Checklist of Questionnaire Packets

Appendix E.23 Questionnaire Checklist

Study to Explore Early Development (SEED)

Checklist of Questionnaire Packets

All of these packets ask for information that will help us learn more about autism and developmental disabilities. You can use this list to check off each of the items as you complete them.

First Questionnaire Packet Total Time: 55-80 Minutes

This packet can be completed by you at your home or we can ask you the questions over the phone or at a visit to our clinic office.

• Paternal Medical History 10 Minutes

Asks questions about medical and psychiatric diagnoses that a physician may have given your child’s biological father.

• Maternal Medical History 10 Minutes

Asks questions about medical and psychiatric diagnoses that a physician may have given your child’s biological mother.

• Autoimmune History 20 Minutes

Asks questions about your family’s history of autoimmune diseases. These questions are about your child and his/her biological mother and father and siblings.

• Paternal Occupational Exposures 5 Minutes

Asks questions about your child’s biological father’s job title, industry, job duties and work duration for all jobs he had just before and during the pregnancy. For fathers who are students, asks questions on his schooling.

• Gastrointestinal Questionnaire 10 Minutes

Asks questions about any digestive problems your child may have now or in the past.

• Services and Treatments Questionnaire 5 Minutes

Asks questions about your child’s current use of commonly used services among children with developmental disabilities. Also asks questions on treatments, including complementary alternative medicines and biological treatments. Only some families will be ask to complete this questionnaire.

• Early Development Questionnaire 20 Minutes

Asks questions about your child’s development during his/her first 18 months. Only some families will be ask to complete this questionnaire.

Second Questionnaire Packet Total Time: 80 Minutes

This packet can be completed by you at your home or we can ask you the questions over the phone or at a visit to our clinic office.

• Child Behavior Checklist 15 Minutes

Asks questions about any behavior problems your child may have. Also asks about his/her social skills.

• Carey Temperament Scale 10 Minutes

Asks questions about your child’s temperament (how he/she thinks, feels, acts, and reacts to different people or situations).

• Child Sleep Habits Questionnaire 10 Minutes

Asks questions about your child’s sleep patterns, behaviors, and any sleep-associated medical conditions.

• Child Social Responsiveness Scale 15 Minutes

Asks questions about how your child behaves in social settings.

• Parent Social Responsive Scales 30 Minutes

Asks questions about how your child’s biological parents behave in social settings. Two forms will be provided: one for your child’s mother and one for your child’s father.

Third Questionnaire Packet Total Time: 60 Minutes

This packet can be completed by you at your home.

• 3 Day Diet Diary 20 Minutes

Asks you to record all of the foods and drinks your child has during a 3-day time period. This includes foods eaten at home, at school or daycare, during play dates, etc. The diet diary should be done during the first three days of the stool diary.

• 7 Day Stool Diary 40 Minutes

Asks you to record all the bowel movements your child has during a 7-day time period. The diet diary should be done during the first three days of the stool diary.