A Cross-Cultural Comparison of Knowledge and Stigma Associated with Autism Spectrum Disorder Among College Students in Lebanon and the United States

Abstract

Although misconceptions associated with ASD are apparent worldwide, they may differ across cultures. This study compares knowledge and stigma associated with ASD in a country with limited autism resources, Lebanon, and a country with substantial autism resources, the United States (US). College students in the US (N=346) and Lebanon (N=329) completed assessments of knowledge and stigma associated with ASD before and after an online ASD training. Although students in the US exhibited higher overall knowledge and lower stigma towards ASD, certain misconceptions were more apparent in the US than in Lebanon. Participation in the training was associated with decreased stigma and increased knowledge in both countries. Thus, online training may be useful for increasing understanding about ASD internationally.

Full text

ORIGINAL PAPER
A Cross-Cultural Comparison of Knowledge and Stigma
Associated with Autism Spectrum Disorder Among College
Students in Lebanon and the United States
Rita Obeid
1
•
Nidal Daou
2
•
Danielle DeNigris
1
•
Christina Shane-Simpson
1
•
Patricia J. Brooks
1
•
Kristen Gillespie-Lynch
1
 Springer Science+Business Media New York 2015
Abstract Although misconceptions associated with ASD
are apparent worldwide, they may differ across cultures.
This study compares knowledge and stigma associated with
ASD in a country with limited autism resources, Lebanon,
and a country with substantial autism resources, the United
States (US). College students in the US (N = 346 ) and
Lebanon (N = 329) completed assessments of knowledge
and stigma associated with ASD before and after an online
ASD training. Although students in the US exhibited
higher overall knowledge and lower stigma towards ASD,
certain misconceptions were more apparent in the US than
in Lebanon. Participation in the training was associated
with decreased stigma and increased knowledge in both
countries. Thus, online training may be useful for
increasing understanding about ASD internationally.
Keywords Stigma  Knowledge  ASD  Online training 
Cross-cultural  Lebanon
Introduction
Autism Spectrum Disorder (ASD) may be increasing in
prevalence internationally (Elsabbagh et al. 2012; but see
Baxter et al. 2014 for evidence that prevalence is not
increasing). Although the prevalence of ASD has not been
systematically assessed in many regions of the world (such
as low-income countries), similar prevalence rates have
been observed wherever prevalence has been assessed. In
contrast, services to support those with ASD and to educate
the public about ASD are far from equally distributed
around the globe (Grinker et al. 2011) or across the lifespan
(Johnson and Levine 2014). Cross-cultural research is
needed to develop autism services that are culturally
appropriate for regions where these service s remai n scarce
(Daley 2002). The current study exam ines attitudes about
ASD in Lebanon, a country with limited supports for
people with ASD (Daou 2014), and the US, a country with
substantial, but unequally distributed, supports for people
with ASD (Mandell et al. 2009). We examine predictors of
knowledge about ASD and stigma towards people with
ASD in each country, and compare baseline knowledge and
stigma associated with ASD across countries.
Misconceptions About ASD: A Global Phenomenon
Prior research has demonstrated that misconceptions and
stigma associated with ASD are apparent worldwide.
Although the current study may be the first to compare
knowledge and stigma associated with ASD across coun-
tries, incomplete and/or inaccurate knowledge about ASD
has been documented among many types of people inter-
nationally, including college students in Great Britain
(Shah 2001), Nigeria (Igwe et al. 2010), and the US (Tipton
and Blacher 2014). Commonly reported misconceptions
Electronic supplementary material The online version of this
article (doi:10.1007/s10803-015-2499-1) contains supplementary
material, which is available to authorized users.
& Rita Obeid
rita.obeid6@gmail.com; robeid@gradcenter.cuny.edu
1
Department of Psychology, The Graduate Center and College
of Staten Island, CUNY, New York, NY, USA
2
Department of Psychology, American University of Beirut,
Beirut, Lebanon
123
J Autism Dev Disord
DOI 10.1007/s10803-015-2499-1

include underestimating the prevalence of ASD (Dillen-
burger et al. 2013), lack of knowledge about core diag-
nostic characteristics (Bakare et al. 2009; Gillespie-Lynch
et al. 2015; Heidgerken et al. 2005; Helps et al. 1999 ;
Kharti et al. 2011), misconceptions about etiology
(Alqahtani 2012), and insufficient knowledge about how to
support thos e on the spectrum (Chown 2010; Imran et al.
2011). Researchers have often found that women and those
who have had more contact with people with ASD are
more knowledgeable about autism (Dillenburger et al.
2013; Koyama et al. 2008; Wang et al. 2012).
Cross-cultural variations in knowledge about ASD may
influence how it is interpreted (including whether or not it
is identified), expressed, and supported (Daley 2002;
Matson et al. 2011; Ravindran and Myers 2012). For
example, the misconception that genetic contributions to
ASD are necessarily heritable from either parent, rather
than sometimes arising from de novo mutations in the
child, may contribute to heightened stigma towards ASD
and reduced identification of ASD in predominantly col-
lectivistic cultures where familial reputation is highly
valued (e.g., Grinker and Cho 2013).
Stigma Towards People with ASD
Stigma is a multifaceted construct defined by Goffman
(1963) as deeply discrediting attributes that do not fit the
normative expectations of society and thus result in a
spoiled social iden tity for individuals or groups who pos-
sess the attributes. Stereotypes towards those who possess
these attributes often result in negative outcomes including,
but not limited to, poor self-esteem and diffi culties with
employment (Corriga n et al. 2003; Link et al. 2001).
Individuals with ASD may frequently encounter higher
levels of social exclusion (Campbell and Barger 2014) and
bullying (Fleischer 2012; Gelbar et al. 2014). Perceived or
experienced stigma towards ASD has been reported by
people on the spectrum in the US (Shtayermman 2009) and
Britain (Humphrey and Lewis 2008), as well as by parents
of people on the spectrum internationally (e.g., Dehnavi
et al. 2011; Gray 2002).
The absence of visible markers of ASD may contribute
to stigma, as unknowledgeable others may perceive a
person with ASD, who looks ‘‘normal,’’ to be acting vol-
untarily in ways that violate social norms (Gray 2002).
Prior studies have found that greater knowledge about ASD
is associated with lower stigma (Ling et al. 2010; Mahoney
2008; but see Butler and Gillis 2011 for evidence that ASD
knowledge is not always associated with stigma). Increased
knowledge may be related to lower endorsements of dis-
criminatory attitudes toward a range of diagnostic cate-
gories (e.g., Corrigan and Penn 1999; Holmes et al. 1999).
Consequently, by increasing knowledge of ASD, it may be
possible to decrease stigma associated with it. However,
much of the information people receive about ASD is from
the media, which may offer stereotypical images of ASD
(Draaisma 2009; Huws and Jones 2011). Therefore, it is
critical to address misunderstandings and stigma sur-
rounding ASD, particularly in countries where ASD ser-
vices are scarce. A further aim of the current study is to
evaluate the potential of online training to improve
understanding about ASD in countries with less (i.e.
Lebanon) and more (i.e. the US) ASD services.
Conceptions of ASD in Lebanon and Other Arab
Countries
ASD in Arab countries such as Lebanon has received rel-
atively little attention from the research community. A
recent review of autism research in Arab countries revealed
a total of 75 articles published between 1992 and 2012
(Hussein and Taha 2013). In contrast, the US produced the
majority of all autism research articles published interna-
tionally between 1980 and 2010, including 1040 autism
publications in 2010 alone (OARC 2012).
The few prevalence studies that have been conducted in
Arab countries have yielded lower ASD prevalence rates
(e.g. 29 per 10,000; Eapen et al. 2007 and 1.4 per 10,000;
Al-Farsi et al. 2011) relative to the global average of 62 per
10,000 reported by Elsabbagh et al. (2012). Many cases of
ASD may go unidentified in Arab countries due to insuf-
ficient understanding of ASD among the public and a lack
of trained professionals (Al-Farsi et al. 2011; Imran et al.
2011; Taha and Hussein 2014). Indeed, in a general pop-
ulation sample from the United Arab Emirates, Eapen et al.
(2007) found that none of the preschoolers that they
identified as having autism had been identified as autistic
prior to their study.
Government-based, ASD-s pecific educational services
are infrequently available in Arab countries and when
available, they are often of low quality (Daou 2014; Hus-
sein and Taha 2013). In addition, services for adults with
ASD are particularly scarce and are often prohibi tively
expensive. Consequently, people on the spectrum may
receive insufficient support services and face heightened
experiences of ostracism in general education settings
(Taha and Hussein 2014). This lack of formal support
likely contributes to reliance on informal supports among
families of people with ASD in Arab countries. When
asked to describe their support resources, mothers of chil-
dren with ASD in Turkey (one of the non-Arab countries in
the Middle East, with strong historical ties to the Arab
countries in the region) identified informal social supports,
but not formal supports (Bilgin and Kucuk 2010). Mothers
also reported stress due to financial burdens, perceived
stigmatization associated with ASD, and their own lack of
J Autism Dev Disord
123

knowledge about the etiolog y and treatment of ASD. A
qualitative analysis of the beliefs held by Saudi Arabian
parents of children with ASD revealed significant mis-
conceptions about ASD. For example, parents tended to
rely on cultural interventions involving religious healers
(Alqahtani 2012), or attributed ASD to vaccines or the
‘‘evil eye’’, which ascribes one’s misfortunes to ‘‘envy in
the eye of the beholder’’ (Spooner 1970, p. 312). This
paucity of ASD knowled ge and supports suggests a need
for studies that examin e knowled ge and stigma associated
with ASD in Arab countries.
Knowledge of ASD in Lebanon
Lebanon is a small (10,452 square km) multilingual and
multicultural country in the Middle East. In comparison to
the more individualistic value orientation common in the
US (wherein independence and personal goals are valued
over interdependence and obligations to others), Lebanon
is a predominantly collectivistic country wherein interde-
pendence and group norms are valued (Matsumoto et al.
2008). Although the dimension of individualism versus
collectivism is often used to examine cross-cultural dif-
ferences in value orientations, it is one of a number of
shifting dimensions that may differ across cultures. Vari-
ation in individualism and collectivism is apparent within,
as well as between, countries and may be assoc iated with
evolving socioeconomic factors (Greenfield 2009). Indeed,
a blend of individualistic and collectivistic attitudes has
been observed in Lebanon (Ayyash-Abdo 2001; Mat-
sumoto et al. 2008) and the US (Greenfield 2009). Overall,
Lebanon appears to be less collectivistic than primarily
collectivistic countries, such as South Korea or China, and
more collectivistic than primarily individualistic countries,
such as the US and Australia (Matsumoto et al. 2008). It
may be most similar to countries, such as Japan and India
that are slightly more collectivistic than individualistic.
Consistent with evidence that individualistic values are
more evident in regions with more economic resources
(Basabe and Ros 2005), the GDP of Lebanon in 2013 was
$9928 while the GDP in the US was $53,1 43 (retrieved
from http://dat a.worldbank.org/indicator/NY.GDP.PCAP.
CD). Given that government-supported services for indi-
viduals with ASD and other developmental disabilities are
rarely available in middle to low-income regions (Divan
et al. 2012; Grinker et al. 2011; Mirza et al. 2009), it is no t
surprising that ASD-related services are scarce in Lebanon
(reviewed in Daou 2014). Indeed, staff in ASD-specific
schools in Lebanon often lack the training needed to pro-
vide evidence-based interventions.
Insufficient support services for individuals with ASD in
Lebanon may contribute to a lack of understanding and
stigma associa ted with ASD. Obeid and Daou (2015) found
that mothers of children with ASD reported decreased
well-being relative to mothers of typically developing
children. The authors suggested that simply having a large
social support networ k is insufficient to improve the well-
being of mothers in the absence of ASD-specific formal
supports. Azar and Badr (2006) attributed the high levels of
stress and depression observed among mothers of children
with intellectual disabilities in Lebanon to stigma associ-
ated with disability and to financial burdens associated with
caring for their children. Indeed, surveys examining atti-
tudes towards people with disabilities among community
members in Jordan and college students in Lebanon
revealed negative attitudes towards people with disabilities
(Nagata 2008). Participants from Jordan who had a dis-
abled family member or who had watched a disability
awareness program on TV endorsed more positive attitudes
than their counterparts. Similar benefits of prior exposure
to those with disabilities were observed among students
from Lebanon, but were not statistically sign ificant. How-
ever, comparisons across countries were not possible in this
research given the use of different sampling methods and
surveys in each country. The current study differs from
most prior research examining conceptions of ASD inter-
nationally in that the same recruitment methods and sur-
veys were used in both Lebanon and the US [see Probst
(1998) for an international comparison using similar
methods across countries].
Conceptions of ASD in the US
In stark contrast to the scarcity of autism services and
research in Lebanon, the US leads the world in production
of autism research (OARC 2012). A number of well-fun-
ded and powerful autism organizations, such as Autism
Speaks, spearhead ASD awareness campaigns in the US. In
addition, the government is required to provide appropriate
services to all school children with disabilities under the
Individuals with Disabilities Education Act (IDEA). Nev-
ertheless, striking disparities in access to support and
identification of ASD are apparent in the US with fewer
resources available to individuals of lower socioeconomic
status and a paucity of supports for adults with ASD, who
are no longer eligible for services under the IDEA (Durkin
et al. 2010; Johnson and Levine 2014). In addition to the
relative absence of services for adults with ASD, awareness
campaigns often focus on young children with ASD and
thus may contribute to the misconception that ASD is a
childhood disorder (Sarrett 2011).
Despite relatively plentiful ASD resources in the US
compared to developing countries such as Lebanon, mis-
conceptions and stigma continue to exist in the US. Campbell
and colleagues conducted a series of studies examin ing ASD
knowledge and stigma among schoolchildren in the US
J Autism Dev Disord
123

(Campbell and Barger 2014). The children exhibited more
negative attitudes and behavioral intentions (or reduced
desire to interact) toward children with ASD relative to
neurotypical children. Girls reported less stigmatizing atti-
tudes toward peers with ASD than boys, although gender
differences in stigma were not consistently observed. Qual-
itative coding of middle school students’ open- ended defi-
nitions of autism revealed that the majority (71.3 %)
provided ‘‘accurate definitions’’ (Campbell et al. 2011).
However, few ‘‘accurate’’ responses identified core diffi-
culties associated with autism. In addition, some responses
that the authors classified as ‘‘accurate’’ may instead be
evidence of confusing autism with other diso rders, such as
‘‘when a person or child cannot comprehend or think cor-
rectly…’’ (p. 384).
Misconceptions about autism have also been observed
among adults in the US. A large-scale survey of residents
of Utah revealed misconceptions about autism etiology,
diagnosis and treatment (Holt and Christensen 2013).
Similarly, health care providers erroneously indicated that
autistic people do not show attachme nts and that autism
occurs more frequently among people of higher socioeco-
nomic status (Heidgerken et al. 2005). Although ASD is
diagnosed more frequently among people of higher
socioeconomic status in the US, this is likely largely
attributable to greater acce ss to health care among the
wealthy in the US (Durkin et al. 2010).
A series of recent studies have assessed knowledge and
stigma associated with ASD among college students in the
US. This emerging line of research reflects recognition that
increasing numbers of individuals on the spectrum may be
entering college (Gelbar et al. 2014; Van Bergeijk, Klin
and Volkmar 2008). White et al. (2011) suggested that
between .7 and 1.9 % of college students in the US might
have ASD. Howeve r, very few ASD-specific services are
available on college campuses (Barnhill 2014), which may
contribute to lack of understanding towards college stu-
dents on the spectrum (Gelbar et al. 2014). Fleischer (2012)
noted that college students on the spectrum often become
targets of stigma and bullying. Among college students,
heightened acceptance of individuals with ASD is associ-
ated with grea ter knowledge of ASD and more encounters
with individuals with ASD (Mahoney 2008).
In the first peer-re viewed study to assess conceptions of
autism among college students in the US, 685 students read
a vignette descr ibing a college student with characteristics
(but not the label) of mild autism and then completed a
self-report measure of openness towards the individual in
the vignette (Nevill and White 2011). Students with a first-
degree relative on the spectrum reported more openness
than their counterparts, with no overall gender differences
in openness. This finding is surprising given that females
often (e.g. Campbell and Barger 2014; Chambres et al.
2008), but not always (e.g. Swaim and Morgan 2001),
exhibit more accepting attitudes toward their peers with
autism than males. No overall differences in openness were
observed b etween students with high or low autistic
symptoms, as assessed by the Autism Spectrum Quotient
(AQ; Baron-Cohen et al. 2001).
Tipton and Blacher (2014) used an anonymous online
version of the Autism Awareness Survey to examine
knowledge associated with ASD among 1057 members of a
college com munity. They found that college communities
are knowledgeable about some aspects of autism; the
average score on the survey was indicative of more correct
than incorrect responses. However, misconceptions (such
as that autism is caused by vaccines) remained common.
Women and participants with autism in the immediate
family had slight ly higher knowledge than others.
Gardiner and Iar occi (2014) used a survey and assoc i-
ated vigne tte to examine associations between autism
knowledge and openness towards people with ASD among
202 college students. While statistical analyses concerning
autism knowledge were not reported, the authors stated that
participants were generally quite knowledgeable about
ASD. The quantity of previous contact with people with
ASD (but not gender, autism traits, or autism knowledge)
was associated with openness to ASD. Women, partici-
pants with social science and arts majors, and those who
were more open to ASD were more willing to volunteer
with people with ASD. Findings suggested that college
students may be accepting of people on the spectrum in
terms of distant relationships, such as living in the same
building, but that far fewer college students may be inter-
ested in engaging more directly with people on the spec-
trum, by hanging out or volunteering with them.
Given that stigma is often assessed using social distance
scales wherein participants are asked how willing they are
to engage with a type of person at varying levels of inti-
macy (Bogardus 1933), these findings suggest that college
students may hold stigmatizing attitudes toward peers with
ASD. Indeed, when college students were given a social
distance scale after reading a vignette about an adult (albeit
not a college student), their responses suggested that they
held stigmatizing attitudes toward characteristics associ-
ated with ASD (Butler and Gillis 2011). Students endorsed
greater social distance towards the character in the vignette
when he exhibited autism symptoms.
These findings suggest that trainings to increase
knowledge and decrease stigma associated with ASD
among college students are needed. To address this need,
Gillespie-Lynch et al. (2015) used a pre-test post-test
design to evaluate an online ASD training. Mirroring
Tipton and Blacher’s (2014) findings, 365 US college
students indicated more correct than incorrect answers on
the Autism Awareness Survey at pre-test. However, their
J Autism Dev Disord
123

open-ended definitions of ASD often included miscon-
ceptions. Women endorsed lower stigma relative to men.
Participation in the training was associated with decreased
stigma and increased knowledge of ASD. The current study
builds on this study by examining knowledge and stigma
associated with ASD in two cultural groups and by testing
the effectiveness of the ASD training in a non-Western
context.
Aims and Hypotheses of the Current Study
The aims of the current study were: (1) to examine pre-
dictors of ASD knowledge and stigma among college stu-
dents in the US and Lebanon, (2) to compare knowledge and
stigma associated with ASD among students in the US and
Lebanon, and (3) to evaluate the cross-cultural effectiveness
of an online training about ASD, which has the potential to
be an accessible and low-cost method of increasing
knowledge and reduc ing stigma associated with ASD.
Hypotheses for aim 1 We expected women and nuclear
family membe rs of people with ASD to exhibit more
knowledge about, and lesser stigma towards, ASD in both
countries (e.g., Campbell and Barger 2014; Chambres et al.
2008; Dillenburger et al. 2013; Gillespie-Lynch et al. 2015;
Koyama et al. 2008; Tipton and Blacher 2014; Wang et al.
2012). Due to mixed findings in the literature (e.g., Gar-
diner and Iarocci (2014); Matthews et al. 20 14; Nevill and
White 2011), we had no hypotheses about potential asso-
ciations between autistic traits and conceptions of ASD.
Hypotheses for aim 2 Given the scarcity of ASD services
in Lebanon (Daou 2014; Hussein and Taha 2013) and
higher stigma associated with the use of mental health
services amo ng individuals in the Middle East (Abdullah
and Brown 2011 ), we expected knowledge about ASD to be
lower and stigma associated with ASD to be higher prior to
training among Lebanese students relative to US students.
We expected Lebanese students to more often endorse
outdated views about ASD, including attributing ASD to
vaccines or negative parenting. Because members of indi-
vidualistic societies may be more tolerant of idiosyncratic
behavior than members of collectivist societies (Hwang and
Charnley. 2010; Jegatheesan et al. 2010), we expected
Lebanese students to more strongly endorse the view that it
is important to help people with ASD appear normal. We
expected Lebanese students to focus more on the social
aspects of ASD in their open-ended definitions of ASD than
US students as social aspects of autism may be more salient
in more collectivistic countries where adaptation to pre-
scribed social roles is favored (Grinker and Cho 2013).
Hypotheses for aim 3 We expected to replicate our prior
research documenting increases in knowledge and decr eases
in stigma following participation in the online ASD training
in a different sample of college students in the US (Gillespie-
Lynch et al. 2015) among the current sample of college
students in the US and in Lebanon.
Method
Participants
Students in the US were recruited from a large urban public
university. An advertisement was posted on a Psychology
Department subject pool website inviting students to enroll
in the study to satisfy research participation requirements
for Introduction to Psychology courses or to earn extra
credit in other psychology courses. Lebanese undergradu-
ates were recruited from a private universit y where English
is the language of instruction; participation was offered as
one of several extra credit options for students registered in
Introduction to Psychology courses. Introduction to Psy-
chology courses fulfill a general education requirement at
both universities and attract stud ents from a diverse range
of majors. Fewer than 15 % of all participants were
declared psychology majors. At both universities, the IRBs
required participants to be 18 years of age or older. All
data collected were anonymous. At recruitment, partici-
pants were given a link to access the survey on Sur-
veyMonkey, where they first provided informed consent.
A total of 948 undergraduates participated in the online
training (US: N = 561, 61.1 % female, M = 20.3 years,
SD = 4.1; Lebanon: N = 387, 63.5 % female, M =
18.8 years, SD = 2.3). However, there were significant dif-
ferences in age between these samples, p \ .001. It was not
possible to correct for this age difference analytically due to
the high level of skew observed in the age variable. Therefore,
the countries were matched on age (p = .41) by truncating
both samples to include only participants who were 18 or
19 years of age. The final age-matched sample that is
described in the rest of this report consisted of 675 under-
graduates (US: N = 346, 60.1 % female, M = 18.4 years,
SD = .50; Lebanon: N = 329, 65.4 % female, M =
18.4 years, SD = .49; see Table 1 for participant character-
istics). It is important to note that the pattern of significance
was largely unchanged by truncating the samples to match
them on age. Any changes in the significance of the results that
were obtained with the age-matched sample when compared
to the original sample are indicated with footnotes.
Measures and Design
The study employed a quasi-experimental research design.
Participants completed a demographics questionnaire fol-
lowed by a set of questions examining knowledge and
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123

attitudes about ASD, an adapted version of the Social
Distance Scale (Bogardus 1933), and an adapted version of
the Autism Awareness Survey (Stone 1987). Participants
then completed an online PowerPoint training about ASD
(Gillespie-Lynch et al. 2015), followed by a set of ques-
tions and surveys identical to the pre-te st. At the end of the
study, participants completed the Broad Autism Phenotype
Questionnaire (Hurley et al. 2007). Participation in the
study lasted approximately 1 h.
Demographics Questionnaire
The demographics questionnaire asked participants to
report their age, gender, education level, major, and per-
sonal experiences with ASD, which was assessed with the
following question. ‘‘Please select as many of the following
types of relationships as you have had with people with
autism spectrum disorders: yourself, your child, your par-
ent, your sibling, your spouse, your extended family
member, your friend, your coworke r, your student, your
fellow student, your acquaintance, or other.’’
Conceptions of ASD
Participants were asked a series of researcher-developed
open-ended and closed-ended questions examining their
knowledge and attitudes toward ASD (see Appendix A).
Open-ended responses to the question ‘‘What are autism
spectrum disorders in your own words?’’ were coded into
non-mutually exclusive categories by noting whether
participants accurately identified symptoms associated with
the DSM-5 criteria for ASD (American Psychiatric Asso-
ciation APA 2013); additional response categories were
adapted from previously developed coding schemes (e.g.
Campbell et al. 2011; Gillespie-Lynch et al. 2015).
Appendix B provides the coding scheme with examples.
The first and third authors independently coded 20 % of the
pre-test and post-test data in the US and Lebanese samples.
Agreement on all codi ng categories was 91 % or higher
(range 91–100 %).
Autism Awareness Survey
To examine knowledge associated with ASD, we adapted
the Autism Awareness Survey (Heidgerken et al. 2005;
Stone 1987) with 10 items from the original scale and three
new items (Gillespie-Lynch et al. 2015, see Appendix C).
Items were scored on a 5-point Likert-type scale, ranging
from -2to?2, with higher scores indicating more
knowledge. Scores were summed to create a total knowl-
edge score that could range from -26 to 26. This version
of the Autism Awareness Survey showed moderate internal
consistency a = .62 (US: a = .59; Lebanon: a = .61).
Social Distance Scale
To examine stigma towards ASD, we used an adapted
version of the Social Distance Scale (Bogardus 1933;
Gillespie-Lynch et al. 2015) consisting of a series of
questions about participants’ willingness to engage with
Table 1 Participant
characteristics of age-matched
samples from the US and
Lebanon
US (N = 346) Lebanon (N = 329) p value
Age 18.4 (.50) 18.4 (.49) .41
Average BAPQ scores 2.76 (.03) 2.72 (.04) .48
% Male 39.9 % 34.6 % .18
Age of exposure to English
0–2 Years 73.3 % 26.2 % \.001
3–7 Years 26.2 % 54.3 %
8 and above 4.6 % 19.5 %
ASD relationships
Self 2.0 % 1.2 % .56
Nuclear family 4.4 % 2.7 % .55
Extended family 27.9 % 15.5 % \.001
Friend 27.3 % 19.8 % .02
Acquaintance 36.3 % 30.4 % .12
Fellow student 22.1 % 9.7 % \.001
Co-worker 4.7 % 0.3 % \.001
My student 4.4 % 4.3 % 1.00
Continuous variables such as age and BABQ scores are reported as means (standard errors) while all other
variables are reported as percentages
BAPQ broad autism phenotype questionnaire
J Autism Dev Disord
123

people with autism at varying levels of intimacy ranging
from spending an evening with to marrying a person.
Responses were scored on a 4-point Likert-type scale with
1 being ‘‘definitely willing’’ and 4 being ‘‘definitely
unwilling.’’ Scores were summed to create a total stigma
score that ranged from 6 to 24, with higher scores per-
taining to higher stigma levels. The internal consistency of
the Socia l Distance Scale used in the current study was
a = .86 for the total sample (US: a = .87; Lebanon:
a = .81).
Broad Autism Phenotype Questionnaire
The Broad Autism Phenotype Questionnaire (BAPQ) is a
36-item self-report measure of characteristics associated
with the broader autism phenot ype, or subclinical charac-
teristics of autism (Hurley et al. 2007). The BAPQ mea-
sures autistic traits in three domains, aloofness (e.g., ‘‘I
prefer to be alone’’), rigidity (e.g., ‘‘I am flexible about how
things should be done’’), and pragmatic language (e.g., ‘‘I
have been told that I talk too much about certain topics’’).
Scores were averaged across items to create a total score,
with higher scores indicating that participants self-reported
heightened autistic traits. The internal consistency of the
BAPQ for the total sample was a = .88 (US: a = .87;
Lebanon: a = .90).
Autism Training
The ASD training consisted of a 75-slide PowerPoint sli-
deshow presented between the pre-test and post-test
(Gillespie-Lynch et al. 2015). Participants were able to
move through the slides at their own pace; periodically
they were required to answer a comprehensi on question to
progress to the next slide. Topics covered (in order) were:
(1) introduction to diagnostic manuals (the DSM and the
ICD), (2) explanation that there is only one ASD with
varying degrees of severity according to the DSM-5, (3)
outline of changes in the diagnostic criteria for ASD
between the DSM-IV and the DSM-5, (4) early signs of
ASD, (5) information about diagnostic assessments,
including that ASD can not currently be diagnosed with
blood tests or brain scans, (6) factors contributing to
increasing prevalence rates such as changes in diagnostic
criteria and awareness, (7) disparities in ASD diagnosis as
a function of gender, ethnicity and soci o-economic status,
(8) cultural factors influencing rates of diagnosis, (9) dif-
ficulties and strengths that are often observed in individuals
with ASD, (10) presence of autistic traits in the general
population, (11) heightened autistic traits among scientists
and other systematic thinkers, (12) the orthogonality of
intelligence and ASD, (13) possible causes of ASD, such as
interactions between multiple genetic (including de novo
mutations) and environmental factors, (14) common myths
about ASD, such as that negative parenting or vaccines
cause autism and that people with autism lack empathy,
(15) challenges faced by adults with ASD, (16) effective
ways to teach people with ASD, (17) introduction to neu-
rodiversity, or the view that autism is a valuable aspect of
human diversity that shoul d be respected rather than cured,
and (18) what the future may hold for peopl e with ASD,
including that they are attending college, entering the
workforce, and playing a role in research.
Analytic Plan
Descriptive analysis of the data indicated that a number of
variables exhibited excessive kurtosis and/or skew.
Researchers remain divided about the appropriateness of
commonly used parametric tests (such as ANOVAs) for
data that is not normally distributed and Likert scale data
more generally. Jamieson (2004) asserted that Likert scales
reflect an ordinal scale of measurement because one cannot
assume that the differences between rating options are
equidistant from one another. Norman (2010) replied that
parametric tests are highly robust and will generate accu-
rate conclusions even when used with highly skewed Likert
scale data. Norman argued that summed items on a Likert
scale (‘‘consisting of sums across many items,’’ p. 629) lie
on an interval scale. However, sums of small numbers of
items (like our stigma measure) and/or scales with fairly
low internal consistency (like our autism knowledge mea-
sure) are not consist ent with an interval scale of measure-
ment and remain on an ordinal scale (Wigley 2013). In
addition, while commonly used parametric tests may be
robust in terms of Type I errors, Type II errors may be
greatly increased when researchers use parametric tests
despite non-normality in their data (Fayers 2011).
Guided by the aforementione d methodological litera-
ture, we used non-parametric tests to analyze summed
scores on the Autism Awareness Survey and the Social
Distance Scale. Spearman’s correlations were conducted to
examine associations between variables, while Mann–
Whitney tests were used to compare dif ferences across
countries. Wilcoxon signed-ranks tests were used to
examine changes between pre-test and post-test on the
knowledge and stigma scales within each country. Para-
metric replications of key non-parametric analyses are
available in Appendix D to demonstrate that findings
remain consistent when gender is controlled for.
We used ordinal logistic regression, with country and
gender as predictors, to examine scores on individual items
of these scales. Binary variables were analyzed using
Binary Logistic Regression with country and gender as
predictors. Gender differences are only indicated when
significant. Data were analyzed using SPSS version 22.
J Autism Dev Disord
123

Due to the large number of statistical comparisons, a
Bonferroni correction was calculated and a conservative
p value of .001 was used.
Results
All participants completed the pre-test. Although comple-
tion rates at post-test were high, the percentage of US
students (91.3 %) completing the post-test was signifi-
cantly higher than the percentage of Lebanese students who
completed the post-test (80.5 %), v
2
= 16.36, p \ .001.
Demographic Characteristics
Table 1 provides comparisons of the demographic char-
acteristics of the age-matched samples with associated
p values. Compa red to Lebane se students, US students
more often reported having an extended family member, a
coworker, or a fellow student with ASD.
1
Participants in
Lebanon were first exposed to English later than partici-
pants in the US. No differences across countries in overall
BAPQ scores were observed. Average BAPQ scores in the
US (M = 2.76) and Lebanon (M = 2.72) were highly
similar to those reported for participants who did not have a
relative on the autism spectrum in the original BAPQ
publication (M = 2.74; Hurley et al. 2007).
Predictors of Baseline Knowledge and Stigma
Contrary to our hypothesis, men and women did not differ in
baseline knowledge on the Autism Awareness Survey in
either country (US: men: M = 7.10, SE = .55, women:
M = 7.30, SE = .40, Z =-.49 p = .62; Lebanon: men:
M = 4.42, SE = .54, women: M = 4.52, SE = .48;
Z =-.09 p = .92). However, women did endorse signifi-
cantly lower stigma in the US and marginally lower stigma in
Lebanon relative to men (US: men (M = 12.49, SE = .35),
women (M = 10.69, SE = .28), Z =-4.27 p \ .001,
r = .23; Lebanon: men (M = 13.57, SE = .32), women
(M = 12.54, SE = .25), Z =-2.38, p = .02,
r = .14.
Also contrary to our prediction, having a nuclear family
member with ASD was not associated with knowledge or
stigma in either country. Nor were significant associations
observed between having an extended family member on
the spectrum and stigma or knowledge (ps C .02). These
null results may be due to the small number of participants
in both countries who indicated that they had family
members with ASD.
We did not have specific hypotheses about associations
between autistic traits (BAPQ scores) and knowledge and
stigma due to inconsistencies in the literature. Among US
students, we observed a negative correlation between
autistic traits and knowledge, r
s
(312) =-.25, p \ .001,
and a positive correlation between autistic traits and
stigma, r
s
(312) = .23, p \ .001. Among Lebanese stu-
dents, autistic traits were unrelated to know ledge or stigma,
ps C .60. In the US sample, higher scores on the Autism
Awareness Survey were associated with lower scores on
the Social Distance Scale, r
s
(330) =-.23, p \ .001.
However, no association was found between knowledge
and stigma for Lebanese participants, p = .04.
Comparing Baseline Knowledge and Stigma
in Lebanon and the US
Conceptions of ASD
Ordinal logistic regressionswereusedtoexamineitem
responses.
2
In all ordinal and binary logistic regressions,
the reference categories for country and gender were
Lebanon and male, respectively. Lebanese and US stu-
dents did not differ in the perceived importance of finding
a cause, p = .70, or a cure for ASD, p = .39. Lebanese
students showed a trend toward being more likely to value
the importance of helping people with autism appear more
normal relative to students from the US (OR .62, CI
.45–.85, p = .003).
3
Consistent with our prediction, binary logistic regres-
sions revealed that Lebanese students were more likely to
indicate that ASD is caused by negative parenting (OR .18,
CI .09–.31, p \ .001) than US students. However, Leba-
nese stud ents were not more likely to indicate that vaccines
cause ASD, p = .82. Although we did not have hypotheses
about beliefs about other etiologies, it is important to note
that no differences were found between students in the US
and Lebanon in terms of inherited or de novo genetic
contributions to ASD or environm ental causes ps C .11.
Counter to our hypotheses, Lebanese students were more
likely to correctly indicate that ASD is diagnosed more
often in wealthier and more educated families living in
countries where richer people have better access to
1
In the full non-age-matched sample, US students more often
reported having a friend with ASD compared to Lebanese students,
p = .001.
2
All statistical analyses were tested for assumptions. The following
variables did not meet the proportional odds assumption of ordinal
regression: importance of helping people with autism appear more
normal, children with autism show attachment, and children with
autism can grow up to go to college and marry. However, this
assumption is violated fairly frequently (Long and Freese 2006) and
similar patterns of significance were observed with non-parametric
analyses.
3
This finding was also not significant (p = .04) in the larger sample
that was not age-matched.
J Autism Dev Disord
123

healthcare (OR .27, CI .18–.40, p \ .001). When asked
how many ASDs there are in the DSM-5, Lebanese stu-
dents were more likely than US students (OR .53, CI .36–
.78, p = .001) to correctly state that there is one ASD in
the DSM-5.
Binary logistic regressions examining qualitative coding
of students’ open-ended definitions of ASD revealed that
Lebanese students were more likely than US students to
correctly define ASD in terms of social and communication
deficits (see Table 2). However, Lebanese students were
also more likely to incorrectly define ASD in terms of a lack
of social interests and emotions. US students were more
likely than Lebanese students to confuse ASD with other
disorders, such as a learning disability or ADHD. It is
noteworthy that US students were 3.49 times more likely to
indicate that they don’t know what ASD is, or how to define
it in their own words, compared to Lebanese students.
Autism Awareness Survey Scores
Consistent with our hypothesis, US students (M = 7.22,
SE = .33) exhibited more knowledge about ASD on the
Autism Awareness Survey than Lebanese students at base-
line (M = 4.47, SE = .36; Z =-5.32, p \ .001, r = .21).
Table 3 reports ordinal regression analyses comparing
baseline scores between the US and Lebanese students on
each item of the Autism Awareness Survey. Lebanese stu-
dents more often viewed people with autism as deliberately
uncooperative relative to US students. They were more
likely to agree that people with autism are generally disin-
terested in making friends, and were less likely to agree that
people with autism show affection. While they were less
likely to endorse the statement that children with autism can
grow up to go to college and marry, they were more likely to
agree that with proper treatment, most children diagnosed
with autism eventually outgrow it.
4
Social Distance Scale Scores
Consistent with our hypothesis that stigma associated with
ASD would be higher in Lebanon, Lebanese students
(M = 12.94, SE = .20; Z =-5.46, p \ .001, r = .22)
endorsed higher rates of stigma than US students
(M = 11.41, SE = .23). Table 4 reports ordinal regression
analyses comparing baseline scores on each item of the
Social Distance Scale, with lower stigma evident in the US
relative to Lebanon for all items except ‘‘spend an evening
with someone with autism’’.
Women endorsed lower stigma than men on all items of
the Social Distance Scale, i.e., greater willingness to move
next door to someone with autism (OR .42, CI .43–.78,
p \ .001), spend an evening with someone with autism
(OR .54, CI .39–.74, p \ .001), collaborate with someone
with autism (OR .63, CI .47–.85, p = .002), befriend
Table 2 Binary logistic
regressions of baseline open-
ended definitions of ASD
Code Standardized odds ratio (95 % CI) p value
1. Social-communication difficulties .41 (.30–.57) \.001
2. Restricted interests/repetitive behaviors .49 (.21–1.13) .09
Sensory .44 (.04–4.93) .51
3. Disability or deficit 1.14 (.83–1.56) .41
Not normal .72 (.39–1.34) .30
Dependent 1.86 (.78–4.42) .16
4. Spectrum 1.27 (.74–2.18) .38
5. Developmental .56 (.32–.98) .04
6. Child specific 2.31 (.99–5.32) .05
7. Etiology .84 (.55–1.29) .42
Brain related .71 (.45–1.13) .15
8. Language difficulties 1.93 (.78–4.81) .16
9. Lack of social interest/emotion .15 (.07–.32) \.001
Anxious/quiet .29 (.06–1.45) .13
10. Self-regulation difficulties 1.38 (.23–8.32) .72
11. Systematic thinking 1.38 (.23–8.32) .27
12. Confusion with other disorders 2.21 (1.43–3.41) \.001
13. Cognitive difficulties 2.15 (1.20–3.83) .01
14. Don’t know 3. 49 (1.80–6.76) \.001
Lebanon is the reference category. Gender was included in all analyses
4
In the full-sample, Lebanese students were also less likely to agree
that ASD is a lifelong disability, p \ .001.
J Autism Dev Disord
123

someone with autism (OR .59, CI .44–.81, p = .001), have
someone with autism marry into one’s family (OR .58, CI
.43–.77, p \ .001), and marry someone with autism oneself
(OR .61, CI .45–.81, p = .001).
Change in Knowledge and Stigma
A Wilcoxon Signed Ranks Test was conducted to examine
whether knowledge increased following the ASD training
Table 3 Ordinal logistic regression analyses of baseline scores on Autism awareness survey items in the US and Lebanon
Strongly
disagree (%)
Somewhat
disagree (%)
Neither agree nor
disagree (%)
Somewhat
agree (%)
Strongly
agree (%)
Standardized odds
ratio (95 % CI)
p value
More frequent males
US 9.8 12.1 41.9 18.2 13.3 .85 (.64–1.13) .27
Lebanon 9.4 7.3 38.9 21.3 12.2
Can go to college/marry
US 2.6 3.5 13.0 21.7 54.6 2.81 (2.08–3.79) \.001
Lebanon 2.1 8.2 16.7 38.3 23.7
Can be diagnosed by 15 months
US 4.6 6.1 32.7 32.4 19.7 1.31 (.99–1.74) .06
Lebanon 8.5 10.9 22.5 32.2 14.9
Show affection
US 3.8 11.6 18.8 30.9 30.3 1.74 (1.31–2.32) \.001
Lebanon 4.6 15.2 20.7 34.3 14.3
Lifelong
US 6.6 12.7 31.2 27.2 17.6 1.39 (1.05–1.84) .02
Lebanon 8.5 17.3 27.4 23.1 12.8
Have empathy
US 5.2 8.1 47.4 23.1 11.6 .78 (.58–1.04) .93
Lebanon 3.3 11.2 32.2 30.4 11.9
Don’t show attachments
US 26.0 22.8 28.3 14.5 3.8 .75 (.56–.99) .05
Lebanon 20.1 26.1 13.4 20.7 8.8
Deliberatively uncooperative
US 29.2 25.1 25.1 13.3 2.6 .54 (.41–.71) \.001
Lebanon 17.6 23.4 18.2 22.5 7.3
One intervention for all
US 29.5 15.9 33.5 9.8 6.6 1.18 (.88–1.56) .27
Lebanon 24.3 23.7 31.3 7.3 2.4
Proper treatment outgrow
US 18.2 22.3 34.1 15.6 5.2 .47 (.35–.63) \.001
Lebanon 7.6 18.5 25.5 31.3 6.1
Most low IQ
US 46.5 21.4 21.1 5.5 0.9 .82 (.61–1.10) .18
Lebanon 40.1 21.6 16.4 8.2 2.7
Violent Tendencies
US 14.2 22.3 34.4 21.4 3.2 1.17 (.88–1.55) .28
Lebanon 15.5 24.6 24.9 21.3 2.7
Disinterested friends
US 18.8 22.3 28.6 19.7 6.1
Lebanon 7.6 15.5 17.0 32.2 16.7 .36 (.27–.48) \.001
Percentages indicate the proportion of respondents who endorsed each response. Modal responses for each item within each sample are in bold.
Lebanon is the reference category for odds ratios. Gender was included in all analyses. The names of items for which the correct response was
disagreement are bolded. Odds ratios and percentages reflect responses to these items prior to reverse scoring them to obtain the overall Autism
Awareness Survey score
J Autism Dev Disord
123

(see Appendix D for parametric analyses controlling for
gender). As predicted, Autism Awareness Survey scores
increased from pre-test to post-test for both US,
Z =-7.37, p \ .001, r = .29, and Lebanese students,
Z =-11.31, p \ .001, r = .48 (see Fig. 1). At post-test,
there were no significant differences in knowledge scores
between US (M = 9.88, SE = .38) and Lebanese stud ents
(M = 10.08, SE = .41; Z =-.62, p = .53).
Identical analyses were conducted to examine whether
participation in the training was associated with decreased
stigma across countries (see Appendix D for parametric
analyses controlling for gender). Stigma was significantly
lower at post-test relative to pre-test for both US, Z =-6.74,
p \ .001, r = .26, and Lebanese participants, Z =-7.80,
p \ .001, r = .33, as shown in Fig. 2.Atpost-test,stigma
remained lower among US students (M = 10.46, SE = .22)
Table 4 Ordinal logistic regression analyses of baseline scores on social distance scale items in the US and Lebanon
Willingness to engage with someone
with autism in the following ways
Definitely
willing (%)
Somewhat
willing (%)
Somewhat
unwilling (%)
Definitely uum
umnnwilling (%)
Standardized odds
ratio (95 % CI)
p value
Move next door
US 47.4 35.5 10.1 3.5 .61 (.46–.79) .001
Lebanon 31.3 45.0 12.5 2.1
Spend an evening
US 46.2 36.4 9.8 4.0 .94 (.70–1.26) .66
Lebanon 41.9 35.0 12.2 1.8%
Collaborate with
US 38.4 38.2 15.9 4.0 .58 (.44–.79) \.001
Lebanon 26.4 34.7 25.8 4.0
Befriend
US 55.2 30.6 6.9 3.8 .57 (.42–.77) \.001
Lebanon 38.9 36.5 11.9 3.6
Have marry into family
US 37.3 35.5 15.3 8.4 .28 (.20–.37) \.001
Lebanon 11.2 29.8 38.0 11.9
Marry/date oneself
US 13.6 28.3 33.5 21.1 .52 (.39–.70) \.001
Lebanon 7.0 15.8 41.0 27.1
Percentages indicate the proportion of respondents who endorsed each response. Modal responses for each item within each sample are in bold.
Lebanon is the reference category for odds ratios. Gender was included in all analyses
-26.00
-22.00
-18.00
-14.00
-10.00
-6.00
-2.00
2.00
6.00
10.00
14.00
18.00
22.00
26.00
Knowledge Summed Scores
Testing Session
United States
Lebanon
Pre-test Post-test
Fig. 1 Changes in knowledge with ASD training: pre-test and post-
test scores on the Autism awareness survey
6.00
8.00
10.00
12.00
14.00
16.00
18.00
20.00
22.00
24.00
Pre-test Post-test
Stigma Summed Scores
Testing Session
United States
Lebanon
Fig. 2 Changes in stigma with ASD training: pretest and posttest
scores on the Social distance scale
J Autism Dev Disord
123

compared to Lebanese students (M = 11.65, SE = .22;
Z =-4.47, p \ .001, r = .48).
Discussion
While the current findings generally supported our
hypotheses that knowledge about ASD would be higher
and stigma associated with ASD would be lower among
college students in the US relative to students in Lebanon,
some aspects of ASD were better understood in Lebanon
than in the US. In addition, variability in knowledge and
stigma was apparent in each country. Comparisons of
characteristics associated with knowledge and stigma in
each country provides insights into factors that may con-
tribute to within and between country variability in atti-
tudes towards ASD.
Predictors of Baseline Knowledge and Stigma
in the US and Lebanon
In contrast to previous research documenting greater ASD
knowledge among females (e.g. Dillenburger et al. 2013;
Koyama et al. 2008; Tipton and Blacher 2014; Wang et al.
2012), gender was not associated with ASD knowledg e at
baseline testing in either country. Recruitment of partici-
pants who were just beginning their college education may
have reduced opportunities for gender differences in edu-
cational and professional trajectories to influence ASD
knowledge in the current study. Our findings showed that
women endorsed lower stigma towards individuals with
ASD in both the US and Lebanon, although this effect was
only marginally significant in Lebanon. This finding was
consistent with previous research, which suggests that girls
and women often (e.g. Campbell 2007; Campbell and
Barger 2014 ; Chambres et al. 2008, Gillespie-Lynch et al.
2015) endorse less stigmatizing attitudes towards people
with ASD. These findings contrast with two prior studies
that did not reveal reduced stigma among female college
students. Butler and Gillis (2011) did not observe gender
differences in stigma towards ASD. However, their sample
was 80.4 % female. Matthews et al. ( 2014) reported that
male college students endorsed more positive affective and
behavioral attitudes towards characters with autistic traits
and labels in vignettes. However, men may have been more
accepting of the characters in the vignettes than women
because all of the characters had stereotypically male
names. Future research should examine the extent to which
lower stigma towards ASD among females is attributable
to potential gender differences in susceptibility to social
desirability or empathy (Eis enberg and Lennon 1983).
Based on research showing that those with a close family
member on the spectrum may be more knowledgeable about
ASD (Tipton and Blacher 2014) and have lower stigma
towards ASD (Gillespie-Lynch et al. 2015), we expected
nuclear family members of individuals with ASD to report
higher knowledge and lower stigma towards ASD in both
countries. However, no relationships between knowledge or
stigma and having a nuclear family member with ASD were
observed. These null effects may be due to the small number
of students who reported having a nuclear family member
with ASD (US: 4.4 %; Lebanon: 2.7 %). In contrast, a larger
number of individuals reported having an extended family
member with ASD (US: 27.9 %; Lebanon: 15.5 %). Nev-
ertheless, no relationship between having an extended
family member on the spectrum and knowledge or stigma
towards ASD was observed in either country. These null
effects may have arisen because some extended family
members may hold stigmatizing attitudes toward their rela-
tives on the spectrum (e.g. Gray 1993) while others may not.
Consistent with some prior research (Ling et al. 2010;
Mahoney 2008, but inconsistent with Butler and Gillis
2011), heightened autism knowledge was associated with
lower stigma in the US. However, no associations between
knowledge and stigma were observed in Lebanon. Simi-
larly, heightened autistic traits were associated with lower
knowledge and higher stigma towards ASD in the US,
while no associations between autistic traits and knowledge
or stigma were apparent in Lebanon. Associations between
autistic traits, knowledge and stigma in the US, but not in
Lebanon, suggest that cultural factors that were not
assessed in the current study may contribute to stigma
towards ASD. One cultural factor that could affect stigma
towards ASD in Lebanon is variability in collectivist value
orientations. Variation in collectivism and individualism
may be common in Lebanon (Ayyash-Abdo 2001) and
greater collectivism may be associated with heightened
stigma towards mental illness (Papadopoulos et al. 2013).
Comparing Baseline Knowledge and Stigma
in Lebanon and the US
As a result of the scarcity of ASD-related services (Daou
2014) and the stigma associated with using disability ser-
vices in Lebanon (Nagata 2008), we expected college
students in Lebanon to exhibit less knowledge and more
stigma towards ASD than college students in the US. In
line with this hypothesis, Lebanese students were found to
have lower levels of knowledge, as measured by the Aut-
ism Awareness Survey, than US students. Students in
Lebanon were more likely than students in the US to
endorse some common misconceptions, including that
individuals with ASD lack interest in social interaction and
are deliberately uncooperative. US students were more
likely than Lebanese students to correct ly agree that ASD
is a lifelong disorder and that individuals with ASD can
J Autism Dev Disord
123

grow up to attend college and get married. These findings
expand upon prior research documenting misconceptions
about ASD in the Middle East (Saudi Arabia: Alqahtani
2012) and developing countries (Nepal: Kharti et al. 2011;
Nigeria: Bakare et al. 2009; Pakistan: Imran et al. 2011)by
demonstrating that knowledge is lower in a country with
reduced access to ASD resources relative to a country with
greater access.
Despite the general pattern of cross-cultural disparities
in knowledge about ASD that the current study revealed,
specific misconceptions about ASD were more common in
the US relative to Lebanon. Consistent with reports that
appropriate care for those on the spectru m in Arab coun-
tries may often be prohibitively expensive (Taha and
Hussein 2014) and evidence suggesting that people with
autism often go undiagnosed in the Middle East (e.g. Eapen
et al. 2007), Lebanese students exhibited greater aware-
ness of the contributions of socioeconomic disparity to
access to ASD diagnoses. Lebanese students were also
more likely to correctly indicate that there is one ASD in
the DSM-5. Given lower overall know ledge among Leba-
nese relative to US students, it is possible that Lebanese
students may not have been aware of the different types of
ASD in the DSM-IV and just assumed it is, and always has
been, one disorder. However, Lebanese students were also
more accurate in reporting that individuals with ASD show
social-communicative difficulties in their open-ended def-
initions of ASD. Lebanese students were also less likely
than US students to confuse ASD with other disorders,
such as learning disabilities.
Together, these findings support our hypothesis that the
social aspects of ASD may be more salient in more col-
lectivistic than individualistic countries, and are consistent
with findings from another primarily collectivistic country,
South Korea, wherein mothers of children with ASD
emphasized the distinction between social symptoms of
autism and intellectual disabilities (Grinker and Cho 2013).
Lebanese students were also more likely than US students
to mistakenly indicate that people with autism are disin-
terested in social intera ction in their open-ended definitions
of ASD. Also consistent with viewpoints about ASD doc-
umented in South Korea, Lebanese students were more
likely than US students to view ASD as a transitory state
and to indicate that ASD arises from negative parenting. In
contrast, students in the US and Lebanon did not differ in
the extent to which they endorsed the view that vaccines
cause ASD.
This evidence that certain misconceptions about ASD
are more common in the US while others are more com-
mon in Lebanon highlights the importance of gathering
insights from people around the globe in order to truly
understand autism. These findings align with research
showing that people in more collectivist countries may
define the self in terms of dynamic social interactions while
people in more individualistic countries may more com-
monly define the self in terms of relatively permanent
individual characteristics (e.g. Markus and Kitayama
1991). While student s in Lebanon emphasized relational
aspects of ASD by emphasizing its impacts on social
interaction and by accurate and inaccurate endorsements of
the influences of social interactions and structures on its
emergence and identification, students from the US more
often viewed ASD as lifelong and often included individual
differences that are not specific to ASD, such as cognitive
difficulties, in their definitions of ASD.
As hypothesized, Lebanese students reported higher
stigma towards ASD than US students. Greater stigma was
apparent in Lebanon for all items on the Social Distance
Scale, except ‘‘spend an evening with someone with aut-
ism.’’ This item differs from other items on the scale in that
it can be interpreted as involving the least amount of
interaction (i.e., a single evening) with an individual with
autism. Thus, Lebanese students may be more willing to
engage with a person with ASD for a single evening as
opposed to the more extended interaction involved in
friendships and dating. The current findings extend upon
prior research documenting stigma towards ASD in the
Middle East (e.g., Turkey: Bilgin and Kucuk 2010) and
other primarily collectivistic regions (e.g., South Korea:
Grinker and Cho 2013; Hong Kong: Ling et al. 2010)by
supporting Azar and Badr’s (2006) hypothesis that stigma
may be higher in Lebanon relative to the US.
In contrast, our hypothesis concerning attitudes towards
normalizing ASD was not supported, as Lebanese students
were not significantly more likely to endor se the impor-
tance of helping people with autism to appear more normal.
Nor did the groups differ in endorsing the importance of
finding the cause or a cure for ASD. These null findings
may arise from conflicting messages about ASD in the US,
including information about organizations such as Cure
Autism Now and the Neurodiversity Movement’s opposing
stance that autism is a valuable aspect of human diversity
that should not be cured (Kapp et al. 2013), in conjunction
with a relative lack of media about ASD in Lebanon.
Change in Knowledge and Stigma
Our final aim was to determine if participation in an online
ASD training was associated with improved attitudes
towards ASD across cultures. Increases in knowledge and
decreases in stigma in both Lebanon and the US following
the online training replicate our prior work in a different
sample of college students in the US (Gillespie-Lynch et al.
2015) and suggest that online training may be an effective
way to improve know ledge and stigma associated with
ASD internationally. Given that stigma remained higher in
J Autism Dev Disord
123

Lebanon than the US even after the training, online training
is likely an important first step toward improving attitudes
towards ASD that should be followed up with in-person
trainings, preferably including contact with people on the
spectrum. Similarly, online assessments of conceptions of
ASD should be followed up with in-person interviews with
people who are directly affected by ASD to gain deeper
insights about how autism is conceptualized in different
countries. However, in-person trainings and interviews are
more challenging to implement than online assessments;
they require funding to support qualified personnel and to
secure training spaces. In addition, the number of people
who can partic ipate simultaneously in in-person assess-
ments is greatly limited relative to online assessments.
Limitations
The quasi-experimental design of the current study and the
differences in attrition rates in the US and Lebanon suggest
that our post-test data should be interpreted with caution. In
future work, randomized assignment to the presence or
absence of the online training (i.e. a true experimental
design) is necessary to verify that the training is effective in
altering conceptions of ASD. The lack of time between
completion of the training and post-testing may have exag-
gerated effects of training. Future research should assess
maintenance across time. Furthermore, the self-report nature
of this study and the absence of assessments of social
desirability make it highly likely that actual stigma levels
were underestimated in the current study. Although the
Social Distance Scale had high internal consistency, its lack
of reverse-scored items did not allow us to identify random
patterns of responding. In addition, the Autism Awareness
Survey exhibited low internal consistency in this study and
prior work (e.g. Campbell et al. 1996; Gillespie-Lynch et al.
2015). It is important to note that its internal consistency did
not improve if the new items we developed were eliminated.
Although BAPQ scores in the current study were highly
similar to those reported in the original article about the
BAPQ (Hurley et al. 2007), having participants complete the
BAPQ after the autism training might have affected how
they responded to the items on the scale.
Future cross-cultural research would benefit from
assessing actual interactions with people on the spectrum
before and after training and by including participants from
a range of settings within each country. The convenience
sample used in the current study of students at a private
university in Lebanon and a public university in the US
may have obscured some differences across countries. The
students in Lebanon may have been more academically
skilled relative to the students at the US institution, while
the use of a survey administered in English may have
disadvantaged Lebanese students even though they have
participated in schooling in English from a young age.
Reliance on college student participants in general, and on
students enrolled in a specific type of course in particular,
limits the generalizability of findings. Comparisons of
attitudes towards ASD among people from a range of
countries that vary in both cultural values and available
resources for ASD will be essential for disentangling the
impacts of cultural values and available resources on
knowledge and stigma associated with ASD.
Conclusions
As the prevalence of ASD increases globally, more indi-
viduals who are on the spectrum may be attending college.
For these students, community understanding about ASD
may impact their academic success. This study represents the
first comparison of cross-cultural differences in knowledge
and stigma associated with ASD among college students.
While students from a country with fewer ASD resources
(Lebanon) reported less overall knowledge and higher stigma
towards ASD at baseline than students from a country with
relatively substantial ASD resources (the US), students from
Lebanon were more knowledgeable about certain aspects of
ASD, including disparities in access to care, than their
counterparts in the US. These findings suggest that infor-
mation about ASD is unequally distributed internationally
and that people from different cultures can provide unique
insights about ASD. Given that an online training about ASD
was associated with increasing knowledge and decreasing
stigma towards ASD in both countries, online training may
be a cost-effective way to reduce misconceptions associated
with ASD in countries with limited supports for individuals
with ASD, as well as in countries where substantial supports
exist but are unequally distributed.
Acknowledgments We would like to thank all the people who
participated in this training and contributed their insights to this
paper. We are grateful to Fumio Someki, Steven Kapp, Christopher
Cruz-Cullari, Dennis Bublitz and Joanne D’Onofrio for feedback on
study materials. We thank David Rindskopf and Seamus Donnelly for
their statistical consultation. The last author initially conceived of this
study, played a guiding role throughout the course of the study and
contributed substantially to the writing of this manuscript. This study
was funded by CUNY Project REACH (Resources and Education on
Autism as CUNY’s Hallmark) and the Far Fund.
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