The purpose of this survey is to learn about biomedical treatments that parents of children with autism use. We would like to know what, if any, treatments you have tried with your child, and whether you found it to be helpful or not.
We are interested in both traditionally prescribed pharmaceuticals as well as complementary and alternative medicine (CAM). CAM is a broad term that refers to a variety of products, treatments, and practices that are not generally considered part of conventional medicine such as supplements, special diets, physical interventions, and more (National Center for Complementary and Integrative Health). For the purposes of this survey, we will only be focusing on biomedical products and treatments.
Please indicate if you are the child’s:
Biological Mother
Biological Father
Other
Primary Caregiver (please specify_____)
What is your
year of birth? _________
What is your current marital status?
Married
Widowed
Divorced
Separated
Never Married
What is the highest level of education completed by the child’s mother?
Less than high school degree
High school degree or equivalent (e.g. GED)
Some college but no degree
Trade/technical/vocational training/military training
Associate degree
Bachelor’s degree
Master’s degree
Professional degree
Doctorate degree
What is the highest level of education completed by the child’s father?
Less than high school degree
High school degree or equivalent (e.g. GED)
Some college but no degree
Trade/technical/vocational training /military training
Associate degree
Bachelor’s degree
Master’s degree
Professional degree
Doctorate degree
What was the sex of the child when they were born?
Male
Female
How old is
your child? ______years
What is your child’s race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other_________
What is your child’s ethnicity?
Hispanic
Non-Hispanic
In what setting does your child currently receive schooling?
Public school
Private school
Special education school
Residential school
Home schooled
Not
currently in school
Aside from your child’s primary autism symptoms (difficulties with language, social interactions, and restricted or repetitive interests or behaviors), what other health issues does your child struggle with?
Digestive problems (e.g., constipation, diarrhea, vomiting, reflux)
Neurological problems (e.g., headaches, tics, seizures)
Sleep problems (e.g., trouble falling asleep or staying asleep)
Immune system problems (e.g., allergies/hay fever, eczema, food sensitivities)
Genetic disorders (e.g., Landau-Kleffner, Fragile X, Down’s syndrome, etc.)
Metabolic disorders (e.g., PKU, mitochondrial disorders)
Psychiatric disorders (e.g., anxiety, OCD, ADD, ADHD, depression, bipolar disorder, etc.)
Challenging behaviors (e.g. aggression, self-injury, elopement/leaves unexpectedly, etc.)
Other
_______________________
Have you used ANY complementary or alternative medicine (CAM) to help improve your child’s health or reduce their autism symptoms? (CAM could be vitamin or mineral supplements, special diets, chelation, antifungals for yeast, craniosacral therapy, music therapy, biofeedback, hyperbaric oxygen therapy, etc.)
Yes
No
*Please
indicate all the following treatments that you have ever
used for your child with autism (include any route of
administration e.g. pill, spray, injection, etc.):
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*Please
indicate all the following treatments that you have ever
used for your child with autism (include any route of
administration e.g. pill, spray, injection, etc.):
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*Please indicate all the following treatments that you have ever used for your child with autism (include any route of administration e.g. pill, spray, injection, etc.):
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*Please indicate all the following treatments that you have ever used for your child with autism (include any route of administration e.g. pill, spray, injection, etc.):
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*Items 13-16 branch logic: For each selection made, subjects will be prompted to answer the following questions:
How was the treatment given?
Taken by mouth and swallowed or chewed
Placed under the tongue or between the gums and cheek
Given by injection (by needle through the skin)
Sprayed into the nose
Applied on the skin
Suppository
Other:
________
Who first suggested the treatment?
Medical professional
Parent or other caregiver
Other relative or friend (non-caregiver)
Other ________
Was this treatment prescribed by a medical professional?
Yes
No
How was the treatment obtained?
Prescription filled at pharmacy
Over-the-counter purchase at pharmacy or another store
Provided by medical professional
Online order
Other__________
When was this treatment used (select all that apply):
Within the past 3 months
Between 3-12 months ago
More than
12 months ago
How did you pay for this treatment?
Covered by insurance only
Paid out-of-pocket only
Both covered by insurance and paid out-of-pocket
To the best of your knowledge, was this treatment intended to address your child’s:
Difficulties with language and/or social interactions**
Restricted or repetitive interests or behaviors**
Aggression
Anxiety
Depression
Hyperactivity
Inattention
Other mental health issues
Other physical health issues
Unsure
Based on
your experience, how would you rate the effectiveness of this
treatment?
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**Item G branch logic: Subjects who select at least one ** option will be prompted to answer question I:
Based on your experience, how would you rate the effectiveness of
this treatment on improving your child’s difficulties with
language, social interactions, and/or restricted or repetitive
interests or behaviors?
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*Please
indicate any FDA approved prescription medication(s) that your
child with autism has taken:
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*Please indicate any FDA approved prescription medication(s) that your child with autism has taken:
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*Please indicate any FDA approved prescription medication(s) that your child with autism has taken:
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*Please indicate any FDA approved prescription medication(s) that your child with autism has taken:
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*Item 17-20 branch logic: For each selection made, subjects will be prompted to answer the following questions:
When was this treatment used (select all that apply):
Within the past 3 months
Between 3-12 months ago
More than
12 months ago
Based on
your experience, how would you rate the effectiveness of this
treatment?
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Please list any other biomedical treatment(s) that you have ever used for your child with autism:
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |