AAP 6 Month Follow-up Survey - word

Form Approved

OMB No. 0920-XXXX

Exp.: XX/XX/20XX

AMERICAN ACADEMY OF PEDIATRICS

SIX-MONTH FOLLOW-UP EVALUATION SURVEY

Thank you completing the training on fetal alcohol spectrum disorders (FASD) about six months ago. We would like to invite you to complete a follow-up 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 identifying 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 in this survey is voluntary. You may decline to answer any question and you have the right to stop the survey at any time.

Please submit questions to the project partners at [email protected].

UNIQUE IDENTIFIER INFORMATION (to help us match you responses to previous surveys)

1. First 2 letters of your mother’s maiden name ___ ___

2. Month of your birthday ___ ___

3. Last 2 digits of your social security number ___ ___

4. State in which you practice ___ ___

The public reporting burden of this collection of information is estimated to average 5 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 (XXXX-XXXX)

KNOWLEDGE QUESTIONS

5. 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

6. Which of the following are the primary facial dysmorphic features associated with fetal alcohol syndrome (FAS)? (Check all that apply)

 Wide inner canthal distance

 Short palpebral fissures

 Full lips

 Smooth philtrum

 Thin upper lip

 Flaring nares

 Don’t know/unsure

7. 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):

1. Requires recognition of neurocognitive impairment, self-regulation impairment, and deficits in adaptive functioning

2. Can be diagnosed without knowledge of confirmed prenatal alcohol exposure

3. Includes recognition of the 3 primary morphologic features of prenatal alcohol exposure

4. Is the least common manifestation of prenatal alcohol exposure

5. All of the above

8. Which of the following could indicate that a child may have been exposed to alcohol prenatally? (Check all that apply)
   ☐ 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

9. Which of the following approaches/care strategies is not applicable for children diagnosed with an FASD?

   1. Regularly scheduled follow-up in the medical home to anticipate/address needs across the lifespan.

   2. 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.

   3. Evaluation by a psychologist to assess neurocognitive functioning, self-regulation, and adaptive functioning skills.

   4. Medication management for co-occurring conditions as needed to optimize care.

   5. All of the above are applicable approaches/care strategies for children with an FASD.

OPINION QUESTIONS

10. To what extent do you agree with the following statements? (Mark one response per row)

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
Prenatal alcohol exposure is a potential cause of growth impairment	1	2	3	4	5
Prenatal alcohol exposure is a potential cause of physical, cognitive and behavioral health problems	1	2	3	4	5
Diagnosis of one of the FASDs may confer a negative stigma to a child and/or his or her family	1	2	3	4	5
Diagnosis of one of the FASDs only needs to be considered for certain populations	1	2	3	4	5

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

12. 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.

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

Alcohol consumption during pregnancy…	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
Is more prevalent in women with lower incomes	1	2	3	4	5
Is more prevalent in women with higher incomes	1	2	3	4	5
Does not vary between income levels	1	2	3	4	5
Is more prevalent in women with lower levels of education	1	2	3	4	5
Is more prevalent in women with higher levels of education	1	2	3	4	5
Does not vary between education levels	1	2	3	4	5
Is more prevalent in African-American women	1	2	3	4	5
Is more prevalent in American-Indian women	1	2	3	4	5
Is more prevalent in Anglo-white women	1	2	3	4	5
Is more prevalent in Asian-American women	1	2	3	4	5
Is more prevalent in Hispanic/Latina-American women	1	2	3	4	5
Does not vary between ethnic or racial groups	1	2	3	4	5

PRACTICE QUESTIONS

14. How often do you do the following? (Mark one response per row)

	Never	Rarely	Sometimes	Usually	Always
Inquire routinely about prenatal exposure to alcohol	1	2	3	4	5
Identify patient as someone who may have one of the FASDs	1	2	3	4	5
Diagnose patient as someone who may have one of the FASDs	1	2	3	4	5
Refer patient for diagnosis and/or treatment services	1	2	3	4	5
Manage/coordinate the treatment of patient	1	2	3	4	5

15. 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

16. How confident are you in your skills to do the following? (Mark one response per row)

	Not at all Confident in my Skills	A Little Confident in my Skills	Moderately Confident in my Skills	Confident in my Skills	Completely Confident in my skills
Inquire about potential prenatal alcohol exposure for pediatric patient	1	2	3	4	5
Identify persons with possible FAS or other prenatal alcohol-related disorders	1	2	3	4	5
Diagnose persons with possible FAS or other prenatal alcohol-related disorders	1	2	3	4	5
Utilize resources to refer patients for diagnosis and/or treatment for FAS(D)	1	2	3	4	5
Manage/coordinate the treatment of persons with FASDs	1	2	3	4	5

17. How willing are you to do the following? (Mark one response per row)

	Not at all Willing	A Little Willing	Moderately Willing	Willing	Completely Willing
Inquire about potential prenatal alcohol exposure for pediatric patient	1	2	3	4	5
Identify persons with possible FAS or other prenatal alcohol-related disorders	1	2	3	4	5
Diagnose persons with possible FAS or other prenatal alcohol-related disorders	1	2	3	4	5
Utilize resources to refer patients for diagnosis and/or treatment for FAS(D)	1	2	3	4	5
Manage/coordinate the treatment of persons with FASDs	1	2	3	4	5

17. Is stigma a barrier as you consider assessing for prenatal alcohol exposure in your clinical practice?

☐ Yes ☐ No

17. During the past six months, did you diagnose any children with fetal alcohol syndrome (FAS) or one of the fetal alcohol spectrum disorders (FASDs)?
    ☐ Yes ☐ No
    
    If YES, please specify which diagnostic schema (if any) you used to support your diagnosis:
    ☐ Institute of Medicine criteria
    ☐ American Academy of Pediatrics algorithm and/or toolkit
    ☐ Seattle 4-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

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

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

If yes, please describe what change you made:

17. Did you encounter any barriers to making a change in your practice?

☐ Yes ☐ No

If yes, please describe:

GENERAL

17. Please feel free to comment on your response to any of the questions in this survey or provide any additional feedback.
    
    
    
    

Comments:

Thank you for taking the time to answer these questions!

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