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Assessment of family physicians’ knowledge of childhood autism

Objective: This study aimed to assess the knowledge of family physicians regarding childhood autism. Methods: The study is a one-way cross-sectional descriptive study, conducted between January and March 2017. The study involved 70 family physicians who were working and/or studying for a master degree in the School of Medicine, Suez Canal University. The researcher collected the sociodemographic characteristics, and then the participants completed the Knowledge about Childhood Autism among Healthcare Workers (KCAHW) questionnaire. Results: The total KCAHW score was 11.2  ± 3.5 (mean  ± standard deviation), the domain with the highest score was domain 1 (5.6 ± 1.8), and family physicians with previous experience had a higher mean score than physicians with no previous experience (12.9 ± 2.7 and 10.7 ± 3.5 respectively). In addition, there was a significant positive correlation between the mean KCAHW score and both the duration of practicing and earlier experience of autism. Conclusion: There is a lack of knowledge of autism among family physicians; they need more training on autism to increase their awareness to improve early detection and intervention so as to improve the quality of life and care of children with autism.


Introduction
In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (fifth edition), autism is classified as an autism spectrum disorder (ASD), along with other disorders such as Asperger syndrome and pervasive developmental disorder not otherwise specified [1]. ASDs are defined as pervasive and lifelong neurodevelopmental disorders, and autism is characterized by impaired socialization, impaired verbal and nonverbal communication, restricted interests, and repetitive patterns of behavior [2]. Moreover, autism is considered as one of the fastest growing disabilities in children [3,4]. Worldwide, the median prevalence of autism is 17 in 10,000 [5]. On the other hand, in underdeveloped countries in

ORIGINAL RESEARCH
variation among health care providers in diagnosis, treatment, and prognosis of autism. A study showed that many professionals in many disciplines did not have exact knowledge of autism and its manifestations in children and adolescents [8].
On the other hand, in spite of there being an increase in awareness and research on childhood autism in many developed countries [9], knowledge and epidemiological research regarding ASDs are still considered to be at a low level [10].
For instance, an Indian study assessed diagnostic practices among health care professionals for autism; 165 psychiatrists, 677 pediatricians, and 95 psychologists were included in the survey. The study reported that professionals perceived autism as a rare disorder, and 80.0% reported that the diagnosis of autism is difficult [11]. In a study in Nigeria, the mean score on the Knowledge about Childhood Autism among Healthcare Workers (KCAHW) questionnaire was 10.67 ± 3.73 out of a possible score of 19; this revealed a low level of knowledge compared with the mean score of 12.35 ± 4.40 obtained among health care workers in an earlier study [12].
Unfortunately, several studies in developed countries also showed considerably late ASD diagnosis. For example, in United Kingdom, physicians diagnosed ASD in only 8.0% of children on their first clinic visit. In many developed countries, the mean age at diagnosis is 7 years, even though it is best to diagnose the condition before the age of 3 years [13].
Early identification is one of the main causes of a favorable outcome and social adaptation in children with autism [14].
Recent studies proved that early diagnosis and intervention as well as multidisciplinary specialist care services can lead to positive outcomes, and this characterizes the management of autism in developed countries [15]. Generally, in Africa there is limited knowledge among physicians, lower community awareness, and a dearth of specialist care services [6,16].
Health care workers in sub-Saharan African subcultures were also found to have various misconceptions about the cause, treatment, and prognosis of ASDs [17,18], and there was a low to moderate level of knowledge of autism among the various categories of health care workers, with a high level of awareness in health care workers in psychiatric facilities [19].
Similarly, in Egypt, few researchers have studied such disease, and very was little known about physicians' knowledge of childhood autism [20].
The present study aimed to assess knowledge of childhood autism among family physicians to produce information from Egypt that adds to the KCAHW research base.

Methods
choose from, with only one of three options being correct. The correct option for each question has score of 1, while the other two options, which are incorrect, have a score of 0 [21].
The KCAHW questionnaire is further divided into four domains: 1. Domain 1 contains eight questions addressed at impairments in social interaction usually found in children with autism. The greatest score possible is 8, and the least score possible is 0. The greatest score possible is 4, and the least score possible is 0.

Domain 4 contains six questions addressing information
on the type of childhood autism, possible comorbid conditions, and the onset of childhood autism. The greatest score possible is 6, and the least score possible is 0.
So a greatest total score of 19 and least total score of 0 are possible for the total questionnaire. The mean total score on the KCAHW questionnaire is a measure of the level of knowledge of childhood autism [21].

Statistical analysis
The data collected were analyzed with IBM SPSS Statistics for Windows version 20; normality tests had been done to check the distribution of data before analysis. The descriptive statistics used were the mean, standard deviation, frequencies, and percentages calculated. The mean total and domain scores were related to the sociodemographic variables of the participants by means of the independent samples t test and Spearman's rho correlation statistics. P < 0.05 was considered statistically significant.

Research ethics
The Ethics Committee of the Faculty of Medicine, Suez Canal University, approved the study.

Results
All family physicians undertaking postgraduate studies for a master degree in the Family Medicine Department were invited to participate in the current study. A sample of 70 family physicians was recruited as follows: 60 of 70 family physicians in the nontraditional system, giving a response rate of 85.7%, and 10 out 12 family physicians in the traditional system, giving a response rate of 83.3%. Thirty-seven physicians (52.9%) in the sample were women; with a mean age was 35.4 ± 6.7 years.
Most of the physicians in the sample (88.6%) were married.
Fifteen participants (21.4%) had been involved with and participated in evaluation and management of children with autism ( Table 1). The mean total score of the KCAHW questionnaire was 11.2 ± 3.5, where the domain 1 scale produced the highest mean score, 5.6 ± 1.8. Also the mean total score of physicians with previous experience of autism was higher than the mean total score of physicians without experience, 12.9 ± 2.7 and 10.7 ± 3.5 respectively (Table 2). Table 3  The data analysis in Table 4  Family physicians play an important role in the identification and

ORIGINAL RESEARCH
long-term management of autism in children [24]. Pediatricians and family physicians are the first health care providers that a family contacts for children younger than 5 years, which is considered the critical age for diagnosis of ASD [25].
The current study is the first study to assess the knowledge of physicians regarding autism in Egypt; few researchers have addressed knowledge of ASD in Africa. In Africa, many studies proved that the level of knowledge and awareness of ASD among physicians were low [12,26].
In the present study, the mean total score on the KCAHW questionnaire among family physicians is 11.2 ± 3.5, which is lower than mean total score in a study in Nigeria of 13.5 ± 3.7, where there was higher percentage of physicians who had seen autism cases than in the current study, 34.7% versus 21.4% respectively [26]. Also the Nigerian study reported that good knowledge (KCAHW score ≥15) was definitely associated with working as a pediatrician or psychiatrist and practicing in a tertiary health facility, while poor knowledge (KCAHW score <15) was significant among general practitioners. This is congruent with the findings of the present study as the participants were family physicians and as the mean total score of physicians with previous experience with autism in their clinics was higher the score of physicians without pervious experience (12.9 ± 2.7 and 10.7 ± 3.5 respectively), because it is considered that previous experience is one of the best tools to acquire knowledge (learning by doing).
Also, among many studies that indicated a low level of knowledge and awareness of childhood autism is a study done in Pakistan that reported that only 44.6% of physicians had heard of autism [10].
Regarding different domains of the KCAHW score, in the present study the mean score in domain 1, which deals with impairments in social interaction, was 5.6 ± 1.8, which is lower than in another study done among final year medical students in Nigeria, which reported a mean total score of 6.2, slightly higher than the result in the present study, while the domain 2 score was like that in this study (0.7). Domain 3 in the present study had a mean score of 2.1, which is also lower than the score of 2.7 in the aforementioned study. For domain 4 the mean score was 2.7, also lower than in the Nigerian study, which reported 3.8 for this domain [27]. These differences may be due to lack of autism cases, late diagnosis, and most cases going to psychiatrists.
Another study on health care workers in Nigeria stated the mean score in domain 1, which showed impairments in social interaction, was 5.80 ± 1.90, near to the mean score of 5.6 ± 1.8 in the present study. The mean score in domain 2, which concerns communication impairments, was 0.82 ± 0.14 versus 0.7 ± 0.5 in the current study. Domain 3, which concerns obsessive and repetitive behavioral pattern, had a mean score of 2.20 ± 0.90, compared with 2.1 ± 1.3 in this study, which could be considered similar. Domain 4, which address the type childhood autism and possible associated comorbidity, had a mean score of 3.53 ± 1.46, compared with 2.7 ± 1.5 in the present study. Finally the mean total score was 12.35 ± 4.40, compared with a mean total score of 11.2 ± 3.5 in this study.
These results show the lower level of knowledge of physicians of autism and need for action to raise their awareness [12].
This lack of knowledge may be due to the curriculum not covering autism in their undergraduate studies, and relatively recent awareness about the disease in Egypt.
In a study to assess knowledge of autism among nurses in Nigeria, the mean total score on the KCAHW questionnaire among nurses was 12.56 ± 3.23. The mean score for pediatric nurses was 11.78 ± 3.64, while for psychiatric nurses it was 13.35 ± 2.58. The mean score for domain 1 was 6.17 ± 1.75 in pediatric nurses and 6.52 ± 1.43 in psychiatric nurses. The mean score for domain 2 was 0.65 ± 0.48 for pediatric nurses and 0.80 ± 0.41 for psychiatric nurses. The mean score for domain 3 was 1.97 ± 1.25 for pediatric nurses and 2.62 ± 1.23 for psychiatric nurses. The mean score for domain 4 was 2.97 ± 1.54 for pediatric nurses and 3.42 ± 0.98 for psychiatric nurses [19]. These results show some higher and some lower scores than in the present study but the mean total score was higher. These variations can be explained by lack of medical training, practice, and working in psychiatric clinics, which receive the main bulk of cases. ticipants, similar to the Nigerian study (but only 31.1%) [26].
Another study stated that 46.0% of physicians were unsure if seizures are commoner with autism [28]. Finally, onset of autism formed a gap in 61.0% of family physicians in the current study compared with 31.1% in the comparative study [26], which involved physicians from different specialties, including pediatricians and psychiatrists, who practice more than family physicians in autism.
This study showed also a statistical relationship and association between age >35 years and domain 2 score, but no relationship with total or other domain scores, compared with a study that found a relationship between age categories and mean total score [12]. This is different from the findings of a study that found physicians who were younger (age <30 years) were likelier to report knowledge of autism [10]. Also, a study in medical students found no association between age and KCAHW score [29]. Regarding sex, no significant relationship was found, similar to many studies [10,29], while a study reported that for men in domain 4 [27], the relation between age and knowledge better reflected more experience over number of years of working.
Regarding marital status, there is a relationship between being married and the mean score of domain 1, which is concerned with social interaction, while the total score is not very similar to that of another study [12].
Also, the study found a relationship between number of years since graduation or number of years of clinical experience and the mean score of the KCAHW questionnaire and some domains as more than 5 years resulted in higher KCAHW scores, and the number of years of clinical experience is associated with domain 2. Also, in another study there was a near significant relationship between total score and number of years of experience (P = 0.056) [12]. Marriage at an older age, more experience, and living with children raise awareness about norms of children, and previous experience of cases of autism is the best tool to learn something as learning by doing.
Finally, this study found a relationship and correlation between earlier involvement in evaluation and management of autism and the mean scores of the KCAHW questionnaire and domains 2 and 4. This is congruent with many studies showing that earlier awareness and participation in evaluation and management of autism is a significant factor that influences knowledge of childhood autism [18,27,29], and previous experience of cases of autism is the best tool to learn something as learning by doing.

Limitations of the study
As the first study in Egypt to use the KCAHW questionnaire, there may have been some limitations associated with the sample size and sampling methods, and it did not include other specialties such as pediatricians and psychiatric physicians.
Also, the study did not include questions about attitudes and cultural beliefs of the participants, which vary with KCAHW scores such that high scorers tend to subscribe to natural causes for ASD as reviewed by Franz et al. [30].

Conclusion
The present study showed a lack of knowledge of autism among family physicians, so there is a need for more training programs on autism to increase awareness of physicians and improve early detection and intervention, which will improve the quality of life and the care of children with autism. Further, research is needed to assess factors associated with poor knowledge to improve awareness among physicians, and assessment of knowledge of autism among the general population.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not for-profit sectors.

Significance statement
The aim of this study is to assess knowledge about autism among family physicians, producing information from Egypt that adds to research base. This study is a cross-sectional descriptive study, it was conducted between January and March 2017, car-