Autism spectrum disorders (ASDs) are biologically-based disorders characterised by abnormalities in two domains: social communication/interaction and the presence of stereotypic and repetitive patterns of interest and behaviour.1–3 They are usually diagnosed during childhood, so it is essential that paediatricians be knowledgeable of them.2,3

In recent years, the concepts of autism and Asperger syndrome have been evolving towards what is currently considered a continuous clinical spectrum.1,4,5 These disorders are difficult to delimit into specific categories, which is consistent with emerging genetic models of ASD that propose the presence of polygenic interactions, polymorphisms, copy number variants and regulation by epigenetic factors. The fifth edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM V) published in May 2013 consolidated the term ASD; it replaced the DSM IV category of pervasive developmental disorders, excludes Rhett syndrome (which is currently considered a specific genetic disorder that happens to have a few overlapping symptoms) and does not differentiate between childhood disintegrative disorder and pervasive developmental disorder not otherwise specified (they are all comprehended in the term ASD).1,4,5

The diagnosis of ASD is essentially clinical and based on the presence of persistent deficits in social communication and interaction and restrictive, repetitive and stereotypic patterns of behaviour, interest or activity, hyper/hyporreactivity to sensory input or unusual interest in sensory aspects of the environment.1,5 The symptoms must be present since early childhood, although they may be undetected until social demands exceed the restricted capabilities of the child. In addition, the most novel aspect introduced by the DSM V is a dimensional measure of severity based on levels of functioning that can be used to determine the position of the individual within the continuous spectrum.1,4,5

The prevalence of this group of disorders has been increasing in recent years, and they are also frequently associated to other diseases and mental illnesses.2,6–9

Although at present there is widespread awareness of the importance of early diagnosis1–3,7,9–13 and ASD is a frequent reason for seeking paediatric care both in primary care and hospital settings, paediatricians have different levels of knowledge of ASD, and this can lead to feeling of helplessness in both health care providers and the families of patients that seek care after detecting warning signs.3,7,9,10,12–21 Furthermore, few studies have measured this knowledge among paediatricians in Spain (a few studies have been published in other countries, some of them even in the adult population, and assessing general knowledge about ASD in different health care settings12,13). Table 1 lists the studies published to date on the knowledge of ASD in different types of health care workers and different subsets of patients. Overall, these studies have reported an inadequate training on ASD, an incomplete knowledge of the possible diagnoses, and a lack of competence in the management of children with ASD in individual practitioners.2,6,10,12,17–21 To date, there are few published studies that focus solely on the training level of paediatricians, and as far as we know, none such study has been published in Spain.

For all of the above, the main objectives of this study were:

• 1.

  To determine the level of knowledge about ASD of hospital-based paediatricians in different regions of Spain (Autonomous Community of Valencia, Community of Madrid and Region of Murcia).

• 2.

  To determine how hospital-based paediatricians perceive their own knowledge of ASD.

• 3.

  To learn the opinion of hospital-based paediatricians regarding the availability of information on the diagnosis and management of these patients.

• 4.

  To determine the main changes needed in the educational curriculum to contribute to improving the knowledge of paediatricians and to the early detection of ASD in each region under study.

We made a brief questionnaire available to paediatricians (adjunct physicians and residents) working in various Spanish hospitals distributed through three autonomous communities: Autonomous Community of Valencia, Community of Madrid and Region of Murcia (Table 2).

The questionnaire was structured based on the study objectives, taking into account the DSM V diagnostic criteria for ASD and comparing our questions with items used in similar studies in the literature. As has been done in other studies,13 we structured the questionnaire into three parts (Appendix B1–3):

• 1.

  Sociodemographic (SDASD questionnaire): includes demographic data of participating paediatricians, including sex, age, paediatric specialty, years of professional experience, prior experience with ASD patients, and hospital in which they worked.

• 2.

  Knowledge about ASD (KASD questionnaire): further divided into four domains with questions assessing the general knowledge of health care workers about ASD.

• 3.

  Opinion on the currently available care for patients with ASD (OASD questionnaire): questions to explore the opinion of health care workers regarding the availability of information on the diagnosis and management of these patients, as well as the training of specialists, in their particular geographical regions.

We administered the questionnaire using Google Forms, which allowed paediatricians to complete them online and submit them directly to the author. We sent the link to the online questionnaire to all professionals that agreed to participate, emphasising that they did not need to consult any educational materials before completing it.

We analysed the data using the Google Forms tools and SPSS version 15. We calculated the mean, median and mode for the total sample for the items in the KASD questionnaires, and compared sociodemographic data by means of ANOVA to assess the association between the knowledge of ASD and the different sociodemographic variables. We also calculated the absolute frequency and percentage of the different opinions assessed in the OASD questionnaire.

A total of 139 paediatricians completed the questionnaire and were included in the study. Seventy-three percent were female, and the highest proportion corresponded to the 20-to-29 years age group, followed closely by the 30-to-39 years group. Consequently, most of the paediatricians (39%) were Paediatrics residents-in-training (MIR). We ought to highlight that 58% of the surveyed paediatricians reported having no past experience with patients with ASD. Table 2 summarises the rest of the sociodemographic variables.

The mean score in the KASD questionnaire of participating paediatricians was 20.34±2.43, while the maximum possible score was 23. Thus, this was a high score that indicated an adequate knowledge of paediatricians about ASD (a total of 91 paediatricians [65%] had a score at or above the mean in every domain).

Although the studies published to date have not focused on the field of paediatrics and have been conducted in other countries, we ought to highlight that the level of knowledge found in our study exceeded those reported in similar works.12,13

We found that the main problem areas involved the concept of restrictive or repetitive patterns of behaviour (fewer paediatricians knew about the aversive responses to certain sounds or textures, hyper/hyporreactivity to sensory inputs or inflexible adherence to routines) and in the definition of ASD and the presence of comorbidities, the latter being the question which paediatricians most frequently answered incorrectly. We also ought to highlight that 19% of paediatricians answered the question regarding the onset of symptoms in patients with ASD incorrectly, a particularly relevant aspect given the importance of early diagnosis in these patients.

We did not find noteworthy or statistically significant differences in questionnaire scores between subsets of paediatricians (by age, sex, work title, years of experience etc.), unlike what has been described in other studies.12,13 We found the greatest difference between the scores of paediatricians working as adjunct physicians in Paediatric Neurology and those of Paediatrics residents, with the former scoring higher, as would be expected, but it was not statistically significant. When it came to the number of years of experience in the field of Paediatrics, the group with six to ten years of experience scored highest, which could be explained by, on one hand, the short time elapsed since the MIR residency training period and, on the other, the years of experience as an adjunct in Paediatrics.

Despite the good results observed in the questionnaire scores, paediatricians generally reported believing that training in ASD was lacking, which is consistent with previous studies on the subject. Sixty-four percent of paediatricians stated that their own knowledge of ASD was limited and that they did not have sufficient training or resources for the early diagnosis of ASD.7,10,12–16 Most considered that education on ASD should be expanded during residency or in subsequent years. Another important finding was that there was a considerable lack of knowledge as to the available resources in the different regions under study, which probably contributes to the feelings of insecurity and lack of control in the management of these patients. We found this lack of knowledge in every autonomous community under study, and the prevailing response of paediatricians as to whether there was a protocol for the referral or the specialised management of patients with ASD was either that there was none, or that they did not know.

According to the data presented above, paediatricians have an adequate general knowledge of ASD, but there are deficiencies in their knowledge about the management of these patients and in the coordination between the different multidisciplinary teams that participate in the care of these patients, which lead to incomplete and deficient care delivery in these patients. Thus, future efforts should focus on achieving adequate communication between these teams (paediatricians, educational institutions, administrations, early intervention) and in keeping the knowledge of ASD updated in order to develop a well-organised system to provide expeditious, efficient and—to the degree possible—convenient care for children with ASD and their families.

The authors have no conflict of interests to declare.