0920-1129 B11 Pre-test ND-PAE

ND-PAE

Form Approved

OMB No.0920-1129

Exp.: XX/XX/XXXX

AMERICAN ACADEMY OF PEDIATRICS

PRE-TRAINING EVALUATION SURVEY

Thank you for your interest in fetal alcohol spectrum disorders (FASD). We would like to invite you to complete a pre-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 PEHDIC@aap.org.

UNIQUE IDENTIFIER INFORMATION (to help us match your pre- and post-training responses)

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)

KNOWLEDGE QUESTIONS

5. 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 impairments in each of the domains of neurocognitive function, self-regulation, and adaptive function.

☐ 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

6. 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 while reassuring them that since the child has no facial features of fetal alcohol syndrome, the child’s problems must be related to another disorder.
☐ e. Educate the parent about impairments seen in children with FASD so they can better understand and respond to their child’s behavioral changes.7. Which of the following should be done when a child in your practice is identified as having developmental/behavioral problems in the context of prenatal alcohol exposure? (Check all that apply)

☐ a. Refer the child to EI services (in a child below the age of 3 years) for evaluation/therapy.

☐ b. Refer the child to the school for educational evaluation (in a child above the age of 3 years).

☐ c. Refer the child to a developmental-behavioral pediatrician, geneticist, or neurologist knowledgeable in FASDs.

☐ d. Refer to an FASD clinic, if there is one in your area.

☐ e. Do nothing unless the child can be diagnosed with FAS because pediatricians are not qualified to make a diagnosis of an FASD.

8. Complete this sentence.
Behavioral problems in children with an FASD ___(Check all that apply)

☐ a. Can be a result of not being identified as having a brain-based disability.

☐ b. Can be a result of unrealistic expectations when a child’s chronological age is incongruent with his or her developmental age.

☐ c. Generally, results from poor parenting.

☐ d. Can be treated for psychiatric diagnoses since underlying brain impairments are secondary to their psychiatric diagnosis.

9. Which of the following is NOT a common neurobehavioral finding in children with prenatal alcohol exposure? (Check all that apply)

☐ a. Little to no interest in playing with other children.

☐ b. Poor reading comprehension, memory deficits, and difficulty with mathematics

☐ c. Short attention span, hyperactivity, and increased distractibility

☐ d. Poor problem-solving abilities, social skill deficits, and language skill delays
☐ e. Impulsivity and aggressive behavior

OPINION QUESTIONS

10. 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

11. Which of the following two statements below best corresponds with your personal viewpoint? Please check only ONE.

☐ 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.

12. 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.

13. How often do you do the following when you suspect patients may be at risk for one of the FASDs? (Mark one number per row)

	N/A	Never	Rarely	Sometimes	Usually	Always
Inquire routinely about prenatal exposure to alcohol	0	1	2	3	4	5
Identify patient as someone who may have one of the FASDs	0	1	2	3	4	5
Diagnose patient as someone who may have one of the FASDs	0	1	2	3	4	5
Refer patient for diagnosis and/or treatment services	0	1	2	3	4	5

14. How confident are you in your skills to do the following? (Mark one number 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

16. During the past six months, did you diagnose any children with fetal alcohol syndrome (FAS) or one of the fetal alcohol spectrum disorders (FASDs)?
☐ N/A [0] ☐ Yes [1] ☐ No [2]

If YES, please specify which diagnostic schema (if any) you used to support your diagnosis: (Mark all that apply)
☐ Institute of Medicine criteria
☐ American Academy of Pediatrics algorithm and/or toolkit
☐ Seattle 4-Digit Diagnostic Code (University of Washington)
☐ Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
☐ Other schema (please specify) _____________________________
☐ I did not use any particular schema

17. During the past six months, did you refer any children for FASD assessment?
☐ N/A [0] ☐ Yes [1] ☐ No [2]

GENERAL

15. Please feel free to comment on your response to any of the questions in this survey.

Please take a moment to tell us about yourself:

What sex were you assigned at birth, on your original birth certificate? Male Female Refused I don’t know Do you currently describe yourself as male, female, or transgender? r Male r Female r Transgender r None of these What is your ethnicity? r Hispanic or Latino r Not Hispanic or Latino What is your race? (Check all that apply) r American Indian/Alaska Native r Asian r Black or African American r Native Hawaiian or Other Pacific Islander r White

What year did you complete or will you complete your training: _______________ Are you, or will you be, a: r Primary Care Pediatrician r Developmental/Behavioral Pediatrician r Geneticist r Other Pediatric Sub-specialty Specify: _____________________________________ r Family Physician r Other (specify): _______________________________ Please indicate your primary employment site setting, that is, the setting where you spend most of your time. Mark only ONE response. r Self-employed solo practice r Two physician practice r Pediatric group practice, 3-10 pediatricians r Pediatric group practice, >10 pediatricians r Multispecialty group practice r Health maintenance organization (staff model) r Medical school or parent university r Non-profit community health center r Non-government hospital or clinic r City/county/state government hospital or clinic r US government hospital or clinic r Other: Please describe the community in which your primary practice/position is located? r Urban, inner city r Urban, not inner city r Suburban r Rural

Thank you for taking the time to answer these questions!

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