Immigrant Children with Autism Spectrum Disorder: The Relationship between the Perspective of the Professionals and the Parents’ Point of View

Abstract

Background:

The purpose of this study was to compare a medical diagnosis of autism spectrum disorder (ASD) with the perceptions of immigrant parents regarding their child’s difficulties.

Methods:

Semistructured interviews were conducted with parents. The children were assessed using the ADOS, and a multiaxial diagnosis was reached using the DSM-IV.

Results:

The majority of parents recognized symptoms in their child that were related to autism. Less often, however, parents believed their children had a developmental delay or communication problem rather than an ASD. There were also parents who failed to see any problem at all in their child although the child was, nonetheless, diagnosed as having an ASD.

Conclusions:

The failure of immigrant mothers to acknowledge a diagnosis of ASD in their younger children may represent an attempt to preserve hope for their child’s future. Mothers of older children may not, however, agree with the psychiatric diagnosis. Community services need to balance the need to convey accurate medical information with the need to protect parents’ investment in their children. This may be particularly true for immigrant parents who are living outside their cultural framework.

Background

The three basic symptoms required for a diagnosis of autism spectrum disorder (ASD) consist of pervasive impairment of reciprocal social interaction and verbal and nonverbal communication skills, stereotyped behavior and restricted interests. ASD is considered a disorder of early childhood, and parents play a key role in raising suspicions of the disease and seeking a diagnosis, confirmation of which will permit timely implementation of stimulation to improve lifelong social adaptation (Lovaas, 1987).

Perceptions of suffering are strongly embedded in a cultural representation of the world and may also be influenced by the social living environment of families (Darghouth, Pedersen, Bibeau, & Rousseau, 2006). Medical points of view do not encompass human beings’ understanding of their suffering. Some authors argue that dominant biomedical discourses focus largely on symptoms, forgetting to address experiences of living with autism (Solomon & Bagatell, 2010). Individuals with autism need to be viewed not only as part of a biomedical condition, but as members of social groups who act, displaying both social competencies and difficulties in relation to socially and culturally ordered expectations of behaviour (Ochs, Kremer-Sadlik, Sirota, & Solomon, 2004).

Prince (2010), an anthropologist with ASD, published an ethnographic article that focuses on autism as a different way of being. Based also on ethnographic data from the emerging autistic community that has grown over the past decade, Bagatell (2010) investigated a debate on whether autism is a condition in need of a cure or rather a way of life. According to representatives of the autistic community, behaviours such as repetitive movements and lack of eye contact need to be understood as a difference and not seen as attitudes that should be changed. In this discourse, people with autism consider the condition a part of who they are, not as a problem that requires a cure. The autistic community advocates identifying coping strategies for symptoms which members find problematic and locating particular niches for their unique perceptions and skills. According to Bagatell (2010), autism, like other disabilities, is socially constructed and the “problem” does not lie in the person with autism, but rather in society’s attitudes (Bagatell, 2010).

Few studies have focused on parents’ perceptions of their autistic child. In a study conducted by Gray in 1993, references of hope were found to be strongly present in parents’ narratives regarding younger autistic children. Those parents wished their child would be able to develop sufficient skills to live a near normal life. A longitudinal follow-up of the same families ten years later showed that these hopes had dwindled, as none of the children had attained the full range of living skills that their parents had originally envisioned (Gray, 2002).

Immigrant families’ perceptions of their child may be influenced by their predicament in the host country (Rousseau, Mekki-Berrada, & Moreau, 2001). While in the 20^th century acculturation was a key concept to understanding how immigrant families have integrated in their host country, in a globalized world, transnational networks have a strong influence on how immigrants navigate between their culture of origin and their new environment (Bagnoli, 2007; Kirmayer, 2012). This has a number of implications for the relationships between parents and their autistic child and between parents and services. First, immigrant parents may use their cultural resources to deal effectively with their autistic child. Twoy et al. (Twoy, Connolly, & Novak, 2007) emphasize that Asian American parents are more able to reframe their child’s difficulty in spiritual terms than their Euro-American counterparts. Similarly, Magana and Smith (2006) show that Hispanics report greater satisfaction in their relationship with their autistic offspring compared to mainstream parents. However, in the case of recent immigrants, the precariousness associated with poor language mastery, socioeconomic difficulties and recent losses may interfere with parents’ capacity to use these cultural resources effectively (Siguouin, 2004). Secondly, the few studies available indicate that the relationships between immigrant and ethnic minority parents and services are generally difficult because of misunderstandings, prejudices and differences in what is perceived as appropriate treatment (Jegatheesan, 2010; Mandell & Novak, 2005). To overcome these difficulties, Welterlin and LaRue (2007) propose to culturally adapt the services, highlighting the importance of gaining a better understanding of the parents’ perspective.

This qualitative study documents the relationship between the medical diagnosis of autism established with the use of standardized instruments and immigrant parents’ perceptions of their child’s difficulties. First, the paper will describe how the parents perceive their child, and what they consider to be a problem in their child’s condition. Secondly, the relationship between the parents’ understanding of their child’s difficulties and the medical diagnosis given to their child will be described.

Methods

Sample and Recruitment

The study was first presented in a formal meeting to all professionals involved with children with either mental retardation and/or ASD in a primary care facility located in a multiethnic neighborhood in Montreal, Canada. Montreal is a multiethnic city welcoming a large number of immigrants from very diverse backgrounds. More than 53% of children in the metropolitan area are first or second generation immigrants (Rousseau, Hassan, Measham, & Lashley, 2008). The target population consisted of the parents of migrant children who had been referred to that primary care facility because of autistic traits by professionals involved with the family: psycho-educators, speech therapists, social workers, pediatricians or teachers. These children were considered by these professionals as being in need of a formal psychiatric assessment to establish a treatment plan and to assess their needs for social support or a special school. The study protocol was explained to the parents and they were informed that, if they so wished, a psychiatric assessment of their child would subsequently be made available. If they refused to participate in the study, but still wanted a child psychiatric report, they were not included in the study; however, a psychiatrist assessed their child and produced a report. If they agreed to participate in the study, they were provided with written, detailed information about it and were asked to sign an informed consent form.

The study was approved by the institute’s Internal Review Board (Comité d’éthique de la recherché CSSS de la Montagne – Site Métro) under protocol PE 569-16.04.09 on April 30, 2009. All the participating parents were duly informed with respect to the study, both orally and in writing, and signed an informed consent form.

Instruments

The children were assessed using the Autism Diagnostic Observation Schedule (ADOS), which is a standardized tool for the assessment of communication, social interaction and symbolic play. It is classically used to assess autism and other pervasive developmental disorders referred to here as autism spectrum disorders (ASD). It consists of four modules, all of which have shown good reliability, sensitivity and specificity for both autism and ASD, both in its English and Spanish forms (Lord, Rutter, DiLavore, & Risi, 2006). The ADOS has also been used in other countries such as Greece (Papanikolaou et al., 2009) and Germany (Bölte & Poustka, 2004), and its psychometric properties were confirmed in these versions.

The children also underwent a clinical assessment, with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) being used to reach a multi-axial diagnosis (American Psychiatric Association, 1994). The severity of the impairment was assessed in accordance with the Global Assessment Functioning (GAF), a numerical scale ranging from 0 to 100 that is used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of children and adolescents (Shaffer et al., 1983). The final diagnosis was based both on a clinical evaluation conducted using the DSM-IV criteria.

Information on sociodemographic factors and immigration was collected from the children’s parents. The parents originated from 33 different countries, which were regrouped for the purposes of analysis into geographical-cultural regions, as follows: Asia, Africa, Latin America and the Caribbean, Europe, the Arab world, and North America.

Semistructured interviews were conducted with the parents to elicit narratives regarding the family’s experience with their child’s difficulties. The semistructured interviews were based on some of the questions designed by Kleinman (1980) to elicit explanatory models of disease. Both parents were asked the following questions: “How do you see your child?”; “Do you think he/she has any problem and/or difficulty? What kind of problem and/or difficulty?”; “How would you describe his/her problems and/or difficulties? Can you put a name to it?” Interviews were conducted in English, French, Spanish or Portuguese. Montreal is a bilingual city and most immigrants speak either French or English. Some of the parents in this sample were recent immigrants and spoke exclusively or principally in their mother tongue. Those who spoke Portuguese or Spanish were able to speak in their own language, since the investigator is also fluent in these two languages. For other languages, an interpreter was present. The children were assessed with their parents, and the evaluation lasted from 45 to 60 minutes. Parents were interviewed individually without the presence of the child or their spouse. The duration of the interviews with the parents ranged from 45 minutes to two hours. They were audiotaped and transcribed for subsequent analysis.

Participants

A total of 51 children were referred to the study. Three were excluded, two because their parents did not agree to participate and one because it proved impossible to conduct the family interview. Therefore, the sample consisted of 48 children; however, 13 were subsequently excluded from the study because the parents’ interviews were found not to contain any appropriate answers with respect to the study objectives. The final sample for this qualitative analysis consisted of 35 children: 11 girls (31.4%) and 24 boys (68.6%) of 2–15 years of age. The mean age of the children was 5.89 ± 3.54 years (mean ± standard deviation). Forty-four parents were interviewed in the study: 32 mothers and 12 fathers. In this multiethnic community, the majority of the children were from families originating from the Arab world (31.4% of the fathers and 28.6% of the mothers), from Asia (20% of the fathers and 16.4% of the mothers) or from Africa (20% of the fathers and 15% of the mothers). In addition, 14.3% of the fathers and 14.3% of the mothers were from Latin America or the Caribbean and 11.4% of the fathers and 14.3% of the mothers were European. A further 2.9% of fathers and 11.4% of mothers were from North America. The majority of the children (65.7%) were born in Montreal, while 34.3% were born in their parents’ native country. The majority of the parents (85%) had immigrated to Canada less than five years previously.

Data Analysis

Domain analysis, a method developed to analyze ethnographic data, was used to analyze the interviews (Pondé, Mendonça, & Caroso, 2009). The first step was to identify semantic relationships between terms in the parents’ narratives. The following universal semantic relationships (Spradley, 1980) appeared in the interviews: Assignment (X is an assignment or feature of Y). For example: “happy”, “active”, “very bright” represent a feature of “my child”, while “slower”, “doesn’t look me in the eyes”, he plays and talks” represent an assignment of “my child”. The second step was to prepare a worksheet listing the semantic relationships, including a declaration of the form in which they were expressed, and examples taken from each narrative. The examples from each narrative, which correspond to fragments from parents’ narratives, were regrouped into categories. These categories were subsequently reduced to three major categories: a) symptoms related to autism; b) developmental delay or communication problem; and, c) no problem at all. A cross-analysis between these three categories and the psychiatric diagnosis was performed in order to detect a trend; however, statistical testing was not conducted as it is not appropriate in observational studies such as this one (Ludwig, 2005).

Results

According to the DSM-IV, 43.8% of the children were diagnosed as autistic, while 43.8% had pervasive developmental disorder not otherwise specified (PDD-NOS), 2.1% had Asperger’s syndrome and 8.3% had a mixed receptive-expressive language disorder. A further 2.1% were given no psychiatric diagnosis. In the GAF scale, 18.8% of the children scored <50, indicating severe symptoms, while 50% scored between 52 and 60, indicating moderate symptoms, and 31.2% scored > 61, indicating mild symptoms.

When parents were asked “How do you see your child?” Almost half of them, (45%) emphasized the positive aspects of the child, but also mentioned some difficulties.

“… he is a very active boy. A very vivid imagination. I can see that he has delayed development. He’s a very bright boy, very smart. He doesn’t talk, that’s not because he doesn’t want to – he doesn’t know how to communicate with other kids. But he loves all older children; he prefers adults to children of his own age.” (Mother of a 3-year-old boy considered autistic according to his psychiatric assessment).

Some parents, (16%) referred only to the child’s qualities without mentioning any problems or difficulties.

“ (...) Well, she is easy-going. She will take care of her brother and look after him. If I tell her to clean her room, she will. Her school-work, she does her homework, she joined the library. (...) But I don’t push her to do what she doesn’t want to do because I mean, that’s all I have.” (Mother of a 14-year-old girl considered autistic according to her psychiatric assessment).

Finally, 39% of parents referred mainly to behavior difficulties and developmental delays, although they also mentioned some positive aspects of the child.

“He sometimes hurts others because he bumps into people. (...) It takes a lot of patience to deal with him. He tests your limits but he… I mean he is very happy, he doesn’t seem miserable, he never cries.” (Father of a 7-year-old boy considered autistic according to psychiatric assessment).

Positive aspects were predominant in the reports given by 72% of the mothers and 39% of the fathers, while mention of symptoms and the negative aspects of the child were predominant in the reports of 61% of the fathers and 28% of the mothers. This pattern was not associated with the parents’ ethnic origin or the child’s diagnosis.

The parents’ perceptions about their child’s problem and/or difficulty according to the response given to the question “Do you think he/she has any problem and/or difficulty? What kind of problem and/or difficulty?” were grouped into three categories: a) symptoms related to autism; b) developmental delay or communication problem; and, c) no problem at all. Each of these categories is described below.

1. Symptoms related to autism. Of the participating parents, 51.5% often talked about the child’s difficulty with communication as being a symptom related to autism. They referred to the fact that the child had still not started to speak, spoke only a few words, that his/her speech was incomprehensible or that he/she appeared not to hear well. In some cases involving older children, parents reported that the child was able to speak but unable to express his/her needs in a comprehensible way. Parents also mentioned poor eye contact, difficulties in socializing, tantrums, hyperactivity, failure to recognize danger, anger, unhappiness, a lack of contact or poor contact with other people, aggression towards other children, poor motor skills, lack of toilet control or bed-wetting, inability to relate to peers, rejection by peers, and low self-esteem. Most of the parents had heard about autism and some thought their child might fit into this diagnostic category. In some cases, parents first suspected their child’s diagnosis after conducting searches in the Internet. Some parents mentioned Western beliefs about autism, particularly what they had heard from medical staff, professors or psycho-educators and friends or what they had learned through the Internet, as well as their own perception of their child.

2. Developmental delay or communication problem. The following are some of the more common answers given by 37% of the participating parents, who believed that their child had a developmental delay or a communication problem. For them, this statement contradicted the diagnosis of autism. These parents believed that, if the difficulty was caused by a delay, then this must mean that the child would catch up with the other children later, whereas autism for them was associated with the idea of chronicity and of a permanent disease. For some parents the problems appeared to be strictly related to communication and as soon as the child started to talk everything would be solved.

   “It seems to me that in his case everything is coming slowly, delayed. That is my feeling and maybe it is because of his hearing or maybe he is slow”. (Father of a 3-year-old boy diagnosed as PDD-NOS according to his psychiatric assessment).

3. No problem at all. Finally, 11.5% of the parents believed that their child had no problem at all. These parents mentioned only positive things about their child, in clear opposition to what they were being told about their child by speech therapists, psycho-educators, social workers or teachers who referred the child for an evaluation.

   “I see him as a normal kid. (…) Because last year at school, they said he did not communicate much with the other kids. (…) The teacher also told me that he is a very smart kid.”(Mother of a 13-year-old boy diagnosed as PDD-NOS according to his psychiatric assessment).

Two mothers from South Asia mentioned some difficulties concerning their child, but when the investigator used the word “problem”, they said that their child had no problem. They appeared to be scared of the word “problem” as if the mere mention of it would generate or aggravate a difficult situation.

This classification permitted cross-analysis of the parent’s perceptions with sociodemographic traits (Table 1). Mothers of younger children were more likely to mention “developmental delay or communication problem” or “no problem at all” compared to mothers of children over six years of age. The parents’ origin also played a role in the mothers’ perceptions of their child’s problems. Mothers from Asia and Latin America and the Caribbean were more likely to mention a “developmental delay or communication problem” or “no problem at all” rather than “symptoms related to autism”, whereas mothers from the Arab world and North America were more likely to refer to “symptoms related to autism”. When the perceptions of mothers from South Asia (Bangladesh, Sri Lanka and India) were analyzed separately from those from other Asian countries, it was found that none of them had referred to “symptoms related to autism”, with all these women reporting a “developmental delay or communication problem”. The mothers’ education level did not appear to affect their perception of their child’s problems; however, when the education level of the father was lower, the mothers were more likely to report a “developmental delay or communication problem”. When the education level of the father was higher, the mothers were more likely to report “symptoms related to autism”. Nevertheless, the number of fathers who responded was insufficient to permit any trend to be identified.

Table 1.

Children’s problems according to their mother’s perceptions

	Symptoms of autism	Developmental delay	No problem at all
Age of the child (years)
1 – 5	10 (47.6%)	10 (47.6%)	1 (4.8%)
6 – 15	8 (57.1%)	3 (21.4%)	3 (21.4%)
Gender
Female	5 (55.6%)	2 (22.2%)	2 (22.2%)
Male	13 (50 %)	11 (43.2 %)	2 (7.7%)
Father’s origin
Asia	6 (40%)	8 (53.3%)	1 (6.7%)
Latin America or the Caribbean	1 (33%)	1 (33%)	1 (33%)
Europe	2 (50 %)	1 (25%)	1 (25%)
Arab world	6 (66.7%)	2 (22.2%)	1 (11.1%)
North America	2 (66.7%)	1 (33.3%)	0%
Mother’s origin
Asia	4 (30.8%)	8 (61.5%)	1 (7.7%)
Latin America or the Caribbean	1 (33.3%)	1 (33.3%)	1 (33.3%)
Europe	3 (60%)	1 (20%)	1 (20%)
Arab world	5 (62.5%)	2 (25%)	1 (12.5%)
North America	5 (83.3%)	1 (16.7%)	0%
Father’s schooling
No university degree	7 (36.8%)	9 (47.4%)	3 (15.8%)
University degree	8 (61.5%)	4 (38.8%)	1 (7.7%)
Mother’s schooling
No university degree	6 (46.2%)	5 (38.5%)	2 (15.4%)
University degree	10 (50%)	8 (40%)	2 (10%)

The relationship between the psychiatric diagnosis assigned to the children after assessment and their parents’ perceptions are shown in Table 2. The majority (76.9%) of children whose mothers reported a “developmental delay or communication problem” were diagnosed as autistic or PDD-NOS, while the remaining 23.1% were diagnosed as having a language disorder. In terms of the severity of symptoms, in 53.8% of the children whose parents considered them to have a “developmental delay or communication problem”, symptoms were considered moderate to severe, while in 46.2% of cases symptoms were considered mild in accordance with the GAF. Of the children considered to be suffering from a “developmental delay or communication problem”, 76.9% were under five years of age, while the remaining 23.1% were older.

Table 2.

Relationship between the psychiatric diagnosis and mothers’ perception about their child’s problem

	Developmental delay	Symptoms of autism	No problem at all
DSM-IV
Autism	7 (53.8%)	8 (44.4%)	1 (25%)
PDD-NOS	3 (23.1%)	9 (50%)	1 (25%)
Language disorder	3 (23.1%)	1 (5.6%)	0
Asperger	0	0	1 (25%)
No diagnosis	0	0	1 (25%)
GAF
Severe/moderate	7 (53.8%)	9 (50%)	1 (25%)
Mild	6 (46.2%)	9 (50%)	3 (75%)

Of the children whose mothers mentioned “symptoms related to autism”, the majority (94.4%) had either autism or PDD-NOS, while 5.6% had a language disorder. In terms of the severity of symptoms, 50% had moderate to severe symptoms and 50% had mild symptoms. With respect to age, half were under five years of age and half were older.

In the group of mothers who considered that their child had “no problem at all”, 25% had autism and 25% PDD-NOS, while another 25% had Asperger’s syndrome and 25% received no psychiatric diagnosis at all. In terms of the severity of symptoms, however, the majority (75%) had mild symptoms, with symptoms that were considered moderate (GAF=60) being found in only one child (25%). The majority (75%) of these children were over 5 years of age. They had all been sent for an assessment by their school, social worker or by a psycho-educator because these professionals considered that the child was not functioning adequately at school, particularly with respect to their social skills. Some parents felt that the professionals were intrusive because they had insisted on sending the child for an assessment. They believed that their child had no problem at all and that, on the contrary, any problem that might exist arose from the fact that other people, including the school, failed to accept his/her differences.

Discussion

When comparing immigrant parents’ perceptions of their child with the child’s psychiatric diagnosis, unsurprisingly a higher proportion of parents whose child had received a psychiatric diagnosis of PDD mentioned “symptoms related to autism”. On the other hand, some parents who shared these perceptions had children who did not receive a diagnosis of PDD and were considered by the clinicians to have a language disorder. Overall, the parents’ perceptions within this group were mostly in agreement with the psychiatric point of view, considering that a severe language disorder is an important differential diagnosis for PDD (Reddy, Graves, & Augustyn, 2011).

In the group of parents who referred to their children predominantly as having a “developmental delay or communication problem”, a high proportion (77%) of these children received a diagnosis of PDD. It may be that these parents tried to avoid receiving a diagnosis of autism for their child as a way of preserving hope with respect to their child’s development and future. Gray (1994; 2002) mentioned that the parents of younger autistic children need to preserve hope for their development in order to maintain an investment in their child. It seems that ascribing their child’s problems to a certain degree of delay meant that the child would become normal at some point, leaving room for hope instead of having to accept that their child had a disorder associated with more long term disabilities, as in the case of autism. Some authors’ emphasize that the narrative around a disease is built up in order to leave room for hope (Good & DelVecchio Good, 1993). For professionals who work in the early stimulation of children with PDD, hope may be important in sustaining the parents’ investment in the child and in motivating them (Smith, Groen, & Wynn, 2000).

In the group of parents who considered that their child had “no problem at all,” 25% of these children were given no psychiatric diagnosis. As in the previous group, 75% of the children were diagnosed with PDD. Children from this group were older and had milder symptoms than the children from the other two groups in which the parents referred to their child having symptoms of autism or a developmental delay or language problem. These children were often perceived by their parents as being shy, like other members of the family, and the parents felt that the school was unable to accept the fact that they were special or different. Parents who felt that their child had “no problem at all” had been sent for an assessment by school professionals; however, they saw no need for any kind of assessment, although they reluctantly agreed to comply with the school’s request. For this group, a diagnosis of autism or any other PDD implies that their child is considered to have a mental problem/disorder, which is not in agreement with the perception that they themselves have of their child. The parents’ perception, nevertheless, differs from that of the healthcare agents, with the result that the parents refuse the proposed interventions. Indeed, these parents do not only refuse the interventions proposed by the agents, but also actually perceive them as offensive.

Almost half the parents interviewed mentioned communication problems as their child’s principal problem. This finding is in agreement with the results presented by Gray (1994), showing that the absence of language skills was the most stressful symptom and the first sign that led parents to seek medical help. The absence of communication is a major concern because it prevents the child from being accepted by a normal school. This worry surfaced in a similar manner in all the ethnic groups represented in the present study.

Parents’ origin appeared to influence the mothers’ perception of their children. Mothers from the Arab world and from North America were more likely to mention autistic traits compared to those from Asia, Latin America and the Caribbean, who were more likely to mention a “developmental delay or communication problem” or “no problem at all”. This trend, combined with the fact that a higher educational level in the father was also associated with being more familiar with the concept of autism, may be related to a greater proximity to Western models, mainly through formal education.

Gender differences dominate the parents’ appraisal of their child. Overall, the mother’s description of her child consisted predominantly of positive aspects, while the majority of fathers tended to emphasize the child’s difficulties. This pattern did not appear to be related to the parents’ origin, the severity of the child’s symptoms, the age of the child or to his/her psychiatric diagnosis. A study involving children diagnosed with congenital anomalies suggests that the mothers experience greater difficulty in adjusting emotionally, with higher levels of psychopathological symptomatology and a poorer quality of life compared to that of the fathers (Albuquerque, Pereira, Fonseca, & Canavarro, 2012). It is reasonable to speculate that the mothers in the present study were more inclined to focus on positive aspects as a way of protecting their child and of protecting themselves from frustration, while fathers in general appeared more unsettled by their child’s difficulties or problems.

Limitations

This is a qualitative, exploratory study, the objective of which was to identify differences or similarities between the perception of recent immigrants with respect to their children, who are considered autistic by the medical community, and the child’s psychiatric diagnosis. The hypotheses raised in this study, however, need to be confirmed in future studies conducted with larger sample sizes.

Conclusions

These results suggest that parents’ perceptions are influenced both by their cultural background and by the representations prevalent in the host society, thus producing a hybrid reconstruction of knowledge that characterizes the migrant experience (Bagnoli, 2007). Overall, mothers tend to focus on the positive aspects of the child, while fathers tend to be more unsettled by the child’s difficulties. Parents of younger children with moderate to severe symptoms tend to avoid speaking about the diagnosis of autism in their narratives. Parents’ origin appears to influence their perception of the child’s problems. Some mention autistic traits, while others prefer to categorize it as a “developmental delay or communication problem” or “no problem at all”. These diverse strategies may be related to the need to preserve hope for their children’s future or to a different perception of the child based on cultural diversity. Community services have to balance the need to convey objective and accurate information with the necessity to protect parents’ investment in their children. Although this is true for all parents of ASD children, it may be particularly important for immigrant parents who are undergoing losses and experiencing a cultural shock and may not be ready to acknowledge that their child is facing major difficulties.