Educational Care for Children Affected by Prenatal Alcoh

Educational Care for Children Affected by Prenatal Alcohol Exposure

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. 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.

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 (xxxx-xxxx)

KNOWLEDGE QUESTIONS

5. Which of the following are neurobehavioral traits associated with the effects from PAE observed in the classroom would negative impact learning and school functioning and require interventions. (Select all that apply).

• A. Problems applying concepts or abstract reasoning leading to failing grades in mathematics in an adolescent child.

• B. A high school student infrequently forgetting class materials without affecting grades.

• C. Problems filtering distractions in a busy 2nd grade classroom leading to daily removal from class during instructional periods and notes home about problematic behavior.

• D. A middle school student getting out of assigned seat to talk with friends only during cooperative work groups

• E. Four-year old with consistent challenges following classroom routines or expectations resulting in refusals to transition activities, and frequent elopement from teachers and the classroom.

6. Sharon is an 8-year-old Caucasian girl who has poor impulse control, does not respond well to authority figures, and has a brief attention span. She struggles in school, especially in math, and her handwriting is completely illegible. What general school supports, and special education services could be implemented for Sharon? Select all that apply.

• A. Classroom accommodations to mitigate distractions such as seating location and non-verbal prompts to focus attention on the instructor and providing warning before classroom activity transitions.

• B. Intensive classroom interventions through the Multi-tier System of Support (MTSS) or to begin the process to determine the need for special education services.

• C. Removal from class to sit in the office when she has problems in class.

• D. Occupational therapy evaluation and services at school as part of the comprehensive assessment for special education eligibility

• E. Before/after school tutoring for math

7. Ben is a 5-year-old African American male who was brought by his grandmother to your office for hyperactive and impulsive behaviors. He doesn’t follow directions unless they are stated repeatedly. His behaviors have been causing problems in the school and home setting. Which of the following could be included in medical necessity for Ben as he makes his way through kindergarten?

• A. Diagnosis and applicable ICD-10 or DSM 5 codes.

• B. General description of the impact of diagnoses on school functioning in school.

• C. Requests for accommodations.

• D. Request to intensify the Multi-tier system of supports (MTSS) to address behavior.

• E. Most recent medical summary report.

8. Marco is a 14-year-old Hispanic male who was recently diagnosed with alcohol-related neurodevelopmental disorder (ARND), one of the FASDs, by a developmental pediatrician and psychologist. Marco has had trouble in school because of extreme impulsivity, poor school performance, meltdowns, and aggressive behavior. He was placed in emotional/behavioral disorder (EBD) classes, which his mother felt made some of the behaviors worse, since he tended to associate with the wrong crowd in these particular classes. He has always been naïve and suggestible, and would do anything for a friend. Despite repeated instruction, he still has not mastered good self-care or grooming skills.

Based on the information given above and what is known about ARND, what additional services may be needed? Select all that apply.

• A. Start transition planning to prepare for adult vocational or occupational goals.

• B. Request the Individualized Education Program (IEP) team to review his cognitive profile and his progress to determine the appropriateness of his placement in the EBD classes. .

• C. Make changes in his IEP to accommodate his learning and language difficulties and to improve his social functioning

• D. Continue placement in an EBD classroom because Marco’s behavior and school performance are likely due to his intentional defiance of school rules.

• E. Refer to an FASD clinic or a developmental-behavioral pediatrician to determine if he has other developmental needs.

• F. Refer to a psychiatrist to assess for other mental health conditions and continue medication management for ADHD.

9. Which of the following educational interventions may be helpful to Marco? Select all that apply.

• A. An IEP for Other Health Impairment that also accounts for all the learning deficits on his behavioral profile.

• B. Send Marco home when he is poorly groomed or disrespectful to instructors.

• C. Speech-language therapy to address specific areas of receptive and expressive language difficulties.

• D. Provision a school advocate who can support him and help him come up with strategies and who can troubleshoot through situations that are causing Marco distress.

OPINION QUESTIONS

8. On a scale of 1 to 5 (1 Strongly Disagree to 5 strongly agree), 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 parents’/caregivers’ response to disclosing a FASD to the school is a barrier to recommending school-based services and/or facilitation of an individual education plan (IEP).	1	2	3	4	5
Concern about school system’s capability to develop and support school-based services and/or an IEP is a barrier to working with the school system.
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

9. On a scale of 1 to 5 (1 strongly disagree; 5 strongly agree); to what extent do you agree with the following statements about school-based interventions (special education and non-special education? (Mark one response per row)

School based services (special education and non-special education) …	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
Can only be accessed in school systems with communities in higher income brackets.	1	2	3	4	5
Have limited capacity to improve educational performance in children with prenatal alcohol exposure.	1	2	3	4	5
Can only be implemented in children with fetal alcohol syndrome (FAS) and an IQ below 70.	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.

10. How often do you do the following? (Mark one number per row)

	N/A	Never	Rarely	Sometimes	Usually	Always
Write a letter of medical necessity for any child (regardless of diagnosis) for school-based services.	0	1	2	3	4	5
Attend (or have a clinic/practice staff member attend) an individual education plan meeting for a patient.	0	1	2	3	4	5
Discuss approaches to overcoming neurobehavioral challenges in children with FASDs with teachers, school psychologist, school social workers, school nurses or other educators.	0	1	2	3	4	5
Discuss how approaches to overcoming neurobehavioral challenges in the school setting with patients and their caregivers.	0	1	2	3	4	5

11. On a scale of 1 to 5 (1 not at all confident; 5 completely confident), 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
Facilitate school supports (special education and non-special education) for the patients in your clinic/practice.	0	1	2	3	4	5
Identify academic or behavior deficits that impede school functioning.	0	1	2	3	4	5
Apply the eligibility categories for special education services for children with prenatal alcohol exposure and/or a FASDs diagnosis.	0	1	2	3	4	5

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

GENERAL

13. 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:

How would you describe your gender identity? :  Male  Female Are you Hispanic or Latino/a?  No  Yes (includes: Mexican, Mexican American, Chicano, Puerto Rican, Cuban, or other Hispanic or Latino/a) With what racial or cultural group(s) do you identify yourself? (Mark all that apply)  Black/African American  Asian  Native Hawaiian or other Pacific Islander  American Indian or Alaska Native  White  Other (specify):______________

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

Thank you for taking the time to answer these questions!

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