AAP Pre-training Survey

Qualtrics Survey Software

Page 1 of 6

You have unlocked your survey. When you have finished editing, please lock your survey again.

Default Question Block

Block Options

Q1
Form Approve
OMB No. 0920-XXX
Exp. Date XX/XX/20X
Thank you for your interest in fetal alcohol spectrum disorders (FASD). We would like to invite you to complete a pretraining evaluation survey. We appreciate your willingness to help us evaluate the effectivenss of the training and its impac
on your practice as you address the prevention, identification, and treatment of FASD.
This survey will take approximately 7 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 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].
CDC estimates the average public reporting burden for this colletion of information as 7 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 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-XXX).




Page Break

Q2
Unique identifyer to help us match pre and post-training responses:
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






Page Break

Q4
Fetal alcohol spectrum disorders (FASDs) is an umbrella term describing the range of effects that can occur in an individua
who was exposed prenatally to alcohol.
True
False





https://uwmadison.co1.qualtrics.com/CP/?ClientAction=EditSurvey&Section=SV_8uAR3...

2/10/2016

Qualtrics Survey Software

Page 2 of 6

Q5
Which of the following are the primary facial dysmorphic features associated with Fetal Alcohol Syndrome? (Check all that
apply)
Wide inner canthal distance
Short palpebral fissures
Full lips
Smooth philtrum
Thin upper lip
Flaring nares
Don't know/unsure




Page Break

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




Page Break

Q7
Which of the 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




Page Break

https://uwmadison.co1.qualtrics.com/CP/?ClientAction=EditSurvey&Section=SV_8uAR3...

2/10/2016

Qualtrics Survey Software

Page 3 of 6

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.




Page Break

Q9
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

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





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




Page Break

Q11
Which of the following two statements below best corresponds with your personal viewpoint. Please check 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.





https://uwmadison.co1.qualtrics.com/CP/?ClientAction=EditSurvey&Section=SV_8uAR3...

2/10/2016

Qualtrics Survey Software

Page 4 of 6

Q12
Many providers do not screen for prenatal alcohol exposure. In your opinion, which of the following factors may contribute t
this situation? (Check all that apply)
Time limitation
Lack of Training
Concern about stigmatizing the child or the mother
Lack of reimbursement for alcohol (or substance use) screening of the mother
Concern about legal implications for parents/caregivers
Assumed (or likely) reluctance of mothers to share information
Discomfort with discussing alcohol use during pregnancy with mothers
Lack of confidence in their skill/ability to facilitate a productive dialogue with mothers




Page Break

Q13
To what extent do you agree with the following statements about alcohol consumption during pregnancy? (Mark one
response per row)

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 income
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




Page Break

Q14
How often do you do the following? (Mark one response per row)
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 services
e. Manage/coordinate the treatment of patient




Page Break

https://uwmadison.co1.qualtrics.com/CP/?ClientAction=EditSurvey&Section=SV_8uAR3...

2/10/2016

Qualtrics Survey Software

Page 5 of 6

Q15
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




Page Break

Q16
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 Moderately
Confident Confident Confident Completely
in my
in my
in my
Confident
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




Page Break

Q17
How willing are you to do the following? (Mark one resonse per row)
Not at all
Willing

A little
Willing

Moderately
Willing

Willing

Completely
Willing

a. Inquire about potential prenatal alcohol exposure for
pediatric patients
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





Q18
Is stigma a barrier as you consider assessing for prenatal alcohol exposure in your clinical practice?
Yes
No




Page Break

https://uwmadison.co1.qualtrics.com/CP/?ClientAction=EditSurvey&Section=SV_8uAR3...

2/10/2016

Qualtrics Survey Software

Page 6 of 6

Q19
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





Q20
If yes, which diagnostic schema (if any) did you use to support your diagnosis: (Mark all that apply)
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





Q21
During the past six months, did you refer any children for FASD assessment?
Yes
No




Page Break

Q22
Please feel free to comment on your response to any of the questions in this survey.





Q23
Thank you for taking the time to answer these questions!





https://uwmadison.co1.qualtrics.com/CP/?ClientAction=EditSurvey&Section=SV_8uAR3...

2/10/2016