1

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

9

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

12

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.

14

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

15

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

19

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,

20

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.

21

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.

22

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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