Autism spectrum disorder etiology: Lay beliefs and the role of cultural values and social axioms

Abstract

Recent research examining the explanations given by the public (i.e. lay beliefs) for autism spectrum disorder often reveals a reasonably accurate understanding of the biogenetic basis of the disorder. However, lay beliefs often manifest aspects of culture, and much of this work has been conducted in western cultures. In this study, 215 undergraduate university students in Macau, a Special Administrative Region of China, completed self-report measures assessing two beliefs concerning autism spectrum disorder etiology: (1) a belief in parental factors and (2) a belief in genetic factors. Potential correlates of lay beliefs were sought in culture-specific values, and more universal social axioms. Participants were significantly more likely to endorse parenting, relative to genetic factors, as etiological. A perceived parental etiology was predicted by values of mind–body holism. Beliefs in a parental etiology were not predicted by values assessing collectivism, conformity to norms, a belief in a family’s ability to obtain recognition through a child’s achievement, or interpersonal harmony, nor by the social axioms measured (e.g. social cynicism, reward for application, social complexity, fate control, and religiosity). Beliefs in a genetic etiology were not predicted by either culture-specific values or social axioms. Implications of the current results are discussed.

Keywords

autism China culture genetics lay beliefs parenting social axioms values

Introduction

Autism spectrum disorder (ASD) is a developmental disorder with an etiology presumed to have a substantial genetic component (Stefanatos, 2013). However, while a genetic contribution to etiology is widely accepted (Tordjman et al., 2014), the specific mechanism itself is unknown. Furthermore, while specific environmental variables (e.g. maternal exposure during pregnancy to higher levels of particulate matter contained within air pollution) may influence the risk for ASD (Raz et al., 2015), the process by which such risk factors would interact with an underlying genetic predisposition toward ASD development has not been well elucidated. On the one hand, initial conceptualizations attributing ASD to cold and unemotional parents (Bettelheim, 1967) are now considered obsolete (Volkmar et al., 1997), and family lifestyle and related family factors such as income and educational level are no longer considered risk factors in ASD onset (Autism Society of America, 2000). On the other hand, the uncertainty, even among experts, concerning the precise nature of ASD etiology, could conceivably create a vacuum allowing speculation about ASD etiology in the lay population to flourish.

Nonetheless, recent research examining lay theories of ASD, much of it from the perspective of family members of individuals with the disorder, generally finds that the most strongly held beliefs regarding causality are those in which genetic variables, and to a comparable extent, neurobiological factors, are implicated (Al Anbar et al., 2010; Dardennes et al., 2011; Mercer et al., 2006). As many as 90% of study participants may report a belief in a genetic etiology in ASD (Mercer et al., 2006). While these numbers may be lower depending on the specific study in question (Al Anbar et al., 2010), they nonetheless tend to represent a majority opinion. In this research, parenting factors as a causal influence on ASD may be outright rejected (Dardennes et al., 2011; Furnham and Buck, 2003) or simply omitted from consideration (Al Anbar et al., 2010; Mercer et al., 2006). Comparable findings are produced in non-family member samples, in which a genetic cause is either the most frequently endorsed (Mitchell and Locke, 2015) or the second most frequently endorsed etiology (Holt and Christensen, 2013; Tipton and Blacher, 2014), even if this belief, while common, is endorsed at various frequencies across studies (e.g. 33.4%–73%; Holt and Christensen, 2013; Mitchell and Locke, 2015; Tipton and Blacher, 2014). In contrast, similar to what is found in samples of family members of an individual with ASD, very few participants attribute ASD to parenting (e.g. <1%, Holt and Christensen, 2013; 2.2%, Mitchell and Locke, 2015) and, in some reports, this variable is not given any consideration whatsoever (Tipton and Blacher, 2014). While a more complex picture emerges when participant beliefs are expressed in narrative, rather than questionnaire format (Huws and Jones, 2010), recent research appears to capture a theme in which non-genetic or non-neurobiological causal attributions in ASD reflect beliefs in potentially unexplored environmental factors (e.g. vaccines, new technologies) as etiological, not poor parenting (Russell et al., 2010).

However, the aforementioned body of research arises uniformly from work conducted in western cultures: France, the United Kingdom, Canada, and the United States. Culture introduces a level of complexity to this field of study because different cultural groups may have culture-specific ways of explaining atypical behavior. An individual’s explanatory model for illness and disability is typically a combination of personal idiosyncratic beliefs and biomedical concepts, and ethnocultural beliefs (Patcher, 1994) Thus, for instance, in Asian cultures, disorders of development may be viewed as punishment for personal or ancestral violations of religious, ethical, or cultural codes (Sage and Jegatheesan, 2010). Unfortunately, only a handful of studies on lay beliefs in Asian cultures have addressed ASD specifically. Recent studies, conducted in Japan, Singapore, and China, find the number of participants definitively attributing ASD to parental/home environmental factors to be greater than that found in western samples although still in the minority (e.g. 15%–21%; Koyama et al., 2009; Lian et al., 2008; Wang et al., 2012). In the study conducted in Japan, only 17% of participants identified a genetic cause although more than 50% attributed ASD to a brain abnormality (Koyama et al., 2009). In the studies conducted in Singapore and China (Lian et al., 2008; Wang et al., 2012), beliefs in other etiologies were simply not queried.

Of note, the aforementioned studies in Japan, Singapore, and China contained methodological specifications potentially limiting their generalizability to the population at large. In the study conducted in Singapore, participants were preschool teachers with a median of 6 years of experience and formal training in early childhood, and nearly half of the sample had experience working with a child with special needs (Lian et al., 2008). Additionally, as part of the research design, participants consisted of those teachers “appointed by their respective centers” to attend a lecture on normal development and childhood disorders (attended after study completion), suggesting that even within this population of teachers, the sample in question may have represented a specific subset of individuals selected on the basis of a set of criteria not made explicit in the published report. Thus, while educational and occupational exposure to young children need not equate unequivocally to knowledge of developmental disorders, and more than half of the participants had not worked with a child with special needs, it could be argued nonetheless that such prior educational and occupational opportunities distinguish this sample from that of other samples potentially drawn from the community at large.

The study in China may have captured a more representative community sample in regard to ASD knowledge (Wang et al., 2012). Participants consisted of relatives (>90% were parents) of children 3–6 years of age enrolled in kindergarten. Most participants had heard of ASD (approximately 94%) although only a small minority had “been in contact with” a child with ASD (5.8%), and very few participants (<1%) had an individual with ASD in the family. In this report, participants were queried about ASD knowledge via the endorsement of statements describing typical ASD symptoms. They were then asked additional questions about ASD. Knowledge about etiology was not addressed directly although participants were asked whether the disorder was associated with parental economic status and educational level. Of note, while only 15.3% incorrectly answered “Yes” to this question, nearly half of the sample responded, “Don’t know.” Thus, this study assessed a belief in a variable only indirectly tied to etiology, and the majority of participants reported a lack of clarity concerning the nature of parental involvement in ASD etiology.

In the study in Japan, an area sampling method was utilized to capture participants from major metropolitan areas (Koyama et al., 2009). However, etiology beliefs were only surveyed in less than half of the sample who correctly identified ASD as the diagnosis contained in a vignette. Thus, it is possible that among the participants who were not able to accurately identify such a diagnosis, a greater percentage would inaccurately emphasize parenting as etiological, and thus the figures contained in the report may potentially be underestimates.

In sum, while the view of parental variables as etiological in ASD tends to be held by a minority of individuals, regardless of culture or geographic region, these beliefs are nonetheless more frequently observed in studies conducted in Asian relative to western cultures. However, it would also appear that prior research in Asian cultures has either (1) targeted individuals who may not fully represent the broader society in terms of ASD knowledge (Koyama et al., 2009; Lian et al., 2008) or (2) has revealed uncertainty in the minds of participants concerning the role that parental variables might have in ASD etiology (Wang et al., 2012). Additionally, only one of the three studies in this modest body of work assessed beliefs in variables other than parenting/parental factors (Koyama et al., 2009). In light of this, we aimed to study lay beliefs concerning ASD etiology in Macau, which, like Hong Kong, is a Special Administrative Region of China, in a sample of individuals representative of the community at large concerning ASD knowledge, and we aimed to do so by assessing beliefs held by experts and beliefs still found within the lay population in Asia.

This research is timely. Lay beliefs of ASD may contribute to greater identification of the disorder (Kogan et al., 2009), and even the age at which an individual is diagnosed (Fernell and Gillberg, 2010), factors associated with timely intervention, and subsequently, improved outcomes (Cohen et al., 2006). In order to further enhance the utility of this area of research, and with an acknowledgment of the differences in lay beliefs in ASD etiology between Asian and western cultures, we sought to examine correlates of lay beliefs in the form of two constructs, values and social axioms. Values are individual difference variables that reflect what an individual deems to be desirable and important, and are a fruitful area of study because they serve to organize more specific attitudes (Schwartz, 1992). As they are formed in part through interactions within one’s own specific culture, culture-specific values have been found to possess great importance (Cheung et al., 2003). In Chinese culture, the significance of indigenous work in this area has been attributed to its ability to “empirically test, challenge, or expand value orientations” (Kulich and Zhang, 2010) put forth by researchers taking a more universal perspective. Thus, beliefs about mental illness etiology in individuals of Chinese ethnicity have been theorized to be a direct reflection of Chinese cultural values (Lam et al., 2010). As such, values of particular relevance to Chinese culture were utilized.

In this study, we chose to focus on five specific values of considerable theoretical and empirical importance in research in Chinese cultures: (1) collectivism, (2) conformity to a normative group, (3) a view that a family’s recognition can be obtained through a child’s achievement, (4) an emphasis on interpersonal harmony, and (5) and a belief in a mind–body holism. A specific but brief rationale for inclusion of each value is provided below.

Collectivism refers to an individual’s view of themselves as being intimately tied to their role in a broader social network, and as a result, well-being is determined less by individual achievement than by the ability to successfully navigate their role in this network (Stewart et al., 2003). Even in comparison to other regions espousing like-minded perspectives, Chinese culture in particular is notable for the extent to which collectivism is manifested (Oyserman et al., 2002). Thus, parents in Chinese cultures may, as part of the normal child-rearing process, act in a way that best enables their children to orient toward a collective well-being (e.g. de-emphasizing emotional expression; Sun, 2008). As a result, stigma associated with psychiatric disorders may not necessarily result from directly observable symptoms, but rather from the extent to which an individual is unable to meet social roles and responsibilities (Stewart et al., 2010).

Conformity to norms is a phrase referring to the degree of civility, modesty, and adherence to conventionally accepted standards of behavior. Within Chinese cultures, there tends to be an adherence to social codes that is perhaps stronger than that observed in western cultures (Ng and Lau, 1990). Thus, when comparing families with ASD who come from eastern and western cultures, the initial developmental concerns may differ. Parents in western cultures may initially report concerns about perceived speech delays (Coonrod and Stone, 2004). In contrast, parents in Asian cultures may express initial concerns about behaviors that transgress accepted norms (Daley, 2004).

Concerning a belief that a family’s recognition can be enhanced through a child’s achievement, in a Chinese family, children’s achievements, in particular their academic performance(s), are believed to directly affect the family’s reputation (Chiu and Ho, 2006). Thus, when children do not meet expectations owing to disability, parents often feel directly responsible (Sage and Jegatheesan, 2010). Unfortunately, in a developmental disorder like ASD, the accomplishments a child could accrue are often limited not only by the social deficits defining the disorder, but also by comorbidities, which frequently accompany ASD (O’Connor and Klein, 2004). Thus, in families with a child with ASD, there is a clear risk for damage to the family’s reputation.

Interpersonal harmony represents the “interdependent relational orientation that is emphasized in traditional Chinese relationships” (Cheung et al., 2004). As part of this orientation, social harmony is of utmost importance, in general, regardless of the specifics of the social situation (Sun, 2008). Thus, communications are most preferably non-confrontational. However, in a disorder such as ASD, social deficits are a defining feature, and interpersonal harmony may be one of the first casualties observed. The actual translation of “autism” in Chinese language implies an over-involvement with one’s own inner life, at the expense of adequate interactions with others, and thus individuals with ASD may be perceived as acting in a way that dramatically compromises interpersonal harmony.

Concerning mind–body holism, Traditional Chinese Medicine conceptualizes an inseparability between human body organs and human mentality (Leong and Lau, 2001). In this conceptualization, psychological and physical problems are inseparable and are thought to influence one another (Sue et al., 1976). Thus, individuals of Asian descent may be more likely to perceive mental illness as owing to biomedical factors (Mori et al., 2007).

In addition to values, social axioms were also incorporated into the current study, in order to measure correlates of lay beliefs that are less situated within a cultural context, but that instead transcend culture (Leung et al., 2002). Social axioms are broad beliefs about people, social groups and social institutions, and the physical environment, with accumulated evidence to suggest that such beliefs are universal in nature (Leung et al., 2012). The study of social axioms thus represents an approach in which broad constructs related to an individual’s world view are assessed, with an eye toward enhancing predictive power (Bond et al., 2004). And in fact, social axioms have been found to predict attitudes toward psychological distress and professional help seeking (Kuo et al., 2006), and more specifically, to predict lay beliefs about the causes of psychiatric disorders (e.g. schizophrenia; Chen and Bond, 2012).

In this study, the Social Axioms Survey (SAS; Leung et al., 2012), a widely used assessment tool in the measurement of social axioms, was utilized. This measure includes five subscales: (1) social cynicism, (2) reward for application, (3) social complexity, (4) fate control, and (5) religiosity. Social cynicism is exemplified by a belief in manipulation as an effective means of getting ahead of others. More broadly, it is manifested in a negative view of human nature or human social institutions. Reward for application is a belief that effort and investment of human resources will lead to positive outcomes. Thus, it reflects a view of a just world in which effort does indeed result in a positive outcome. Social complexity reflects a complexity in world view, in which there are no general rules that are viewed as consistently effective across time and place, and in which one perceives outcomes as being achievable via multiple pathways. Fate control relates to locus of control, and reflects the extent to which one believes that life events are pre-determined and are influenced by impersonal and external forces. Religiosity reflects a belief in the existence of supernatural forces and the beneficial functions of holding religious beliefs.

The extant literature concerning lay beliefs of etiology in disorders of development in Asian cultures is somewhat limited. Given this, and owing to the variation in methodology utilized across and within cultures to examine lay beliefs of ASD etiology, no hypotheses were offered concerning etiology beliefs. Similarly, little work has gone into the theoretical correlates of ASD beliefs. Thus, this study should be considered exploratory in nature. The current research was conducted with the following research questions in mind.

What percentage of participants in a Chinese culture endorses parenting relative to genetic factors as etiological in ASD?

Are beliefs in ASD etiology associated with culture-specific values and/or more universally held social axioms?

Methods

Participants

Participants were 215 undergraduate university students of Chinese ethnicity (mean age = 19.3; standard deviation (SD) = 1.30) enrolled in introductory psychology courses at a university in Macau. Participants received course credit for participation. Sample demographic characteristics are provided in Table 1. Exclusionary criteria included a lack of familiarity with the word, “autism”; this led to the exclusion of five potential participants. Of the total sample, 12 of the 215 (5.6%) participants reported having a relative with ASD, and 11 of the 215 (5.1%) participants reported having been enrolled in a class or course in which ASD was, at minimum, discussed. Of the total sample, 53 of the 215 participants (24.6%) had at least one parent with a bachelor’s degree or higher.

Table 1.

Participant characteristics.

Age	Gender	Year of university attendance	Major	Resident
19.3 (1.30)	Males (85)	Freshman (158)	Business (127)	Macau SAR (181)
	Females (130)	Sophomores (26)	Government and Public Administration (18)	People’s Republic of China (28)
		Juniors (17)	Science and Technology (11)	Other (6)
		Senior (14)	Arts and Humanities (7)
			Not available (5)
			Social Sciences and Humanities (47)
			Communication (26)
			Psychology (15)
			Sociology (6)

SAR: Special Administrative Region.

Measures

Participants completed a battery of questionnaires online. All questionnaires were translated from English into Chinese utilizing back-translation procedures by bilingual individuals of Chinese ethnicity. These questionnaires consisted of the following.

1. Measures of etiology beliefs

Two individual statements concerning ASD etiology were devised for this study, for which participants rated their level of agreement: (1) “Autism is caused by genetic factors” and (2) “Having a bad upbringing (e.g. neglecting, emotionally cold parents) causes autism.” Participants were told to “rate the following items …” on a 7-point Likert scale. For additional analyses, responses were coded into one of three categories on the basis of the strength of agreement with each statement, a procedure implemented because several of the response options were endorsed by very few participants (e.g. three of the Likert scale response options concerning parental variables as etiological were endorsed by fewer than five participants each).

2. Measures of values

The collectivism, conformity to norms, and family recognition through achievement subscales of the Asian American Values Scale—Multidimensional (AAVS-M; Kim et al., 2005) were utilized. The AAVS-M is a measure of Asian cultural values which was developed on the basis of information gathered from a predominantly Chinese sample in the United States. This measure consists of five individual subscales (the humility and emotion self-control scales were not included in this study). Participants completed items on a 7-point Likert scale, from 1 (“strongly disagree”) to 7 (“strongly agree”) on the collectivism (seven items), conformity to norms (seven items), and family recognition through achievement scales (7 of the original 14 items were adopted for this study). These scales were initially derived through principal components analysis and verified with a second sample utilizing confirmatory factor analysis. Internal consistency varied from 0.79 to 0.90 in the initial study, in which subscale test–retest reliability was also established.

Nine items derived from the Chinese Value Survey (CVS) (Chinese Culture Connection, 1987) were utilized in order to create a new scale for this study, titled, “Interpersonal Harmony.” The CVS is a measure of cultural values embedded within a Chinese social value system, originally developed on the basis of information gathered from researchers in the Chinese social sciences. Respondents are tasked with rating the importance of such interpersonal relationship variables as “face,” and sense of shame on a 7-point Likert scale from 1 (“not important at all”) to 7 (“very important to me”). Scales have been created and revised based on factor analytic research over time (e.g. (Bond, 1988). This study utilized 7 of the 11 items from the original report’s Integration factor, and two of the eight items from the Confucian work dynamism factor, on the basis of content validity, in order to create a scale specifically assessing interpersonal harmony.

A mind–body holism scale devised in a prior study investigating general practitioner perspectives on holism and mind–body interactions in primary care (Hasegawa et al., 2005) was included in this study. The scale utilized in the current report consisted of five items answered on a 7-point Likert scale (“strongly agree” to “strongly disagree”), derived from a subset of the originally published 7-item scale. In the original report, these seven items and an additional item from a separate scale loaded onto a single factor with an eigenvalue >1. The two items from the original scale not included in this study were those more explicitly referring to a physician’s purview and point of view (e.g. “it is an important part of the doctor’s job to explore psychological issues in organic physical illness”).

The items contributing to the scales assessing values can be found in Appendix 1.

3. Measures of social axioms

The SAS (Bond et al., 2004; Leung et al., 2012), consisting of the social cynicism, reward for application, social complexity, fate control, and religiosity subscales, was used in this study (Appendix 2). The Chinese version of the SAS (Leung et al., 2012) was utilized, consisting of five subscales with eight items each: social cynicism, reward for application, social complexity, fate control, and religiosity. In a study across more than 10 countries from numerous continents, mean internal consistency values ranged from 0.67 to 0.85 (Leung et al., 2012).

Statistical analyses

Response frequencies for the two perceived etiologies were tabulated, and mean item scores were calculated. Mean item scores for the two beliefs were compared using a within-subjects t-test. Correlations between the two scores utilizing the original 7-point Likert scales were calculated in order to obtain Pearson’s correlation coefficients. The relationship between beliefs, and region of residence for the two most common participant geographic regions of origin were examined (i.e. Macau and the People’s Republic of China). Multinomial logistic regression was conducted with each perceived etiology (parenting and genetic) as a dependent variable, and each of the five Chinese cultural values and five social axioms as independent variables; for this purpose, perceived ASD etiologies were collapsed into a three-tiered response option structure (disagree, neutral, and agree).

Results

In general, participants more consistently held views concerning the legitimacy of parenting causes of ASD relatively to that of genetic causes (Table 2). That is, 85.1% of participants mildly, moderately, or strongly agreed with a parenting cause as etiological, whereas only 3.7% expressed mild, moderate, or strong disagreement with this statement (11.2% expressed neither disagreement nor agreement). In contrast, only 34.4% of participants mildly, moderately, or strongly agreed with a genetic cause as etiological, whereas 45.6% mildly, moderately, or strongly disagreed with a genetic factor as etiological (20% expressed neither disagreement nor agreement). Results indicate a significantly greater agreement in a parenting (M = 5.53, SD = 1.07) relative to a genetic factor (M = 3.63, SD = 1.43) as etiological, t(214) = 14.15, p < 0.001).

Table 2.

Perceived etiology item scores.

	n (%)
Autism is caused by genetic factors (mean = 3.63; SD = 1.43)
Strongly disagree	18 (8.4)
Moderately disagree	34 (15.8)
Mildly disagree	46 (21.4)
Neither disagree nor agree	43 (20.0)
Mildly agree	63 (29.3)
Moderately agree	7 (3.3)
Strongly agree	4 (1.9)
Having a bad upbringing (e.g. neglecting, emotionally cold parents) causes autism (mean = 5.53; SD = 1.07)
Strongly disagree	1 (0.5)
Moderately disagree	3 (1.4)
Mildly disagree	4 (1.9)
Neither disagree nor agree	24 (11.2)
Mildly agree	57 (26.5)
Moderately agree	93 (43.3)
Strongly agree	33 (15.3)

SD: standard deviation.

In examining the relationship between original region of residence among the two largest demographic groups in the study (i.e. Macau and the People’s Republic of China), and beliefs refuting and agreeing with parental (χ²(2, N = 185) = 0.83, p = 0.36) and genetic factors as etiological (χ²(2, 167) = 0.01, p = 0.93), no significant differences were observed.

There was a significant negative relationship between a belief in a parental cause and that of a genetic cause r_s = −0.14, p < 0.05. Results from the Chinese cultural values and social axioms scales are presented in Table 3. A multinomial logistic regression was conducted, with the collapsed three-level response categories of beliefs as a dependent variable, and the individual values and social axioms as independent variables. This was done first for the belief in parenting, and, then next for the belief in a genetic factor, as etiological. Data in this study were deemed eligible for use in a multinomial logistic regression in their comprising non-metric dependent variables and metric independent variables, and case-specific data (in which each independent variable had a single value for each case). Additionally, there was no definitive evidence of multicollinearity (e.g. none of the independent variables possessed standard errors >2), and the ratio of case number to variable exceeded 20:1. Multinomial logistic regression revealed a statistically significant relationship between the combination of Chinese cultural values and social axioms, and a belief in parenting (χ²(20, N = 214) = 61.01, p < 0.001), but not genetic factors, as etiological (χ²(20, N = 214) = 26.50, p > 0.05. On the basis of a likelihood ratio test, there was a statistically significant relationship between only the independent variable mind–body holism (i.e. values; p < 0.05), and the dependent variable parenting as etiological. Mind–body holism was significant in distinguishing neutral responses concerning parenting as etiological from responses agreeing with a parental etiology (Table 4). Higher mind–body holism scores were associated with a greater likelihood of a belief in a parental etiology.

Table 3.

Self-report results.

Scale	Mean (SD)	Alpha
Social axioms
Cynicism	25.01 (3.93)	0.71
Reward for application	30.05 (3.69)	0.78
Social complexity	32.14 (3.35)	0.76
Fate control	24.56 (4.06)	0.69
Religiosity	25.63 (4.59)	0.86
Chinese cultural values
Collectivism	29.11 (4.38)	0.71
Conformity to norms	33.55 (4.72)	0.68
Family recognition through achievement	29.60 (5.08)	0.65
Mind–body holism	27.44 (4.87)	0.93
Interpersonal harmony	49.98 (5.47)	0.74

SD: standard deviation.

n = 215.

Table 4.

Summary of multinomial logistic regression for predictors of a perceived parenting etiology.

Predictor	Disagree						Neutral
Predictor	B	SE B	Wald	OR (95% CI)	df	P	B	SE B	Wald	OR (95% CI)	df	p
Values
Collectivism	0.18	0.11	2.99	0.08 (0.68–1.03)	1	0.08	−0.00	0.08	0.00	1.00 (0.86–1.16)	1	0.98
Conformity to norms	0.13	0.12	1.11	1.14 (0.90–1.44)	1	0.29	−0.04	0.09	0.22	0.96 (0.81–1.14)	1	0.64
Family recognition through achievement	0.02	0.09	0.06	1.02 (0.86–1.21)	1	0.81	−0.07	0.07	1.00	0.93 (0.81–1.07)	1	0.32
Interpersonal harmony	−0.14	0.11	1.64	0.87 (0.71–1.08)	1	0.20	−0.03	0.05	0.30	0.98 (0.89–1.07)	1	0.59
Mind–body holism^a	0.14	0.11	1.68	1.15 (0.93–1.41)	1	0.20	−0.23	0.07	10.32	0.79 (0.69–0.91)	1	0.00
Social axioms
Social cynicism	−0.24	0.14	2.91	0.79 (0.59–1.04)	1	0.09	0.04	0.08	0.26	1.04 (0.89–1.22)	1	0.61
Reward for application	0.14	0.13	1.05	1.15 (0.88–1.49)	1	0.31	0.02	0.09	0.06	1.02 (0.86–1.21)	1	0.80
Social complexity	0.07	0.18	0.16	1.08 (0.76–1.53)	1	0.69	−0.12	0.10	1.46	0.89 (0.73–1.08)	1	0.23
Fate control	−0.20	0.09	4.43	0.82 (0.69–0.99)	1	0.04	0.04	0.07	0.38	1.05 (0.91–1.20)	1	0.53
Religiosity	0.12	0.10	1.58	1.13 (0.93–1.37)	1	0.21	0.02	0.06	0.11	1.02 (0.90–1.16)	1	0.74

SE: standard error; OR: odds ratio; CI: confidence interval.

Cox and Snell’s R² = 0.247; Nagelkerke’s R² = 0.389. Reference category = agree.

Significant on the basis of a likelihood ratio test.

Discussion

In this study, a university student sample residing in Macau, a Special Administrative Region of China, endorsed statements concerning ASD etiology. The majority of participants reported a belief in neglectful and emotionally cold parenting as etiological. In contrast, only a little more than a third of the participants endorsed a genetic etiology. There was also a significant difference in the strength with which each belief was endorsed. On average, participants expressed mild to moderate agreement with a statement describing parenting as etiological in ASD. In contrast, participants responded with either mild disagreement or a more neutral response, when presented with a statement positing a genetic factor as etiological in ASD.

In the context of the extant literature, what appears noteworthy about this study is not necessarily the relatively low percentage of participants attributing ASD to a genetic disorder. The near 35% of participants who endorsed this belief actually minimally exceeds (Holt and Christensen, 2013), and nears figures (Tipton and Blacher, 2014) reported in at least some studies in western cultures, and is double that reported in a study in Japan (Koyama et al., 2009). What appears more remarkable about this study is the high percentage of participants attributing ASD to parenting. This percentage dramatically exceeds what is reported in western samples (e.g. Holt and Christensen, 2013; Mitchell and Locke, 2015) although to some extent reflects what is found in other studies in lay populations in Asia, who are more likely to attribute ASD to a parental etiology than their western counterparts. However, the percentage of participants in this study who held such views is far higher than that reported in prior studies in Asia (e.g. 15%–21%; Koyama et al., 2009; Lian et al., 2008; Wang et al., 2012). Nonetheless, it is unclear whether previous studies in Asia utilized samples truly representative of the community at large concerning ASD knowledge, owing to investigations that only included individuals familiar with symptoms common to ASD diagnostic criteria (Japan; Koyama et al., 2009), or samples in which approximately half of the participants had direct experience working with a child with special needs (Singapore; Lian et al., 2008). It is thus argued herein that in Asia, the prevalence of lay beliefs in parenting as etiological in ASD likely exceeds 15%–21%, and cross-study methodological variations/limitations notwithstanding; it is possible that the true prevalence far exceeds these prior estimates. In this study, more than 50% of participants expressed moderate to strong agreement in a parental etiology.

Unfortunately, the variation in sampling across studies obfuscates potential relationships between ASD knowledge and factors such as education and age. On the one hand, several of the studies conducted in western cultures consist of samples in which the majority possessed a university degree (Al Anbar et al., 2010; Dardennes et al., 2011; Tipton and Blacher, 2014), and in others, the percentages of university degree holders among the total sample did not drop below 30% (Holt and Christensen, 2013; Mitchell and Locke, 2015). These samples tend to show a rejection of parenting as etiological, and an acceptance of a genetic contribution to etiology. In a sample from China, more than 60% of participants possessed at the very least some higher education experience, but nonetheless, most participants in this study could not definitely state their opinion concerning the role of parenting in ASD etiology (Wang et al., 2012). In contrast, in the study in Singapore, few participants had attained a tertiary education (i.e. 18.1%), but most rejected a parental cause as etiological (Lian et al., 2008), perhaps because of the nature of their educational and occupational experiences. Thus, it would appear that education may be a contributing factor to an understanding of ASD etiology, but the nature of the education itself may be even more crucial in determining the nature of the beliefs held.

Thus, the lack of familiarity with ASD etiology in this study may have had less to do with this being a sample of young adults (the majority of whom were in their first year of university study), and more to do with the fact that the majority had not been exposed to information about ASD via relatives with the disorder or through formal instruction. Furthermore, most participants were not only first year university students, but also students enrolled in fields of study not necessarily concerned with the study of human behavior for its own sake (e.g. Business). Less than 7% of the sample was self-declared psychology majors. Thus, schooling was unlikely to have provided instruction in areas of knowledge assessed in this study. A post-hoc analysis examined potential differences in beliefs between participants from Macau and those from the People’s Republic of China, which, like Macau, consists of a predominantly Chinese ethnic population, but has in the past been described as less culturally varied than Macau owing to a greater degree of western influence in the latter (Gunn, 1996). Participants from the People’s Republic of China manifested beliefs similar to that of the sample as a whole, the majority of whom were residents of Macau. These results further argue for similarity in etiology beliefs across regions of Asia, and within China in particular. Of note, it is possible that beliefs in parenting variables as etiological may be held even more strongly and consistently in older members of the community in Macau. In the study conducted in Japan (Koyama et al., 2009), there was an increased perception of parenting as etiological and a lesser likelihood of viewing genetics as etiological as participants increased in age (measured across three separate generations).

The current results are not without precedent. In non-western cultures, ASD may be attributed to variables like divine punishment (Jegatheesan et al., 2010), and such beliefs are not uncommon even in healthcare workers (Bakare et al., 2009). However, even when traditional beliefs revolving around the influences of deities and divinities are rejected, family attributions may predominate. In a recent report in Macau assessing beliefs concerning mental illness etiology (but not ASD etiology in particular), traditional beliefs, as exemplified by statements such as “ghosts can cause a mental disorder,” were generally rejected (i.e. mean responses to this statement fell between “disagree” and “slightly disagree”), while much greater acceptance was evident for psychosocial causes (e.g. a mean response falling between, “slightly agree” and “agree” was evident for the statement, “problems in family relationships can cause a mental disorder”) (Found and Duarte, 2013). Similarly, in a study in Lahore, Pakistan, traditional beliefs reflecting the influences of deities were not assessed, but approximately 35% of non-physician healthcare workers (e.g. psychologists, speech therapists) attributed ASD to parenting nonetheless, while the percentage was even higher in physicians (Imran et al., 2011).

Thus, there appears to be a greater emphasis on parental and family factors in attributions of mental illness etiology in eastern relative to western cultures, but such attributions are not limited or specific to ASD (Furnham and Chan, 2004). It may be that the nature of ASD itself leads to such attributions. In China, behaviors associated with a developmental disorders such as ASD are often attributed to defiance and personality, rather than a developmental disorder per se (Huang et al., 2013), and these attributions could presumably implicate parenting practices (Ho et al., 2008; Sun, 2008. It is likely that the nature of the behaviors manifested in ASD contribute to such attributions. ASD-associated behaviors may not only appear quantitatively atypical (e.g. significant hyperactivity), but also qualitatively atypical (e.g. self-stimulation). A recent study in Hong Kong investigating stigma of various mental illnesses (Lam and Sun, 2014) found that participants held much less negative views of anxiety disorders, aging, and depression, in contrast to the views held for psychotic disorders such as schizophrenia, and for bipolar disorder. The latter are presumably associated with more overtly atypical behavior in the minds of study participants. While this study focused on stigma, it is believed that stigma may have roots in beliefs concerning the origins of illness in the family (Muhlbauer, 2002). Certainly, the very real and at times devastating consequences of having a family member with mental illness in a Chinese society (Raguram et al., 2004) would appear to suggest some placement of blame on parents. Interestingly, in a study from Singapore examining beliefs concerning developmental disorders (Lian et al., 2008), etiology beliefs were assessed only in regard to ASD, and not for attention-deficit/hyperactivity disorder and learning disability, potentially suggesting that the authors may have recognized the nature of lay opinion in these areas.

In this study, Chinese culture-specific values and universally held social axioms were investigated as potential correlates of ASD etiology beliefs. While these variables were not contributory in determining beliefs concerning a genetic etiology, they were predictive of a belief in a parental etiology. However, when examined individually, only the value of mind–body holism was predictive of beliefs in a parenting etiology. Mind–body holism, espoused in Traditional Chinese Medicine, reflects a belief in psychological and physical statuses as influencing one another (Sue et al., 1976). This perspective emphasizes the preservation of harmony and an overall state of equilibrium, in which excessive emotions are viewed as harmful, in potentially causing body disruptions (Sun, 2008). Parenting practices may be viewed as crucial in socializing children to curb such emotional displays, as a means of imparting the beliefs and practices necessary for the maintenance of balance and harmony. The absence of such a relationship for a perceived genetic etiology may speak to the rather reductionistic nature of a genetic conceptualization, one potentially at odds with a mind–body holism strictly defined. That is, a genetic etiology better conforms to the biomedical perspective commonly accepted in western cultures, in which individual problems are due to functional limitations of the body (Swain et al., 2003), limitations based on circumscribed physiological phenomena.

It is not clear why other individual values and social axioms were not predictive of etiology beliefs, nor why none of the odds ratios for the values and social axioms were anything other than small in effect size. These variables have found considerable support elsewhere as being key psychological constructs (Bond, 1988; Bond et al., 2004; Leung et al., 2002). Additionally, they have been found to be predictive of behavior (Bond et al., 2004), and of relevance to this study, beliefs concerning mental illness (Chen and Bond, 2012). In fact, they have even found their way into intervention methods in ASD (Chan et al., 2013). While it is possible that such constructs were simply not explanatory concerning the beliefs assessed in this study, it is also possible that the methodology employed (e.g. discrete ordinal categories as outcome variables in a relatively small sample) compromised the ability to find contributions from such constructs.

Nonetheless, implications of this study are evident. Clearly, psychoeducation of the lay population is needed. However, as has been argued elsewhere concerning ASD, this psychoeducation requires framing within a socio-cultural context (Kim, 2012). Traditional Chinese culture has been posited as collectivistic, but also as one that is hierarchical/vertical in nature (Armstrong and Swartzman, 2001). Thus, information concerning ASD etiology may be better received from expert sources such as physicians and psychologists, with the obvious caveat that such information be accurate. Of great importance is the role of the media in this context. The most common (even if not the most trusted) source of information concerning ASD is often the media (Holt and Christensen, 2013). In China, leading print media has increasingly framed ASD as a family problem, and family members are cited or quoted more than any other source, while concurrently, less emphasis has been given to scientific discourse (Bie and Tang, 2014). More problematic is that while the etiology most often discussed is genetic, causes overall are discussed infrequently. As a result, a genetic etiology is noted in less than 5% of such stories (Bie and Tang, 2014). A dearth of information concerning the biogenetic bases of ASD in the context of a culture strongly emphasizing parental responsibility for the development of attitudes and behavior conducive to the collective well-being (Tamis-LeMonda et al., 2008) might naturally be expected to lead to causal attributions emphasizing parenting factors.

Interventions aimed at increasing knowledge of ASD among the lay population have practical, not just theoretical implications. Misinformation concerning ASD is associated with bullying (Huws and Jones, 2008), and a maladaptive identity in those with the disorder (Humphrey and Lewis, 2008). In contrast, greater awareness of the disorder can ameliorate the negative judgments of disorder-associated behavior (Chambres et al., 2008), and contribute to a sense of exoneration in those with ASD themselves (Punshon et al., 2009). This may be more important in Chinese cultures in which the stigma for such disorders is so strong.

Limitations are evident in this study. When queried about beliefs in etiology, participants were not explicitly informed that they were free to scale either response option (family vs genetic) independently of the other, and there was a significant negative relationship between responses for these two etiologies. On the other hand, the relationship, while significant, was quite modest in effect size, suggesting that these two categories were not viewed as orthogonal by participants. Regardless, the scope of this study, in its utilization of Likert scale response options for a condition in which the specifics of an etiology elude even experts (Tordjman et al., 2014), is limited. Huws and Jones found that lay opinions of ASD can be rather nuanced, and similar results have been found in non-western cultures, in which ASD is attributed to multiple and often conflicting external causes (Desai et al., 2012). Thus, the categories included in this study may not capture the breadth and depth of opinion concerning ASD etiology. Additionally, the participants represent a rather narrow demographic of university students, mainly those in their first year of study. It should be noted, however, that in the context of the overall society of Macau (e.g. only approximately 25% of participants had at least one parent with a completed university education), this group may represent a potentially more educated demographic, whose knowledge might be expected to supersede that of other demographic strata (with the exception of those members of the community with direct contact with individuals with ASD). Thus, it could be argued that community samples might be more extreme in their views of ASD etiology as being attributable to parenting. This study could also be criticized for utilizing somewhat random correlates of ASD etiology beliefs. While this paradigm has been utilized elsewhere (Chen and Bond, 2012) as a means of identifying global and culture-specific roots of beliefs in mental illness etiology, the values chosen for inclusion were chosen on the basis of a somewhat limited extant literature, and did not adhere strictly to a concise theoretical conceptualization. Thus, other values could conceivably be more or less predictive. Lastly, while the current report found good internal consistency for the scales utilized to assess values, the actual items chosen for three of the scales were subsets of larger sets from the original studies.

In summary, this study reveals a predominant view of ASD as being caused by parenting variables, while only approximately one-third of the current sample viewed genetics as etiological. There were associations between the Chinese culture-specific value of mind–body holism, and beliefs in parenting as etiological in ASD although other variables and universal social axioms were not predictive of either a belief in a genetic or parenting etiology. It is suggested herein that beliefs in parenting as etiological in ASD are more prevalent in Asian cultures that has been previously reported, and that there is an urgent need for a greater awareness of ASD in these regions. Attempts to increase this awareness need to be framed with a local cultural context.

Footnotes

Appendix

Appendix 2

Social Axioms Survey

Social cynicism

People create hurdles to prevent others from succeeding.

People dislike others who succeed in life.

Powerful people tend to exploit others.

People who become rich and successful forget the people who helped them along the way.

Kind-hearted people usually suffer losses.

Opportunities for people to get wealthy promote dishonesty.

Kind-hearted people are easily bullied.

The only way to get ahead is to take advantage of others.

Reward for application

One will succeed if he/she really tries.

Success requires strong willpower.

Building the way step by step leads to success.

Adversity can be overcome by effort.

Difficult problems can be overcome by hard work and persistence.

Hard-working people will achieve more in the end.

Endurance and determination are keys to achieving goals.

Hard-working people are well rewarded.

Social complexity

There is usually more than one good way to handle a situation.

A person’s behavior is influenced by many factors.

People can suddenly lose everything they have.

Many issues appear far more complicated than they really are.

People with different opinions can all be correct.

People may have opposite behaviors on different occasions.

A bad situation can suddenly change for the better.

One has to deal with matters according to the specific circumstances.

Fate control

There are certain ways for people to improve their destiny.

Fate determines a person’s success in life.

Matters of life and death are determined by fate.

There are ways for people to find out about their fate.

The people whom one will love in his or her life are determined by fate.

Luck can be enhanced by certain tactics.

Fate determines one’s success and failures.

Religiosity

Beliefs in a religion help one understand the meaning of life.

Religious faith contributes to good mental health.

Religion slows down human progress.

Religion makes people healthier.

There is a supreme being controlling the universe.

Religion makes people happier.

Belief in a religion makes people good citizens.

Religion helps people make good choices for their lives.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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