Abstract
The global prevalence of autism spectrum disorders (ASD) continues to rise, underscoring the importance of assessing physicians’ preparedness to recognize ASD symptoms promptly and provide appropriate care and support to affected children and their families.
Objective
The aim was to assess the level of knowledge among medical professionals described above and involved in the care of children with ASD.
Methods
A prospective cross-sectional study was conducted using a structured questionnaire in Kazakh and Russian. A total of 638 Almaty medical professionals participated: 312 general practitioners (GP), 194 pediatricians, 88 neurologists, and 44 psychiatrists. Analyses were performed in Stata 15.1, with GP and pediatrician data examined as primary healthcare (PHC) groups, and neurologists and psychiatrists analyzed as specialists from both PHC and inpatient settings. The questionnaire showed good internal consistency (Kuder–Richardson Formula 20: 0.842 for neurologists/psychiatrists; 0.854 for pediatricians/GPs). Tetrachoric correlations were used for factor extraction. Descriptive statistics, Chi-square tests, and principal factor analysis assessed relationships between professional characteristics and ASD knowledge.
Results
Psychiatrists demonstrated a greater recognition of certain ASD signs and a stronger need for further education than neurologists, with key areas centered on social, behavioral, and sensory symptoms. Pediatricians with more experience than GPs, demonstrated a higher awareness of ASD symptoms and diagnosis, with social impairment and diagnostic knowledge being the main factors shaping understanding in both groups.
Conclusion
The low awareness of physicians in providing care to children with ASD revealed the need to develop strategies to improve their knowledge, in particular among GPs.
Introduction
Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition characterized by deficits in social communication together with restricted and repetitive behaviours. 1 Globally, ASD prevalence has been estimated at approximately 0.62–0.72%, although variations exist across regions due to differences in awareness, diagnostic practices, and healthcare systems. 2 Subgroup estimates include 0.25% for autistic disorder, 0.13% for Asperger syndrome, and 0.18% for atypical autism and related developmental disorders. ASD is diagnosed more frequently in boys, with a male-to-female ratio of about 4:1.3,4 Early identification of ASD remains a major public health priority worldwide, as timely diagnosis is associated with improved developmental outcomes and more effective support for families.
The etiology of ASD is still unknown; however, recent scientific studies have linked ASD to both genetic and non-genetic or environmental risk factors. 5 Despite advances in screening and awareness, many children continue to be identified late, often between 4 and 8 years of age, which negatively affects intervention outcomes.6–9 Internationally, developmental surveillance and ASD screening are commonly conducted during routine pediatric visits at 18 and 24 months. 10 Validated tools such as the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F), the Social Communication Questionnaire (SCQ), and the Parents’ Evaluation of Developmental Status (PEDS) are widely used for early detection. 7 In Kazakhstan, the M-CHAT-R/F has been incorporated into clinical protocols and pediatric standards. 11 In addition, recent international research highlights the potential role of artificial intelligence based approaches as supportive tools for early ASD detection and monitoring.12–14
Apart from the availability of screening tools, early diagnosis of ASD also heavily depends on the awareness and knowledge of healthcare professionals
In Kazakhstan, healthcare services are provided through the State Guarantee Package and Mandatory Social Health Insurance, with all children, pregnant women, and retired individuals covered free of charge under the State Guarantee Package. The national health system includes inpatient and PHC services, where diagnosis, treatment, and rehabilitation of children with ASD are provided. 22 Given the complexity of ASD, multisectoral support is organized at both national and regional levels, including a project funded by the Ministry of Higher Education and Science that integrates medical, pedagogical, and social services (https://autismbirge.kz/). The country is also transitioning to a GP-based PHC model but still relies on paediatricians for early ASD detection. The legal confirmation of diagnosis (International Classification of Diseases (ICD) F codes) remains under psychiatrists, while under ICD-11, neurologists will also gain this responsibility.
Considering these structural transitions in the country, there is limited evidence on how well medical professionals recognize and manage the early signs of ASD, particularly within a multisectoral context involving psychiatrists, neurologists, paediatricians, and GP. To address this gap, we first developed a contextually adapted questionnaire based on international literature and validated instruments, and then used it to assess the level of ASD-related knowledge among these professionals.
Methods
To assess the level of knowledge among medical professionals the questionnaire was developed based on international literature sources and included a combination of open-ended and closed questions.23–25 The development process followed the conceptual framework of previously validated instruments evaluating healthcare workers’ knowledge of ASD. These studies informed the structure and content domains—social interaction, communication and language, behavioral patterns, and general knowledge about ASD. In addition, the questionnaire was adapted to reflect recent updates introduced in the ICD 11th Revision, ensuring consistency with current diagnostic concepts and supporting Kazakhstan’s planned transition to ICD-11.
As a result, the questionnaire was designed to include 23 questions, of which 16 focused specifically on assessing the knowledge of medical professionals regarding ASD. The remaining questions collected demographic information (such as years of professional experience and medical specialty) and explored clinical practices related to ASD. In Kazakhstan, medical specialists use two languages - Kazakh and Russian; therefore, the questionnaire was developed in these languages so that all respondents had an equal opportunity to participate in the survey.
The final version of the questionnaire was reviewed by independent clinical experts from different specialties as GPs (2), pediatrician (1), neurologists (2) and psychiatrist (1), to determine the clarity and comprehensibility of the questions. Following minor adjustments suggested by the experts, the questionnaire was piloted among 15 medical professionals from relevant specialties.
A cross-sectional survey was conducted among medical professionals, including GPs and pediatricians from PHC, as well as psychiatrists and neurologists from both PHC and inpatient in Almaty city. The Almaty City Health Department assisted in distributing the questionnaire.
The survey was administered via Google Forms and paper-based versions, depending on the preference of the medical professionals. It was conducted on an anonymous and voluntary basis, and participants could withdraw at any time. This study was conducted in accordance with ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Local Ethics Committee of Kazakh National Medical University, Kazakhstan (Protocol No. 13 (149), 29 March 2024). All participants were provided with detailed information about the purpose, scope, and voluntary nature of the study at the beginning of the questionnaire. Participants were required to read a consent statement and indicate their agreement by selecting “Yes” to a separate consent question before accessing the survey. Only those who provided consent were allowed to proceed. Additionally, they were given the opportunity to contact the researchers through the contact information provided in the questionnaire.
Participants were selected according to the following inclusion criteria: Medical professionals registered as GP, pediatricians, neurologists, or psychiatrists; practicing in PHC or specialized medical institutions within Almaty city; provided informed consent and agreed to participate voluntarily. Exclusion Criteria: Medical professionals outside the four target specialties; those not practicing within Almaty city; participants who did not provide consent or withdrew from the survey; incomplete or invalid questionnaires, if identified during data cleaning, were excluded from analysis. The survey conducted from April to August 2024.
In health information system of the Almaty city 1222 medical professionals in four specialties were registered: GPs - 808; pediatricians -279; neurologist -89; and psychiatrists – 46. Based on the cross-sectional study design formula, and taking into account possible errors, the research team increased the sample size to 20% (312 GPs and 194 pediatricians, 88 neurologists and 44 psychiatrists)
Potential sources of bias included self-reporting and voluntary participation. Anonymity and inclusion of multiple specialties were used to minimize these effects.
Statistical analysis
We analyzed the results separately for general practitioners and pediatricians as PHC professionals, as well as for psychiatrists and neurologists from both PHC and inpatient care. This helped us to design the group-based research and later target our activities. For the statistical analysis, Stata 15.1 software (StataCorp, 4905 Lakeway Drive College Station, Texas 77845 USA) was used. The Kuder-Richarson reliability coefficient (KR-20) value to examine the reliability of the questionnaire by measuring internal consistency, where binary data are recommended. 21 The study variables were subjected to descriptive analysis. The internal consistency coefficient KR20 of the measurements obtained using the questionnaire was: 0.842 (Neurologists and Psychiatrists) and 0.854 (pediatricians and GPs).
The correlations between dichotomized scale items were evaluated using tetrachoric correlation analysis, which lead to obtain a factor matrix. The principal factor method was used for factor analysis. The number of observations was n=638, and the number of factors retained was designated as n=3, which was found to be the optimal number of factors by considering the eigenvalues, explanatory properties, and factor loadings. Orthogonal varimax rotation was chosen after applying the principal factor analysis. The study variables were subjected to descriptive analysis. Frequency and percentage distribution of the healthcare workers’ opinions were also analyzed using Chi Square test.
The reporting of this cross-sectional study conforms to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. 26 The completed STROBE checklist is provided as a supplementary file 1.
Results
Psychiatrists and neurologists’ awareness
Awareness of physicians on classification of autism spectrum disorders in Kazakhstan.
Note. p<0.05*; Chi square.
The distribution of correct answers by position of physicians.
Note. p<0.05*; Chi square.
Factor analysis of the tetrachoric correlation matrix for neurologists and psychiatrists.
Note. P <0.001*; rtet - tetrachoric correlation coefficient; Extraction Method: Principal Component Analysis.
GP and pediatricians awareness
Pediatricians had significantly more work experience than general practitioners, with over half having more than 11 years in practice (p < 0.001). Knowledge of ASD types according to ICD-11 is demonstrated by 22.9% of all respondents who selected “all of the above are correct,” with a slightly higher percentage among pediatricians (24.2%) compared to GPs (22.1%). Conversely, a lack of awareness is evident, as 23.4% of GPs and 17.5% of pediatricians reported that they “don’t know” the ASD types. These differences were statistically significant (p < 0.001)
Pediatricians had a significantly higher awareness of diagnostic tests for ASD (51.0% vs. 40.4%, p = 0.019). Delay or total lack of development of spoken language was significantly more acknowledged by pediatricians (83.0%) compared to GPs (69.9%), p = 0.001. Additionally, may be associated with abnormal eating habits was noted by more pediatricians (73.2%) than GPs (63.5%) with p = 0.023
Factor Analysis of the Tetrachoric Correlation Matrix for pediatricians and GPs: Of the 16 questions assessing ASD knowledge among Pediatricians and General Practitioners (GPs), all showed a statistically significant positive correlation with the total score (p<0.001). The correlation coefficients ranged from 0.20 to 0.74, indicating a moderate to strong relationship between individual responses and the overall score.
Factor Analysis of the Tetrachoric Correlation Matrix for pediatricians and GPs.
Note. P <0.001*; rtet - tetrachoric correlation coefficient; Extraction Method: Principal Component Analysis.
In total, the three factors explained 100% of the variance, with Factor 1 and Factor 2 being the primary contributors to the understanding of ASD among Pediatricians and GPs. These factors suggest that awareness of social impairments and diagnostic knowledge is most significant in this group.
Discussion
The aim of this study was to evaluate medical professionals’ knowledge of early signs of ASD using a contextually adapted and validated questionnaire. Our findings indicate that psychiatrists and paediatricians generally demonstrated higher awareness of core ASD features, whereas significant gaps remain in early identification, diagnostic coding, and multidisciplinary management, particularly among GPs and neurologists. Factor analysis revealed that knowledge of social and behavioural impairments, as well as non-verbal behaviours and sensory symptoms, were the primary contributors to ASD knowledge among neurologists and psychiatrists. The questionnaire demonstrated strong reliability (α = 0.8), supporting its suitability for assessing ASD knowledge in this context. 27
We found that pediatricians, in general, demonstrate better knowledge compared to GPs, particularly regarding the diagnosis and symptoms of ASD. Factor analysis shows that pediatricians outperformed GPs specifically in recognizing diagnostic tests, language delay, eating habits, and preoccupation with object parts. The PHC in Kazakhstan is represented by the family-based principle and is organized in catchment areas that is composed of 1800 to 2000 population per one catchment area and includes both children and adults. However, as it was mentioned earlier Kazakhstan is in transition to GP family-based practice and there are still pediatric catchment areas that serves children aged 0 to 5 years old and after 5 years transfer to GPs. Thus, the higher level of knowledge among pediatricians may be related not only to greater work experience but also to the fact that core ASD assessments typically occur before age five. Another contributing factor may be the higher frequency of co-occurring somatic problems and feeding difficulties in children with ASD, such as gastrointestinal issues, sleep disturbances, and pronounced food selectivity. These concerns are typically managed within pediatric practice, giving pediatricians more direct exposure to ASD-related comorbidities compared to GPs. This increased clinical contact may further explain their higher level of ASD awareness. Furthermore, children with ASD are referred to psychiatrists and neurologists for diagnosis confirmation, according to clinical protocol or standard of Pediatric care.11,28 This system may contribute to gaps in ASD knowledge among GPs, as children are often first seen by paediatricians, and GPs may have limited exposure to early developmental disorders, potentially delaying recognition and intervention
In comparing ASD knowledge across the four medical specialties, neurologists and psychiatrists demonstrated the strongest awareness of core ASD features, particularly in the areas of social communication, sensory behaviors, and non-verbal impairments. Pediatricians and GPs also showed solid understanding of social impairments and diagnostic practices; though their awareness was lower in domains related to sensory and repetitive behaviors. In Kazakhstan, the national health information system relies on accurate ICD-10 diagnostic coding, and the planned transition to ICD-11 will further standardize registration of developmental disorders, including ASD. Correct diagnostic coding is essential for monitoring ASD prevalence, allocating healthcare resources, and ensuring appropriate follow-up and service planning. Therefore, assessing physicians’ knowledge of ICD coding is critical for understanding their readiness for accurate classification of ASD. However, across all groups, knowledge of ASD classification according to ICD-11 was notably low, fewer than 26% answered correctly, and psychiatrists showing the highest interest in receiving further training. Additionally, with the transition to ICD-11, many changes in the classification of neurodevelopmental disorders, including ASD, have been widely discussed in neurology conferences and professional meetings, which may have increased neurologists’ familiarity with coding updates. Psychiatrists, who often rely more on DSM-based frameworks, may have had fewer opportunities to engage with these ICD-specific revisions, which could explain their lower familiarity with ASD coding and greater expressed need for additional training. The overall low interest in training on this topic may also be related to the continued use of ICD-10 in current clinical practice. However, as the healthcare system plans to transition to ICD-11 in 2027, structured training should begin early to ensure that all specialists are adequately prepared for accurate classification and registration of children with ASD.
Similar findings have been reported in other studies, which highlight an insufficient understanding of ASD, its etiology, and the management of children with ASD among pediatricians and GPs and respondents expressed a desire for additional education on this subject. 29 Even physicians with better knowledge of ASD often struggled to apply this knowledge effectively or faced challenges in recognizing the disorder. 30 Imran et al. reported that physicians in Lahore, Pakistan, had moderate familiarity with core ASD features but exhibited substantial gaps in knowledge regarding early onset and clinical application, particularly among primary care providers. 19 Similarly, Alaghband-Rad et al. found that only 10% of healthcare professionals in Iran rated their ASD knowledge as “excellent/very good,” with limited access to clinical guidelines. 31 Moreover, a lack of awareness of ASD can create a barrier to providing proper care, particularly due to poor communication skills with individuals on the autism spectrum. 31 A lack of educational programs on this topic may also contribute to the overall lower level of knowledge among physicians.32,33 Thus, Kazakhstan may benefit from studying residents’ knowledge of ASD and considering more focused training in residency programs on managing children with ASD.
Another study, identified a need among GPs to acquire communication skills and strategies for working with ASD children. GPs reported that they often struggled to establish sensory connections with children with ASD, which left them feeling inadequately prepared to assist, often focusing more on the parents’ condition instead. 24 Similarly, Doherty et al. emphasize the importance of training, knowledge, and awareness for health professionals, family members, caregivers, and support services. 30 They noted that insufficient knowledge about how to care for children with ASD negatively influenced the quality of care and service user satisfaction. Communication challenges were also prevalent, with GPs tending to focus on communicating with parents or guardians rather than directly engaging with the child with ASD.34,35
Strengths and limitations: A strength of our study is that we determined physicians’ knowledge of PHC, which is the first point of contact between physician and patient and caregiver. Accordingly, focusing on GPs, pediatricians, neurologists and psychiatrics can be more effective when implementing any measures to improve the provision of care to the target population. Moreover, the support of the Health Department in one of the large cities as Almaty gave us the opportunity to involve a larger number of respondents. Our results allowed us to determine the need for training among medical professionals. There are five medical universities in Almaty city, so there are the necessary resources to organize future training. We did not divide the knowledge of physicians according to the source of funding of PHC as private or public. Perhaps such a distribution would give us the additional information about whether there is a connection between private or public forms of PHC and physicians’ knowledge about the ASD. However, under the conditions of a unified system of compulsory social health insurance and having uniform standards, the authors believe that there would be no significant difference.
Conclusion
The low awareness of ASD among medical professionals, particularly GPs and neurologists, underscores the need for targeted strategies to enhance knowledge and clinical competence, especially in primary care. Strengthening a multidisciplinary approach is crucial for supporting children with ASD and their families, as collaborative care improves the quality and effectiveness of services. Multidisciplinary teams should receive training not only in ASD recognition and management but also in communication skills and strategies to support the physical and psychological well-being of caregivers.31,32
In Kazakhstan, PHC is delivered by a range of professionals, including GPs, nurses, psychologists, and specialists. A two-stage training approach may be effective: the first stage could provide tailored education addressing the specific needs of each specialty (e.g., GPs focusing on early diagnosis and symptom recognition, while neurologists and psychiatrists receive training in routine behaviours and language development), and the second stage could emphasize interdisciplinary collaboration through joint training sessions, fostering effective team-based care. Strengthening knowledge of ICD-11 classification across all specialties is also essential in preparation for the planned national transition. Future research should evaluate best practices for coordinated, multidisciplinary care and strategies to engage and support families.
Equally important is raising public awareness of ASD, as parents are often the first to notice early symptoms. Research indicates low population awareness in Kazakhstan, and many parents are unsure how to support ASD children.36,37 PHC preventive services should therefore include public education on ASD symptoms, but only after ensuring that healthcare professionals are well-prepared and trained in effective communication for disseminating evidence-based information.
Supplemental Material
Supplemental Material - The assessing medical professionals’ knowledge of autism spectrum disorders
Supplemental Material for The assessing medical professionals’ knowledge of autism spectrum disorders by Aliya Nurmukhanbetova, Eleonora Nurbaulina, Sandugash Kurmanalina, Zhanar Sabyrdilda, Balnur Iskakova, Nazgul Akhtayeva, Lyazzat Kosherbayeva, Laura Kozhageldiyeva in Journal of Public Health Research
Footnotes
Ethical consideration
The study was approved by the Local Ethics Committee of Kazakh National Medical University, Kazakhstan (Protocol No. 13 (149), 29 March 2024).
Consent for publication
All authors consent for publication.
Author Contributions
All authors contributed equally to the writing of the article and reviewed this version of the manuscript and approved it.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Materials and these articles are with the authors.
Supplemental material
Supplemental material for this article is available online.
References
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