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Abstract
Background The incidence of autism spectrum disorders (ASDs) is increasing greatly, with high demands for earlier diagnosis and intervention. However, little is known about ASD knowledge and beliefs among physicians in China.
Methods A questionnaire survey was used to assess the knowledge and beliefs about the diagnosis and management of ASD and 24 beliefs regarding the treatment and prognostic aspects of ASD among physicians of any medical specialty in China.
Results A total of 1160 physicians were recruited and surveyed, with an average score of 8.48±2.66 (total of 18 points) for the questionnaire on the main symptoms of ASD and 14.35±3.69 (total of 24 points) for beliefs about ASD. Physicians’ age, sex, specialty and practice years were related to their knowledge of identifying patients with ASD. Physicians specialising in paediatrics/psychology/psychiatry scored higher than those specialising in other specialties both in response to diagnostic questions (8.98±2.63 vs 8.30±2.65, p<0.001) and beliefs about ASD (15.57±3.44 vs 13.97±3.97, p<0.001).
Conclusions Knowledge and beliefs about ASD symptoms, diagnosis and treatment are insufficient among physicians in China. Education and training programmes on this topic should be enhanced in physicians of all specialties, especially for male physicians who have short years in practice.
- child psychiatry
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Autism spectrum disorder (ASD) has now been considered to be a public health issue worldwide.
There are high demands for earlier diagnosis and intervention in China.
WHAT THIS STUDY ADDS
The knowledge and beliefs about ASD symptoms, diagnosis and treatment were insufficient among physicians in China.
Paediatricians/psychologists/psychiatrists knew more information on ASD than those specialising in other specialties.
Male physicians with a short practice period had fewer medical knowledge of ASD.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Training programmes of continuing medical education on ASD knowledge should be carried out in all specialties of physicians in China.
Introduction
With a high worldwide prevalence, autism spectrum disorder (ASD) has now been considered an emerging public health issue.1 2 Studies have shown a rising trend of ASD prevalence in the past two decades, estimated to be 1%–2% worldwide.3–7 The prevalence of ASD is 2.5 per 100 in the USA8 and 0.94 per 100 in Korea.9 The prevalence of ASD in China was estimated to be 0.70% (95% CI: 0.64% to 0.74%) resulting from a multicentre population-based survey,10 with more than 10 000 000 patients with ASD. Among them, more than 2 000 000 were aged less than 12 years.
Early diagnosis and intervention are beneficial for better outcomes in children with ASD. Studies have revealed that early intervention using the Early Start Denver Model Programme among children as young as 18 months can improve learning and language abilities and adaptive behaviour and reduce symptoms of autism.4 11–16 Early diagnosis enables early intervention, which will have positive effects on functional outcome, life expectancy and quality of life for individuals with ASD.17 However, the knowledge of healthcare workers would affect the diagnosis and management of children with ASD.18
In many countries, paediatricians as well as child and adolescent psychiatrists and psychologists are the first contact professionals of children presenting with ASD symptoms. China still has a shortage of paediatricians, psychiatrists and psychologists, particularly child psychiatrists and psychologists.19 Only tertiary paediatric hospitals or tertiary general hospitals in metropolitan cities have paediatric psychiatrists and psychologists. Therefore, identifying children with ASD may be performed by physicians in multiple disciplines, including general physicians, paediatricians, neurologists, rehabilitation professionals, psychologists and psychiatrists. Studies showed that the age of the first visit for ASD diagnosis in China is commonly between 3 and 6 years, which is much later than the 1.5–2 years suggested by the American Psychological Association.20 21 In China, few primary healthcare institutions are implementing early ASD screening programmes in children aged 18–24 months.20
Early diagnosis is attributed to physicians’ correct understanding of the symptoms’ profile and the developmental trajectory of ASD. Healthcare professionals who assess child development should have a sound understanding of autism.22 It is also important for all clinicians involved in patient care to recognise red flags of ASD so that early referral and intervention can be made.23
To date, few studies have been carried out to assess knowledge and beliefs about ASD among physicians in China. A large knowledge gap in China should be addressed. Herein, we carried out this survey to investigate the knowledge and beliefs of physicians about ASD in China.
Methods
Between January 2016 and June 2019, we conducted a survey using a self-administered questionnaire to assess knowledge and beliefs about ASD among physicians from China.
We recruited participants from the Academic Annual Conferences in all special medical fields from 2016 to 2019 in China. Survey recruitment invitations were sent to the physicians at that time of meeting with a description of survey purpose; voluntary and anonymous participation and a hyperlink to the online survey were also included. Participants were regarded to consent to the study once the questionnaire was completed. The contents of the questionnaire were quoted and adapted from the research questionnaires developed by Daley and Sigman,24 Imran et al 25 and Bakare et al,26 which were shown to have good internal consistency and repeated measures consistency(For details see Appendix 1). The independent translators translated it to Chinese, and blindly translated it to English backward to assure the meaning of the items in the questionnaire is consistent with the original instrument. Any content equivalence of the questionnaire would be discussed and resolved by the team consisting of the authors and translators. We added several items with respect to Chinese culture. For the treatment domain, we added items of ‘traditional Chinese medicine can treat ASD’, ‘acupuncture can treat ASD’, ‘there is no training centre for ASD’ and ‘physicians’ knowledge of ASD is insufficient in China’. Pilot studies were carried out in 20 physicians, and possible confusing survey questions were revised in order to suit Chinese custom and avoid ambiguous interpretation. The Chinese-language questionnaire is available from the authors upon request.
The survey comprised two sections: (1) demographics of the respondents (age, gender, working years, academic degree, specialty, hospital level); (2) respondents’ knowledge of diagnosis and management of ASD including main symptoms; clinical characteristics; treatment options for improving core symptoms of ASD; 24 beliefs regarding social, emotional, cognitive, treatment and prognostic aspects of ASD; ASD training requirement; and knowledge about referral of patients with ASD and local ASD training institutions. Respondents were asked to assess the characteristics as ‘necessary’, ‘helpful but not necessary’, ‘not helpful’ and ‘uncertain’ for the diagnosis of ASD. We scored the answers as follows: for example, if the description of item was necessary to diagnose ASD, a score of 2 points would be given for the answer ‘necessary’, 1 point for the answer ‘useful’, 0 for the other answers. Respondents were instructed to rate each statement of 24 beliefs about ASD either as ‘agree’, ‘disagree’ or ‘not sure’. For each question, the correct answer was scored as ‘1’ and incorrect response counted as ‘null’.
Statistical analysis
SPSS V.16.0 software was used for analysis. One-way analysis of variance and independent samples t-tests were used to compare the difference in knowledge and beliefs about the diagnosis and management of ASD among different groups based on demographics. Univariate regression was performed to evaluate the strengths of the association between outcome variables with several explanatory variables (age, sex, academic degree, specialty, institution level, practice years). A multivariate linear regression analysis was conducted to investigate the independent effects of the relevant factors on the knowledge of ASD diagnosis. A p value less than 0.05 was considered statistically significant.
Community involvement
There was no explicit community involvement in this study.
Results
A total of 2100 questionnaires were distributed to the physicians by a web link using mobile phones. A total of 1497 physicians completed the questionnaires, accounting for a response rate of 71.3%. A total of 337 questionnaires were excluded from the analysis due to omissions of items or percentage of choosing the same option for questions >80%. Finally, 1160 questionnaires were included in the analysis. Among the 1160 respondents, 547 were women and 613 were men. A total of 84.7% of the participants were aged less than 40 years (median age: 33.1 (IQR 28.8–38.1)), and 53.3% had a master’s degree or higher. There were 292 paediatricians/psychiatrists/psychologists, and 868 were from other specialties, which meant subclinical specialties except ‘paediatrics/psychology/psychiatry’, such as surgery, internal medicine, gynaecology and obstetrics, etc (table 1). A total of 740 physicians were from tertiary hospitals. Approximately 40% of the respondents had been practising for less than 5 years.
Demographics of the respondents and the scores of knowledge and beliefs about ASD among respondents
The average score of all the participants was 8.48±2.66 (total of 18 points) for the questionnaire on the main symptoms of ASD and 14.35±3.69 (total of 24 points) for some beliefs about ASD. Only 20.1% of the participants knew the main symptoms of ASD. Participants with longer practice duration and who specialised in paediatrics/psychology were more likely to know the diagnostic symptoms of ASD and have correct beliefs about ASD (table 1).
For the ASD belief part, 67.3% of the participants considered that ASD was not a lifelong disorder. A total of 49.2% considered that measles, mumps, rubella vaccination increased the risk of ASD, and 57.4% considered that heavy metal poisoning was a major cause of autism. With respect to ASD treatment, 24.9% did not know children with ASD required intervention; 10.6% considered that ASD could be treated with antipsychotics, 12.9% considered that ASD could be treated with antidepressive drugs and 11.03% considered that ASD could be treated with traditional Chinese medicine or acupuncture. It should be noted that 6.2% of the participants considered monotherapy with vitamins and micronutrients to cure core symptoms of ASD, and 66.5% considered vitamins and micronutrients to improve core symptoms of ASD.
Regarding knowledge about the referral of patients with ASD, 85.3% of the participants knew which institution or department should be referred to for diagnosis. A total of 75.5% did not know the local intervention institutions for ASD training. A significant difference was found between the paediatricians/psychologists/psychiatrists and those with other specialties in most of the beliefs (table 2). A total of 95.3% of the participants thought knowledge and training regarding ASD were lacking among professionals in China.
Detailed percentage of correct answers in response to questions on beliefs about ASD
Physicians’ age, sex, specialty and practice years were related to their knowledge of identifying patients with ASD. Physicians with an age ranging from 20 to 30 years, who were male, who had other specialties or short practice years had less knowledge of the core symptoms of ASD (table 1). Female physicians scored higher than their male counterpart both in response to diagnostic questions (8.75±2.67 vs 8.23±2.61, p<0.001) and beliefs about ASD (14.82±3.39 vs 13.94±3.90, p<0.001). Physicians specialising in paediatrics/psychology/psychiatry scored higher than those specialising in other specialties both in response to diagnostic questions (8.98±2.63 vs 8.30±2.65, p<0.001) and beliefs about ASD (15.57±3.44 vs 13.97±3.97, p<0.001) (table 1). Moreover, as for the association between the correct responses to diagnostic questions and related variables evaluated in the present study, multivariate linear regression analysis showed independent correlations of variables of female gender and paediatrics, psychiatry and psychology specialties with more abilities to identify patients with ASD (β=0.486, p=0.002; β=0.537, p=0.003, respectively; table 3).
Correlation between scores in response to diagnostic questions and age, gender, academic degree, practice years and specialties (multivariate linear regression analysis)
Discussion
This study revealed that knowledge and beliefs about ASD symptoms, diagnosis and treatment are insufficient among physicians in China. A considerable number of physicians in China had incorrect beliefs about ASD diagnosis and management. Most physicians knew little about local ASD intervention centres and could not provide optimal recommendations about referrals and interventions for patients with ASD. The results are similar to the findings from other developing countries.25 27 Çitil et al suggested that insufficient knowledge and beliefs about ASD among paediatricians could result in diagnostic and interventional delays in Turkey.28 Mukhamedshina et al found that primary care paediatricians had difficulties in early identification of ASD and had limited ability to provide ASD knowledge in general in Russia.17
Our study revealed that a very low percentage of participants correctly knew the main symptoms of ASD. Another study in China in child healthcare also revealed that few participants knew that the main symptoms of ASD include language disorder (38.4%) and social dysfunction (29.6%).29 In a survey from Iran, Effatpanah et al revealed that healthcare workers and paediatricians had misconceptions about ASD regarding developmental, cognitive and emotional features.30
Our survey revealed that most participating physicians had incorrect beliefs about ASD management. Nearly 80% of the participants did not know that ASD needs early intervention. Approximately 70% of the participants incorrectly believed that vitamins or micronutrients could cure or improve ASD core symptoms. The results were similar to Ma et al’s finding that many child healthcare providers in China had incorrect beliefs about ASD. Ma et al found that 80% of the participants considered that there are effective drugs to treat ASD, and 94% considered that ASD is curable.29 The results revealed that medical professionals in China not only lacked sufficient knowledge about ASD but also lacked general training regarding ASD diagnosis and treatment. Fortunately, almost all participants thought that professionals in China lacked special knowledge and training regarding ASD. China has a high variability in healthcare access among different areas. General practitioners in local community hospitals are the main population who may first contact a large portion of children with ASD. Training and education among general practitioners in local hospitals will increase the overall identification rate and improve treatment for patients with ASD. Ahlers et al found that the involvement of available clinicians with additional training in autism screening resulted in improvements in time to diagnosis and reduced charges for families.31
Our study revealed that physicians’ sex, specialty and hospital level might be associated with their beliefs about ASD management. Female physicians and physicians specialising in paediatrics and psychology were more likely to have correct beliefs about the management of ASD. Age and institution level were not related to the knowledge about ASD. The years in practice influence the capability of identifying ASD symptoms. Female physicians had more knowledge of ASD diagnosis and were more likely to have correct beliefs about ASD management. The reason may be that women have taken more responsibilities in parenting,32 so female physicians may have more knowledge of milestones or red flags of development in children.
Therefore, training and education should be targeted at physicians of all specialties, especially male physicians who have short years in practice. Physicians in all specialties who assess child development around China will be the crucial population for formal and direct training on ASD.
However, this study had some limitations. First, our cross-sectional study could not determine whether improving professionals’ knowledge and beliefs about ASD could improve the diagnosis outcomes, which can be investigated in a longitudinal cohort later. Second, the present survey recruited voluntary participants, which was likely to produce a bias of sampling. This might make generalisation of the results difficult due to the voluntary nature. Third, our sample size was also limited, which might result in bias and could not power the conclusion. Moreover, the results of the study might not be representative of others’ views. However, the results from this study can provide important data on knowledge and beliefs about ASD among physicians in mainland China.
Conclusion
The present study indicated that knowledge and beliefs about ASD symptoms, diagnosis and treatment are insufficient among physicians in China. Physicians from all specialties should be targeted for education and training programmes on this topic, especially for male physicians who have short years in practice.
Supplemental material
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Ethical Committee of Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine (ZN-2015-055). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We are grateful to the National Natural Science Foundation of China (no. 81973060) and Medical Health Science and Technology Project of Health Commission of Zhejiang Province (no. 2019RC239) for funding this study. We thank all participants involved in this study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors SM, XF, YM and YC were major contributors to analysing the data and writing parts of the results and discussion. SM and JL were responsible for recruiting participants, collecting questionnaires, sorting out data and writing methods. SM and RY participated in the design of this study and the specific questionnaire, and they wrote the introduction. RY was the corresponding author and responsible for the overall contents as the guarantor, who led the work, designed this study and modified the article. All authors have read the manuscript and have agreed to submit it in its current form for consideration for publication in the journal.
Funding This study was supported by the National Natural Science Foundation of China (no. 81973060) and Medical Health Science and Technology Project of Health Commission of Zhejiang Province (no. 2019RC239).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.