Self Administered Forms (Mother)

The Study to Explore Early Development (SEED) - Phase 3

Attachment 8.h. Services and Treatments Questionnaire SEED 3

Self Administered Forms (Mother)

OMB: 0920-1171

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Form Approved

OMB No. 0920-XXXX

Attachment 8.h. Exp. Date: XX/XX/20XX






Study ID #: ______________

Date of Completion:________



Study to Explore Early Development




Services and Treatments Questionnaire



Many children participate in classroom based preschool programs, individual group programs, complementary therapies, alternative therapies, or other therapies to meet their developmental needs. We would like to get a sense of the types of services and treatments your child has received. Has your child ever used any of the following services or therapies?



Service

NO/ DON’T KNOW


YES


Age at first service date (any location; (specify years and months)

Is child still receiving service?

IF NO:

Age at last service date

(any location; specify years and months)

IF YES:

Total Hours per week

IF YES:

Service takes place…

(check all that apply)

Preschool program (general)



_____years & ____ months

Yes No



_____years & _____ months


Shape1

Enter IN school


Preschool program (special needs)



_____years & ____ months

Yes No



_____years & _____ months


Shape2

Enter IN school


Respite care



_____years & ____ months

Yes No



_____years & _____ months


Shape3

Enter OUT of school


ABA Behavior modification



____years & ____months

Yes No



____years & _____ months


in school

out of school

Classroom aide, para-educator or shadow



_____years & ____ months

Yes No



_____years & _____ months


in school

out of school

Occupational therapy, including sensory therapy



_____years & ____ months

Yes No



_____years & _____ months


in school

out of school

Physical therapy



_____years & ____ months

Yes No



_____years & _____ months


in school

out of school

Social skills training



_____years & ____ months

Yes No



_____years & _____ months


in school

out of school

Speech language therapy



_____years & ____ months

Yes No



_____years & _____ months


in school

out of school

Other: specify:____________



_____years & ____ months

Yes No



_____years & _____ months


in school

out of school

Other: specify:____________



_____years & ____ months

Yes No



_____years & _____ months


in school

out of school

Other: specify:____________



_____years & ____ months

Yes No



_____years & _____ months


in school

out of school



In the next sections, note the types of additional therapies your child has ever received and the types of medications he or she has ever been prescribed to treat behavioral symptoms.



Complementary or alternative therapies ever used to treat behavioral symptoms

NO/ DON’T KNOW


YES


Age when first used (specify years and months)

Is child still receiving treatment?

IF NO:

Age when last used

(specify years and months)

If EVER used,

Specify type of therapy or diet



Chelation therapy



_____years & ____ months

Yes No



_____years & _____ months


Chiropractic Care or massage therapy



_____years & ____ months

Yes No



_____years & _____ months


Diet: Gluten and/or Casein Free



_____years & ____ months

Yes No



_____years & _____ months


Diet: Yeast Free Diet



____years & ____months

Yes No



____years & _____ months


Diet: Other



_____years & ____ months

Yes No



_____years & _____ months


Dietary or Vitamin Supplements



_____years & ____ months

Yes No



_____years & _____ months


Herbal supplements, medication or tea



_____years & ____ months

Yes No



_____years & _____ months


Hyperbaric Oxygen Therapy



_____years & ____ months

Yes No



_____years & _____ months


Immune treatments (e.g. stem cell transplants or antibiotic or antiviral therapies)



_____years & ____ months

Yes No



_____years & _____ months


Other: specify:_______________



_____years & ____ months

Yes No



_____years & _____ months


Other: specify:_______________



_____years & ____ months

Yes No



_____years & _____ months


Other: specify:_______________



_____years & ____ months

Yes No



_____years & _____ months





Medications ever used to treat behavioral symptoms

NO/ DON’T KNOW


YES


Age at first dose

(specify years and months)

Is child still receiving medication?

IF NO:

Age at last dose

(specify years and months)

If EVER used,

Specific name(s) of medication(s)


Antidepressants, anti-anxiety, or obsessive-compulsive medications, such as Prozac or Zoloft



_____years & ____ months

Yes No



_____years & _____ months


Atypical Antipsychotics, such as Risperdal or Abilify



_____years & ____ months

Yes No



_____years & _____ months


Medications used to treat seizures and/or stabilize mood, such as Tegretol, Lamictal



____years & ____months

Yes No



____years & _____ months


Non-stimulant medications used to treat hyperactivity or inattention, such as Tenex or Clonidine



____years & ____ months

Yes No



_____years & _____ months


Stimulant medications often used to treat hyperactivity or inattention, such as Ritalin or Adderall



_____years & ____ months

Yes No



_____years & _____ months


Other medication



_____years & ____ months

Yes No



_____years & _____ months


Other medication



_____years & ____ months

Yes No



_____years & _____ months


Other medication



_____years & ____ months

Yes No



_____years & _____ months


Other medication



_____years & ____ months

Yes No



_____years & _____ months



END QUESTIONNAIRE



Common Medications Used to Treat Symptoms of Autism Spectrum Disorders




Antidepressant, anti-anxiety, and obsessive-compulsive medications:


  • Zoloft® (Also called sertraline.)

  • Effexor® (Also called venlafaxine.)

  • Prozac® (Also called fluoxetine.)

  • Wellbutrin® (Also called buproprion.)

  • Paxil® (Also called paroxetine.)

  • BuSpar® (Also called buspirone.)


Atypical antipsychotics (commonly used to treat irritability and/or challenging behaviors):


  • Risperdal® (Also called risperidone.)

  • Clozaril® (Also called clozapine.)

  • Abilify® (Also called aripiprazole.)

  • Haldol® (Also called haloperidol.)

  • Seroquel (Also called quetiapine.)

  • Mellaril® (Also called thioridazine.)

  • Zyprexa® (Also called olanzapine.)

  • Orap® (Also called pimozide.)


Hypertension agents (as alpha adrenergic agonists, commonly used to hyperactivity and inattention):


  • Tenex® (Also called Guanfacine.)

  • Clonidine® (Also called Catapres.)


Medications used to treat seizures and/or stabilize mood:


  • Depakote® (Also called valproic acid.)

  • Eskalith® (Also called lithium carbonate.)

  • Tegretol® (Also called carbamazepine.)

  • Lithobid® (Also called lithium carbonate.)

  • Cibalith-S® (Also called lithium citrate.)

  • Lamictal® (Also called lamotrigine.)



Stimulant Medications (often used to treat hyperactivity and inattention):


  • Ritalin® (Also called methylphenidate.)

  • Dexedrine® (Also called dextroamphetamine.)

  • Concerta® (Also called methylphenidate.)

  • Dextrostat® (Also called dextroamphetamine.)

  • Metadate® ER (Also called methyphenidate.)

  • Focalin® (Also called dexmethylphenidate.)

  • Adderall® (Also called amphetamine.)

  • Strattera® (Also called atomoxetine.)

  • Cylert® (Also called pemoline.)

  • Daytrana® (Also called methylphenidate transdermal patches.)


Public reporting burden of this collection of information is estimated to average 10 minutes, 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 (0920-0010).



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