Form 1 Pediatricians

This survey asks for information on your knowledge, attitudes and practices about diagnosis, treatment and prevention of Fetal Alcohol Syndrome (FAS) and other prenatal alcohol-related disorders. Please answer the questions by circling the number of the appropriate response or by filling in the blanks. (Pediatricians)

1. During a typical work week, what proportion of your time do you spend in the following professional activities? If you do not spend any time in a particular activity, please indicate this by entering zero (0) hours in the appropriate space.

Activity: %Hours:

Direct patient care (self-employed)………………………………………

Direct patient care (other than self-employed)……………………...……

Administration……………………………………………………....……

Academic medicine...……………………………………………….……

Research…………………………………………………………….……

Fellowship training………………………………………………….……

Other……………………………………………………………………... _____

T OTAL …………………………………. 100%

1a. Are you currently in a pediatric residency training program? Yes……1 No……2

The following questions are for pediatricians who provide some DIRECT PATIENT CARE. If

y ou do NOT provide direct patient care, please check this box and go to Q# 22

G ENERAL KNOWLEDGE

2. What would you estimate the overall prevalence of Fetal Alcohol Syndrome in the United States to be?

1 in 10 1 in 100 1 in 1,000 1 in 10,000 1 in 100,000

3. Please check which of the two statements below corresponds most closely with your personal viewpoint. Please pick only ONE box.

O ccasional consumption of alcohol (one Pregnant women or women planning

drink per day or less) during pregnancy to become pregnant should completely

p regnancy is not harmful to the mother or abstain from consuming alcohol.

fetus. (Skip to Question #3)

I believe that occasional alcohol consumption is safe during the following trimesters of pregnancy, (check all that apply):

1 ^st trimester 2^nd trimester 3^rd trimester

4 . In your opinion, how many drinks per week can a pregnant woman consume without risk of adverse pregnancy outcomes? (Circle your answer)

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14+

5 . In your opinion, how many drinks per occasion can a pregnant woman consume without risk of adverse pregnancy outcomes? (Circle your answer)

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14+

6. Please indicate whether you agree or disagree with the following statements:

	Agree	Disagree	Don’t Know
FAS occurs at similar rates in all socioeconomic groups of society	1	2	3
FAS occurs at similar rates among all cultures and ethnic groups	1	2	3

7. Please indicate whether you agree or disagree with the following statements:

	Agree	Disagree	Don’t Know
Alcohol’s effect on fetal development remains unclear	1	2	3
Prenatal alcohol exposure is a significant risk factor for permanent brain damage	1	2	3
Alcohol withdrawal in a baby at birth is the worst outcome of prenatal alcohol exposure	1	2	3
Young adults with FAS usually achieve successful independence at the expected time (18 to 21 years)	1	2	3
Early diagnosis and ongoing surveillance of FAS may lead to implementation of secondary prevention of disabilities	1	2	3

8. Do you consider any of the following problems to be associated with Fetal Alcohol Syndrome?

	Yes	No	Don’t Know
Infantile withdrawal symptoms	1	2	3
Delayed development	1	2	3
Birth defects/malformations	1	2	3
Psychiatric disorders (DSM-IV criteria)	1	2	3
Lowered IQ/retardation	1	2	3
continued next page

	Yes	No	Don’t Know
Behavioral problems	1	2	3
Low birth weight	1	2	3
Long term emotional disorders	1	2	3
Addictions	1	2	3
Legal problems	1	2	3
Attention deficit hyperactivity disorder	1	2	3

9. Which of the following are included in the facial dysmorphia associated with Fetal Alcohol Syndrome? (Check all that apply)

Large inner-canthal distance Short palpebral fissures

F ull lips Smooth philtrum

T hin upper lip Flaring nares

Don’t Know/Unsure

10. It is easiest to diagnose FAS at what age?

Newborn Early Childhood

Adolescence Adulthood

Don’t Know/Unsure

11. Please indicate whether you agree or disagree with the following statement.

	Agree	Disagree	Don’t Know
Making a diagnosis of FAS stigmatizes the child and family	1	2	3

Please consider your own practice over the past 5 years when answering the following questions.

I f you do not provide direct patient care, please check the box and proceed to Q# 22

D IAGNOSIS & TREATMENT

12. Do you provide advice and education on the consequences of alcohol use during pregnancy to

your adolescent female patients? (Check ONE box)

Always/almost always

S ometimes

Rarely/never

13. During the past 12 months, how many patients have you… (if none, enter “0”)

	Number of patients in past 12 months
suspected as having FAS?
recognized as having FAS?
diagnosed as FAS?
referred to confirm a diagnosis of FAS?
provided care for FAS?

14. Do you make use of published diagnostic criteria for FAS in your practice?

Yes……1 No……2

If yes, which one of the following do you use?

Institute of Medicine criteria

American Academy of Pediatrics criteria

Seattle 4 digit diagnostic criteria

Other (please specify) _______________________________________________

15. Many providers do not make the diagnosis of FAS in their practice. Please indicate which of the following factors may contribute to this situation. (Please select all that apply)

Lack of time needed to make diagnosis

Lack of specific training to make the diagnosis

Belief that making the diagnosis will not make a difference to the individual

Other (please specify)_________________________________________

T RAINING/PERCEIVED COMPETENCE/PERCEIVED NEEDS

16. Do you recall receiving any formal training in the following FAS competencies and if so, indicate where you received this training:

		YES
	NO	Medical School	Post-grad (residency)	CME (received credit)	Other
Ability to recognize the constellation of features associated with FAS and other alcohol-related effects
continued on next page

		YES
	NO	Medical School	Post-grad (residency)	CME (received credit)	Other
Understanding of the basic biomedical mechanisms that result in FAS
Ability to select valid and reliable assessment instruments to screen for/diagnose FAS and other alcohol-related disorders
Ability to identify risk factors and interventions for secondary FAS disabilities
Ability to plan and perform clinically relevant treatment and management plans to assist and aid both the patient with FAS and their families
When appropriate, be able to make a referral for further workup in a child with FAS
Appreciation and ability to use interdisciplinary team evaluations for individuals with FAS
Ability to assist clients in accessing local FAS-related resources, including family support
Utilization of techniques for effectively communicating information to individuals with FAS, their family members, and care providers
Demonstration of the ability to provide ethical protections to the patient with FAS regarding confidentiality and autonomy
Ability to educate pregnant women about the effects of alcohol on their babies
Ability to screen women for risky or hazardous drinking
Ability to conduct alcohol cessation brief interventions

17. If you have received any formal training on FAS in any venue (medical school, residency, CME), overall, would you say that training was:

Poor

Fair

Good

Excellent

18. In general, how prepared do you feel to:

	Very Prepared	Somewhat Prepared	Somewhat Unprepared	Very Unprepared
Identify children with possible FAS or other alcohol-related disorders
Diagnose children with FAS and other alcohol-related disorders
Manage/coordinate the treatment of children with FAS and other alcohol-related disorders

19. Please rate how helpful the following kinds of materials or supports would be to you in your clinical practice.

	Very Helpful	Somewhat Helpful	Not Very Helpful	Not At All Helpful
Concise provider and staff information on prevention, diagnosis, and intervention on FAS and other alcohol-related disorders
Patient education materials on the impact of alcohol use during pregnancy on children
Clinical guidelines for best practices for diagnosis of FAS and other alcohol-related disorders
Registry of specialists available for consultation about FAS and other alcohol-related disorders
Listing of community-based resources for children with FAS
Materials for office practice including FAS screening and referral checklists and pocket reminders of diagnostic criteria

20. What mechanisms would be most helpful to you for receiving training on FAS prevention, diagnosis, and intervention? (Check all that apply)

	Very Helpful	Somewhat Helpful	Not Very Helpful	Not At All Helpful
Regional Conferences (CME)
Internet-based learning opportunities
On-site training for myself and colleagues
Self-study materials (eg, CD-ROM, videos)

21. Please indicate whether the following types of FAS-related training and educational materials are available in the community where you practice, and whether these resources are helpful, or would be helpful if they became available.

	Available	Not Available	Very Helpful	Somewhat Helpful	Not Very Helpful	Not At All Helpful
Regional Conferences (CME)
Internet-based learning opportunities
On-site training for myself and colleagues
Self-study materials (eg, CD-ROM, Videos)

B ACKGROUND INFORMATION

22. Are you currently in a pediatric residency training program? Yes……1 No……2

23. What is your gender? Male Female

24. What is your primary employment site? (Please select only one)

Solo practice / 2 physician practice Community-based health center

Group practice / Staff model HMO Other (please specify)

Medical School or parent university

Hospital or clinic

25. Please check this box if you identify yourself as Hispanic/Latino. This question is optional, but important to the survey.

Hispanic/Latino

26. With what racial group do you identify yourself? (Mark all that apply) This question is optional, but important to the survey.

White Asian

American Indian/Alaska Native

African American Native Hawaiian/Pacific Islander

2 7. What is your age?

2 8. Years in practice:

29. Do you consider your primary employment location to be: Circle ONE response

Urban inner city Rural

Urban not inner city Suburban

30. In what area of interest do you spend most of your time?

General pediatrics

Subspecialty area (specify)___________________________________________________

Some questions from this survey were taken from:

Clarke M, Tough SC. A National Survey Regarding Knowledge and Attitudes of Health Professionals About Fetal Alcohol Syndrome. Health Canada Final Report, January 2003.

Shane T. Diekman, et al. A Survey of Obstetrician-Gynecologists on Their Patient's Alcohol Use During Pregnancy. ACOG. Vol 95, Number 5: 756-763. May 2000

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