AAP 6 Month Follow-up Survey

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Q1
Form Approved
OMB No. 0920-XXXX
Exp. Date XX/XX/20XX

Thank you for completing the training on fetal alcohol spectrum disorders (FASD) about 6
months ago. We would like to invite you to complete this final evaluation survey. We
appreciate your willingness to help us evaluate the effectiveness of the training and its impact
on your practice as you address the prevention, identification, and treatment of FASD.
This survey will take approximately 5 minutes to complete. Your responses will be kept
secure and no individually identifiable information will be included. Risks to participating in
this survey are minimal and include the risk of your information becoming known to
individuals outside the AAP.
Your participation is voluntary. You may decline to answer any questions and you have the
right to stop the survey at any time.
Please submit questions to the project partners at [email protected].
CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including
the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the
data/information 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 Information Collection Review Office, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN PRA (0920-XXXX).

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Q2
Unique identifier information (to help us match your previous surveys)
First 2 letters of your mother's
maiden name:
2-digit month of your birth:
Last 2 digits of your social security
number:

Q3
In what State do you practice? Use the drop down menu to find your State.

AL



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Q4
Fetal Alcohol Spectrum Disorders (FASDs) is an umbrella term describing the range of effects that can occur in an individual
who was exposed prenatally to alcohol.
True
False

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Wide inner canthal distance
Short palpebral fissures
Full lips
Smooth philtrum
Thin upper lip
Flaring nares
Don't know/unsure

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Q6
The diagnosis of "neurobehavioral disorder associated with prenatal alcohol exposure" (ND-PAE) as identified in the
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5):
a. Requires recognition of neurocognitive impairment, self-regulation impairment, and deficits in adaptive
functioning
b. Can be diagnosed without knowledge of confirmed prenatal alcohol exposure
c. Includes recognition of the 3 primary morphologic features of prenatal alcohol exposure
d. Is the least common manifestation of prenatal alcohol exposure
e. All of the above

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Q7
Which of the following could indicate that a child may have been exposed to alcohol prenatally?
Growth deficiencies
Clinically significant abnormalities in neuroimaging and/or a history of seizures
Cognitive/developmental deficiencies or discrepancies
Executive function deficits
Delays in gross/fine motor function
Problems with self-regulation/self-soothing
Delayed adaptive skills
Confirmed history of alcohol exposure in utero
Don't know/unsure

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Q8
Which of the following approaches/care strategies is not applicable for children diagnosed with an FASD?
Regularly scheduled follow-up in the medical home to anticipate/address needs across the lifespan.
Refer child’s case to therapist to provide all follow-up and lifelong monitoring because traditional behavioral
therapies work best for children with an FASD.
Evaluation by a psychologist to assess neurocognitive functioning, self-regulation, and adaptive functioning
skills.
Medication management for co-occurring conditions as needed to optimize care.
All of the above are applicable approaches/care strategies for children with an FASD.

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Neither
Agree
Strongly
nor
Disagree Disagree Disagree

Agree

Strongly
Agree

a. Prenatal alcohol exposure is a potential cause of growth
impairment
b. Prenatal alcohol exposure is a potential cause of a physical,
cognitive and behavioral health problems
c. Diagnosis of one of the FASDs may confer a negative stigma to a
child and/or his or her family
d. Diagnosis of one of the FASDs only needs to be considered for
certain populations

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Q10
In your opinion, how much alcohol is safe to drink during pregnancy?

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Q11
Please check which of the following two statements below best corresponds with your personal viewpoint. Please mark only
ONE.
Occasional consumption of one standard alcoholic drink per day or less (i.e., 1.5 oz. hard liquor, 12 oz. of beer
or 5 oz. of wine) during pregnancy is not harmful to the mother or the fetus
Pregnant women or women who are trying to become pregnant should completely abstain from consuming
alcohol.

Q12
To what extent do you agree with the following statements about alcohol consumption during pregnancy? (Mark
one response per line)
Alcohol consumption during pregnancy...

Strongly
Disagree

Disagree

Neither
Agree nor
Disagree

Agree

Strongly
Agree

a. Is more prevalent in women with lower incomes
b. Is more prevalent in women with higher incomes
c. Does not vary between income levels
d. Is more prevalent in women with lower levels of
education
e. Is more prevalent in women with higher levels of
education
f. Does not vary between education levels
g. Is more prevalent in African-American women
h. Is more prevalent in American Indian women
i. Is more prevalent in Anglo-white women
j. Is more prevalent in Asian-American women
k. Is more prevalent in Hispanic/Latina-American
women
l. Does not vary between ethnic or racial groups

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Never

Rarely

Sometimes

Usually

Always

a. Inquire routinely about prenatal exposure to alcohol
b. Identify patient as someone who may have one of the FASDs
c. Diagnose patient as someone who may have one of the FASDs
d. Refer patient for diagnosis and/or treatment for FAS(D)
e. Manage/coordinate the treatment of patient with FAS(D)

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Q14
Physicians in my practice consider a diagnosis of one of the FASDs in patients with at least one physical, cognitive or
behavioral feature of prenatal alcohol exposure
Yes
No
Not sure

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Q15
How confident are you in your skills to do the following? (Mark one response per line)
Not at all
A Little Moderately
Confident Confident Confident Confident Completely
in my
in my
in my
in my
Confident
Skills
Skills
Skills
Skills
in my Skills
a. Inquire about potential prenatal alcohol exposure for
pediatric patient
b. Identify persons with possible FAS or other prenatal
alcohol-related disorders
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
d. Utilize resources to refer patients for diagnosis and/or
treatment for FAS(D)
e. Manage/coordinate the treatment of persons with FASDs

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Q16
How willing are you to do the following? (Mark one response per line)
Not at all
Willing

A Little
Willing

Moderately
Willing

Willing

Completely
Willing

a. Inquire about potential prenatal alcohol exposure for
pediatric patient
b. Identify persons with possible FAS or other prenatal
alcohol-related
c. Diagnose persons with possible FAS or other prenatal
alcohol-related disorders
d. Utilize resources to refer patients for diagnosis and/or
treatment for FAS(D)
e. Manage/coordinate the treatment of persons with FASDs

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Q17
Is stigma a barrier as you consider assessing for prenatal alcohol exposure in your clinical practice?
Yes
No

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disorders (FASDs)?
Yes
No

Q19
If yes, which diagnostic schema (if any) did you use to support your diagnosis:
Institute of Medicine criteria
American Academy of Pediatrics algorithm and/or toolkit
Digit Diagnostic Code (University of Washington)
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Other schema (please specify)



I did not use any particular schema

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Q20
During the past six months, did you refer any children for FASD assessment?
Yes
No

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Q21
As a result of participating in the FASD learning activity 6 months ago, did you make a change in your practice?
Yes
No

Q22
If yes, describe what change you made:

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Q23
Did you encounter any barriers to making a change in your practice?
Yes
No

Q24
If YES, please describe:

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Q26
Thank you for taking the time to answer these questions!

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