RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION FOR SUBJECT FOR DISSERTATION

1 NAME OF THE CANDIDATE Mrs. VANITHA.N AND ADDRESS I Year M.Sc (N) Student,

ACHARYA COLLEEGE OF NURSING,

BANGALORE -32

2 NAME OF THE INSTITUTION ACHARYA COLLEEGE OF NURSING,

CHOLANAGAR, R. T. NAGAR POST,

BANGALORE -32

3 Course of study and subject M.Sc. (Nursing)

CHILD HEALTH NURSING

4 Date of admission to the course 20.04.2010

5 Title of the topic A study to evaluate the effectiveness of video assisted teaching programme regarding autism among primary school teachers at selected rural schools of Bangalore.

1 6. BRIEF RESUME OF THE INTENDED WORK 6.1 INTRODUCTION

Wish you could see the World thru their eyes…….. Autism…….. They see things differently

Autism is not a puzzle, nor a disease. Autism is a challenge but certainly not a divesting one. It is about finding a way to survive in an overwhelming confusing world. It is about developing differently in a different pace and with different leaps.1

Autism is a disorder of neural developmental disorder characterized by impaired social interaction and communication and by restricted and repetitive behavior. The neurological disorder sets in with the first three years of life and impacts on information processing in the brain by altering how nerve cells and their synapses connect and organize.2

There is every reason to assume that autism has always existed. However, the word was first used by the Swiss psychiatrist, Eugen Bleuler, in 1911, and this concept evolved enormously since then. Leo Kanner is generally believed to be the first person to employ the term in the way we understand it today. 3

Autism is one of the three recognized disorders in the autism spectrum disorders (ASD), the other two being Asperger syndrome and pervasive developmental disorder. In rare cases, autism is strongly associated with agents that cause birth defects, other controversial proposed environment causes such as heavy metals, pesticides or childhood

2 vaccines. It has a higher incidence in first born males from well educated bright families in which the mother has a history of perinatal complications.2

Appropriate early intervention is important to treat child with autism. The parents, physicians, and specialists should discuss what is best for the child. Parents should be educated regarding behavioral techniques so that they can participate in all aspects of the child's care and treatment. Counseling and support may be helpful for the parents. Special education classes are available for autistic children. Medication can be recommended to treat specific symptoms such as seizures, hyperactivity, extreme mood changes, or self- injurious behaviors.4

Children under 16 yr of age constitute over 40 percent of India’s population and information about their mental health needs is a national imperative. From the early 1960s, there have been efforts at conducting epidemiological studies in community, clinic and school settings. Community surveys have the advantage of being more representative; they include children and adolescents who do not attend school and those who do not access mental health services.5

School plays a significant role in children's mental health care. Teacher's assessment is predictive of the child's subsequent mental health. Although it is difficult for both teachers and parents to recognize especially depression in a child, observations made by adults will complement the information received from the child. Teachers' knowledge of mental health should be increased and clear-cut instructions should be provided for them by health care professionals. Teacher’s assessments of child’s mental health should be utilized to a greater extent than presently.6

3 6.2 NEED FOR THE STUDY

India is a home to almost 19% of the world’s children. More than one third of the country’s population, around 480 million, is below the age of 25 years (54% of the population). According to an assumption, 40% of these children are in need of care and protection, which indicates the extent of the problem.7

The prevalence of autism in India was about 0.5 per 1000 during the 1990’s as opposed to today’s 1-2 per 1000. Estimated prevalence to be approximately 6.6 per 1,000 (or 1/150) children in the United States, in 2008, and as many as 12 in 1,000 (or 1/80) children with an ASD in Europe and Scandinavia. Among Asian country like Hong Kong reported 1.68 cases of autism per 1000 for children less than 15 years. In Denmark incidence of autism is increasing continuously it was about 0.5 new cases per 10,000 children in 1990’s and about 4.5 new per 10,000 children in 2000. In Germany a study found that inpatient admission rates for children with ASD increased to 30% from 2000 to 2005.8

The etiology of autism is still unclear but recent studies suggest that genetics play a major role in conferring susceptibility. Recent neuro imaging research studies indicate that autism may be caused by atypical functioning in the central nervous system, particularly in the limbic system: Amygdale and Hippocampus. In autistic children, losses of language and/or social skills occur during the second year of life, usually between 15 and 21 months of age. Co-morbidity with mental retardation, epilepsy, disruptive behaviors and learning difficulty is very common. Although there is currently no known cure for autism there is evidence to suggest that early intervention therapy can improve functioning of autistic children. Judicious use of psychotropic drugs is necessary to manage associated aggression, hyperactivity, self-mutilation, temper tantrums; but drugs are not a substitute for behavioral and educational interventions. The family physician can play an important role in detecting autism early, coordinating its assessment and treatment, counseling the parents and classroom teacher, and monitoring the child's progress on a long term basis.9

4 Autism is the third most common developmental disability whose incidence is greater than that of Down’s Syndrome 2 and Cerebral Palsy. According to Cohen and Volkmar (1997), no other childhood disability has such clearly defined and consistent diagnostic criteria; indeed, the manifestations of autistic symptoms are remarkably consistent across nations and cultures. Daley (2002) speculates that the reason why autism is such a misunderstood and misdiagnosed condition is because it frequently falls between the cracks of mental retardation and mental illness .Indeed, many of its behavioral manifestations are seen as indicative of “madness‟; hence it carries immense stigma.10

A study was conducted to identify the cases of autism among children with language, communication and behavior disorder, to ascertain the associated co- morbidities and create a sensitive awareness among various health care professionals in All India Institute of Medical Science, New Delhi, India. 62 patients fulfilled the DSM IV criteria for autism out of 72 referred. The result showed that male: female ratio was 8:1 and the important co-morbidities included mental challenged (95%), hyperactivity (53%) and seizures (10%) cases. The researchers suggested that, autism does occur in Indian children but diagnosis often missed hence, the health care professionals need to be acquainted with knowledge regarding the developmental disabilities of autistic children by a more structured teaching programme.11

A qualitative study was conducted for systematic review of prevalence studies of autism spectrum disorders in. Among the samples one group of studies estimated the prevalence of typical autism and the other group on all autism spectrum disorders (ASD). The extent of variation among studies and overall prevalence were estimated using meta- analysis, of which 37 estimated the prevalence of typical autism and 23 the prevalence of all ASD. The study concluded that there was high degree of heterogeneity among observed studies and autism prevalence estimates 61% in the particular study location.

5 A comparative study was conducted to determine the views of teachers and parent on autism .Surveying of beliefs regarding various aspects of the disorder was done among 47 teachers and parents of autistic children. Parent and teacher responses were compared to those obtained from a group of 22 "specialists" in autism, drawn from across the country. Both parents and teachers were found to harbor misconceptions regarding cognitive, developmental, and emotional features of autism.13

Children with autism can still perform daily functions and can be integrated in normal classrooms while at school. However, this is predicated upon the teacher’s willingness children and their patience to learn methods for teaching autistic children. Autistic children learn a lot, even though they are limited due to their disability, autistic children can really surprise us when it comes to how much knowledge they can retain.14

Teachers can have an immense impact on young people’s health. Everyday at least 5-6 hour it is the school teachers who come in contact with school children. If teachers are educated especially about autism, with the help of a learning module, it will help the teachers to identify signs and symptoms of autism as early as possible and take remedial measures promptly. Currently the need of autistic children in India are not being met in either the regular or special education systems with an understanding teacher or possibly an aide, a more able autistic child could function very well in a regular school and learn valuable social skills from his peers. Also the rigidity and pressure of schools in India can make it difficult for an autistic child to cope without special allowances. Some middle and lower functioning children, who form the majority of autistic children, may attend special schools, but these schools almost always lack an understanding of effective methods of handling the challenging behaviors of autistic children.15

From the above mentioned information, it was found that autism is prevalent in India and teachers are lacking knowledge regarding the disabilities of children with autism. So the investigator found it relevant to provide a video assisted teaching programme on autism which includes definition, incidence, etiology, risk factors, signs

6 and symptoms and role of parents and teachers in management of child with autism in order to create awareness among rural primary school teachers and improve their knowledge in assisting the autistic children.

6.2 REVIEW OF LITERATURE The purpose of review of literature is the identification, selection, critical analysis and reporting of existing information on the problem chosen for the study.

Review of literature helps to know what is already known that is these helps in developing a broad conceptual content into which the research problem will fit in. Main goal is to develop a sound knowledge in development of nursing theory, education, practice and research

The results of studies conducted in various aspects of autism are presented below: 6.2.1-Review of literature related to autism among children. 6.2.2-Review of literature related to knowledge of primary school teachers regarding autism.

6.2.1-Review of literature related to autism among children:

A study was conducted to assess the prevalence of autism spectrum disorder. The Autism and Developmental Disabilities Monitoring (ADDM) Network collected data from 11 ADDM Network sites in 2006 and compared with the child developmental referral centre (CDC) data from 10 sites in 2002. It was found that 2,757 (0.9%) of 307,790 children aged 8 years residing in the 11 ADDM sites were identified as having an ASD in 2006, indicating an overall average prevalence of 9.0 per 1,000 population. The average prevalence of ASDs identified among children aged 8 years increased 57% from 2002 to 2006. The researcher concluded that an increased prevalence of identified ASDs among U.S. children aged 8 years and indicated the need to regard ASDs as an urgent public health concern.16

7 A study was conducted to assess the incidence of childhood autism. Cumulative incidence up to age 5 years was calculated for childhood autism among a birth cohort from four successive years (1988 to 1991). The cumulative incidence recorded was 27.2 per 10,000 populations and by sex were 38.4 per 10,000 in males, and 15.5 per 10,000 in females. The proportions of children with high-functioning autism who had Binet IQs of 70 and over and those with Binet IQs of 85 and over were 25.3% and 13.7% respectively.17

A study was conducted to assess the increased prevalence rate of autism with changes in diagnostic criteria. The patient acquiring an autism diagnosis was elevated in periods between 1992 and 2005 in which the practices for diagnosing autism changed. Using the probability of diagnostic change between 1992 and 2005 to generalize to the population with autism, it was estimated that 26.4% of increase caseload. Through this study it was concluded that changes in diagnostic practices is found to be associated with increased case load of autism.18

A study was done to examine the treatment rates and patterns in children and adolescents with ASDs. Data collected among 353 parents of children and adolescents with ASD from public schools. Results showed that 46.7% of subjects had taken at least one psychotropic medication in the past year, 17.3% of subjects had taken some type of specially formulated vitamin or supplement, 15.5% on a modified diet, 11.9% had some combination of psychotropic medication, and 4.8% had taken an anticonvulsant. The result indicated that greater age, lower adaptive skills and social competence, and higher levels of problem behavior were associated with greater medication use.19

A study was conducted to determine apparent behavioral characteristics of autism in early childhood in. A comparison of behavioral data obtained from parents and clinical observation of 26 children (23 boys and 3 girls) younger than age 48 months with a clinical diagnosis of autism in CDC was taken for the study. Results suggested that deficits in the areas of social interaction, imitation, play, and nonverbal communication are more prominent than insistence on sameness and routines in young children with autism.20

8 A pilot study was done to evaluate the effectiveness of a group-based intervention aiming at improving social and communication skills in individuals with ASD. A sample of 17 children and adolescents received treatment according to the manualised Frankfurt Social Skills Training (KONTAKT) for 11 months. Parent, teacher, expert and blind expert ratings were assessed to judge outcome regarding peer interaction, autistic behaviors, adaptive functioning and family burden before and after the treatment. The participants exhibited improvements in social skills from 0.02 to 0.69 after treatment. Findings indicated that KONTAKT might be useful for enhancing social skills and reducing autism-related psychopathology over time in different contexts.21

6.2.2-Review of literature related to knowledge of primary school teachers regarding autism.

A study conducted to examine teacher’s knowledge on symptoms, concerns, and self-efficacy for teaching Children with autism. A sample of 105 general education teachers, 29 special education teachers, and 32 other educational specialist professionals (e.g., aides, speech pathologists, occupational therapists, and Title teachers) from eleven elementary schools were selected. The study showed that Special education teachers have higher knowledge regarding autism and higher self-efficacy in teaching children with autism. (Mean= 3.65) than general education teachers (Mean = 2.47). General education teachers show higher ratings of concern about having a student with autism in their class (Mean= 4.04) than special education teachers (Mean= 3.03). Thus the researcher concluded that general education teachers need additional workshops, teacher preparation courses, and fieldwork experiences on autism.22

A study was conducted to identify strategies used by teachers in education of children with ASD. A sample of 185 teachers educating 226 children with ASD was surveyed. From The study it was revealed that top five strategies being used (Gentle Teaching, sensory integration, cognitive behavioral modification, assistive technology, and Social Stories) are recognized as lacking a scientific basis for implementation. Results highlight clear implications for pre-service and in-service educator training, and

9 the need for continued research to document evidence-based strategy use in public schools for students with ASD.23

A descriptive study was conducted to assess the knowledge, practices employed, and training needs of special education teachers serving students with autism. A survey instrument was used to collect data from 498 participants in the study and they reported the greatest knowledge in general autism, and the least knowledge in sensory motor development. The greatest level of implementation was in individualization and support strategies and lowest in social skills. The Participants indicated the need for training regarding social skill development and sensory motor development for children with autism.24

A study was done to assess the Knowledge, attitudes and practices on childhood developmental and behavioral disorder (CDABD) among 503 pre-school teachers, aged 30-44 years. Result revealed that 56% of the teacher achieved a pass rate in knowledge. The pass rate in aspects of ND (normal development), ASD and attention deficit/hyperactive disorder, was 66%, 68% and 32%, respectively. The researchers concluded that there is a deficit in knowledge of pre-school teachers regarding CDABD and suggested for special need (SN) education, more training and resource support to improve their knowledge and skills to aid integration.25

A study was conducted to examine attitudes and physiological responses demonstrated by pre-service learners towards young children with ASD. The Self- Assessment Manikin (SAM) and two physiological measures (skin conductance and heart rate responses) were obtained. Four behaviors (two control and two problematic) depicting preschool-age males with ASD were viewed by pre-service learners who either had limited (n = 15) or substantial experience (n = 15) in working with this population. Results revealed significant differences between behaviors (control versus problematic) on two out of three SAM ratings and on both physiological measures. The result reveled that regardless of level of experience, pre-service learners exhibited decreased skill in managing problematic behavior and increased arousal to develop managerial ability of such children. The researcher concluded that the pre-service learners need to be educated regarding autism spectrum disorder. 26

10 6.4 STATEMENT OF THE PROBLEM:

A study to evaluate the effectiveness of video assisted teaching programme regarding autism among primary school teachers at selected rural schools of Bangalore.

6.5 OBJECTIVES:

1. To assess the knowledge regarding autism among primary school teachers 2. To evaluate the effectiveness of video assisted teaching programme by comparing the mean pretest-posttest knowledge scores of primary school teachers 3. To determine the association between the pre and post test knowledge level of primary school teachers with selected socio demographic variables

6.6 OPERATIONAL DEFINITION:

Evaluation:

In this study, it refers to the method of estimating and interpreting the effectiveness of video assisted teaching programme regarding autism among primary school teachers.

Effectiveness:

In this study, it refers to the significant enhancement in the level of knowledge among primary school teachers regarding autism as measured through the correct responses to the structured knowledge questionnaire by comparing pre and post test knowledge scores.

Video assisted teaching programme:

11 In this study, it refers to a systematic organized teaching programme prepared by the investigator and validated by experts contains video clips regarding autism such as definition, incidence, etiology, risk factors, signs and symptoms and role of parents and teachers in management of children with autism.

Knowledge: In this study, it refers to level of understanding of information about autism which will be measured by the structured knowledge questionnaire.

Autism:

In this study, it refers to neuro developmental disorder characterized by impaired social interaction and communication, and by restricted and repetitive behaviors.

Primary school teachers:

In this study, it refers to Primary school teachers of selected government and private schools in rural areas.

6.7 HYPOTHESIS:

H1: The mean post test knowledge score of primary school teachers will be higher than the mean pretest knowledge score regarding autism.

H2: There will be significant association between selected socio demographic variables with the mean pre and post test knowledge level of primary school teachers regarding autism.

6.8 RESEARCH VARIABLES:

Independent variables: In this study, independent variable is video assisted teaching programme.

12 Dependent variable: In this study, dependent variable is knowledge of the primary school teachers regarding autism.

Socio Demographic variable: In this study, socio demographic variables are age, gender, religion, qualification, marital status, type of family, teaching experience, teaching classes and source of information.

6.8 ASSUMPTIONS:

In this study it is assumed that  primary school teachers may have some knowledge regarding autistic child’s activities such as impaired communication, social interaction and low IQ.

 the structured knowledge questionnaire could be an effective tool in evaluating the knowledge of primary school teachers.

 video assisted teaching could be an effective method in improving the knowledge of primary school teachers regarding autism.

6.9 DELIMITATIONS:

The study is delimited to  primary school teachers working in selected rural schools of Bangalore

 the sample size is limited to 60

 study is delimited to one month

PROJECTED OUTCOME: The video assisted teaching programme will be provide beneficial information in improving the knowledge of primary school teachers regarding autism and the findings

13 will elicit the relationship between the information expected and the information received by primary school teachers regarding autism.

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

7.1.1 RESEARCH DESIGN: The research design which would be more suited for this study will be one group pretest and post test used under quasi experimental approach.

Schematic representation of research design: GROUP PRE-TEST INTERVENTION POST-TEST

Primary school O1 X O2 teachers working in rural areas of Day-1 Day-1 Day-7 Bangalore

KEY WORDS:

O1- Pre-test to assess the knowledge of primary school teachers regarding autism..

X- Administration of video assisted teaching programme regarding autism to primary school teachers.

O2- post test to assess the knowledge of primary school teachers after administration of video assisted teaching programme.

7.1.2 RESEARCH SETTING:

This study will be done at selected rural schools of Bangalore.

7.1.3 POPULATION

Target population – all rural primary school teachers Accessible population –primary school teachers working in selected schools.

14 7.1.4 SAMPLE:

The sample consists of the primary school teachers working at selected rural schools, Bangalore.

7.1.5 SAMPLE SIZE: The sample size consists of 60 primary school teachers who fulfill the inclusion criteria.

7.1.6 SAMPLING TECHNIQUE:

Convenience sampling technique will be adopted to select the sample for the study.

7.1.7 SAMPLING CRITERIA:

Inclusion criteria:

 The study includes primary school teachers of selected government and private schools in rural areas of Bangalore.

 The teachers who are willing to participate in the study.

 The teacher who can read and write Kannada.

Exclusion criteria:

 The teachers who are not available at the time of data collection.

7.2 METHODS OF DATA COLLECTION:

INSTRUMENT USED FOR THE STUDY

The data collection will be done with the help of structured knowledge questionnaire. It consist of

15 Section A- It consist of demographic data like age, gender, religion, qualification, marital status, type of family, teaching experience, teaching classes and source of information. Section B- the investigator will collect the data by giving structured knowledge questionnaire.

7.2.1 PLAN FOR DATA COLLECTION PROCEDURE:

Content validity of the tool will be ascertained in consultation with guide and experts like pediatrician, pediatrics nurse and psychologist. Reliability of the tool will be ascertained by split half method. Prior to the study, written permission will be obtained from the concerned authority. After obtaining permission from the concerned authority an informed consent will be obtain from the subject. The process of the study will be explained to the subjects. After explaining the process of study, socio demographic data will be collected with the help of a structured questionnaire. The knowledge of primary school teachers regarding autism will be assessed by using structured knowledge questionnaire. Video assisted teaching programme will be provided to primary school regarding autism on the same day of pre test. After 7 days post test will be conducted to evaluate the effectiveness of video assisted teaching programme regarding autism among primary school teachers.

7.2.2 DATA ANALYSIS METHOD:

Data analysis will be done by using descriptive and inferential statistics. The descriptive statistics like mean and standard deviation, frequency distribution and percentage will be used to assess the demographic variables. The inferential statistics like paired ’t’ test and chi square test (χ 2) will be used to compare the pre and post test knowledge score and to find out the association between the mean pretest and posttest knowledge scores with selected sociodemographic variables respectively.

16 7.3 DOSE THE STUDY REQUIRES ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALS Yes, A video assisted teaching programme will be given to primary school teachers in selected rural schools at Bangalore.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED? Yes, A written permission from institutional authority will be obtained. Consent from the primary school teachers before conducting the study. Confidentiality and anonymity of the subjects will be maintained.

LIST OF REFRENCES:

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3. Adam Feinstein. The History of Autism. South Asian regional conference on Autism; 2008 Jan15; New Delhi . p. 4

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5. Shoba Srinath, Satish Chandra Girimaji, G. Gururaj, Shekhar Seshadri, D.K. Subbakrishna, Poornima Bhola, Narende et al. Epidemiological studies of child and adolescents psychiatric disorders in urban and rural areas of Bangalore, India. Indian J Med [serial online] 2004 Feb .[2005 Jul]; (122):p 67-79 Available from: URL: icmr.nic.in/ijmr/2005/july/0708.pdf

6. Honkane M, Moilanen I, Taanila A, Hurtig T, Koivumaa-Honkanen H. Class teacher as promoter and predictor of a child's mental health. J Autism Dev Disord [series online] 2008 [2008may]; 38(5):961-71. Available from: URL: www.springer.com/psychology/child

17 7. Chandrakant SP. Child in India. Indian Journal of Psychiatry 2008 Apr-Jun; 50(2): 85-86.

8. The epidemiology of Autism [online]. 2010 [2010Oct16]; Available from: URL: URL:www.en.wikipedia.org/wiki/ Epidemiology_of_autism

1. Karande S. Autism:A review for family Physician. [online]. 2006 may; 60(5): 205-15. Available from: URL: http://www.ncbi.nlm.nih.gov/pubmed.

2. Vaidya, S. A sociological study of families with autism in Delhi: Issues and Challenges. The Asian Pacific Autism Conference, Sydney. 2009 Aug

3. Kalra V, Seth R, Sapra S. Autism –experience in a tertiary care hospital. [online]. 2005Mar. Availablefrom: URL : http://www.ncbi.nlm.nih.gov/pubmed .

4. William J G,Higgins J P T, Brayne C E G. Systematic review of prevalence studies of autism spectrum disorders. [Online]. 2004 [2005apr 29]. Available from: URL: http://www.ncbi.nlm.nih.gov/pubmed .

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6. Teachers autistic children-useful tips for teachers and educators. [online]. 2010 [2010Apr11];116. Available from: URL : http://www.articlesbase.com/adhd-articles

7. Autism in India. [online]. 2010: Available from: URL: www.autism- india.org/afa_autisminindia.

8. Catherine Rice. Prevalence of Autism Spectrum Disorders---Autism and Developmental Disability Monitoring Network. [Online]. 2008 [2008 Dec 18]: Available from: URL: www.cdc.gov/mmwr/preview/mmwrhtml/ss5810a1.htm

9. Honda, H., Shimizu, Y., Imai, M. and Nitto, Y. Cumulative incidence of childhood autism: a total population study of better accuracy and precision. Developmental Medicine & Child Neurology 2007 Feb 28; 47: 10–18.

10. Marissa King, Peter Bearman. Diagnostic change and increased prevalence of autism. Internal journal of epidemiology 2008 Sep 4;38(5): 1224 – 1234.

18 11. Andrea Witwer, Luc Lecavalier. Journal of Child and Adolescent Psychopharmacology 2005 Sep 28; 15(4):671-681.

12. Wendy L. Stone, Edward L. Hoffman, Susan E. Lewis, Opal Y. Early recognition of autism. Arch Pediatr Adolesc Med. 1994;148(2):174-179.

13. Evelyn Herbrecht, Fritz Poustka, Sabine Birnkammer, Eftichia Duketis, Sabine Schlitt, Gabriele Schmötzer et al. Pilot evaluation of the Frankfurt Social Skills Training for children and adolescents with autism spectrum disorder. Child and adolescent psychiatry Vol 18, number 6, 327-335.

14. Laura A. Schwarber. A comparison of general education and special education teachers’ knowledge, self-efficacy, and concerns in teaching children with autism. [online]. 2006 Available from: URL: drc.ohiolink.edu/handle/2374.OX/19163

15. Hess KL, Morrier MJ, Heflin LJ, Ivey ML. Autism treatment survey: services received by children with autism spectrum disorders in public school classrooms. J Autism Dev disorder 2008 May;38(5):961-71.

16. Hendricks, Dawn R. A descriptive study conducted to assess the knowledge, practice employed, and training needs of special education teachers serving students with autism. [Online]. 2007[2008May]; 1446.Available from: URL: gradworks.umi.com/32/88/3288685.

17. Wee Bin Lian, Selina Ho Kah Ying, Sylvia Choo Henn Tean, Daisy Chan Kwai Lin, Yeo Cheo Lian, Ho Lai Yun. Pre-school teachers' knowledge, attitudes and practices on childhood developmental and behavioral disorders. Journal of Paediatrics and Child Health [Serial online] 2008 Apr [2007 Oct 10]; 44(4):187-94. Available from: URL: www3.interscience.wiley.com/journal.

18. Examining the attitudes and physiological responses pre-service learners have towards children with autism spectrum disorders. Science direct 2009 Nov;4(3):450-456.

19 SIGNATURE OF CANDIDATE

10. REMARKS OF THE GUIDE

11 NAME AND DESIGNATION :

11. GUIDE MRS. ASWALT AMALI 1 ROSE.S HOD CHILD HEALTH NURSING SIGNATURE 11. 2

11. HEAD OF THE DEPARTMENT MRS. ASWALT AMALI 3 ROSE.S

SIGNATURE 11. 4

12. REMARK OF THE CHAIRMAN 1 OR PRINCIPAL

SIGNATURE

20 12. 2

21