Clinic Visit - Case Parent

ID # _________________

Appendix F.2 Early Development Questionnaire

EDQ: OMB Coversheet

Form Approved

OMB NO. __________

Exp. Date __________

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Early Development Questionnaire

© Sally Ozonoff & Brenda Williams, 2000

Child’s Name______________________________________ Date______________

Child’s Date of Birth_________________________________ Child’s Sex M F

Name of Respondent: _______________________________

Relationship to Child: _______________________________

Ethnicity of Child:  African-American  American Indian  Asian

 Caucasian  Hispanic  Pacific Islander

• Other: _____________________________

This form lists behaviors seen in infants and young children. Please read each statement and decide how often your child demonstrated the behavior during his or her first 18 months of life. Many parents find it helpful to consult a baby book or baby calendar to refresh their memories before completing this form.

If your child experienced a regression (e.g., a loss of previously acquired skills) before 18 months of age, only rate his or her behavior up to the point of the regression (specify age at regression: _________months). If your child experienced a regression after 18 months of age or had no regression, rate his or her behavior up until 18 months of age. Your child may have developed some of these behaviors after 18 months, but please ONLY rate his or her behavior up to 18 months.

Use the following scale to rate your child’s behavior:

0=Never

1=Rarely

2=Occasionally

3=Often

DK= Don’t know or can’t remember

From birth to 18 months of age…	Never Rarely Occasionally Often	Don’t know or can't remember
My child looked at others during social interactions.	0 1 2 3	DK
My child engaged in repetitive motor behavior (e.g., spinning, bouncing, twisting fingers in front of eyes or flapping hands).	0 1 2 3	DK
When given a choice between two items, my child clearly let me know which one he or she wanted.	0 1 2 3	DK
My child smiled back at me when I smiled at him or her.	0 1 2 3	DK
My child rarely noticed or seemed interested in new objects or toys in his or her environment.	0 1 2 3	DK
My child could listen and pay attention to a book for at least 5 minutes.	0 1 2 3	DK
My child put his/her arms up when he or she wanted to be picked up.	0 1 2 3	DK
My child was more interested in playing with a certain part of a toy (e.g., spinning the wheels of a car) than playing with the whole toy.	0 1 2 3	DK
My child’s speech, at whatever level acquired, was easy to understand.	0 1 2 3	DK
My child showed or brought me things that interested him or her.	0 1 2 3	DK
My child became upset if there was a minor change in his or her routine or environment.	0 1 2 3	DK
My child put 2 or 3 words together into meaningful phrases.	0 1 2 3	DK
When I called my child’s name, he or she looked at me right away.	0 1 2 3	DK
My child stared at lights or visually inspected objects at close range for extended periods of time.	0 1 2 3	DK
Before my child used words, his or her babbling or “baby talk” was clearly directed toward me.	0 1 2 3	DK
If my child wanted something, he or she would point to request it.	0 1 2 3	DK
My child covered his or her ears in response to certain sounds (e.g., vacuum cleaner, traffic).	0 1 2 3	DK
My child followed simple verbal instructions (e.g., “Go get your shoes”).	0 1 2 3	DK
If I pointed or looked toward something, my child would look at it too.	0 1 2 3	DK
When held, my child cuddled or molded into my body.	0 1 2 3	DK
When my child wanted something, he or she used my hand as a tool (i.e., an extension of his or her own arm) or pushed my body or arm to get help from me.	0 1 2 3	DK
My child initiated interactive games, such as peek-a-boo or hide-and-seek, with me.	0 1 2 3	DK
My child enjoyed lining up toys or other objects.	0 1 2 3	DK
My child spontaneously used 5 or more words, other than “mama” or “dada”, on a daily basis.	0 1 2 3	DK
My child imitated things I did, such as clapping, waving goodbye, or blowing a kiss.	0 1 2 3	DK
My child was attached to an unusual object (e.g., piece of pipe, clothespin, stone) and insisted on carrying it around with him or her.	0 1 2 3	DK
My child seemed to understand what I said to him or her, even if he or she couldn’t respond back verbally.	0 1 2 3	DK
My child preferred to play with others than to play alone.	0 1 2 3	DK
My child seemed particularly interested in the smell or texture of things.	0 1 2 3	DK
My child babbled or used word approximations (e.g., “baba” for bottle) to get my attention.	0 1 2 3	DK
If my child saw something that interested him or her, he or she would point to it, and then look at me to see if I was looking at it too.	0 1 2 3	DK
My child rocked in his or her crib or play pen for extended periods of time.	0 1 2 3	DK
My child shook his or her head to mean “No”.	0 1 2 3	DK
My child engaged in simple pretend play activities (e.g., fed dolls, pushed cars around while making car noises).	0 1 2 3	DK
My child played with one toy or object over and over again to an unusual degree.	0 1 2 3	DK
My child nodded his or her head to mean “Yes”.	0 1 2 3	DK
My child seemed interested in other children.	0 1 2 3	DK
My child mouthed objects to an unusual degree.	0 1 2 3	DK
When my child really liked something, he or she would let me know by smiling or making noises that were clearly directed toward me.	0 1 2 3	DK
My child injured him/herself deliberately (biting self or banging head).	0 1 2 3	DK
My child imitated sounds I made or words I said after hearing them.	0 1 2 3	DK
My child showed a clear preference for me over less familiar people.	0 1 2 3	DK
My child accurately indicated one or more body parts when asked.	0 1 2 3	DK
My child spontaneously and regularly used 10 or more meaningful words.	0 1 2 3	DK
My child became upset if his or her activity was interrupted and would insist on starting it over again from the beginning.	0 1 2 3	DK

Part 2:

Next we would like to know at what age your child achieved certain developmental milestones. If he or she does not yet perform a behavior, indicate as N/A.

At what age (in months) did your child first learn to…

roll over sit alone unsupported

crawl walk

use single words

Please list a few of his/her first words:

speak in phrases

Please list some of the first phrases your child used:

Part 3:

During the development of some children, there is a period of time when skills seem to be lost (i.e., a regression). A variety of skills from different domains of functioning can be lost; these abilities may or may not be regained. Please read the description of each skill area below. If your child lost any of the listed skills, please circle Yes next to the items and indicate how long the skill was lost (i.e., less than 3 months, 3 to 6 months, greater than 6 months). Otherwise, circle No. Thank you.

A. Communication:			Length of loss in months
			<3	3-6	>6
Yes	No	All words or phrases (e.g., requesting food or other needs, addressing parents, greeting, replying when called by name, or labeling familiar objects or animals).
Yes	No	Most meaningful words or phrases, although may have retained a few.
Yes	No	Gestures or imitative behaviors such as pointing, clapping, waving goodbye.
Yes	No	Ability to understand language spoken by others.
B. Social:
Yes	No	Interest in parents, siblings, relatives, or peers.
Yes	No	Smiling in response to another person’s smile.
Yes	No	Reaching for caregiver (e.g., putting arms up to be lifted).
Yes	No	Direct eye contact during communication.
Yes	No	Interest in interactive games such as Peek-a-boo.
Yes	No	Pretend or imaginative play.
C. Adaptive Functioning:
Yes	No	1. Ability to feed self, at whatever level acquired.
Yes	No	2. Ability to dress self, at whatever level acquired.
Yes	No	3. Toileting skills, at whatever level acquired.
D. Motor:
Yes	No	Ability to manipulate small objects, such as legos, or stack blocks.
Yes	No	Ability to carry, throw, or kick a ball, or climb onto furniture.
Yes	No	Ability to physically move about independently.

Part 4:

If you answered Yes to any item on the previous page, please fill out the remainder of this questionnaire. If you answered No to all items on page 5, you are done with the questionnaire. Thank you for your time.

1. At what age (in months) did your child begin to lose any of the skills reported on page 5?

2. At what age (in months) did the loss of skills appear to stop?

3. Did you have any concerns about your child’s development before the regression? If so, please describe your concerns (and your child’s age at the time).

4. Was your child’s loss of skills gradual or sudden? Please describe.

5. If your child lost language skills, did he/she lose: SOME WORDS or ALL WORDS?

(please circle)

6. About how many words (maximum) did your child use before the loss?

6. About how many words (maximum) does he/she use now?

8. Was there any suggestion that the loss of skills was associated with a physical illness, such as a high fever, encephalitis, or seizure activity, or with an immunization? Yes or No

If yes, please describe:

9. Was there any suggestion that the loss of skills was associated with other stressors, such as birth of a sibling, death in the family, moving, or other environmental events/factors? Yes or No

If yes, please describe:

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