Knowledge, attitudes, and perceptions of autism spectrum disorder in a stratified sampling of preschool teachers in China

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction, and restricted, repetitive patterns of behavior, interests, or activities [1]. The disorder has a global prevalence of 0.62 % [2], while recent prevalence estimates in the US run as high as 1.4 % [3]. ASD is associated with enormous financial burdens [4], to a far greater extent than that which occurs with other childhood disabilities [5]. However, interventions are available, and can be quite efficacious when applied early in development, leading to improved social communication and social interaction, and even increased IQ scores [6–9]. Prompt intervention is crucial since intensive behavioral interventions may have diminished effectiveness in older children [10, 11].

The implementation of intervention in young children rests upon disorder identification. As such, diagnosis at younger ages plays a crucial role in prognosis and developmental outcomes. Several trends have aided the diagnostic process. While much of the recent increase in prevalence has been attributed to a broadening diagnostic concept and increased ascertainment methods [12, 13], greater awareness of ASD in the general population has also played a contributory role [14, 15], and has been correlated with a younger age at diagnosis [16].

However, this increase in awareness is not universal. In China, while increased understanding of ASD is found among service providers [17], the general population exhibits common inaccurate perceptions concerning disorder etiology and intervention options [18]. Problematic behavior associated with ASD is often attributed to willful disobedience or a disordered personality in China [19]. It is likely that such attributions contribute to delays in help-seeking behavior [18], and are partly responsible for the considerable stigma experienced by families of children with ASD. The relatively low ASD prevalence estimates in China (i.e., 0.11 %) [2, 20] suggest a deficiency in diagnosis, possibly due in part to low levels of awareness in the general population.

In sum, these results highlight the urgent need for increased awareness of ASD in China. One segment of society in which this need may be the most acute is teachers. Global policy and Chinese initiatives give great importance to the instruction of children with special needs within regular classrooms [21–23]. Thus, outside of parents and caregivers, teachers are the group most likely to work the closest with children and adolescents with ASD. Teachers have been the focus of much recent research concerning knowledge of and attitudes towards ASD [24–26]. However, much of this research has been gathered in primary and secondary school instructors [23–27], whereas relatively less attention has been devoted to the state of knowledge in preschool teachers [28, 29], and overall, little work of its kind has been conducted in China. Not only are increasing numbers of children with ASD being enrolled in mainstream preschool programs [30], but educational programs for children with ASD are often most beneficial when initiated at a younger age [31]. Preschool teachers work with the very population in which timely diagnosis is most likely to lead to a beneficial outcome [32]. As such, their ability to detect developmental anomalies and subsequently provide recommendations to parents and school staff for referral to medical care are invaluable.

In the current study, in comparison to a strong knowledge base on typical childhood development, knowledge of ASD among preschool teachers in China was lacking. The majority of teachers were unable to provide accurate responses to half of the questionnaire items pertaining to ASD. A conceptualization of ASD as psychological in origin predominated, despite current expert consensus of the disorder as having a strong genetic component [41, 42]. Lack of accurate knowledge of the disorder may in part stem from the Chinese terms for autism, GuduZheng or ZibiZheng. The literal translations of both terms equate to ‘loneliness disease’ or ‘isolation disease,’ implying a more psychological etiology. Perhaps not surprisingly then, the majority of participants also expressed the view that with proper diagnosis and treatment, the disorder could be ‘cured’ or ‘outgrown.’ These results are especially concerning since 96 % of teachers were familiar with the term ‘ASD,’ which in itself suggests that instruction in early child development is insufficient in providing teachers with a knowledge base in neurodevelopmental disorders.

The lack of graduate level education may have also contributed to the picture captured during the current study. None of the participants had more than a university level education (i.e., none possessed a master’s degree). These results provide a potential explanation for why an undergraduate level of education has been deemed insufficient in providing teachers with the skills needed to work with children with ASD [29]. Supporting such an interpretation is that within the current sample, education level did have a significant effect on knowledge of ASD: teachers with vocational school or college instruction scored significantly higher on ASD knowledge tests than teachers with lower levels of academic instruction. However, it is also important to note that on the basis of multivariate analyses, studies have shown that further education in Chinese parents did not significantly affect their knowledge of ASD [18]. Furthermore, consistent with prior research [26, 28], teachers with previous work experience with children with special needs possessed significantly more accurate understanding of ASD (and childhood development overall) than those who did not. Presumably, such face-to-face interactions could increase understanding of child development in general, enabling teachers to be better able to discern differences between typically developing children and those with special needs.

In addition to the influence of teacher background, variables pertaining to the school of instruction also contributed to the accuracy of knowledge of ASD. However, contrary to expectations, teachers at Province-level schools, which have greater resources relative to District-level or City-level schools, possessed on average less accurate knowledge of the disorder. The cause of this finding is unclear, although it may reflect the lack of experience working with children with special needs on the part of teachers in Province-level schools. Mandatory education policies for all children, regardless of their ability level, have been required in China [43]. However, in principle, such policies are not enforced. Children with ASD have been refused school enrollment with the rationale that the schools in question lack an understanding and an ability to work with such children [44]. Thus, teachers in the more prestigious state-run schools may be less likely to have had face-to-face experience with children with ASD simply because the parents of such children were forced to turn to less prestigious schools for enrollment [45]. In fact, in Guangdong province, Province-level schools have higher tuition fees than District-level schools, and also utilize quotas in the selection of students. These quotas include families who are able to pay greater fees, students accepted on the basis of results of regional lotteries, and students accepted on the basis of merit. Thus, in Province-levels schools, whereas 10 % of students are government- and/or school-sponsored, up to 60 % of students gain enrollment through a lottery process, owing to the demand for enrollment exceeding available enrollment quotas. In contrast, District-level schools have no such quotas, but rather enroll all local students, with the only preference being given to those residing in greater geographic proximity to the school. It is thus conceivable that Province-level schools may simply enroll a smaller number of students with special needs, particularly since parents with the financial means to do so may choose to enroll their children with special needs in programs dedicated to the education of this population. On the other hand, parents with fewer financial resources may not have the ability to enroll their children in such specialized programs and may instead need to send their children to District-level schools.

Teacher knowledge of ASD (and child development in general) was associated with geographic region. Teachers in Guangzhou had significantly higher knowledge scores than those in Foshan. Guangzhou is the third largest city in China, and it houses several universities. It is probable that teachers in this region are better positioned to learn about and receive training in the education of children with special needs. Research examining the effects of specialized education for children with ASD has been noted to target cities such as Guangzhou [38], although such reports have not made similar mention of Foshan.

Teacher beliefs concerning the interaction of TCM and ASD were assessed with two items. Half of the teachers queried were unsure of whether ASD is caused by a yin/yang imbalance within the body, an idea central to TCM conceptualizations of mental illness [46]. This may suggest that teachers are as likely to refer children with ASD to TCM physicians as physicians from western specialties. On the other hand, 70 % of respondents did not believe that ASD manifests in regional physical pain, another hallmark of TCM. However, this finding may be attributable to the strong belief among respondents that ASD is psychological in nature, thereby negating potential manifestations of physical pain.

An assessment of teacher attitudes towards service provision revealed several trends. While on average, opinions concerning the current state of services were fairly neutral, most participants (>80 %) did believe that expanded funding for children with special needs was needed. These perspectives are in line with views espoused by parents of ASD, who are dissatisfied with services available in China [47]. However, paradoxically, nearly 80 % of participants also expressed the belief that parents, not the school system per se, are responsible for obtaining needed services, and comparable percentages of teachers favored (30 %) and opposed (43 %) an integration of children with special needs into mainstream classrooms. Thus, while participants generally favored expanded government funding and insurance coverage for children with ASD, less agreement was evident concerning the preferred location of such services. This is not surprising given that children with special needs may be refused enrollment in schools in China [19, 48], and even in government-run schools catering to children with special needs, children with ASD may still face difficulty gaining admission [19, 49]. The current results are also potentially problematic in that teachers were more likely to oppose the presence of a parent of a child with ASD in the classroom. However, in the absence of a school support system for children with special needs, parents may advocate for their presence in the classroom [45].

On the other hand, the current results are encouraging in revealing a desire for teachers to participate in the education of children with ASD. In China, the decision to deny enrollment of children with ASD to schools is often attributed to teachers not possessing the knowledge and skills needed to educate this demographic [19]. Thus, while more than 70 % of the current sample expressed a desire to participate in the education of children with special needs, only 31 % felt adequately equipped to do so. Similar findings have been reported elsewhere, as teachers express little confidence in being able to meet the needs of students with ASD [27], but feel that additional instruction would benefit their classroom practice [28]. These findings represent a potentially more positive future for children with ASD in China, who although may receive some funding from the government, they at present have to rely on non-governmental, private organizations [50] or medical institutions for services [51].

We found little awareness of organizations and institutions devoted to the care of individuals with ASD. Eighty-seven percent of teachers were not familiar with Beijing Stars and Rain, a reputable organization for children with ASD that has been publicized in both the lay press and scholarly work [36]. Regional organizations, such as the Kangna School in Guangzhou, fared only a little better (i.e., 29 % were familiar with this school). Regardless of culture, most lay people are exposed to information about ASD via the media [52, 53]. It is thus surprising that this information is lacking, as media coverage in China has tended to increase the advocacy for a charity when discussing ASD [54]. Nonetheless, the total amount of coverage given to ASD in Chinese media is still lacking as compared to that in other geographic regions [54].

Likewise, most teachers did not recognize intervention approaches empirically validated for use in ASD, such as applied behavior analysis. In contrast, most teachers (>70 %) did recognize sensory and auditory integration training. This is not surprising, since relatively few venues are available for applied behavior analysis in China, whereas sensory and auditory integration approaches may be much more commonly utilized [36]. However, the implications of these findings require further research. There has been an acknowledgement by the scientific community of the role sensory deficits/anomalies play in ASD, as evidenced by the decision to include ‘hyper- or hyporeactivity to sensory input’ for the first time as part of DSM diagnostic criteria [1]. However, while at least in the case of auditory integration training, empirical support in western cultures is lacking [55, 56], research in China has shown preliminary evidence of the benefits of more physically-oriented interventions [57]. Regardless, the current findings do corroborate what has been found in samples of parents of children with ASD in China and teachers globally: they lack knowledge concerning intervention approaches and are often not likely to obtain an assessment, much less initiate a treatment [18, 26].

Overall, the current results further highlight how preschool teachers in China tend to be familiar with aspects of typical child development, but have much less familiarity with the nature and interventions validated for atypical child development. In comparison with a sample of teachers in Singapore [28], teachers in the current sample were much better acquainted with facets of typical child development: 84 % were able to answer greater than 50 % of questions on this topic accurately, whereas in Singapore, only 56 % of teachers were able to do so. However, whereas over 60 % of respondents in Singapore were able to provide accurate responses to more than half of the questions administered pertaining to ASD, only 17 % of the current sample were able to do so. Interestingly, in the study by Lian et al. [28], teachers in Singapore were more willing to allow children with special needs into mainstream classrooms and schools. Differences concerning inclusive education across studies may reflect differences in the understanding of the benefits of inclusive education. On the other hand, teachers in both studies did agree on the need for greater governmental responsibility in the expansion of services and insurance coverage for children with special needs.

The current study is not without its limitations. While an attempt was made to compare teachers from a more urban and international region with those from a less urban region, the use of Foshan can be criticized. Foshan neighbors Guangzhou and is likely heavily influenced by its neighboring city. Additional work focused on rural regions is recommended, and may incorporate cities in other regions of China. This need is especially important as our current study found that teachers in less resource-rich schools were more familiar with ASD than those from more resource-rich schools. Thus, there may be an interaction between level of school resources, the likelihood of admission for a student with special needs, and subsequent teacher knowledge. Additionally, while a reasonably large number of teachers were surveyed in the current study, teachers from only 2 of 10 districts in Guangzhou were participants. Population-based studies encompassing more than pre-schools may be more representative of the true state of knowledge of ASD within the community.

Ultimately, our study corroborates previous findings in China in uncovering a lack of awareness and knowledge concerning ASD in the general population [58]. We found associations between such knowledge and teacher education level and experience as well as geographic location and type of school. Additionally, we found that teachers did in fact recognize their own lack of knowledge of ASD, and that this awareness co-existed with an interest in increasing their knowledge and skills in this area. Lastly, teachers were of the belief that the government should be more involved in the services offered to children with ASD. These results echo calls made elsewhere [59] for the incorporation of programs and educational curricula in teacher-training that focuses on children with special needs. In fact, this topic has come under increasing scrutiny worldwide [28, 59, 60]. It is argued herein that such curricula revisions might have the secondary benefit of adding, in an incremental fashion, to the trend towards earlier diagnoses and intervention, and subsequently, improved outcomes.