A Survey Of Autism Knowledge In A Health Care Setting

A Survey of Autism Knowledge in a Health Care Setting
Amanda D. Heidgerken,1
Gary Geffken,1
Avani Modi,1
and Laura Frakey1
The current study extends research by Stone [Cross-disciplinary perspectives on autism?
Journal of Pediatric Psychology, 12, (1988) 615; A comparison of teacher and parent views of
autism. Journal of Autism and Development Disorders, 18, (1988) 403] exploring the knowledge
and beliefs about autism across multiple health care professions. One hundred and eleven
CARD personnel (i.e., professional with the Center for Autism Related Disabilities, CARD),
specialists (i.e., psychiatry, speech and language pathology, and clinical psychology), and
primary health care providers (i.e., family practice, pediatrics, and neurology) completed a
measure assessing knowledge of diagnostic criteria, course, treatment, and prognosis of
autism. Results indicated that all three groups reflected accurate endorsement of the DSM-IV
criteria. Primary health care providers and specialists were found to differentially endorse a
variety of statements regarding prognosis, course, and treatment in comparison with CARD.
Overall, primary providers demonstrated the greatest number of differences. Clinical
implications and future recommendations are discussed.
KEY WORDS: Autism; health care; survey; diagnosis; knowledge.
INTRODUCTION
Autism is a pervasive developmental disorder
with an onset in early childhood. Current prevalence
rates are estimated to affect between 1 in 500 and 1 in
1000 (National Institute of Child Health and Human
Development, 2003), being approximately four times
more common in males than females. In recent years,
the prevalence rates of autism have escalated (Croen,
Grether, Hoogstrate, & Selvin, 2002; Rapin, 1997;
Volkmar, Klin, & Cohen, 1997). For example,
California statistics identified a 17.6% per year
increase in the prevalence rates of autism between
the birth cohorts of 1990–1992 (Croen et al., 2002).
As the knowledge base regarding the etiology, prog-
nosis, and treatment of autism has expanded, diag-
nostic criteria have become more refined. There has
also evidenced an increased awareness of the disorder
in addition to the improvement of diagnostic sensi-
tivity (Wing & Potter, 2002). Authors examining the
increases in prevalence rates have stated that the
observed increase in children with autism is partly
attributed to trends including the improvements in
identification and diagnosis among professionals and
lay people, the development of standardized assess-
ment and screening tools, and an increased flow of
referrals to specialists and autism-related services
agencies (Croen et al, 2002).
The identification and diagnosis of autism occurs
in multiple settings and is made by a variety of health
and community professionals, including pediatricians,
psychologists, medical specialists, psychiatrists, and
school psychologists. Given that deficits associated
with autism manifest prior to age 36 months, pedia-
tricians and family practitioners are commonly the first
health care providers the child and family have contact
with through routine infant/toddler wellness checks.
As such, pediatricians and family practitioners are
typically one of the first medical professionals to whom
parents will voice concerns regarding their child’s
development. In accordance, a recent report by the
American Academy of Pediatrics recognized that the
1
Correspondence should be addressed to: Department of Psychi-
atry, University of Florida, Box 100234 , FL, 32610, USA.
E-mail: Amanda@psychiatry.ufl.edu
323
0162-3257/05/0600-0323/0 Ó 2005 Springer ScienceþBusiness Media, Inc.
Journal of Autism and Developmental Disorders, Vol. 35, No. 3, June 2005 (Ó 2005)
DOI: 10.1007/s10803-005-3298-x

primary care physician is now more likely to encounter
a child with autism as a result of the increased
prevalence (American Academy of Pediatrics, 2001).
Due to the comorbidity of select medical problems
associated with autism such as seizures (Bryson, 1997),
these children are also likely to see more specialized
health care providers such as neurologists. In addition,
these children are often seen by psychiatrists and
psychologists in relation to behavioral and develop-
mental concerns.
While autism is identified and diagnosed in
multiple settings, unfortunately the path to diagnosis
and treatment for autism is often not smooth, as
autistic children traditionally encounter multiple
health care professionals along the way (Farber &
Capute, 1984). This process is often long and
complicated by diagnostic confusion. Many times,
diagnosis involves contact with numerous individu-
als, which can lengthen the latency period to proper
diagnosis and treatment (Stone, 1987). Given the
importance of early intervention, delays in diagnosis
can lead to deleterious effects, for early and intensive
behavioral and educational interventions can make
lasting long-term impacts on outcomes (American
Academy of Pediatrics, 2001). In addition, outdated
and inaccurate beliefs regarding the prognosis and
treatment of autism differentially impacts the services
that the health care providers are likely to advocate
for their patients.
Researchers have suggested that the diagnostic
confusion in the process is in part due to the rapid
changes in our understanding of autism, stating that
our knowledge has outstripped the criteria used by
many health professionals in diagnosis (Stone, 1987).
For example, as the diagnostic criteria for autism
changes, many of the standardized measures used in
assessment (e.g., Childhood Autism Rating Scale;
Schopler, Reichler, & Renner, 1988) become com-
promised as they were based on outdated diagnostic
criteria (e.g., DSM-III-R; American Psychiatric
Association, 1987). As the diagnostic criteria become
more refined, measures based on previous criteria
may become overly inclusive (e.g., include criteria
such as sensory over/under responsiveness), and
therefore cannot be used in isolation, but rather in
conjunction with more updated criteria such as the
DSM-IV (American Psychiatric Association, 1994) or
ICD-10 criteria (Lord, 1997). Therefore, continual
education regarding the most recent research is
necessary to accurately diagnose and treat autism.
While numerous studies have been conducted to
explore the nature and treatment of autism, few
studies have been conducted examining the knowl-
edge and beliefs about autism that influence diagnos-
tic decisions across the multiple settings in which
autism is diagnosed. To better understand these
issues, Stone (1987) developed an instrument to
assess professionals’ general knowledge of autism
and of the DSM-III-R criteria used to diagnose the
disorder. The study examined autism knowledge in
four disciplines including pediatrics, clinical psychol-
ogy, school psychology, and speech/language pathol-
ogy. The responses of these professionals were
compared to a select group of professionals consid-
ered to be experts in the field of autism. Results
indicated that the responses given by the experts were
consistent with the current research being conducted
on autism as well as the then current DSM-III-R
criteria for diagnosis of autism. Significant discrep-
ancies were found between health care disciplines and
the autism experts. These health care disciplines
shared several misconceptions regarding autism
across social/emotional, cognitive, and general
descriptive features of autism. In addition, the health
professionals overall differed significantly from
experts in identifying criteria for diagnosis. Differen-
tial patterns of responding were also evidenced within
the health care professions. This trend of differential
responses regarding beliefs about autism within
professions is supported by research by Shah (2001)
who concluded that while medical students did not
vary according to their level of experience in endorse-
ment of the diagnostic criteria and core symptomol-
ogy of autism, that there were significant differences
in their knowledge regarding possible causes, cogni-
tive profiles, treatment, and prognosis.
A follow-up study was conducted by Stone and
Rosebaum (1988) using the Autism Survey to eval-
uate parents’ and teachers’ views of autism. In this
study, the diagnostic criteria were excluded and only
the knowledge and beliefs portions were assessed.
Both parents and teachers were found to have
significant misconceptions regarding many of the
features of autism, including developmental, cogni-
tive, and emotional features when compared to
specialists in the field. For example, they were less
likely to view children with autism as mentally
retarded and to view autism as a developmental
disorder. They were more likely to agree that autism
existed only in childhood, that autistic children
possess special talents or abilities, and to view autism
as an emotional disorder. Helps, Newson-Davis, and
Callis (1999) replicated results using a revised version
of the Autism Survey which confirmed differential
324 Heidgerken, Geffken, Modi, and Frakey

belief patterns of mainsteam and special education
teachers in comparison with mental health profes-
sionals. Furthermore, they stated the need for more
training for all three groups.
As such, Stone (1987), and Stone and Rosebaum
(1988) demonstrated continued misperceptions by
health care professions, parents, and teachers regard-
ing the nature of autism and revisions of the DSM-III-
R criteria, reflecting beliefs consistent with outdated
research. In 1994, the diagnostic criteria for autism was
once again revised based upon advances in research
and clinical knowledge. While Helps et al. (1999)
suggested continued misperception among teachers
and mental health workers, it is unknown if this change
in conceptualization and diagnosis has generalized to
other health professionals who are most likely to come
into contact with, and aid in the diagnosis of, children
with autism. In comparison with prior DSM-III-R
criteria, previously recognized criteria such as hyper-
sensitivity and hyposensitivity to environmental stim-
uli and the absence of hallucinations and delusions are
no longer considered in diagnosis. The addition of
broad categories with multiple descriptors, in compar-
ison with the DSM-III-R criteria, also permits children
to present with a diverse combination of symptomol-
ogy and still meet criteria for autism. As the group of
children diagnosed with autism becomes a more
heterogeneous population, identification and diagno-
sis can become complicated. It therefore becomes
necessary that individuals working in health care
professions with children be aware of the advances in
the nature and diagnosis of autism. Therefore, the
current study was conducted to further explore pro-
fessionals’ knowledge regarding general and diagnos-
tic characteristics of autism in the current health care
professionals. Whereas Stone (1987), and Stone and
Rosebaum (1988) used DSM-III-R criteria as a com-
parison for diagnostic sensitivity, the current study
used the DSM-IV criteria.
The current study also extended the previous
studies by looking at those health professionals who
are likely to work more closely with children with
autism as specialists in the diagnosis and treatment
(i.e., psychologists, psychiatrists, speech and language
pathologists) in comparison with more traditional
primary health care providers who are less likely to
work with concentrated populations of children with
autism (i.e., pediatricians, neurologists, and family
practice). Similar to the previous studies conducted
by Stone (1987), Stone and Rosebaum (1988) these
two populations were compared with a group of
professionals who work in a center that specializes in
the working with children with autism from the
Center of Autism Related Disabilities (CARD).
METHODS
Participants
The Autism Survey was completed by profes-
sionals and residents training in the fields of
neurology, pediatrics, child psychiatry, clinical psy-
chology, speech pathology, and family practice
from Shands Hospital at the University of Florida.
In addition, professionals employed by the Center
for Autism and Related Disabilities (CARD) also
completed the survey. Of those surveys returned,
111 completed surveys were obtained from individ-
uals classified as professionals. Professionals used in
the current study included family practice (n = 8),
pediatrics (n = 20), neurology (n = 5), psychiatry
(n = 18), speech and language pathology (n = 9),
clinical psychology (n = 16), and CARD (n = 35).
Of those individuals surveyed approximately 44
were classified as M.D., 30 as Ph.D., and 15 as
M.S. degree. For purposes of analysis, these pro-
fessions were grouped according to CARD (i.e.,
CARD, n = 35), Specialists (i.e., psychiatry, speech
and language pathology, and clinical psychology,
n = 43), and Primary Providers (i.e., family prac-
tice, pediatrics, and neurology, n = 33).
Procedures
The Autism Survey as developed by Stone (1987)
was administered to evaluate specialists’, primary
providers’, and CARD employees’ knowledge about
autism. This measure has been shown to demonstrate
adequate psychometric properties in past research
(Cambell, Reichle, & Bourgondien, 1996). This
measure is comprised of two sections. Part I of the
survey assesses 22 beliefs regarding social/emotional,
cognitive, and treatment/prognosis of autism. The
statements were originally based on common mis-
perceptions regarding autism derived from research
and practice. Questions include statements such as
‘‘autism is an emotional disorder’’ and ‘‘autism can
occur in mild as well as extreme forms.’’ The
responder was instructed to rate each item on a
6-point scale of Fully Agree, Mostly Agree, Some-
what Agree, Somewhat Disagree, Mostly Disagree,
and Fully Disagree. The responses were coded as 1–6
with 3 or less indicating disagreement and 4 or more
Autism Survey 325

indicating agreement with the statement. Part II of
the survey assesses the responders’ knowledge regard-
ing specific DSM-IV diagnostic criteria for assessing
autism. Part II is comprised of two questions in which
18 descriptors of behavior, intellect, and symptomol-
ogy are listed. In the first question, participants are
instructed to mark those items that which are ‘‘
necessary’’ for diagnosis. In the second question,
participants are instructed to mark from an identical
list, those items which are ‘‘helpful, but not neces-
sary’’ for diagnosis. While the original survey was
developed to identify DSM-III-R criteria, the current
study used DSM-IV criteria as the standard. Surveys
were completed anonymously and returned by mail
to the researchers.
RESULTS
Part I
Part I of the survey comprised of 21 statements
regarding general beliefs about autism was analyzed
by using Multivariate Analysis of Variance (MANO-
VA). Part I explored differential endorsement by
specialists and primary health care providers of
general characteristics of autism prognosis and treat-
ment not associated with diagnostic criteria in com-
parison with CARD. A MANOVA was run with
group (i.e., specialist, primary provider, CARD) as
the dependent variable, and each of the 22 statements
regarding beliefs about autism as the independent
variables. Follow-up Tukey post-hoc tests were con-
ducted to further explore significant findings. Results
of the MANOVA indicated a significant Wilk’s
Lamba of .212 (F(44, 152) = 4.05, p < .001). Sig-
nificant findings of the MANOVA are listed in
Table I. Significant Tukey post-hoc findings are listed
in Table II.
Significant effects were found for ‘‘Autistic
children do not show social attachments, even to
parents’’(F(2, 152) = 21.6, p = .001), ‘‘It is impor-
tant that autistic children receive special education
services at school’’ (F(2, 152) = 5.3, p = .007),
‘‘Autism occurs more commonly among higher
socioeconomic and educational levels’’ (F(2,
152) = 11.22, p = .001), and ‘‘Autistic children do
not show affectionate behaviors’’ (F(2, 152) = 9.62,
p = .001) with both specialists and primary provid-
ers agreeing with these items more highly than
CARD.
Significant main effects were found for ‘‘Autistic
children are more intelligent than scores from appro-
priate tests indicate’’ (F(2, 152) = 5.2, p = .007),
‘‘Autistic children usually grow up to be schizo-
phrenic adults’’ (F(2, 152) = 5.74, p = .004), and ‘‘It
is difficult to distinguish between autism and child-
hood schizophrenia’’ (F(2, 152) = 6.36, p = .003)
with primary providers being more likely to endorse
these statements than CARD. ‘‘I feel comfortable
diagnosing or identifying a child as autistic’’ (F(2,
152) = 5.59, p = .005) was also significant with
primary providers endorsing this statements less than
CARD.
‘‘Autism is a developmental disorder’’ (F(2,
152) = 18.96, p = .001) was endorsed significantly
less by primary providers than specialists and CARD.
In addition, the statements of ‘‘Autistic children’s
withdrawal is mostly due to cold, rejecting parents’’
(F(2, 152) = 8.8, p = .001), ‘‘Autistic children are
deliberately negativistic and noncompliant’’ (F(2,
152) = 12.23, p = .001), and ‘‘With the proper
Table I. Significant Main Effects For Part I MANOVA Assessing General Beliefs About Autism
Item F Significance level Observed power
6. Autistic children are more intelligent than scores from appropriate test indicate 5.2 .007 .819
7. It is difficult to distinguish between autism and childhood schizophrenia 6.36 .003 .892
9. Autistic children do not show social attachments, even to parents 21.6 .001 1.0
10. Autistic children usually grow up to be schizophrenic adults 5.74 .004 .857
13. Autistic children are deliberately negativistic and noncompliant 12.23 .001 .995
14. It is important that autistic children receive special education services at school 5.29 .007 .826
15. Autism occurs more commonly among higher socioeconomic and educational levels 11.22 .001 .991
16. Autism is a developmental disorder 18.96 .001 1.0
17. Autistic children’s withdrawal is mostly due to cold, rejecting parents 8.80 .001 .967
20. With the proper treatment, most autistic children are eventually outgrow autism 9.40 .001 .976
22. Autistic children do not show affectionate behaviors 9.63 .001 .979
21. I feel comfortable diagnosing or identifying a child as autistic 5.59 .005 .847

treatment, most autistic children are eventually out-
grow autism’’ (F(2, 152) = 9.4, p = .001) demon-
strated significant effects, being endorsed more highly
by primary providers than the other two groups.
Part II
Part II of the survey assessed the respondents’
knowledge of the diagnostic criteria required for
autism. More specifically, primary health care pro-
viders and specialists were compared to CARD
employees to explore their knowledge of the DSM-
IV criteria that is used to diagnose autism. First,
CARD’s frequency of endorsement for each of the
DSM-IV criteria was explored. Results are listed in
Table III. Items are labeled to indicate whether it is a
broad category for diagnosis or one of the descriptors
listed by which the broad category can be met.
Overall, results indicate agreement between CARD’s
endorsement of descriptors and current DSM-IV
criteria. Of note, whereas unusual sensory responses
no longer is a diagnostic criteria, 26% of the
specialists endorsed the item as necessary for diag-
nosis and 77% rated it as useful in diagnosis. Over
half of the specialists (54%) also rated inappropriate
giggling and laughing as helpful in diagnosis.
Part II was further assessed by running separate
MANOVAs for each of the two items. Group (i.e.,
specialists, primary providers, and CARD) was
entered as the dependent variable, and the 21
descriptive items were entered as the independent
variables. The omnibus MANOVA for ‘‘necessary’’
items revealed a Wilks’ Lambda of .596 (F(38,
172) = 1.351, p = .1), indicating that the three
Table II. Part I Significant Post-hoc Comparisons Between CARD and Specialist and Primary Providers Regarding General Autism Beliefs
Profession
Item
CARD
n = 30
Primary
n = 29
Specialist
n = 41
6. Autistic children are more intelligent than scores from appropriate tests indicate 2.47 2.34*
7. It is difficult to distinguish between autism and childhood schizophrenia 4.87 3.59**
9. Autistic children do not show social attachments, even to parents 5.47 3.79*** 3.46***
10. Autistic children usually grow up to be schizophrenic adults 5.93 5.52**
13. Autistic children are deliberately negativistic and noncompliant 5.97 5.17**
14. It is important that autistic children receive Special Education services at school 1.83 1.24* 1.24*
15. Autism occurs more commonly among higher socioeconomic and educational levels 5.43 3.83*** 4.46**
16. Autism is a developmental disorder 1.23 2.69***
17. Autistic children’s withdrawal is mostly due to cold, rejecting parents 6.00 5.45***
20. With the proper treatment, most autistic children are eventually outgrow autism 5.70 4.76***
21. I feel comfortable diagnosing or identifying a child as autistic 3.13 4.41**
22. Autistic children do not show affectionate behaviors 5.47 4.31*** 4.49***
* £ ..01; ** £ ..005; *** £ .001.
Table III. CARD percentage endorsement of helpful and necessary descriptors for diagnosis
CARD %
DSM-IV criteria Broad
(B) category or Descriptor (D)
DSM-IV Criteria Must have Helpful
Lack of eye contact 40 80 D
Social interaction difficulties 94 60 B
Lack of social responsiveness 54 74 D
Language delays 89 49 D
Impaired conversation, if able to speak 31 69 D
Peculiar speech characteristics 20 71 D
Rigid or stereotyped play activities and interests 83 57 D
Need for sameness; resistance to change in routine 51 74 D
Usual mannerisms such as finger flicking 23 89 D
Preoccupation with objects 31 83 D
Onset of symptoms before three (3) years 81 51 B
Autism Survey 327

groups did not differ significantly on their endorse-
ment of items ‘‘necessary’’ for diagnosis autism
according to DSM-IV criteria.
The MANOVA for items that were rated as
‘‘helpful but not necessary’’ revealed a Wilk’s
Lambda of .471 (F(42, 170) = 1.85, p = .003).
Significant effects between groups were found for
inappropriate laughing and giggling (F(2,
170) = 5.54, p = .005), unusual sensory responses
(F(2, 170) = 5.73, p = .004), lack of social respon-
siveness (F(2, 170) = 5.48, p = .005), thought dis-
order (F(2, 170) = 3.38, p = .04), and unusual
mannerisms such as finger flicking (F(2,
170) = 6.51, p = .002). Post-hoc analyses were used
to explore further significant difference between the
groups of responders. Table IV lists significant post-
hoc findings and the descriptive category (i.e., broad
category or descriptor). In comparison with special-
ists and primary providers, CARD employees were
more likely to endorse inappropriate laughing and
giggling (p = .02, p = .008) and sensory responses
(p = .02, p = .007) as being helpful but not neces-
sary in diagnosis. Compared to CARD, primary
providers were more likely to endorse thought
disorders (p = .05) and less likely to identify unusual
mannerisms (p = .001) as helpful in diagnosis. Of
note, specialists were also less likely to attribute the
broad DSM-IV criteria of lack of social responsive-
ness as being helpful but not necessary (p = .004)
than did CARD.
DISCUSSION
The current study was conducted to extend the
research by Stone (1987),and Stone and Rosenbaum
(1988) exploring professionals’ knowledge regarding
autism. More specifically, the study examined spe-
cialists and primary providers’ knowledge of updated
DSM-IV criteria and general autism knowledge in
comparison with a group of individuals who work in
a center which specializes in the diagnosis, identifica-
tion, and treatment of autism.
While all three groups reflected accurate
changes in the DSM-IV diagnostic criteria necessary
for autism, results of the study indicated that when
compared to experts in the field of autism, special-
ists and primary providers continue to exhibit some
belief patterns consistent with outdated research.
For example, both groups were less likely to
endorse that children with autism share social
attachment or affectionate behaviors to their par-
ents and to others around them. In addition, both
groups demonstrated the tendency to hold on to
outdated beliefs as initially presented by Kanner
(1943). For example, despite more recent epidemi-
ological research which suggests that autism occurs
across socioeconomic status (Volkmar et al., 1997),
specialists and primary providers were more likely
to endorse higher prevalence in the upper socioeco-
nomic categories. Despite advances in the treatment
of autism, both groups were also less likely to
endorse the necessity of Special Education place-
ment at school. This is concerning in that based on
these beliefs, the providers are less likely to refer
parents to pursue services and to advocate for the
services available for children with autism through
the school system. Of note, though, specialists and
primary providers were more likely than the CARD
to reflect recent changes in the DSM criteria
exhibiting decreased endorsement of unusual sen-
sory responses as being helpful in the diagnosis of
autism. This likely reflects many professionals’
continued beliefs that sensory peculiarities are key
characteristics of autism (Burke, 1991; Waterhouse,
Fein, & Modahl, 1996).
Overall, it was found that those individuals who
are less likely to serve as primary health care
providers for children with autism demonstrated
greater number of differences when compared with
Table IV. Significant results of Tukey Post-hoc Tests for Endorsement of Items as ‘‘Helpful’’ For Diagnosis In Comparison With CARD
Item
Mean
DSM-IV criteria Broad
(B) category or Descriptor (D)
CARD (n = 34) Specialist (n = 32) Primary (n = 42)
Inappropriate laughing and giggling .56 .25* .24**
Unusual sensory responses .79 .47* .45**
Lack of social responsiveness .76 .40** B
Thought Disorder .02 .19*
Unusual Mannerisms .79 .47***
* £ .05; ** £ .01; *** £ .001..

experts and specialists in the field. For example,
despite more detailed descriptive criteria outlining the
differential diagnostic criteria between schizophrenia
and autism (i.e., hallucinations or delusions are
present for at least a month; American Psychiatric
Association, 1994), primary providers remain more
likely to agree that is difficult to distinguish autism
from childhood schizophrenia. In addition, they were
more likely to endorse that children with autism are
likely to grow up to be schizophrenic adults. These
views reflect research from the 1950s during which
time researchers speculated that autism was an early
form of schizophrenia (Volkmar et al., 1997). The
prevalence rates of individuals diagnosed with autism
who are later diagnosed with schizophrenia are
unclear. Recent research, though, has suggested that
there are low prevalence rates of onset of schizophre-
nia prior to age 15, with some researchers suggesting
that only 5% of schizophrenics present with symp-
toms before age of 15 (Clark & Lewis, 1998).
Whereas the diagnostic criteria for autism requires
impairment prior to age 3, schizophrenia usually
emerges later. In addition, in comparing the two
disorders, researchers have concluded that indivi-
duals with schizophrenia were less likely to display
most of the characteristics of autism, and more likely
to display symptomology differentially associated
with schizophrenia (i.e., hallucination, delusions;
Konstantareas & Hewitt, 2001). This diagnostic
confusion is further exemplified by primary provi-
ders’ higher likelihood of endorsing thought disor-
ders as being a helpful symptom in diagnosing
autism. While some researchers have stated that the
differential diagnosis of autism and schizophrenia is
difficult to distinguish in a subgroup of children
diagnosed with Asperger disorder (Konstantareas &
Hewitt, 2001), primary health care providers were
more likely to generalize this characteristic as
descriptive of all children diagnosed with autism.
Primary providers were also more likely to
reflect outdated beliefs dating back to the 1950s
attributing causation to parenting factors and par-
ental psychopathology (Newsom, 1998). More speci-
fically, they were more likely to endorse the statement
that withdrawal is due to cold, rejecting parents.
Researchers since the 1960s, though, have acknowl-
edged that parental factors and pathogenesis are not
causal in autism (Volkmar et al., 1997).
Primary providers also demonstrated outdated
views of the treatment and course of autism. For
example, despite the DSM-IV criteria requiring
delays and impairments being present in the first
30 months of life, primary providers were less likely
to agree that autism is classified as a developmental
disorder. In contrast to current research that suggests
the etiology of behaviors associated with autism are
likely attributable to factors such as underlying
neural and genetic factors (for review see Rapin,
1997), primary providers continue to hold the belief
that children with autism are deliberately negativistic
and noncompliant. They also endorsed that children
with autism can outgrow the disorder with proper
treatment. Research has suggested that the effects of
treatment varies according the severity of impairment
with prognosis for children falling in the more
profound/severe end of the spectrum typically requir-
ing a form of supervised living placement throughout
adulthood. Children falling in the less severe end of
the continuum are often able to achieve adequate
functioning in language and social behavior, but are
still likely to retain some persistent speech and
behavioral peculiarities (Newsom, 1998).
The increased number of differing beliefs regard-
ing autism and diagnosis in the group of primary
providers is supported by the findings that they feel
less comfortable in diagnosing children with autism.
This may reflect a differential exposure to updated
research in the area of autism and a more diverse
concentration of clientele. This becomes deleterious
in that often, professionals such as pediatricians and
family practice physicians are the first ones to come
into contact with the children. This is problematic on
many levels because this can lead to delays in
diagnosis, as well as delays in early intensive treat-
ment. Given that research has suggested that inter-
ventions can help to improve deficits such as
children’s communication skills, attention, and social
interaction skills, it is important that these children
receive early intervention (American Academy of
Pediatrics, 2001). For example, intensive early inter-
vention projects have concluded that 30–50% of
autistic children can succeed in regular education
classrooms following intervention (for review see
Newsom, 1998). Of further concern is that primary
health care professionals were less likely to endorse
the need for special education services. Health
professionals that demonstrate inaccurate percep-
tions as noted above regarding the treatment and
prognosis of autism, are less likely to be aware of and
advocate for these much needed services in the areas
of behavior, education, and development (American
Academy of Pediatrics, 2001). As such, the current
study calls for continued education for health care
professionals across disciplines, particularly primary
Autism Survey 329

health care physicians, regarding appropriate referral
and intervention services. The current results also
advocate for the presence of strong referral networks.
If primary health care providers of autistic children
are not comfortable with diagnosis, it is of impor-
tance that they receive enough education to recognize
the signs in order to refer the children to specialists in
the field in a timely manner.
It is of importance to note, though, the limita-
tions of the current study in generalizing to other
health care settings. More specifically, the inclusion
of psychiatry as specialists working with children
with autism in the current study was based upon its
large autism clinic population at the hospital from
which the data was collected. Other psychiatry
settings may not mirror this concentration of clien-
tele. Whereas the current study was limited by sample
size that did not allow for examination of each of the
individual health care professions, further explora-
tion of the individual differences between select
professions (i.e., psychiatry, psychology, pediatrics,
family medicine) might also lead to a better under-
standing of diagnostic dynamics. Finally, the current
exploration of DSM-IV questions was limited to
those items that were also included in the previous
DSM-III-R criteria. As such, differential responding
may be found if the survey is revised to reflect the
presence of broad and descriptive categories. As such,
future studies should focus on these areas. In
addition, it will be important to further explore the
referral criteria for autism evaluations and related
services used by health care professionals for diag-
nosis autism.
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