Spring and Fall Parent Interviews

Appendix A.5
Other Large Scale Studies

* The following items were fielded as part of other large scale studies

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*Note. These items were fielded as part of the Third National Health and Nutrition Examination Survey
(NHANES III).
Did -receive any newborn care in an intensive care unit, premature / nursery, or any other type of special
care facility? [yes/no]
How much did -weigh at birth? (if don’t know then ask)
Did -weigh more than 5-1/2 pounds (2500 grams) or less?
Did -weigh more than 9 pounds.(4100 grams) or less?
Was child born at term (40 weeks), before term (less than 40 weeks) or after term (after 40 weeks)?
If before term, how many weeks before?
If after term, how many weeks after?

*Note. These items were fielded as part of the Missouri Maternal and Infant Health Study
When did this child speak his/her first words (other than ma-ma or da-da)
6 to 8 months
9 to 12 months
13 to 18 months
19 to 24 months
after 24 months
don't know
When did this child begin to use two-word sentences?
12 to 18 months
19 to 24 months
25 to 30 months
31 to 36 months
after 36 months
don't know
In your opinion, does this child have a problem in any of the areas -listed below?
If you think that the child has a problem in any of -these areas, please rate how severe you think the
problem is –
no problem; mild problem; moderate problem; severe problem; or don’t know
pays attention, listens
can hear speech and other sounds
makes the speech sounds correctly
talks without stuttering
understands what people mean
knows the right words to use
puts the right endings on words
knows how to put words together to say sentences

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Indicate if these describe this child now or at some time in the past.
Never; in the past but not now; yes – now; or don’t know
a lot of coughing and throat clearing
usually has a hoarse, raspy, or breathy voice
talks too loudly
talks too softly
has a problem chewing
has a problem swallowing
stutters
has difficulty expressing himlherself for hislher age
does not pay attention to spoken language
has experienced a sudden interruption in speech/language development

Do you think that this child has a speech, language, or hearing problem? [yes/no]

Have you ever been told by a health or education professional that is child had a speech, language,
or hearing problem? [yes/no]
If YES , what kind of communication problem was it? (mark all that apply)
a problem speaking
a problem learning language
a problem hearing
Has this child ever received speech-language therapy? [yes/no]
If YES, how old was he/she when speech-language therapy began?
0-2 years
3-4 years
5-6 years
7-9 years
don't know
If YES, for how long did he/she receive speech-language therapy?
Less than a year
1-2 years
2-3 years
2-4 years
More than 4 years

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Are there any blood (biological) relatives of this child who have or have had speech, language, hearing, or
learning problems? [yes/no]
If YES, indicate which blood (biological) relative and type of problem he/she experienced.
Mother
Father
Brothers or
Grandparents
Aunt or Uncles
Sisters
Hearing loss
Stuttering
Other Speech
Impairment
Language
impairment
Reading/
learning
disability
Needed special
classes

Did/does this child have any of the following (mark all that apply) [yes/no]
cleft palate
abnormalities of the face or head
Malformation of the ear
other , specify
As an infant, did this child have difficulty sucking or swallowing? [yes/no]

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Has this child ever had hearing checked by a hearing specialist (an audiologist)? [yes/no]
If YES , what were the results?
normal hearing
hearing loss
don't know
Does this child wear a hearing aid? [yes/no]
If YES , at what age did he/she begin to wear a hearing aid?
before one year
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
don't know
Does this child have special seating in the classroom so that he/she can hear the teacher better? [yes/no]
At what age did this child take his/her first steps without support?
6-9 months
10-12 months
13-15 months
16-18 months
After 18 months
Don’t know
Has this child ever received physical therapy? [yes/no]
Has this child ever received occupational therapy? [yes/no]
In general, how would you rate this child's health since birth?
excellent
very good
good
fair
poor
don't know
How would you rate this child's general health for the past 12 months?
excellent
very good
good
fair
poor
don't know

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In the past year, has this child been treated by a doctor for any of the following conditions? [yes/no, for
each one]
ear infection (otitis media)
asthma or lung disease
other health or medical problems (please specify)
attention deficit disorder
psychological problems
Has this child ever had an ear infection or earache? [yes/no]
If YES, at what age did this child have his/her first ear infection or earache? [Mark only one]
before 6 months
6 months to 1 year
1 year old
2 years old
3-4 years old
5-6 years old
7-9 years old
Don’t know
When did he/she have the most recent ear infection or earache?
Has one now
Within the past month, but not now
Before one year
1-2 years old
3-4 years old
5-6 years old
7-9 years old
Has this child ever had three or more ear infections or earaches in a year? [yes/no]
If YES, at what age(s) did he/she have these repeated ear infections?
Before one year
1-2 years old
3-4 years old
5-6 years old
7-9 years old
Has this child had surgery by a doctor to place tubes in his/her ears to treat ear infections?
If YES, at what age(s) did he/she have tubes placed? [Mark all that apply]
Before one year
1-2 years old
3-4 years old
5-6 years old
7-9 years old
For each of the following medications, please mark whether this child has ever taken or is currently taking
the medication.
Never; yes-currently taking; took in the past but not anymore; or don’t know
medication for seizures
medication for hyperactivity or ADD
antibiotics
steroids or anti-inflammatory drugs
drugs for asthma
other medications (please specify, perhaps include potential ototoxic medications in above list)

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Since leaving the hospital as an infant, has o no o yes o don't know this child ever had surgery? [yes/no]
If YES, what part of body was operated on? [Mark all that apply]
appendix
tonsils or adenoids
ears: tubes in ears
ears: other ear surgery
eye(s)
head, face, or mouth
brain
spinal cord
heart
intestine,stomach,orbowel
kidneys, bladder, or ureter
arms or legs
back
Has this child ever been exposed to a very loud (painfully loud) noise? [yes/no]
If YES , at what age was he/she exposed to the loud noise? [Mark only one]
0-2 years
3-4 years
5-6 years
7-9 years
Did [CHILD] experience any of the following prior to or during delivery? [yes/no/don’t know]
a.
b.
c.
d.
e.
f.
g.
h.

congenital infections such as CMV, rubella, and herpes;
APGAR scores of 0-4 at 1 minute or 0-6 at 5 minutes;
mechanical ventilation for more than 5 days;
head trauma;
post-natal infections such as bacterial meningitis;
severe hyperbilirubinemia (sufficient to require an exchange transfusion);
persistent pulmonary hypertension of the newborn (PPHN);
extracorporeal membrane oxygenation (ECMO);

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