Children and Youth Services Review 35 (2013) 1670–1678

Contents lists available at ScienceDirect

Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

“At a moment, you could collapse”: Raising children with autism in the
West Bank
Sarah Dababnah a,⁎, Susan L. Parish b
a
School of Social Work, University of North Carolina at Chapel Hill, 325 Pittsboro Street, CB 3550, Chapel Hill, NC 27599-3550, USA
b
The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MS 035, Waltham, MA 02454-9110, USA

a r t i c l e i n f o a b s t r a c t

Article history: The current qualitative study examined knowledge, attitudes, burdens and coping strategies related to caring for
Received 19 April 2013 a child with an autism spectrum disorder (ASD) in the West Bank. Based on a sample of 24 Palestinian parents,
Received in revised form 24 June 2013 the study found that parents struggled with financial stressors, child behavioral and medical challenges, and de-
Accepted 13 July 2013
pression. Few parents were aware of ASDs prior to their children's diagnoses. Furthermore, discrimination and
Available online 19 July 2013
stigma from extended family members and the larger community intensified parents' feelings of shame and ex-
Keywords:
periences of social isolation. While some parents coped by withdrawing from the community or denying the di-
Autism agnosis, others aimed to increase social interactions and access information. Religious coping was found to be
ASDs partly adaptive for some of the participants. The study underscored the vital need to increase community aware-
Caregiving ness of ASDs and increase social support for parents in the West Bank.
Coping © 2013 Elsevier Ltd. All rights reserved.
Palestinians
West Bank

1. Introduction 1.1. Background

Images and ideas about the West Bank are often associated with vi-
olence related to the Israeli–Palestinian conflict. There has been little re-
search attention paid to individuals with autism spectrum disorders
(ASDs) in this contentious area. No published studies have investigated
ASDs or other developmental disabilities in the West Bank, despite
reports elsewhere of a rapid rise of diagnoses (e.g., see Centers for
Disease Control and Prevention [CDC], 2012). The aim of this paper is
to gather first-hand perspectives about the caregiving experiences of
parents who are raising children with ASDs in this conflict-ridden
region. The high prevalence of stress and related mental health issues
for caregivers of children with ASDs in high-income countries has
been widely reported (Abbeduto et al., 2004; Estes et al., 2009;
Koegel, 1992; Montes & Halterman, 2007; Phetrasuwan & Shandor
Miles, 2009). However, little research has focused on parents in
low-income countries, particularly those affected by widespread
war and trauma. This study was undertaken to understand the chal-
lenges faced by parents of children with ASDs in the West Bank, and
their coping strategies.
⁎ Corresponding author at: University of North Carolina at Chapel Hill, School of Social
Work, 325 Pittsboro Street, CB 3550, Chapel Hill, NC 27599-3550, USA. Tel.: +1 919 962
1225.
E-mail addresses: dababnah@unc.edu (S. Dababnah), slp@brandeis.edu (S.L. Parish).
The West Bank is the eastern area of the Palestinian territories, bor-
dered by Jordan and Israel, and owes its name to its location on the Jordan
River. Together with East Jerusalem, the Golan Heights and Gaza Strip, it
has been the center of decades of land disputes between Palestinians and
Israelis. The Palestinian Authority has exercised control over parts of the
West Bank since 1994, sharing rule with Israel in a complex, and fre-
quently tenuous arrangement.
The West Bank has a population of 2.6 million people in an area ap-
proximately the size of Delaware (United States Central Intelligence
Agency [CIA], 2012). The majority of the population is Palestinian
Arabs (83%) who are predominantly Muslim, although a sizeable popu-
lation of Christians and other religious minorities exists. About 17% of
the total population is comprised of Israeli Jews, who primarily live in
distinct settlements in the West Bank.
In addition to linguistic and cultural differences between Jewish and
Arab residents of the West Bank, numerous other distinctions exist be-
tween the communities. Due to a long history of often violent conflict
between Arab and Jewish West Bank inhabitants, access to Jewish set-
tlements is restricted to residents. Furthermore, while Israeli govern-
ment spending has rapidly increased to the settlements in the past
year (Levinson, 2012), the Palestinian economy is constrained in part
by restricted access to land and other resources (CIA, 2012). Differential
access to governmental goods and services potentially can lead to wide
health and socioeconomic disparities. Additionally, anti-terrorism mea-
sures, such as checkpoints, delay health care access for Palestinian

0190-7409/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.childyouth.2013.07.007
 S. Dababnah, S.L. Parish / Children and Youth Services Review 35 (2013) 1670–1678
residents of the West Bank (Devi, 2007). While no known studies have
compared health and social inequalities in the West Bank, Arab–Jewish
disparities have been reported within Israel. Israeli Arabs have shorter
life expectancy than Israeli Jews (Israel Central Bureau of Statistics,
2012). Other research has highlighted lower educational attainment
(Okun & Friedlander, 2005) and higher prevalence of emotional distress
of Arabs as compared to Jews in Israel (Levav et al., 2007). Thus, the cur-
rent study focuses on Palestinian Arabs in the West Bank, given that
they are part of a largely underserved and understudied population.
1.2. Autism: uncharted territory in the West Bank
The increase in the prevalence of ASDs has been widely reported in
the United States (CDC, 2012). However, few reports of the prevalence
of ASDs exist for the Middle East; none are available for the West
Bank. The first epidemiological study of ASDs in the Middle East was a
random community sample of nearly 700 three-year old children in
the United Arab Emirates, which found a prevalence rate of 29 per
10,000 children (Valsamma, Abdul Azim, Taoufik, & Feisal, 2007). Nota-
bly, none of the children identified with ASDs through the study had
been previously diagnosed. These findings underscore the need for im-
proved diagnostic practices in the United Arab Emirates. Another study
described a small group of Saudi Arabian children with ASDs (Al-Salehi,
Al-Hifthy, & Ghaziuddin, 2009) and found later diagnosis of females
relative to males, a disproportionately elevated number of children tak-
ing medication, and a high number of children from consanguineous
unions. A study to validate screening instruments in Arabic highlights
early efforts to improve detection of ASDs in the Arab world (Eldin
et al., 2008).
Large-scale studies of parental stress and family burden related to
ASDs in the Middle East are wholly absent. However, an extensive
body of research in Western countries has concluded that families face
considerable emotional, psychological and financial burdens related to
caring for children with ASDs (e.g., see Benson & Karlof, 2009; Carter,
Martínez-Pedraza, & Gray, 2009; Liptak, Stuart, & Auinger, 2006; Parish,
Thomas, Rose, Kilany, & McConville, 2012). These burdens are associated
with a range of challenges affecting families, including negative child be-
haviors (Bromley, Hare, Davison, & Emerson, 2004; Estes et al., 2009).
While there is a dearth of knowledge on the impact of raising chil-
dren with ASDs on Middle Eastern families, a small body of research
exists on children with special needs and their families in the Islamic
world. One cross-cultural study found comparatively high levels of
stress and mental health issues among Jordanian mothers of children
with intellectual disabilities, compared to Irish and Taiwanese mothers
(McConkey, Truesdale-Kennedy, Chang, Jarrah, & Shukri, 2008). In
communities where family life is typically a central aspect of culture,
biases against people with disabilities often extend to the whole
family. For example, ethnographic research with Jordanian families
of special needs children found frequent social isolation of the entire
family (Young, 1997). Furthermore, mothers of children with devel-
opmental disabilities in the United Arab Emirates reported stigma
and discrimination from service providers and the wider community
(Crabtree, 2007).
Extant research has focused on gender-based caregiving disparities
among parents and siblings of individuals with special needs in the
Middle East. An ethnographic study in the United Arab Emirates of par-
ents of children with developmental disabilities, including ASDs, noted
a tendency to blame mothers of the affected child (Crabtree, 2007).
Similar findings emerged from a study of Jordanian children with dis-
abilities, which also reported increased responsibility and burden on
mothers for the care of a child with a disability (Young, 1997). Supervision
of children with disabilities is often broadened to unmarried, nondisabled
daughters (Duvdevany & Abboud, 2003).
Crabtree (2007) suggested that the ability to care for and be compas-
sionate towards people with special needs is considered a sign of devout-
ness in Islamic cultures. However, Sharifzadeh (1998) noted Middle
1671
Eastern parents of children with disabilities often experience guilt and
shame from their communities, interwoven with religion. Shame is asso-
ciated with a perception of fate and the stigma of a punishment from God
(Hasnain, Shaikh, & Shanawani, 2008). Notions of fate and parental
blame seem to be more prevalent when the child's disability is intellec-
tual (as compared to other disabilities) in some predominantly Islamic
communities (Ansari, 2002).
In light of this limited body of literature, Palestinian children with
ASDs and their families are at risk for discrimination and social exclu-
sion. Yet, there is a paucity of research that characterizes these families'
experiences to date. Western research has highlighted the importance
of parents' development of positive coping strategies to mitigate the
impact of burdens (Boyd, 2002; Carter et al., 2009; Hastings et al.,
2005; Khanna et al., 2010). Kuhaneck et al. (2010) outlined six strate-
gies used by a sample of mothers to positively cope with parenting a
child with an ASD, including sharing responsibilities with a partner
and knowledge-seeking. Hastings et al. (2005) reported four primary
coping styles derived from a factor analysis of 135 mothers and fathers
of children with ASDs. They identified four coping styles: active avoid-
ance (e.g., behavioral disengagement, emotional outbursts), problem-
focused (e.g., knowledge acquisition, seeking informal and formal sup-
ports), positive (e.g., reframing, optimism, humor), and religious/denial.
Multiple studies of parents with children with ASDs have reported that
active avoidance coping strategies are associated with elevated parent
stress and depression, whereas there is a negative correlation between
problem-focused methods and parent stress and depression (Cappe,
Wolff, Bobet, & Adrien, 2011; Carter et al., 2009; Dabrowska & Pisula,
2010; Dunn, Burbine, Bowers, & Tantleff-Dunn, 2001; Hastings et al.,
2005; Smith, Seltzer, Tager-Flusberg, Greenberg, & Carter, 2008). While
the ASD literature is less clear regarding positive coping, researchers
have noted that this coping style is negatively associated with
maternal-reported depression (Hastings et al., 2005), parent isola-
tion and spousal relationship problems (Dunn et al., 2001). Finally,
while Hastings et al. (2005) found religious/denial coping strategies
to be maladaptive in their sample, the ASD field has not clearly investi-
gated how parent denial (i.e., refusal of child's diagnosis and/or devel-
opmental delay) and their use of religion are associated with child,
parent and family outcomes. Gray (2006) suggested that over time fam-
ilies of children with ASDs tend to move towards emotion-focused and
religious coping strategies. Tarakeshwar and Pargament (2001) de-
scribed a complex relationship between religion and coping with stress
related to caring for a child with an ASD. In their mixed methods study
of mostly Christian families, they found that religious practices can be
helpful for parents of children with ASDs, in terms of obtaining social
support and making meaning of a diagnosis with no clear cause. How-
ever, some religious practices, such as a difficulty to attend church ser-
vices, served to isolate families.
Specific aspects of positive and problem-focused coping styles are
particularly valuable to caregivers of children with special needs. For ex-
ample, parents' attitudes and their ability to positively reframe stressors
are critical, as negative appraisal of caring for a child with an ASD has
been positively associated with parent stress (Stuart & McGrew, 2009),
while reports of positive experiences related to caregiving have been
negatively associated with parent stress (Kayfitz, Gragg, & Orr, 2010).
Knowledge acquisition is an important problem-focused coping skill, as
families of individuals with disabilities might restrict the individual's in-
volvement in community and social life, education, or employment due
to lack of awareness of their abilities (Hasnain et al., 2008). Informal so-
cial supports, such as parent support groups, are also critically important
to parents of children with ASDs and are strongly associated with re-
duced levels of parent depression (Benson, 2006; Benson & Karlof,
2009; Boyd, 2002; Carter et al., 2009). Family and partner support are
also important for maternal psychological well-being, maternal depres-
sion, and life satisfaction (Ekas, Lickenbrock, & Whitman, 2010). Thus,
while studies describing Middle Eastern parents' experiences of coping
are largely absent, the literature base as a whole suggests the importance
1672 S. Dababnah, S.L. Parish / Children and Youth Services Review 35 (2013) 1670–1678
of the promotion of social support and positive coping strategies for par-
ents of children with ASDs.
To address these gaps in the research, a qualitative interview
and focus group study was conducted with Palestinian Arab parents
of children ages 18 and under with ASDs living in the West Bank.
We examined parent knowledge, attitudes, burdens and coping
strategies and addressed the following research questions: 1) What
knowledge do parents have of ASDs? 2) How do parents describe
the attitudes of their communities and families, as well as their
own, towards children with ASDs? 3) What burdens and concerns
do parents report related to caring for a child with ASDs? 4) What
methods do parents employ to cope with caregiving stress, burdens
and discrimination?
2. Method
2.1. Participant recruitment and description
Recruitment was organized in partnership with the Palestinian
National Team for Autism, which includes representatives from
eight non-governmental centers that serve children with develop-
mental disabilities in the West Bank and Jerusalem, one parent rep-
resentative, and community health workers. Representatives from
the non-governmental centers agreed to contact potential participants
and distribute information about the study. In order to include children
who do not receive services from the public school system or non-
governmental centers in the West Bank, parents were also recruited
through the Community-Based Rehabilitation Program. Operating in
the West Bank for more than twenty years, this program trains local
health workers to work with children with disabilities in home and
community settings.
Center contacts and community health workers distributed fact
sheets about the study to parents of eligible children. The fact sheets
contained information about human subject protection and individual
rights of study participants. Once an individual indicated interest in par-
ticipating, center contacts scheduled the individual for either a focus
group or one-on-one interview. Participants were given the option of
attending one of the four scheduled focus groups or arranging an indi-
vidual interview. These options were offered to parents in order to
accommodate challenges with scheduling, transportation, and other
caregiving responsibilities. Individual interviews were conducted in pri-
vate homes or other community settings throughout the West Bank.
Focus groups were held at community centers in a large city in the
West Bank. About half of the parent interviews were conducted in one
of the four groups. Although there were no differences between the par-
ents opting to participate in focus groups (n = 11) versus those who
chose individual interviews held at community centers (n = 11), the
two parents interviewed in their homes resided in isolated areas and in-
frequently traveled beyond their villages. The average duration of the in-
dividual interviews was approximately 1.5 h, while the focus groups
averaged approximately 2 h.
With the assistance of community health workers, parents of chil-
dren (up to age 18) with ASDs were recruited in 14 West Bank villages
and refugee camps. Due to time and monetary limitations, a sample of
20 to 30 parents was targeted. All of the children with ASDs had been
diagnosed by primary care doctors or local agencies. No additional eval-
uations were conducted by the study team. To protect their confiden-
tiality, identifying information was not collected from participants,
except place of residence. Table 1 describes key aggregated characteris-
tics of the sample. In total, 24 parents participated. Twenty parents were
mothers; the remaining four were fathers. The participants were from
Ramallah, Nablus, Hebron, and nearby refugee camps and villages. Re-
spondents indicated that they had 16 boys and eight girls with ASDs.
All children were of school age except one. They ranged in age from 4
to 17 years old (mean of 10 years).
Table 1
Sample description (N = 24).
Parent characteristics n Percentage
Mother 20 83.3
Married parent 22 91.7
Parent of male child with autism 16 66.7
Parent has N1 child with special needs 3 12.5
Parent has child with severe behavioral problemsa 7 29.2
Parent has a “high-functioning” childa 4 16.7
Parent has a child with autism and comorbid conditionsb 5 20.8
M (SD) Range
Age of child (years) 10.0 (3.6) 4–17
Number of children in family 4.2 (1.6) 1–7
a
Parent characterization of child's behavior.
b
Comorbid conditions included epilepsy and physical stunting.
2.2. Instrument
Interview and focus group guides were created for parent interviews
and focus groups, respectively. (The guides are available from the first
author on request.) The guides were developed based on past research
(cited in the Introduction) of issues affecting families of children with
ASDs, as well as concerns specifically related to the Middle Eastern con-
text. Each questionnaire contained a series of eight open-ended ques-
tions and related probes focused on parent stress, coping strategies,
and the impact of the child's disability on the family, including the
child's strengths and challenges.
2.3. Procedures
The entire research protocol was approved by the authors' university-
based Institutional Review Board. Research staff had no interaction with
potential research participants until the time of the interview. The partic-
ipants received no compensation. Those who traveled for interviews or
focus groups were reimbursed for travel. Free childcare was offered, but
not used.
Research study staff was trained on research ethics and confidential-
ity. Informed consent was verbally obtained from each participant prior
to beginning the interview, as written informed consent was waived by
the authors' Institutional Review Board to protect confidentiality. As de-
scribed above, disabilities are highly stigmatized in some areas of the
Arab and Muslim world and their families face considerable discrimina-
tion as a result (Ansari, 2002; Crabtree, 2007; Young, 1997). Thus, these
confidentiality measures were intended to offer additional assurance to
interviewees that their identity and data would not be compromised.
Accordingly, each interviewee was instructed to not share his or her
own name or other identifying information except for area of residence.
Participants in focus groups were instructed to not share information of
others in group and provided verbal agreement before beginning the
interview.
All interviews were conducted by facilitators who were bilingual in
Arabic and English. The facilitators were all female and employed at a
local university. With the exception of one, the parent interviews were
conducted exclusively in Arabic. The remaining parent interview was
conducted primarily in English. All sessions were audio recorded. A na-
tive speaker of Arabic, who is also fluent in English, transcribed the
audio recordings in Arabic and translated the transcription into English.
The transcripts were reviewed to remove all identifying participant in-
formation. The first author, who is proficient in spoken Levantine Arabic,
attended all of the interviews and reviewed the transcripts for accuracy.
Once transcripts were transcribed and reviewed, the audio recording
was destroyed.
 S. Dababnah, S.L. Parish / Children and Youth Services Review 35 (2013) 1670–1678
2.4. Data analysis
Interview transcripts were imported into Atlas.ti (ATLAS.ti Scientific
Software Development GmbH, 2010). Using grounded theory method
(Corbin & Strauss, 2008), one researcher read each transcript twice
before coding ensued. The analysis process began by labeling each re-
sponse (open coding). After the initial review, the codes were character-
ized into general categories (axial coding) aligned with the research
questions. To further analyze the data and identify themes, subcategories
were developed within each broad category. A second investigator
reviewed the codes and themes. The researchers conferred to discuss
any points of coding disagreement, and jointly determined the final
coding.
3. Results
The themes below correspond with the research questions presented
earlier. Specifically, the investigators were first concerned with parental
knowledge about ASDs. Then, a number of subthemes are presented
regarding personal, family, and community attitudes towards children
with ASDs and their families, including parents' reports of community
discrimination and family support. Next, this section highlights partici-
pants' concerns and burdens and concludes with coping methods, includ-
ing denial of the ASD diagnosis and positive coping methods.
3.1. Parent knowledge
A majority of respondents (n = 16) were aware of their children's
delayed development before diagnosis, and many (n = 12) were
aware before their doctor recognized or acknowledged such delays. A
significant number of participants (n = 11) noticed developmental de-
lays before age two, and an additional five reported noticing them be-
fore age three. The primary delay noted was speech and non-response
to basic requests (n = 7). Five parents mentioned co-occurring physical
health conditions, such as vitamin D deficiencies and epilepsy. Parents
also reported a number of child behavioral concerns, including excessive
hyperactivity and unusual hand and body motions (n = 9), aggressive
or destructive behaviors, including screaming (n = 8), and isolation or
inability to interact or play with peers (n = 5). Four parents mentioned
clear cases of regression, in which their child achieved typical speech and
social milestones, then subsequently lost skills. Parents reported that re-
gression occurred at ages ranging from 15 months to four years.
Although more than half of the parents recognized that their child
had a developmental delay, the vast majority (n = 16) was unfamiliar
with ASDs and acknowledged they misunderstood ASDs when their
children were first diagnosed. For example, one father reported that,
at first, he believed that ASDs were the result of “lack of oxygen.” A
mother reported, “I thought autism meant ‘introvert’, that if I help him
by letting him interact with other kids, he will improve. I did not
know that autism is a neurological disease…” Another parent said,
“We thought autism is something simple, and means he is only an iso-
lationist. Then we learned autism is like Down syndrome.” Two parents
revealed current misunderstanding of the disorders. For example, one
mother was confused by media images of the “typical” case of ASDs,
which did not align with her child's own symptoms and contributed to
her denial of his diagnosis. Nonetheless, as discussed in Section 3.4 (Pa-
rental coping strategies), many parents recognized their own lack of
knowledge and sought guidance in books and the internet for an expla-
nation of the symptoms they observed in their children.
3.2. Parent, family and community attitudes
3.2.1. Personal attitudes
Many parents (n = 7) described positive traits of their children with
ASDs. They proudly mentioned that their children are physically attrac-
tive or are successful in learning basic skills (e.g., cooking, toileting,
1673
dressing). However, four parents described having a child with a disabil-
ity as a “sign of shame”. A mother stated, “If there is a big problem, or a
shame, you have to – you must – hide it. You can't go out with her, or
talk about her.” Eight parents admitted that they actively hid the
fact that their children have ASDs from others in their community.
One mother said, “Some people come to visit me on occasion and
tell me, ‘I would like to ask about your son.’ I tell them he is shy.”
The social nature of Palestinian life caused stress for the parents. A
mother, crying, relayed, “I become withdrawn because I do not
want to feel embarrassed in front of people. [My son] is very active
and when people come over…. it is not very nice.” One parent blamed
the stigma on society:
You can see that we [parents] can talk about these things, because
we are not ashamed that we have kids with special needs, but look
at our society. I cannot say that I have a girl with special needs. This
is my problem that I have to hide this fact.
Nonetheless, parents with children with less severe behavioral or
adaptive issues reported including their children in community activities.
A parent reported being ashamed to bring her son out of the house when
she first learned of his condition. However, over time, this evolved:
I was normal. If I need to go somewhere, I do not take anyone with
me other than him. If I need to go visit someone, I take him with
me. When he sees me put my clothes on, he gets ready with his
clothes and shoes because he wants to go out.
Other parents also developed positive routines with their children in
the community. A father described, “Every time I come home, [my son]
is looking out the kitchen window waiting for me so I can take him out
for a spin. Then, we come back home together. We do that every day.”
3.2.2. Sibling burden
Generally parents reported that their other children cared for the
child with an ASD (n = 5). A mother reported, “When [my son] breaks
one of his siblings' things, they get very upset… Then they got used to it,
and even though they complain about his situation, they love their
brother very much and their relationship is very good.” However, a
third of the parents (n = 8) reported that their nondisabled children
experienced shame from their peers. One father recounted a story re-
garding his 10-year old son:
[My son] will not let his friends come into the house. He only talks to
them at the door. He brought a friend inside the house while his
brother was screaming. So his friend told my son, “Do you have a re-
tarded [sic] brother?” Since then when his friends come, he says he
will only play outside the house and never let them inside the house,
since his brother might scream. He is still young and cannot under-
stand his brother is a special case. So, there is some sort of embar-
rassment to the younger siblings and to the family.
Female siblings were reported to shoulder a lot of responsibility for
the care of the child with an ASD (n = 4). One father with two children
with special needs explained:
Everyone's role in the family is affected, including their older siblings
who cannot go to school, because a lot of time is spent caring for these
kids. We got the grades for the older sister and they were failing
grades. She failed not because of her own fault, but because of the suf-
fering that she is going through and the efforts she spends at home.
She spends a lot of time helping her mother around the house. She
cannot even read.
One mother suggested that female siblings are socially expected to be
responsible caregivers. “We keep a careful eye on our social obligations.
1674 S. Dababnah, S.L. Parish / Children and Youth Services Review 35 (2013) 1670–1678
We never miss a wedding, engagement, or graduation. But one of my girls
has to pay the price. When we go out, one has to stay at home.”
3.2.3. Spouse support
Only one mother reported that her husband blamed her for her
child's disability and threatened to take another wife, but he changed
his mind after she had another child without disabilities. Three parents
reported that their spouses (one wife, two husbands) denied the fact
that their child had an ASD. Only one participant, a mother, described
incidents of spousal anger about the child's behavior. However, many
interviewees (n = 9) reported that their spouse supported them in
positive ways. For example, emotional support was mentioned the
most often as critical for the parents. A father said, “I talk to my wife
for the most part. We are the opposite of each other. If she sees me
upset about [our son], then she tries to be calm. I do the same.” Two par-
ents indicated that their spouses expressed a religious rationale for their
child's disabilities, “[My husband] always reassured me and told me this
is from God. This is a test from God. [He said] we have to be patient and
accept it. He tells me we don't know what God means by this.” Instru-
mental supports (e.g., direct services, financial assistance) were also
helpful to the parents. Two mothers indicated that their husbands of-
fered them respite from primary caregiving responsibilities, such as tak-
ing the child on errands.
3.2.4. Extended family support and rejection
Multiple parents (n = 11) reported that their extended family
members provided them with emotional and instrumental support.
For example, one mother described her sister-in-law as her emotional
confidante when she needed to “vent” about problems. Instrumental
support from extended family members was reported to include finan-
cial assistance, occasional childcare, and transportation; these were
mentioned by many of the participants. For instance, one mother de-
scribed how her extended family took care of her son with an ASD in
order for her and her husband to spend time with their other children.
Nonetheless, a third of the parents (n = 8) relayed severe problems
to obtain their families' acceptance of their child's disability. One mother
said:
Some of the people from my family were understanding. Others
were not. They were telling us to get rid of him. To get rid of him!
[They said], “Why are you taking care of him?” That is how some
people think. When he got sick, they kept telling us, “Why are you
even spending money on him?”
Child behavioral issues were reported as an obstacle to acceptance of
the child by extended family. As one mother explained, “I have a great
family, but they are not accepting of [my son] because he is a source
of annoyance for them…. He breaks things…. He keeps opening the re-
frigerator. They tell him to stop over and over again.”
Four mothers reported that their extended family, such as in-laws,
explicitly blamed them for their child's disability. For example, one
mother recalled:
My in-laws were very upset. My mother-in-law told me, “I wanted a
healthy boy. My son married you to get a healthy boy.” Like it was a
hereditary disease from my family…. Everyone blames me. I keep
telling them it is God's will. They tell me that I can make [my son]
better.
Extended family members were reported to encourage parents to
not discuss the child's disability outside of the family. Despite these oc-
currences of blame and rejection, most parents attributed their families'
negative attitudes to lack of knowledge about ASDs and denial of a de-
velopmental delay. Denial was at times framed in a religious context,
as one mother explained, “[My family tells me my son] is not autistic
and ‘This is God's will’ and ‘Leave it to God.’”
3.2.5. Community discrimination and shame
Five parents mentioned blatant discrimination and the resulting
stress they experienced from the community due to having a child
with special needs. Some of these parents attributed community discrim-
ination to ignorance. One mother recounted a time when she took her
daughter on public transportation. Multiple people on the bus chastised
her for her inability to teach her child with disabilities to “differentiate
between right and wrong.” However, beyond ignorance, parents de-
scribed multiple examples of community attitudes related to shame.
One woman described an encounter, “I was talking to my manager
about how I am upset about my son's condition. He told me, ‘Do not men-
tion that autism stuff to anyone. They will feel pity on you. Do not make
rumors about yourself.’” Other parents were reluctant to take their chil-
dren outside frequently. One explained:
It is very difficult to walk with your disabled child in the street. Ev-
eryone leaves what they are looking at or doing and starts watching
your kid. You feel like you are the star of a puppet show. Everyone in
the street is looking at you.
Notably, no parent reported supportive or compassionate ASD-
related encounters with the larger community.
3.3. Parental concerns and burdens
3.3.1. Financial burden
More than half of the parents (n = 14) interviewed explicitly men-
tioned the financial toll taken by the need for ASD-related testing, ser-
vices, and other supports and supplies. For example, some parents
sought costly testing and services outside the West Bank, in Jordan,
Europe and the United States. Services included mainstream behavioral
therapies, hyperbaric oxygen treatments, and nutritional modifications.
One respondent noted that her son with ASDs “cost the same as the
other six kids combined.” Another mother added, “My husband is a gov-
ernment employee. Believe me, 70 percent of his salary goes just for [my
son]. The rest of the family lives off 30 percent.” Some of the parents
(n = 4) mentioned the costs of purchasing special diets for their
children. Additionally, as many children (n = 6) continued to strug-
gle with toilet training, parents reported the expense of diapers in
particular. Families also reported that specialized childcare, trans-
portation, and property destruction (described below) were addi-
tional financial burdens.
3.3.2. Behavioral and medical concerns
The majority of parents (n = 14) expressed concern regarding their
children's poor behavior. Nine parents mentioned significant issues
with their child's hyperactivity. Ten reported major problems with ag-
gression or other types of externalizing behavior, such as screaming,
self-injury or property destruction. A mother gave the example, “I hide
anything sensitive like the phone and the remote…. He took 400 shekels
[approximately 110 USD] and threw them from the window. He
threw my [jewelry] from the window, too.” Other parents noted
their children wandered, displayed repetitive behaviors, or preferred
to be alone.
In addition to concern about the maladaptive behaviors exhibited by
their children with ASDs, participants also reported concerns about
delays associated with their children's impairments. Toileting and
other daily living skills such as eating were frequent parental con-
cerns (n = 7). Seven parents also reported being troubled by their
children's dysfunctional speech or complete lack of speech. A smaller
number of parents (n = 5) reported that their children had serious
co-occurring medical conditions such as epilepsy that caused them
concern.
Children's challenging behaviors and limited daily living skills to-
gether reportedly constrained families' freedom, isolated them from
community life, and increased financial burden. One father noted that
 S. Dababnah, S.L. Parish / Children and Youth Services Review 35 (2013) 1670–1678
his family was unable to complete simple errands, “If we want to
take him outside somewhere with us, he gets loud and screams.
We take him to the supermarket, but he does not like it and we
have to leave.” These behaviors caused embarrassment, as one
mother recounted:
I have to take [my son] to the main road every day for the car to pick
him up [to go to school]. [He] thinks every car passing is the car that
will pick him up, and he tries to get into it. It's a problem because he
starts to scream and cry. That happens early in the morning before
the neighbors wake up. It makes me very stressed.
Another mother noted that her family never went on trips or to res-
taurants, “I believe we have the right to live like everyone else. We
would like it if we could go out or travel. Everybody travels. I would
like to go to the beach.” Multiple parents described the monetary costs
incurred from children's property destruction at home. For example,
one parent noted, “In general [my daughter] requires a lot of money.
Our biggest problem is breaking things around the house. Anything
she holds, she breaks.”
3.3.3. Concerns about the future
Worrying about their child's future was a concern expressed by five
of the parents. The sample articulated regret that their children might
not experience life course milestones such as graduation or marriage.
Some parents reported hoping for any symptom improvement. A mother
said, “My life dream is that [my daughter] improves, that God cures her
and she can depend on herself.” Others expressed their commitment to
caring for their child, while sustaining hope that ASDs can be cured. A
parent said:
The most important thing is that I hope – I'm not going to ask for the
impossible – that [my daughter] becomes normal again. I'm not ask-
ing much. Inside me, I'm convinced that the condition she is in now
is like going upstairs, so she will never come back down. I hope I can
perform my duties and obligations to the last day.
Parents also reported concern about their child's welfare in adult-
hood and as they themselves aged. One mother reported that her
husband asked, “When [he] grows up a little more, how are we
going to deal with him? How will his siblings feel about him after
we are gone?”
3.3.4. Depression
More than half of the parents (n = 13) explicitly mentioned that
they suffered from significant depressive symptoms. Nine parents
also noted that their spouses had similar symptoms. Others parents
explained that depression extended to the whole family, including
siblings. For many participants, the initial shock of the diagnosis
was painful to remember. One mother recalled her meeting with
the doctor, “It was painful, painful, painful…. The whole world be-
came very small to me, smaller than a dot…. The little hope I had be-
fore that was lost.” Three participants had multiple children with
special needs, which heightened their feelings of depression and
frustration. A mother tearfully relayed:
[The diagnosis] was a huge shock for me. This was not my first expe-
rience. I suffered before with another child that was seven and a half
years old. When I heard my daughter's [diagnosis]…. I asked, “Why
God, me?” Two years before that my son died in my hands. It was very
difficult for me and I started to think about committing suicide…. We
were just getting over our sorrow for [our son] and we got hit by [our
daughter's] news. Happiness did not even make it to our house.
While some of these parents reported that they isolated themselves
and often cried, many (n = 10) noted that they now put their energy
1675
into speaking to others or seeking information. One mother said, “When
[my son] first started medications, for a year or two, even the closest peo-
ple to us did not know. And then, I was very upset and I used to cry. But
when everyone knew, I was relieved.” Other parents described similar re-
actions, “I cried the whole day from morning until sunset. Then, I felt cry-
ing will not change anything. I stopped crying and started to look for ways
to try to help him.”
Many of the parents (n = 12) who had recovered from the initial
shock of the diagnosis continued to suffer from stress and depression.
A father explained:
Like any father, I was upset, because your child has a dim future. It
was a challenge for me to find solutions because of the lack of
resources… This was a source of worry and fatigue because you
work alone with the child. It is a big responsibility.
Respondents mentioned frustration, anger and depression resulting
from a child being denied services due to their autistic symptoms.
These consistent frustrations weighed on parents. One mother de-
scribed having chronic headache from her daughter's condition.
Some participants reported that they presented a stoic face to out-
siders, but continued to silently suffer. A parent described her de-
spair, “I do not feel upset when I talk to anyone about autism or
my son's condition, but as a family we are living a difficult life
and are not comfortable. We are suffering.” Another mother
noted, despite her stress and depression, she generally was able
to be outwardly and inwardly strong, “but at a moment, you
could collapse.”
3.4. Parental coping strategies
3.4.1. Denial of the diagnosis
Four parents reported that they initially denied that their child had a
developmental delay. Two parents mentioned that they knew their
child has a delay even before two years of age, but chose not to act on
it. A mother said, “I could not even comprehend the idea and I said
there is nothing wrong with him. I was looking for reasons to say that
the kid is normal and nothing is wrong.” For some parents, denial lasted
for years, even well into the school years. One interviewee said, “My
husband, he said to me, ‘Don't listen to anybody. She will be talking
after one to two years. Maybe….’ But now, when she was eight exactly,
all of the house, we said, ‘Yes, there is something wrong with [her].’”
One father admitted he was currently not “convinced” of the ASD diag-
nosis and gave the example:
In Ramadan during the taraweh prayer, which is very long, [my son]
prays it with me. He listens to the Friday khutbah [public speech]
while he is sitting down with no problem. It's puzzling to me. He does
have some autistic behaviors, but someone who is hyper….does not
pray the taraweh and is committed to it.
3.4.2. Acceptance and religion
Eight respondents explicitly noted that they had accepted their
child's condition. Five parents related their acceptance to their be-
lief that the condition was “from God” or “God's will”. A mother de-
scribed how her faith in God enabled her to deal with her problems.
She said, “I believe I'm psychologically more comfortable than my
husband… I only think for today and I believe that whatever God
is planning for tomorrow is what will happen.” Parents also de-
scribed traits such as patience and love for their child as originating
from God, as one mother noted, “God gives patience before the
problem.” For many of the remaining participants, however, com-
plete acceptance was more difficult despite faith in God. One moth-
er, as she cried, said, “We had patience. We accepted it…. I do not
want to make a big deal out of it, but thank God for everything.”
1676 S. Dababnah, S.L. Parish / Children and Youth Services Review 35 (2013) 1670–1678
Some parents believed that God would cure their children. One
stated:
We need a miracle. Of course, God is capable of everything, [including]
for [my son] to be like his siblings. Thank God all of his siblings are
great and they are educated, but I still do not feel complete happiness
and satisfaction in that because of his condition. I'm heartbroken. I
wish from God that He cures him from the disease that he has. That
is all I hope for.
Lastly, one mother described religious practices helped to make
them feel better, as she expressed, “When I start crying, I go for wudoo
[ritual washing] and prayer.”
3.4.3. Social interaction and support
Parents (n = 9) frequently reported that they avoided social inter-
actions or discussing their child outside of the family altogether. Parents
acknowledged the fact that they avoided others because they did not
want to feel “embarrassed.” A parent explained:
For us, we live in isolation. We have fences and closed gates. I
never mix with my neighbors. My neighbor always tells me,
‘How come you don't come and visit?’ I tell myself, she knows
my situation. My kid could scream, need to be bathed. My care
for my child is more important than going to visit others….
[The neighbors] actually think I am being too proud to come
and visit.
Some parents rationalized their avoidance as not wanting to trouble
others. One said, “I do not vent to anyone other than myself. I feel that
everyone has enough trouble of their own. I do not want to give them
more concerns.” Similarly, another described, “In the beginning, we
were talking to everyone about [our child's condition] and we got sick
of it. Everyone has his own problems. Someone will listen once or
twice, but that is enough.”
Despite the difficulty reported in discussing their children's ASD
diagnoses, social interactions were important for some parents
(n = 8), all mothers, as a coping mechanism. These mothers report-
ed that they were comforted through conversations with their spouses,
other family members, and friends. At times, parents expressed that
they wished to talk with others, but “only if someone asks”. One parent
conveyed the spectrum of emotions she experienced related to social
interactions:
Some days you come and find us feeling like we cannot say a word. I
like to talk about my situation, but some days do not. When my
friend comes to visit me, I talk to her forever, but I still feel that what
is inside of me did not come out. I still feel that there is more I could
say.
3.4.4. Information seeking
As described earlier, many of the parents (n = 10) redirected
their negative feelings about the diagnosis to find positive ways
to help their children. It was a frustrating process for some, as one
parent described, “We looked everywhere if there is a center… if
there was a book we can read, anything on TV, a program. I was
looking for anything.” Only half of these parents (n = 5) were
able to access the internet or books to educate themselves on
ASDs. A mother said:
Our problem is that we have no information on this condition. Imag-
ine if the doctors themselves do not know what autism is. I went to
the internet and read about autism and what causes it. And, until this
day, I do. Now, I know what autism is and how it is diagnosed. Now, I
look for how I can treat it.
4. Discussion
This study investigated the experiences of Arab parents raising chil-
dren with ASDs in the West Bank. Participants lacked extensive knowl-
edge about ASDs, but most recognized a delay early in their children's
development. Negative family and community attitudes were a tremen-
dous source of stress, shame and blame for parents. While extended fam-
ilies sometimes offered financial and instrumental support, they also
encouraged parents' feelings of shame. Parents described enormous bur-
dens within their families and strong fears about their children's futures.
Their children often displayed severe behavioral and adaptive challenges.
Depression was pervasive in the sample, and often extended to parents'
spouses and other children. The parents experienced significant financial
hardships from their children's care needs. In total, these daunting finan-
cial, psychological, and caregiving burdens led parents to feel confined to
their homes, embarrassed about their child's condition, and desperate for
answers. While the parents in this study demonstrated remarkable resil-
ience, the findings overall revealed them to be incredibly vulnerable to
further psychological, emotional and financial stressors.
The current study builds on the vast body of Western literature of
stress and coping in families of children with ASDs, as well as the more
limited research focused on Middle Eastern and Muslim families of chil-
dren with special needs. The parents in this study clearly expressed vari-
ous burdens and related stress, such as financial strain, depression, social
isolation, stigma and discrimination. These findings of social isolation
and stigma were echoed in research from Jordan (Young, 1997) and
the United Arab Emirates (Crabtree, 2007). Furthermore, as in prior re-
search, the current study demonstrated that the strains described by
individual parents affected their spouses and other children. Gender-
based caregiving disparities were also clear in this sample, as mothers
specifically noted that they experienced blame and discrimination
from their families and the wider community. It is not clear if other sig-
nificant disparities related to gender would have been evident had ad-
ditional fathers participated in the research. Lastly, female siblings
shouldered significant caregiving responsibilities, similar to the findings
of Duvdevany and Abboud (2003).
Although extant stress and coping literature is based primarily on
Western populations, there were striking commonalities between the
coping strategies highlighted in this study and those described in the
work of Hastings et al. (2005). Active avoidance (emotion-focused)
coping, in the form of social isolation and disengagement, clearly
contributed to parents' overall feelings of stress, shame, depression,
and social exclusion. Conversely, problem-focused coping, specifi-
cally support- and knowledge-seeking strategies, was valued. Spou-
sal support and knowledge-seeking strategies were also effective
maternal coping strategies highlighted by Kuhaneck, Burroughs,
Wright, Lemanczyk, and Darragh (2010). Spousal emotional and in-
strumental support in particular mediated some of the toll caring for
a child with an ASD placed on parents in this research. Yet, it is important
to note that only mothers in the study reported seeking social support to
cope with their children's challenges. Finally, despite reports of shame
and denial of the ASD diagnosis, respondents largely described their chil-
dren positively and with pride. Positive parental perceptions have been
identified as powerful coping mechanisms to adapt to stressors, particu-
larly in situations in which the individual cannot change the condition
(Hastings et al., 2005).
An important point of departure between Hastings et al. (2005) and
the current study is the role of religion as a coping mechanism. While
the former research combined religion with denial coping strategies and
characterized them as maladaptive, the data from this study reveal a
more complex picture. Certainly, the data uncovered instances in which
denial of the ASD diagnosis and religion were inextricably intertwined.
Yet, while the parents expressed strong personal feelings of shame and
experienced blame from their families and communities related to caring
for a child with special needs, the shame and blame were not always
clearly connected to the concepts of fate or punishment from God
 S. Dababnah, S.L. Parish / Children and Youth Services Review 35 (2013) 1670–1678
(e.g., see Ansari, 2002). In fact, at times the refrains of “God's will” and
religious activities seemed to offer a sense of peace to the parents and
a source of strength to focus on their children's challenges. Notably, ac-
ceptance, a factor in the positive coping style outlined by Hastings et al.
(2005), was closely tied to religious beliefs in this study. Clearly, in a
land so central to three of the world's major faiths, spirituality is
a critical component to understanding how individuals and families
cope and worthy of future study.
5. Limitations
The findings of the present study cannot be generalized beyond
Palestinian Arab parents living in the West Bank. Future research should
address the experiences of Jewish residents of the West Bank, and
Palestinian Arab parents living elsewhere, to examine cross-cultural dif-
ferences in caring for children with ASDs. Additionally, the sample was
small and the majority of participants were mothers, which limits under-
standing of fathers' perspectives and potential gender-based caregiving
disparities. Further, the sample was restricted to parents whose children
had been diagnosed with ASDs. The most isolated and underserved fam-
ilies were likely not represented in this study. No information was collect-
ed on time since diagnosis, which would have deepened understanding of
parental coping mechanisms. Finally, only one parent had a preschool-
aged child with an ASD.
6. Implications for policy and practice
Given the family- and community-centered nature of Palestinian
culture, policymakers and practitioners must address the considerable
social isolation expressed by participants. An aggressive campaign is
needed to improve the negative perceptions of ASDs in the West Bank. In-
creased public awareness can facilitate the social inclusion of children
with ASDs and the creation of parent support groups for this population.
Furthermore, financial assistance programs, mental health services, and
well-trained clinicians are urgently needed. Essential to any effort is the
support and guidance of faith and other community leaders, who can
lend moral authority to combat the troubling discrimination faced by
families of children with ASDs in the West Bank.
7. Conclusion
In summary, Palestinian Arab parents of children with ASDs living in
the West Bank reported high levels of emotional and financial burden
resulting from their children's care needs and the reactions of their ex-
tended families and communities. While some parents exhibited remark-
able resilience in the face of these burdens, many families struggled to
cope with daily stressors. This study illuminates the vital need for in-
creased public awareness of ASDs and stronger support networks for vul-
nerable families raising children with ASDs in the West Bank.
Acknowledgments
Support for this research was provided by the UNC Center for Global
Initiatives and the Anne-Linda Furstenberg Fund for Qualitative Re-
search. S. Dababnah acknowledges the support of the Sam and Betsy
Reeves Doctoral Fellowship. S.L. Parish acknowledges the support of
the Lurie Institute for Disability Policy at Brandeis Univerisity. The
study greatly benefited from the insight and expertise of Allam Jarrar,
Yoke van der Meulen and colleagues at the Institute of Community
and Public Health (Birzeit University), George Rantisi, Haya Basil, and
Kathleen Rounds. Finally, we are grateful to the families, providers and
organizations who graciously donated their time and resources to this
research.
1677
References
Abbeduto, L., Seltzer, M. M., Shattuck, P. T., Krauss, M. W., Orsmond, G., & Murphy, M. M.
(2004). Psychological well-being and coping in mothers of youths with autism, Down
syndrome, or Fragile X syndrome. American Journal on Mental Retardation, 109(3), 254.
Al-Salehi, S. S. M., Al-Hifthy, E. H., & Ghaziuddin, M. (2009). Autism in Saudi Arabia:
Presentation, clinical correlates and comorbidity. Transcultural Psychiatry, 46(2),
340–347. http://dx.doi.org/10.1177/1363461509105823.
Ansari, Z. A. (2002). Parental acceptance–rejection of disabled children in non-urban
Pakistan. North American Journal of Psychology, 4(1), 121.
ATLAS.ti Scientific Software Development GmbH (2010). ATLAS.ti version 6.2. Berlin: Sci-
entific Software Development GmbH.
Benson, P. R. (2006). The impact of child symptom severity on depressed mood among
parents of children with ASD: The mediating role of stress proliferation. Journal of Au-
tism and Developmental Disorders, 36(5), 685–695. http://dx.doi.org/10.1007/s10803-
006-0112-3.
Benson, P. R., & Karlof, K. L. (2009). Anger, stress proliferation, and depressed mood among
parents of children with ASD: A longitudinal replication. Journal of Autism and Develop-
mental Disorders, 39(2), 350–362. http://dx.doi.org/10.1007/s10803-008-0632-0.
Boyd, B.A. (2002). Examining the relationship between stress and lack of social support in
mothers of children with autism. Focus on Autism and Other Developmental Disabil-
ities, 17(4), 208–215. http://dx.doi.org/10.1177/10883576020170040301.
Bromley, J., Hare, D. J., Davison, K., & Emerson, E. (2004). Mothers supporting chil-
dren with autistic spectrum disorders. Autism, 8(4), 409–423. http://dx.doi.org/10.
1177/1362361304047224.
Cappe, E., Wolff, M., Bobet, R., & Adrien, J. L. (2011). Quality of life: A key variable to con-
sider in the evaluation of adjustment in parents of children with autism spectrum
disorders and in the development of relevant support and assistance programmes.
Quality of Life Research, 20(8), 1–16. http://dx.doi.org/10.1007/s11136-011-9861-3.
Carter, A. S., Martínez-Pedraza, F., & Gray, S. A. O. (2009). Stability and individual change in
depressive symptoms among mothers raising young children with ASD: Maternal and
child correlates. Journal of Clinical Psychology, 65(12), 1270–1280. http://dx.doi.org/10.
1002/jclp.20634.
Centers for Disease Control and Prevention (2012). Prevalence of autism spectrum
disorders — Autism and Developmental Disabilities Monitoring Network, 14
sites, United States, 2008. Morbidity and Mortality Weekly Report, 61(SS03),
1–19.
Corbin, J., & Strauss, A. (2008). Basics of qualitative research: Techniques and procedures for
developing grounded theory (3rd ed.). Thousand Oaks, CA: Sage Publications, Inc.
Crabtree, S. A. (2007). Maternal perceptions of care-giving of children with developmen-
tal disabilities in the United Arab Emirates. Journal of Applied Research in Intellectual
Disabilities, 20(3), 247–255.
Dabrowska, A., & Pisula, E. (2010). Parenting stress and coping styles in mothers and fathers
of pre-school children with autism and Down syndrome. Journal of Intellectual Disability
Research, 54(3), 266–280. http://dx.doi.org/10.1111/j.1365-2788.2010.01258.x.
Devi, S. (2007). Health in the West Bank. The Lancet, 370(9596), 1405–1406. http://
dx.doi.org/10.1016/S0140-6736(07)61591-8.
Dunn, M. E., Burbine, T., Bowers, C. A., & Tantleff-Dunn, S. (2001). Moderators of stress in
parents of children with autism. Community Mental Health Journal, 37(1), 39–52.
Duvdevany, I., & Abboud, S. (2003). Stress, social support and well-being of Arab mothers
of children with intellectual disability who are served by welfare services in northern
Israel. Journal of Intellectual Disability Research, 47, 264–272.
Ekas, N. V., Lickenbrock, D.M., & Whitman, T. L. (2010). Optimism, social support, and
well-being in mothers of children with autism spectrum disorder. Journal of Au-
tism and Developmental Disorders, 40(10), 1274–1284. http://dx.doi.org/10.
1007/s10803-010-0986-y.
Eldin, A. S., Habib, D., Noufal, A., Farrag, S., Bazaid, K., Al-Sharbati, M., et al. (2008). Use of
M-CHAT for a multinational screening of young children with autism in the Arab
countries. International Review of Psychiatry, 20(3), 281–289. http://dx.doi.org/10.
1080/09540260801990324.
Estes, A., Munson, J., Dawson, G., Koehler, E., Zhou, Xiao-Hua, & Abbott, R. (2009).
Parenting stress and psychological functioning among mothers of preschool children
with autism and developmental delay. Autism, 3(4), 375–387. http://dx.doi.org/10.
1177/1362361309105658.
Gray, D. E. (2006). Coping over time: The parents of children with autism. Journal of
Intellectual Disability Research, 50(12), 970–976. http://dx.doi.org/10.1111/j.
1365-2788.2006.00933.x.
Hasnain, R., Shaikh, L. C., & Shanawani, H. (2008). Disability and the Muslim perspective: An
introduction for rehabilitation and health care providers: No. 47. Buffalo, NY: Center for
International Rehabilitation Research Information and Exchange.
Hastings, R. P., Kovshoff, H., Brown, T., Ward, N. J., Espinosa, F. D., & Remington, B. (2005).
Coping strategies in mothers and fathers of preschool and school-age children with
autism. Autism, 9(4), 377–391. http://dx.doi.org/10.1177/1362361305056078.
Israel Central Bureau of Statistics (2012). Life expectancy at selected ages, by sex and re-
ligion. Retrieved from. http://www1.cbs.gov.il/shnaton63/st03_25x.pdf
Kayfitz, A.D., Gragg, M. N., & Orr, R. R. (2010). Positive experiences of mothers and fathers
of children with autism. Journal of Applied Research in Intellectual Disabilities, 23(4),
337–343. http://dx.doi.org/10.1111/j.1468-3148.2009.00539.x.
Khanna, R., Madhavan, S. S., Smith, M. J., Patrick, J. H., Tworek, C., & Becker-Cottrill, B.
(2010). Assessment of health-related quality of life among primary caregivers of chil-
dren with autism spectrum disorders. Journal of Autism and Developmental Disorders,
41(9), 1–14. http://dx.doi.org/10.1007/s10803-010-1140-6.
Koegel, R. R. L. (1992). Consistent stress profiles in mothers of children with autism. Jour-
nal of Autism and Developmental Disorders, 22(2), 205–216.
Kuhaneck, H. M., Burroughs, T., Wright, J., Lemanczyk, T., & Darragh, A.R. (2010). A qual-
itative study of coping in mothers of children with an autism spectrum disorder.
1678 S. Dababnah, S.L. Parish / Children and Youth Services Review 35 (2013) 1670–1678
Physical & Occupational Therapy in Pediatrics, 30(4), 340–350. http://dx.doi.org/10.
3109/01942638.2010.481662.
Levav, I., Al-Krenawi, A., Ifrah, A., Geraisy, N., Grinshpoon, A., Khwaled, R., et al. (2007).
Common mental disorders among Arab–Israelis: Findings from the Israel National
Health Survey. The Israel Journal of Psychiatry and Related Sciences, 44(2), 104–113.
Levinson, C. (2012, July 31). Israeli government spent NIS 1.1 billion on settlements in
2011, reports show. Haaretz. Retrieved from. http://www.haaretz.com/news/
national/israeli-government-spent-nis-1-1-billion-on-settlements-in-2011-reports-
show-1.454790
Liptak, G. S., Stuart, T., & Auinger, P. (2006). Health care utilization and expenditures for
children with autism: Data from U.S. national samples. Journal of Autism and Develop-
mental Disorders, 36(7), 871–879. http://dx.doi.org/10.1007/s10803-006-0119-9.
McConkey, R., Truesdale-Kennedy, M., Chang, M., Jarrah, S., & Shukri, R. (2008). The im-
pact on mothers of bringing up a child with intellectual disabilities: A cross-cultural
study. International Journal of Nursing Studies, 45(1), 65–74.
Montes, G., & Halterman, J. S. (2007). Psychological functioning and coping among mothers
of children with autism: A population-based study. Pediatrics, 119(5), e1040–e1046.
http://dx.doi.org/10.1542/peds.2006-2819.
Okun, B.S., & Friedlander, D. (2005). Educational stratification among Arabs and Jews in
Israel: Historical disadvantage, discrimination, and opportunity. Population Studies,
59(2), 163–180. http://dx.doi.org/10.1080/00324720500099405.
Parish, S. L., Thomas, K., Rose, R., Kilany, M., & McConville, R. (2012). State insurance parity
legislation for autism services and family financial burden. Intellectual and Develop-
mental Disabilities, 50(3), 190–198. http://dx.doi.org/10.1352/1934-9556-50.3.190.
Phetrasuwan, S., & Shandor Miles, M. (2009). Parenting stress in mothers of children with
autism spectrum disorders. Journal for Specialists in Pediatric Nursing, 14(3), 157–165.
http://dx.doi.org/10.1111/j.1744-6155.2009.00188.x.
Sharifzadeh, V. S. (1998). Families with Middle Eastern roots. In E. W. Lynch, & M. J. Hanson
(Eds.), Developing cross-cultural competence (pp. 441–482) (2nd ed.). Baltimore,
MD: Paul H. Brookes Publishing Co.
Smith, L., Seltzer, M., Tager-Flusberg, H., Greenberg, J., & Carter, A. (2008). A compar-
ative analysis of well-being and coping among mothers of toddlers and mothers
of adolescents with ASD. Journal of Autism and Developmental Disorders, 38(5),
876–889. http://dx.doi.org/10.1007/s10803-007-0461-6.
Stuart, M., & McGrew, J. H. (2009). Caregiver burden after receiving a diagnosis of an
autism spectrum disorder. Research in Autism Spectrum Disorders, 3(1), 86–97.
http://dx.doi.org/10.1016/j.rasd.2008.04.006.
Tarakeshwar, N., & Pargament, K. I. (2001). Religious coping in families of children
with autism. Focus on Autism and Other Developmental Disabilities, 16(4),
247–260. http://dx.doi.org/10.1177/108835760101600408.
United States Central Intelligence Agency (2012). The world factbook: West Bank.
Retrieved from. https://www.cia.gov/library/publications/the-world-factbook/
geos/we.html
Valsamma, E., Abdul Azim, M., Taoufik, Z., & Feisal, Y. (2007). Prevalence of pervasive de-
velopmental disorders in preschool children in the UAE. Journal of Tropical Pediatrics,
53(3), 202–205.
Young, W. C. (1997). Families and the handicapped in northern Jordan. Journal of Compara-
tive Family Studies, 28(2), 151–169.