Evaluation of an Autism Training in a Much-Needed Context: The Case of France

Abstract

Background:

Autistic people in France have called for community education to reduce autism stigma. As such, training is needed to help university students appreciate autistic peers and autistic people they may work with in their future careers.

Methods:

We adapted an autistic-affirming training from a training developed in other cultural contexts and evaluated it with 107 university students in France using a pretest–post-test design.

Results:

Questionnaire responses suggested that our brief online training helped improve attitudes toward inclusion, autism knowledge, and stigma among future educators and psychologists in France. Participants' open-ended definitions of autism revealed increased alignment with the neurodiversity movement after training.

Conclusions:

Findings suggest that wider-scale autistic-led adaptations of autism trainings like the one described in this report could begin to ameliorate autism stigma in France.

Community brief

Why is this an important issue?

Autistic people in France have been treated very badly in the past. They have been left out of school and hurt by professionals. They still face stigma. This means they are often misunderstood, made fun of, and excluded. Some are forced to take medications they do not want. Autistic people in France have been trying to help other people in France understand autism.

What was the purpose of this study?

We wanted to see whether autism training could help university students in France to better understand autistic people. We wanted to see whether our training could help students appreciate autistic people more (or lower stigma). We also wanted to see whether the training could help students understand that it is important to include autistic people in classes with other students at school.

What did the researchers do?

Researchers in France, Lebanon, and the United States modified an autism training that had been used in other countries. The training was autistic affirming, which means it taught people to listen to autistic people and to see their strengths. We translated it into French. We included training topics that French collaborators thought were important. We asked university students in France who were studying education and psychology to do our training online. We also asked them to fill out surveys about autism.

What were the results of the study?

After doing our training, students knew more about autism than they did before training. Some learned that autism is part of a person for their whole life. They seemed to appreciate autistic people more after training. They also agreed that it is important to include autistic people in school with other students more than they had before.

What do these findings add to what was already known?

This study shows that autistic-affirming training can also help people in France appreciate autistic people. Much autism training only focuses on stigma and knowledge. Our training may also have helped future educators and clinicians understand how important it is to include autistic people in school with other students.

What are potential weaknesses in the study?

The students in our study were mostly women. They were all training for jobs where they can help people. We do not know whether our training would help other French people. We also cannot be sure that our training really helped the students who did it. Students may have been dishonest about how they felt about autism. In future studies, people should see whether training changes what people do, not just what they say.

How will these findings help autistic adults now or in the future?

By teaching students in France about autism, we hope to begin to help make life better for autistic people in France. We hope studies like this will help people to understand autistic people better. We also hope more people conduct trainings like that used in this study around the world to improve understanding and treatment of autistic people.

Background

In the late 1990s, Singer¹ and Blume² coined the term neurodiversity to describe the uniqueness of all brains. By doing so, they developed a framework for challenging discrimination based on “neurological differences.” The term neurodiversity became the foundation for the neurodiversity movement. Neurodiversity reframes autism as a valuable minority identity and highlights the large degree to which living in a society that is not designed for autistic people contributes to many of the challenges autistic people face.^3–5

Although recognition that autistic people face discrimination is widespread, few postsecondary institutions provide training to help students or community members better understand and support autistic students.^6,7 This gap in available supports is concerning because autistic university students often experience both academic strengths and stigma.

Stigma can be a critical barrier to neurodivergent students realizing their potential at university.^8–12 Public stigma is a multifaceted process whereby community members demean people they view as “different” from “normal” by labeling them as “different,” stereotyping or making assumptions about “differences,” distinguishing between “us” and “them,” and discriminating against “them.”^13,14 Autistic people who experience discrimination are more likely to struggle with loneliness, isolation, stress, depression, and even suicidal ideation.^8,15,16 Living as an “othered identity” can also lead to internalized stigma, which in turn can contribute to mental health difficulties among autistic people.¹⁷

As the number of identified autistic university students increases,¹⁸ education to help university students understand autistic people they might work with is clearly needed. Researchers have used brief online trainings to reduce stigma toward autistic peers among university students in Japan, Lebanon, and the United States.^6,7,19–21 However, researchers have not evaluated autism training in most cultural contexts, including in France where stigmatizing misconceptions about autism may be particularly prevalent.^22,23 One approach for improving stigmatizing conceptions is to focus on an autistic-affirming training, which includes a focus on autistic strengths, challenges, and negative misconceptions of autistic people and highlights that autistic traits are human traits, present across the entire population.

Why is autism training needed in France?

Stigmatizing misconceptions about autism that were common in the United States in the 1960s (e.g., that it is caused by poor parenting) remained common in France until at least the mid-1990s. Faced with these misconceptions, parental advocacy groups began to disrupt their dominance.^22–24 Psychiatrists often sent autistic young people to hospitals and other treatment centers that used psychodynamic interventions. In these treatment venues, autistic people received traumatizing “treatments” like “packing,” which involves tightly wrapping a child in, often cold, wet sheets to help them “reconnect with their bodies.”^25–27

In response to parental advocacy, “packing” was banned in France in 2016.²⁷ However, autistic people in France continue to face discrimination and to struggle to obtain support from the government to alleviate this discrimination.^28,29

Although autistic people in France have struggled to be heard by policy makers, parents of autistic people in France have been better heard when advocating for needed changes.^28,30 Faced with stigmatizing misconceptions about their children and themselves and pronounced barriers to needed educational opportunities for their children, French parents started standing up against the status quo.³⁰ In response to mounting pressure from parental associations, policy makers adopted a series of measures to facilitate access to earlier and better care.²²

Under the 1996 French law, autism was officially recognized as a disability. By reframing autism as a disability rather than a “psychiatric disease,” this law enabled families to distance themselves from archaic misconceptions about autism. These misconceptions were especially prevalent among French psychiatrists at the time. In 2012, parents successfully advocated for resources to lead informational campaigns about autism for the French public.

However, the media the parent organizations produced at the time was not well aligned with the principles of the neurodiversity movement. More specifically, the media often framed autism as a “tragedy” or “pathology” rather than as a valued form of human diversity. Indeed, only a third of 1000 French participants in a study felt that adequate information was available to the public about autism and other disabilities.³¹

Some professionals also resisted the changes that parental advocacy sparked.²² According to Alliance Autiste,²⁶ a French autistic NGO, support offered to autistic individuals in France is often inadequate and does not align with national recommendations.^32,33 The current national policies in France, including the fourth National Autism Plan, favor an inclusive educational model for autistic people to the maximum extent possible.³⁴ Despite this policy, some autistic people still cannot access appropriate educational opportunities.³⁵ Alliance Autiste asserts that autistic people continue to experience educational exclusion.

Some are still forcibly hospitalized and medicated.³⁶ Existing research suggests that the lack of required training about autism for French professionals negatively impacts the degree to which French autistic students experience true educational inclusion. For example, Boujut et al.³⁷ found that teachers of autistic children in general education classrooms in France (3.9% of whom had received specialized disability-focused training) reported higher levels of professional isolation, more burnout, and less adaptive coping strategies than their peers in special education classrooms (90.7% of whom had received disability training).

In their study, Boujut et al. noted that these teachers did not perceive their professional practices as effective, in part due to a lack of time, means, or support. As is evident from the proportions of each group that had disability training, disability-focused training is not required for general education teachers in France.

To help autistic individuals receive the support they need, Alliance Autiste^26,36 called for training to decrease autism stigma in France. Alliance Autiste also advocated for robust data collection to hold French schools accountable for efforts to increase educational inclusion. In parallel, the Secrétariat d'État Chargé des Personnes Handicapées³⁸ has called for increased accessibility of primary school, higher education, and employment for people with disabilities in France and beyond. One way of increasing the inclusion of autistic people is through increased training for the professionals who support people with disabilities.

Aims and hypotheses of this study

To help develop strategies to begin to ameliorate discrimination toward autistic people in France, we adapted an autism training previously evaluated with aspiring educators in Québec, Canada, and the United States (Georgia).³⁹ For the initial Canadian and U.S. study, two individuals (the first author and a research assistant) translated the training and assessments into French Canadian. In accordance with best practices,⁴⁰ the research assistant who took part in the initial translation process was unaware of the study measures.

The researchers observed improvements in attitudes toward inclusion with training across both cultural contexts. Although the researchers also noted improvements in self-efficacy about teaching autistic students in both countries, follow-up analyses revealed that improvements were due to social desirability bias in Georgia but were not impacted by social desirability in Québec. Lastly, autism knowledge only improved in Québec. Saade et al.³⁹ noted that the lack of back translation may have impacted the internal consistency of the Autism Stigma and Knowledge Questionnaire (ASK-Q) (the measure of autism knowledge used in their study).

In their study, the internal consistency of the ASK-Q was much lower in Québec (α = 0.31) than in Georgia (α = 0.70). In this study, wherein we adapted the training and measures for use in France, we back translated all the measures we used and the training materials we adopted, as recommended for cross-cultural assessments.^40,41

We expected that participation in our autistic-affirming training would be associated with improvements in French participants' autism knowledge, attitudes toward inclusion, and stigma toward autistic individuals from pre- to post-test. We were also interested in exploring a possible relationship between increased autism knowledge and decreased stigma. Based on evidence that more autism knowledge is often associated with less stigma toward autistic people,^42,43 and some evidence that providing information about autism can improve stigma.^6,7,19–21 B.B.-F. hypothesized that pre–post changes in stigma would be negatively correlated with pre–post changes in knowledge.

Methods

Brief online autism training

Given the importance of inclusion, acceptance, and belonging for autistic people's quality of life and well-being and the evidence that autistic people in France have historically and still currently face educational exclusion, we developed our autistic-affirming training. To do so, we adapted a previously evaluated training that focused on promoting the educational inclusion of autistic students.³⁹ We supplemented this training with more recent information from a training developed in collaboration with autistic college students.⁴²

Recent evidence suggests that autism training developed in collaboration with autistic people may be more effective than training developed without substantive autistic input.²¹ From the training developed in collaboration with autistic students, we drew often overlooked information about autism (e.g., associations between motor and communication difficulties) and an introduction to the neurodiversity movement.

We drew accessible strategies from the training conducted by Saade et al.³⁹ that university students and/or educators can use to promote the full inclusion of autistic students. Among these strategies is treating neurodivergent peers with respect, structuring the environment to help reduce sensory stressors, and involving autistic learners in planning their own futures. Unlike much prior autism training, which has focused solely on strategies to support autistic children,⁴⁴ the training developed by Saade et al.³⁹ took a lifespan approach and emphasized a wide range of strategies to promote the educational and social inclusion of autistic people in multiple settings.

Such strategies had largely been absent in prior training, which have tended to focus on specific interventions for autistic people (most commonly Applied Behavior Analysis). Like the training described by Saade et al.,³⁹ our training provided strategies that emphasize equality between autistic people and others such as Universal Design (UD)⁴⁵ and peer-mediated supports.⁴⁶ UD proponents argue that the process of tailoring educational materials to the needs of one type of diverse learner (e.g., an autistic learner) is also beneficial to other types of diverse learners (e.g., non-native speakers).⁴⁷

Saade et al.³⁹ had initially translated the training and questionnaires into French Canadian. Given dialect differences between French Canadian and French from France, S.S., B.B.-F., and E.C. adapted the language used in the training as well as the questionnaires to make sure the language was understandable and adapted to the study participants. Lastly, an autistic bilingual translator who was unaware of the details of the training, as well as the measures used in this study, back translated the training and the questionnaires from French to English. This translation process aligns with recommendations for effective translation in cross-cultural research.^40,41

The final training included digital slides consisting of written text, illustrations illustrating concepts and comprehension checks (Supplementary Data; available exclusively in French). The training included information about autism (e.g., current diagnostic criteria and contributions of motor differences to potential communication difficulties), misconceptions about autism (e.g., that autistic people lack empathy or vaccines cause autism), Naturalistic Developmental Behavioral Interventions (NDBI),⁴⁸ UD strategies,⁴⁹ peer training to favor the social inclusion of autistic people,⁵⁰ the importance of involving autistic people in their own transition planning,⁵¹ and the neurodiversity movement.¹ Participants could progress through the training at their pace.

Study procedures

This study received institutional review board (IRB) approval from the ethics committee of the university formerly known as Paris Descartes and now known as Université Paris Cité (IRB No.: 00012019-86). We recruited participants between March 23rd, 2020, and May 31st, 2020, by means of (1) university mailing lists or Facebook pages and (2) learning platforms such as Moodle for courses available to first-year and second-year students. We sent students interested in participating in the study a consent form and a Qualtrics link to the study. Participants were considered eligible to participate in this study if they were a psychology or an education student, fluent in French, and willing to spend at least 45 minutes on our study.

We selected this inclusion criterion (being willing to spend at least 45 minutes on our study) based on our perception that spending less than 45 minutes on our training could be associated with less than serious participation. Fifty-six of the 82 participants recruited at the Psychology Institute of the Université Paris Cité participated in our study for credit, for example, to receive an extra point on their final grade (41 of these participants were recruited from autism-focused classes). The remaining participants (who were generally not in autism-focused classes) did not receive any form of compensation for participating.

Demographic characteristics

Out of 115 participants, 109 completed the entire study. Out of those 109 participants, we removed 2 participants' data as they did not meet our inclusion criteria (1 was not a student, and another completed the study in 25 minutes, which did not satisfy the prespecified inclusion criteria). In the final analyses, we focused on the 107 students who completed the entire study. The final sample included 92 women (86%), 13 men (12.1%), and 2 participants who selected “other” (1.9%; see Table 1 for participant characteristics). Two participants (1.9%) identified as autistic, and only three participants (2.8%) said they had met an autistic fellow student. Many participants had either worked with autistic people (33.6%) or never met an autistic person (30.8%).

Table 1.

Participants' Characteristics (N = 107)

Variable	n (%)
Gender
Female	92 (86.0)
Men	13 (12.1)
Other	2 (1.9)
Major
Psychology	97 (90.7)
Education	10 (9.3)
Relationship autism
Participant is autistic	2 (1.9)
Nuclear family member	6 (5.6)
Friend	8 (7.5)
Fellow student	3 (2.8)
Worked with autistic person	36 (33.6)
Educator of autistic person	13 (12.1)
Never met autistic person	33 (30.8)
Site
Psychology: Université Reims-Champagne Ardenne	15 (14)
Education: Institut National Supérieur du Professorat et de l'Éducation (INSPE) of Reims	7 (6.5)
Psychology: Université de Paris	82 (76.7)
Education: Institut National Supérieur du Professorat et de l'Éducation (INSPE) of Versailles	3 (2.8)
Educational level at the time of the study
First year	55 (51.4)
Second year	22 (20.6)
Third year	11 (10.3)
Fourth year	13 (12.1)
Fifth year	6 (5.6)
Age in years
18–24	89 (81.7)
25–34	10 (9.2)
35–44	4 (3.7)
45–54	3 (2.8)
55–64	1 (0.9)
Completed an autism training before our training
Yes	37 (34.6)
No	70 (66.4)

The majority of the sample was between 18 and 24 years old (83.2%) and were at the undergraduate level (82.2%). Participants were enrolled in two universities (Université Reims Champagne-Ardenne and Université Paris Cité) and two higher education institutions (Reims' and Versailles' Institut National Supérieur du Professorat et de l'Éducation). Ninety-seven students were pursuing a psychology degree (90.7%) while 10 were in education (9.3%). The majority of the sample was located in Paris (79.5%). One-third of the sample had already taken some form of autism training before completing our training.

Measures

Sociodemographic Questionnaire

In this study, we used a sociodemographic questionnaire developed by the research team to inquire about participants' characteristics, including gender, age, educational level, current diploma pursued, and whether they were fluent in French. In this questionnaire, we also asked two questions about prior autism training: “Have you received any training related to autism in the past” and “What was the approximate length of this training (in hours)?”

Participatory Autism Knowledge-Measure

We adapted the Participatory Autism Knowledge-Measure (PAK-M) from prior autism knowledge measures in collaboration with autistic college students. ²¹ The PAK-M has demonstrated acceptable internal consistency in the United States (α = 0.72–0.88) and Lebanon (α = 0.74),^37,42 and slightly lower internal consistency in South Korea (α = 0.68).⁴⁰ It consists of 29 items evaluating participants' agreement with current scientific knowledge about autism (e.g., “autistic people often notice details that people without autism miss”).

Participants were asked to respond to a series of questions ranging between −2 (disagree) through 0 (neither agree nor disagree) to 2 (agree). We reverse-coded nine items meaning that higher agreement initially meant lower accuracy (e.g., “Do vaccines cause autism?”). Higher final scores always mean more accuracy. Total scores could range from −58 (less autism knowledge) to 58 (more knowledge). In this study, Cronbach's alpha for the total score was α = 0.66 at pretest and α = 0.61 at post-test. Although lower than most internal consistency recommendations,⁵² internal consistencies were similar to the internal consistency for autism knowledge scales used in prior work (e.g., United States α = 0.68; Lebanon α = 0.62).⁵³

Autism Stigma and Knowledge Questionnaire

The ASK-Q is composed of 49 questions evaluating an individual's understanding of autism and perceived stigma toward autism in their communities. ⁵⁴ We asked participants whether they agree or disagree (two response options) with statements about autism (e.g., “Many children with autism have trouble tolerating loud noises or certain types of touch”). In the scale's initial validation, the ASK-Q displayed high internal consistency (α = 0.88).⁵⁴

The initial validation of the scale showed that the measure was multidimensional with evidence of reliable Diagnostic and Classification Model groupings for each subscale of α_Diagnosis = 0.98, α_Etiology = 0.95, α_Treatment = 0.98 and α_Stigma = 0.93. In this study, Cronbach's alphas (pretest: α_Diagnosis = 0.23; α_Etiology = 0.21; α_Treatment = 0.18; α_Stigma = 0.32; α_Total = 0.43; post-test: α_Diagnosis = 0.35; α_Etiology = 0.21; α_Treatment = 0.18; α_Stigma = 0.32; α_Total = 0.45) were much lower than recommended.

Given its unacceptable internal consistency in this context, we did not end up using the ASK-Q to evaluate this training. Although research supports that the ASK-Q has sufficient reliability in multiple cultural contexts,^55,56 other studies have documented lower internal consistency.³⁹ This indicates that researchers should evaluate this measure for differential item functioning across cultural contexts to result in more systematically adequate internal consistency when translated.

Social Distance Scale

We assessed explicit stigma using a social distance scale⁵⁷ (that had been adapted in collaboration with autistic college students).²¹ It consists of 10 items (5 reverse scored) that evaluate participants' willingness to interact with autistic individuals at various levels of intimacy (e.g., “How willing would you be to start a collaborative project with someone with autism?”). Participants were asked to rate items on a scale ranging from −2 (disagree) through 0 (neither agree nor disagree) to 2 (agree).

We summed the scores obtained on each item to derive a composite stigma score ranging between −20 and 20. The English version of this scale has had good internal consistency in other cultural contexts (e.g., Lebanon α = 0.85; United States α = 0.87–0.90)²¹ as did the French translation used in this study (pretest: α = 0.85; post-test: α = 0.80)

Attitudes Toward Inclusion

The Teacher Attitudes Toward Inclusion Scale (TATIS) is typically used to evaluate attitudes toward the inclusion of children with disabilities in the classroom. ⁵⁸ In a past autism training evaluation,³⁹ researchers adapted it to focus only on autistic students. For instance, the researchers replaced the phrase “student with mild to moderate disabilities” with “autistic students.” Participants responded on a scale ranging from −2 (disagree) through 0 (neither agree nor disagree) to 2 (agree).

We ended up shortening the 14-item measure to 7 items (3 reverse scored) for this study. The total score ranged from −14 (less favorable attitudes toward inclusion) to 14 (more favorable attitudes). Internal consistencies for the 7-item adaptation in this study (pretest α = 0.73; post-test α = 0.82) were similar to those obtained for the full measure in past work (Québec/Georgia α = 0.78).³⁹

Social Desirability Scale

We used Haghighat's Brief Social Desirability Scale. ^58,59 Given that we did not expect social desirability to change with training, we only measured it at post-test. This brief social desirability scale comprised five binary scored items (true or false) evaluating participants' need for social approval (e.g., “Do you always practice what you preach to people?”). We combined scores obtained on these five items into one composite score ranging between 0 (low social desirability) and 5 (high social desirability). In this study, Cronbach's alpha for social desirability was α = 0.57. Given its low internal consistency, we did not examine social desirability in depth.

Open-ended questions

Before and after the training, we asked participants to answer an open-ended question: “What is autism? Please use your own terms to clarify your definition of autism.” At the end of the training, we asked participants two questions: “What did you enjoy about this training” and “How can we improve this training?”

Data analysis

For the purposes of this study, we selected an alpha level of 0.05 or less. We used SPSS 24 to run the quantitative analyses. When we examined the data, we observed that outcome measures did not meet the assumptions for parametric analyses. As recommended by Tabachnick and Fidell,⁶⁰ any z-score that exceeded 3.29 was considered an outlier. For stigma, residuals were not normally distributed at either time point, and we observed two outliers, one at pretest and one at post-test. For knowledge and attitudes toward inclusion, residuals were not normally distributed at post-test.

Therefore, we used nonparametric analyses to run all of the analyses. We removed the outliers from our data set and noted that this removal did not change the pattern of results. As such, we decided to include outliers in our reported analyses. We used Spearman correlations to examine associations between variables at pretest. We also used Wilcoxon signed-ranks tests to examine changes in continuous variables with training.

We used content analysis to code participants' definitions of autism at both pretest and post-test.⁶¹ We also used content analysis to code participants' responses to the following questions: “What did you enjoy about this training” and “How can we improve this training?” at post-test. Concerning the autism definition question, two team members (K.G.-L. and S.S.) developed the codes inductively, based on patterns in the data, and deductively based on the coding of definitions of autism in past research.^20,62

K.G.-L., who was unaware of the time point each response was from while coding, served as the primary coder. She and S.S. obtained an inter-rater reliability of 90% or higher on 20% of the sample before K.G.-L. coding all of the data. See Supplementary Appendix SA for the full coding scheme. As for the other two questions: “What did you enjoy about this training” and “How can we improve this training?” S.S. developed the codes inductively, based on patterns in the data, and deductively based on the coding of those same questions in prior work.²¹

We obtained reliability of 90% or higher on 20% of the sample for each qualitative question. Lastly, we used McNemar's tests to examine potential changes in participants' definitions of autism with training. The McNemar test is a nonparametric test used to analyze paired nominal data. McNemar's test rests on a comparison of changes that occur in either direction.⁶³ This test uses a 2 × 2 contingency table to examine the marginal homogeneity of two dichotomous variables.⁶⁴

Results

Correlations revealed that participants who reported receiving autism training in the past did not differ from their counterparts in any outcome variables (see Table 2). However, participants who received credit for participating (many of whom were recruited from autism classes) demonstrated higher pretest knowledge, r(105) = 0.26, p = 0.007, but reported no differences in stigma and attitudes toward inclusion relative to those who did not receive credit.

Table 2.

Associations Between Participant Characteristics and Pretest Dependent Variables

	Credit	Male	Pleasant	Training	Work	Stigma	Knowledge	Inclusion
Male	−0.10
Pleasant experience	−0.06	−0.06
Past training	−0.09	−0.09	−0.02
Worked with autistic people	−0.07	−0.02	0.39^**	0.07
Prestigma	0.03	0.06	−0.39^**	−0.03	−0.07
Preknowledge	0.26^**	−0.06	−0.12	0.11	−0.02	−0.25^*
Preinclusion	0.05	−0.03	−0.12	0.10	0.20^*	−0.27^**	0.10
Social desirability	−0.02	−0.27^**	0.16	0.02	−0.02	−0.10	−0.18	−0.05

Spearman's correlations: ^*p < 0.05; ^**p < 0.01; ^***p < 0.00.

Participants who had worked with autistic people in the past reported more pleasant experiences with autistic people, r(105) = 0.39, p < 0.001, and greater support for inclusion, r(105) = 0.20, p = 0.04, than those who had not. Heightened pretest stigma was associated with less pleasant reported past contact with autistic people, r(105) = −0.39, p < 0.001, less autism knowledge, r(105) = −0.25, p = 0.01, and less positive attitudes toward inclusion, r(105) = −0.27, p = 0.005. Reduced social desirability bias was only associated with being male, r(105) = −0.27, p = 0.005, and none of the outcome variables.

Were improvements observed after training?

Participation in the training was associated with large effect size improvements across all outcome variables (see Table 3). The median autism stigma score decreased from pretest (Mdn = −15.0) to post-test (Mdn = −17.0), Z = 5.25, p < 0.001, r = 0.51. Autism knowledge also improved after participation in the training Z = −8.93, p < 0.001, r = 0.86. The median autism knowledge score increased from pretest (Mdn = 32.0) to post-test (Mdn = 45.0). Lastly, attitudes toward inclusion also seemed to improve after participation in the training Z = −6.33, p < 0.001, r = 0.61. The median score obtained on attitudes toward inclusion increased from pretest Mdn = 3.0) to post-test (Mdn = 6.0).

Table 3.

Wilcoxon Signed-Ranks Tests to Examine Changes in Continuous Variables with Training

	Pretest	Post-test	Z	p	Effect size
	Median	Median	Z	p	Effect size
Stigma	−15.0	−17.0	5.25	<0.001	0.51
Autism knowledge	32.0	45.0	−8.93	<0.001	0.86
Support for inclusion	3.0	6.0	−6.3	<0.001	0.61

Stigma was assessed using the social distance scale, autism knowledge was assessed through the PAK-M, and support for inclusion was assessed with the TATIS.

PAK-M, Participatory Autism Knowledge-Measure; TATIS, Teacher Attitudes Toward Inclusion Scale.

We used correlations to determine whether improvements with training were attributable to social desirability bias and to evaluate our hypothesis that improvements in stigma would be associated with improvements in knowledge. Improvements in outcome variables were not associated with social desirability bias, p's > 0.27. However, participants who were receiving credit for participating demonstrated less improvement in knowledge than their counterparts who were not receiving credit, r(105) = −0.29, p = 0.003.

This is likely because those who received credit had higher knowledge at pretest. When we split the data based on whether participants received credit or not, we noted improvements in knowledge for both those who did and did not receive credit for participating (p's < 0.001). Contrary to our second hypothesis, improvements in autism knowledge were not correlated with improvements in stigma, p = 0.095. However, improvements in knowledge were associated with improvements in attitudes toward inclusion, r(105) = 0.22, p = 0.003.

Qualitative coding of open-ended responses revealed that participants were less likely to include something negative in their definition of autism at post-test relative to pretest, p = 0.004 (see Table 4). Few participants included something positive in their definition of autistic people at either time point, p = 0.66 (e.g., “It is a brain that works differently, that has emotional empathy”). Participants were more likely to describe autism as a neutral difference (e.g., “Autism is not a disease but rather a different way of functioning”) at post-test relative to pretest, p = 0.009).

Table 4.

McNemar's Examining Potential Changes in Participant’ Open-Ended Definitions of Autism

	Pretest (%)	Post-test (%)	p	Φ
Social	84	74	0.052	0.37
RIRB	48	47	1.00	0.03
Negative	94	82	0.004	0.63
SC: Disease	15	10	0.30	0.27
Positive	19	21	0.66	0.10
Neutral difference	20	35	0.009	0.44
Spectrum	50	48	0.74	0.05
Cause	46	70	<0.001	0.74
SC: Neurobiological	43	67	<0.001	0.69
Timing: Onset	19	16	0.61	0.13
Timing: Lifelong	5	19	<0.001	0.82
Timing: Variations	4	11	0.057	0.50
Prevalence Groups	2	10	0.008	0.88
Needs help	7	10	0.42	0.21

RIRB, restricted behaviors and repetitive behaviors; SC, social communication skills.

Around half of the participants described autism as a spectrum at both time points (e.g., “There is more than one autism profile composed of a spectrum of different autistic traits.”). Participants were more likely to refer to causes in their definitions of autism at post-test than at pretest, particularly neurobiological explanations, p's < 0.001 (e.g., “Autism is a neurodevelopmental disorder with a still unknown origin”). Participants were also more likely to highlight factors that may influence group differences in autism prevalence at post-test than at pretest, p = 0.008 (e.g., “Autistic people are more likely to be boys.”). Participants were also more likely to highlight that autism is lifelong at post-test than at pretest, p < 0.001 (e.g., “An autistic person stays autistic throughout their life.”).

What did participants like and recommend improving in the training?

When asked at the end of the study, “What did you enjoy about this training?” many participants mentioned a positive aspect of the training (87.5%) such as “Learning new strategies to improve autistic people's daily life” and “Deepening my knowledge of autism and reflecting on the importance of their inclusion.” Many participants (54%) indicated that they had learned new things from the training: “The training taught me new things,” whereas 25% indicated that it reinforced things they had learned in their classes: “Even though I had already taken a course on the subject, the training served as a booster shot.”

Lastly, 21% indicated that it had changed their perspectives: “Allows some people who have no knowledge of autism to change their perspective.” See Supplementary Appendix SB for the full coding scheme and percentages of responses that received each code.

When asked: “How can we improve this training?” a quarter of participants mentioned shortening the length of the training (25%) and possibly splitting it up into multiple sections (4.17%). A third of participants suggested that it be made more interactive such as “Make it a but more interactive: adding mini questionnaires in the slides. Adding images and examples to illustrate some concepts.” See Supplementary Appendix SC for the full coding scheme and the percentage of responses that received each code. One participant's response is particularly important to highlight as it aligns with Alliance Autiste's recommendation to involve autistic people in training about autism in France:⁶⁵ “Include more testimonials, have autistic people or people living with them share their experiences.”

Discussion

Extending upon findings in other cultural contexts,^{6,7,19–21,39} the current findings indicate that a relatively brief autistic-affirming online training may help improve attitudes toward inclusion, autism knowledge, and stigma among future educators and psychologists in France. To the best of our knowledge, this is the first study in the peer-reviewed literature to have evaluated an autism training offered in French to French University participants. As such, the current training may help address concerns raised by autistic advocates, members of the general public, and policy makers in France, who have called for antistigma training and better access to information about autism.^26,36,65

Compared to participants in both the United States and Lebanon,²⁰ fewer participants in this study described having met a fellow autistic student. The results obtained from this study, align with reports that access to both autism diagnoses and schooling has been limited for autistic people in France.^35,36 Indeed, around a third of the participants in this study reported having never met any autistic people at all.

One needs to interpret this finding with caution as autistic people may not get diagnosed until adulthood.⁶⁶ Lack of opportunities to meet autistic people may contribute to misconceptions and stigma toward autistic people. Research in the broader antistigma literature suggests that opportunities to engage in high-quality contact with people with disabilities are far more effective at reducing stigma than purely knowledge-focused interventions.⁶⁷ In alignment with this, the goal of this autistic-affirming training was to provide a broad, comprehensive, and balanced view of autism.

Our findings also provide some support for the relative importance of contact over facts for stigma reduction. For example, findings did not support our second hypothesis, that improvements in knowledge would be clearly associated with improvements in stigma. Participation in a prior autism training was also not related to any outcome variables. However, having worked with autistic people was associated with more pleasant experiences with autistic people and more positive attitudes toward inclusion.

As in many past studies,^42.53 more pleasant experiences with autistic people were, in turn, associated with lower levels of stigma in this study. Together, these findings suggest that positive experiences with autistic people (and their perspectives, e.g., exposure to the neurodiversity movement) may have more influence on autism stigma than simply providing facts.

However, participants who received credit for participating (many of whom were enrolled in autism-focused classes) demonstrated heightened pretest autism knowledge. Although the fact that some participants received credit while others did not is a limitation of this study, it also suggests that the training can be helpful for diverse students. This is also true for students with more or less autism knowledge before training. Although changes in knowledge were not associated with changes in stigma, improved knowledge was associated with improved attitudes toward inclusion. The current findings suggest that both access to facts and opportunities for direct positive contact with autistic people may be helpful in promoting inclusion, a key goal for autistic advocates, policy makers, and educators in France.

In addition to the aforementioned improvements in closed-ended measures, qualitative coding of participants' open-ended definitions of autism revealed a number of promising improvements in their conceptions of autism. With training, participants' definitions became more neurodiversity affirming. The neurodiversity movement views autism both positively, as a valuable minority identity, and neutrally, as one way of being different in the vast web of human diversity.³ After participation in our training, which included information about the neurodiversity movement, participants de-emphasized negative descriptions in their definitions of autism and increasingly described autism in terms of neutral differences.

Also, suggesting increasingly neurodiversity-affirming conceptions of autism after training, participants became more likely to emphasize that autism is lifelong. This finding is consistent with the idea that autism is an integral part of one's identity, and is associated with neurobiological differences. Changes in participants' definitions of autism following training also reflect increasing awareness of the stark disparities in access to autism diagnoses that autistic people who are not White males often face.^68,69

Our qualitative findings suggest that our autistic-affirming training may have helped participants develop not only more positive attitudes about the inclusion of autistic people, but also knowledge and perspectives that may encourage them to fight for needed changes in the systems that oppress autistic people (see Botha and Frost¹⁷ for a description of this systemic oppression).

Limitations and future directions

This study has a number of limitations that must be taken into consideration. First is the issue of generalization. Our sample was small, limiting power and generalizability of findings. Participants in our study did not represent the French population, nor did they represent all French students. Our sample was mostly female, which is not atypical in this kind of research.³⁹ Our sample was also solely composed of future psychologists and educators.

In light of those limitations, we advise future researchers to replicate this study with students pursuing other degrees. Examples of such fields of study include speech therapy and occupational therapy. We also advise future researchers to replicate our study in different universities across France to capture greater diversity of majors, institutions, and identities. Future training should be adapted/developed and delivered in collaboration with autistic people, as recommended by Alliance Autiste.⁶⁵

Furthermore, one also needs to consider that what people say about stigmatization may not predict their actual behaviors. The lack of behavioral assessments for stigma is a pervasive issue throughout most of the autism antistigma literature. The same limitation applies to attitudes toward inclusion. Relatedly, we only included explicit stigma measures. We did not account for implicit stigma. Although explicit biases are more likely to be influenced by social desirability,^70,71 implicit biases are more likely to be automatic and impact unconscious or impulsive decisions.⁷²

Implicit biases may be more difficult to shift than explicit stigma. For example, Jones ⁷ found that participation in autism training was associated with reduced explicit stigma but had no effect on implicit biases. However, participation in an autism training that served as one of the inspirations for the training described in the current report was associated with improvements in both implicit and explicit biases toward autism.²¹

Other limitations include the absence of a randomized design, which prevents us from drawing causal conclusions, and the lack of examination of maintenance effects. Recent research suggests that a similar autism training for university educators led to improvements that maintain over time.⁷³ Future research should assess maintenance directly with students.

Some measures also exhibited low internal consistency, such as the ASK-Q, social desirability measure, and to a lesser degree, the PAK-M. These issues highlight the ongoing difficulties the research community is facing. Measuring complicated constructs that change over time and other contexts, like autism knowledge reliably across cultural contexts, could be tricky. Clearly, measurement adaptations and development in collaboration with autistic people are needed to improve existing approaches to measuring understanding of and acceptance of autism. In the process of developing this study, we became aware of concerns within the broader autistic community that social distance scales might inadvertently contribute to increases in stigma by normalizing the exclusion of autistic people.

Although some recent evidence suggests that this may not be the case,²¹ these concerns further highlight the importance of respecting lived expertise by collaborating with autistic people when developing measures of autism knowledge and acceptance. A recent highly participatory study found that an acceptance-oriented stigma scale, which did not normalize exclusion, was arguably as effective as more exclusion-oriented stigma measures have been in measuring changes in stigma after training.⁷³

When asked about ways to improve our training, one participant said: “Training should be offered to the population at large to reduce stereotypes and help improve living conditions of autistic individuals who do not have sufficient help. Talking about it in schools during childhood.” Researchers utilizing future adaptations of this and other training should heed such advice. More specifically, we advise researchers to become more participatory and develop innovative strategies to educate people in the general public (e.g., by making autism training a part of schooling across the lifespan) in collaboration with autistic people.

Conclusion

This study suggests that a relatively brief autistic-affirming online training helped students in France develop a greater understanding and acceptance of autistic people. The current training, if used more widely, could help address calls from autistic advocates and members of the French public for training to increase broader access to information about autism, decrease stigma, and improve the inclusion of autistic individuals. These results and the associated training materials could hopefully support French NGOs such as Alliance Autiste in their fight to include autistic individuals in all societal spheres. Ultimately, our hope in conducting such training is to help autistic individuals reach their full potential by helping community members understand and appreciate this potential.

Footnotes

Acknowledgments

We thank Flore Picard for back translating all questionnaires from French to English and providing useful critiques of measures. We also thank all participants and heads of faculty and teachers who helped with recruitment.

Authorship Confirmation Statement

S.S. contributed to the development of research protocol, analyzed qualitative data, and participated in writing, proofreading, revising, and editing the article. B.B.-F. developed the research protocol for his master's thesis, participated in recruiting participants, collecting data, writing, and proofreading the article. K.G.-L. led development of the research protocol as part of a broader cross-cultural collaboration, analyzed qualitative data, provided feedback on earlier drafts of the article, conducted additional literature review, revised primary analyses to align with data distributions, and contributed very substantially to the writing of the final version of this article.

C.B.-R. supervised the master's thesis of B.B.-F., participated in recruiting participants, and proofreading the article. E.B. participated in recruiting participants and proofreading the article. A.J.H. consulted in measurement adaptation and study design, provided extensive feedback on earlier drafts, participated in proofreading, and editing the article. E.C., scientific head of the study, cosupervised the master's thesis of B.B.-F., participated in recruiting participants, analyzed quantitative data, and participated in writing, proofreading, and editing the article.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The authors did not receive any funding for this study.

Supplementary Material

References

Singer

. NeuroDiversity: The Birth of an Idea [Kindle Edition]. 2nd edition. Judy Singer; 2016.

Blume

. Neurodiversity. The

Atlantic

. 1998. https://www.theatlantic.com/magazine/archive/1998/09/neurodiversity/305909/ Accessed November 30, 2022.

Kapp

, Gillespie-Lynch

, Sherman

, Hutman

. Deficit, difference, or both? Autism and neurodiversity. Dev Psychol. 2013; 49(1):59–71.

Kapp

, ed. Autistic Community and the Neurodiversity Movement: Stories from the Frontline. NY, USA: Springer; 2020.

Robertson

. Neurodiversity, quality of life, and autistic adults: Shifting research and professional focuses onto real-life challenges. Disabil Stud Q. 2010; 30(1):59–71.

Gillespie-Lynch

, Brooks

, Someki

, et al. Changing college students' conceptions of autism: An online training to increase knowledge and decrease stigma. J Autism Dev Disord. 2015; 45(8):2553–2566.

Jones

, DeBrabander

, Sasson

. Effects of autism acceptance training on explicit and implicit biases toward autism. Autism Int J Res Pract. 2021; 25(5):1246–1261.

Cage

, Di Monaco

, Newell

. Experiences of autism acceptance and mental health in autistic adults. J Autism Dev Disord. 2018; 48(2):473–484.

Gelbar

, Smith

, Reichow

. systematic review of articles describing experience and supports of individuals with autism enrolled in College and University Programs. J Autism Dev Disord. 2014; 44(10):2593–2601.

10.

McLeod

, Meanwell

, Hawbaker

. The experiences of college students on the autism spectrum: A comparison to their neurotypical peers. J Autism Dev Disord. 2019; 49(6):2320–2336.

11.

Sturm

, Kasari

. Academic and psychosocial characteristics of incoming college freshmen with autism spectrum disorder: The role of comorbidity and gender. Autism Res. 2019; 12(6):931–940.

12.

Cheriyan

, Shevchuk-Hill

, Riccio

, et al. Exploring the career motivations, strengths, and challenges of autistic and non-autistic university students: Insights from a participatory study. Front Psychol. 2021; 12:4455.

13.

Goffman

. Stigma: Notes on the Management of Spoiled Identity. NY, USA: Simon and Schuster; 2009.

14.

Link

, Phelan

. Conceptualizing stigma. Annu Rev Sociol. 2001; 27(1):363–385.

15.

Holden

, Mueller

, McGowan

, et al. Investigating bullying as a predictor of suicidality in a clinical sample of adolescents with Autism Spectrum Disorder. Autism Res Off J Int Soc Autism Res. 2020; 13(6):988–997.

16.

Milton

, Sims

. How is a sense of well-being and belonging constructed in the accounts of autistic adults?. Disabil Soc. 2016; 31(4):520–534.

17.

Botha

, Frost

. Extending the minority stress model to understand mental health problems experienced by the Autistic Population. Soc Ment Health. 2020; 10(1):20–34.

18.

Bakker

, Krabbendam

, Bhulai

, Begeer

. Background and enrollment characteristics of students with autism in higher education. Res Autism Spectr Disord. 2019; 67:101424.

19.

Someki

, Torii

, Brooks

, Koeda

, Gillespie-Lynch

. Stigma associated with autism among college students in Japan and the United States: An online training study. Res Dev Disabil. 2018; 76:88–98.

20.

Obeid

, Daou

, DeNigris

, et al. A cross-cultural comparison of knowledge and stigma associated with autism spectrum disorder among college students in Lebanon and the United States. J Autism Dev Disord. 2015; 45(11):3520–3536.

21.

Gillespie-Lynch

, Bisson

, Saade

, et al. If you want to develop an effective autism training, ask autistic students to help you. Autism. 2022; 26(5):1082–1094.

22.

Chamak

, Bonniau

. Changes in the diagnosis of autism: How parents and professionals act and react in France. Cult Med Psychiatry. 2013; 37(3):405–426.

23.

Feinstein

. A History of Autism: Conversations with the Pioneers. NJ, USA: John Wiley & Sons; 2011.

24.

Autisme France. Report on the experiences of autistic people and their families in France at the dawn of the 21st century-Testimonies of hope for tomorrow. Autism France [in French]; 1994. https://www.biblio.com/book/rapport-vecu-autistes-familles-france-laube/d/534764847 Accessed December 2, 2022.

25.

France's Autism Treatment “Shame.” BBC News; 2012. https://www.bbc.com/news/magazine-17583123 Accessed August 19, 2022.

26.

Alliance

Autiste

. Alternative report of the NGO Alliance Autism-Autistic children-France- Children' s Rights Committee

. Autism Alliance [in French]. 2015:26. https://allianceautiste.org/wp-content/uploads/2015/07/20150225_AllianceAutiste_rapport_alternatif_France_CRC_fr_5.pdf Accessed December 12, 2022.

27.

Chamak

. Lobbying by association: The case of autism and the controversy over packing therapy in France. Soc Sci Med. 2019; 230:256–263.

28.

Alliance Autiste. Public Service.fr: Equitable access to justice for handicapped autistic people [in French]. 2021. https://allianceautiste.org/2021/06/service-public-fr-acces-equitable-a-la-justice-pour-les-personnes-handicapees-autistes/ Accessed December 12, 2022.

29.

Chamak

. Autism and stigmatisation [in French]. Inf Psychiatr. 2011; 87(5):403–407.

30.

Chamak

. Autism and social movements: French parents' associations and international autistic individuals' organisations. Sociol Health Illn. 2008; 30(1):76–96.

31.

Durand-Zaleski

, Scott

, Rouillon

, Leboyer

. A first national survey of knowledge, attitudes and behaviours towards schizophrenia, bipolar disorders and autism in France. BMC Psychiatry. 2012; 12(1):128.

32.

Haute Autorité de Santé. Autism Spectrum Disorder: Adult interventions and life course [in French]. HAS. 2017:68.

33.

Haute Autorité de Santé, ANESM. Autism and others Pervasive Developmental Disorders: coordinated educational and therapeutic interventions for the child and the teenager [in French]. 2012.

34.

Gouvernement. Liberty. Equality. Brotherhood. Disability: A priority for the five-year term. https://www.gouvernement.fr/en/disability-a-priority-for-the-five-year-term Accessed August 19, 2022.

35.

ELENA Study

Group

, Rattaz

, Munir

, et al. School inclusion in children and adolescents with autism spectrum disorders in France: Report from the ELENA French Cohort Study. J Autism Dev Disord. 2020; 50(2):455–466.

36.

Alliance Autiste. Report on the application of the CDPH in France with analysis of responses from France (03/11/2020) to the points list (30/10/2019) in the context of the examination of the French State during the 25th UN session of the Committee on the rights of persons with disabilities (16/08/2021–23/08/2021) [in French]. 2021. https://allianceautiste.org/docs/AA_OrgIntl/ONU-CDPH/Rapport_2021/20210805_Alliance-Autiste_Rapport-application-CDPH-France.htm Accessed December 2, 2022.

37.

Boujut

, Dean

, Grouselle

, Cappe

. Comparative study of teachers in regular schools and teachers in specialized schools in France, working with students with an autism spectrum disorder: Stress, social support, coping strategies and burnout. J Autism Dev Disord. 2016; 46(9):2874–2889.

38.

Secrétariat d'État Chargé des Personnes Handicapées. Commitment 3- Making up for the delay in schooling [in French]. 2021. https://handicap.gouv.fr/engagement-3 Accessed August 19, 2022.

39.

Saade

, Bean

, Gillespie-Lynch

, Poirier

, Harrison

. Can participation in an online ASD training enhance attitudes toward inclusion, teaching self-Efficacy and ASD knowledge among preservice educators in diverse cultural contexts?. Int J Incl Educ. 2021:1–16; doi: 10.1080/13603116.2021.1931716

40.

Bracken

, Barona

. State of the art procedures for translating, validating and using psychoeducational tests in Cross-Cultural Assessment. Sch Psychol Int. 1991; 12(1–2):119–132.

41.

Sousa

, Rojjanasrirat

. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline: Validation of instruments or scales. J Eval Clin Pract. 2011; 17(2):268–274.

42.

Kim

, Cheon

, Gillespie-Lynch

, Kim

. Is autism stigma higher in South Korea than the United States? Examining cultural tightness, intergroup bias, and concerns about heredity as contributors to heightened autism stigma. Autism. 2022; 26(2):460–472.

43.

Morrison

, DeBrabander

, Faso

, Sasson

. Variability in first impressions of autistic adults made by neurotypical raters is driven more by characteristics of the rater than by characteristics of autistic adults. Autism. 2019; 23(7):1817–1829.

44.

Alexander

, Ayres

, Smith

. Training teachers in evidence-based practice for individuals with autism spectrum disorder: A review of the literature. Teach Educ Spec Educ J Teach Educ Div Counc Except Child. 2015; 38(1):13–27.

45.

Woronko

, Killoran

, Woronko

, Killoran

. Creating Inclusive Environments for Children with Autism. IntechOpen; 2011.

46.

Locke

, Rotheram-Fuller

, Kasari

. Exploring the social impact of being a typical peer model for included children with autism spectrum disorder. J Autism Dev Disord. 2012; 42(9):1895–1905.

47.

Burgstahler

. Universal Design in Education: Principles and Applications. Univ Wash. 2021:6.

48.

Schreibman

, Dawson

, Stahmer

, et al. Naturalistic developmental behavioral interventions: Empirically validated treatments for autism spectrum disorder. J Autism Dev Disord. 2015; 45(8):2411–2428.

49.

Bublitz

, Wong

, Donachie

, Brooks

, Gillespie-Lynch

. Applying Universal Design to Build Supports for College Students with Autism Spectrum Disorder. 2015:25.

50.

Kasari

, Rotheram-Fuller

, Locke

, Gulsrud

. Making the connection: Randomized controlled trial of social skills at school for children with autism spectrum disorders: Social skills intervention. J Child Psychol Psychiatry. 2012; 53(4):431–439.

51.

Chandroo

, Strnadová

, Cumming

. A systematic review of the involvement of students with autism spectrum disorder in the transition planning process: Need for voice and empowerment. Res Dev Disabil. 2018; 83:8–17.

52.

Ponterotto

, Ruckdeschel

. An overview of coefficient alpha and a reliability matrix for estimating adequacy of internal consistency coefficients with psychological research measures. Percept Mot Skills. 2007; 105(3 Pt 1):997–1014.

53.

Gillespie-Lynch

, Daou

, Sanchez-Ruiz

, et al. Factors underlying cross-cultural differences in stigma toward autism among college students in Lebanon and the United States. Autism. 2019; 23(8):1993–2006.

54.

Harrison

, Bradshaw

, Naqvi

, Paff

, Campbell

. Development and psychometric evaluation of the Autism Stigma and Knowledge Questionnaire (ASK-Q). J Autism Dev Disord. 2017; 47(10):3281–3295.

55.

Harrison

, Paff

, Kaff

. Examining the psychometric properties of the autism stigma and knowledge questionnaire (ASK-Q) in multiple contexts. Res Autism Spectr Disord. 2019; 57:28–34.

56.

, Stronach

, Harrison

. Public knowledge and stigma of autism spectrum disorder: Comparing China with the United States. Autism Int J Res Pract. 2020; 24(6):1531–1545.

57.

Bogardus

. A social distance scale. Sociol Soc Res. 1933; 17:265–271.

58.

Cullen

, Gregory

, Noto

. The Teacher Attitudes Toward Inclusion Scale (TATIS) Technical

Report

. 2010. https://eric.ed.gov/?id=ED509930 Accessed April 5, 2019.

59.

Haghighat

. The development of the Brief Social Desirability Scale (BSDS). Eur J Psychol. 2007; 3(4). doi:10.5964/ejop.v3i4.417

60.

Tabachnick

, Fidell

. Using Multivariate Statistics. Pearson New International Edition, Sixth Edition. London, UK: Pearson;. 2014.

61.

Hsieh

, Shannon

. Three approaches to qualitative content analysis. Qual Health Res. 2005; 15(9):1277–1288.

62.

Riccio

, Kapp

, Jordan

, Dorelien

, Gillespie-Lynch

. How is autistic identity in adolescence influenced by parental disclosure decisions and perceptions of autism?. Autism. 2021; 25(2):374–388.

63.

Little

, ed. The Oxford Handbook of Quantitative Methods in Psychology. Vol. 1, Foundations. Oxford, UK: Oxford University Press;. 2013.

64.

Sundjaja

, Shrestha

, Krishan

. McNemar and Mann-Whitney U tests. Treasure Island, FL, USA: StatPearls Publishing; 2022.

65.

Alliance Autiste. INSHEA: Request for information regarding training that might be of interest to us and the possible consultation of organizations of handicapped autistic people [in French]. 2022. https://allianceautiste.org/2022/11/inshea-demande-d-informations-au-sujet-de-formations-nous-concernant-et-de-l-eventuelle-consultation-des-organisations-de-personnes-autistes-handicapees/ Accessed December 12, 2022.

66.

Lewis

. A mixed methods study of barriers to formal diagnosis of autism spectrum disorder in adults. J Autism Dev Disord. 2017; 47(8):2410–2424.

67.

Corrigan

. Lessons learned from unintended consequences about erasing the stigma of mental illness. World Psychiatry. 2016; 15(1):67–73.

68.

Cumin

, Pelaez

, Mottron

. Positive and differential diagnosis of autism in verbal women of typical intelligence: A Delphi study. Autism. 2022; 26(5):1153–1164.

69.

Durkin

, Elsabbagh

, Barbaro

, et al. Autism screening and diagnosis in low resource settings: Challenges and opportunities to enhance research and services worldwide. Autism Res. 2015; 8(5):473–476.

70.

Dovidio

, Kawakami

, Johnson

, Howard

. On the nature of prejudice: Automatic and controlled processes. J Exp Soc Psychol. 1997; 33(5):510–540.

71.

Stier

, Hinshaw

. Explicit and implicit stigma against individuals with mental illness. Aust Psychol. 2007; 42(2):106–117.

72.

Strack

, Deutsch

. Reflective and impulsive determinants of social behavior. Pers Soc Psychol Rev. 2004; 8(3):220–247.

73.

Waisman

, Williams

, Cage

, et al. Learning from the experts: Evaluating a participatory autism and universal design training for university educators. Autism. 2023; 27(2):356–370.

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