Form 0920-1129 B10 Post-Test Screening, Assessment and Diagnosis

FASD: Screening, Assessment, & Diagnosis

Form Approved

OMB No. 0920-1129

Exp.: XX/XX/XXXX

AMERICAN ACADEMY OF PEDIATRICS

POST-TRAINING EVALUATION SURVEY

Thank you completing the training on fetal alcohol spectrum disorders (FASD). We would like to invite you to complete a post-training 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 10 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 your pre- and post-training surveys)

Today’s date: ___ ___ /___ ___/ ___ ___ ___ ___

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 10 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 (0920-1129)

TRAINING SATISFACTION

5. To what extent do you agree the following educational objectives were met? (Mark one response per row)

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
Describe the diagnostic criteria and approaches for diagnosis for each condition along the continuum of FASDs, including ARND, ND-PAE, FAS, pFAS, and ARBD.	1	2	3	4	5
Distinguish major physical and neurobehavioral features for differential diagnosis of FASDs from other genetic and behavioral disorders as well as relevant comorbidities.	1	2	3	4	5
Explain the importance of screening every patient for a history of prenatal alcohol exposure at birth and during their first clinic visit.	1	2	3	4	5

KNOWLEDGE QUESTIONS

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

 a. Wide inner canthal distance

 b. Short palpebral fissures

 c. Full lips

 d. Smooth philtrum

 e. Thin upper lip

 f. Flaring nares

 g. Don’t know/unsure

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

☐ a. Growth deficiencies
☐ b. Thrombocytopenia
☐ c. Cognitive/developmental deficiencies or discrepancies
☐ d. Executive function deficits
☐ e. Delays in gross/fine motor function
☐ f. Problems with self-regulation/self-soothing
☐ g. Delayed adaptive skills
☐ h. Hypothyroidism
☐ i. Macrocephaly

8. 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. Potential differential and comorbid diagnoses include which of the following? (check all that apply)

☐ a. Attention Deficit Hyperactivity Disorder (ADHD)
☐ b. Early trauma
☐ c. Fragile X syndrome
☐ d. Williams syndrome
☐ e. Intellectual disability

9. 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): (Check all that apply)

☐ 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. Does not apply to pediatric primary care as it is a mental health diagnosis

10. A child with no physical stigmata of FAS has evidence of structural brain abnormalities and functional neurocognitive disabilities, which manifest as problems with behavior, adaptive skills, and self-regulation. Which of the following is the most appropriate plan of action? (check all that apply)

☐ a. Collect a comprehensive history of prenatal exposures, including tobacco, alcohol, illicit drugs or other medications.
☐ b. Evaluate for possible genetic and environmental etiologies.
☐ c. Consider an FASD diagnosis such as ND-PAE in your differential diagnosis.
☐ d. Provide anticipatory guidance to parents/caregivers regarding establishing routines and reassess at the next health supervision visit.

OPINION QUESTIONS

11. 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
Concern about mothers’/parents’ response to screening for prenatal alcohol exposure is a barrier to screening.	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

12. Which of the following two statements below best corresponds with your personal viewpoint?

Please check only ONE box

☐ 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 higher incomes	1	2	3	4	5
Is more prevalent in women with higher levels of education	1	2	3	4	5
Does not vary between ethnic or racial groups	1	2	3	4	5

PRACTICE QUESTIONS

If any of the following screening, diagnostic or referral items do not apply to you in your current position, please circle “N/A” for each item that is not applicable.

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

	N/A	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 patients	0	1	2	3	4	5
Identify persons with possible FAS or other prenatal alcohol-related disorders	0	1	2	3	4	5
Diagnose persons with possible FAS or other prenatal alcohol-related disorders	0	1	2	3	4	5

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

	N/A	Not at all Willing	A little Willing	Moderately Willing	Willing	Completely Willing
Inquire about potential prenatal alcohol exposure for pediatric patients	0	1	2	3	4	5
Identify persons with possible FAS or other prenatal alcohol-related disorders	0	1	2	3	4	5
Diagnose persons with possible FAS or other prenatal alcohol-related disorders	0	1	2	3	4	5

GENERAL QUESTIONS

16 Based on what you learned in this activity, do you plan to change:

1. The strategies you implement in practice (e.g., how you diagnose/manage ☐ Yes ☐ No
   patients, coordinate care, etc.)?

2. What you do in practice (e.g., how you perform exams, instruct, counsel ☐ Yes ☐ No
   patients/families, etc.)?
   
   If YES to either of the above questions, please identify any changes in practice that you plan to make:
   
   
   If NO and you do not plan to make changes in practice, other than lack of time and resources, why not? (select all that apply)
   ☐ Systems-related barriers –

please describe:

☐ The activity reinforced what I am already doing in practice
☐ No practice changes were recommended
☐ Changes were not appropriate options for my practice
☐ Other - please describe:

17. On a scale of 1 to 7, what was the return on your investment of time/effort for participating in this activity? (1 low return to 7 high return)

Low return			Medium return			High return
1 ☐	2 ☐	3 ☐	4 ☐	5 ☐	6 ☐	7 ☐

18. Do you feel a commercial product, device, or service was inappropriately promoted in the educational content?
☐ Yes ☐ No

If yes, please comment:

19. On a scale of 1 to 5 (1 not at all valuable to 5 highly valuable), please rate the value of the including of MOC points for participating in this activity.

Not at all valuable	Somewhat valuable	Neutral	Valuable	Highly valuable
1 ☐	2 ☐	3 ☐	4 ☐	5 ☐

20. This MOC activity is relevant to my current practice. ☐ Yes ☐ No

If yes, please explain why:

21. Please share any additional comments and suggestions for how to improve this educational session.

Thank you for taking the time to answer these questions!

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