IU expresses a person's cognitive, emotional, and behavioral reaction to an unwanted situation 7 . In this study, we share some approaches for identifying problem-and emotion-avoidant-based coping strategies, which are influenced by cognitive functions and are adopted by the parents of autistic children.
Researchers have demonstrated that higher education can result in higher cognitive functions. In other words, individuals who are more highly-educated have a greater executive ability to manage their problems 8,9 . They also might excel at converted attention 10 . However, the relation between education and coping strategies is unclear. In the literature, studies reveal that a parent's level of education can have both positive and negative influences 11,12 .
There is little information on coping strategies and their relation to the education of parents of autistic children in developing countries, such as Bangladesh. Therefore, in this study, we aimed to determine the coping strategies of these kinds of parents and focused our investigation on how education influences different parental coping strategies to help autistic children improve their quality of life.

Methodology:
We performed a cross-sectional study after obtaining ethical approval from the human ethical committee of the State University of Bangladesh (SUB). All participants were the parents of ASD children. A total of 44 parents of ASD children participated in this study. The parents were selected from various special schools in Dhaka city of Bangladesh. They were asked to fill out the questionnaires after giving their written informed consent. A revised version of a coping checklist was used in the questionnaires in this study 13 . Coping strategies and years of education completed by the parents were also included. The coping strategies were divided into eight groups: Confrontive coping, Distancing, Self-controlling, Seeking social support, Accepting responsibility, Escape-avoidance, Planful problem-solving, and Positive reappraisal. The details of all groups are shown in Table 1. For each group, participants were asked to rate the strategy using a four-point scale ranging from zero to three (0-3) ("do not use" to "use frequently,"). 13 Table 1: Detail points under eight (8) coping strategies were mentioned in Table 1 Confrontive coping 1) Stood my ground and fought for what I wanted. 2) Tried to get the person responsible to change his or her mind. 3) I expressed anger to the person(s) who caused the problem. 4) I let my feelings out somehow 5) Took a big chance or did something very risky 6) I did something which I didn't think would work, but at least I was doing something. Escape-Avoidance 1) Wished that the situation would go away or somehow be over with 2) Hoped a miracle would happen 3) Had fantasies or wishes about how things might turn out 4) Tried to make myself feel better by eating, drinking, using drugs or medication, etc. 5) Avoided being with people in general. 6) Refused to believe that it had happened. 7) Took it out on other people. 8) Slept more than usual. Positive reappraisal 1) Changed or grew as a person in a good way. 2) I came out of the experience better than when I went in.

3) Found new faith. 4) Rediscovered what is important
in life. 5) I prayed. 6) I changed something about myself. 7) I was inspired to do something creative. I was in a similar situation before. 6) Came up with a couple of different solutions to the problem. Accepting responsibility 1) Criticized or lectured myself. 2) Realized, I brought the problem on myself 3) I made a promise to myself that things would be different next time 4) I apologized or did something to make up.
All parents were invited to participate when they came to drop off or pick up their children at the school; those who chose to participate were asked to select the strategies they implement to manage their ASD Figure 1: Number of parents with their different coping strategies were shown.
children. We explored the results and examined those strategies that were ranked with a 3 ("use frequently") by the parents, as they identified those strategies as effective for managing their ASD children.
The educational years of the parents were collected from the questionnaires to observe the relationship between their education and coping styles. The educational levels of parents of ASD children were then divided into five groups. According to the educational system in Bangladesh, Secondary School Certificate (SSC) and Higher Secondary School Certificate (HSC) examinations are held during students' 10 th and 12 th years of education. Therefore, if an individual has not acquired an SSC, this means that he or she possesses fewer than 10 years of education. A total of 18 years are required to obtain a Bachelor's degree and for more than a Bachelor's degree, students need over 18 years.

Data Analysis:
All data were analyzed using the statistical packages for the social sciences (SPSS 16) software program and an Excel 2013 file. A Chi square test was carried out to determine the relationship between parent education and different coping strategies.

Discussion:
To identify the coping strategies and their relation with parents' level of education, we created a survey to be administered among parents of autistic children, which comprised one questionnaire containing eight groups of coping strategies. The parents' educational level was also recorded. All parents chose different types of strategies according to their abilities. We found that parents' education was significant only for the strategy, "accepting responsibilities." During "confrontive coping," an individual might exhibit aggressive behaviors to change the unwanted situation by expressing anger 14 . In this domain, most parents (32/44) "at least try" to manage their situation and a low number (8/44) indicated that they expressed anger. This result indicated that most parents accepted the situation with a positive attitude and pursued additional and new medication and therapies to improve the management of their child. For cases in the "distancing from problem" domain, most parents (10/44) chose "not overanalyzing," which might better enable them to accept the situation so they can focus on managing their autistic children with a more positive attitude.
In the "seeking social support" domain, most parents (26/44) were seeking to "get professional help." Some studies found that more parents seek "professional help" 15,16 comparing with our study. This indicates that Bangladesh still lacks opportunities for parents to seek professional help to manage their autistic children.
Alternatively, seeking professional help can create space for leisure time for parents 17 which might also bring about improvements in their strategies for managing their autistic children 18 . Most parents (19/44) "separate own feelings" in cases where they have implemented "Self controlling," which might strengthen their mental ability to manage their children 19 . "Conduct self-evaluation" was used by most parents (17/44) under the "accepting responsibility" domain. Nearly the same number of parents chose other strategies, such as "Understand own role in problem" (13/44), "Promise to not repeat the same mistake next time" (15/44) and "Apologize or do something to make up" (15/44). We assume that all strategies under "accepting responsibility" were beneficial to parents because they helped them manage their autistic children with a positive attitude. For the strategy, "planful problem solving," most parents (32/44) "apply more effort" to managing their children; here, it may be assumed that they accepted the reality of the situation, which enabled them to focus on managing their children. Some subscales of the "Escape-avoidance" coping strategy cause a situation in which the parents are isolated, which can lead to a lack of social support 20 .
In this study, most parents selected "wish that the situation would go away or somehow be over with" (6/44), "have fantasies or wishes about how things might turn out" (6/44) and "pass off responsibility to others" (6/44). It seems the parents have no tendency to avoid the situation fully. This tendency might be helpful to take more social support to manage their children. "Positive reappraisal" was ranked lowest on the questionnaire for parents. Most parents (35/44) selected "change daily lifestyle" to manage their children with special needs. Most parents who participated had average to higher levels of education: HSC (13/44), Bachelor's degree (9/44), and higher than a Bachelor's degree (6/44). The number of parents with a lower level of education was less than that of parents with average or high levels of education. As people with higher levels of education have higher cognitive and executive functions, 8,9 we can assume that most parents in our study are capable of managing their autistic children in a positive manner. In this study, we found that parents' level of education was only significantly related to strategies regarding "accepting responsibilities," which indicated that parents take responsibility in their own way using other strategies, such as "conduct self-evaluation," "understand their role," "making an apology" and "making a promise not to make the same mistake next time," which all reflect higher cognitive function on the part of the parents.

Conclusion:
We surveyed eight groups of coping strategies and their relation with parents' education using questionnaires. We found that parents' education was significantly related to the strategy, "accepting responsibilities." Given the results of this survey, we concluded that the parents of autistic children need more social support and higher education to manage their autistic children and would also benefit from counseling to improve their own quality of life. Limitations of the Study: 1. Small sample size. Larger sample size might give us consistent information. 2. Only mother or father was participated in this survey. Coping plans of both mother and father would give strong management plans about their children.