A Case-Control Study of Smoking and Alcohol Intake as Prenatal Risk Factors

of Autism Spectrum Disorder (ASD) among Filipino Children

A Research Proposal

Submitted By:
Jimenez, Margaret Stephanie
Jimenez, Sarah Jane
Joaquino, John Marquis
Jordan, Stephanie Patricia
Preceptor:
Dr. Georgina Paredes
Department of Preventive and Community Medicine
College of Medicine, UERMMMCI

CHAPTER 1.
INTRODUCTION

A. RESEARCH PROBLEMS AND SUBPROBLEMS

Are the following prenatal risk factors, specifically smoking or alcohol intake associated
with Autism Spectrum Disorder among Filipino Children?

B. HYPOTHESIS
Null Hypotheses:
a) There is no difference in the risk of developing autism among children of mothers who
smoke and children of mothers who do not smoke during prenatal period
b) There is no difference in the risk of developing autism among children of mothers who do
drink alcoholic beverages and children of mothers who drink alcoholic beverages during
the prenatal period

Alternative Hypotheses:
a) There is a difference in the risk of developing autism among children of mothers who
smoke and children of mothers who do not smoke during prenatal period

The odds of having a child with ASD is higher among mothers with a higher pack
years of smoking than those with lower pack years

b) There is a difference in the risk of developing autism among children of mothers who do
drink alcoholic beverages and children of mothers who drink alcoholic beverages during
the prenatal period

The odds of having a child with ASD is higher among mothers who are chronic
alcoholic drinkers than those who are not.

c) SIGNIFICANCE OF THE STUDY

ASD is a neurodevelopmental disorder that causes impaired intellectual, communicative
and behavioral development1. As a lifelong debilitating condition, it affects not only the children
with the disease but also their families and caregivers. Thus, it is a disease that has both social
and biological impact, and as such is an urgent public health concern2.
There is a significant population of Filipinos affected by the disease, with an estimated 1
out of every 150 children born with ASD 3. Furthermore, autism ranks 3rd out of the top 10
developmental disorders among pediatric patients. However, only 2% of those born with disease
are given appropriate care4. Moreover, the prevalence and risk factors of ASD in the Philippines
are unknown because of lack of funding being given to studies on this disease. The lack of a
national center or institute for diagnostic and treatment procedures underscores the deficiencies
in the identification and care of Filipino children with autism, as well as a lack of a centralized
resource of knowledge about the disease 4.
Finally, since studies agree that interplay between multiple genetic and environmental
factors contribute to the development of ASD 5, findings obtained from studies abroad might not
be applicable to the Filipino population.
Therefore, research on the risk factors of Autism Spectrum Disorders helps to fill a gap in
knowledge about the pathogenesis of the disease, as well as lays the foundation for future
researches in the Philippines.

d) GENERAL AND SPECIFIC OBJECTIVES

General Objective: To determine the association of exposure to prenatal risk factors,
specifically smoking and alcohol intake, in developing Autism Spectrum Disorder

among Filipino children

Specific Objectives:
i. To describe the socio-demographic characteristics of mothers of children (411 years old) with ASD according to:
a) Age of the mothers
b) Age of mothers when they got pregnant
c) Number of children
d) Occupation
e) Income Status
f) Educational Attainment
ii. To determine the prevalence of prenatal smoking and alcohol exposure among
mothers with and without children with ASD
iii. To determine the odds ratio of smoking and drinking alcoholic beverages
before or during pregnancy among mothers of children with ASD versus
mother of children without ASD
iv. To determine which among the socio-demographic maternal characteristics,
prenatal smoking exposure and prenatal alcohol exposure show the strongest
association with the development of ASD among children.

CHAPTER 2.
REVIEW OF RELATED LITERATURE

Autism Spectrum Disorder: An Overview

Autism Spectrum Disorder, or ASD, is a cluster of lifelong behaviorally defined
neurodevelopmental disorders. According to the Diagnostic and Statistical Manual of Mental
Disorders6, it is composed of Autistic Disorder, Aspergers syndrome, and Pervasive
Developmental Disorder. These are diagnosed through clinical observation, and encompass
impairments in social, communicative, and behavioral development, and are accompanied by
abnormalities in intellectual functioning, learning, attention, and sensory processing. Findings
show that children with ASD present with generalized and profound impairment in executive
functioning, with significant differences compared to typical children with regards to cognitive
flexibility, working memory, and response inhibition7.
Although the studies on the possible genetic causes of ASD are numerous, they agree that
affected individuals are heterogenous in terms of the cause of their disorder as well as the degree
to which each is affected functionally and neurobiologically8. The genetic defect may be in either
a single gene or a combination of genes, each having a small to moderate effect in increasing
ASD risk9. Examples of genetic defects include cell signaling abnormalities, Joubert's syndrome,
Rett's syndrome, tuberous sclerosis, Fragile X syndrome, and maternally inherited duplications
of chromosome 15q11-13. However, these account for only 10% of ASD cases, each single cause
contributing to no more than 1% of cases on average 10.
Thus, the focus of autism research is currently expanding to include the role of
environmental factors in the pathogenesis of the disease 5. For example, prenatal factors

significantly associated with ASD are advanced maternal age, parity, and advanced paternal
age11. Although there is insufficient evidence to implicate any one factor in autism etiology,
exposure of a broad class of conditions that compromise perinatal and neonatal health may
increase the risk12. Exposure to smoking and alcohol intake during pregnancy are two common
risk factors for the development of neurodevelopmental disorders, and as such may be associated
with the pathogenesis of ASD13,14.
It must be emphasized that the exact etiology of ASD is not yet known, and studies agree
that an interplay between multiple genetic and environmental factors contribute to the
development of ASD. Thus, findings obtained from studies on ASD abroad might not be
applicable to the Filipino population. This further underscores the need for more research
regarding the disease in the Philippines.

ASD in the Global and Philippine Setting

Surveillance efforts indicated that the age of 8 years old is a reasonable index age at
which monitoring peak prevalence of ADS2. Children who met the criteria of the case definition
for ASD were consistent with records, documented behaviors with the use of the diagnostic and
statistical manual of mental disorders 4th edition, text revision6. To analyze changes in prevalence
of ASD, the CDC compared collected data from 10 sites in the United States and compared data
from the same sites of 20022. 9 sites were observed to have an increase in ASD prevalence with
increases with males in all sites and females in 4 sites out of 10. The study acknowledged that the
proportion of children with characteristics consistent with the criteria for an ASD classification
who had been previously documented ASD classification varied across all sites in majority of the

sites in the United States. Results identified a higher prevalence of ASD for non-Hispanic white
children compared with non-Hispanic black children.
Results also showed showed an increase in prevalence of identified ASD among U.S
children aged 8 and underscore a need to regard ASD as an urgent public health concern 2. In the
United States an average of 1 child in every 150 has ADS and there is needed to improve early
identification of ADS2. There is a lack of awareness about autism among medical professionals 1.
Features of children with less than 2 years of age are subtle and difficult to define and the need to
be reassessed of ADS after the age of 2 is required1.
In a descriptive hospital based study with children with autism, the major clinical
symptoms observed and commonest complaints were delayed development of speech and being
lost in ones own world1. Children presented with difficulties in toilet training. ADS patients
showed no interest in play and used the toys inappropriately. Imaginative and pretend play was
absent. Children expressed behavioral problems like hyperactivity aggression and self-injury,
which is due to increase levels of endorphins1. Continued monitoring is needed to document and
understand changes over time, including the multiple ascertainments and potential risk factors2.
All professionals involved in the diagnosing ASD in children should consider either
LED-10 or DSM-IV-TR systems15. Professionals should aim to identify ASD early since it
provides opportunity for early referral and intervention so the child with ADS may have an
improved functioning later in life. Active monitoring by health care professionals is
recommended of 18 months and again at 24-36 months for key signs of ADS. Every pre-school
child diagnosed with ADS should have an individualized intervention plan that sets out goals,
types, frequency and intensity of intervention 15. Continued monitoring is varied according to the
childs changing need. No single language or communication intervention is appropriate for all

children; the optimal communication intervention for an individual child with ASD depends on
the need of a particular child.
ASD in the Philippines is not well characterized, both in terms of its prevalence and the
management of the disease. According to the Autism Society of the Philippines, the estimated
prevalence of Filipino children with autism in 2007 is 500,0003. However, there is no formal
figure due to the lack of funding towards researches on this disease.
A study by Dr. Alexis Reyes, a leading Filipino Developmental Pediatrician, extrapolated
that 0.5 million Filipinos exhibit neuro-behavioral disorder if the prevalence rate in the United
States will be the basis. Using this figure, only two percent of them will be given appropriate
care16. Data gathered from the Philippine General Hospital reveals that autism is ranked third in
the top 10 developmental disorders16, 17. However, it is important to note that no records from
private hospitals or clinics were obtained.
The study presents significant issues regarding the national outlook on Autism. It
emphasized a strong need for an appropriate national program that addresses the deficiencies
regarding the treatment and care regarding children with autism. Numerous deficiencies with
regards to patient care in the Philippine setting were identified: first, there is a lack of a national
center or institute for diagnostic and treatment procedures. Second, treatment is limited to
Western medical and behavioral approaches which are not always suitable for the cultural needs
of the patients. Third, the role of the non-medical professionals are not recognized. Creative
therapies used by psychologists and counselors are not put in the mainstream and are limited to
private practice. Fourth, the Autism Society of the Philippines, a non-profit organization founded
by parents of children with ASD is not incorporated with the medical professions systemically.
Lastly, the fundamental role of parents and family members with ASD, which is of fundamental

value in the total handling of the disease, is not given recognition.

A more recent local study reported that there is no formal curriculum that addresses the
plight of persons with Autism Spectrum Disorder (ASD) in the educational system 17. A few
teachers, on their own, without any formal training in childrens disorders are able to spot
possible disorders. These suspected cases are then referred to private practitioners, namely the
Developmental Pediatricians, Psychologists and Psychiatrists. The study also stated that the
number of individuals with ASD is around 570,000 in 1 out of 150 individuals, however this
estimate is again not confirmed. The study suggests that a more comprehensive approach in the
treatment and the handling of ASD patients is needed in the Philippines. It should include nonmedical practitioners and a form of multi-disciplinary team approach to the problem where the
parent should be empowered and have a major role in the team, and that the siblings and
extended family should be tapped as resources especially since Filipinos have close knit family
ties followed by creative therapies per individual.
In summary, the literature shows that in developed countries such as the United States,
Autism Spectrum Disorder is diagnosed and managed systematically, with specific intervention
plans that account for the roles of the parents, the clinicians, and the government. In contrast,
there is no standardized, integrated and comprehensive approach to management of patients with
ASD in the Philippines. Moreover, although the exact prevalence of the disease locally is not
known, it is one of the major developmental disorders among pediatric patients.

Prenatal Alcohol Exposure as a Risk Factor for ASD

Alcohol consumption in moderate amounts is not generally harmful; nonetheless, in
excessive amounts, it can have harmful effects; mainly alcohol dependency or alcoholism

leading to metabolic deficiencies and even injury to major organs particularly the liver and even
the central nervous system. There are however certain situations such as pregnancy whereby
alcohol even in small amounts can have injurious effect18.
Ethanol consumption among pregnant women has found out to have damaging effect in
the central nervous system of the infant leading to impaired cognitive and behavioral function 19.
In another recent study where the researchers determined the frequencies of different
neurodevelopmental disorders using a cohort study found out that that 9% among 71 children
who have mothers with prenatal alcohol exposure exhibits autism20. Nonetheless, the study did
not determine if there is an association between prenatal alcohol exposure and developing
autism. Furthermore, in this study, autism was only classified as a co-morbid of FAS or fetal
alcohol syndrome.
A case-control study explored the relationship between FASD (fetal alcohol syndrome
disorder) and ASD (autism spectrum disorder) in individuals attending a specialist diagnostic
clinic. The study found out that 72% of the subjects have autism and that therefore there is an
association between FASD and having ASD21.
Nonetheless, for both studies, it must be noted that only a small population was used
which may indicate that samples may not be a representative of the total population.
Furthermore, the focus of both studies was FASD and not ASD per se. Indicating that both
studies did not clearly state whether ASD was due to prenatal alcohol exposure or just a comorbid or a manifestation of FASD.
A study on Autism families with a high incidence of alcoholism results also showed an
association between prenatal alcohol exposure and autism13. Nonetheless, the researchers also
pointed out that there are no literatures or studies that distinctly indicate that alcohol exposure

among mothers can be associated to ASD simply because the incidence of alcoholism is so much
greater than autism that the sample size of children with autism should be larger in order to have
a valid association.
With this, it must be clear that the association of prenatal alcohol exposure (whether in
low or high doses) in developing ASD alone is not yet fully established.

Prenatal Smoking Exposure as a Risk Factor for ASD

Tobacco is considered one of the biggest environmental hazards in the world and it has
been widely established that prenatal maternal smoke exposure affects the mental development
of a child, including decreased cognitive functioning by 3 years old, decrease in vigilance in the
child and behavior problem22. However there are only a few sources that explore and focus on its
effects on the growth and development of the unborn child. A Swedish case-control study was
considered one the largest studies on perinatal risk factors of autism and one of the very few
studying maternal smoking and autism. Results showed that there was an association between
early pregnancy and daily smoking of the mothers (OR=1.4; CI = 1.1-1.8)14. This study is
considered one of the pioneering studies on perinatal risk factors of autism among the few
studies.
Additionally, children in utero who were exposed to smoking may exhibit cognitive
deficits such as delayed language development, difficulties in learning and memory tasks,
reading and mathematics, and decreased general cognitive functioning23. They concluded that
smoking in pregnancy may be a marker for increased risk of psychiatric symptoms in the
offspring. Scores in the Autism Spectrum Screening Questionnaires were significantly higher (p
< 0.001) for children born of smoking mothers compared to children born of non-smoking

mothers23. The researchers concluded that intrauterine and neonatal factors related to deviant
intrauterine growth or fetal distress is important in the pathogenesis of autism.
Studies that focus on the mechanisms regarding the specific effects of smoking to
prenatal development are numerous. Tobacco contains over 2000 chemical constituents, all of
which may induce neurotoxic effects such as decreasing cerebral blood and causing brain
hypoxia resulting to production of high levels of carboxyhemoglobin and relative brain
hypoxia24. Nicotine may affect a broad spectrum of neurotransmitter receptors in the fetal brain
leading to abnormal cell proliferation and differentiation as well as abnormal up-regulation and
down-regulation of neurotransmitter receptors25. Post-mortem studies on autistic subjects have
exhibited a notable reduction in cortical nicotinic receptor binding 26. Moreover, other findings
have suggested that fetal nicotine exposure may affect brain development and 5HT synaptic
function linked with behavioral abnormalities27.
Hence, there is an evident need for additional studies that may provide more information
regarding the effects of maternal smoking on the development of autism among children owing
to the lack of sources.

CHAPTER 3.
METHODOLOGY

A. Study Design / Plan of Investigation

This study is a simple random sampling, case-control study. Cases are mothers with
children diagnosed with ASD. They will be obtained in the following manner. A list of
institutions, schools, and private clinics in Metro Manila (such as SHINE Intervention Center,
Circles and Triangles, Autism Society of the Philippines) will be compiled. Three institutions
will be randomly selected. A list of students per institution will then be obtained. Each institution
will be assigned a percentage of the sample size based on the number of students enrolled, and
cases will be selected via simple random sampling.
Controls will be mothers whose children are not diagnosed with ASD. They will be
related to or have the same characteristics (such as age, occupation, and socioeconomic status) as
the mothers of children with ASD. As such, they will be neighbors or workmates of the selected
cases.
Both cases and controls will be asked to answer a set of facilitated questionnaires
regarding demographic data, alcohol intake and smoking habits, before and during the period in
which they were pregnant with the autistic child. For alcohol intake, cases and controls will be
classified as chronic drinkers, non-chronic drinkers, and without exposure. For smoking, cases
and controls will be classified as having high pack years, low pack years, and without exposure.
Coding and encoding of the data gathered will proceed while data collection is still
ongoing. When sample size is achieved, data editing will proceed then followed by data analysis.

B. Scheme of the Study

C. Description of Study Group and Subjects

Cases are mothers of children diagnosed to have ASP by a licensed developmental
pediatrician. These children will be obtained from established autism societies primarily the
Autism Society of the Philippines (ASP) and other private clinics or institutions such as SHINE
Intervention Center and Circles and Triangles; all of these institutions are located in Metro
Manila. Special Education Division or SPED schools will also be a source of the cases. These
children should be within the age bracket of 4-11 years old at the time of implementation of the
study.
Controls will be mothers whose children are not diagnosed with ASD. They will be

related to or have the same characteristics (such as age, occupation, and socioeconomic status) as
the mothers of children with ASD. Suggested participants in the control group are work mates
and neighbors of mothers with autistic children; so that the characteristics and the environmental
conditions of both mothers will be the same.
Inclusion criteria are mothers of children ages 4-11 years old who are diagnosed to have
ASD by a board-certified developmental pediatrician and who are members of the Autism
Society of the Philippines or regularly go to special education clinics in Metro Manila. Minimum
child age is set as 4 years old since it is the median age at which a child is diagnosed to have
ASP; maximum age is set at 11 years old to prevent recall bias on the part of the mother.
Exclusion criteria include mothers with comorbid conditions such as psychiatric
disorders, illicit drug intake, or any hereditary disease. Children with ASD symptoms who are
diagnosed with other comorbid diseases such as Fetal Alcohol Syndrome and Downs syndrome
will also be excluded.

D. Sample Size Estimation

Objective

Specification

Sample size estimate

To describe the association of

smoking before or during
pregnancy in developing ASD
among their children

p = 0.12
d = 2.4

(1.96)2(0.12)(0.88)
(2.4)2
=14 (for each control and
case group)

To describe the association of

alcoholism before or during
pregnancy in developing ASD
among their children.

p = 0.09
d = 1.8

(1.96)2(0.09)(0.91)
(1.8)2
= 19 (for each control and
case group)

Total Population: 38 (case and control)

E. Data Collection Methods

The participants will be asked to answer a set of questionnaires (see Appendix A and B).
The researchers will be present during the time of collection so that any questions that the
participants may have can be accommodated. In addition to the questionnaire, the controls will
be also be asked to accomplish a screening checklist containing major DSM-IV criteria for the
diagnosis of ASP (see Appendix C). This is to ensure that the children of control mothers do not
have ASP.
The questionnaire or the data instrument that will be used will be formulated based on
literature review, key informant interviews (KII), and focused group discussions (FGDs). The
questionnaire will also be subjected to a series of pre-tests prior to implementation.

F. Operational Definition of Variables

Autism Spectrum Disorder: According to the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV, 1994), Autism Spectrum Disorder is composed of Autistic Disorder,
Aspergers syndrome, and Pervasive Developmental Disorder. It is a group of developmental
disabilities that can cause significant social, communication and behavioral challenges. It begins
before the age of 3 and lasts throughout life. Symptoms may not show until 24 months or later. A
person with an ASD might not respond to their name by 12 months of age, not be able to point at
objects, not play pretend play, they avoid eye contact and rather be alone, they have difficulty in
understanding other peoples feelings, they have delayed speech and language skills, they exhibit

echolalia wherein they repeat words and phrases over and over again, they give unrelated
answers in response to questions, they get upset with minor changes, they have obsessive traits,
flap their hands and rock their bodies28.
Social skills are the most common symptoms in all types of ASD. Examples of social
issues related to ASDs are they do not share interests with others, only interacts to achieve
desired goals, has flat and inappropriate facial expression, does not understand personal space
boundaries, avoids and resists physical contact and is not comforted by others during distress.
Examples of communication issues related to ASDs are, delayed in speech and language skills,
they usually reverse pronouns (e.g they interchange me and I), uses no or a few gestures, talks in
a robot voice and does not understand jokes and sarcasm28.
People with ASD show unusual interests and behaviors. Examples of these are they like
lining up toys or other objects, they play with the same toys in the same way every time, they
like specific parts of objects, they are very well organized, follow certain routines. People with
ASDs repeat actions over and over again which may involve one or more body parts. Repetitive
activities are know as self-stimulation or stimming They thrive in routine, once their routine is
broken they usually lose control and have tantrums28.
Other symptoms related to ASD are hyperactivity, impulsivity, short attention span,
aggression, temper tantrums, unusual eating and sleeping habits, unusual moods or emotion
reactions and lack of fear or more fear than expected28.
Smoking: defined as a practice in which tobacco is inhaled through cigarettes, expressed
in pack years. Pack years is equal to the number of cigarettes smoked per day, multiplied by the
number of years smoked, divided by 20.
o Low pack years: defined as mothers with pack years less than 5
o High pack years: defined as mothers with pack years greater than or equal to 5.

o No exposure: defined as mothers who have never smoked (pack years = 0).
Alcohol intake: defined as the consumption of any beverage containing ethanol, and may
include beers, wines, and spirits.
o Chronic alcohol drinker: defined as people who have dependency on alcohol
which includes strong craving for alcohol and inability to limit drinking. For
women, mostly defined as consuming an average of more than 1 drink per day.
o Non-chronic alcohol drinker: Includes moderate drinking and binge drinking.
o Moderate drinking: Defined as having no more than 1 drink per day
o Binge drinking: Defined as 4 or more drinks on a single occasion for
women, generally within about 2 hours.

G. Data Processing and Analysis

After gathering the data, data coding and encoding will proceed using Microsoft Excel
and by following a coding manual. Data editing will follow so as to inspect and correct some
errors during the pre-coding of the data.
Results will be analyzed using the odds ratio (OR). The formula for OR is as follows:
Odds Ratio = ad/bc
An OR = 1 will indicate no association between the outcome (development of ASD in
children) and exposure to the risk factor (smoking or alcohol intake during pregnancy). An OR >
1 will indicate the presence of an association (mothers with more exposure to smoking or alcohol
intake during pregnancy have a higher likelihood of having children with ASD). An OR < 1 will
indicate the presence of an inverse association (mothers with less exposure to smoking or alcohol
intake during pregnancy have a higher likelihood of having children with ASD).
To compute for the odds ratio, the following 2 x 2 tables will be used:
(+) autistic children

(-) autistic children

(+) smoking
(-) smoking

a
c

b
d

(+) alcohol intake

(-) alcohol intake

(+) autistic children

a
c

(-) autistic children

b
d

After computing the odds ratio, regression analysis will be done to determine which
among the maternal characteristics surveyed (such as age of pregnancy, number of children,
socioeconomic status, degree of alcohol intake, degree of smoking intake) contributed the most
to the development of autism among children.
H. Dummy Tables
Objective 1: To describe the socio-demographic characteristics of mothers of children (4-11
years old) with ASD according to:
Table 1. Socio-demographic characteristics of mothers of children with
ASD
Characteristic
Age of mothers when they
conceived their child with
ASD
Below 18 years old
18 25 years old
26 35 years old
35 40 years old
Above 40 years
old
Income Status
High
Middle
Low
Highest educational
attainment
Elementary

Frequency

Percentage

High School
College

Marital Status
Single
Married
Widowed

Objective 2, 3, 4 and 5: (2)To determine the prevalence of prenatal smoking exposure among
mothers with and without children with ASD. (3) To determine the prevalence of prenatal alcohol
exposure among mothers with and without children with ASD (4) To describe the association of
smoking before or during pregnancy in developing ASD among their children (5) To describe the
association of alcoholism before or during pregnancy in developing ASD among their children.
Table 2. Comparison of smoking and alcohol exposure between mothers with and without
children with ASD.
Mothers with autistic
children
Frequency
Percentage
Smoking
Without exposure:
With exposure:
- High pack years
- Low pack years
Alcohol
Without exposure:
With exposure:
- Chronic alcoholic
- Non-chronic alcoholic

Mothers without autistic

children
Frequency
Percentage

CHAPTER 4.
TIMELINE AND BUDGET
A. Schedule of Activities
Weeks
1.
2.
3.

4.

5.
6.

7.

8.
9.

Coordinatin
g with
schools
KII
interviews
Selection of
participant
s for pretesting
FGD for
pre-testing
of
questionnai
re
Editing
questionnai
re
FGD for
final pretesting of
questionnai
re
Final
editing of
questionnai
re
Selecting
cases
Data
Collection
for cases

10. Selecting
Controls
11. Data
Collection
for controls
12. Data
Processing
13. Data
Analysis
14. Writing of
paper

1
0

1
1

1
2

1
3

1
4

1
5

1
6

1
7

1
8

1
9

2
0

B. Budget
Items
Printing
- Ink
- one ream of bond paper x 2
- photocopy and binding (proposal and thesis presentation)
- ball pens (2 boxes)
Subtotal
Transportation Fare
KII token
Food
- First FGD; Pre-testing (moderator and 10 participants)
- Second FGD; Pre-testing (moderator and 10 participants)
Subtotal
Total
C.

Amount (Pesos)
-

100
500
500

1200
1000
400

100

360

360

720
3320

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Exposure and Psychiatric Symptoms in Adolescence. Acta Pediatrics 96 (3): 377-382
24. Taylor, E. , Rogers, J. (2005). Practitioner review: Early Adversity and Developmental
Disorders. Journal of Child Psychology & Psychiatry, 46: 451-467.

25. Mendola, P., Selevan, S., Gutter, S., Rice, D. (2002). Environmental Factors Associated
with a Spectrum of Neurodevelopmental Deficits. Mental Retardation and Developmental
Disabilities Research Reviews, 8: 188-197.
26. Lam, T, Leung, G., Ho, L. (2001). The Effects of Environmental Tobacco Smoke on
Health Services Utilization in the First Eighteen Months of Life. Pediatrics, 107: E91.
27. Slotkin TA, Tate CA, Cousins MM, Seidler FJ. Prenatal Nicotine Exposure Alters the
Responses to Subsequent Nicotine Administration and Withdrawal in Adolescence:
Serotonin Receptors and Cell Signaling. Neuropsychopharmacology 31: 2462-2475,
2006.
28. Center for Disease Control and Prevention (2010). Autism Spectrum Disorder. Signs and
Symptoms. Retreived on September 18, 2011 from http://www.cdc.gov/ncbddd/
autism/signs.html

APPENDIX A.
SAMPLE CONSENT FORM

University of the East Ramon Magsaysay Memorial Medical Center

Inc.
Department of Preventive and Community Medicine
College of Medicine

You are being invited to participate in the study entitled A case-control study of smoking and
alcohol intake as prenatal risk factors of Autism Spectrum Disorder (ASD) among Filipino
children under the supervision of Dr. Ramon Jason Javier. The following have been explained well to
me and I fully understand them before I signed this consent form.
Ikaw ay inaanyayahan na lumahok sa pananaliksik na pinamagatang A case-control study of
smoking and alcohol intake as prenatal risk factors of Autism Spectrum Disorder (ASD) among
Filipino children sa pamamahala ni Dr. Georgina Paredes Ang mga sumusunod ay ipinaliwanag na
mabuti sa akin at lubos ang aking pang-unawa sa mga ito bago ko nilagdaan ang kasulatang ito.

The objective of the study is to determine the association of exposure to prenatal risk factors,
specifically smoking and alcohol intake, in developing Autism Spectrum Disorder among Filipino
children.
Ang layunin ng pananaliksik ay upang malaman kung meron bang relasyon ang paninigarilyo o
paginom ng alak sa panahon ng pagbubuntis sa pagkakaroon ng Autism Spectrum Disorder.
This study will be helpful to fill a gap in knowledge about the environmental causes of Autism, as
well as lays the foundation for future researches in the Philippines.
Ang pananaliksik na ito ay makakatulong ng malaki sa pagkontribyuta ng mga pangunahing
kaalaman sa kondisyon na Autism.
The number of study participants is 38.
Ang bilang ng mga sasali sa pag-aaral na ito ay 38.
The study will involve a one page survey questionnaire
Sa pag-aaral na ito, kinakailangang sumagot ng isang pahinang survey questionnaire or
katanungan
All your records or information about you will be kept strictly confidential.
Ang lahat ng iyong mga rekord o pangalan ay konpidensyal at hindi malalaman ng iba.
Your participation is voluntary and you can withdraw anytime for any reason.
Ang pagsali mo sa pag-aaral na ito ay sarili mong kusa at maaari kang tumiwalag anumang oras
sa anumang kadahilanan.

You can call or ask questions anytime regarding this study. The contact person for further
information or for consultation on diverse events is Sarah Jane A. Jimenez, 09052443580.
Maaari kang magtanong ng kahit anong oras hinggil sa pag-aaral na ito. Ang tatawagan at
kakausapin ay si Sarah Jane A. Jimenez, 09052443580.
I gave my consent subject to the conditions above.
Pumapayag akong sumali sa pag-aaral ayon sa mga nakasaad sa itaas.
Signature
Lagda
________________________________
Participant
Pastisipante
__________________________________
Witness
Saksi

______________________________
Witness
Saksi

__________________
Date Signed:
Petsa
Informed Consent obtained by: _______________________________________
Name and Signature

APPENDIX B.
SAMPLE QUESTIONNAIRE.
Control No._____
Birthday: _______
Occupation:_______
Marital Status:
Attainment:
Single____
Married ____
Widowed____

_____6-10 years
_____10-20 years
_____20 or more years

Age:___
7.

What age did you start smoking?______

8.

On the average, how many cigarettes

do you smoke per day?
____ 1-2
____3-5
____6-10
____10-20 (1 pack)
____20 or more

9.

Do you drink any alcoholic beverage?

___ Yes
___ No

Highest Educational
Elementary _____
High school _____
College____

How many children do you have? _____

Directions: Please answer the following
questions by checking the most truthful
answer. Note that there are no right or
wrong answers to all the questions.

If no, please go to number 14

1.

Do you have a child diagnosed with

Autism Spectrum Disorder (ASD)?
___ Yes
___ No

If No, please go to number 5

2.

What age was your child diagnosed

with ASD?
___4-6 Years old
___7-10 years old
___10 and above

3.

Which among your

diagnosed with ASD?
____Eldest
____Middle
____Youngest

4.

How old were you when you were

pregnant with your child with ASD?
____ below 18 years old
____ 18 25 years old
____26 35 years old
____35 40 years old
____ above 40 years old

5.

children

was

10. How long have you been drinking

alcoholic beverages?
_____less than a year
_____ 1-3 years
_____4-6 years
_____6-10 years
_____10-20 years
_____20 or more years
11. What age did you start
alcoholic beverages? _____

12. How often do you usually drink?

____ 1x a week
____ 2 to 3x a week
____Everyday
____Monthly
____2-3 times a year
13. What kind of alcoholic beverages do
you drink? Check all that applies
___Beer
Per day, how many bottles do you
drink?
___ 1 to 2 bottles
___ 3-6 bottles
___ 7 bottles

Have you ever smoked a cigarette?

____ Yes
____ No

___Wine
Per day, how many glasses do you

If No, please go to number 9.

drink?
6.

How long have you been smoking?

_____less than a year
_____ 1-3 years
_____4-6 years

drinking

___ 1 to 2 glasses
___ 3-6 glasses
___ 7 or more

___Hard liquor (Gin, Vodka, Tequila,

___No, did not changed smoking habit

etc.)
___1 to 2 shots
___3 to 5 shots
___ 5 or more shots
If your answer to question number 1 is
NO; please disregard question 14 and 15.
14. Did you stop smoking when you were
pregnant with your child with ASD?
___ Yes completely stopped
___No, but smoked less than the usual

15. Did you stop drinking alcoholic

beverages when you were pregnant
with your child with ASD?
___Yes, completely stopped
___No, but drank less than the usual
___No, did not changed drinking habit
***Thank you for your participation ***

APPENDIX C.
SCREENING CHECKLIST FOR CONTROLS.