FASD: Screening, Assessment, & Diagnosis (pre-training e

FASD: Screening, Assessment, & Diagnosis

Form Approved

OMB No.xxxx-xxxx

Exp. Date 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. This project is being conducted with support from the Centers for Disease Control and Prevention (CoAg# OT18-1802). We plan to share findings with CDC in de-identified, aggregate form.

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 (xxxx-xxxx)

KNOWLEDGE QUESTIONS

5. 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

6. 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

7. 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

8. 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 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

9. 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 not an 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 challenges.

OPINION QUESTIONS

10. 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.

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. 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? (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

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

Thank you for taking the time to answer these questions!

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