Mental Health Literacy of Autism Spectrum Disorder in Korea: Recognition, Etiology, Treatment

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Abstract

INTRODUCTION

Mental disorders are globally revealing high prevalence rates. According to a meta-analysis [1], approximately 30% of individuals experience a common mental disorder (e.g., depression and anxiety disorder) during their lifetime. Despite high prevalence rate, the general public has little knowledge of mental disorders; the public is unaware of what to do for prevention, avoid seeking help, and do not know how to help those with mental disorders [2]. This could contribute to approximately 70% of those with mental disorders not being treated for their disorder [3]. Accordingly, researchers have concentrated on the general public’s perception about psychiatric disorders that guide their perception, management or prevention–mental health literacy (MHL) [4]. MHL is associated with identifying and recognizing specific mental disorders, acknowledging where to collect information regarding mental health, understanding the risk factors and causes of various treatments, and attitudes associated with help seeking behavior [4].

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with high prevalence rates; globally one in 132 individuals is diagnosed with ASD [5]. Symptoms include deficiency in communication (e.g., difficulty in understanding non-verbal cues, rendering inappropriate reactions during conversations, difficulty making friends) and dependency on routines and being highly sensitivity to changes in environment (DSM-5). Early diagnosis of ASD is critical since it is related to treatment outcomes; the earlier intervention occurs, the better the outcome [6]. Early intervention is also related to the raising family’s acceptance and adjusting to their child’s disorder [7]. A critical factor for early intervention is to recognize symptoms of mental disorders [2,8]. However, despite a standardized diagnostic criterion the age of being diagnosed with ASD is high; the average age of being diagnosed with ASD in U.S, and Japan was 3.1 and 7.2, respectively [9,10].

After recognizing a mental disorder, it is critical to receive effective treatment. A key factor that contributes to which treatment to receive is related to the individual’s perception on the disorder’s etiology. Since ASD is a neurodevelopmental disorder, parents’ treatment choices were dependent on their perception of the etiology of ASD [11]; those with a perception that food allergy were the cause of ASD revealed higher odds of using special diet or vitamins for treatment and those that perceived their mother being ill during pregnancy as the cause had higher odds of using medication. Until now, the exact etiology of ASD has not been identified. Although, currently, the most accepted etiology is genetic factors, there are other suggested factors such as chemicals and nutrition air pollution, pesticides, mercury, and deficiency of vitamin D or fatty acid [12]. Even parents detached to the child were once regarded as the cause of ASD [13]. Since there is no exact mechanism known for ASD, perception regarding etiology of ASD could vary among parents and the general public.

Most studies on MHL have focused on mental disorders such as schizophrenia or depression [14-16]. However, since early diagnosis and intervention are crucial for neurodevelopmental disorders including ASD [17,18], this area requires more attention. A review study emphasizes that cultural differences must be considered when studying MHL [19]. However, studies regarding MHL in Korea are scarce. There were studies of MHL regarding a specific disorder such as schizophrenia 15 or of specific demographic groups such as the elderly [20,21] or married immigrant women [22]. To our knowledge, there is no study that investigated MHL of ASD in Korea. So, we will investigate MHL (recognition and perception about causes and treatment of ASD) and variables related to their perception in Korea. Results from this research will facilitate improving mental health literacy in South Korea.

METHODS

RESULTS

Recognition of ASD

The frequency of answers that participants provided regarding the diagnosis of the child is provided in Table 1. There were 169 responses that correctly recognized the child in the vignette as with ASD. The next most frequent responses were ‘don’t know’ (58 responses) followed by language/communication disorder (52 responses), neat freak (46 responses), and developmental problem/disorder (42 responses).

Table 1.

Frequency of diagnoses in ASD case

Means and factor loadings for questionnaire items on ASD etiology and treatment

Table 2 displays the mean score for each 24 items with factor analysis (Varimax rotated) results. The five factors accounted for 61.19% of variance in total. The first factor comprised items 1, 5, 6, 7, 8, 9, 15, 16, 24 labeled as ‘parenting and behavioral’ and accounted for 32.57% of the variance. The second factor labeled ‘environmental exposure’ comprised items 2, 12, 13, 23, 25, 26, accounted for 11.50% of variance. The third factor including items 14, 17, 19 were labeled as ‘will and faith’ and accounted for 7.67% of variance. The fourth factor labeled ‘brain abnormality and pregnancy’ comprised items 4, 20, 22 that accounted for 5.14% of variance. The fifth item labeled ‘genetic and drug’ was comprised of items 10, 11, 18 and accounted for 4.32% of variance.

Table 2.

Means and factor loadings for questionnaire items on ASD etiology and treatment

Perception on ASD’s etiology and treatment factors by participant characteristics

Table 3 shows the difference of perception on ASD’s etiology and treatment factors by socio-demographic characteristics, having acquaintance with ASD, and ASD recognition. Men had higher ‘will and faith’ perception than women. Post-hoc comparisons using Bonferroni showed that participants in their 20’s had a higher perception in ‘brain abnormality’ factor compared to the 30s (p<0.01), 40s (p=0.03), and 60s (p=0.03). Moreover, respondents with income higher than 50,000,000 won revealed higher perception in ‘parenting and behavioral’ factors compared to those with income less than 20,000,000 won (p=0.04). Religious participants revealed a higher belief in ‘parenting and behavioral’ and ‘will and faith’ factors. Respondents that knew someone with ASD revealed lower perception on ‘will and faith’ and ‘genetic and drug.’ Those that recognized the child in the vignette as with ASD revealed lower perception in the ‘will and faith’ factor.

Table 3.

Difference of perceptions on ASD’s etiology and treatment factors by socio-demographic variables and ASD literacy

Variables associated with etiology and treatment factors of ASD

Table 4 shows the result from multiple regression analysis regarding variables associated with perception on etiology and treatment factors of ASD. Men were associated with ‘will and faith’ factor. Age was negatively associated with ‘brain abnormality’ factor. Higher income was associated with ‘parenting and behavioral’ and ‘brain’ factors and negatively associated with ‘will and faith’ factor. Knowing someone with ASD and correctly recognizing ASD was negatively associated with ‘will and faith’ and ‘genetic and drug’ factors.

Table 4.

Results of multiple regression analysis of each variable to etiology and treatment factors of ASD

DISCUSSION

This study investigated MHL of ASD of the public in South Korea. According to our results, recognition of ASD among the public in Korea is relatively low; approximately 25% of participants correctly recognized the child in the vignette as with ASD. This rate is lower than China [27] or Japan [28] that reveals a recognition rate of 57.8% and 45.8%, respectively. The next most frequent responses were ‘don’t know’ followed by ‘language/communication disorder’, ‘neat freak’, and ‘developmental problem/disorder’. Previous cross-cultural study [29] regarding MHL found that there was a difference between Asia countries in terms of ability to recognize mental illnesses even though sharing a similar culture. South Korea also has low rate in recognizing and identifying other mental disorders such as schizophrenia and obsessive compulsive disorder [29]. Our study shows that improvement is needed in public recognition of highly-stigmatized mental disorders, particularly ASD, in South Korea. Since recognition and awareness are crucial in management and care [2], there must be intervention to promote awareness of ASD in Korea.

Factor analysis revealed five factors for etiology and treatment of ASD that are ‘parenting and behavioral,’ ‘will and faith,’ ‘brain abnormality and pregnancy,’ ‘environmental exposure,’ and ‘genetic and drug’ factors. These factors are in line with a previous study’s [25] factors that were ‘psychogenic and external,’ ‘pregnancy and environmental treatment,’ ‘genes and drugs,’ ‘diet,’ and ‘brain abnormalities.’ Other studies did not perform a factor analysis but studied the cause for ASD by studying similar themes. For example, Mitchell and Locke [30] divided their factors of the cause for autism as follows: genetic, neurological, environmental exposure, mental illness, vaccinations, nutrition issues during pregnancy, dietary or nutrition deficiencies, family, drugs, and parenting. A study from Japan [28] divided their factors of etiology by stress, genetics, temperament, upbringing, complications during birth, brain abnormality, social environment, no particular cause.

Perception of the public in South Korea regarding ASD’s etiology and treatment varied among socio-demographic variables, recognition of ASD, and knowing someone (family, relative, or friend) with ASD. Men revealed higher perception on the ‘will and faith’ factor. Multiple regression analysis also revealed an association with men and the ‘will and faith’ factor. This is compatible with a previous study [28] revealing that women have more accurate information on ASD. This could be attributable to women being more engaged in child bearing in Korean society [31] and so they may have more accurate knowledge regarding child development.

According to ANOVA and multiple regression analysis results, younger respondents were associated with ‘brain abnormality and pregnancy’ factor. A previous study [32] from Australia reveals that there are age differences in MHL regarding depression and schizophrenia; elderly were less accurate on recognizing mental disorders and they thought character weakness could be the cause for schizophrenia. Conversely, a study conducted in Japan regarding MHL of ASD [28] revealed no generation difference between perception of ‘brain abnormality’ as the cause of ASD; all generations consider ‘brain abnormality’ as the main cause of ASD. Jeon and Furnham [29] revealed differences between recognizing a mental disorder varies within countries in Asia. Our study reveals that there are cultural differences between perception regarding etiologies of ASD.

Respondents with higher income had a higher perception of ‘parenting and behavioral’ factors than those with lower income. According to multiple regression analysis, higher income was associated with ‘parenting and behavioral’ and ‘brain abnormality and pregnancy’ factors and negatively associated with ‘will and faith’ factors. Results are somewhat consistent with a previous study [33,34] revealing those with lower income generally manifesting discrepancy in understanding ASD. For example, those with lower income considered parenting as the cause for autism, are less likely to consult a doctor for help, and are more optimistic that there are treatments for autism. However, it seems that those with higher income in Korea also hold perceptions regarding ‘parenting and behavioral’ factors. This reveals that regardless of income level there is room for development on MHL of ASD however focusing on different aspects.

Those belonging to a religion had a higher perception on ‘parenting and behavioral’ and ‘will and faith’ factors compared to those without religion. This is compatible with a previous study [25] that revealed individuals with religion holding perceptions on environmental factors (e.g., providing a warm and loving environment can enable people to overcome autism) regarding ASD. This reveals that those with religion hold an optimistic view regarding treatment of ASD.

Respondents that know someone with ASD revealed lower perception on ‘will and faith’ and ‘genetic and drug’ factors. Multiple regression revealed a negative association between acquaintance with someone that has ASD and ‘genetic and drug’ and ‘will and faith’ factors. This result is in line with a study [34] that revealed parents holding mixed perceptions on etiology of their child’s ASD; genetic cause was the leading reason that parents perceived but at the same time, parents held perceptions on exposure causes. The predominant etiology of ASD is currently lead by genetic factors. However, ASD is a neurodevelopmental disorder that has no clear etiology and no treatment for cure. As a consequence, parents are confronted with conflicting information about treatment of ASD [35].

Respondents that correctly recognized the child in the vignette as with ASD held lower perception on the ‘will and faith’ factor compared to those that incorrectly recognized the child. Regression analysis revealed that recognition of ASD was negatively associated with ‘will and faith’ and ‘genetic and drug’ factors. Furnham and Buck [25] revealed that interest in mental illness was associated with genes and drugs factor inconsistent with our result. This affirms that respondents capable of recognizing ASD in Korea have mixed perceptions of the cause or treatment of ASD. This implies that more emphasis is needed on education towards the public about the cause and treatment for ASD.

This study had several limitations. First, due to the crosssectional design of this study, we cannot assume causal relationships between socio-demographic variables, knowing someone with ASD, and recognition of ASD with causal and treatment perceptions of ASD. Second, since our study was based on a self-administered questionnaire, there may have been a reporting bias.

Despite limitations mentioned above, this study is the first that systematically investigated MHL of the public in Korea on ASD. Overall, the MHL of ASD in Korea is low and needs improvement. Perception of the etiology and treatment of ASD varied depending on socio-demographic variables, recognition of ASD and knowing a person with ASD. Promotion of public literacy about ASD considering socio-demographic characteristics and acquaintance with ASD are needed. Future studies using a larger representative sample of Koreans are needed to generalize our findings.

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