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IAN Research IAN Research Reports IAN Research Questions Parental Depression History Questionnaire Intro Basic Family Information Child with ASD Questionnaire Social Responsiveness Scale (SRS) Social Communication Questionnaire (SCQ) Treatment List Questionnaire for Each Treatment Weight and Height Intro Weight and Height Questionnaire Mother Basic Medical History Questionnaire Father Basic Medical History Questionnaire Sibling Without ASD Questionnaire Child with ASD - First Diagnosis Child with ASD - Current Diagnosis Child with ASD - Regression Child with ASD - Fragile X Child with ASD - Seizures Child with ASD - Mental Retardation Child with ASD - Motor Delay Child with ASD - ADHD Diagnosis Child with ASD - Anxiety Child with ASD - Bipolar Disorder Child with ASD - Depression Child with ASD - Attention and Mood Issues by ASD Child with ASD - Type of School Child with an ASD - Previous Research Participant? Mother - Education Mother - Learning Disability Mother - Speech Delay Mother - Speech Therapy Mother - Special Education Mother - ADHD Mother - Anxiety Mother - Bipolar Disorder Mother - Depression Father - Education Father - Learning Disability Father - Speech Delay Father - Speech Therapy Father - Special Education Fathers - ADHD Father - Anxiety Father - Bipolar Disorder Father - Depression Sibling - Speech Delay Sibling - Speech Therapy Sibling - Special Education Sibling - ADHD Sibling - Anxiety Sibling - Bipolar Disorder Sibling - Depression Understanding Research Government Initiatives Autism Spectrum Disorder Research User Guide for IAN Research Participants Research Studies Studies No Longer Recruiting

CHILD WITH ASD QUESTIONNAIRE

Parents taking part in the IAN Research project answer a series of questions via the Internet from the comfort of their own homes and at their own convenience. They can stop the process at any time, starting again when they are ready. (This is a wonderful feature, as parents of children with ASDs experience many interruptions in their daily lives!)

Data collected from thousands of parents --stripped of identifying information-- will be shared with autism researchers seeking answers to crucial questions.

The Child with an ASD questionnaire asks parents specifically about their child who has been diagnosed with an Autism Spectrum Disorder. Many of the questions are about a child's diagnosis and medical history. There are 65 potential questions which take approximately 15 minutes to complete.

Please note: items which appear as orange and underlined are linked to Research Results --an explanation of that particular question's importance together with a graph showing our results so far.  Click on the link to see what parents have been reporting about themselves, their children with ASDs, and their non-affected children.

Autism Spectrum Disorder History

  1. What was the child's FIRST autism spectrum disorder (ASD) diagnosis?
  2. When did the child receive this FIRST ASD diagnosis?
  3. Approximately how old was the child when he/she received this FIRST ASD diagnosis?
  4. Who gave the child this FIRST ASD diagnosis?
  5. Where did the child receive this FIRST ASD diagnosis?
  6. Is the child's CURRENT ASD diagnosis different than the FIRST?
  7. What is the child's CURRENT ASD diagnosis?
  8. When did the child receive this CURRENT ASD diagnosis?
  9. Approximately how old was the child when he/she received this CURRENT ASD diagnosis?
  10. Who gave the child this CURRENT ASD diagnosis?
  11. Where did the child receive this CURRENT ASD diagnosis?
  12. How old was the child when you FIRST became concerned that something was wrong with his/her development?
  13. If you remember, please give the child's exact age (in years and months) that you FIRST became concerned that something was wrong with his/her development.
  14. What was your FIRST concern about the child's development?
  15. Did the child lose words, daily living skills, motor abilities, or social skills that he/she previously had?
  16. How significant was the child's loss of skills?
  17. Which type of skill was affected the most?
  18. What age was the child when you FIRST noticed this loss of skills?
  19. Did your child's development plateau or halt such that he/she stopped gaining new skills but retained previously acquired skills?
  20. What age was your child when you FIRST noticed this plateau of halt in his/her development?
  21. Has the child ever been given an IQ test or intelligence test?
  22. What was the child`s most recent IQ test score?
  23. Has the child ever been given the ADOS (Autism Diagnostic Observation Schedule)?
  24. Did the ADOS show that the child had an autism spectrum disorder?
  25. Have you ever completed the ADI (Autism Diagnostic Interview) for the child?
  26. Did the ADI (Autism Diagnostic Interview) show that the child had an autism spectrum disorder?
  27. Has the child had an MRI (magnetic resonance imaging) of his/her brain?
  28. Were the results from the MRI (magnetic resonance imaging) normal for the child?
  29. Has the child had a CT Scan of his/her brain?
  30. Were the results from the CT Scan normal?
  31. Has the child had an (EEG) electroencephalogram of his/her brain?
  32. Were the results of the (EEG) electroencephalogram normal for the child?

Developmental History

  1. How old was the child when he/she first walked?
  2. If you remember, please give the exact age (in years and months) that the child first walked.
  3. How old was the child when he/she said his/her first words?
  4. If you remember, please give the exact age (in years and months) that the child said his/her first words
  5. How old was the child when he/she was able to use two to three words together for meaningful speech?
  6. How old was the child when he/she was toilet trained?

Birth History

  1. What was the length of the pregnancy with the child?
  2. Which one of these describes the child's birth (single birth, twins, triplets, etc.)? 
  3. What was the child`s BIRTH ORDER?
  4. How much did the child weigh at birth?

Additional Medical History

  1. Has the child ever been diagnosed with Fragile X?
  2. Has the child ever been diagnosed with Tuberous Sclerosis?
  3. Has the child ever been diagnosed with Seizures or Epilepsy?
  4. Has the child ever been diagnosed with Mental Retardation?
  5. Has the child ever been diagnosed with a Motor Delay?
  6. Has your child ever been diagnosed with Cerebral Palsy (CP)?
  7. Has the child ever been diagnosed with or received treatment for Depression?
  8. Has the child ever been diagnosed with or received treatment for Bipolar Disorder (Manic/Depressive Disorder)?
  9. Has the child ever been diagnosed with or received treatment for Attention Deficit/Hyperactivity Disorder (AD/HD) or Attention Deficit Disorder (ADD)?
  10. Has the child ever been diagnosed with or received treatment for an Anxiety Disorder?
  11. Has the child ever been diagnosed with or received treatment for Schizophrenia?

Educational History

  1. What type of school (or preschool) does the child attend?
  2. What is the child's current grade or level of school?
  3. Does the child receive any special education services from the public school system?
  4. What is the child's CURRENT special education code?
  5. How would you best describe the child's classroom setting?
  6. Does the child have a personal aide or one-on-one assistant in the classroom?
  7. Does your child have classroom opportunities for inclusion with typically developing peers?

Family History

  1. Does the child have any second-degree relatives (that is, aunts and uncles by blood, and grandparents) who have been diagnosed with the following? (Choices include Autism Spectrum Disorder, Fragile X, Seizure Disorder or Epilepsy, Mental Retardation, Schizophrenia, Attention Deficit/Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD), and language delays or speech problems.)
  2. Does the child have any first cousins who have been diagosed with the following? (Choices include Autism Spectrum Disorder, Fragile X, Seizure Disorder or Epilepsy, Mental Retardation, Schizophrenia, Attention Deficit/Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD), and language delays or speech problems.)

Prior Participation in Autism Research

  1. Has the child ever been in a RESEARCH STUDY about autism spectrum disorders (prior to this one)?
  2. Has the child ever been in a RESEARCH STUDY about the GENETICS of autism spectrum disorders?
  3. Has the child ever been in a RESEARCH STUDY about DRUGS/MEDICATIONS for treating autism spectrum disorder?

Summary

  1. What do you think about the length of this form?


Kennedy Krieger InstituteAutism Speaks