Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder that is characterized by a deficit in social communications and interaction, and repetitive behaviors and interests that manifest in early childhood according to the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) [1]. Some notable symptoms of ASD include but are not limited to: little or no eye contact; conversational difficulties; issues with disruptions in their routine; language disabilities; and intellectual impairment with significant variations in severity [1–7]. Although there is no cure for ASD currently, various treatments are available for improving symptoms to a certain degree in the forms of cognitive and behavioral therapy, and medications [6]. During the last three decades, different tools have been developed for assessment of ASD. These include Autism Diagnostic Observation Schedule (ADOS) [8], the Autism Diagnostic Observation Schedule-2 (ADOS-2) [9], Autism Diagnostic Instrument-Revised (ADI-R) [10] alongside the DSM-5 criteria [6, 11]. The prevalence of ASD in the US is estimated to be 1 out of every 54 children [12]. However, based on a study in 2012 [13], the World Health Organization estimates that globally 1 out of every 160 children is diagnosed with ASD [14]. Considering that many countries don’t have an adequate infrastructure to identify all the ASD cases, the reliability of this global estimate is questionable [15]. As the first step in building an infrastructure to identify all ASD cases and make accurate referrals for appropriate interventions, it is important to assess the knowledge of general practitioners and family physicians who are usually the first to come across children with various developmental disabilities including ASD [16–20].
An inadequate level of general knowledge of physicians regarding mental health issues such as ASD could have adverse effects on patients’ health and quality of life in various ways [20–22]. For example, the lack of general knowledge of physicians about ASD could further delay its diagnosis [23] and initiation of timely and appropriate cost-effective interventions, particularly in communities in which mental health is considered a stigma and a potential implicit bias in physicians’ regarding their patient’s mental health concerns [24, 25]. Since mental health illnesses, including ASD, are associated with stigma in many countries around the world, some medical students refrain from pursuing formal training in psychiatry as their field of choice [26–28]. The increased negative perceptions and attitude toward those with mental health problems, and increased stigma and misconceptions related to these conditions [18, 29], may result in a shortage of properly trained physicians specialized in mental health disorders such as ASD.
Moreover, greater focus is needed to educate a new generation of motivated medical school students about mental disorders including ASD [18, 30], who will be able to improve the perceptions of general populations about these disorders, and to develop their interests in pursuing related opportunities to seek formal residency and fellowship trainings in Psychiatry and other related fields. However, currently the medical education systems in many countries lack sufficient focus on ASD and other related disorders. There are some instances where physicians only have heard of mental health issues such as ASD through the media [18]. This limited knowledge can result in lack of sufficient confidence on the part of the physicians for diagnosing ASD and perhaps other mental health conditions [20], and discourage them from seeking further education and experience in the field.
Several studies from different countries have assessed the knowledge, attitude, and practices of physicians regarding ASD [31–35], and studies from many countries such as Turkey [31, 35], Pakistan [33, 34], Nepal [36], and Nigeria [32] all noted a deficiency in ASD knowledge among physicians. Studies from Pakistan [33, 34] also reported a significant degree of misconceptions regarding ASD among general practitioners and physicians. In addition, Minhas et al. highlighted a high degree of stigma, lack of available services, and the limited levels of ASD knowledge in general physicians in Pakistan and India, which takes a significant toll on parents and reduces their faith in the medical professional's ability to help children with ASD [37]. This study also noted that physicians specializing in ASD and other mental health conditions stay within urban areas, leaving rural populations with little to no support [37]. Some studies indicated a lack of formal training regarding ASD and the management of diagnosed children in terms of the available options [38, 39]. On the other hand, other studies have also shown that physicians that specialized in ASD, and/or had experience with ASD scored higher in knowledge assessments regarding ASD [40, 41], were able to understand the need for an early diagnosis [40, 42], had a more positive attitudes towards those with ASD [40, 43], and were able to better handle children with ASD in their practice [39].
Romania is an ethnically diverse, upper-middle-income country in Eastern Europe [44, 45]. The 2002 reformations to the 1997 Romanian Social Health Insurance Act provided a more comprehensive health insurance [46], and comprehensively covers roughly 85% of the population [47]. Statistics from 2016 show that Romania has approximately 2.26 physicians per 1,000 population [44]. It is also estimated that there are approximately 1,018 new cases of mental disorders per 100,000 annually, and roughly 1% of the population in Romania suffer from mental disorders [48]. Additionally, the National Program for Health Evaluation, Health Promotion, and Health Education that is supported by the Office of the United Nations High Commissioner for Human Rights (OHCHR) reported that the most frequent mental health disorders in children and adolescents in Romania are: anxiety disorders, depression, Attention Deficit Hyperactivity Disorder (ADHD), aggressive behavior (bullying), and ASD [49]. Based on a 2016 cohort of over 9000 children from 122 regular schools and 95 schools for children with special education needs (SEN), researchers in Romania reported a prevalence of 14.3% for ASD in children aged 7–9 years old [50]. However, since the study population for this study involved children with SEN, this estimated prevalence of 14.3% is clearly an overestimate and suffers from a serious selection bias, and may not accurately represent the ASD prevalence of Romania’s population. Additionally, Romania’s relatively limited service infrastructure for ASD diagnosis and lack of services for adults with ASD in most regions of the country [51] may be contributing factors of underreporting and stigma toward ASD in the country.
A significant proportion (90.4%) of Romanian children who require psychiatric care initially visit a general physician for advice and guidance [52]. Many of the instruments used internationally for ASD assessment include ADOS [8], ADOS-2 [9], and ADI-R [10] that are considered as the gold standard for assessment of ASD are translated [53–55] and are available in Romania [56] which are used in many public or private units in the country. Other instruments translated in Romanian and are available for use in Romania include Social Communication Questionnaire (SCQ) [57] and Autism Spectrum Rating Scale (ASRS) [58]. However, there are some instruments that are not adapted to Romanian cultures and customs [59]. For example, the Checklist for Autism in Toddlers (CHAT) and it’s other versions are not available for assessment of ASD in Romania [59] but are used internationally to assess a broad range of developmental disorders including ASD in children under 3 years of age. In 2011, the Romanian Health Ministry developed the Screening Questionnaire for Autism Spectrum Disorders [Chestionarul de Screening pentru Tulburări de Spectru Autist (CS-TSA)] modeled after the CHAT to specifically aid Romanian physicians in the early detection of ASD between the ages of 0–3 years. [60]. Since 2016, CS-TSA has been included in the subsidized services of the National Health Insurance Company. Since then, it has become mandatory for family practitioners to administer the questionnaire. However, the Romanian medical school curriculum has not changed significantly since 1996. The current postgraduate curriculum requires one month of pediatric psychiatry training for family physicians in the residency program and three months of pediatric psychiatry training for pediatricians. Though the medical school curriculum regarding ASD hasn’t changed in the past decade, access to more ASD cases, a greater awareness of the disorder in physicians other than specialists, and greater access to knowledge disseminated from other researchers and media (as a potential source for general knowledge about ASD in public) may have contributed to increase in ASD knowledge of Romanian physicians with pediatric psychiatry training.
In this cross-sectional study, we aim to assess the knowledge, attitude, and practices of physicians regarding ASD in Romania. In addition, we investigate factors associated with knowledge about ASD in Romanian physicians. Though a previous study has used factor analysis for a similar assessment [18], to the best of our knowledge, we are the first study that has assessed association of various factors with knowledge, attitude, and practices of physicians regarding ASD.