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PERCEIVED STRESSORS AND COPING MECHANISM AMONG CAREGIVERS OF AUTISTIC CHILDREN IN TACLOBAN CITY: BASIS FOR RECOMMENDATION

A Research Proposal Presented to The Faculty of College of Nursing Holy Infant College Tacloban City

In Partial Fulfillment of the Requirements for the Degree in Bachelor of Science in Nursing

By: GIZEL O. FRANCISCO FRANCE IRISH L. NACION ARVIN IAN C. PEAFLOR FAYE M. REMANDABAN MARIEL C. SABANDAL CRISTYLLE V. VILLANUEVA

January 2012

CHAPTER I INTRODUCTION Rationale of the Study Stress is a universal phenomenon. All people experience it. Parents refer to the stress of raising children, working people talk of the stress of their jobs, and students at all levels talk of the stress of school. Stress can result from both negative and positive experiences. For example, a bride preparing for her wedding, a graduate preparing to start a new job, and a husband concerned about caring for his wife and family are following a diagnosis of cancer all experience stress reactions (Kozier & Erb, 2008). The degree of stress in someones life is highly dependent upon individual factors such as their physical health, the quality of their interpersonal relationships, the number of commitments and

responsibilities they carried, the degree of others' dependence upon, expectations, the amount of support receive from others, and the number of changes or traumatic events that have recently occurred in their lives (http://helpguide.org). The model of stress is broadly discussed but the researcher focus more on Cargiving autistic children. Autism is a mental disorder wherein a person having this particular disorder displays a delay in

social interaction, language and symbolic play. However everyone must be aware that these children are still a human being that need love and care. National Autism Consciousness Week (NACW) was held last January 22 -29, 2012 in the Philippines which was attended by 500 autistic children with their family, its purpose is to enlighten the public what is autism really means. Mrs. Gina Nazareth stated that Meron silang role dito sa mundo kung bakit sila binigay sa atin, and thats for us to find out featured in a news media 24 Oras. Mas matutuwa sana kami kung i-rerespeto din sila, hindi kakaawa-an, hindi parang pinagbibigyan kundi dahil part sila ng society natin added by Mrs. Dang Koe in an interview during NACW in Pasay. Children having this particular disorder find it harder to interact and engage in normal activities, thus in most cases, these particular patients need supervision (http://psychcentral.com). When Ryan has a tantrum it is not because he didnt make his way, it is because he cannot communicate to us what he wants that can be extremely frustrating to anyone says Rylenden in her documentary about autism entitled: A day in the life of Ryan (youtube.com). Most recent reviews tend to estimate a prevalence of 1 per 110 children that is being born has autism; Autism Syndrome Disorder (ASD) affects an estimated 1 million Filipino but only 5% of them are aware that they have autism and only 2% avail medical aid

(wikipedia.org/wiki/Autism). According to DSWD region 8 Information Officer, there are about 101 persons with autism, aging zero to 59 years old, in Tacloban City, a study of the Department of Social Welfare and Development (DSWD) field office eight revealed

(http://www.pia.gov.ph) The role of a caregiver is more demanding in this kind of appointment because unlike any other caregiver, this situation where in autistic children cannot communicate clearly has a problem in social interaction etc can bring a lot of stress on the part of caregiver (http://psychcentral.com). Caregiving often takes a great deal of time, effort, and work. Many caregivers struggle to balance caregiving with other responsibilities including full-time jobs and caring for children especially autistic ones. Lisod jun mag bantay kay Jaybee, panagsa kapuyon na ka pero pasensyahan na jud kutob sa makaya (Its so difficult to supervise Jaybee, sometimes you feel like giving up but still you need to have patience) as what Aling Mariquita said, featured in a news media 24 Oras of GMA-7 Davao. Based on this information, it is very stressful for a caregiver to handle such responsibility, and without proper and effective coping strategies they may tend to experience Caregiver Stress which is a syndrome that can lead to exhaustion and has some traits in common with exhaustion.

Caregivers may experience burnout which is a mixture of physical, emotional, and mental exhaustion when they don't get adequate help

or

when

they

overextend

themselves

physically,

mentally,

or

financially. Fatigue, anxiety attacks, and even depression may come from this caregiver burnout (humanlyexhausted.com). A child's deficits in social skills, such as the lack of appropriate play, are also stressful for families. Individuals lacking appropriate leisure skills often require constant structure of their time, a task not feasible to accomplish in the home environment. As a parent, teacher, or caregiver one may know the frustration of trying to communicate and connect with children or adults who have autism. One may feel ignored as they engage in endlessly repetitive behaviors. Or may despair at the bizarre ways they express their inner needs. And he/she may feel sorrow that his/her hopes and dreams for them may never materialize (http://psychcentral.com). With this enough notion, the researchers are eager to deal with the respondents as a whole system. Not just dealing with the stressors itself but the whole aspect that affects the entire person which might be emotional, psychological or physiological. In this study, nursing assessment is needed in order to give emphasis on the stress level of these caregivers. Health education in the nursing profession is the primary and integral part of responsibility as student nurses. Through this study the researcher intend to direct or advise these caregivers on how to cope up with the situation they are in based on the level of

stress felt in caring these kinds of children. This study will also determine the level of stress so as to provide or recommend suitable interventions and actions to relive their stress felt. Theoretical Background This study is anchored on the Adaptation Model by Sister Callista Roy. This model comprises the four domain concepts of a person, health, environment, and nursing and involves a six step nursing process. The person can be a representation of an individual or a group of individuals. Roys model sees the person as a biopsychosocial being in constant interaction with a changing environment. The person is an open, adaptive system who uses coping skills to deal with stressors. Roy sees the environment on all conditions, circumstances and influences that surround and affect the development and behavior of the person (Andrews and Roy, 2004). Furnham (1997) defined stress as the mental and physical condition that results from a perceived threat or demand that cannot be dealt with readily. Stress is perceived as an inevitable

characteristic of life (Boss, 1988). Stressor events are considered normative or part of expected life events and transitions. Some stress producers such as creative activities or physical exercise are

considered healthy and a normal part of life (McGuigan, 1999; McKenry & Price, 1994). No single situation can be pinpointed as the cause of a

reaction to stress as a variety of dissimilar situations are capable of producing the reaction (Selye, 1983). With change, pressure or stress can occur. Sources agree that the word stress is often overused and that many definitions of the term exist (Furnham, 1997; McGuigan, 1999; Selye, 1983).

Several definitions of stress exist in the literature. One of the classic definitions of stress is by Hans Selye, who defined it as the non specific response of the body to any demand made upon it. Viewed in this manner, every demand made on the body is unique or specific. The stress-producing factor, called the stressor, can be either pleasant (eustress) or unpleasant (distress) (Selye, 1983). The adaptive response of the body to an agent or situation is the same, according to Selye. What varies is the degree of response. The classification of stress (eustress or distress) varies depending on the nature of a situation, an individuals physical and psychological well-being, and on the characteristics of a family unit (McCubbin & Patterson, 1983b). Individuals and families subjectively define stress which is reflected by their values and previous experience in meeting crises and dealing with change. When subjectively defined as unpleasant or undesirable by the individual or family, stress becomes distress (McCubbin & Patterson, 1983b).

Another theory that is formulated out from the nursing context is the theory of Han Selye. He states that stress has become a universal explanation for human behaviour in industrial society. This analysis is framed in terms of Latour's actor-network theories, and traces the translation of stress from the animal laboratory into the narratives of modern life experiences. This mapping reveals that translation was brought about by Selye's recruitment of a broadly based constituency outside of the academic physiology, whose members each saw in stress a validation of their pre-existing ideas of the relationship of the human mind and body in industrial civilization (http://en.wikipedia.org). Moreover, Selye also formulated the General Adaptation

Syndrome, or GAS. It is a term used to describe the body's short-term and long-term reactions to stress. Stressors in humans include such physical stressors as starvation, being hit by a car, or suffering from a severe weather. In addition to this, humans can suffer such emotional or mental stressors as the loss of a loved one, the inability to solve a problem, or even having a difficult day at work (Kee et al., 2005). The First stage of the general adaptation stage is the Alarm Reaction, which is the immediate reaction to a stressor. In the initial phase of stress, humans exhibit a fight or flight response, which prepares the body for physical activity. However, this initial response

can also decrease the effectiveness of the immune system, making persons more susceptible to illness during this phase (Kee et al., 2005). The Second stage might also be named the Stage of Adaptation, instead of the Stage of Resistance. During this phase, if the stress continues, the body adapts to the stressors it is exposed to. Changes at many levels take place in order to reduce the effect of the stressor. For example, if the stressor is starvation (possibly due to anorexia), the person might experience a reduced desire for physical activity to conserve energy, and the absorption of nutrients from food might be maximized (Kee et al., 2005). The Third is the Stage of Exhaustion. At this stage, the stress has continued for some time. The body's resistance to the stress may gradually be reduced, or may collapse quickly. Generally, this means the immune system, and the body's ability to resist disease, may be almost totally eliminated. Patients who experienced long-term stress may succumb to heart attacks or severe infection due to their reduced immunity. For example, a person with a stressful job may experience long-term stress that might lead to high blood pressure and an eventual heart attack (Kee et al., 2005). Furthermore, Selye gives emphasis that stress is not purely negative phenomenon; in fact, he frequently pointed out that stress is not only an inevitable part of life but results from intense joy or

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pleasure as well as fear or anxiety. Stress is not even necessarily bad; it is also the spice of life, for any emotion, any activity, that causes stress. Some later researchers have coined the term eustress or pleasant stress, to reflect the fact that such positive experiences as a job promotion, completing a degree or training program, marriage, travel, and many others are also stressful (Smyth, 2004). In addition, Selye also pointed out that human perception of and response to stress is highly individualized; a job or sport that one person finds anxiety as provoking or exhausting might be quite appealing and enjoyable to someone else. Looking at one's responses to specific stressors can contribute to better understanding of one's particular physical, emotional, and mental resources and limits. Stress is one cause of a General Adaptation Syndrome (Smyth, 2004). Meanwhile, stress is the wear and tear in the body (Selye). He developed his framework to explain the physiologic response to stress. Selye viewed stressor as any positive or negative occurrence or as any emotion requiring a response. Interaction to environment or others inevitably produces stress, depending on its individual

perception and definition. However, Selye discovered that many individuals demonstrate the same symptoms, regardless of the stressor (Keltner et al., 2007).

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Similar to Selyes theory to stress, another theory also came out in relation to it; this gives birth to the Theory of Lazarus. He states that working more with humans and came to the conclusion that neither the stressor, nor the response could define stress, but rather it was the individual's perception and appraisal of the stressor that would determine if it would create stress. Psychological stress is a

relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being. Lazarus believed that the basis of coping is not a result of anxiety, per se, but of personal, cognitive appraisal of treat. There are two stages of cognitive appraisal. The first stage in his model is primary appraisal where the subject analyzes the stressor and determines if it will be positive or negative, exciting or harmful, etc. The second stage is secondary appraisal, where the subject determines if he or she can cope with the given stressor. Even if the stressor is determined as harmful in the first stage, if the subject decides, he or she can cope with it in the second stage, stress will be kept at a minimum (Lazarus and Folkman, 2000). Lazarus argued that in order for a psychosocial situation to be stressful, it must be appraised as such. He argued that cognitive processes of appraisal are central in determining whether a situation is potentially threatening, constitutes harm/loss, a challenge, or is benign. This primary appraisal is influenced by both person and

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environmental factors, and triggers the selection of coping processes. Problem-focused coping is directed at managing the problem, while emotion-focused coping processes are directed at managing the negative emotions. Secondary appraisal refers to the evaluation of the resources available to cope with the problem, and may alter the primary appraisal (Lazarus and Folkman, 2000). In other words, primary appraisal also includes the perception of how stressful the problem is; realizing that one has more than or less than adequate resources to deal with the problem which affects the appraisal of stressfulness. Furthermore, coping is flexible in that the individual generally examines the effectiveness of the coping on the situation; if it is not having the desired effect, he/she will generally try different strategies to cope up with the situation (Lazarus and Folkman, 2000). According to McCubbin and Patterson (1983b), stress is not

stereotypic, but varies depending upon the nature of the situation, the characteristics of the family, and the psychological and physical wellbeing of the family members. An unexpected event that is not disastrous may be stressful, such as winning the lottery or receiving a promotion (McKenry & Price, 1994). Families with similar

circumstances could perceive the same event either as a crisis or as a normative event, depending on their coping resources (e.g., economic, emotional, family support). One classification of events used by family stress researchers is normal or predictable events versus

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unpredictable, situational, or non-normative events. Normal events are viewed as a part of life and represent transitions in the family life cycle. By definition, these are of a short duration. Non-normative events are the product of a unique situation that could not be predicted and is often not likely to reoccur (Boss, 1988). Stress has behavioral, cognitive, and physiological symptoms or consequences. When faced with a stressor, the physiological

symptoms link to the bodys fight-or-flight response. Psychological symptoms that can occur are anxiety, fear, emotional disorder, and defensive attitudes and behavior (Furnham, 1997). There also are various factors that seem to make individuals prone to stress, such as worry, external locus of control (a 25 belief that life is controlled by external forces). However, the type of personality of an individual has direct relation to the intensity of stress felt and the way one cope with stress. Research has indicated that certain personality traits can make us more vulnerable to stress (http://stresscourse.tripod.com). These personalities are categorized as type A, B, C, and D. The individuals that come under personality type A are of a highly independent nature. These can best be described as the bulldozers. People falling under the type A personality classification will have characteristics that portray them as people with a lot of time urgency and impatience. Money and finances mean a lot to them, so much so, that even their relationships,

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they think, should be based on money. Type A personality people prioritize their work over all their relationships, since they are so particular about time and the way they spend their time. They have the urge to do something productive all the time or else may be engulfed with guilt of wasting time. A good thing about these people are that they are achievers in everything that they get themselves into, they have the ability to succeed even in ventures they know nothing about due to their competitiveness and challenging spirit. You will find such people planning out their time and also adhering to the plan most of the time. Other characteristics of the type A personality include aggressiveness and a short tempered nature, they are achievement oriented and have a great deal of trouble relaxing and taking it easy (http://www.buzzle.com). The type B personality people are quite the opposite of the type A personality people. They are described as the bombers. These people are patient to a large extent, are easygoing and take things slowly and steadily. They do not believe in hurrying into things, take time to think and ponder before acting and may also delay their work to the last minute. These people love to socialize and be in the company of both known and unknown people. They often manage to grab quite a lot of attention wherever they go and seek comfort more than success while working. They are considerate, caring and approachable and know how to maintain their relationships well. They

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also know how to maintain a balance between their professional and personal life, which leads them to be lot more satisfied with their lives. These characters are extroverts to the soles of their boots, and think that life is nothing else but getting under the spotlight and spell binding the rest. Individuals that fall under the personality type B are human magnets that can attract attention of everyone in a gathering without so much of an effort. This makes type B special, among the various other personalities. Persons of personality type B thrive on the interactions with the others. Your act of ignoring them or their efforts is as good as you sticking a knife in their back, for them

(http://www.buzzle.com). Type C personality people are perfectionists and tend to take everything seriously. The apt term to describe these people is the Seekers. They dress very neatly and work very devotedly. They have a tendency to go deep into details of things and are always striving for accuracy in whatever they do. They are very consistent and follow all the rules and procedures in both work and life in general. This trait in them makes them very dependable as they do not rush things, and because they always check a thing inside out before proceeding further. They are deep thinkers, who like to know each and every detail of how and why certain things work. They are very patient and do not rest unless and until they get at the bottom of things. One of the peculiar type C personality traits is that these people are unable to

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express their emotions, feelings or needs to other people. These people are true introverts and you will never find them showing their anger or being over ecstatic about anything. In fact these people often ignore and deny their feelings and maintain a kind of rational, nononsense and unemotional outward demeanor all the time. They have a tendency to please other people, even if it means that they hurt themselves in the process. They deny their feelings and cannot stand up for themselves; tend to suffer from stress and depression more than any other personality type. Some of the other common health related type C personality disorders are rheumatoid arthritis, asthma, multiple sclerosis, lupus and amyotrophic lateral sclerosis. Clearly, most of these are autoimmune disorders. Researches show that due to the strong mind-body connection in humans, when an individual with type C personality suppresses his wishes and does things only for others repeatedly, the immune system responds by attacking the self, instead of defending it. A type C personality can never say no to others, becomes stressful because of this, and ends up with many illness and diseases (http://www.buzzle.com). Individuals with a Type D personality have the tendency to experience increased negative emotions across time and situations and tend not to share these emotions with others, because of fear of rejection or disapproval (http://en.wikipedia.org). These gentlemen really believe in inertia which they have no shortage of. These people

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prefer to stick to the trodden paths and established routines over the uncertainty of change. These are followers of the spent actions and executors of the direct commands. You will find them doing their best not to stretch their neck out when it comes to taking responsibility and risk. With the help of professionals in the field of personality development and through sheer power of self motivation or self improvement, these people can overcome their handicap to some extent. These individuals, which make 21 percent of the population, are afflicted by negativity such as worry, irritability, gloom, etc., and hardly feel self-assured. To avoid rejection, tends not to open up and share their negative emotions. This causes them to suffer from enormous amount of stress which makes them prone to heart related diseases. The study shows that as many as 18 to 53 percent of cardiac patients have type D personality (http://www.buzzle.com). This study is also bounded to the theory of Banduras (1997) which is the Self-efficacy Belief. This theory states that in human functioning, peoples level of motivation, affective states and actions are based more on what they believe and what is objectively true. For this reason, how people behave can often be better predicted by the beliefs they hold about their capabilities than by what they are actually capable of accomplishing, for these self-efficacy perceptions have determined that individuals do with the knowledge and skill they have (www.des-emory.edu.com).

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One very difficult form of stress to cope with and manage is emotional stress. After all, it is often self-created, it can come out of nowhere and the stress caused by it only heightens the emotions felt. Thus, as the emotional stress increases, the emotions get worse, heightening the emotional stress. Thus, the problem recreates the cause and the problem only gets worse.Emotional stress is often triggered by a dramatic event that puts a person's nervous system under severe strain. This could be an event such as losing a loved one, seeing someone die, or being put into a life-threatening situation. An event such as this can put severe strain on a person's mind and nerves and the incredible strain can cause changes in the way that the brain works. In fact, a severe emotional strain could even cause someone to suffer from post-traumatic stress disorder (loweryourstress.com). According to an article entitled Dealing with Emotional Stress Emotional stress is often triggered by a dramatic event that puts a person's nervous system under severe strain. This could be an event such as losing a loved one, seeing someone die, or being put into a life-threatening situation. An event such as this can put severe strain on a person's mind and nerves and the incredible strain can cause changes in the way that the brain works. In fact, a severe emotional strain could even cause someone to suffer from posttraumatic stress disorder. However, emotional stress does not arise from a sudden shock. It can also arise from a total emotional strain

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that adds up to an overwhelming strain that prevents a person from thinking about anything other than the problems that seem to have no solution. Then, as the stress mounts, the mind is left in its own cocoon of stress that can only call attention to it, cutting the person off from the world outside. Thus, emotional stress can lead to detachment, and inability to concentrate, fatigue, and even memory problems.

Unfortunately, emotional stress also increases moodiness, which can often make things worse. In fact, those attacks of emotional excess can turn emotional excess up to unbearable levels, leading to further attacks. Then, as these bouts of emotional stress keep adding up, it all becomes too much and the sufferer is left almost completely lost and alone in their own cycle of emotion that hammers incessantly at the brain (articlesbase.com). Stress actually occurs before a child takes his/her first breathe (Bittman, 1999) in a survey of U.S. adults aged 25 to 74 years of age, just 8% of young adults said they had even one stress-free day in a given week, compared with 12% of mid-lifers and 19% of those over 60. The difference appears to be one of attitude according to Almeida of The University of Arizona. Were finding that older people are mellowing a bit, he said. According to his research, the older we get, we kind of realize that hey, its not worth getting upset about the small things (Mundell, 2002). In the study, Almeida and his colleagues examined data from a large government survey of over 1,000

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American adults known as The National Study of Midlife in the United States. As part of the study, researchers telephoned participants every evening for eight consecutive evenings, quizzing them on the amount and type of stressors they had faced that day. And we found that, in sheer number of stressors that people reported, there was no difference between younger adults and midlife adults, Almeida said. While these daily hassles tended to really upset those aged 25 to 39, boomer types aged 40 to 59 were more likely to shrug them off. The younger people in our sample would report that as more disruptive, more upsetting, than older people, Almeida said (Mundell, 2002). Autism causes kids to experience the world differently from the way most other kids do. It's hard for kids with autism to talk with other people and express themselves using words. Kids who have autism usually keep to themselves and many can't communicate without special help. They also may react to what's going on around them in unusual ways. Normal sounds may really bother someone with autism so much so that the person covers his or her ears. Being touched, even in a gentle way, may feel uncomfortable. Kids with autism often can't make connections that other kids make easily. For example, when someone smiles, you know the smiling person is happy or being friendly. But a kid with autism may have trouble connecting that smile with the person's happy feelings. A kid who has autism also has trouble linking words to their meanings. Imagine trying to understand what

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your mom is saying if you didn't know what her words really mean. It is doubly frustrating then if a kid can't come up with the right words to express his or her own thoughts. Autism causes kids to act in unusual ways. They might flap their hands, say certain words over and over, have temper tantrums, or play only with one particular toy. Most kids with autism don't like changes in routines. They like to stay on a schedule that is always the same. They also may insist that their toys or other objects be arranged a certain way and get upset if these items are moved or disturbed. If someone has autism, his or her brain has trouble with an important job: making sense of the world. Every day, your brain interprets the sights, sounds, smells, and other sensations that you experience. If your brain couldn't help you understand these things, you would have trouble functioning, talking, going to school, and doing other everyday stuff. Kids can be mildly affected by autism, so that they only have a little trouble in life, or they can be very affected, so that they need a lot of help (http://kidshealth.org). For parents of autistic children, there's often no such thing as a good night's sleep. Children on the autism spectrum are often prone to wakefulness well into the night, making it hard for others to sleep and leading parents to worries that their child will harm himself if Mom and Dad fall asleep. This fear is well founded. It is not unusual for autistic children to leave the house in the middle of the night - all without a care in the world (voices.yahoo.com).

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According to a thesis entitled The effect of age on stress levels and its affect on overall performance by Dr. Marian and James Schultz there are different predisposing factor related to the occurrence of stress among caregiver. These include the age, finances/salary and vital signs. Based on their notion there is no age at which we are exempt from stress. Most of us are well aware that as a person chronologically ages, there are more responsibilities and situational stressors that become part of our lives which subsequently can bring about consequences affecting our well being. As adults, stress is a daily event, but children are not exempt from its impact and subsequent consequences. Symptoms of stress are especially apparent in teenagers (Bittman, 1999) On the study entitled Family Caregiving Stress Filled and Isolating by Steven Zarit, professor and head, human development and family studies, and his colleagues studied the 15 most common stressors for caregivers -- including financial strain, patient behaviors, and frequency of help from family and friends, and caregiving time demands. The findings, published in a recent issue of Aging & Mental Health, showed that the 67 people in the study experienced radically different types and amounts of stress "Behavior issues are a common stressor, but caregivers don't always report that their family member has behavior issues," said Zarit. "Some people feel more strain from the sense that they've lost a relationship with their family member or

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because of conflict with siblings or other relatives. It's different for everyone." Caregivers with higher levels of depressive symptoms exhibited lower levels of warmth and higher levels of hostility during both loss and conflict tasks. In the loss task, the child was asked to share with family members his/her experience of a previously identified sad event, such as a death or an injury. In the conflict task, parent and child were asked to resolve a disagreement previously identified by each of them in separate interviews, such as a disagreement about chores, sibling conflict, or privileges. As expected, caregivers tended to show more hostility and less warmth during the conflict task than during the preceding loss task. However, caregivers with

moderate/severe depressive symptoms showed a greater rise in hostility from the loss to the conflict task than caregivers with minimal/mild depressive symptoms. By including a task designed to elicit warmth, the study allowed for a more valid exploration of how caregivers respond to childrens need for support and nurturance, expanding upon traditional procedures for collecting observational data. The study provides a better test of models for understanding how parenting behaviors associated with caregiver depression may lead to child maladjustment (sciencedaily.com).

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The relationship of stress and care imparted by the caregivers is well defined. Studies have indicated that stress can affect the way of caring psychological challenge children such as autism. The body doesnt distinguish between physical and psychological threats. When one is stressed over a busy schedule, an argument with a friend, a traffic jam, or a mountain of bills, the body reacts just as strongly as if one was facing a life-or-death situation. If one has a lot of responsibilities and worries, the emergency stress response may be on most of the time. The more the bodys stress system is activated, the easier it is to trip and the harder it is to shut off. Long-term exposure to stress can lead to serious health problems. Chronic stress disrupts nearly every system in your body. It can raise blood pressure, suppress the immune system, increase the risk of heart attack and stroke, contribute to infertility, and speed up the aging process. Longterm stress can even rewire the brain, leaving you more vulnerable to anxiety and depression (http://helpguide.org). Coping may be described as dealing with change successfully or unsuccessfully. A coping Strategy (coping mechanism) is a natural or learned way of responding to a changing environment or specific problem or situation. According to Folkman and Lazarus (1991), coping is the cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person (Kozier & Erb 2008).

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Two types of coping strategies have been described: problemfocused and emotion-focused coping. Problem/Solution-focused coping refers to efforts to improve a situation by making changes or taking some action (Lazarus, 2000). Some Example of this coping are: Taking Control this response involves changing the relationship between yourself and the source of stress. Examples: escaping from the stress or removing the stress. Information Seeking the most rational action. This involves the individual trying to understand the situation and putting into place cognitive strategies to avoid it in future. Information seeking is a cognitive response to stress. Evaluating the pros and cons of different options for dealing with the stressor

(simplypsychology.org). Emotion-focused coping includes thoughts and actions that relieve emotional distress. Emotion-focused coping does not improve the situation, but the person often feels better (Kozier & Erb 2008). These includes; keeping yourself busy to take your mind off the issue, Letting off steam to other people, Praying for guidance and strength, Ignoring the problem in the hope that it will go away, Distracting yourself (e.g. TV, eating), Building yourself up to expect the worse (simplypsychology.org). Both types of strategies usually occurs together (Lazarus, 2000). Coping strategies are also viewed as long term or short term. Long-term coping strategies can be constructive and realistic. For example, in certain situations, talking with others and trying to find out

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more about the situation are long-term strategies. Other long-term strategies include a change in lifestyle patterns such as eating a healthy diet, exercising regularly, balancing leisure time with working, or using problem solving in decision making instead of anger or other nonconstructive responses (Kozier & Erb 2008). Short-term coping strategies can reduce stress to a tolerable limit temporarily but are ineffective ways to permanently deal with reality. They may even have a destructive or detrimental effect on the person. Examples of shortterm strategies are usually alcoholic beverages or drugs, daydreaming and fantasizing, relying on the belief that everything will work out, and giving in to others to avoid anger (Kozier & Erb 2008). Coping strategies vary among individuals and are often related to the individual's perception of the stressful event. Three approaches to coping with stress are to alter the stressor, adapt to the stressor, or avoid the stressor. A person's coping strategies often change with a reappraisal of a situation. There is never only one way to cope. Some people choose avoidance; others confront the situation as a means of coping. Still other seeks information or relies on religious beliefs (Kozier & Erb 2008). Coping can be adaptive or maladaptive. Adaptive coping helps the person to deal effectively with stressful events and minimizes distress associated with them. Maladaptive coping can result in unnecessary distress for the person and others associated with the person or stressful event. In nursing literature, effective and

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ineffective coping are often differentiated. Effective coping results in adaptation; ineffective coping results in maladaptation (Kozier & Erb 2008). The effectiveness of an individual's coping is influenced by a number of factors, including: 1. The number, duration, and intensity of the stressors. 2. Past experiences of the individual. 3. Support systems available to the individual. 4. Personal qualities of the person. If the duration of the stressors is extended beyond the coping powers of the individual, that person becomes exhausted and may develop increased susceptibility to health problem. Reaction to longterm stress is seen in family members who undertake the care of a person in the home for a long period. This stress is called caregiver burden and produces responses such as chronic fatigue, sleeping difficulties, and high blood pressure. Prolonged stress can also result in mental illness. As coping strategies or defense mechanisms become ineffective, the individual may have interpersonal problems, work difficulties, and a significant decrease in abilities to meet basic human needs (Kozier & Erb 2008). Examples of the negative effect of stress on Basic Human Needs are; Physiologic needs altered elimination pattern, change in appetite, altered sleep pattern. Safety and Security

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Expresses nervousness and feelings of being threatened, Focuses on stressors, inattention to safety measures. Love and Belonging isolated and withdrawn, becomes overly dependent, blames other for ones problems. Self-esteem fails to socialize with others, becomes a workaholic, and draws attention to self. Self-actualization

preoccupied with own problems, shows lack of control, unable to accept reality (Kozier & Erb, 2008). Another Definition of coping is a behavioral and cognitive effort to master, reduce, or tolerate the internal and external demands that are created by stressful transactions (Folkman & Lazarus, 1986). The concept of coping, like that of stress, is not a unified construct with a 41 41 meaning that is readily agreed upon by experts (Eckenrode,

1991). A prerequisite for coping is the presence of a condition or event that is appraised as harmful or threatening to an individual (Lazarus & Folkman, 1986).

There are two functions of coping: (a) regulation of emotions or distress, and (b) management of the problem that is causing the distress (Folkman & Lazarus, 1984). Coping processes for handling stress vary from encounter to encounter according to what is at stake for the individual (e.g., self-esteem, physical health) and the options for coping (e.g., whether something can be done to change the situation) (Folkman & Lazarus, 1986). Whether people suffer from

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stress or not is often dependent on their coping strategies (Furnham, 1997). Coping strategies are responses to the perceived stressor threat. Like stress, coping can have both positive and negative consequences (Boss, 1998). Coping strategies are not always positive. Coping strategies outlined by Carver, Scherer, and Weintrab (1989) (as cited in Furnham, 1997) are positive reinterpretation, planning, seeking support for problems, religion, acceptance, denial, alcohol use, humor, and mental disengagement. Commonly used approaches are life-style changes such as diet and exercise, meditation, and

relaxation. (Furnham,1997). In addition, the meaning a family attaches to a stressful situation is a form of coping behavior (McCubbin, Thompson, & McCubbin, 1996). A familys coping resources are its individual and collective strengths during the time a stressor event occurs (Boss, 1988). Job skills, health, economic security, social supports, relationship skills, and proximity of support are examples of coping resources. Resources are defined as the means capable of meeting the demands placed upon a family (Deacon & Firebaugh, 1988). They are whatever is available to use (Goldsmith, 1996) or the economic, psychological, or physical assets individuals can draw upon in response to stressor events (Boss, 1988).

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When individuals or family members have sufficient resources, they are less likely to view a stressful event as a problem (McKenry & Price, 1994). Resources mediate the impact of a stressful event (McCubbin & Patterson, 1983b). Family stress has been found to be lower among families with financial resources, social support, and 42 42 adaptive family system characteristics (Voydanoff, 1984) and satisfaction with life (Bailey, Woodiel, Turner, & Young, 1998). Spirituality and health has no definite relationship. However, it seems that the body, mind and spirit are connected. The health of anyone of these elements seems to affect the health of the others. Some research shows that things such as positive beliefs, comfort and strength gained from religion, meditation and prayer can contribute to healing and a sense of well-being. Improving your spiritual health may not cure an illness, but it may help you feel better, prevents some health problems, and help you cope with illness, stress or even death (www.familydoctor.org.com). A person coping with behavior problems may also have other difficulties not targeted by this single-stressor intervention. Some caregivers will not need to cope with behavior problems at all. "The majority of caregivers are living at home, with little or no help," said Zarit. "The family has to pay the physical, emotional, and financial cost of the caring, which can be staggering. When the caregiver gets

31

overwhelmed, it raises the probability of a breakdown in the care situation." In a few cases, there are reports of neglect or abuse. Most interventions operate as a preventive measure -- they reach people before the stress becomes overwhelming. "Because stress profiles vary so widely, we just don't know how much of a given stressor will hit a threshold and when we should make an intervention," Zarit said. According to Zarit, a promising approach is to use an adaptive intervention, one that can be customized to address the varying risk factors of each individual. Some of these interventions exist in the real world and are successful. However, most of these interventions are published and never become used widely, said Zarit. Even if current interventions are not always effective, options exist to alleviate stress and maintain well-being in a caregiving relationship. Zarit's past research has found that family meetings -- which enlist the support of extended family -- can improve well-being for both individuals in the relationship (sciencedaily.com). On the Article entitled Caregiver Depression: A Silent Health Crisis it state that One of todays all-too silent health crises is caregiver depression. A conservative estimate reports that 20% of family caregivers suffer from depression, twice the rate of the general population. Of clients of Californias Caregiver Resource Centers, nearly 60% show clinical signs of depression. And former caregivers

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may not escape the tentacles of this condition after caregiving ends. A recent study found that 41% of former caregivers of a spouse with Alzheimers disease or another form of dementia experienced mild to severe depression up to three years after their spouse had died. In general, women caregivers experience depression at a higher rate than men (caregiver.org). Acording to sudy conducted last May 2007 in the San Jose State university by Twoy R, and et.al, entitled Coping strategies used by Parents of Children with autism, shows that the level of adaptation was within the normal limits with coping scores similar to the norm scores of the family crisis oriented personal evaluation skills (F-COPES) with males scoring slightly higher than females in the coping scale. Subscale scores of the F-COPES that indicated that the parents sought encouragement and support from friends, informal support from other family who face similar problems, and formal support from agencies and programs. Reframing revealed similar result as the norm with less use of spiritual support, and more passive appraisals were noted from the parent of children with ASD

(http://www.ncbi.nlm.nih.gov). A study entitled Coping Over Time: The parents of children with autism, authored by Gray shows result that coping strategies changed from the time of the initial study, as fewer parents coped through reliance on service providers, family support, social withdrawal

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and individualism and relatively more parents coped through their religious faith and other emotion focused strategies. The results tentatively support previous research on coping that indicates that aging is linked to the use of more emotion-focused coping strategies (http://www.ncbi.nlm.nih.gov). A research in Taiwan authored by Chang and et al, entitled Coping Mechanism of Parents of Children recently diagnosed with autism in Taiwan: A Qualitative Study, wherein it aims to understand the coping mechanism of Taiwanese parents whose children have recently diagnosed with autism. The result was that the study sample of parents of children with autism described nine main coping mechanisms that fell into three core categories: adjusting to self-change, developing treatment for the autistic child and seeking support (http://www.ncbi.nlm.nih.gov). The following are few coping strategies that Laura may help find strength and the support that a caregiver may need. (1) Educate yourself. Learn the vocabulary necessary to effectively communicate your childs need. Remember, knowledge is power and if nothing else, youll be able to quickly ascertain the depth of education or experience a professional may or may not have with respect to your particular set of circumstances. (2) Get more than a second opinion. Dont just consult more than one doctor; consult more than one type of doctor. If, for example, your child is having difficulty with assimilating

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information, dont conclude your fact finding at your pediatricians general practitioners office. You may want to see a specialist, a neurologist, or even an ophthalmologist. Sometimes a child can be too quickly diagnosed by school officials as learning disabled when in fact the child may actually have a vision problem. Consulting several doctors will help to ensure the most accurate diagnosis possible. (3) Keep up on current research. Be careful, however, this may prove to be an emotional trap for a loving parent who can become obsessed with finding answers. It might be a good idea to assign a family member or friend to be the go to person when new information needs to be sought. This point person can be the one to surf the net, subscribe to newsgroups, visit parents forums and read medical journals or science articles on the latest research. Delegating this task will allow you to focus on quality time with your child and focus on his or her developmental needs. (4) Maintain a separate identity. You are not your child and this isnt happening to you. The disease or disability is happening to your child, and dont forget that. As attempting as it is, you cannot take that specific burden on yourself. Financial burdens, housing burdens and transportation burdens yes, those can be yours but not the disability itself. If able, the child must learn that, ultimately, he will be his best advocate. Empower him or her as early as possible. As much as you may desperately wish to relieve your child of the burden you believe he or she surely must be suffering, you

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cannot. Your child may not be able to comprehend the gravity of his or her situation, but a child has no difficulty grasping your responses to it. Try not to allow your grief and anxiety to define your child. The best thing you can do for your child is to teach self-sufficiency, encourage resourcefulness and advocate self-determination. (5) Dont take no for an answer no one is a better advocate for your child than your child or you. Do not allow anyone to speak for you if they do not respect your views, needs or best interests, or those of your child. Build a team of trusted professionals, cheerleaders and supporters. (6) Give yourself a break. Avail yourself of professional, peer or group counseling. You may feel alone, but youre not. Let others help you. Allowing another person to help you can be a tremendous gift for you both. Understanding the extent to which you feel overwhelmed can be detrimental to your decision-making ability. Take good care of yourself, so you can be the best caregiver for your child

(http://ezinearticle.com).

Though serving an autistic child is very difficult to bear, there is this something like very unique part because one can experience how

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hard it is to care such children. Many people still wonder the impact of stress on these caregivers and how they affect in the routine of their daily lives. However, caregiving is an important aspect in the lives of these kinds of children, and also a great deal when it comes to supervising such creature.

B A S I S Caregivers of Autistic Children In Tacloban City F O R R E C O M M E N D A T I O N

Profile of Caregivers of Autistic Children a. Age b. Gender c. Civil Status d. Monthly income e. Highest Educational Attainment f. Relation to the autistic child g. Personality type

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Perceived Stressors and level of stress: 1. Personal stressors 2. Family stressors 3. Caregiving stressors

Perceived symptoms of stress 1. 2. 3. 4. 5. Physical Emotional Behavioral Psychological Relational symptoms

Coping mechanism & extent of employment 1. Emotion-Focused Coping Figure I. Conceptual Framework of the Study Figure I, illustrates the conceptual framework of the study. The study will use purely descriptive research design to determine the profile of the respondent who care for an autistic child; specifically the study on hand will describe the variables included in the study such as

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the age, gender, civil status, monthly income, highest educational attainment, relation to autistic child personality type. Furthermore it will also determine the perceived stressors which are categorized into three namely personal, family and caregiving stressors, and the level of stress of the respondents, the perceived physical, emotional, behavioral, mental and relational. The symptoms of stress as manifested by the respondents, their coping mechanisms and extent of their employment. Based on the findings of the study, basis for recommendation may be formulated.

THE PROBLEM

Coping mechanism extent of employment

&

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Statement of the Problem This study aims to determine the perceived stressors and coping strategies among caregivers of autistic children in Tacloban City. Findings will serve as basis for recommendation. Specifically, it seeks to answer the following questions: 1. What is the profile of the respondent in terms of:
1.1 Age; 1.2 Gender; 1.3 Civil status; 1.4 Monthly income; 1.5 Highest educational attainment; 1.6 Relation to the autistic child; and 1.7 Personality type?

2. What are the perceived stressors of the respondents in terms of the following:
2.1 Personal stressors; 2.2 Family stressors; and 2.3 Caregiving stressors?

3. What is the level of stress of the respondents? 4. What are the perceived symptoms of stress commonly manifested by the respondents in terms of the following:
4.1 Physical; 4.2 Emotional; 4.3 Behavioral; 4.4 Mental; and 4.5 Relational symptoms?

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5. What coping mechanisms do the respondents employed, and to what extent?

5.1 Emotion-Focused Coping 5.2 Problem-Focused Coping

6. Based on the findings of the study, what recommendation can be formulated?

Significance of the Study The findings of this study are beneficial towards evaluating the stress levels of caregivers of autistic children. The study would likewise

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present the importance of stress management for Caregivers of autistic children so as to prevent stress related problems to the respondents. The findings of this study will be of great benefit to the following: Caregivers of autistic children. Caregivers of autistic are the main respondents of this study. Determining their levels of stress can be a great achievement thus providing the necessity to look for interventions to alleviate or change their ineffective coping towards stress. Family of Autistic Children. This research will provide

different ideas and recommendation that will be of great help in promoting stress free child care. School Administrators. Knowing the stress level of caregivers and the different stressors and factors that contribute to its

aggravation and alleviation, the care system will provide proper interventions and programs for these caregivers that are prone to stress impacted by autistic children and will enable them to manage their stress in a healthy and efficient manner. Student Nurses. Student nurses will be able to base their care management to their patients especially autistic ones in coping with stress using the proposed stress management guide.

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Nurse Educators. Knowing the stress level of caregivers and the different stressors and factors that contribute to its aggravation and alleviation, the nurse educators will reinforce the students knowledge regarding stress and stress management for these persons Autism Society of the Philippines. Coping with stress among autism caregivers is easily facilitated when interacting to those whom they can share some of their common experiences. Future Researchers. The result of this study may be used as input data for future researchers.

DEFINITION OF TERMS

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RESEARCH METHODOLOGY This section presents the research methods and approaches to be used in conducting the present study. This includes the discussion of the research design, research locale, research respondents,

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research instrument, gathering and processing, analysis and statistical treatment of data. Research Design The research design to be utilized in this study will be a purely descriptive research design. Descriptive Research will accurately portray a population that was chosen because of some specific characteristics (Cristobal and dela Cruz- Cristobal, 2009). This method was used to describe the respondents according to their Profile, The Perceived Stressors in terms of personal, family, and care giving stressors; Perceived Symptoms of Stress categorized to Physical, Emotional, Behavioral, Mental, and Relational Stress; and Coping Mechanism used by them and the extent of employment either Emotion-Focused or Problem-Focused Coping strategies. The design had clearly given more information and explanation of each variable. Research Locale The study will be conducted at Sto.Nio Sped Center. Sto. Nio SPED Center (SNSC) is a Public school located at Cor. T Claudio St., and Santo Nio Extension, Tacloban City, Philippines established in 1988. At present, the school has grown to a population of 1,038 pupils and 34 teachers. It caters not only to fast learners but also to children with special needs such as hearing impaired, the visually impaired and mentally challenged. It has also eight pre - elementary classes. A

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leading center providing and promoting quality education for persons with autism and other developmental disabilities become independent, well-adjusted, and productive members in the community. Sto. Nio Sped Center believes that persons with autism and developmental disabilities are human beings created in the image of God and therefore should be given equal opportunities to develop their unique potential for self enhancement and employment. Research Respondents The researcher will be utilizing as subjects the Caregivers of Autistic Children in Sto. Nio Sped Center. Sto. Nio SPED Center (SNSC). There is a total population of 32 caregivers, and all of them are desired to participate in this study. Research Instrument The study will utilize a researcher made interview guide consisting of four (4) parts. Part I is a checklist that will describe the profile of the respondents in terms of age, gender, civil status, monthly income, highest educational attainment, relation to autistic child, and personality type. Part II will elicit information on the perceived stressors of the respondents which include personal, family and caregiving stressors. Each stressors consists of six (6) statements where in the respondent

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will indicate their level of stress using likert type scale and their responses will be scored from 3 (always) 2 (sometimes) 1 (never). Part III is a checklist that will measure the symptoms of stress commonly manifested by the respondents; these include physical symptoms, emotional symptoms, behavioral symptoms, mental stress, and relational stress. Part IV will measure the common coping mechanisms employed by the respondents and extent by which it is being used by them.

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APPENDIX C PERCEIVED STRESSORS AND COPING MECHANISM AMONG CAREGIVERS OF AUTISTIC CHILDREN IN TACLOBAN CITY: BASIS FOR RECOMMENDATION Research Instrument PART I: PROFILE OF THE RESPONDENTS INSTRUCTION: Below is checklist that will answer your personal profile. Please fill- out the questions below by putting a check () mark on the space provided. The given information will remain confidential.

Name (optional): __________________________________ Age: __________ Gender: ( ) Male ( ) Female

Civil Status: ( ) Single ( ) Married

Others (please specify): ________________________ Religion: (Please specify):_______________________________ Monthly Income: ( ( ( ( ( ) 1000 and Below ) 1001 2000 ) 2001 3000 ) 3001 4000 ) 4001 5000 ( ( ( ( ( ) 5001 - 6000 ) 6001 - 7000 ) 7001 - 8000 ) 8001 - 9000 ) 9001 - Above

Highest Educational Attainment:

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( ( ( ( (

) Elementary Level ) Elementary Graduate ) High School Level ) High School Graduate ) College Level

) College Graduate ( ) Postgraduate with units

) Postgraduate with degree ( ) Never been to school

Relation to the Autistic Child: ( ( ) Son/ Daughter ) Nephew/ Niece ( ( ) Cousin

) Not a Relative

Others please specify: ________________________

Personality Type: ( ) Type - A (Independent, Impatient, Competitiveness, Aggressive) ( ) Type - B (Easygoing, Do not hurry in to things, Love to socialize, approachable, relationship oriented) ( ) Type - C (Perfectionist, Take everything seriously, Deep thinkers, patient, Tends to deny feelings) ( ) Type - D (Follow direct commands, Fear of rejection, Responsibility oriented)

Part II: PERCEIVED STRESSORS AND LEVEL OF STRESS OF THE RESPONDENTS

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INSTRUCTION: The following is a list of the Perceived Stressors. If a symptom applies to you, please rate the severity of the symptom you have experienced on the 3 point scale next to the item. Kindly put a check () mark on the appropriate box as to: SCALE 3 2 1 INTERPRETATION Always Sometimes Never

Part III: PERCEIVED SYMPTOMS OF STRESS COMMONLY MANIFESTED BY THE RESPONDENTS

PERCIEVED STRESSORS 1. Personal Stressors 1. Not being able to make ends meet 2. Lack of sleep 3. Needing to express emotions but not able to 4. Getting upset about small things 5. High level of hostility 6. Exhausted in dealing with other life changes 2. Family Stressors 1. Child- care 2. Caring for other dependents 3. Financial trouble 4. Low level of warmth relationship with family members 5. Support deficit from family and friends 6. Conflict with husband, sibling and relatives 3. Care Giving Stressors 1. More demand of care giving time 2. Caring autistic children is difficult because they have their own world 3. Unpredictable child behavior 4. Increase caregiving burdens 5. Serving an autistic child is difficult to bear

LEVEL OF STRESS 3 2 1

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INSTRUCTION: The following is a list of Physical, Emotional, Behavioral, Mental and Relational Symptoms of Stress. If a symptom applies to you over the past six months or you anticipate the symptom occurring in the coming year, kindly put a check () mark on the appropriate box. Choose all that applies. 1. Physical Stress ( ) headache ( ) loss bowel movement ( ) dizziness ( ) tiredness ( ) sleep problems ( ) others (please specify): ___________________________________ 2. Emotional Stress ( ) anger/ irritability/ impatient ( ) depressed/ detachment ( ) anxious/ panic ( ) fatigue ( ) work against will ( ) others (please specify): ___________________________________ 3. Behavioral Stress ( ) poor work performance/ low motivation ( ) unable to complete task ( ) criticizing others ( ) arguing with or picking fights ( ) poor time management ( ) others (please specify): ___________________________________ 4. Mental Stress ( ) lack of concentration/ attention ( ) irrational beliefs ( ) forgetfulness ( ) difficulty of making decision ( ) making more mistakes in doing work 5. Relational Stress ( ) resenting good times other have ( ) nagging ( ) not trusting others ( ) withdrawn/ isolated ( ) using people to your advantage ( ) others (please specify): ___________________________________ Part IV: COPING MECHANISM AND THE EXTENT OF EMPLOYMENT

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INSTRUCTION: The following is a list of Coping Mechanisms that are effective for combating and preventing Stress. Kindly put a check () mark on the appropriate box as to: SCALE 3 2 1 Coping Mechanism How do you usually handle stressful situation? 1. Emotion-Focused Coping
1. I maintain a sense of humor 2. I use relaxation techniques to reduce body

INTERPRETATION Always Sometimes Never Extent of Employment 3 2 1

tension such as yoga or imagery guide.

3. I keep myself busy 4. I pray for guidance and strength 5. I Distract myself thru (watching T.V., eating, etc)

6. I ignore problem in a hope that it will just go away 2. Problem-Focused Coping

1. I am able to ask for and receive support from

2.
3. 4.

5.

6.

friends, family members or professionals as a buffer against stress. I try to Learn the vocabulary necessary to effectively communicate with the childs need I try to arrive a certain solution for the problem encountered In conflict situations, I am able to speak up on my own behalf, honestly express my opinions, feelings, and wishes, give constructive criticism, and refuse unrealistic requests. I am able to establish priorities, take action on my plans, schedule effectively, avoid procrastination and pace my efforts. I take time out

BIBLIOGRAPHY

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1. Books Erb, K. &. (2008). Fundamentals of Nursing. Philippines: Pearson Education, Inc. Furnham, A. (2005). The Psychology of Behaviour at Work. USA and Canada: Routledge Press Inc., 270 Madison Avenue, New York, NY 10061. Lange, A. &. (1999). The Roy Adaptation Model. London: Mosby.

2. Documentary RLeynden1. (2009, January 28). Autism Documentary: A Day in the Life of Ryan. Part 1. North America: Youtube.com.

3. Electronic Sources Alexander Davidyan. (2008, January 10). Theories of Stress. Retrieved December 2011, from http://www.severehypertension.net/hbp/more/theories-of-stress/ Angelou, M. (n.d.). Coping With Autism:. Retrieved from http://www.child-autism-parent-cafe.com/stress-on-families.html

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Auutism Thesis. (2011, november 15). Retrieved from http://thesistown.com/writing/thesis-topics/autism-thesis/ Caring for a Child with Autism Spectrum Disorder: Severe Autism. (n.d.). Retrieved December 2011, from http://www.care.com/special-needs-caring-for-a-child-withautism-spectrum-disorder-severe-autism-p1167q224590.html#What are some of the challenges of having a child with severe autism? Deborah Leader, R. (2009, July 25). Caregiver Coping Tips. Retrieved January 27, 2012, from COPD: http://copd.about.com/od/caregiversupport/qt/caregivertips.htm Dumbleton, T. (2010). Dealing With Emotional Stress. Retrieved december 2011, from http://articles.submityourarticle.com/Trevor-Dumbleton406/stress-2645.php Griffin, R. M. (n.d.). What It's Like to Have Autism. Retrieved from WebMD Feature: http://www.webmd.com/brain/features/understanding-autismsymptoms

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Kanade, S. (2011, December). Personality Types A B C D. Retrieved January 2012, from http://www.buzzle.com/articles/personality-types-a-b-c.html Krohne, H. W. (2002). Stress and Coping Theories. Retrieved december 2011, from http://userpage.fuberlin.de/~schuez/folien/Krohne_Stress.pdf Mcleod, S. (2009). Emotion Focused Coping with Stress. Retrieved January 27, 2012, from http://www.simplypsychology.org/emotion-focused-coping.html Melinda Smith, M. R. (2011, december). Understanding Stress. Retrieved december 2011, from http://helpguide.org/mental/stress_signs.htm Moore, A. (2005 - 2007). Emotional Stress. Retrieved January 2012, from http://www.loweryourstress.com/essential-oils-tobanish-stress.html O'Brien, S. (n.d.). Why Being a Caregiver is Hard on Your Health. Retrieved december 2011, from http://seniorliving.about.com/od/healthnutrition/a/caregiverstress .htm

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Sally Bloch-Rosen, P. (1999, april 8). Asperger's Syndrome, High Functioning Autism,. Retrieved from http://www.aspergersyndrome.com/html/research_paper.html Staff, M. c. (n.d.). Caregiver stress: Tips for taking care of yourself. Retrieved December 2011, from http://www.mayoclinic.com/health/caregiver-stress/MY01231 State, P. (2010, april 22). Family Caregiving Stress Filled and Isolating. Retrieved december 2011, from http://www.sciencedaily.com/releases/2010/04/100422112641.ht m Whitehead, S. (1984, april). The Child Care Worker . Retrieved December 2011, from http://www.cyc-net.org/profession/prowhitehead.html Wrosch, C. (2011, May 9). Bearing Through It: How Caregivers of Mentally Ill Kin Can Cope. Retrieved december 2011, from http://www.sciencedaily.com/releases/2011/05/110519113018.ht m

4. Interview

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Bairulla, M. (2012, January 24). National Autism Consciousness Week itinanghal sa Davao. (D. Mais, Interviewer) Koe, G. N. (2012, January 22). Daan-daang pamilya, lumahok sa National Autism Consciousness Week. (R. Reyes, Interviewer)