Occupational Therapy Services for Autistic Children in Saudi Arabia

This report presents a mixed-method study investigating occupational therapy services for autistic children within the Ministry of Health in Saudi Arabia. The research explores the purpose of the study, research question, aim and objectives, and background information on autism spectrum disorder (ASD), including its prevalence and challenges faced by affected children and their families. It examines the existing gaps in ASD services, particularly the limited availability of occupational therapy programs, and the influence of factors such as service characteristics, family characteristics, and child characteristics on service utilization. The study's rationale, research design, and sampling methods are outlined, including the use of surveys and interviews to gather data from healthcare staff and families with autistic children. The report aims to identify the current state of occupational therapy services, evaluate families' experiences, and recommend improvements to address limitations and unmet needs in the provision of care for autistic children in Saudi Arabia. The findings will help identify areas where the Saudi government should give more efforts to promote utilization and efficiency of available services in the country.

Running head: OCCUPATIONAL THERAPY
Occupational therapy
Name of the student:
Name of the University:
Author’s note

The title:
An Investigation of the Occupational Therapy Services for Autistic Children in
Ministry of health in Saudi Arabia – Mixed Method Study
1. Purpose of the study
Autism spectrum disorder (ASD) is a development disorders whose diagnosis is growing
worldwide (Emberti Gialloreti and Curatolo 2018). The kingdom of Saudi Arabia is a region
where the incidence of ASD has increased. Based on most recent review, the prevalence of
autism is 18 per 10, 000. In response to the diagnosis of ASD, the government of Saudi
Arabia has engaged in various efforts to advance ASD services and improve research related
to management of these conditions. However, the main gap or drawback is very limited
number of ASD services exist in Saudi Arabia (Alnemary et al. 2017). However, the uptake
of services in hospital setting is very low. The investigation by Alnemary et al. (2017)
regarding such services in KSA has revealed that many children with autism fail to receive
early intervention before 3 years of age in hospitals and community health services. This
points out to the fact that currently, the health care services in Saudi Arabia do not have any
criteria to specify the age of children and the age group at which early intervention should be
given to children (Alquraini 2013).
Past research on investigating types of services in Saudi Arabia to help children with
autism highlights lack of details regarding any occupational therapy services for autism
(Alquraini 2013). A study by Babatin et al. (2016) regarding availability of services for
autistics children in Saudi Arabia shows lack of essential services for autism. There were
only 16% occupational therapy programs and 39% integrative educational program. The
evidence shows the gap in relation to ASD service in Saudi Arabia. Past research highlights
significant deficiencies in the availability of autism services (Alnemary et al. 2017). The

findings cannot be generalized for the whole country as the research was done only for
Jeddah. However, the strength of the evidence is that it suggests the importance of future
research in the area of special services for autism in Saudi Arabia and investigating
perspective of families regarding the barriers in accessing ASD service.
The study by Alshaigi et al. (2019) with parents of children with autism in Saudi Arabia
further indicates the influence of stigmatization behind low visit to hospitals too. For
example, parents reported feelings of self stigmatization and they believed that diagnosis of
ASD has affected their social lives and interactions in the society. Hence, the high level of
stigma in parents suggest the need for ASD services where parental stigma is addressed too
and they are guided regarding ways to cope with new changes in their lives.
Above discussion shows the need to develop knowledge in this area to understand the
potential of occupational therapists in improving lives of autistic children. They have the
skills to provide holistic care and fulfil physical, social, emotional and cognitive needs of
autistic children (Kuhaneck and Watling 2015). To address the gap in past research, the main
purpose of this research is to investigate about the availability of occupational therapy
services in the whole country and the experience of families in utilizing those services. The
above discussion highlights the rationale for conducting research in this area. By using
appropriate study design, the findings from this research can help to identify areas where the
Saudi government should give more efforts to promote utilization and efficiency of available
services in the country.
Research question:
The research question that guides this research project is as follows:

What are occupational therapist services for autistic children in the Ministry of Health in
Saudi Arabia?
Aim and objective:
The main purpose of the study is to investigate about the availability of Occupational
therapy services for autistics children in hospitals of Saudi Arabia and evaluate its impact on
supporting families with autistic children. The key objectives of the research are as follows:
 To explore autistic families perspective regarding satisfaction with the occupational
therapy services
 To identify the changes required in this service to support children affected by autism
 To recommend improvement in service provisions to address limitations found in
occupational therapy services in Saudi Arabia.
2. Background:
Autism or autism spectrum disorder (ASD) is a type of developmental disorder that
leads to neuro-developmental abnormalities in early childhood and it is characterised by
communication related and behavioural problems (Baxter et al. 2015). According to the
DSM-5 (diagnostic and statistical manual of mental disorders) criteria of mental disorder,
some of the important symptoms that lead to diagnosis of ASD include communication
impairment, difficulty in social interaction, repetitive behaviour and lack of interest, delay in
language and inability to function at work and school (Samsam, Ahangari and Naser 2014).
These symptoms appear mostly by two years of age and it may continue in adolescent and
adult stage too.
ASD is a high prevalent condition affecting many children throughout the world
(Baxter et al. 2015) The global statistics that gives idea regarding the prevalence of ASD is

the report by WHO which shows that one in every 160 children are affected by the condition
(World Health Organization, 2018). From the review of epidemiological studies in the past
50 years, it has been found that the incidence of ASD is increasing globally (Emberti
Gialloreti and Curatolo 2018). The main reason behind this is improvement in diagnostic
criteria, presence of better diagnostics tool and increased reporting about the condition
(Hansen, Schendel and Parner 2015). The key challenges for children affected by autism are
that for some children, the symptoms of autisms severely lead to life-long disabilities and
they are dependent on others for daily life activities (Moulton et al. 2016). An investigation
regarding daily living skills in youths with ASD indicates impairment in daily living skills for
individuals with the disorder. Attainment of daily living skills (DLS) becomes difficult
because of severity of symptoms (Bal et al. 2015). In addition, families with autistic children
are highly affected because of stigma experiences and discrimination in the society because
of their children’s disability (Ellen Selman et al. 2018). This study gives the implication that
early intervention and access to appropriate service is crucial to encourage development of
DLS and improve quality of life of such individuals.
Although this study aims to identify autistic families perspective regarding the
experience of using occupational therapy service, past study shows why utilization of ASD
services in general is low in certain region. Alnemary et al. (2017) explains impact of factors
like service characteristics, family characteristics and child characteristics on utilization of
services. The family characteristics affecting access to ASD services include income, parental
education, family’s geographical location and parent’s knowledge about the condition.
Children characteristics like age at treatment initiation and number of medical and non-
medical interventions had an impact on service utilization. In the context of Saudi Arabia, the
main gap found was lack of early intervention services and poor access to available services
for younger children (Alnemary et al. 2017). Due to lack of evidence regarding effectiveness

of current ASD services, identifying individual services is considered critical (Sulaimani and
Gut 2019)). The focus on evaluating perspective of parent’s perspective is significant as it
will to identify gap in current services and develop innovative services that fulfils holistic
needs of children with autism in Saudi Arabia.
The significance of investigating about occupation therapy services in Saudi Arabia is
also necessary because of gaps in service and presence of various unmet needs of children
with ASD. Alqahtani (2012) gave the evidence regarding preference for non-medical services
among parents instead of focussing on direct contact with health care providers to seek
treatment for autism. By conducting semi-structured interview with parents in King Fahad
Medical City, parents reported used of non-medical interventions like diet program and
hyperbaric oxygen to heal their children from autism. The key conclusion from this outcome
is that instead of biological services for autism, behavioural and educational interventions
have dominated in Saudi Arabia. It also indicates poor experience of parents while seeking
treatment for autism in hospital setting. This study can have positive implications on mental
health care professionals. In order to provide proper interdisciplinary intervention, all health
professionals must focus on implementing behavioural and educational interventions too
(Wong et al., 2015). This can have positive effect on health care outcomes and quality of life
of children with autism. Therefore, the environment of these children can be strongly
modified so that they can live a fulfilling life. The Ministry of health needs to take urgent
response to address these gaps in ASD services in Saudi Arabia.
Occupational therapy is a kind of service that aims to help clients engage in activities
of daily living and achieve meaning in their lives (Kuhaneck and Watling, 2015). In the
context of treatment of individuals with ASD, occupational therapists play a role in
addressing activities of daily living (ADL), adaptive behaviour and social performance
(Rodger and Kennedy-Behr 2017). However, the literature reviews on services for children

with autism in Saudi Arabia shows that there are very few occupational therapy program for
young children. For example, Babatin et al. (2016) highlights that lack of availability of
essential services like occupational therapy and educational integration program in Saudi
Arabia. Adib et al. (2019) argues that speech and occupational therapy is necessary to
promote better communication skills, enhance positive social behaviours and improve daily
social skills. The caregiver’s satisfaction with ASD is also affected by availability of
occupational therapy services. Hence, the above discussion highlights that currently health
care system of Saudi Arabia are underprepared to meet special needs of children with autism.
The above limitation highlights the need to identify current occupational therapy services for
autistic families in Saudi Arabia and critically analyse the perspective of families in utilizing
this kind of services.
3. Research Design:
Based on the research aim and key research objectives, mixed method research design
has been taken for the research by conducting both surveys and interview with research
participants. Mixed method research design involves combining elements of qualitative and
quantitative research design and the strength of this research design is that it expands and
strengthens making valid conclusion of a research (Schoonenboom and Johnson 2019). For
this study, the main rationale behind taking mixed method research design is that survey will
help to collect quantitative data related to number of occupational therapy services for autistic
children within the Ministry of Health, Saudi Arabia and interview method will help to
evaluate perspective of autistics families regarding the experience of using these services
(Morse 2016). For the survey part, data collection will be done using close ended questions
and interview will be done using open ended question to get detailed information regarding
experience of accessing these services. The interview method will be particularly useful in

evaluating attitude, perception and concerns related to utilization of occupational therapy
services in the kingdom of Saudi Arabia (Peters and Halcomb 2015).
Sampling
The main target population or sample of interest for this study includes families with
autism children in Saudi Arabia and health care staffs working under the ministry of health in
at least three cities of Saudi Arabia. To recruit the desired sample, purposive sampling
strategy will be applied for this study (Lune and Berg 2016). It is a type of non-probability
sampling method where a sample for research is selected based on researcher’s judgment and
the objectives of the study (Schreier and Flick 2017). The advantage of this sampling strategy
is that as it is focused on particular characteristics of a population, the process makes it easier
to make generalization about the sample (Palinkas et al. 2015). This study will have two
groups of research participants. The first group will involve health care staffs and other
administrative staff workers under the Ministry of Health in Saudi Arabia who will complete
the survey on occupational therapy services in the country. The second group will involve
families with at least one autistic children living in Saudi Arabia.
Sampling size
As this used both quantitative and qualitative research approach, the sample size for
each of the approach will differ too. For the survey part, it is expected to collect response
from at least 50 staffs working in different cities of Saudi Arabia. To prevent impact of
confounding factors on study outcome, only those staffs will be selected who have clinical
background and services in the area of ASD services. Palinkas et al. (2015) supports that
purposeful sampling technique is beneficial in selecting those sample groups, who have lost
of experienced related to the phenomenon of interest. Taking large sample size will be
feasible because of survey method. In addition, the rational for taking samples from different

city is to generalize the finding and make opinion regarding the overall state of the country in
addressing the needs of children with autism (Boddy 2016). In contrast, for the qualitative
part of the research using interview, it is expected to conduct interview with at least 20
parents. The main reason for keeping the sample size low for interview method is to save
time and collect rich data regarding experience by using detailed interview questionnaire
(Malterud, Siersma and Guassora 2016). It is expected to complete the interview within 15
minutes and small sample size will favor analysis of findings in limited time period. Use of
interview method is suitable when nothing is known about the topic to be explored. This
research is done as nothing is known about autistics families’ experience of using
occupational services. According to Malterud, Siersma and Guassora (2016), small sample is
appropriate for interview method. Eligible participants for both the phase of research will be
recruited by formal meetings and completion of informed consent process.
Inclusion and exclusion criteria for the interviews:
The inclusion and exclusion criteria for recruiting participants in the interview method
are as follows:
Inclusion criteria Exclusion criteria
Saudi occupational therapist with at least two
years of experience
Non-Saudi Occupational therapist
Health care professionals involved in ASD
related services within the Ministry of health
Health care professionals working under other
medical department other than ASD
All staffs must have at least two years of
experience in ASD services
Staffs with less than two years of experience in
ASD services

The following is the inclusion and exclusion criteria for taking participants in survey
method:
Inclusion criteria Exclusion criteria
Autistic families or caregivers with at least one
children with autism
Families with children having other disabilities or
developmental disorders apart from ASD
Data Collection Methods
As stated earlier, two data collection method that will be used for the mixed method
research including survey method and semi-structured interview method (Morse 2016). The
main tool for the survey method will be a 10 item questionnaire that will collect data on
demographic details, work experience, number of occupational therapy services, regions in
which it is available and number of occupational therapist working in the these services. The
findings from the survey will inform regarding current number of occupational services
available in Saudi Arabia.
For the semi-structured interview method, data will be collected using interview
questions. It will have ten interview questions with open ended question. The interview
questionnaire will collect data related to frequency of utilizing occupational therapy services,
experience and benefits of using the service and the problems or barriers identified in
accessing or utilizing these services.
Data collection and analysis:
The interview response will be audio tapped and transcribed verbatim by research
staffs. In addition, analysis of the interview content will be done using the thematic analysis
method by identifying common themes from interview response and using those themes to

make conclusion about the research (Broadhurst and Harrington 2016). According to Braun
et al. (2018), thematic analysis is a common data analysis method in qualitative research as it
helps in identifying patterns and evaluating explicit meaning from research data. For the
survey part, data analysis will be using statistical method and evaluating the percentage of
occupational therapy services available according to regions.
Study setting
The survey will be done via online method and the interview with autistic families
will be done in a conference of the Regional ASD center of the three selected cities of Saudi
Arabia. This location has been chosen to get easy access to experiences staffs who can take
the interview.
Pilot Study
To ensure validity and reliability of the interview questionnaire, pilot testing will be
done by first conducting interviews with two staffs. This will help to identify suitability of the
interview question and any problem in research design (Hazzi and Maldaon 2015). After this
method, changes in design or content of the interview will be done.
Reflexivity
Throughout the research process, the focus will be to engage in reflexivity to
challenges in research design, identify confounding factors and maintain trustworthiness of
the study (Palaganas et al. 2017). According to Zorlu and Duman (2018), reflexivity is
important in research study to ensure that researchers go through a systematic process of
knowledge construction and considering steps that could further improve the research
process. To ensure credibility throughout the study, a reflective diary will be maintained

where all methodological decisions will be recorded and reflection on it will be done based
on research interest and values.