Data Collection Instrument Summary Table
Instrument |
Time (min) |
Respondent |
Subject |
Item# |
Administration Mode(s) |
Instrument Origin |
Purpose |
Screener |
|
|
|
|
|
|
|
Social Communication Questionnaire (SCQ) |
10 |
Caregiver1 |
Child |
1- 2 |
Phone or Self-Administer |
Standardized |
To screen children for ASD. Captures information on child’s reciprocal social interaction, language, communication, reciprocal conversation, and repetitive and stereotyped patterns of behavior. |
Self-Administered Questionnaires |
|
|
|
|
|
|
|
Paternal Medical History |
10 |
Father |
Father |
3 |
Self-Administer |
CADDRE |
To obtain information on medical and psychiatric conditions of father other than autoimmune disorders. |
Maternal Medical History |
10 |
Mother |
Mother |
3 |
Self-Administer |
CADDRE |
To obtain information on medical and psychiatric conditions of mother other than autoimmune disorders. |
Child Behavior Checklist (CBCL) |
15 |
Caregiver1 |
Child |
3 |
Self-Administer |
Standardized |
To assess behavior problems and social competencies of the child.
|
Carey Temperament Scale (Carey) |
10 |
Caregiver1 |
Child |
3 |
Self-Administer |
Standardized |
To assess child’s temperament. |
Sleep Habits Questionnaire |
10 |
Caregiver1 |
Child |
3 |
Self-Administer |
Standardized |
To assess child’s behaviors and medical disorders of sleep. |
Stool & Diet Diary |
60 (40 min Stool, 20 min Diet) |
Caregiver1 |
Child |
9 |
Self-Administer |
CO:GI-Study |
To assess child’s stool and corresponding dietary patterns. |
Autoimmune Worksheet |
20 |
Mother |
Nuclear family |
3 |
Self-Administer |
CADDRE |
To obtain information on nuclear family’s autoimmune history. |
Social Responsiveness Scale |
45 min. (15 min per form) |
Caregiver1
|
Nuclear Family |
3 |
Self-Administer |
Standardized |
To obtain information on behaviors related to the nuclear family. |
GI Questionnaire |
10 |
Caregiver1 |
Child |
3 |
Self administered |
CADDRE |
To obtain information on GI disturbances in the child. |
Paternal Occupational Exposure Questionnaire |
5 |
Father |
Father |
3 |
Self administered |
CADDRE |
To obtain information on paternal occupational exposure. |
Clinical Intake Form |
3 |
Caregiver1 |
Child |
3 |
Self administered |
CADDRE |
To obtain information on child to assist with the clinical evaluation. |
Caregiver Interview |
3
*
50 minutes for alternative interview |
Caregiver1 |
Mother & Child
|
5 |
Phone
|
CADDRE
|
To obtain etiologic information related to the mother’s medical & reproductive history & child’s postnatal medical experiences. |
Vineland Adaptive Behavior Scales |
45 |
Caregiver1 |
Child2 |
7 |
Phone |
Standardized |
To assess child’s adaptive behavioral information (i.e., socialization, daily living skills) and language skills. |
Early Development Questionnaire |
20 |
Caregiver1 |
Child2 |
7 |
Self-administered |
Ozonoff, Williams, Landa |
To assess regression of language skills, social skills, and functional behavior of child. |
Services & Treatment |
5 |
Caregiver1 |
Child2 |
7 |
Phone |
CADDRE |
To assess the types and frequency of any services and treatments the child is currently receiving |
Autism Diagnostic Interview-Rev (ADI-R) |
120 |
Caregiver1 |
Child2 |
7 |
In-Person home/clinic |
Standardized |
To assess whether a child has behaviors consistent with ASD based on social and communicative behaviors |
Parent Clinical |
|
|
|
|
|
|
|
Biologic Samples |
15 |
Mother & Father |
Mother & Father |
8 |
In-Person home/clinic |
CADDRE use of Standard procedures
|
To study genetic components related to autism (including gene-environment interactions), and altered immune function and dysfunction (autoimmunity). |
Child Clinical: Child Evaluation |
|
|
|
|
|
|
|
Autism Diagnostic Observation Schedule (ADOS) |
40 |
Child |
Child2 |
7 |
In-Person home/clinic |
Standardized |
To assess whether a child has ASD based on observation of the child’s social interaction and communication skills and through the use of structured play activities. |
Mullen Scales of Early Learning |
45 |
Child |
Child |
7 |
In-Person home/clinic |
Standardized |
To assess the child’s level of cognition in five domains: gross motor, visual reception, fine motor, receptive language, and expressive language. |
Dysmorphology Exam |
15 |
Child |
Child |
7 |
In-Person home/clinic |
CADDRE use of Standard procedures |
To collect anthropometric measurements & any dysmorphic characteristics (i.e, digit ratios) |
Biosampling |
20 |
Child |
Child |
7 |
In-Person home/clinic |
CADDRE use of Standard procedures
|
To examine genetic components (e.g. gene-environment interactions), immune function and dysfunction (autoimmunity), metabolism of xenobiotics, and hormone function possibly related to autism |
Medical Record Abstraction |
|
|
|
|
|
|
|
Maternal Primary Physician (PP) and Labor & Delivery (LD) Forms |
N/A |
N/A |
Mother |
10 |
Medical Record Abstraction |
CADDRE/ CHARGE |
To obtain information on maternal medical and reproductive history, as well as obstetric and delivery complications and events. |
Child Neonatal (N) and Pediatric (P) Forms |
N/A |
N/A |
Child |
10 |
Medical Record Abstraction |
CADDRE/ CHARGE |
To obtain neonatal and postnatal medical experiences of the child. |
1A Caregiver is defined as a parent or relative of legal age who has resided with and been caring for the child since the child was 6 months of age or younger.
2Case– indicates these instruments will only be administered to CASE group.
CADDRE Study –revised 30 AUG 2005
Appendix H.1 DC Instrument Summary.doc
Page
File Type | application/msword |
File Title | Data Collection Instrument Summary |
Author | NCBDDD |
Last Modified By | lvc9 |
File Modified | 2006-12-29 |
File Created | 2006-11-27 |