1 LEVEL OF STRESS OF CAREGIVERS IN THE CARE OF AUTISTIC CHILDREN IN TACLOBAN CITY: BASIS FOR RECOMMENDATION

A Thesis Presented to the Faculty of College of Nursing Holy Infant College

In Partial Fulfillment of the Requirements for the Subject Nursing Research

Arvin Ian C. Peaflor Crystelle V. Villanueva France Irish L. Nacion Gizel X. Francisco Faye M. Remandaban Mariel C. Sabandal

Virginia S. Ariza, RN, MAN Research Adviser

CHAPTER I

2 INTRODUCTION

Rationale of the Study Stress is a physical and emotional stage which is always present in the person as a result of living. It is simply a fact of nature -- forces from the inside or outside world affecting the individual. The individual responds to stress in ways that affect the individual as well as their environment. Because of the overabundance of stress in ones modern lives, one usually think of stress as a negative experience, but from a biological point of view, stress can be a neutral, negative, or positive experience. In general, stress is related to both external and internal factors. External factors include the physical environment, including job, relationships with others, home, and all the situations, challenges, difficulties, and expectations one is confronted with on a daily basis. Internal factors determine your body's ability to respond to, and deal with, the external stress-inducing factors. Internal factors which influence the ability to handle stress include ones nutritional status, overall health and fitness levels, emotional wellbeing, and the amount of sleep and rest they get. 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. The situations and pressures that cause stress are known as stressors. It is anything that puts high demands in a person or forces one to adjust can be stressful. This includes positive events such as getting married, kind of job where a person is in, going to college, or receiving a promotion.

3 The word "caregiver" is not just those who are caring for a patient with Alzheimer's disease. But a caregiver is anyone who provides help to another person in need, whether that's an ill spouse or partner, a disabled child, or an aging relative. Furthermore, Autism is a mental disorder wherein a person having this particular disorder displays a delay in social interaction, language and symbolic play. Individuals with autism have great difference in terms of skills, behaviors and sensory system from normal people. Stimulations like sounds, vision and touch have a huge effect on a person with autism. Infants or children having this particular disorder find it harder to interact and engage in normal activities, thus in most cases, these particular patients need supervision. 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. Most recent reviews tend to estimate a prevalence of 12 per 1,000 for autism and close to 6 per 1,000 for ASD; because of inadequate data, these numbers may underestimate ASD's true prevalence (wikipedia.org/wiki/Autism). 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. Constant stress can lead to "burnout" and health problems for the caregiver. Caregivers may feel guilty, frustrated, and angry from time to time. As a result of this crucial role, Caregiver Stress is more common which is defined as a syndrome that can lead to exhaustion and has some traits in common with exhaustion. In fact, the stress caregivers experience is a mixture of physical, emotional, and mental exhaustion. This is often called "burnout". Caregivers may experience burnout when they don't get adequate help or when they overextend themselves

4 physically, mentally, or financially. Fatigue, anxiety attacks, and even depression may come from this caregiver burnout. 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. This research is intended 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. It is therefore important for the researcher to conduct this study, which is aiming to determine the level of stress so as to provide or recommend suitable interventions and actions to relive their dreadful stress. The researchers will implement interventions with enough knowledge and skills carried with humanitarian and caring considerations. Focusing more on every aspect that makes these caregivers prone to stress and not just by its physiological effects should be considered. This study focused more on deeper issues and effects associated with caring autistic children related to having stress. This research view will possibly propose effective stress management that can reduce the stress felt by these caregivers.

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

5 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

6 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).

7 Stage 2 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 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

8 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). 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 three 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

9 determining whether a situation is potentially threatening, constitutes harm/loss, a challenge, or is benign. This primary appraisal is influenced by both person and 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). This study is also bounded to the theory of Banduras (1997) which is the Selfefficacy 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). 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

10 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). McGuigan (1999) identified three different classes of stress definitions: (1) stimulus-based, (2) response-based, and (3) interactive. Stimulus-based models conceive stress as an environmental event that affects the body. The interactive class incorporates response and stimulus elements and is an interactive state in which stressors and bodily reactions affect each other. Interactive models suggest that certain characteristics associated with an individual lead them to perceive some events or environmental factors as more threatening than others (Furnham, 1997). 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 well-being 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 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

11 25 belief that life is controlled by external forces), Type A behavior, pessimism, and poor coping strategies (Furnham, 1997). Stress overload results from an imbalance between psychological coping skills, inner psychological states, environmental stressors, and support deficits. This imbalance can be represented in a range of psychological, behavioral, and physical problems (MacLennan, 1992). Using the concept of stress pileup as defined by McCubbin and Patterson (1993a), if a familys resources to cope with stressors are already exhausted in dealing with other life changes, the family may be unable to make adjustments if confronted with additional stressors. At this point, some negative consequences would be anticipated in the family system or by its member(s). 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, 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 because of conflict with siblings or other relatives. It's different for everyone." 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 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

12 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 wellbeing 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). Moreover, another study correlates this stress related topic. A new study from Concordia University, AMI-Qubec and the University of British Columbia (Bearing Through It: How Caregivers of Mentally Ill Kin Can Cope) has found family

caregivers can experience high levels of stress, self-blame, substance abuse and depressive symptoms unless they refocus their priorities and lighten their load. "Being the principal caregiver to a mentally ill family member is a stressor that often creates high levels of burden and contributes to depressive symptoms," says lead author Carsten Wrosch, a professor in the Concordia University Department of Psychology and a member of the Centre for Research in Human Development. "Caring for a relative with a mental illness can be strenuous, Wrosch continues.That said, even in this situation, caregivers can experience high levels of wellbeing if they adjust their goals and use effective coping strategies."

13 "We found participants who had an easier time abandoning goals blamed themselves less frequently for problems associated with caregiving and used alcohol or drugs less frequently to regulate their emotions," says co-author Ella Amir, a Concordia graduate and executive director at AMI-Qubec, a grassroots organization committed to helping families manage the effects of mental illness. "Pursuing new goals it a double-edged sword," he adds. "It provides purpose, but also increases caregiving burden, since there are times when a family member's illness suddenly takes a turn for the worse. And stressors can crop up unexpectedly in other close relationships or in the workplace." (sciencedaily.com). 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.

14 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. Long-term stress can even rewire the brain, leaving you more vulnerable to anxiety and depression. 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) Stress actually occurs before a child takes his/her first breath (Bittman, 1999) In a survey of U.S. adults aged 25 to 74 years of age, just 8% of young adults said they

15 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 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). The National Alliance for Caregivers estimates that there are 44.4 million caregivers age 18 and older in the United States, representing 21% of all U.S. households. The vast majority of these caregivers are women, who are either living with the care-recipient or visiting them at least weekly, and who receive no paid and very little unpaid assistance with their family members care. In a 2003 national survey, 23% of caregivers reported that they were caring for someone with Alzheimers disease, dementia, or other developmental problems. 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

16 for autistic children to leave the house in the middle of the night - all without a care in the world (voices.yahoo.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 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. Caregiving does not cause depression, nor will everyone who provides care experience the negative feelings that go with depression. But in an effort to provide the best possible care for a family member or friend, caregivers often sacrifice their own physical and emotional needs and the emotional and physical experiences involved with providing care can strain even the most capable person. The resulting feelings of anger, anxiety, sadness, isolation, exhaustionand then guilt for having these feelingscan exact a heavy toll. 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 post-traumatic stress disorder

17 However, emotional stress does not arise from a sudden shock. It can also arise from a total emotional strain 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. In order to deal with emotional stress, the person who suffers from it needs to take a break from everything that is creating all the emotions. For instance, going on a vacation can be an excellent diversion, as it provides the brain with new inputs that are not charged with associations. By leaving the so-called "scene of the crime" the person who suffers from emotional stress will be able to remove some of the emotional stress by removing its triggers. Then, hopefully, the loop will be broken, allowing the person to start fresh. Though serving an autistic child is very difficult to bear, there is this something like very unique part because one can experience how 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.

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B A S I S F O R R E C O M M E N D A T I O N

Conceptual Framework

Profile of Caregivers Autistic Children a. b. c. d. e.

of

Caregiv ers of Autistic Child in Taclob

Age Gender Religion Civil Status Highest Educational Attainment f. Relation to Perceived Stress and extent the autistic of Manifestation child a. Mental Stress b. Physical Stress c. Emotional Stress d. Behavioral Stress

19

Coping mechanism extent of employment

&

Figure I. Conceptual Framework of the Study

THE PROBLEM Statement of the Problem This study aimed to determine the level of stress of caregivers of autistic children in Sto.Nio Sped Cente. The findings of the study will serve as basis for the recommendation. Specifically, it seeks to answer the following questions: 1.) What is the profile of the respondents in terms of: 1.1 1.2 Age; Gender;

20 1.3 1.4 1.5 1.6 2.) Religion; Civil Status; and Highest Educational Attainment Relation to the autistic child

What are the perceived stresses manifested by the respondents in the care of

autistic child? 3.) To what extent do the respondents manifest the perceived stress? 2.1 2.2 2.3 2.4 4.) 5.) Mental Stress; Physical Stress; Emotional Stress; and Behavioral Stress

What coping mechanisms do the respondent employed, and to what extent? Based on the findings of the study, what recommendation can be proposed?

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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 present the importance of stress management for Caregivers of autistic children so as to prevent stress related problems to the respondents. 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.

22 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. 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.

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. 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.

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Definition of Terms To fully understand the terms used in this study, the following are defined operationally: Stress - is defined as an organism's total response to environmental demands or pressures a state of mental or emotional strain or suspense. Caregivers - anyone who provides help to another person in need, whether that's an ill spouse or partner, a disabled child, or an aging relative. They may be the parents, guardian, relatives, or someone whove been granted to care for someone that needs assistance. Autistic Children - A pervasive developmental disorder characterized by severe deficits in social interaction and communication, by an extremely limited range of activities and interests, and often by the presence of repetitive, stereotyped behaviors.

24 Level of Stress is the extent by which the caregiver is experiencing stress. This describes how stress affects the caregivers. Religion Refers to the Roman and Non-Roman Catholic. Demographic Profile the different data from the caregiver who is involved in the study. This includes name, age, gender, civil status, religion, educational attainment, occupation and monthly income. Through this relationship, this will serve as the basis for recommendation. Coping Mechanism - any effort directed to stress management, including task-oriented and ego defense mechanisms, the factors that enable an individual to regain emotional equilibrium after a stressful experience CHAPTER II RESEARCH METHODOLOGY Research Design This study primarily utilized descriptive research design; this design is utilized for the purpose of accurately portraying a population that was chosen because of some specific characteristics. It also used to determine the extent or direction of attitudes and behaviors. This design aims to gain more information about characteristics within a peculiar field of study. The purpose is to provide a picture of a situation as it naturally happens. It may be used to develop theories, justify current clinical practices or determine what other practitioners in similar situations are doing. No manipulation of variables is involved in descriptive design. Research Environment

25 The investigation will soon be conducted at Sto.Nio Sped Center, 6500 Tacloban City, Philippines. A leading center providing and promoting quality education for persons with autism and other developmental disabilities become independent, welladjusted, and productive members in our 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. The center also believes that education plays a vital role in the fulfillment of this God given human right that makes it the duty and passion of every person.

Research Respondents The subjects of this study were those caregivers of autistic children, they may be the parents, relatives, and/or significant others. They were the one who will personally provide information through answering appropriate boxes on the checklists. Research Instruments This study will utilize researcher made survey questionnaire. It consist 3 parts instruments consisting of the following: Part I is a checklist on demographic profile of respondents such as Age, Gender, Religion, Civil Status, Highest Educational Attainment, and Relation to the autistic child. Part II is a checklist on the perceived stress consisting of 5 different stress situations that the respondents possibly experienced during the course of their caregiving

26 experience regarding to mental, physical, emotional and behavioral stress. Each situation contains 4 boxes for the respondents to choose whether they experience these situations: (1) Severe, (2) Moderate, (3) Mild or (4) Low. Part III is a checklist regarding to the skills and coping mechanisms, this part consist of 10 coping mechanisms that the respondents possibly been using in combating their stress felt during their caregiving experience. Each Skills used is rated as: (1) very poor, (2) Low or Moderate, (3) Good or (4) Very Good to assess the extent of employment of these Coping mechanisms.

LEVEL OF STRESS OF CAREGIVERS IN THE CARE OF AUTISTIC CHILDREN IN TACLOBAN CITY: BASIS FOR RECOMMENDATION Research Instruments PART I DEMOGRAPHIC PROFILE OF CAREGIVERS INSTRUCTION: Kindly fill up the given form. NAME: ___________________________________________ (Optional) AGE: _____________________________________________ GENDER: (please check) Male ( ) Female ( ) CIVIL STATUS: (please check) Single ( ) Married ( ) Others (please specify) RELIGION: ________________________________________ HIGHEST EDUCATIONAL ATTAINMENT: (please check) Elementary level ( ) Elementary graduate ( )

27 High School level High School graduate College level College graduate Postgraduate with units Postgraduate w/ degree Illiterate RELATION TO THE AUTISTIC CHILD: Son/Daughter Cousin Nephew/Niece Not a Relative ( ( ) ) ( ( ) ) ( ( ) )

( ) ( ) ( ) ( ) ( )

Other please specify: ______________________

PART II STRESS MANIFESTED BY THE CAREGIVER IN THE CARE OF AUTISTIC CHILDREN INSTRUCTION: The following is a list of Mental, Physical, Emotional and Behavioral symptoms of Stress. If a symptom applies to you over the past 6 months or you anticipate the symptom occurring in the coming year, please rate the severity of the symptom you have experienced or anticipate experiencing on the 4 point scale next to the item. Kindly put a check mark on the appropriate box as to: SCALE 1 2 3 4 INTERPRETATION Severe Moderate Mild Low 4 3 2 1

STATEMENTS I experience the following: A. MENTAL STRESS 1. Lack of Concentration / Attention 2. Decision making difficulties 3. Worry 4. Irrational belief and self talk 5. Forgetfulness A. PHYSICAL STRESS 1. High blood pressures 2. Headaches 3. Sleeplessness 4. Fatigue, Low energy, Tired 5. Reduced Immunity (Prone to Illness) A. EMOTIONAL STRESS

28 1. 2. 3. 4. 5. A. 1. 2. 3. 4. 5. Anger and Irritability Depressed, Sad, Downhearted Work against will Impatient Anxiety, Panic, Fearful BEHAVIORAL STRESS Poor Work Performance Low motivation Lack of self initiative Poor time management Unable to complete tasks

PART III COPING MECHANISM AND THE EXTENT OF EMPLOYMENT INSTRUCTION: The following is a list Coping Skills, Habits and Personal Resources that are effective for combating and preventing Stress. Please rate on the four point scale the level of your ability to apply each skill to reduce your stress. Kindly put a check mark on the appropriate box as to: SCALE 1 2 3 4 INTERPRETATION Very poor Low or Moderate Good Very good 4 3 2 1

STATEMENTS I use the following coping skill to combat stress: 1. I have good nutritional habits that include eating a balanced diet, taking appropriate nutritional supplements and limiting caffeine, sugar and fat intake. 2. I am aware when stress builds up in my body and use relaxation techniques to reduce body tension. 3. I am physically fit and use regular exercise to combat and prevent stress. 4. I am able to ask for and receive support from friends, family members or professionals as a buffer against stress. 5. I believe in a higher power and spiritual connectiveness to life. 6. I am able to establish priorities, take action on

29 my plans, goals and set limits, schedule effectively, avoid procrastination and pace my efforts. 7. 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. 8. I am good at managing money, do not needlessly worry about financial matters, and have enough money to meet most of my needs and use in the service of reducing stress. 9. I am able to reduce stress by consciously monitoring, challenging and changing negative thought patterns, placing problems into proper perspective, practicing relaxation techniques, mentally rehearsing coping behaviors and using positive self-talk and visual images. 10.I do not take myself too seriously and use humor to balance life's frustrations.

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