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RESEARCH ARTICLE Open Access
A survey of Autism knowledge and attitudes
among the healthcare professionals in Lahore,
Pakistan
Nazish Imran
1*
, Mansoor R Chaudry
2
, Muhammad W Azeem
3
, Muhammad R Bhatti
4
, Zaidan I Choudhary
5
and
Mohsin A Cheema
6
Abstract
Background: The diagnosis and treatment of Autism in Pakistan occurs in multiple settings and is provided by
variety of health professionals. Unfortunately, knowledge and awareness about Autism is low among Pakistani
healthcare professionals & the presence of inaccurate and outdated beliefs regarding this disorder may
compromise early detection and timely referral for interventions. The study assessed the baseline knowledge and
misconceptions regarding autism among healthcare professionals in Pakistan which can impact future awareness
campaigns.
Methods: Physicians (psychiatrists, pediatricians, neurologists and family physicians) and non-physicians
(psychologists and speech therapists) participated in this study. Knowledge of DSM-IV TR criteria for Autistic
Disorder, beliefs about social, emotional, cognitive, treatment and prognosis of the disorder were assessed.
Demographic information regarding the participants of the survey was also gathered.
Results: Two hundred and forty seven respondents (154 Physicians & 93 Non-physicians) participated in the study.
Mean age of respondents was 33.2 years (S.D 11.63) with 53% being females. Reasonably accurate familiarity with
the DSM IV-TR diagnostic criteria of Autistic Disorder was observed. However, within the professional groups,
differences were found regarding the utilization of the DSM-IV-TR criteria when diagnosing Autistic Disorder. Non-
Physicians were comparatively more likely to correctly identify diagnostic features of autism compared with
Physicians (P-value <0.001). Significant misunderstandings of some of the salient features of autism were present in
both professional groups.
Conclusion: Results suggests that current professionals in the field have an unbalanced understanding of autism
due to presence of several misconceptions regarding many of the salient features of autism including
developmental, cognitive and emotional features. The study has clinical implications and calls for continued
education for healthcare professionals across disciplines with regards to Autism in Pakistan.
Background
Autism Spectrum Disorders (ASD) are pervasive and
lifelong neurodevelopmental disorders characterized by
impaired socialization, impaired verbal and nonverbal
communication, and restricted interests and repetitive
patterns of behavior [1]. It is believed to be one of the
fastest growing disabilities in children [2,3]. Although
knowledge and research on ASDs are on the rise world-
wide [4], most studies across different nations, have
reported wide variation among healthcare professionals
regarding diagnosis, treatment and prognosis of Autism.
An earlier survey by Stone et al. (1987) clearly demon-
strated that many professionals in various disciplines did
not possess accurate knowledge about Autism and its
manifestations in children and adolescents [5]. Autism
was thought to be a temporary disability and rooted in
emotional factors. Variations were also found between
the primary care providers (family physicians,
* Correspondence: nazishimrandr@gmail.com
1
Child & Family Psychiatry Department, King Edward Medical University/
Mayo Hospital, Lahore, Pakistan
Full list of author information is available at the end of the article
Imran et al.BMC Pediatrics 2011, 11:107
http://www.biomedcentral.com/1471-2431/11/107
© 2011 Imran et al; licensee BioMed Central Lt d. This is an Open Access artic le distributed under the terms of the Creative Commons
Attribution License (http://creative commons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, pro vided the original work is properly cited.
pediatricians & neurologists) and specialists (child psy-
chiatrists, speech therapists and psychologists) in a sur-
vey of autism knowledge in the United States[6]. Health
care workers (HCW) in Sub-Saharan African subcul-
tures were also found to have various misconceptions
regarding etiology, treatment and prognosis of Autism
spectrum disorders [7,8]. A survey conducted by the
African Network for the Prevention and Protection
against Child Abuse and Neglect(ANPPCAN) in 2007
showed low to moderate level of knowledge about aut-
ism among the various categories of healthcare workers
(HCW) with highest level of awareness in healthcare
workers of psychiatric facilities in the region [9]. Look-
ing at the studies from subcontinent, Indian psychia-
trists, psychologists, and pediatricians generally agreed
on characteristics required to diagnose Autism [10],
while in another study done in Karachi, Pakistan, Gen-
eral Practitioners who were less than 30 years of age
and five or fewer years after acquisition of their medical
degrees, were found to be more informed and accurate
in their understanding of Autism[11].
In Pakistan, child psychiatric services are still in their
infancy. There are no formal referral pathways to psy-
chiatric centers for children. The diagnosis and treat-
ment of Autism occurs in multiple settings and is
provided by variety of health professionals including
family physicians, pediatricians, neurologists, psychia-
trists, psychologists and speech & language therapists.
Most of these health professionals have little or no for-
mal training in child and adolescent psychiatry [12,13].
Thus many questions regarding this puzzling disorder
remain unanswered in Pakistan. Unfamiliarity with
DSM-IV TR diagnostic criteria of Autistic Disorder and
the presence of inaccurate and outdated beliefs held by
Pakistani healthcare professionals may have delayed the
positive effects which early interventions have been
shown to have upon the prognosis [14,15]. To date, little
research has been published from developing countries
regarding the above mentioned issues. The present
study seeks to address this knowledge gap in Pakistan.
Methods
The Institutional Review Board of King Edward Medical
University, Lahore, Pakistan approved this study. The
study was conducted between August 2009 and January
2010 in Lahore, which is the second largest city of Paki-
stan. Respondents were recruited in two ways. All psy-
chiatrists, psychologists, neurologists, pediatricians, and
speech & language therapists with minimum of six
months of clinical experience in all five teaching hospi-
tals within the public sector in Lahore were invited to
participate in the study. In addition, family physicians
were recruited by distributing the questionnaire in two
consecutive Continuing Medical Education meetings
organized by Pakistan Academy of Family Physicians
(Lahore Chapter). The speech therapists who partici-
pated were also recruited from an Institute in Lahore,
Pakistan which at the time of study was the only one
providing a qualification course in speech therapy in the
city.
The survey form used, comprised of four sections
(Additional file 1). The first section queried participants
about their background and experience with autism.
The second listed ten behaviors or characteristics of aut-
ism according to DSM IV-TR diagnostic criteria.
Respondents were asked to rate the characteristics as
“Necessary”,“Helpful but Not Necessary”or “Not Help-
ful”for the diagnosis of Autistic Disorder. Among the
items of each of the three options, only the category of
“Necessary”comprised factors representing the correct
diagnosis of Autism. The three categories were mutually
exclusive. When multiple categories were assigned to
the same item, those responses were discounted.
The third segment was a modified version of a section
of Autism Survey as developed by Stone et al. [5] which
has been shown to demonstrate rigorous psychometric
properties [16]. Twenty-two beliefs regarding social,
emotional, cognitive, treatment and prognostic aspects
of Autism were presented. Some items of the standar-
dizedAutismSurveyweresubstituted with more com-
mon mistaken notions regarding Autism in Pakistan.
These were established while piloting the four section
questionnaire. The respondents were instructed to rate
each statement either as “Agree”,or“Not Sure”,or
“Disagree”.
The final part of the survey queried various treatment
options considered helpful by the professionals.
The data was analyzed by using SPSS Version 17.0
[17]. Descriptive statistics of socio-demographic infor-
mation were gathered. For the purpose of analysis,
healthcare professionals were separated into two groups;
Physicians (family physicians, pediatricians, psychiatrists,
neurologists) and non-physicians (psychologists, speech
and language therapists). For all purposes, a p-value of
<0.05 was considered statistically significant.
Results
The total number of surveys distributed was three hun-
dred and twenty-five. Two hundred and sixty three were
returned representing a response rate of 80.9%. Sixteen
questionnaires were incomplete and excluded. The final
total of respondents numbered two hundred and forty
seven. Mean age of respondents was 33.2 years (S.D
11.63) with 53% being females. Physicians were hundred
and fifty four (48 family physicians, 63 pediatricians, 36
psychiatrists and 7 neurologists). Non-physicians were
ninety three (79 psychologists and 14 speech therapists).
A significantly higher number of physicians than non-
Imran et al.BMC Pediatrics 2011, 11:107
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physicians had encountered youths with Autism in their
clinical practice, i.e. 77 compared with 58 (P value =
0.042). About 70% of both groups were practicing for
less than five years. An increase in the number of years
of practice was directly related to a larger number of
affected youths seen (P value <.001).
Table 1 compares the rankings of the relevance of var-
ious aspects/behaviors when considering a diagnosis of
Autistic Disorder as considered by Pakistani physician
and non-physician groups.
Table 2 shows the responses of Pakistani physicians
and non-physician groups regarding general beliefs
about Autism, its prognosis and treatment.
Regarding interventions, psychotropic medications
were considered helpful by 70% of respondents. 27.1%
regarded mood stabilizers as useful; psychostimulants
were endorsed by 24.8%, followed by antipsychotics,
23.1%; antidepressants, 18.3% and hypnotics, 4.2%.
Speech therapy and special educational interventions
were found helpful by 75% and 68% of respondents
respectively.
Discussion
Based upon our review of the relevant medical literature,
the current study is the first to examine the knowledge
of standardized diagnostic criteria of Autistic Disorder
and the beliefs about the disorder held by Pakistani
healthcare professionals from various disciplines. In gen-
eral, the different professionals appear to have a similar
impression of the disorder as represented by the social
deficits, communication difficulties and restricted inter-
ests demonstrated by children with Autism. An impor-
tant finding is that the early onset of the disorder, that
is before 36 months of age; (a diagnostic hallmark of
Autism) is either unknown/undervalued and/or not
applied in the diagnostic process. Studies have found
parents of children with Autism noticing and then
voicing their concerns to health professionals, when
their children were between the ages of fifteen to nine-
teen months [18,19]. However this recognition does not
necessarily translate to an early diagnosis by the health-
care professionals. One of the main presentations of
Autism is speech delay but that is not considered atypi-
cal in Pakistan at thirty six months or beyond, resulting
in many children being assessed, referred and diagnosed
far beyond early childhood. Accounting for this lack of
emphasis on early age of presentation may be the lack
of understanding of typical presenting complaints, reluc-
tance and fear of labeling a child at an early age, and/or
the overlap of symptoms of autism with other comorbid
disorders such as cognitive delay. Changing the negative
opinions and beliefs of HCW regarding autism should
encourage appropriate help seeking behaviors among
parents leading to encouragement of early interventions
which are essential for favorable prognosis.
Differences between the groups were shown by discre-
pant views about the relevance of particular characteris-
tics used when diagnosing Autism. The discrepancy in
knowledge found among healthcare workers was not
totally unexpected due to health service structure in
Pakistan. This is also consistent with the results of pre-
vious studies documenting some differences and misper-
ceptions about various aspects of autism across
disciplines [5,6,11,20,21]. Since child specialty centers in
Pakistan are few, many of the children with Autism and
intellectual disabilities are first referred to special educa-
tion centers by various professionals, usually without
comprehensive assessments and standardized diagnostic
evaluations. Youth in the Autism spectrum are more
likely to be brought to psychiatric facilities to treat
externalizing behaviors and aggression, intellectual
delays affecting motor, feeding, or late onset of develop-
mentally appropriate self-care functions or epilepsy.
These difficulties are considered to be areas of practice
Table 1 Comparative Percent Rankings of Characterstics as “Necessary”For Diagnosis of Autism Among Physicians
and Non Physicians Group.
Rank PHYSICIANS Percentage Rank NON -PHYSICIANS Percentage
Diagnostic characteristics Diagnostic characteristics
1 Social interaction difficulties 73.2 1 Social interaction difficulties 95.7
2 Lack of social responsiveness 71.1 2 Lack of social responsiveness 92.4
3 Lack of eye contact 68.0 3 Rigid or stereotyped play activities 90.2
4 Language delays 65.4 4 Lack of eye contact 88.2
5 Rigid or stereotyped play activities 59.7 5 Need for sameness, resistance to change in routines 85.7
6 Onset of symptoms before 36 months 56.2 6 Language delays 78.7
7 Need for sameness, resistance to change in routines 53.6 7 Preoccupation with objects. 72.7
8 Unusual mannerisms such as finger flicking 47.6 8 Peculiar speech characteristics 69.2
9 Peculiar speech characteristics 43.5 9 Onset of symptoms before 36 months 59.1
10 Preoccupation with objects. 41.1 10 Unusual mannerisms such as finger flicking 54.9
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of psychiatrists and psychologists in Pakistan. Family
physicians and pediatricians in most cases have no for-
mal child psychiatry exposure during their training and
feel less confident in assessing and managing these chil-
dren. Similar to the global trend, in Pakistan, family
physicians and pediatricians are typically the first medi-
cal professionals to whom parents will express their
concerns regarding the child’s development. The need
for these medical practitioners to be equipped with
more knowledge about Autism cannot be over empha-
sized in order to aid early diagnosis and interventions
[22,23]. On the other hand majority of psychologists
and speech therapists have internships in special educa-
tion centers during their training and therefore perhaps
are more aware of the typical presentations and diagnos-
tic criteria of Autism. Our results differ in this respect
to a study done in Nigeria in which undergraduate med-
ical students were more likely to recognize symptoms
and signs of autism compared to nursing and Psychol-
ogy students [24].
Respondents in our study also shared several miscon-
ceptions regarding autism across social, emotional,
cognitive and general descriptive features of autism,
which are consistent with previous studies showing sig-
nificant differences in healthcare professionals, parents,
teachers and medical students’knowledge regarding
possible causes, cognitive profiles, treatment and prog-
nosis of autism[5,24-26].
DSM IV-TR diagnostic criteria require delays and
impairments being present in the first 36 months of life
and respondents in this study were likely to agree that
Autism is a developmental disorder, but also classified it
as an emotional disorder. The mistaken overlap of these
pathophysiologic distinct categories may be linked to
the relative low incidence of recognition of impairments
in early life as one of the features for diagnosing Autism.
Non Physicians were again more likely to consider aut-
ism as a developmental disorder. The participating
health professionals were also likely to endorse the out-
dated view that the cause of social withdrawal in Autism
was a parental bonding and child attachment difficulty.
Even though the etiology credited once to aloof, reject-
ing parenting, now this has been shown irrelevant by
researchers in the field [27].
Table 2 Comparison Of Physicians and Non- Physicians Regarding General Beliefs about Autism.
Sr
#
Beliefs Physicians
N = 154
Positive
Responses (%)
Non -Physicians
N=93
Positive
Responses (%)
P
-Value
1 Autism can occur in mild as well as extreme form 84.8 93.4 .004*
2 Children with autism usually grow up to be schizophrenic adults 24 17.4 0.306
3 Autism is an emotional disorder 40.4 23.9 .001*
4 Most children with autism are also mentally retarded 34.9 46.7 0.17
5 It is difficult to distinguish between autism and childhood schizophrenia 37.9 28.6 0.077
6 Autism occurs more commonly among higher socio economic and educational levels 25.7 20.7 0.667
7 Autistic children’s withdrawal is mostly due to cold, rejecting parents 42.5 35.6 0.424
8 Most children with autism have special talents or abilities 55.9 69.2 0.061
9 Autism is a rare condition in this country as compared with the West 33.6 36.4 0.852
10 Autism is under-recognized and often missed in general practice 85.5 70.1 .003*
11 There is a lack of awareness regarding autism among professionals in Pakistan 86.7 76.1 0.072
12 Autism is a communication disorder 56 46.7 .022*
13 Children with autism do not show social attachments, even to parents 57.8 74.2 .009*
14 It is impossible to tell if a child has autism before four years of age 23.1 27.2 .001*
15 Autism exists only in childhood 43.1 50.5 .028*
16 Even with early intervention, the prognosis for independent community functioning of
individuals with autism is poor
32.9 46.7 .028*
17 Autism is a developmental disorder 51 71 .009*
18 With the proper treatment, most children with autism eventually “outgrow”autism. 49.3 44 0.469
19 Autism is a lifelong condition 44.6 51.6 0.561
20 Children with autism are “untestable.”34 20.2 .003*
21 Parental counseling on training techniques is one effective treatment of autism. 76.2 96.8 .001*
22 Dietary intervention is one of treatment options 35.6 50 0.038
(% given are the respondents answering in affirmative)
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Outdated views regarding the course of Autism were
also observed with the majority believing that Autism
exists only in childhood and many children will outgrow
the disorder with proper treatment. This is similar to
results reported by previous studies [5].
While not corroborative with the previously noted
survey misconception, study respondents endorsed that
a child with Autism is more likely to grow up to be an
adult with Schizophrenia, consistent with speculation of
Autism as an early form of Schizophrenia [27]. This
finding may support that respondents have difficulty dis-
tinguishing between Autism and Childhood-Onset Schi-
zophrenia. This response further supports that
healthcare professionals in Pakistan feel less comfortable
in diagnosing children with Autism. Recent research on
the other hand shows less likelihood of the presence of
autism symptoms in patients with schizophrenia [28].
Overall, the results of our study have significant clini-
cal implications. The fact that more than a quarter of
study participants were not likely to endorse the need
for speech therapy and special education services, they
were also less likely to advocate for these much needed
services for children with Autism in Pakistan.
In order to improve child mental health in Pakistan,
physicians and other relevant professionals working in
large cities do have a significant role to play in disse-
minating accurate information and providing training
to other healthcare workers about Autism. The need
to improve the areas of knowledge gaps identified by
this study cannot be overemphasized. Some of the
ways to help with this huge task may be to incorporate
important aspects of child developmental disorders in
undergraduate and post graduate medical curriculum.
The visits to special schools especially for pediatricians
and family physicians during their training could be
beneficial. Various conference forums and the effective
use of media to promote evidence based medicine and
the erosion of myths about Autism held by the general
population and in particular among the healthcare pro-
fessionalsismuchneededinPakistan[29-31].More
emphasis is needed to implement policies to change
the negative attitudes of health professionals regarding
various aspects of autism to promote care for children
with Autism Spectrum Disorders in this region. It
should include continuous medical education of Pedia-
tric and Psychiatric nursing staff as well because they
are expected to provide counseling to families of these
children.
Several limitations exist with the design of the cur-
rent study and must be considered when interpreting
and placing value on the results obtained. The largest
limitation was the sample size. Although several efforts
weremadetoincreasethesamplesizebyvisitstoall
teaching hospitals in public sector in Lahore as well as
approaching health care professionals at various con-
ferences, the resulting number of participants was still
somewhat low. It is possible that the results do not
reflect the perspectives of the professionals as a whole.
Also the survey developed for the present study was
based on several examples from the literature, but the sur-
vey itself was not validated. There is the possibility that
questions were confusing despite the fact that the study
questionnaire was piloted among a group of healthcare
professionals and the identified deficiencies eliminated.
Generalization to other settings is another limitation.
Regarding a weakness in study design, (since it has
been shown that persons generally answer in the affir-
mative when not sure about a particular item), asking
respondents to list behaviors or characteristics they use
in diagnosing autism rather than presenting a list upon
which to comment, may have led to a more accurate
knowledge of diagnostic criteria of Autism, rather than
a possible overestimate.
Another difficulty encountered was the absence of an
expert group in the study, included in previous studies
[5,10,32], introducing a weakness for comparison.
Although there are many highly qualified professionals
in Pakistan, without dedicated Autism centers and stan-
dard criteria for determining health professionals’exper-
tise in Autism, it was difficult to establish such a group
for comparison in this study.
Conclusion
Despite the limitations of the study, the results provide
an important overview of the diagnostic practices and
knowledge of Autism from a low income developing
country with absence of child mental health policy.
Resultssuggeststhatcurrentprofessionalsinthefield
have an unbalanced understanding of autism due to pre-
sence of several misconceptions regarding many of the
salient features of autism including developmental, cog-
nitive and emotional features. The study has clinical
implications and calls for continued education for
healthcare professionals across disciplines with regards
to Autism in Pakistan.
Future studies are needed which should include multi-
ple sites across Pakistan encompassing both urban and
rural settings with a larger sample size. These studies
can provide baseline data to guide policies and planning
of healthcare delivery to children with Autism and other
developmental disorders in Pakistan.
Additional material
Additional file 1: The Autism Survey Questionnaire. The survey form
used in the study.
Imran et al.BMC Pediatrics 2011, 11:107
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List of Abbreviations Used
(ASD): Autism Spectrum Disorder; (DSM- IV): Diagnostic and Statistical
Manual of Mental Disorders, 4
th
edition.; (HCW): Health care Workers.
Acknowledgements
We would like to thank Dr Tamara Daley for forwarding us a copy of
questionnaire used in their autism study conducted in India, and Dr.
Wudarsky for reviewing the manuscript.
Results of this study were presented as a Poster at the 57
th
Annual
Meeting of American Academy of Child & Adolescent Psychiatry in New
York, October 26 to 31, 2010.
FUNDING :None.
Author details
1
Child & Family Psychiatry Department, King Edward Medical University/
Mayo Hospital, Lahore, Pakistan.
2
Academic Department of Psychiatry &
Behavioural Sciences, King Edward Medical University/Mayo Hospital, Lahore,
Pakistan.
3
Riverview Hospital for Children and Youth, Department of Children
and Families CT, Yale Child Study Center, Middletown, CT, USA.
4
Department
of Psychiatry& Behavioural Sciences, King Edward Medical University/Mayo
Hospital, Lahore, Pakistan.
5
Academic Department of Psychiatry &
Behavioural Sciences, King Edward Medical University/Mayo Hospital, Lahore,
Pakistan.
6
Department of Physiology and Cell biology, University of Health
Sciences, Lahore, Pakistan.
Authors’contributions
NI: Conception & design, data analysis and interpretation, article drafting.
MRC: conception & design, data collection, analysis. MWA: Design of the
study, manuscript writing, critical revision. MRB: Study plan, write up and
critical revision. ZIC: literature search, data collection & interpretation. MAC:
Design, data analysis, manuscript writing.
All the authors read and approved the final draft of the article.
Competing interests
The authors declare that they have no competing interests.
Received: 19 August 2011 Accepted: 22 November 2011
Published: 22 November 2011
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Pre-publication history
The pre-publication history for this paper can be accessed here:
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Cite this article as: Imran et al.: A survey of Autism knowledge and
attitudes among the healthcare professionals in Lahore, Pakistan. BMC
Pediatrics 2011 11:107.
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