Parenting experience and behavioral changes in children diagnosed with autism spectrum disorder during the implementation of the new normal in Metro Manila, Philippines

Introduction

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has far-reaching implications for societies worldwide. As the World Health Organization (WHO) indicates, the virus primarily leads to mild to moderate respiratory ailments but can result in severe consequences, including death (1).

Even before the COVID-19 pandemic, the Philippine healthcare system faced challenges such as system fragmentation, limited government engagement, and scarce workforce and financial resources (2). The pandemic exacerbated these weaknesses. However, despite these difficulties, the Philippines could continue delivering healthcare services during the pandemic through a robust local mechanism characterized by effective collaboration and strong implementation of national health programs (2,3).

Following the first reported case in January 2020, the Philippine government has implemented various measures to curb the spread of the virus (3). These measures included lockdowns, restrictions on gatherings, business closures, and the promotion of social distancing. Amid these measures, the development and rollout of COVID-19 vaccines marked a pivotal moment in the fight against the pandemic (4). The Philippine government implemented guidelines to address ongoing concerns to adapt to the new normal. These guidelines, released by the Department of Health in August 2020 (5,6), outlined new behavior patterns, circumstances, and public health requirements that would become institutionalized in everyday activities beyond the pandemic (7).

However, the impact of these changes extended beyond general populations, affecting vulnerable groups such as individuals diagnosed with autism spectrum disorder (ASD). Autism, a neurodevelopmental disorder characterized by challenges in social interactions and communication, poses unique challenges for individuals, especially children, in adapting to the disruptions caused by the pandemic (8,9).

As the pandemic unfolded, the challenges faced by parents and caregivers of children with autism became more pronounced. The lack of support, limited access to professional help, and abrupt changes in routine intensified stress and feelings of helplessness (10,11). A study conducted in the Philippines points to a connection between the pandemic and the overall change in the functioning of parents with children diagnosed with autism (12).

The COVID-19 pandemic and the measures implemented to combat it have brought about drastic changes in the lives of children diagnosed with ASD and their families (13-15). The new normal guidelines have significantly impacted parents with children diagnosed with ASD, yet limited research addresses this specific context in the Philippine setting. Filipino culture, which emphasizes strong family bonds and community support, has been challenged by the pandemic’s restrictions (16). Parents of children with ASD have faced disruptions in essential routines, such as therapy sessions and social interactions, due to online schooling and limited access to services (12). Traditional support systems like extended family and community networks have also become less accessible, increasing the burden on these parents (16). The collective stress of the pandemic, combined with the specific needs of their children, has made it difficult for these parents to cope, highlighting the need for focused research to understand and address their unique challenges.

In this study, we sought to explore the impact of implementing new normal guidelines in the Philippines on parents raising children with autism. It also aimed to identify the different behavioral changes observed in these children during the implementation of new normal guidelines. We present this article in accordance with the COREQ reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-68/rc).

Methods

Study design

A phenomenological qualitative study design was chosen to explore the experiences of parents raising children with ASD in the new normal. This approach allows for an in-depth examination of perspectives, emotions, and coping strategies, providing a comprehensive understanding of daily challenges and successes (17). It also enables a thorough investigation of behavioral changes in children with ASD, shedding light on the impact of new normal-related disruptions on both children and their families. Embracing this approach captures the richness and complexity of these experiences, offering a nuanced portrayal of evolving dynamics between parents and their children with ASD in the challenging new environment.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was thoroughly reviewed and approved by the University Ethics Review Committee of Adamson University under the approval code 2020-02-PHA-16. Informed consent was obtained from all participants, with a strong emphasis on protecting their privacy and confidentiality, given the topic’s sensitive nature.

Study area

The study was conducted in selected institutions located in Metro Manila, where stringent COVID-19 restrictions were prevalent. Metro Manila is acknowledged as one of the most severely affected regions in the Philippines, coping with the challenges imposed by the new normal (18). Since Metro Manila is known to be the capital city of the Philippines, it makes up for a large population wherein people come to work and live. Moreover, it has become one of the most affected regions of COVID due to numerous factors such as population density, rapid urbanization, and the fact that the Philippine’s international airport is in Manila, have all been plausible reasons for the spread of the virus (19).

Study participants

Five ASD institutions in Metro Manila participated. To explore parents’ diverse experiences and observe behavioral changes in their children during the implementation of the new normal, we conducted six deliberate focus group discussions (FGDs) with 3–9 participants each. Employing the FGD method deliberately, we facilitated group dynamics, thus yielding rich and interactive data. This approach proved particularly valuable in a context where there was limited prior information about the participants (20).

Data collection

Participants were selected from autism institutions based on pre-established inclusion criteria, which included being Filipino parents or guardians of children under 18 diagnosed with autism, and actively caring for them during COVID-19. We coordinated with the heads of these institutions for participant identification, following their institutional requirements. Furthermore, we conducted interviews with participants who were randomly selected by the institutions. As data collection progressed, it became apparent that most of the parents and guardians who participated in the study were between 41 and 50 years old. FGDs, led by authors M.A.L. and G.S.P., with G.M. and D.G.K. handling field notes, took place in the provided private rooms. The four authors had no prior relationship with the participants and were trained in the proper conduct of research, including qualitative methods and ethical considerations. Data collection spanned March to May 2023, involving six FGDs with 31 purposively selected participants. A validated topic guide, created by the authors, guided the discussions (Table S1). Written and verbal consent were obtained prior to the FGDs. Data saturation was reached after six FGD sessions, when no new information was emerging. Member checking was performed to ensure the accuracy of the responses and to prevent errors during transcription. Peer debriefing involved submitting transcriptions to the institutions, but no further feedback was received. No follow-up FGDs were conducted.

Data analysis

All FGDs conducted were audio recorded and fully transcribed verbatim in Filipino. Four researchers (M.A.L., G.M., G.S.P., and D.G.K.) completely analyzed and examined the data gathered. The gathered data was analyzed thematically using Braun and Clark’s six-step approach (21). MAXQDA was utilized to track the coding and manage the data that arose from the transcripts. The researchers comprehended the data by thoroughly familiarizing themselves with its contents and engaging in the information through repeated analysis of the transcribed data. Transcript analysis was conducted by labeling phrases and sentences with codes to represent their main ideas. Then, sentences with similar meanings were grouped under the same code, creating new codes for sentences with different meanings. This process continued until all the related phrases had been coded. The researchers grouped similar codes from transcripts into categories and related major codes to subcategories for enhanced validity. Codes were validated through discussions with co-researchers and peer debriefing, with descriptive details added. The thematic analysis concluded with reporting emerged findings and offering narratives for identified themes. Representative quotes were translated into English.

The FGD findings were categorized into two groups: Behavioral changes that were found in the children with ASD during the implementation of the new normal guidelines and parenting experiences that showcased how the parents responded in addressing their child’s needs, either positively or negatively. Quotations were utilized throughout the results to illustrate these findings.

We conducted a thorough study to ensure their findings were valid, credible, and reliable. We followed specific criteria outlined for credibility, transferability, dependability, and confirmability (22). We employed strategies such as excluding irrelevant data, verifying accuracy with participants, prolonged observation, transparent record-keeping, and seeking peer feedback. Detailed descriptions were provided to enhance the findings’ applicability. Also, by engaging in member checking, we prevented any incorrect data interpretation and guaranteed authenticity, originality, and reliability. Additionally, we incorporated reflexivity and positionality into our research process by recognizing and reflecting on our biases, perspectives, and their influence on the study. This was achieved through self-reflections and continuous dialogue with co-researchers, which helped us understand and manage how these factors could impact the research (23). In summary, we are dedicated to a thorough and transparent approach, using varied methods to ensure study reliability, credibility, and reflexivity.

Results

General characteristics

Table 1 provides a summary of the demographic characteristics of the participants. The participants are primarily between the ages of 41 and 50 years. Females make up a significant majority, comprising 90.3% of the sample. In terms of their relationship to the child, most participants are mothers (58.1%), followed by guardians (35.5%) and fathers (6.5%). Additionally, the majority of participants have their child enrolled in a private institution (71.0%), while the remaining children are enrolled in public institutions (29.0%). All participants reside in Metro Manila and are employed.

The study’s findings are divided into two sections, presented in Tables 2,3. The first section discusses parenting experiences from the data gathered during the FGD sessions, while the second section explores observed child behavioral changes. Quotes are used throughout to illustrate and explain the themes.

Parenting experience

Table 2 summarizes parenting experiences during the new normal guidelines for children with autism. It covers challenges, positive aspects, and resilience. Importantly, children’s behaviors affect parents’ experiences; for example, a child’s negative behavior can contribute to parental stress and heightened emotions.

Challenges experienced by the parents of children with ASD during the implementation of new normal guidelines

The new normal burdens families with ASD-diagnosed children, especially those with low incomes or caregiving responsibilities. Many rely on overseas relatives for crucial support, struggling with escalating costs for ASD care, including therapies, education, and healthcare, posing a financial stability challenge.

“We are facing financial difficulties due to the pandemic. It hasn’t been easy to find income, and at the same time, therapy is their top priority. Being able to provide her with the necessary therapy is a significant challenge we have encountered.” (D1, Mother, Private Institution)

Moreover, the new normal presents time constraints for families with ASD-diagnosed children, challenging the balance between work and caregiving. Conflicts arise between job demands and child support, prompting parents and caregivers to seek time management solutions for aligning their child’s needs with professional responsibilities in this changing environment.

“I am experiencing a conflict between my work and caring for my child with autism, which hurts both aspects.” (C3, Father, Public Institution)

“I am busy, and based on my observation, my mom doesn’t have much attention for the child because I work at night while the child is active during the morning.” (E2, Mother, Private Institution)

The implementation of the new normal guidelines led to certain children displaying disruptive behaviors, causing a challenging adjustment for parents and guardians. The sudden change in routines proved difficult to manage, particularly with children who potentially exhibit aggressive behavior in response to unexpected changes.

“It is indeed difficult to change her routine. That’s where the challenges begin, as she may have meltdowns or tantrums when her schedule is disrupted. It can be a source of difficulty for me to manage these situations.” (A6, Mother, Private Institution)

Some respondents faced challenges with broken family dynamics and denial about their child’s condition, hindering acceptance and prolonging uncertainty. This delayed crucial interventions, complicating their adjustment to new normal guidelines.

“Since we are a broken family, I am the one primarily responsible for taking care of the child.” (C3, Father, Public Institution)

“So, the child’s parents are in denial about the situation. However, I took the initiative to have the child checked by a neurologist, and it was confirmed that he has ASD.” (C2, Aunt, Public Institution)

Positive experiences of the parents with children diagnosed with ASD during the implementation of new normal guidelines

New normal guidelines empowered primary caregivers to balance caregiving and work effectively. Unlike pre-pandemic reliance on external help, participants found they could now manage both responsibilities, caring for their children while fulfilling work commitments from home.

“I focused, I focused on her and gave her my full attention.” (C1, Mother, Public Institution)

“I gave my time and attention to my child because it’s necessary to focus on my child.” (A9, Mother, Private Institution)

The new normal, featuring remote work and fewer social activities, strengthened parent-ASD-child bonds. Increased time together improved understanding and communication, as parents tailored activities to children’s needs, deepening emotional connections and unintentionally nurturing better family relationships.

“We always have bonding time, and we make sure to allocate dedicated moments for just the two of us. Each one of us (family members) finds time for him because he is important to all of us.” (E3, Grandmother, Private Institution)

Furthermore, the new normal guidelines inadvertently increased social support for ASD families. Parents received more help from extended family, and autism care professionals adapted by providing virtual consultations and support services. This expanded support network has made these challenging times more manageable for families with ASD children.

“Well, it became very challenging for the entire family to be confined inside the house (talking about the restrictions imposed by the implementation of the new normal guidelines). We truly had to come together and support each other to overcome those difficulties.” (B2, Mother, Public Institution)

Lastly, parents noted improved behavior in their children due to new guidelines, reinforcing their commitment to adapting and benefiting their kids. Witnessing their child’s development strengthened their resolve to provide unwavering support. Parental contentment often stems from acknowledging and celebrating progress, irrespective of circumstances.

“Last time, we went to a party. It was his first time going out. So, he wanted the music to be turned off because he didn’t like it, as he wasn’t used to it since he was always at home. But when the new normal came, it was a significant improvement for my child because he realized, “Oh, there should be things like this. This is how it is outside the house.” That was a big improvement.” (F5, Grandmother, Private Institution)

Resilience of parents of children diagnosed with ASD during the implementation of new normal guidelines

Most respondents demonstrated exceptional adaptability in meeting their child’s needs during the new normal guidelines, given limited healthcare accessibility. Parents and caregivers honed outstanding adaptation skills to cater to their children’s needs during and after the pandemic.

“There are still times when I need to condition him, explaining to him that in school, writing is necessary. There are instances when he refuses to write and resorts to crying. So, what I do is the next day, I explain to him again that he needs to write and study. Sometimes, I offer incentives or rewards, like going out for a weekend trip, if he doesn’t cry or if he writes.” (A8, Mother, Private Institution)

Despite challenges, parents resiliently adapted to the new normal, prioritizing their child’s well-being. They modified caregiving routines to align with guidelines, incorporating remote learning and safety measures like masks and hand sanitizer. This underscores their adaptability and the significance of tailored care for children with special needs like ASD.

“Afterwards, alcohol, he knows. He developed self-awareness that he should also sanitize.” (A8, Mother, Private Institution)

“There has been a big, significant change because, for example, he is now wearing a mask even though he’s not used to wearing one when going out. But he’s okay with adjusting to wearing a mask; he doesn’t remove it because, of course, he wants to go out, so wearing a mask is fine with him.” (D1, Mother, Private Institution)

Some parents prioritized a positive mindset, well-being, and religious support amidst new normal challenges. These highlighted the importance of adaptive coping strategies and strengthened support systems. This deepened their understanding of how resilience, spirituality, and parental well-being intricately interact.

“Perhaps because when you’re a mother, you would do anything for your child, right? That’s why it becomes an inspiration that, as a mother, you shouldn’t give up. Also, the support from family and, of course, prayers.” (B1, Mother, Public Institution)

Behavioral changes

Table 3 illustrates behavioral changes in children with autism during the new normal. Two main categories emerged: (I) positive observations, including improved social interactions, communication, routine recognition, enthusiasm, and independence; and (II) negative observations, such as recurring tantrums, reduced social interaction, hypersensitivity, aggression, and narrowed interests.

Positive observations

During the new normal, children, having been in lockdown for nearly two years, notably enhanced their social skills. Parents observed increased enthusiasm to go out and significant changes in social interactions, suggesting an accelerated social development that might have taken place gradually in normal circumstances.

“When he started going to school, you noticed that his social skills developed more. So, he enjoys going out more and more.” (B3, Mother, Public Institution)

In the lockdown, parents observed a decline in their child’s communication skills. The new normal, with professional help and a hybrid learning model, notably improved communication. This approach, blending remote and in-person education, made it more manageable for parents to support their child’s needs. In the lockdown, parents observed a decline in their child’s communication skills. The new normal, with professional help and a hybrid learning model, notably improved communication. This approach, blending remote and in-person education, made it more manageable for parents to support their child’s needs.

“He is capable of communicating with you, and when he has something to say, he can express it.” (B5, Mother, Public Institution)

Children displayed adaptability in the new normal, embracing guidelines and routines. Initially confined by the pandemic, they independently adopted practices like wearing masks and social distancing, showcasing increased awareness and integration of these protocols into their daily lives.

“They know how to avoid getting infected by the virus and they practice hand hygiene. She also makes sure to keep her sleeping areas clean because they mostly stay indoors. That’s what we observe from her.” (D1, Mother, Private Institution)

Some parents noted their children’s enthusiasm when they could finally go outside during the new normal. While this enthusiasm might have been more consistent under normal circumstances, it highlights the profound impact of the new normal guidelines on their children.

“What I noticed about him, well, it’s like, what do you call it, the term for it is, escaping or breaking free, he seemed to become excited, excited to go out, that’s all, that’s what I noticed about him.” (C3, Father, Public Institution)

“Nowadays, he’s always outside. It seems like he’s happier that way.” (E1, Mother, Private Institution)

Some parents noticed their children becoming more independent in the new normal, likely because they could go out safely and had increased awareness. The guidelines made children more self-sufficient, but parents still offered occasional guidance to help them improve.

“It seems that what has become of him is good, he has matured. As he gets older, he becomes something, somehow, he becomes independent in other things.” (B4, Mother, Public Institution)

“Ah, yes, he has become more independent now since he knows his routine already, so he goes to work on things on his own, although there are still times when you need to condition him and explain things to him.” (A8, Mother, Private Institution)

Negative observations

Participants noticed increased tantrums in their children during the new normal, attributing it to the struggle to adapt to new guidelines. The shift from in-person school, where ASD symptoms were less pronounced, to the unpredictable routine of the new normal caused confusion and adjustment issues, triggering tantrums as a coping mechanism.

“He is adjusting to the new routes in his routine because the path he used to take is different now. He remembers the usual path, so when we change the route, he will show tantrums and aggression.” (A2, Caregiver, Private Institution)

“When we stayed at home, we had to figure out what he wanted, and we had to follow his preferences. Because if we didn’t follow him, he would get triggered and have tantrums.” (B5, Mother, Public Institution)

Participants noted a decrease in their children’s interactions with family members and other children, largely due to the limitations imposed by the new normal, impacting opportunities for social interactions among children with autism.

“She is afraid of other kids, she doesn’t know how to socialize, she doesn’t know how to play or even greet.” (A6, Mother, Private Institution)

“When going outside, that’s where we struggle with him. He doesn’t want to go out; he prefers to stay at home compared to other children who engage in social activities.” (C2, Aunt, Public Institution)

Some participants noticed their children becoming more sensitive to things like noise, touch, and light. This hypersensitivity leads to discomfort and sensory overload from everyday environmental triggers. During the new normal, as daily activities resumed and noise levels increased, parents found it challenging to handle their child’s heightened sensitivity.

“That’s the thing with sounds. There are times when he really doesn’t process or perceive the sounds properly. That’s when he becomes agitated and triggered. His ears are sensitive.” (C2, Aunt, Public Institution)

Participants observed heightened aggression in their children during the new normal, stemming from disrupted routines and reduced social interactions. The uncertainty of the new guidelines led to increased anxiety and frustration, occasionally resulting in aggression, a typical response in individuals with ASD when faced with overwhelming situations.

“I struggled when we lost access to therapies because they served as my partners in my child’s special education. When we no longer had therapy, my child became somewhat more aggressive.” (D5, Mother, Private Institution)

Some participants noted that their children’s interests and activities were restricted in the new normal, resulting in reduced enthusiasm for entertainment, despite fewer restrictions. For instance, while some malls were open, they still did not permit children to hang around as freely as before the pandemic.

“Based on my observation, he became more inclined to play alone rather than socialize and interact with others.” (A3, Father, Private Institution)

Mind map

The mind map (Figure 1) is organized into two primary categories: Parenting Experiences and Behavioral Changes observed in the child as the New Normal guidelines emerged following the pandemic in the Philippines. This visualization makes it easier to understand how the themes are interrelated. For instance, each negative observation reported by parents about their child’s behavior led to specific challenges they had to confront. As these challenges arose, parents displayed resilience by adapting to their child’s needs and coping with the new normal setting. This resilience often resulted in positive experiences, as many parents noted that they had more time to cater to their child’s needs due to the reduced restrictions imposed by the government.

Figure 1 Mind map illustrating the relationships and interactions between key themes and subthemes.

Furthermore, the mind map shows that as parents adjusted to the new normal, they not only observed positive changes in their child’s behavior but also improved their time management skills. This improvement allowed them to balance caregiving responsibilities with other work commitments, such as office duties. As a result, the negative observations seen in their children during the strict lockdown in the Philippines were either eliminated or significantly reduced. The end goal of the resilience practices and methods adopted by parents was to achieve positive outcomes for their children with ASD, both in terms of behavior and overall family dynamics.

Discussion

This study outlines six critical findings related to parenting experiences and behavioral changes in children diagnosed with ASD during the new normal. The first three findings focus on observed behavioral changes in children with ASD, including reduced social interactions (a negative aspect), the child’s enthusiasm in embracing new guidelines (a positive aspect), and the child’s newfound independence in following these guidelines (another positive aspect). The subsequent three findings delve into the parenting experiences of parents and guardians. The first addresses challenges stemming from specific family situations impacting parenting during the new normal. The second discusses how parents can provide focused care to create a positive experience for their child. Lastly, the third highlights parents’ resilience in adapting to the new normal guidelines. These findings underscore the crucial need for additional support for families of children with ASD, particularly during transitional periods like these.

Parents interviewed for this study expressed concern about their child’s decreasing social interactions, including limited engagement with family members and other children. Similar findings have been reported in China, where parents of children with ASD worry about the severity of their child’s social issues, especially during times of restrictions (24). A study in Brazil also noted that restricting interactions can lead to a regression in the social skills of children with ASD (25). These observations have deepened our understanding of how the new normal guidelines affect the social interactions of children with ASD in Metro Manila. However, it is crucial to recognize that these findings are specific to Metro Manila, an urbanized and densely populated area with unique social dynamics. Implementing these guidelines has led to significant changes in public interactions, often resulting in minimal to nonexistent engagement in this region. Consequently, the restrictions imposed by the new normal guidelines have become a major factor in the decline of social interactions among children with ASD in Metro Manila.

Despite a large view of the negative observations seen from ASD-diagnosed children, noteworthy positive observations are also evident. Most parents interviewed for this study reported that their ASD-diagnosed child showed enthusiasm during the implementation of the new normal guidelines, particularly when they were finally allowed to go outdoors and interact with other children to some extent. Along with this, excitability was also observed in their child. These findings contrast with previous research, which suggested that ASD-diagnosed children primarily exhibit enthusiasm when confined alone with their technologies (26) or when engaged in online interventions, such as online schooling (27,28). The divergence between our findings and those of previous studies highlights the context-specific nature of these observations. While previous studies focused on technology and online interventions, our results are grounded in the limited outdoor experiences of children in Metro Manila during the new normal.

Interviewed parents were also pleased to observe traits of independence among their ASD-diagnosed children, as many of them became more mature and reliable due to the implementation of the new normal guidelines. Studies have shown that the independence observed in ASD-diagnosed children is closely linked to their ability to complete tasks and adhere to given instructions, even during challenging times such as a period of containment (29). This has been a significant finding, as most parents sought alternative interventions to help keep their ASD-diagnosed children sane and productive during this difficult period. As a result, independence bloomed, and many children exhibited a newfound sense of self-reliance, contributing positively to their overall well-being.

The diverse range of behavioral observations also led to variations in the parenting experience during the implementation of the new normal guidelines. This posed significant challenges for parents, particularly those in unique family situations. Participants reported that factors such as being in a broken family or having a family member working abroad (a common Filipino scenario) contributed to the complexity of their responsibilities. In cases where one parent was solely responsible for caring for an ASD-diagnosed child, heightened stress and emotional strain were prevalent. This mirrors findings from a study highlighting the substantial impact of solo parenting on the well-being of those caring for a child with ASD (30,31).

However, these challenges are specific to the socio-economic conditions in Metro Manila and may not fully represent parents’ experiences in other parts of the Philippines. Our findings also revealed that the socio-economic background and type of institution (public vs. private) where children with ASD are enrolled may have influenced the results. Parents with children in public institutions frequently faced challenges meeting their children’s needs, primarily due to financial constraints exacerbated by the pandemic. These families often struggled to access necessary resources and support, reflecting the limited government aid available under the ‘New Normal’ policies. In contrast, parents whose children attended private institutions generally reported fewer difficulties, attributing their ability to better support their children’s needs due to higher income levels. It is important to note that some parents chose not to disclose their income, so our findings are based primarily on the comments they provided. This disparity underscores how financial capability affects the level of care and resources available to children with ASD, with some families demonstrating remarkable resilience despite significant economic hardships.

Despite their negative experiences, parents also highlighted significant positive aspects during the implementation of the new normal guidelines. They believed that the implementation was valuable, enabling them to provide focused care with increased attention and effort to meet their child’s specific needs. This contrasts with findings from a study in Jordan, where parents reported feelings of loneliness, helplessness, and drained energy during childcare, hindering their primary caretaker roles (32). Despite the restrictions imposed by the new normal guidelines, parents of children with ASD in Metro Manila managed to maintain focused caregiving, benefiting from the increased availability of time that the situation provided. However, these positive experiences may be influenced by the specific conditions in Metro Manila, where access to resources and support systems may differ from those in other regions of the Philippines.

Parents emphasized that resilience was crucial in helping their families navigate the unique circumstances of the new normal guidelines. Participants reported successfully adapting to these guidelines by incorporating measures like mask-wearing and hand hygiene to ensure their child’s safety without encountering significant challenges. This finding contrasts with a study in Turkey, where parents faced difficulties getting their children to comply with similar measures, such as wearing face masks, handwashing, and maintaining social distance. The study highlighted the challenges children with autism face in understanding and adhering to these protective measures (33). Findings suggest that, in Metro Manila, the new normal guidelines have provided parents with an opportunity to teach their ASD-diagnosed children the importance of following safety rules, allowing them to go outside and play without compromising their safety.

This study offers valuable insights, enhanced by FGDs, which promote mutual understanding and trust among participants, creating an open and honest environment. Rigor was ensured through member checking, extended observation, maintaining an audit trail, peer debriefing, and providing detailed descriptions. Including both public and private institutions in Metro Manila added diversity to the parenting experiences examined. However, it is essential to acknowledge the study’s limitations, mainly focusing solely on Metro Manila. The unique socio-economic and cultural dynamics of this region may not fully represent the broader population in the Philippines. Therefore, it is recommended to include participants from outside Metro Manila to gain a more comprehensive understanding of parenting experiences and behavioral changes in children with ASD during the new normal. Additionally, the sensitivity of the subject matter might have led some participants to withhold their true emotions or experiences. To address this, we engaged with each parent individually, ensuring that everyone had an equal opportunity to express their viewpoints and emphasizing that there were no right or wrong answers.

Conclusions

The implementation of new normal guidelines has had a notable impact on both the behavior of children diagnosed with ASD and the experiences of their parents or guardians. Negative observations, such as recurring tantrums and reduced social interaction, seem to be linked to the guidelines, particularly the confinement of these children to their homes. However, despite these challenges, there are positive outcomes, including increased enthusiasm and independence, attributed to effective home-based interventions introduced under the new normal guidelines.

This study offers comprehensive insights into the diverse experiences of parents and guardians of children diagnosed with ASD. It highlights their resilience in adapting to the new guidelines, demonstrating greater flexibility in delivering quality care. Due to the guidelines, the increased time spent on caregiving has led to improvements in caregiving practices. However, challenges remain, such as the impact of family dynamics and the increased time demands brought about by the absence of social support and adjustments required by the new normal.

In summary, it is essential to acknowledge the varied impacts of the new normal guidelines on both the behavior of children diagnosed with ASD and the experiences of their parents. Recognizing the need for comprehensive support for parents and caregivers is essential. By providing targeted assistance and resources, parents and caregivers can better adapt to changing circumstances. Ensuring families have access to the necessary resources and support is crucial for the progress of the children as well as the overall well-being of the family.

Policy implications

To better support families of children diagnosed with ASD in the Philippines, policymakers and practitioners should consider several key measures. In partnership with local government units and schools, establishing regional support centers would provide localized resources and training, ensuring that assistance is relevant to diverse communities. Implementing financial assistance programs to cover the costs of ASD-related therapies would alleviate the financial burden on families, leveraging existing social welfare frameworks to distribute aid effectively. Promoting community-based initiatives, such as support groups and activities organized by local barangays [communities], would foster peer support and facilitate resource sharing at the grassroots level. Strengthening collaboration with non-governmental organizations (NGOs) focused on autism and disability would also enhance resource availability and provide specialized training for both families and practitioners. These measures would make interventions more practical, accessible, and culturally relevant, addressing the unique needs of Filipino families as they navigate the challenges posed by the new normal guidelines. Additionally, these findings can serve as a foundation for future research, guiding the development of more targeted and practical strategies to support children diagnosed with ASD and their families, particularly during challenging times.

Acknowledgments

We extend our heartfelt gratitude to the heads of the participating institutions for their invaluable assistance in helping the researchers recruit participants and facilitating the smooth conduct of data collection through focus group discussions within their institutions. We also express our sincere appreciation to the parents and guardians who generously provided their consent, time, and wholehearted participation, which greatly enriched the depth and validity of the research findings.

Footnote

Reporting Checklist: The authors have completed the COREQ reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-68/rc

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-68/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-68/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-68/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was thoroughly reviewed and approved by the University Ethics Review Committee of Adamson University under the approval code 2020-02-PHA-16. Informed consent was obtained from all participants, with a strong emphasis on protecting their privacy and confidentiality, given the topic’s sensitive nature.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. World Health Organization. Coronavirus disease (COVID-19). 2021 August 21. Available online: https://www.who.int/health-topics/coronavirus#tab=tab_1
2. World Health Organization. Philippines: a primary health care case study in the context of the COVID-19 pandemic. 2024 August 17. Available online: https://www.who.int/publications/i/item/9789240076747
3. Hapal K. The Philippines’ COVID-19 Response. Journal of Current Southeast Asian Affairs 2021;40:224-42. [Crossref]
4. Mathieu E, Ritchie H, Ortiz-Ospina E, et al. A global database of COVID-19 vaccinations. Nat Hum Behav 2021;5:947-53. [Crossref] [PubMed]
5. DOH. A guide to the new normal. 2020 August 25. Available online: https://doh.gov.ph/spotlight/guide-to-new-normal
6. A guide to the new normal. | Department of Health website. 2020 August 25; Available online: https://doh.gov.ph/spotlight/guide-to-new-normal
7. National Action Plan | IATF. 2020 March. Available online: https://iatf.doh.gov.ph/national-action-plan/
8. Di Renzo M, Di Castelbianco FB, Vanadia E, et al. Parent-Reported Behavioural Changes in Children With Autism Spectrum Disorder During the COVID-19 Lockdown in Italy. Contin Educ 2020;1:117-25. [Crossref] [PubMed]
9. World Health Organization. Autism. 2023 November 15. Available online: https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders
10. Stankovic M, Stojanovic A, Jelena S, et al. The Serbian experience of challenges of parenting children with autism spectrum disorders during the COVID-19 pandemic and the state of emergency with lockdown. Eur Child Adolesc Psychiatry 2022;31:693-8. [Crossref] [PubMed]
11. UNESCO. Another COVID-19 Front line: Parents of children with disabilities. 2022 June. Available online: https://en.unesco.org/news/another-covid-19-front-line-parents-children-disabilities
12. Fadare M. A special journey: Parents’ challenges on home schooling children with autism spectrum disorder. 2022 August 2. Available online: https://www.orapuh.org/ojs/ojs-3.1.2-4/index.php/acadrep/article/view/OAR2202/OAR2202?fbclid=IwAR2IVm7aZd6OIovuHdgieCYMhMWs0UCEtvRJd_XK9pCSh3KrvN8K69Jv_7c
13. Bozkus-Genc G, Sani-Bozkurt S. How parents of children with autism spectrum disorder experience the COVID-19 pandemic: Perspectives and insights on the new normal. Res Dev Disabil 2022;124:104200. [Crossref] [PubMed]
14. Fong HX, Cornish K, Kirk H, et al. Impact of the COVID-19 lockdown in malaysia: an examination of the psychological well-being of parent-child dyads and child behavior in families with children on the autism spectrum. Front Psychiatry 2021;12:733905. [Crossref] [PubMed]
15. Tokatly Latzer I, Leitner Y, Karnieli-Miller O. Core experiences of parents of children with autism during the COVID-19 pandemic lockdown. Autism 2021;25:1047-59. [Crossref] [PubMed]
16. Cahapay MB. How Filipino parents home educate their children with autism during COVID-19 period. Int J Dev Disabil 2022;68:395-8. [Crossref] [PubMed]
17. Tenny S, Brannan J, Brannan G. Qualitative study. 2022 September 18. Available online: https://www.ncbi.nlm.nih.gov/books/NBK470395/?fbclid=IwAR3HafzLMDOlLtW6pkle7PA_9_aNJYfglAfK3XEW2hlZUUyxT8P1UQcjgwE
18. Jiang Y, Laranjo JR, Thomas M. COVID-19 lockdown policy and heterogeneous responses of urban mobility: Evidence from the Philippines. PLoS One 2022;17:e0270555. [Crossref] [PubMed]
19. World Health Organization. COVID-19 in the Philippines. 2022 April 6. Available online: https://www.who.int/philippines/emergencies/covid-19-response-in-the-philippines
20. Scheelbeek PFD, Hamza YA, Schellenberg J, et al. Improving the use of focus group discussions in low income settings. BMC Med Res Methodol 2020;20:287. [Crossref] [PubMed]
21. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2008;3:77-101. [Crossref]
22. Johnson JL, Adkins D, Chauvin S. A Review of the Quality Indicators of Rigor in Qualitative Research. Am J Pharm Educ 2020;84:7120. [Crossref] [PubMed]
23. Wilson C, Janes G, Williams J. Identity, positionality and reflexivity: relevance and application to research paramedics. Br Paramed J 2022;7:43-9. [Crossref] [PubMed]
24. Huang S, Sun T, Zhu Y, et al. Impact of the COVID-19 Pandemic on Children with ASD and Their Families: An Online Survey in China. Psychol Res Behav Manag 2021;14:289-97. [Crossref] [PubMed]
25. Azevedo Machado B, Silva Moro J, Massignam C, et al. Fear, changes in routine and dental care for children and adolescents with autism spectrum disorder in the COVID-19 pandemic: A survey with Brazilian parents. Spec Care Dentist 2022;42:352-60. [Crossref] [PubMed]
26. Palma R, Lam H, Shrivastava A, et al. “Monday Feels Like Friday!” - Towards Overcoming Anxiety and Stress of Autistic Young Adults During Times of Isolation. 2023 March 13. Available online: https://dl.acm.org/doi/abs/10.1007/978-3-031-28032-0_24
27. Ballantine J, Rocheleau J, Macarios J, et al. "Change Isn't Exactly Easy": Autistic University Students' Lived Learning Experiences During the COVID-19 Pandemic. Autism Adulthood 2023;5:325-34. [Crossref] [PubMed]
28. Genova H, Arora A, Botticello AL. Effects of School Closures Resulting From COVID-19 in Autistic and Neurotypical Children. Front Educ 2021;6:761485. [Crossref]
29. Kodak T, Bergmann S. Autism Spectrum Disorder: Characteristics, Associated Behaviors, and Early Intervention. Pediatr Clin North Am 2020;67:525-35. [Crossref] [PubMed]
30. Baker K, Devine RT, Ng-Cordell E, et al. Childhood intellectual disability and parents' mental health: integrating social, psychological and genetic influences. Br J Psychiatry 2021;218:315-22. [Crossref] [PubMed]
31. Parenteau C, Bent S, Hossain B, et al. A Qualitative Analysis: The Experience of Parents of Children with Autism Spectrum Disorder During the COVID-19 Pandemic. J Am Acad Child Adolesc Psychiatry 2020;59:S251. [Crossref]
32. Shattnawi KK, Bani Saeed WM, Al-Natour A, et al. Parenting a Child With Autism Spectrum Disorder: Perspective of Jordanian Mothers. J Transcult Nurs 2021;32:474-83. [Crossref] [PubMed]
33. Mutluer T, Doenyas C, Aslan Genc H. Behavioral Implications of the Covid-19 Process for Autism Spectrum Disorder, and Individuals' Comprehension of and Reactions to the Pandemic Conditions. Front Psychiatry 2020;11:561882. [Crossref] [PubMed]