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Chapter 1
Introduction
Background and Rationale of the Study
Autism spectrum disorder (ASD) is a general term for a group of complex
disorders of brain development that are group in varying degrees, by difficulties in social
interaction, verbal and nonverbal communication and repetitive behaviors. With the May
2013 publication of the DSM-5 diagnostic manual, all autism disorders were merged into
one umbrella diagnosis of ASD (Mayes, Black & Tierney, 2013). The diagnosis of these
disorders can sometimes be detected at 18 months or younger. By age 2, a diagnosis by
an experienced professional can be considered very reliable (Center for Disease Control
and Prevention, 2014). There is no known single cause for autism, but it is generally
accepted that it is caused genetic vulnerability, environmental factors, and psychological
factors (Autism Society Organization, 2014).
In the last decade, multiple genes have been implicated in autism, although
genetic factors might be largely responsible for the occurrence of autism they cannot
fully account for all cases and it is likely that in addition to a certain combination of
autism-related genes, specific environmental factors might act as risk factors triggering
the development of autism (Grabrucker, 2013). Prenatal exposure to the chemicals
thalidomide and valproic acid has been linked to increased risk of autism. It also appears
to include such influences as parental age at conception, maternal nutrition, infection
during pregnancy and prematurity (Autism Speaks, 2014). Pregnancy-related exposures
have been the focus of a significant amount of epidemiological research on possible risk
factors for autism. Maternal stress, nutrition, maternal illness and complication,
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medications taken, and trauma, during the prenatal period are also linked to the high
prevalence rate of ASD. Type of delivery, feeding method of the child, age of gestation
as well as low birth weight of the child also contributes to the occurrence of ASD.
As more parents and clinicians become aware of the signs and symptoms of ASD,
over time, it becomes easily detected and diagnosed thus prevalence goes up. Recent
reviews estimate a global median prevalence of 62/10 000, that is one child in 160 has an
autism spectrum disorder (WHO, 2013). From one in 10,000 children during 1980’s,
prevalence rate continues to increase as years passed by. In 2014, the Centers for Disease
Control and Prevention’s (CDC) Autism and Developmental Disabilities Monitoring
Network (ADDMN) reported that approximately one in 68 children in the United States
have an Autism Spectrum Disorder during their 2008 survey.
Autism is a condition affecting populations worldwide. Posserud et al. (2010),
the Autism Society (2010), Autism Speaks (2008) and Wong (2007) as cited by Kopetz
and Lee (2012) calculated and identified respective country’s approximate prevalence
rates of autism diagnoses of children living in other countries throughout the world.
Rough estimation suggests population of autism people in the Philippines as 500,000 in
total. With this, the researcher aims to know the prevalence rate of children in Inayawan,
Cebu City. Knowing how many children have autism can help communities develop
realistic plans to support these children and their families. Understanding the number and
characteristics of children who have ASD is a key to promoting awareness of the
condition and identifying important clues for further research.
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Statement of Objectives
1. To determine the prevalence rate according to ASD risk category of children aged
16-30 months in Inayawan, Cebu City.
2. To determine the similarities of risk cases of ASD based on certain risk factors
through cluster analysis.
Hypothesis
There is an occurrence of risk for ASD among the children aging 16 to 30 months
in barangay Inayawan, Cebu City and there are several factors identified that probably
cause the condition, such as, familial history of mother and father, age upon pregnancy,
maternal illness, presence of major stressors, medications taken during pregnancy,
trauma, exposure to teratogens, type of delivery, maternal complications and feeding
method of the child.
Significance of the Study
This study aims to classify the risk of ASD occurring in children here in the city
and determines its prevalence rate as well as the factors that contribute to the occurrence
of such disorder. These data will aid health care professionals especially the nursing field
for basis of health teachings and appropriate interventions towards the public regarding
ASD, thus creating awareness and knowledge.
The study will be beneficial to the following:
Parents. The awareness that the study impart serves as a primary prevention to
parents and future parents on the development of ASD. The knowledge on the modifiable
contributing factors aids their practices to have fewer chances in the development of ASD
in their children.
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Department of Health (DOH). This can be utilize by the DOH in obtaining the
national prevalence rate of ASD in the Philippines and thus may aid in the development
of evidence-based health policies and clinical process guidelines necessary to
comprehensively manage ASD in the Philippines. This will enable the government to
formulate action plans for ASD in the aspects of health, social welfare and education.
Children with ASD. This study indirectly helps in the improvement of
interventions and management of children with moderate and higher risk of having ASD
with the aid of the national government specifically the DOH.
Researchers. This helps the researchers in determining the prevalence of children
having the risk of developing ASD and the factors that contribute to the development of
such disorder in Cebu City. The findings of this study can used as basis for further
evidenced-based research for future researchers. This can become their base knowledge
and may lead to future improvement of this study in a broader concept of the prevalence
of ASD and prevention and consequences of the disorder.
Scope and Delimitation
This study is mainly focused on determining the similarities of risk cases of ASD
based on certain risk factors such as the family on father and mother’s familial history
and age, child’s information upon birth. The respondents selected by the researchers are
Filipino mothers who are living in Barangay Inayawan for at least a year, with children
between the ages of 16 to 30 months. They must be able to understand Bisaya, Tagalog
and English.
Definition of Terms
Age. This refers to chronological age of the parents during the pregnancy.
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Age of Gestation. It is the common term used during pregnancy to describe how far
along the pregnancy is. It is measured in weeks, from the first day of the woman's last
menstrual cycle to the date of birth (University of Maryland Meedical Center, 2014).
Birth Weight. It refers to the first weight of the baby, taken just after he or she is born
(National Institute of Health, 2014).
Familial History. It is the tracing of their lineage in order to know if they are
predisposed to Autism Spectrum Disorder.
Occurrence. This refers to the existence of autism spectrum disorder (ASD) in the
specified locale.
Prevalence. This refers to the total number of ASD cases from the population of the
specified locale.
Sex. It refers to the state of being male or female (Merriam Webster’s Dictionary, 2014).
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Chapter 2
Review of Related Literature and Studies
The etiology of autism is still unclear but recent studies suggest genetics plays a
major role in conferring susceptibility. Researchers suspect that there are a number of
different genes that, when combined together, increase the risk of getting autism. In
families with one child with autism, the risk of having another child with autism is 3% to
8%. A number of studies have found that first-degree relatives of children with autism
also have an increased risk of autism spectrum disorders. Furthermore, studies have
shown that parents from families with autistic members are more likely to have autistic
children (Caglayan, 2010). In addition, parents who have a child with ASD have a 2%-
18% chance of having a second child who is also affected (Center for Disease Control
and Prevention, 2014).
According to the study of Croen, Najjar, Fireman, and Grether (2007), advance
maternal and paternal age are independently associated with ASD risk due to age-
associated increase in de novo mutations in male germ cells. Furthermore, in the study of
Foldi, Eyles, Flatscher-Bader, McGrath and Burne (2011), offspring of older fathers have
an increased risk of having autism and schizophrenia. This leads to more opportunities
for copy error mutations in germ cells from older fathers. Evidence also suggests that
epigenetic patterning in the sperm from older men is altered.
However, genetics alone do not account for all instances of autism. For good
reason, the increasing prevalence of autism has generated great interest in the potential
involvement of toxins in our environment. For example, prenatal exposure to the
chemicals thalidomide and valproic acid has been linked to increased risk of autism
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(Autism Speak, 2014). Autism risk factors, for example, appear to include such
influences as parental age at conception, maternal nutrition, infection during pregnancy
and prematurity.
In a new study, researchers identified an association between autism spectrum
disorder risk and prenatal weight gain, after accounting for important related factors such
as a woman’s pre-pregnancy BMI (University of Utah Health Sciences, 2013).
Pregnancy-related exposures have been the focus of a significant amount of
epidemiological research on possible risk factors for autism. Although many studies
support the hypothesis that obstetrical complications may increase the risk of autism
(Kolevson, Gross, Reichenberg, 2007), the specific complications, magnitude of effect
and overall conclusions of these studies are inconsistent. More so, maternal illness is also
deeming to be related to the increase risk for ASD and developmental delay. Though
Benaroch (2012) states that there is a low risk for ASD following influenza, recent
studies shows that hospital-diagnosed maternal bacterial infections during pregnancy
were associated with an increased risk of autism spectrum disorders in children. Women
with bacterial infections diagnosed during a hospitalization had a 58 percent greater risk
of having a child with an Autism Spectrum Disorder (ASD). Infections diagnosed during
a hospitalization in the second trimester were associated with children having more than a
three-fold increased risk of developing ASD (Zerbo et.al, 2013).
Khashan, Mcnamee, Henriksen, Pedersen, Kenny and Abel (2011) and the study
of Kinney, Munir, Cowley and Miller (2008) suggested that the effect of prenatal stress
on neurodevelopment varies according to the timing of exposure, and can cause a variety
of postnatal abnormalities, including not only the behaviors that resemble the defining
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core symptoms of AD, but also other problems, such as seizure disorders, cognitive
deficits, and in immune function, that also have greatly elevated.
According to Roberts et.al. (2013) as cited in Harvard School of Public Health,
women in the U.S. exposed to high levels of air pollution while pregnant were up to twice
as likely to have a child with autism as women who lived in areas with low pollution.
Twelve to 13 percent of autism cases stem from pregnancy issues that result in
prematurity, low birth weight or Caesarian section, according to a new report by the
Centers for Disease Control and Prevention (CDC). To elaborate further, Anderson
(2010) said that premature children also seemed to be a higher risk of brain injury
because of their early birth, which could potentially contribute to some Autism like-
symptoms. Johnson and Marlow (2011) also reported similar findings last April 2009, in
a study of 988 children born before the 28th week of pregnancy. In the extremely low
gestational age newborn (ELGAN) study group found that more than 21 percent of these
are premature babies tested positive on Modified Checklist for Autism in Toddlers at 2
years old. In this new study, children born before 26 weeks gestation are more likely to
have Autism like traits at age 11.
Moreover, breastfeeding has been associated with increases in cognitive ability
and academic performance (Jain, Concato, Leventhal, 2002). Absence of breastfeeding
and the use of infant formula without docosahexaenoic acid and arachidonic acid was
significantly associated with an increase in the odds of having autistic disorder. As a
result of this preliminary study indicate that children who were not breastfed or were fed
infant formula without docosahexaenoic acid/arachidonic acid supplementation were
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significantly more likely to have autistic disorder (International Breastfeeding Journal,
2014).
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Chapter 3
Research Methodology
Research Design
This study utilized a non-experimental quantitative, descriptive – normative
research design, specifically a cross – sectional survey. It makes use of survey method to
gather data at a particular point in time with the intention to describe the nature of
existing conditions, or identify standards against which existing conditions can be
compared or determine relationship that exist between specific events (Cohen, Manion &
Morrison, 2000 cited in Mangal & Mangal, 2013).
Research Locale
The research was conducted in Cebu City specifically in Barangay Inayawan. It is
part of the urbanized area in Cebu City ranked as the 4 th populous barangay with a total
population size of 28,329, with no known census on the different age groups available as
of May 2010 (National Statistics Office, 2012). The area has no known current
prevalence rate of ASD.
Research Respondents
The respondents of the study are the mothers residing in Barangay Inayawan,
Cebu City with children or child aged 16 to 30 months. They have to speak and
understand Bisaya, Tagalog or English.
Research Sample and Sampling Technique
Total enumeration was utilized by the researcher, where all that fits in the
inclusion criteria were subjected as respondents. To qualify in the study the following
criteria is made. The respondents must be currently living in Inayawan, Cebu City for at
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least a year, who has a child or children aging 16 to 30 months old and if they are able to
understand and speak Tagalog, Bisaya or English. The researchers screened 503 children
in Inayawan, Cebu City aged 16-30 months.
Research Instruments
In screening the children to determine the risk for ASD, the proponents utilized the
Modified Checklist for Autism in Children Revised with Follow-up (M-CHAT-R/FTM). It
is a 2-stage parent-report screening tool to assess risk for ASD and is a recommended
tool by the American Academy of Pediatrics (DOH, 2014). In scoring, for all items
except 2, 5, and 12, the response “NO” indicates ASD risk; for items 2, 5, and 12, “YES”
indicate ASD risk. The child can either be in low risk, moderate risk or high risk of ASD.
Low risk: Total score is 0-2; if child is younger than 24 months, screen again after second
birthday. No further action required unless surveillance indicates risk for ASD. Moderate
risk: Total Score is 3-7; Administer the Follow-Up (second stage of M-CHAT-R/F) to get
additional information about at-risk responses. If M-CHAT-R/F score remains at 2 or
higher, the child has screened positive. Action required: refer child for diagnostic
evaluation and eligibility evaluation for early intervention. If score Follow-Up is 0-1,
child has screened negative. No further action required unless surveillance indicates risk
for ASD. Child should be rescreened at future well-child visits.High risk: Total score is
8-20; It is acceptable to bypass the Follow-Up and refer immediately for diagnostic
evaluation and eligibility evaluation for early intervention. If the child screens positive,
Follow-Up items based on which items the child failed on the M-CHAT- R is selected;
only those items that were originally failed need to be administered for a complete
interview. The child will either pass or fail then it is scored again. The interview is
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considered to be a screen positive if the child fails any two items on the Follow-Up. (See
appendix C.)
The study also used a standardized or structured interview. This style is most
useful when looking for very specific information, it keeps data concise and reduces
researcher bias (Santiago, 2009). The researchers used the interview guide to gather
necessary information about the respondents. It consists set of questions relating to
perinatal factors that would likely result to the occurrence of any disorder from the ASD.
The interview guide consists of two major parts, namely, parent’s information and child’s
information. Parent’s information is further subdivided into maternal and paternal factors
that may lead to the development of ASD. Under the paternal factors are information
about the father’s age, upon conception of the child 30 months and under, and any
familial history of ASD. While maternal factors is classified into prenatal, intranatal and
postnatal factors. Under the prenatal factors includes major stressors, maternal illness,
medications, trauma and exposure to teratogens. Intranatal factors include, type of
delivery, maternal complications, duration of labor and fetal presentation. And postnatal
factors include, method of breastfeeding. Other pertinent information from the parents are
also included like name or code, address, civil status and nationality. Child’s information
includes birthdate, current age, sex, birth weight and age of gestation upon delivery.
These compose the interview guide that the researchers will utilized in the study. To test
the suitability of the instrument, pilot testing is done before conducting the data gathering
procedure proper.
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Data Gathering Procedure
A preliminary procedure is done before conducting the data collection. The data
gathering procedure started with securing permission from the Dean of the College of
Nursing of Cebu Normal University for the conduction of the study after the approval
from the panelist. Then, transmittal letter was sent to the Barangay captain of Barangay
Inayawan, Cebu City seeking permission to conduct the study in the area.
Data collection is done in two levels. First, respondents of the study will be
determined with the help of the Barangay Health Workers (BHW) and the DOH. Consent
for the conduction of the study will be secured and participant’s code will be made by the
researchers to maintain anonymity of the respondents. This is made to give the
researchers the ability to trace back the respondents if needed so. The researchers then
conduct a house to house interview with the use of M-CHAT-R/FTM to assess all children
aged 16- 30 months. With the assessment tool, these children was scored then classified
according to their risk. They may be on the low risk, moderate risk or on high risk.
Follow-up will be administered in children that scored having moderate risk, to get
additional information about the at-risk responses. Second, among the children with
moderate and high risk of ASD in barangay Inayawan, Cebu City, The researchers then
interview the respondents using the guide questions (refer to appendix C) prepared by the
researchers. Pilot study was conducted to the guide questions a month before the
expected date of the gathering of data, in Inayawan, Cebu City. Then lastly, factors were
clustered.
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Statistical Treatment of Data
Statistical analysis of the data in the study composes of two parts – finding the
prevalence and clustering of factors contributing to the risk of ASD. In finding for the
prevalence rate, descriptive statistics is utilized, specifically, frequency count and
percentage distribution. Descriptive statistics is used to describe and summarize data.
Frequency count is an attempt to discover the number of occurrences of ASD in the
specified locale, while percentage is the sum of all frequencies expressed as a fraction of
100 (Polit & Tatano, 2012). In clustering the factors contributing to the risk of ASD,
cluster analysis is utilized. Cluster Analysis is a method for grouping sets of individuals
based on their characteristics. Characteristics being meant are the factors that influences
the tendency for ASD.
Role of Researcher
The researchers of the study identified the occurrence of risk in children in
Inayawan, Cebu City. They will also gather necessary data regarding the respondents
and their child or children to further cluster the factors that may contribute to the
development of ASD. With the data gathered, the researchers, who are also the
interviewers, will analyze the results and formulate conclusion of the study.
Ethical Considerations of the Study
As this study required the participation of human respondents, certain ethical
issues were addressed. The consideration of these ethical issues was necessary for the
purpose of ensuring the privacy as well as the safety of the participants. Among the
significant ethical issues that were considered in the research process include consent and
confidentiality. In order to secure the consent of the selected participants, the researcher
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relayed all important details of the study, including its aim and purpose. By explaining
these important details, the respondents were able to understand the importance of their
role in the completion of the research. The respondents were also advised that they could
withdraw from the study even during the process. With this, the participants were not
forced to participate in the research.
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Chapter 4
Result and Discussion
This chapter shows the results taken from the respondents that were gathered from
barangay Inayawan in the time frame of two months, from July-September 2014.
Table 1. The prevalence rate of children having risk of ASD
Category Total Number of
Children
Percentage on Total Number
of ChildrenGender Low Risk Moderate Risk High Risk
Male 260 (51.69%) 7 (1.39%) 2 (0.40%) 269 53.48%
Female 227 (45.13%) 6 (1.19%) 1 (0.19%) 234 46.52%
Total 487 (96.82%) 13 (2.58%) 3 (0.60%) 503 100%
Low risk: Total score is 0-2 Moderate risk: Total Score is 3-7; High risk: Total score is 8-20;
The researchers have interviewed 503 mothers of children aged 16 to 30 months
using the M-CHAT-R/FTM tool. As shown on the figures, there are more male respondents
with the total of 269 (53.48%) compared to the female respondents with only 234
(46.52%). Mostly, the children were classified on the lower risk but ta 2.58% were
classified on the moderate risk and 0.60% on the higher risk. Most children in both the
moderate and high risk category are males.
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Table 2. Factors Contributing to Risk in ASD per Category
Factors (Non genetic and
genetic)
CategoryTotal number of respondents
PercentageLow Risk
Moderate Risk
High Risk
Parent’s ProfilePaternal Age
Too young 0 0 0 0 0 %Appropriate Age 466 13 3 482 95.83%Too old 21 0 0 21 4.17%Maternal AgeToo young 55 4 1 60 11.93%Appropriate Age 409 9 2 420 83.50%Too old 23 0 0 23 4.57%Familial History 159 9 2 170 33.80%Perinatal FactorsPrenatalMaternal Illness 72 10 2 84 16.70%Medications 45 5 1 51 10.14%Trauma 10 0 0 0 0.02%Exposure to Teratogens
79 7 3 89 17.69%
Stress 487 13 3 503 100%IntranatalType of deliveryNSVD 487 13 3 503 100%Cesarean Section 0 0 0 0 0%Forceps 0 0 0 0 0%Induced delivery 0 0 0 0 0%Complications 22 3 1 26 5.17%Postnatal Feeding MethodBreastfeed 442 10 2 454 90.26%Bottle feed 15 2 1 18 3.58%Mixed feeding 30 1 0 31 6.16%WeightLarge for Gestational Age
8 2 1 11 2.19%
Appropriate weight
420 7 1 428 85.09%
Small for Gestational Age
59 4 1 64 12.72%
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Looking closely on the age aspect of both the mother and father of the identified
cases, there is no significant risk involve in the paternal and maternal age as shown in
Table 2, which most of the cases falls down in appropriate age.
On the other hand, maternal stress is highly observed in which all cases
experienced stress during pregnancy. As stated in Chapter 2 on the study of Kinney,
Munir, Cowley and Miller (2008) suggested that the effect of prenatal stress on
neurodevelopment varies according to the timing of exposure, and can cause a variety of
postnatal abnormalities, including not only the behaviors that resemble the defining core
symptoms of ASD.
In the aspect of familial history there is around 33.80% in the identified cases
which concludes that familial history is one of the etiology in the development of ASD.
In families with one child with autism, the risk of having another child with autism is 3%
to 8%. A number of studies have found that first-degree relatives of children with autism
also have an increased risk of autism spectrum disorders. Furthermore, studies have
shown that parents from families with autistic members are more likely to have autistic
children (Caglayan, 2010).
Though most of the identified cases have appropriate weight, there is still a
percentage of 12.72% that falls in small for gestational age. In which this result
reinforced the fact that twelve to 13 percent of autism cases stem from pregnancy issues
that result in prematurity, low birth weight, according to a new report by the Centers for
Disease Control and Prevention (CDC). To elaborate further, Anderson (2010) said that
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premature children also seemed to be a higher risk of brain injury because of their early
birth, which could potentially contribute to some Autism like-symptoms.
To explain further, there is a low significant relation in terms of maternal illness
and exposure to teratogens during pregnancy based on the results above. The type of
delivery on the other hand showed no significant risk in the development of ASD since
all the cases identified delivered their baby via normal spontaneous vaginal delivery.
However there were cases identified who undergone maternal complications during
delivery, this signifies that complications is significant in ASD. Many studies support the
hypothesis that obstetrical complications may increase the risk of autism (Kolevson,
Gross, Reichenberg, 2007).
Table 3. Variable Exploration thru Forced Cluster Analysis
Variable Moderate Risk Low Risk Grand centroidGender 1.6250 1.4148 1.4215Weight 2.3750 2.0965 2.1054Family History 1.6875 1.8480 1.8429Paternal Age 2.0000 2.0431 2.0417Maternal Age 1.6875 1.9343 1.9264Maternal Illness 1.4375 1.8501 1.8370Medications 1.8125 1.9138 1.9105Trauma 1.8750 1.9795 1.9761Exposure to Teratogens 1.6875 1.9405 1.9324Stress 1.1250 1.1684 1.1670Type of Delivery 1.0000 1.0000 1.0000Complication 1.8125 1.9548 1.9503Feeding Method 1.0000 1.1643 1.1590
It is shown on the table above that only maternal illness has a significant result in
terms of category. This implies that children whose mother experienced illness during
pregnancy have higher chances of having a child who will have a tendency of acquiring
ASD. Though the children in the study, only has the risk for ASD, recent studies have
shown that maternal illness is linked to ASD and developmental delays (Zerbo et.al,
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2013). It is generally believed that this is due to the effect of the inflammatory process to
the development of the fetus.
Correlation: Category, Maternal Illness
Pearson correlation of Category and Maternal Illness = -0.188P-Value = 0.000
To further test the relationship between category and maternal illness, Pearson’s
correlation was utilized. And it is seen that there is a negative correlation between
category and maternal illness.
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Chapter 5
Conclusion and Recommendation
This chapter shows the conclusion and recommendations identified by the
researchers to further improve further researches relating to ASD.
Conclusion
Therefore it is concluded that only 16 among 503 children have moderate and
high risk for ASD and with the identified moderate and at high risk children. Maternal
illness has due influence in the tendency of acquiring risk for ASD.
Recommendation:
1. For the DOH to reassess and confirm the presence of ASD in the identified
children with moderate and high risk for ASD.
2. For future researchers to validate the current conclusion of the study.
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Bibliography
Electronic Book
Mangal, S.K. &Mangal, S., (2013) Reasearch Methodology in BehaviouralSciences.PHI Learning Private Limited, Delhi. pp. 71retrived from http://books.google.com.ph/books?id=uaVbAAAAQBAJ&pg=PA71&dq=non+experimental+quantitative+descriptivenormative&source=bl&ots=svzArXZmBe&sig=BXBSHhLSVSQ035esX7OZfTj gIW0&hl=en&sa=X&ei=0qc_U56bN-K5iQem6YHGbq&VED=0cduq6aeWba
Websites
Age (n.d.). Retrieved April 5, 2014, from http://www.merriamwebster.com/dictionary/age
Autism Speaks. (2014). What is autism?. Retrieved April 5, 2014 Retrieved from: http://www.autismspeaks.org/what-autism.
Autism Speaks. (2014). What is autism?. Retrieved April 5, 2014 Retrieved from: http://www.autismspeaks.org/what- autism.
Autism Spectrum Disorders. (n.d.). : A Parent’s Guide to Symptoms and Diagnosis on the Autism Spectrum. Retrieved April 5, 2014, from http://www.helpguide.org/mental/autism_spectrum.htm
Birth Weight: MedlinePlus. (n.d.). U.S National Library of Medicine. Retrieved April 5, 2014, from http://www.nlm.nih.gov/medlineplus/birthweight.html
Centers for Disease Control and Prevention Facts about ASD. (2014). Facts about ASD Retrieved April 5, 2014, from http://www.cdc.gov/
Harvard School of Public Health. (2013). Exposure to high pollution levels during pregnancy may increase risk of having child with autism. ScienceDaily. RetrievedApril6,2014fromwww.sciencedaily.com/releases/2013/06/130618101734.htm
Illness. (n.d.). Retrieved April 5, 2014, from http://www.merriam-webster.com/dictionary/illness
23
Kinney, D., et. al., (2008). Prenatal Stress And Risk For Autism. Retrieved http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2632594/.
Occurrence (n.d.). Retrieved April 5, 2014, from http://www.oxforddictionaries.com/definition/english/occurrence
Perinatal definition - Medical Dictionary definitions of popular medical terms easily defined on MedTerms. (n.d.). Retrieved April 5, 2014, from http://www.medterms.com/script/main/art.asp?articlekey=7898
Press Release. (in press). Centers for Disease Control and Prevention. Retrieved April 5, 2014, from http://www.cdc.gov/media/releases/2014/p0327-autism-spectrum-disorder.html
Reproductive Health. (2014). Centers for Disease Control and Prevention. Retrieved April5,2014,from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/ pregcomplications.html
Santiago, N., 2009, 'Interview types: structured, semi-structured, and unstructured', Examiner.com, accessed 23 January 2013. Cited in Harvey, L., 2012-14, Social Research Glossary, Quality Research International, http://www.qualityresearchinternational.com/socialresearch/
sex. (n.d.). Retrieved April 5, 2014, from http://www.merriam-webster.com/dictionary/sex
Teratogens. (n.d.). Retrieved April 5, 2014, from http://www.chw.org/medical-care/genetics-and-genomics-program/medical-genetics/teratogens/
University of Maryland Medical Center. (n.d.). Gestational age Retrieved April 5, 2014, from http://umm.edu/health/medical/ency/articles/gestational-age
University of Utah Health Sciences. (2013). New study examines linkbetween pregnancy weight gain, autism spectrum disorders. ScienceDaily. Retrieved April 8, 2014 from www.sciencedaily.com/releases/2013/10/131028090250.htm
24
World Health Organization. (2013). Questions and answers about autism spectrum disorders (ASD). Retrieved April 8, 2014 Retrieved from http://www.who.int/features/qa/85/en/
Journals
Andrea L. Roberts, Kristen Lyall, Jaime E. Hart, Francine Laden, Allan C. Just, Jennifer F. Bobb, Karestan C. Koenen, Alberto Ascherio, and Marc G. Weisskopf.Perinatal Air Pollutant Exposures and Autism Spectrum Disorder in the Children of Nurses’ Health Study II Participants. Environmental Health Perspectives, 2013 DOI: 10.1289/ehp.1206187
Benaroch, R. (2012). The Pediatric Insider Maternal illness and autism. Accessed at February26,2014.retrivedathttp://pediatricinsider.wordpress.com/2012/11/15/ maternal-illness-and-autism/
Bilder,D., Bakian,A., Viskochil, J., Clark, E., Botts, E., Smith, K., Pimentel, R., Mcmahon, W., & Coon, H. .Maternal Prenatal Weight Gain and Autism Spectrum Disorders. Pediatrics, October 2013
BioMed, Breastfeeding, infant formula supplementation, an Autistic Disorder: the result of a parent survey. (20060915). London, United Kingdom: BioMed Central.
Caglayan, A. O. (2010). Genetic Causes Of Syndromic And Non-syndromic Autism. Developmental Medicine & Child Neurology, 52(2), 130-138.
Croen, L. A., Najjar, D. V., Fireman, B., & Grether, J. K. (2007). Maternal And Paternal Age And Risk Of Autism Spectrum Disorders. Archives of Pediatrics and Adolescent Medicine, 161(4), 334-340.
Hogan-Brown, A. L., Losh, M., Martin, G. E., & Mueffelmann, D. J. (2013). An Investigation of Narrative Ability in Boys with Autism and Fragile X Syndrome.American journal on intellectual and developmental disabilities, 118(2), 77-94.
Foldi, C. J., Eyles, D. W., Flatscher-Bader, T., Mcgrath, J. J., & Burne, T. H. (2011).NewPerspectives on Rodent Models of Advanced Paternal Age: Relevance to Autism. Frontiers in behavioral neuroscience, 5, 5.
Geschwind, D. H. (2011). Genetics Of Autism Spectrum Disorders. Trends in Cognitive Sciences, 1, 5-6.
25
Grabrucker, A. M. (2013). Environmental Factors in Autism. Frontiers in psychiatry, 3, 1.
Jain, A., Concato, J., Leventhal, JM. (2002): How good is the evidence linking breastfeeding and intelligence? Pediatrics, 109:1044-1053.
Johnson, S., & Marlow, N. (2011). Preterm Birth and Childhood Psychiatric Disorders. Pediatric research, 69(5 Part 2), 11R-18R.
Khashan, A. S., Mcnamee, R., Henriksen, T. B., Pedersen, M. G., Kenny, L. C., Abel, K. M., et al. (2011). Risk of affective disorders following prenatal exposure to severe life events: A Danish population-based cohort study. Journal of Psychiatric Research, 45(7), 879-885.
Kolevson A, Gross R, Reichenberg A. (2007) Prenatal and perinatal risk factors for autism: a review and integration of findings. Arch Pediatr Adolesc Med; 161: 326– 33.
Kopetz, P.B. and E.D.L. Endowed, (2012). Autism worldwide: Prevalence, perceptions acceptance, action. J. Soc. Sci., 8: 196-201.
Mayes, S. D., Black, A., & Tierney, C. D. (2013). DSM-5 under-identifies PDDNOS: Diagnostic agreement between the DSM-5, DSM-IV, and Checklist for Autism Spectrum Disorder. Research in Autism Spectrum Disorders, 7(2), 298-306.
Padua, R.N., Alcalaca, A.C., Panares,Z.A., Palompon, D.R., Cañete, L.Y., Binaluyo, J.F., Ariston, R.E., Itaas, E.C., Japos, G.V., Mirasol, J.M. (2011). Elements of Evidenced-Based Research and Statistical Models. Pp. 174 - 186
Polit, D. F., & Beck, C. T. (2012). Nursing research: generating and assessing evidence for nursing practice (Ninth ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Zerbo, O., Iosif, A.M., Walker, C., Ozonoff, S., Hansen, R., Hertz-Picciotto, I., (2013). Journal of Autism and Developmental Disorders Is Maternal Influenza or Fever During Pregnancy Associated with Autism or Developmental Delays? Results from the CHARGE (CHildhood Autism Risks from Genetics and Environment) Study. vol.43, issue 1, pp.25-33.
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Appendix A
Transmittal Letter
July 4, 2014
Hon. Lutherlee I. SoonBarangay CaptainInayawan, Cebu City
Dear Hon. Soon,
Greetings!
We, the Level IV Students of Cebu Normal University - College of Nursing, would like to implement an approved research with the title “Autism Spectrum Disorder (ASD): Prevalence and Clustering among Children in Inayawan, Cebu City”. Significant findings from this research will aid the government, specifically the Department of Health (DOH) in determining the national prevalence rate. We have chosen Barangay Inayawan for our research because it is ranked as the 4th populous barangay as of May 2010. The area also has no known current prevalence rate of ASD and that will be of great contribution in identifying the prevalence of ASD among children in Cebu City and nationally.
The researchers will utilize a standardized or structured interview with the use of an interview guide to gather necessary information about the respondents. The researchers will then conduct a house to house interview after the pilot study was made using the guide questions prepared by the researchers. Children aging from 16 month to 30 months will be classified if there is risk of occurrence of ASD and factors will be clustered. Participant’s code will be made by the researchers to maintain anonymity of the respondents.
In line with this, we would like to request from your office that we be allowed to conduct a house to house interview within the time frame of July to September 2014 to the parents of the identified specific age group of children in your community.
Attached herewith are the approved research proposal and informed consent for your reference and perusal.
May this request merit your approval.
Respectfully yours,
ELISHA GINE B. ANDALES
HENELLE VALERIE S. ENAD
SHARMAINE JOSH O. LI
CRISTEL B. ARESTANGProponents
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Noted:
(Signed) JEZYL C. CUTAMORAResearch AdviserCebu Normal University
(Signed) LAURENCE L. GARCIADean, College of NursingCebu Normal University
Approved:
(Signed) HON. LUTHERLEE I. SOONBarangay CaptainInayawan, Cebu City
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Appendix BCebu Normal University
College of Nursing
July 4, 2014__________________________________________________
Good day,
We, the level IV students of Cebu Normal University - College of Nursing, are interested to study about the prevalence of children having the risk of developing ASD and the factors that may contribute to the occurrence of such disorder in Barangay Inayawan, Cebu City, of a specific age group. The study will be of great help in determining the prevalence rate of children having the risk of developing ASD locally and nationally, which will be of aid to the Department of Health (DOH). This will also be a help towards community awareness of increasing incidence of ASD.
We, the researchers will collect a data by giving questionnaires to the parents and assess by observing their children. To qualify in the study the child must be a resident of Barangay Inayawan, Cebu City, who is 16 to 30 months of age with a parent preferably his/her mother who speaks and understands Tagalog, English and or Bisaya. All data that are gathered and collected will only be used by the researchers and advisers within the duration of the study. These data will be treated with up most confidentiality. When the purpose of the data had been served and after the completion and analysis of the data will be completed, copies of these data will be destroyed.
Participation of the study is purely voluntary and will not entail monetary reimbursement and so as monetary collection. Participants can withdraw or refuse in participating in the study. In the incidence of withdrawal, no legal actions or consequences will be made and the data that had been gathered thus far will not be included in the study.
For any questions and inquiries about the research, please contact any of the following researchers:
Name Contact Number Email AddressAndales, Elisha Gine B. 09335092907 elishagine_andales@yahoo.com.phArestang, Cristel B. 09322362873 uzumakicris17@gmail.comEnad, Henelle Valerie 09339288056 henelle.valerie.enad@gmail.comLi, Sharmaine Josh O. 09437019585 Sharmaine_li@yahoo.com
CERTIFICATE OF CONSENT
I, whose name and signature appears on this consent, give my authorization voluntarily for my daughter/s or son/s and I to participate in this research study. I have read and understand the foregoing information or it has been read and explained to me. I have had the opportunity to ask questions about it and any questions that I have asked have been answered to my satisfaction.
Signature over printed name of Parents:
_________________________________ _________________________________
Date: ______/_______/________ Day Month Year
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Appendix CInterview Guide
CHILD’S INFORMATIONName (optional): ____________ Gender:____________ Birthday:_________________ AOG:___________Weight upon birth (grams):_________
FATHER’S INFORMATION:Name (optional):________________________________________Age:________ Marital Status: __________Address:__________________________________________Nationality:___________Familial History:___ NO ___Yes (Specify:________________)
MOTHER’S INFORMATION:Name (optional): _____________________________________________Age:_____ GPTPAL Score: _____________Marital Status: __________Address:___________________________________________Nationality:____________ Familial History: ___ No ___Yes (Specify:___________________)
PERINATAL INFORMATION:Prenatal:Maternal Illness: ____________________________________________________Major Stressors: ___ No ___Yes (Specify:_______________________________)Medications Taken: _________________________________________________Trauma: ___No ___Yes (Specify: _____________________________________)Exposure to Teratogens:
Alcohol intake: ____ No ____Yes If yes: _____ quantity __________ type of beverage
______frequency __________ date of last drinkSmoking habits:____ No____Yes (Specify: ___sticks/day; ___packs/year)
Intranatal:Type of Delivery: ____ Hospital: ____ Caesarean Section ___ NSVD
____ Forceps Delivery ____ Induced Delivery
____ Home delivery Maternal Complications: ___No ___Yes (Specify:_______________________)
Duration of Labor: _________ Presentation of child upon birth: ________Postnatal:Feeding Method of the Child: ____ Breastfeed ____Bottlefeed____Mix
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Appendix D
MCHAT-R/F
Scoring Algorithm For all items except 2, 5, and 12, the response “NO” indicates ASD risk; for items 2, 5, and 12, “YES” indicate ASD risk. The following algorithm maximizes psychometric properties of the M-CHAT-R: LOW-RISK: Total Score is 0-2; if child is younger than 24 months, screen again after second birthday. No further action required unless surveillance indicates risk for ASD. MEDIUM-RISK: Total Score is 3-7; Administer the Follow-Up (second stage of M-CHAT-R/F) to get additional information about at-risk responses. If M-CHAT-R/F score remains at 2 or higher, the child has screened positive. Action required: refer child for diagnostic evaluation and eligibility evaluation for early intervention. If score on Follow-Up is 0-1, child has screened negative. No further action required unless surveillance indicates risk for ASD. Child should be rescreened at future well-child visits. HIGH-RISK: Total Score is 8-20; It is acceptable to bypass the Follow-Up and refer immediately for diagnostic evaluation and eligibility evaluation for early intervention.
Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your child do the behavior a few times, but he or she does not usually do it, then please answer no. Please circle yes or no for every question. Thank you very much.
1. If you point at something across the room, does your child look at it? (FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)
2. Have you ever wondered if your child might be deaf?
3. Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)
4. Does your child like climbing on things? (FOR EXAMPLE, furniture, playgroundequipment, or stairs)
5. Does your child make unusual finger movements near his or her eyes? (FOR EXAMPLE, does your child wiggle his or her fingers close to his or her eyes?)
6. Does your child point with one finger to ask for something or to get help? (FOR EXAMPLE, pointing to a snack or toy that is out of reach)
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7. Does your child point with one finger to show you something interesting? (FOR EXAMPLE, pointing to an airplane in the sky or a big truck in the road)
8. Is your child interested in other children? (FOR EXAMPLE, does your child watch other children, smile at them, or go to them?)
9. Does your child show you things by bringing them to you or holding them up for you to see – not to get help, but just to share? (FOR EXAMPLE, showing you a flower, a stuffed animal, or a toy truck)
10. Does your child respond when you call his or her name? (FOR EXAMPLE, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?)
11. When you smile at your child, does he or she smile back at you?
12. Does your child get upset by everyday noises? (FOR EXAMPLE, does your child scream or cry to noise such as a vacuum cleaner or loud music?)13. Does your child walk?
14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her?
15. Does your child try to copy what you do? (FOR EXAMPLE, wave bye-bye, clap, or make a funny noise when you do)
16. If you turn your head to look at something, does your child look around to see what you are looking at?
17. Does your child try to get you to watch him or her? (FOR EXAMPLE, does your child look at you for praise, or say “look” or “watch me”?)
18. Does your child understand when you tell him or her to do something? (FOR EXAMPLE, if you don’t point, can your child understand “put the book on the chair” or “bring me the blanket”?)
19. If something new happens, does your child look at your face to see how you feel about it? (FOR EXAMPLE, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?)
20. Does your child like movement activities? (FOR EXAMPLE, being swung or bounced on your knee)
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Appendix F
Work Plan/Time Table of Activities
Date Started Date Finished Proposed ActivitiesExpected Outputs
March 1, 2014 April 7, 2014 Proposal WritingFull blown proposal
April 2014 May 2014Seeking Approval of the
LGU
Approved transmittal
letter
May 2014 May 2014Identification of
respondentsMay 2014 June 2014 Pilot testing
June 2014 August 2014 Data collection
Completion and
compilation of all
necessary data
August 2014 September 2014 Data analysis
August 2014 September 2014Completion of terminal
reportTerminal
report
ActivityMonths
1 2 3 4 5 6 7
Proposal WritingSeeking Approval of
the LGUIdentification of
respondentsPilot testing
Data collectionData analysisCompletion of terminal report
GANTT Chart
Note: Number of months depends on the project duration
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Appendix G
LINE ITEM BUDGETName of Project : Autism Spectrum Disorder: Prevalence and Clustering
amongChildren in Inayawan, Cebu CityProponents : Elisha Gine B. Andales, Cristel B. Arestang, Henelle Valerie S. Enad, Sharmaine Josh O. LiProject Affiliation : College of NursingFiscal Year : 2014
Items/Particulars AmountMAINTENANCE AND OTHER OPERATING EXPENSES
1. Office Supplies and Reproduction2. Communications3. Meals and venue for meetings, participant
interaction and data analysis4. Research assistance5. Transportation6. Token
2,000.00500.00
1,000.00
5,000.002,000.001,500.00
TOTAL Php 12,000.00
Prepared by:
ELISHA GINE B. ANDALES CRISTEL B. ARESTANGHENELLE VALERIE S. ENADSHARMAINE JOSH O. LI
Research Members
Approved by:
JEZYL C. CUTAMORA Research Adviser
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C U R R I C U L U M V I T A EPERSONAL INFORMATION
Name: Elisha Gine B. AndalesGender: FemaleAddress: Molave, Zamboanga del SurContact Number: 09335092907E-mail Address: elishagine_andales@yahoo.com.phReligion: ChristianBirthday: April 6, 1995Civil Status: Single
EDUCATIONAL BACKGROUNDCollege:
Cebu Normal University - College of NursingOsmeña Boulevard Cebu CitySchool Year 2011-present
Secondary:Molave Vocational Technical SchoolMabini St., Molave Zamboanga del SurSchool Year 2007-2011
Primary: Molave Regional Pilot School Capistrano St., Molave Zamboanga del SurSchool Year 2001-2007
C U R R I C U L U M V I T A E
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PERSONAL INFORMATIONName: Henelle Valerie S. EnadGender: FemaleAddress: #10 Vincent Drive S. Osmena St.
Gun-ob Lapu-Lapu CityContact Number: 09339588056E-mail Address: henelle.valerie.enad@gmail.comReligion: Roman CatholicBirthday: December 8, 1994Civil Status: Single
EDUCATIONAL BACKGROUNDCollege:
Cebu Normal University - College of NursingOsmeña Boulevard, Cebu CitySchool Year 2011-present
Secondary:St. Alphonsus Catholic SchoolPoblacion, Lapu-Lapu CitySchool Year 2007-2011
Primary: St. Alphonsus Catholic School
Poblacion, Lapu-Lapu CitySchool Year 2001-2007
C U R R I C U L U M V I T A EPERSONAL INFORMATION
Name: Sharmaine Josh O. LiGender: Female
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Address: Elisa Valley, Lahug, Cebu CityContact Number: 09437019585E-mail Address: Sharmaine_li@yahoo.com.phReligion: ChristianBirthday: October 3, 1994Civil Status: Single
EDUCATIONAL BACKGROUNDCollege:
Cebu Normal University - College of NursingOsmeña Boulevard, Cebu CitySchool Year 2011-present
Secondary:Bethany Christian SchoolBuena Hills Subdivision, Guadalupe, Cebu CitySchool Year 2007-2011
Primary: Bethany Christian School Buena Hills Subdivision, Guadalupe, Cebu CitySchool Year 2001-2007
C U R R I C U L U M V I T A EPERSONAL INFORMATION
Name: Cristel B. ArestangGender: FemaleAddress: National Road Catmon- Daan,
Catmon, Cebu City
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Contact Number: 09322362873E-mail Address: uzumakicris17@gmail.comReligion: Roman CatholicBirthday: August 10, 1994Civil Status: Single
EDUCATIONAL BACKGROUNDCollege:
Cebu Normal University - College of NursingOsmeña Boulevard, Cebu CitySchool Year 2011-present
Secondary:Cebu AcademyPoblacion, Carmen, CebuSchool Year 2007-2011
Primary: Carmen Central Primary School
Cogon East, Kangyan, Carmen, CebuSchool Year 2001-2007