Data Collection Instruments Summary Table

Data Collection Instrument Summary Table

Instrument	Time (min)	Respondent	Subject	Item#	Administration Mode(s)	Instrument Origin	Purpose
Screener
Social Communication Questionnaire (SCQ)	10	Caregiver1	Child	1- 2	Phone or Self-Administer	Standardized	To screen children for ASD. Captures information on child’s reciprocal social interaction, language, communication, reciprocal conversation, and repetitive and stereotyped patterns of behavior.
Self-Administered Questionnaires
Paternal Medical History	10	Father	Father	3	Self-Administer	CADDRE	To obtain information on medical and psychiatric conditions of father other than autoimmune disorders.
Maternal Medical History	10	Mother	Mother	3	Self-Administer	CADDRE	To obtain information on medical and psychiatric conditions of mother other than autoimmune disorders.
Child Behavior Checklist (CBCL)	15	Caregiver1	Child	3	Self-Administer	Standardized	To assess behavior problems and social competencies of the child.
Carey Temperament Scale (Carey)	10	Caregiver1	Child	3	Self-Administer	Standardized	To assess child’s temperament.
Sleep Habits Questionnaire	10	Caregiver1	Child	3	Self-Administer	Standardized	To assess child’s behaviors and medical disorders of sleep.
Stool & Diet Diary	60 (40 min Stool, 20 min Diet)	Caregiver1	Child	9	Self-Administer	CO:GI-Study	To assess child’s stool and corresponding dietary patterns.
Autoimmune Worksheet	20	Mother	Nuclear family	3	Self-Administer	CADDRE	To obtain information on nuclear family’s autoimmune history.
Social Responsiveness Scale	45 min. (15 min per form)	Caregiver1	Nuclear Family	3	Self-Administer	Standardized	To obtain information on behaviors related to the nuclear family.
GI Questionnaire	10	Caregiver1	Child	3	Self administered	CADDRE	To obtain information on GI disturbances in the child.
Paternal Occupational Exposure Questionnaire	5	Father	Father	3	Self administered	CADDRE	To obtain information on paternal occupational exposure.
Clinical Intake Form	3	Caregiver1	Child	3	Self administered	CADDRE	To obtain information on child to assist with the clinical evaluation.
Caregiver Interview	3 * 50 minutes for alternative interview 0*	Caregiver1	Mother & Child	5	Phone	CADDRE	To obtain etiologic information related to the mother’s medical & reproductive history & child’s postnatal medical experiences.
Vineland Adaptive Behavior Scales	45	Caregiver1	Child2	7	Phone	Standardized	To assess child’s adaptive behavioral information (i.e., socialization, daily living skills) and language skills.
Early Development Questionnaire	20	Caregiver1	Child2	7	Self-administered	Ozonoff, Williams, Landa	To assess regression of language skills, social skills, and functional behavior of child.
Services & Treatment	5	Caregiver1	Child2	7	Phone	CADDRE	To assess the types and frequency of any services and treatments the child is currently receiving
Autism Diagnostic Interview-Rev (ADI-R)	120	Caregiver1	Child2	7	In-Person home/clinic	Standardized	To assess whether a child has behaviors consistent with ASD based on social and communicative behaviors
Parent Clinical
Biologic Samples	15	Mother & Father	Mother & Father	8	In-Person home/clinic	CADDRE use of Standard procedures	To study genetic components related to autism (including gene-environment interactions), and altered immune function and dysfunction (autoimmunity).
Child Clinical: Child Evaluation
Autism Diagnostic Observation Schedule (ADOS)	40	Child	Child2	7	In-Person home/clinic	Standardized	To assess whether a child has ASD based on observation of the child’s social interaction and communication skills and through the use of structured play activities.
Mullen Scales of Early Learning	45	Child	Child	7	In-Person home/clinic	Standardized	To assess the child’s level of cognition in five domains: gross motor, visual reception, fine motor, receptive language, and expressive language.
Dysmorphology Exam	15	Child	Child	7	In-Person home/clinic	CADDRE use of Standard procedures	To collect anthropometric measurements & any dysmorphic characteristics (i.e, digit ratios)
Biosampling	20	Child	Child	7	In-Person home/clinic	CADDRE use of Standard procedures	To examine genetic components (e.g. gene-environment interactions), immune function and dysfunction (autoimmunity), metabolism of xenobiotics, and hormone function possibly related to autism
Medical Record Abstraction
Maternal Primary Physician (PP) and Labor & Delivery (LD) Forms	N/A	N/A	Mother	10	Medical Record Abstraction	CADDRE/ CHARGE	To obtain information on maternal medical and reproductive history, as well as obstetric and delivery complications and events.
Child Neonatal (N) and Pediatric (P) Forms	N/A	N/A	Child	10	Medical Record Abstraction	CADDRE/ CHARGE	To obtain neonatal and postnatal medical experiences of the child.

¹A Caregiver is defined as a parent or relative of legal age who has resided with and been caring for the child since the child was 6 months of age or younger.

²Case– indicates these instruments will only be administered to CASE group.

CADDRE Study –revised 30 AUG 2005

Appendix D3 DC Instrument Summary.doc

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