Exploring the Nexus of Quality of Life and Coping Strategies in Children with Autism Spectrum Disorder: A Case-control Study

Abstract

Autism spectrum disorder (ASD) poses significant challenges to children, affecting various aspects of their functioning and overall quality of life (QOL). While factors such as social support and access to interventions play crucial roles in determining the QOL, coping strategies are fundamental in shaping the experiences and outcomes of individuals with ASD. This case-control study aimed to address this gap by exploring the nexus between QOL and coping strategies in children with ASD. This cross-sectional study included 214 children with and without, who were ASD enrolled in different rehabilitation centers in the Al-Hasa region of Saudi Arabia. QOL was measured using the Short Form-12 (SF-12) health survey to assess the physical and mental components. Coping strategies were assessed using the validated Brief COPE inventory. We examined the association between the SF-12 and coping strategies in children with autism and healthy children using binary logistic regression analysis. QOL measures indicated that children with ASD had poorer scores across various domains compared to healthy children. Children relied more on substance abuse, emotional support, and religious coping. Logistic regression indicated that among the QOL dimensions, role physical [odds ratio (OR) = 1.04, 95% confidence interval (CI): 1.01-1.07, P = 0.01], bodily pain (OR = 1.02, 95% CI: 1.00-1.04, P = 0.02), social health (OR = 1.04, 95% CI: 1.02-1.07, P = 0.00), role emotion (OR = 1.02, 95% CI: 1.01-1.03, P = 0.00), and mental health (OR = 1.03, 95% CI: 1.00-1.06, P = 0.03) were associated with ASD. Certain coping strategies, such as self-distraction (OR = 2.40, 95% CI: 1.64-3.51, P = 0.01), substance abuse, (OR = 0.51, 95% CI: 0.31-0.86, P = 0.02), emotional support (OR = 0.47, 95% CI: 0.30-0.73, P = 0.00), venting (OR = 2.05, 95% CI: 1.22-3.42, P = 0.01), and religion (OR = 0.73, 95% CI: 0.54-0.99, P = 0.04), were linked to ASD. Children with ASD had a poorer QOL and relied more on substance abuse, emotional support, and religious coping compared to normal children. The findings of this study have implications for mental health professionals and clinicians, as children with autism and poor QOL may require greater levels of emotional support and services.

Main article text

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication and interaction, alongside restricted, repetitive patterns of behavior, interests, or activities (American Psychiatric Association, 2013; Genovese and Butler, 2023). According to the World Health Organization, ASD affects approximately 1 in 36 people globally (Maenner et al., 2023) and poses significant challenges to individuals across various domains of functioning. Children diagnosed with ASD often face difficulties in forming and maintaining social relationships, adapting to routine changes, and coping with sensory sensitivities, which can profoundly affect their overall quality of life (QOL) (Bradley et al., 2004; Kuhlthau et al., 2014).

QOL is a multifaceted construct encompassing physical, psychological, social, and environmental dimensions that contribute to an individual’s subjective well-being and life satisfaction (World Health Organization, 1997). For children with ASD, factors such as social support, access to appropriate interventions, and the ability to cope with stressors play crucial roles in determining the QOL of children with ASD (Karst and Van Hecke, 2012; Bishop-Fitzpatrick et al., 2016). Coping strategies, defined as cognitive and behavioral efforts to manage stressors and adapt to challenging situations, are fundamental to shaping the experiences and outcomes of individuals with ASD (Hastings and Brown, 2002; Vaughan Van Hecke et al., 2007). Despite the growing recognition of the importance of coping strategies and QOL in individuals with ASD, there is a dearth of research on the intricate relationship between these constructs, particularly in children. Existing studies have primarily focused on coping strategies or QOL independently, with limited exploration of their interplay and mutual influence. Thus, there is a compelling need for empirical investigations that systematically examine how coping strategies relate to the QOL in children with ASD. A cross-sectional study conducted in Riyadh, Saudi Arabia reported that the prevalence of ASD was 2.51% (25 per 1000) among children between 2 to 4 years with a 3:1 female-to-male ratio (AlBatti et al., 2022). The prevalence of ASD was found to be 2.81 per 1000 in both Jeddah and Makkah, 3.68 per 1000 in Makkah, and 2.618 per 1000 in Jeddah (Sabbagh et al., 2021).

This case-control study aimed to address this gap by exploring the nexus between QOL and coping strategies in children with ASD. By employing a rigorous methodology, including standardized assessment tools and careful matching of participants, this study sought to uncover the specific coping strategies utilized by children with ASD reporting varying levels of QOL. Through a comprehensive examination of these constructs, this study aimed to inform the development of tailored interventions and support services aimed at enhancing the well-being and overall QOL of children with ASD in Saudi Arabia.

METHODOLOGY

Study design

This case-control study adopted a cross-sectional design to examine the relationship between the QOL and coping strategies of children with and without ASD between October 2023 and March 2024. Participants were recruited from clinics, special education schools, and autism support groups. The Deanship of Scientific Research at King Faisal University in Al-Hasa, Saudi Arabia granted ethical approval for this study (KFU-REC-2023-SEP-ETHICS1350). The study was conducted in compliance with the Declaration of Helsinki on Research Involving Human Subjects. All participants were informed of the purpose and goal of the study, and the survey was conducted after all the requirements were met.

Participants

The participants in this study included 125 children aged 6-18 years diagnosed with ASD. The diagnosis of ASD was confirmed in all participants by using the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. The inclusion criteria were established by reviewing the children’s medical records and obtaining verbal informal consent from the children and their parents. Children who had one or more of the following were excluded: comorbid ASD-related diseases, neurological disorders, and those aged <6 years and >18 years. The control group included 89 normative controls who satisfied the inclusion and exclusion criteria.

Sampling method

To date, no study has examined the QOL and coping strategies of children with ASD in Saudi Arabia, and no previous study has been conducted that allows us to determine the sample size for this study. Although this was a case-control study, we selected a convenience sampling method because it was appropriate for our research. Convenience sampling may be useful in this case because it selects participants from a specific group within a specific period, as in our study. Therefore, convenience sampling may be the most practical method for collecting initial data when researching specific, difficult-to-reach populations, like children with disabilities.

Data collection tools

To achieve the goal of the present study, various measures were used, including the Short Form-12 version 2 (SF-12v2) Health Survey to measure QOL and the Brief COPE inventory to assess coping strategies. The study also included a demographic questionnaire prepared by the researchers.

Short Form-12

Short Form-12 (SF-12) is a widely used survey tool for assessing health-related QOL. It comprises 12 questions that measure physical and mental health outcomes. The SF-12 health survey is an abbreviated version of Short Form-36 (SF-36) (Sanderson and Andrews, 2002). It was demonstrated that the 12 items predicted at least 90% of the SF-36-derived physical and mental summary scale scores (Ware et al., 1996). This self-reported scale measures eight domains: physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health. In the present study, the physical component scale (PCS-12) and mental component scale (MCS-12) consisted of six items each and were computed and normalized for the SF-12v2 according to published algorithms (Ware et al., 1995). Higher scores indicated better mental and physical health, with scores ranging from 0 to 100 (Orji et al., 2020). A score of ≤50 on the PCS-12 has been recommended as the cut-off to determine a physical condition, while a score of ≤42 on the MCS-12 indicates clinical depression (Ware et al., 1995). The physical component summary and the mental component summary showed a good internal consistency and reliability, as evidenced by alpha coefficients of 0.89 and 0.76, respectively (Ware et al., 1994). The internal consistency reliability (Cronbach’s alpha) of the measure used in the present study was found to be 0.80 and 0.76 respectively.

Brief COPE

Coping strategies were evaluated using the Brief COPE inventory. Brief COPE is a self-report questionnaire designed to assess a variety of coping strategies that individuals use to handle stress (Carver, 1997). It includes 28 items, each rated on a scale, to evaluate how frequently different coping mechanisms are employed, such as problem-focused coping, emotion-focused coping, and avoidance strategies. Brief COPE consists of 14 subscales, including self-distraction, active coping, denial, substance abuse, emotional support, use of information support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. A 4-point Likert scale, with 1 representing “not at all” and 4 representing “a great deal,” was used by respondents to rate their use of coping mechanisms. The coping score for each subscale was calculated as the sum of the individual item scores. A high score on this scale indicates greater use of any specific coping strategy (Lode et al., 2007). As reported by Carver (1989), the internal consistency reliability of the Brief COPE inventory ranged from 0.42 to 0.89. In this study, the internal consistency reliability for this measure (Cronbach’s alpha) ranged from 0.43 and 0.85 in the current sample.

Demographic and clinical variables

Demographic information, such as age, sex, living area, family type, income, occupation, housing status, and socioeconomic status, as well as clinical variables, including ASD severity, comorbid conditions, and developmental history, were collected through parent/caregiver and medical records.

Procedure

Trained senior medical students and interviewers conducted face-to-face interviews with parents or guardians of the selected children, ensuring confidentiality and cultural sensitivity. Collaboration between healthcare facilities and educational institutions facilitated access to medical records and academic data. Prior to data collection, informed consent was obtained from parents or guardians, emphasizing the voluntary nature of participation. Strict measures were taken to protect the privacy of participants, ensuring that the data were anonymized and securely stored.

Statistical analysis

Statistical Package for the Social Sciences (SPSS) software (version 27.0, IBM, SPSS, Chicago, IL, USA) was used for statistical analyses. Descriptive statistics was used to characterize the study population. The chi-squared (χ²) test was used to analyze categorical variables. The means of the children with ASD and the normal control group were compared using Student’s t-test for qualitative variables. To examine the predictive value of QOL and coping strategies for ASD, a binary logistic regression model was developed, in which children with and without ASD served as dichotomous variables. QOL, coping strategies, and demographic variables that were observed to be significantly different between the two groups were considered independent variables. Hosmer–Lemeshow and R² were computed to assess the model’s goodness of fit. Statistical significance was set at P < 0.05.

RESULTS

Table 1 presents the demographic characteristics. This study invited 245 children living in different areas of the Al-Hasa region of Saudi Arabia to participate. Of these 245 children, 125 of 145 (86.21%) with autism and 89 of 100 (89.00%) normative children fulfilled the study criteria. In total, 214 children with valid protocols were included in the final analyses. Most children with ASD were boys (77.60%) rather than girls (24.40%). Among the normal children, 51.69% were boys and 48.31% were girls. The difference in sex between the groups was statistically significant (χ² = 15.75, P < 0.01). The age of these children ranged from 6 to 18 years, and there was a significant difference between the groups (χ² = 11.74, P < 0.01). Furthermore, compared to elementary and high school students, middle-class participants had a significantly higher frequency of ASD (χ² = 23.99, P < 0.00). In addition, it was also observed that the percentage of normal children was significantly higher in children belonging to joint families compared to nuclear families (χ² = 13.94, P < 0.01). Moreover, the findings revealed a significantly higher frequency of ASD in patients with a poor socioeconomic status (<10,000 Saudi Riyals). No significant differences were found between these groups in terms of area of residence, family occupation, or housing status.

Table 1:

Demographic characteristics of children with and without ASD.

Variables	Test group n = 125 n (%)	Control group n = 89 n (%)	Chi-square test	P value
Gender			15.75	0.00**
Male	97 (77.60)	46 (51.69)
Female	28 (24.40)	43 (48.31)
Age			11.74	0.01**
6-12 years	88 (70.40)	42 (47.19)
13-18 years	37 (29.60)	47 (52.81)
Grade			23.99	0.00**
Elementary	44 (35.20)	13 (14.61)
Middle	65(52.00)	41 (46.07)
High school	16 (12.80)	35 (39.32)
Family status			62.55	0.00**
Joint	56 (44.80)	86 (96.63)
Nuclear	69 (55.20)	3 (3.37)
Area of residence			1.05	0.31
Urban	115 (92.00)	85 (95.50)
Rural	10 (8.00)	4 (4.50)
Monthly income			13.94	0.01**
<10,000 Saudi Riyals	70 (56.00)	41 (46.06)
10,001-15,000 Saudi Riyals	44 (35.20)	23 (25.85)
>15,001 Saudi Riyals	11 (8.80)	25 (28.09)
Family occupation			2.84	0.24
Government employees	55 (44.00)	47 (52.81)
Private employee	36 (28.80)	17 (19.10)
Business	34 (27.20)	25 (28.09)
Housing status			1.88	0.17
Own	64 (51.20)	54 (60.67)
Rented	61 (48.80)	35 (39.33)

Note: *P < 0.05, **P < 0.01.

Abbreviation: ASD, autism spectrum disorder.

Table 2 presents the mean scores and standard deviations (SDs) of the two groups of participants for the measures of QOL and coping strategies, along with the t-values. For the measure of QOL, results revealed significant differences between the mean scores of the two groups of participants for the following measures: role functioning (t = −4.42, P < 0.00), role physical (t = −4.65, P < 0.00), bodily pain (t = −5.59, P < 0.00), general health (t = −4.05, P < 0.02), vitality (t= −3.99, P < 0.03), social functioning (t = −4.40, P < 0.00), role emotion (t = −4.96, P < 0.00), and mental health (t = −5.84, P < 0.00).

Table 2:

Descriptive statistics for children with ASD and healthy control for QOL and coping strategies.

	Test group		Control group
Quality of life	M	SD	M	SD	t-value	P value
Role functioning	55.80	32.24	74.66	28.53	−4.42	0.00**
Role physical	31.20	19.99	42.69	14.20	−4.65	0.00**
Bodily pain	57.40	26.94	77.80	25.40	−5.59	0.00**
General health	59.60	26.14	73.59	23.03	−4.05	0.02*
Vitality	49.40	28.46	64.49	25.36	−3.99	0.03*
Social functioning	30.56	27.18	47.41	28.18	−4.40	0.00**
Role emotion	48.40	38.59	74.71	37.78	−4.96	0.00**
Mental health	38.48	16.51	51.91	16.64	−5.84	0.00**
Coping strategies
Self-distraction	4.52	1.84	5.48	1.62	−3.95	0.00**
Active coping	4.99	1.70	4.91	1.96	0.32	0.74
Denial	4.04	1.92	4.03	1.84	0.02	0.98
Substance abuse	2.80	1.40	2.26	0.84	3.18	0.02*
Emotional support	5.50	1.61	4.51	1.75	4.24	0.00**
Use of information support	5.24	2.00	4.85	1.77	1.45	0.15
Behavioral disengagement	3.80	1.70	3.96	1.52	−0.73	0.46
Venting	4.47	1.80	4.91	1.87	−1.73	0.08
Positive reframing	4.84	1.99	5.22	1.91	−1.41	0.16
Planning	5.09	2.09	5.07	1.78	0.06	0.95
Humor	3.68	1.73	3.71	1.64	−0.16	0.87
Acceptance	5.36	1.96	5.32	1.97	0.21	0.83
Religion	6.61	1.74	5.20	2.00	−3.75	0.00**
Self-blame	4.08	1.96	4.41	1.89	−1.25	0.21

Note: **P < 0.01; *P < 0.05.

Abbreviations: ASD, autism spectrum disorder; M, mean; QOL, quality of life; SD, standard deviation.

Mean scores clearly revealed that participants with ASD had poorer QOL in terms of role functioning (M = 55.80, SD = 32.24), role physical (M = 31.20, SD = 19.99), bodily pain (M = 57.40, SD = 26.94), general health (M = 59.60, SD = 26.14), vitality (M = 49.40, SD = 28.46), social functioning (M = 30.56, SD = 27.18), role emotion (M = 48.40, SD = 38.59), and mental health (M = 38.48, SD = 16.51) compared to normal children (mean scores = 74.66, 42.69, 77.80, 73.59, 64.49, 47.41, 74.71, 51.91; SDs = 28.53, 14.20, 25.40, 23.03, 25.36, 28.18, 37.78, 16.64).

For different coping methods adopted by participants, significant differences were found in self-distraction (t = −3.95, P < 0.00), substance abuse (t = 3.18, P < 0.02), emotional support (t = 4.24, P < 0.00), and religion (t = 3.75, P < 0.01). Participants with ASD showed greater reliance on substance abuse (M = 2.80, SD = 1.40), emotional support (M = 5.50, SD = 1.61), and religious coping (M = 6.61, SD = 1.74) than normal children (mean scores = 2.26, 4.51, and 5.20; SDs = 0.84, 1.55, and 2.00, respectively). Normative children reported greater use of self-distraction coping (M = 5.48, SD = 1.62) than children with ASD (M = 4.52, SD = 1.84). However, the difference between the mean scores of these groups was not significant for active coping, denial, use of information support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, and self-blame.

In addition to QOL and coping strategies, sociodemographic characteristics such as sex, age, grade, family status, and monthly income were found to be significantly different between children with autism and healthy children. These confounding variables were incorporated as independent variables in a binary logistic regression model, along with QOL dimensions. Hosmer–Lemeshow statistics showed that there was no indication of a poor fit (P = 0.71). Table 3 presents the predictive value of each variable.

Table 3:

Results of binary logistic regression model for QOL of children with ASD.

Variables	OR	95% CI	P value
Gender (ref: female)
Male	0.59	0.22-1.60	0.30
Age (ref: 13-18 years)
6-12 years	0.72	0.20-2.56	0.61
Grade (ref: high school)
Elementary	0.44	0.07-2.88	0.39
Middle	1.43	0.34-6.08	0.63
Family status (ref: nuclear)
Joint	4.47	2.03-8.85	0.00**
Monthly income (ref: >15,001 Saudi Riyals)
<10,000 Saudi Riyals	0.24	0.06-0.95	0.24
10,001-15,000 Saudi Riyals	0.21	0.05-0.89	0.28
Quality of life
Role physical	1.04	1.01-1.07	0.01**
Bodily pain	1.02	1.00-1.04	0.02*
Social health	1.04	1.02-1.07	0.00**
Role emotion	1.02	1.00-1.03	0.00**
Mental health	1.03	1.00-1.06	0.03*

Note: *P < 0.05, **P < 0.01.

Abbreviations: ASD, autism spectrum disorder; CI, confidence interval; OR, odds ratio; QOL, quality of life.

The results of logistic regression analysis indicated that family status (OR = 4.47; P = 0.00) was significantly related to ASD. The analysis revealed that ASD was 4.47 times more likely in children living in joint families. However, there was no significant association between ASD and sex, age, grade, or monthly income. In this study, we hypothesized that QOL could predict ASD. The analysis showed that physical role, bodily pain, social health, role emotion, and mental health were significantly related to ASD, even after regulating important confounders such as gender, age, grade, family status, and monthly income.

Similar to QOL, we examined the role of coping strategies adopted by participants in predicting ASD. We included confounders (sex, age, grade, family status, and monthly income) and coping strategies as independent variables in the binary logistic regression model. Based on the logistic regression analysis presented in Table 4, grade [elementary education: odds ratio (OR) = 2.12; P = 0.05] and family status (OR = 3.18; P = 0.00) were significantly related to ASD. The analysis revealed that ASD was 2.12 times more likely in children with elementary education and 3.18 times more likely in children living in joint families. However, sex, age, and monthly income were not significantly associated with ASD in this study. We also hypothesized that coping strategies could predict ASD. The results indicated that self-distraction, substance abuse, social support, venting, and religious coping were significantly related to ASD, even after regulating the confounder variables.

Table 4:

Results of binary logistic regression model for coping strategies of children with ASD.

Variables	OR	95% CI	P value
Gender (ref: female)
Male	0.41	0.15-1.13	0.87
Age (ref: 13-18 years)
6-12 years	1.33	0.36-4.90	0.67
Grade (ref: high school)
Elementary	2.12	1.01-6.98	0.05*
Middle	0.29	0.06-1.32	0.11
Family status (ref: nuclear)
Joint	3.18	2.63-10.32	0.00**
Monthly income (ref: >15,001 Saudi Riyals)
<10,000 Saudi Riyals	0.28	0.07-1.12	0.07
10,001-15,000 Saudi Riyals	0.25	0.06-1.10	0.06
Coping strategies
Self-distraction	2.40	1.64-3.51	0.01**
Substance abuse	0.51	0.31-0.86	0.02*
Emotional support	0.47	0.30-0.73	0.00**
Venting	2.05	1.22-3.42	0.01**
Religion	0.73	0.54-0.99	0.04*

Note: *P < 0.05, **P < 0.01.

Abbreviations: CI, confidence interval; OR, odds ratio.

DISCUSSION

The present study was conducted to examine differences in QOL and coping strategies between children with ASD and healthy children. To the best of our knowledge, this is the first study in Saudi Arabia to explore the differences in QOL and coping strategies between children with and without ASD. The findings of our study revealed significant differences between the two groups in all dimensions of the SF-12. As expected, QOL measured using the SF-12 was poorer in children with ASD compared to healthy controls, which seems to be mostly consistent with previous findings in healthy participants (Bastiaansen et al., 2004; Lee et al., 2008; Kuhlthau et al., 2010; Ikeda et al., 2014; Potvin et al., 2015; Mason et al., 2018; Katsiana et al., 2020). Children with ASD often face challenges that affect their QOL. One reason for this could be the difficulties children face in social interactions, communication, and sensory processing, which can affect their daily functioning and overall well-being. Consequently, they may struggle to build relationships, adapt to new situations, and participate in typical activities. Deficits in social skills and communication were also evident (American Psychiatric Association, 2013).

This study investigated the coping strategies adopted by the participants. Of the 14 coping strategies, only 4 coping strategies (self-distraction, substance abuse, emotional support, and religion) have been identified as important in dealing with psychological distress. Previous studies have revealed that seeking social support, problem solving, physical exercise, avoidance, using social media, watching movies, and relationships with others are frequently used coping strategies for psychological distress among individuals with disabilities (Werner and Smith, 2001; Deasy et al., 2014; Kim et al., 2020). Analysis in this study showed a significant difference in the mean coping strategy scores between the two groups of children. Participants with ASD reported greater use of substance abuse, emotional support, and religious coping. Presently, there are no similar studies for comparison; however, Ghanouni and Quirke (2023) reported that adults with autism tend to use social support to reduce and manage stress caused by their disability. It has been reported that social support is a protective factor against depressive symptoms and mental health issues in adults with ASD (Hedley et al., 2017). Previous findings have revealed that social support is significantly associated with QOL for adolescents with developmental disabilities and can help improve resilience (Migerode et al., 2012). In addition, some individuals with ASD may turn to substance abuse as a way to cope with social difficulties, sensory sensitivities, or comorbid mental health conditions such as anxiety or depression. Buck et al. (2014) found that adolescents and young adults with ASD had higher rates of substance use than healthy children. Moreover, religious coping involves seeking solace, guidance, or meaning through religious or spiritual beliefs and practices. Individuals with ASD may gravitate toward religion as a source of comfort or structure in their lives. Religious beliefs and practices can help people cope with difficult situations such as physical illnesses (Koenig et al., 2001; Pargament et al., 2005). Results of our analysis also showed that healthy children rely on self-distraction coping to deal with their normal stress. Self-distraction coping involves diverting one’s attention from stressors or difficulties. Neurotypical children may employ this coping strategy more readily than children with ASD because of differences in cognitive processing and social interaction. For example, normal children may engage in activities such as watching TV, playing video games, or spending time with friends to distract themselves from stressors. Although there are no studies to which we can directly compare our findings, these findings are not compatible with other research that has revealed optimism as a widely used method among children when they face a problem (Dehghan Manshadi et al., 2020).

Remarkable findings were obtained in this study. Children’s QOL is significantly associated with ASD. The results of this study revealed that physical role, bodily pain, social health, role emotion, and mental health were the best predictors of ASD. A direct comparison of this study with previous results examining the relationship between QOL and ASD was impossible due to the use of different QOL measures and sample characteristics, but research focusing on the association between QOL dimensions is missing. The findings of the study reported that the physical component of the SF-12 was related to ASD. These results are in line with those of previous studies, which indicated that children with ASD experience poorer motor function than their typically developing counterparts do (Pitzianti et al., 2021). Poor physical functioning, including deficits in gross and fine motor skills (Mohd Nordin et al., 2021), may affect children with ASD participating in sports and other physical activities (Bandini et al., 2013; Tyler et al., 2014), exacerbating social and emotional deficits and related comorbidities (Toscano et al., 2022). Many factors may limit the participation of children with ASD in daily physical activities, including a lack of positive experiences, frequent failures, emotional problems, low self-esteem, time constraints, lack of motivation, and fear of injury (Rimmer et al., 2011; Memari et al., 2015). Studies related to ASD and bodily pain are scarce. Our results show a significant association between body pain and ASD. The association between bodily pain and ASD can be logically justified by several factors. Individuals with ASD may experience sensory sensitivity that can lead to atypical responses to pain. As a result, they may have difficulty accurately communicating their pain levels or react differently to pain than neurotypical individuals. Additionally, individuals with ASD may differ in the perception and processing of pain signals, which could contribute to the observed association. Furthermore, behavioral challenges commonly associated with ASD, such as self-injurious behaviors or difficulties with adaptive skills, may also influence how pain is experienced and expressed in this population. Overall, considering the unique sensory and behavioral characteristics of individuals with ASD, it is plausible to find a significant association between bodily pain and ASD in research studies.

The findings of this study suggest that social health is associated with ASD. Previous findings provide some clues about the mechanisms underlying this association (Chevallier et al., 2012; Han et al., 2019). The link between social health and ASD can be logically justified based on the core characteristics of ASD. One of the hallmark features of ASD is difficulties with social communication and interactions. Individuals with ASD often experience difficulties understanding social cues, interpreting emotions, maintaining eye contact, and forming relationships. These difficulties can affect various aspects of social health, including the ability to build and maintain meaningful social connections, participate in social activities, and experience a sense of belonging within a community. Moreover, research has shown that social health plays a crucial role in the overall well-being and QOL (Kapp, 2018). Individuals with strong social support networks tended to experience better mental health, higher resilience, and greater overall life satisfaction. Given the social challenges inherent in ASD, it is not surprising to find a link between social health and ASD. By addressing social difficulties and providing appropriate support and interventions to enhance social skills and connections, individuals with ASD can improve their social health and overall well-being.

The results of our study indicate that role emotion is a significant predictor of ASD. This result is in line with earlier research findings that youth with ASD have poorly differentiated emotional responses, exhibit more negative and less positive affect, and experience the physiological consequences of emotion with limited cognitive insight compared to youth without ASD (Samson et al., 2012). Individuals with ASD often experience sensory sensitivities or differences that can affect their perception and response to emotional stimuli. For example, they may become overwhelmed by certain sensory inputs, making it more difficult for them to effectively regulate their emotions. ASD is also associated with difficulties in executive functioning, including planning, organizing, and regulating emotions. These difficulties can manifest as challenges in managing emotions in various situations and in adapting to changes in routines or expectations.

Many previous studies have demonstrated that the presence of a mental health condition is associated with a lower QOL in people with autism (Khanna et al., 2014; Mason et al., 2018). Our results indicate that the mental health component of the SF-12 is poor in children with ASD. The presence of mental health issues in individuals with ASD may be due to the unique challenges and social difficulties associated with the disorder, rather than causal factors.

This study also examined the relationship between demographic characteristics and ASD. The analysis of this study indicated that family status was found to be a significant predictor of QOL in children with ASD. Our results showed that children living in joint families were at a high risk of ASD. Currently, there is a dearth of similar studies through which we can compare our results. However, there is no established correlation between living in joint families and increased risk of ASD. ASD is primarily understood to be a neurodevelopmental condition influenced by genetic and environmental factors, rather than by family structure. ASD is believed to result from a combination of genetic predispositions and environmental influences during early brain development. Factors such as advanced parental age, prenatal exposure to certain substances, and genetic mutations play a role in the development of ASD (Almandil et al., 2019). Living in a joint family in which multiple generations live together does not inherently increase the risk of ASD. Family structure is unlikely to directly affect the biological mechanisms underlying ASD development. Therefore, it is illogical to suggest a causal relationship between living in joint families and ASD risk. Risk factors for ASD are more closely associated with genetic predispositions, prenatal influences, and early childhood experiences. These factors are not dependent on family structure and can affect individuals regardless of their living arrangements.

Binary logistic regression analysis revealed that self-distraction, substance abuse, emotional support, venting, and religious coping were significant predictors of ASD. Our results demonstrated that children with ASD use both adaptive (emotional support and religion) and maladaptive (substance abuse) coping strategies. It has been proposed that adaptive coping techniques can aid in efficient stress management. Individuals who actively practice adaptive coping are more likely to feel hopeful, controlled, and confident in their abilities, which can improve their QOL. This theoretical framework aligns with earlier research findings (Leslie-Miller et al., 2021; Smida et al., 2021). The hallmarks of maladaptive coping are self-distraction, denial, and avoidance. It is hypothesized that these behaviors do not help people manage stressors efficiently, but increase their emotional stress. Theoretical frameworks propose that these maladaptive coping mechanisms can perpetuate negative emotional states and contribute to the development of the symptoms of depression, anxiety, and stress (Almeida et al., 2021; Mishra et al., 2023; Salazar et al., 2021).

This study offers a thorough understanding of the coping mechanisms that can enhance the QOL of children with ASD by analyzing the unique contributions of each coping mechanism. The discussion of theoretical underpinnings and empirical data clarifies the mechanisms behind the observed correlation and function of coping strategies in the context of children’s disabilities. It also highlights the significance of promoting adaptive coping strategies and addressing maladaptive coping strategies to improve the QOL of children with ASD.

The present study also investigated the role of demographic factors in predicting the coping strategies adopted by children with ASD. Our analysis indicated that grade and family status were significant predictors of coping strategies among children with ASD. The results indicated that elementary school children were at a high risk of developing ASD. Unfortunately, there are no data available for the direct comparison of our findings. However, previous studies have reported that the education level of parents with autism might affect their understanding of their condition, access to rehabilitation, and coping strategies, leading to improvements in various domains of QOL (Perumal et al., 2014). Our results also show that children living in joint families are at a high risk of ASD. However, no relevant studies have compared our results. There is no direct evidence that a joint family system predicts ASD. ASD is a neurodevelopmental disorder influenced by a combination of genetic and environmental factors. Family dynamics can affect a child’s development, and attributing ASD solely to the joint family system oversimplifies complex conditions. To understand ASD, it is important to consider various factors, such as genetic predisposition, prenatal environment, and early childhood experiences.

LIMITATIONS

There are several limitations to these types of studies; here, we highlight a few of the obvious ones. The first limitation of this study was the potential for selection bias in the participant recruitment. Recruiting children from clinics, special education schools, and autism support groups may result in a sample that does not fully represent the broader population of children with ASD. These settings may attract individuals with specific characteristics or access to resources, thus potentially skewing our findings. Additionally, the study’s focus on children aged 6-18 years limits the generalizability to older or younger age groups. Moreover, relying solely on parent/caregiver reports for demographic and clinical variables introduces the possibility of response bias or inaccuracies. Furthermore, while matching participants based on age, sex, and ASD severity enhances comparability between groups, other potentially influential factors, such as developmental history, may not be fully accounted for. This study’s cross-sectional design also limits the ability to establish causal relationships between coping strategies and QOL. Longitudinal studies can provide deeper insights into these associations over time. Finally, while the study aimed to adhere to ethical guidelines, variations in the interpretation or implementation of these guidelines across different institutions may introduce inconsistencies in ethical processes.

CONCLUSION

In this study of 245 children from the Al-Hasa region, 214 were included in the final analysis, with most children with ASD being male. Middle school students had a higher frequency of ASD. Children from joint families had a higher prevalence of ASD, which was linked to a poorer socioeconomic status. QOL measures revealed significant differences between children with ASD and healthy children, with children with ASD showing poorer scores across various domains. Children with ASD relied more on substance abuse, emotional support, and religious coping. Logistic regression analysis indicated that family status significantly correlated with ASD. While no significant association was found between ASD and gender, age, grade, or monthly income, certain coping strategies such as self-distraction, substance abuse, and social support were linked to ASD. Family status and grade were significant predictors of ASD. This study hypothesized that QOL and coping strategies could predict ASD, with the results supporting this notion. These findings shed light on the complex interplay between sociodemographic factors, coping mechanisms, and ASD prevalence, emphasizing the importance of tailored interventions and support for the affected children and their families.

AUTHOR CONTRIBUTIONS

All the authors contributed significantly to the work that was published, regardless of whether it was in the areas of conception, study design, execution, data acquisition, analysis, or interpretation.

COMPETING INTERESTS

The authors declare no conflicts of interest in this work.

INSTITUTIONAL REVIEW BOARD STATEMENT

This study was conducted in accordance with the Declaration of Helsinki and approved by the Deanship of Scientific Research, King Faisal University, Saudi Arabia (KFU-REC-2023-SEP-ETHICS1350).

INFORMED CONSENT STATEMENT

Informed consent was obtained from all the participants involved in the study.

DATA AVAILABILITY STATEMENT

The data that support our findings can be found by directly asking the corresponding author.

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