Abstract : Medications are used widley in treating autism this study was conducted to elaborate on  parents knoweldge about maedications used on autism and to explore parents believes on the benefit of these medications to their children, inaddition to highlight on their worries and burden in using medication.

Method: A cross sectional study was conducted in Saudi Arabia,One hundred parent particpated and completed survey quesstionnaire assessing their knowledge as well as their worries in medication use for their autistic children.

Results: Indicated that there was 60% of participants believe on the benefit of medication while 62% were worrisome to use medication to their children.

Conculsion: Although majority of parents has various medications worries and concerns, they are willing to use medications to help their children overpass their challenges.

Autism is a life long developmental disability characterized by weak social communication skills and language impairment combined with sterotype, repetitive behaviors [1]. In addition behavior and psychiatric problems such as attention deficit hyperactivity disorder, aggression and anxiety disorder are common in individuals with autism [2].

Majority of autistic individuals require medications to treat complex behavior problems, Lynn K., et al. 2013 found that around 30% to 60% of autistic children are being on one or more prescribed medication [3]. Treatments options for are variable including psychotherapy and psychopharamcolgy, for instance atypical antipsychotic medication has been used widely to reduce behavioral problem in autism disorders [4]. Risperidal Considerd as one of the atypical antipsychotic medication that has been approved by food and drug adminstration (FDA) and used extensively in autism [4]. The saftey and long term efficacy of atypical antipsychotic in treating challenging behaviors in individuals with autism were explored in Lynn K., et al. 2013 study [3].

Raising child with autism is considered as a hard mission for the parents, furthermore the descision to use medication for their children could be challenging, hold countless worries and this could be due to several factors including: inadequate drug information, fear of medication side effect and lack of evidence about medication efficacy on children [5], moreover researches measuring parents knoweldge and satisfaction in using medicatons to their children with autism are limited (Frances, 2005; Kasari, 2002; Lord., et al. 2005; Rogers & Vismara, 2008; Scahill &Martin, 2005; Volkmar, Lord, Bailey, Schultz, & Klin, 2004).  In our practice in Saudi Arabia (SA), we found parents alttitude towards using medication.

Is similar to what was descibed in literature globally, parents are relactant to use Medication to their children with autism, lacking knoweldge and access to drug information, in addition to the fear of  social stigma are common barriers in using medication. This observations had been noticed in other studies  such as  Metz., et al. (2005), determine in their study the factors affecting parents decisions in treatment plan [6]. Moreover parents choices on treatment plan were explored by Anne Bowker study (2011) [6].

In Saudi Arabia researches in autism are limited, further no studies were found addressing parents perception about medication use in children with autism as far as we Know, this is the first study conducted to addresses the problem from parents prespective. In addition, we are aiming to add evidence to our observation on this important topic.

Study aims to assess parents knoweldge and believes about medication use for their autistic children

• To assess parents knowledge about the medication use in autism
• To assess parents worries about using medciation
• To assess perception difference according to gender
• To assess compliance rate in medication use

Study design and participants
A cross sectional study was conducted in Riyadh, the capital of Saudi Arabia, Survey questionnaire were distributed to tertiary care hospitals with specialized autism clinics running on regular basis (King Abdullah specialized children hospital, King Fahad Medical City Military hospital). In addition to autism rehabtilation center and to Families attending  community autism related activities during the month of April 2016 which corresponds to the international autism awareness month.

Parents and relatives of autistic children who were on medication (atypical antipsychotropic agents were included) to assess their knowledge about medication use on autism and elaborate on the factors interfere with their decision, inclusion criteria was both males and females, autistic children on medication, care given directly involved with child’s care and medication adminstration.

Measure
A Twenty three survey questions were developed by the authors in English and Arabic Languages to assess parents perception in medication use in autism, it was reviewed by biostation, Pharmasicit and experts who are working with autism patients, content and face validity were done, a self administered questionnaire were handed to the parents by clinical cordinators and volunteer. Questionnaire filled and returned  back after 10 to 20 minutes.

Survey questionnaire consisted of introductory cover page, consent form, followed by survey questionnaire which include 3 sections, the first section include questions related to demographic characteristic of the participants, (age, gender, martial-status, and educational level),  the second section includes questions related to believes and worries relted to medication use and the third section covers  questions related to compliance with  medication used and satisfaction about drug information given to them  as well as other drug information resources, all items are rated on a 3-point Likert scale1 as Yes, 2 as No and 3 as I don’t know.

Statistical analysis
Descriptive statistics for categorical data were displayed as number and percentage and mean ± Standard deviation (SD) or median ± Inter Quartile range (IQR) for continuous data. The group differences for categorical variables were assessed with Fisher's exact test or the Chi square test A P value of <0.05 was considered statistically significant. A statistical Analysis system version 9.4 was used for data analysis.

Ethical Considerations
The proposal was approved by ethical board (IRB) at King Abdullah Reseach center (KAMRC) Participation in the study was voluntary, Informed consent provided to the study participants before data collection. All the data kept under lock and key, only the PI and co-PI will have access to it. The confidentiality and anonymity of the participants were kept all through out of the study and in the dissemination phase.

Two hundred questionnaire were distributed to parents of autism spectrum disorders and 100 were returned (50% return rate). Majority of respondents were females (84%). The 32% of responders were from 31 years to 40 years old. In regard to educational level 59% has university degre and 21% has secondary education, Marital status 65% were married and 17% were singles. For more detail please refer Table 1.

The majority of parents had 74% of Compliance rate and adherance to medication . However, only 24% of parents could not adherence to medication due to unknown reasons. (Figure 1)

Out of 100 participants, 60% of paricipants had fair knoweldge about benefits and effect of medication, whereas 14% of participants believed to have no prior knowledge about it. There were 26% of particpicant who were not very sure about the benefits of medications (Figure 2).

The 61% believed that medication can be used to treat the comorbid conditions associated with autism while 25% believed that medication can cure autism. However, 14% believed in dual effect of the medication Figure 3.

More than half of the participants were worried to use medication to their children (Figure 4).

It is the evidence from the above table that majority of of participants 61% believed that autism as psychiatric medication whereas 16.2% had believed that it was not an psychiatric medication. There were 23% of participants who were not sure whether autism medication is psychiatric medication or not.

The majority of participants who believed autism as psychiatric medication had reported that these medication were not sedative or addictive in nature.

There were 59 participants who expressed their worries about the adherence to treatment whereas, 37 participants were not worried about the treatment adherence. 35 out of 96 participants (36.5%) expressed their uncertainties whether medication can treat.

Co morbid conditions or not whereas 24% of participant had no concerns about it. 16% of participants had concerns if medication can cure austim whereas 8% of participants and no worries about it. There were only 8% of participatants who expressed their worries about the medication that it can treat both comorbidity and austim, while 6% of participants had not worries about it. However, the comparison between parent’s worries and treatment adherence was no statistical significant (p-value: 0.8125).

The 51 out of 97 participants belived to have treatment adherence whereas, 46 participants had no belief and 18 participants were not sure about it. The parents’ beliefs found to be statistically significant with treatment adherence (p-value:0.0104).

The majority of female 58.3% (49/84) had perception that autism medications are psychiatric medication whereas 68.75% (11/16) of male agreed with them. However, there were no enough evidence statistically to support that gender and perception for autism as psychiatric medication had any association (P-value: 0.7982). The majority of male had perception that autism medication are not sedative in nature whereas majority of female had not agreed with male. We had again not enough evidence statistically to support that gender and perception about autism medication causes sedation had any association (P-value: 0.2870). The majority of female 38.09% had perception that autism medications are addictive in nature whereas male had not clear perception about it.

This study was conducted to assess parents’ beliefs and worries about medications use to their children with autism.Results showed good response rate all over 77%  and this could be explained by the attention given to autism over years by different medical and non medical sourses in the pupose of rasing knoweldge and awareness about autism. Majority of respondents were females 84% with more than half of participants had university education. Also this study found that 60% of the responders believed on the benefit of the medication and moreover around same percent 61% believe that medication were used to treat comorbid conditions more than it was used to cure autism 25% and these findings were consistant with previous studies.

A study by  Zablotsky., et al. 2015 reported that 52.6% of parents using one medication or more to treat the comorbid conditions such as anxiety, attention deficit hyperactivity disorders and others [7,8]. Over all complianc rate and adherance to medication was 74% among study particpants although, more than half of the total sample indicated that they are worried to start medication to their children, the difference between parents worries and treatment adherence was statistical non-significant (p-value: 0.8125). Meantime the parents’ beliefs found to be statistically significant with treatment adherence (p-value:0.0104). Compliance and treatment adherence rate in our study was higher than what was reported in previous studies  (Logan., et al. 2014) and this results might be explained because parents do not have many treatment options available.

In addition  by comparing parents perception about autism medications by gender, study showed that female participants had higher rate of fears and concerns than male and this could be explained by the higher number of female particpants (84.0%) and this may considered as one of study limitation. Similar observation was noted in R Hock.,  et al. (2015) study [9] and this could be due to that mothers are the main caretaker of their autistic children. Also this study identifed many factors that  raise parents distress and affect their decisions to treat their autistic children including, 60% of participant considered autism medications as one of the  psychiatric medications, while 36.08% felt that medication use has sedative effect, moreover less than half of parents worried from the addiction that could result from austim medications (38%).

Thease results could reflect the lack of knoweledge and right drug information among parents of autistic individuals, yet these results support the findings reported by previous studies (Bowker., et al. (2010), Bashir., et al. 2014 ). Never the less a study by Schieve., et al. (2018)  reported that parents of autistic children encounter a signifance stresses comparing to Parents of Children without Special health needs in which family centered treatment could be a valuable option for parents [10].

Lastly, autism is a complex disorder with unkown etiology and little evidence -based research conducted on exciting treatment options that impact negatively on parents and leave them overwhelmed and subsequently make their decisions on treating their children more harder (Kasari 2002). Further family centered research on the autism treatment should be conducted to add more Evidence and knoweldge about mysterious disorder. Study has several limitations First small sample size in which study results can’t be generalized, second Missing date that can affect the power of the study and third Female represent the majority of study sample which might be a selection bias. Further studies with  bigger sample size, both gender are recommeded.

Parents of autistic children are often encounter many challenges through out their journey to raise their children, they have blend feelings between welling to do “looking for better” and worrries of wrong choice causing harm particulary in the absence of convincing evidence. Further researches should be conducted in the extent of parenting of children with special needs aiming to promote parents competence in decision making for their children treatments plan.

Acknowledgements
Authors acknowledges the support of Dr.Maha Alamari clinical phamascit and her team from pharmaceutical care department at King Abdulaziz Medical City in preparation study questionnaire.

Conflicts of interest
The authors has no conflicts to declare. And no external fund was received