Mother's Developmental Survey
The following survey is being conducted by www.aba4autism.com and the Psychology Department at the University of Tennessee at Martin. The survey must be completed by the biological mother of the child. At this time we are asking that the child in the survey be 10 years or younger. Please complete all questions that relate to you and your child. Use one survey per child. If you have any further questions you can contact Denise Jones at (731) 881-7540; Angie MacKewn (731) 881-7370; or Dr. Gary Brown at (731) 881-7542 or email webmaster@www.aba4autism.com.
By submitting the results of this survey you are consenting to the inclusion of your data in the research project. If you do not wish to continue the survey simply exit out of it. We insure that all information will be kept confidential. Thank-you for taking the time to complete one survey per child age 10 and under. Also, please send this link to family and friends with children.
Demographic Information
Name:
Email address:
City:
State/Province:
Zip Code:
Please check all behaviors that your child has exhibited (check all that apply)
Does not play well when with other children. Insists on sameness; resists and may become upset by changes in routine. Laughs or giggles inappropriately No fear of dangerous situations or dangerous activities such as climbing. Little or no eye contact with adults or other children. Can pick up small objects such as pencil; holds pencil in two fingers. Engages in odd play or plays in an unusual manner. No pretend or imaginary play. Insensitive to pain; child may get hurt but does not notice Able to perform age appropriate self-help skills such as getting dressed Echolalia (repeats words/phrases in place of normal language), child parrots what a parent, another child, or someone on TV or radio is saying Prefers to be alone; child is aloof, sits apart from others Does not want to be held or be cuddled. Suffers/ed from a sleep disorder; hard to put to sleep Child spins objects or stares at spinning objects, such as fans. Child stares at lights Child is especially attracted to fluorescent lights Not responsive to verbal cues; acts like a deaf child Inappropriate attachment to objects; carries a toy or some other object around all the time Difficulty in expressing needs; uses gestures or pointing instead of words Noticeable physical overactivity or extreme underactivity
Does not play well when with other children.
Insists on sameness; resists and may become upset by changes in routine.
Laughs or giggles inappropriately
No fear of dangerous situations or dangerous activities such as climbing.
Little or no eye contact with adults or other children.
Can pick up small objects such as pencil; holds pencil in two fingers.
Engages in odd play or plays in an unusual manner.
No pretend or imaginary play.
Insensitive to pain; child may get hurt but does not notice
Able to perform age appropriate self-help skills such as getting dressed
Echolalia (repeats words/phrases in place of normal language), child parrots what a parent, another child, or someone on TV or radio is saying
Prefers to be alone; child is aloof, sits apart from others
Does not want to be held or be cuddled.
Suffers/ed from a sleep disorder; hard to put to sleep
Child spins objects or stares at spinning objects, such as fans.
Child stares at lights
Child is especially attracted to fluorescent lights
Not responsive to verbal cues; acts like a deaf child
Inappropriate attachment to objects; carries a toy or some other object around all the time
Difficulty in expressing needs; uses gestures or pointing instead of words
Noticeable physical overactivity or extreme underactivity
Initiates play with other children or parent
Oversensitivity to certain sounds, textures, or smells.
Tantrums - displays extreme distress for no apparent reason
Unresponsive to normal teaching methods
Makes eye contact when speaking
Was difficult to bottle or breast feed.
Spit up after feeding.
Uneven gross/fine motor skills (May not kick or throw ball but can stack blocks)
No pointing by age 1
No baby talk by age 1
No single words by 16 months
No two-word phrases by age 2
Covers ears with hands when in a crowd
Responds to comforting by parent when upset
Lines up toys repeatedly
Does not understand body language or tone of voice
Robot-like voice if verbal
Preoccupied with certain activities, people, or subjects
Child climbs over objects
No creative thinking, cannot make-up and tell a story
Fixates on certain objects, obsessive-compulsive like behavior
Seizures
Child's Background Information
1. How old is your child?
2. Sex of your child? Male Female
3. What birth order is this child? (only child, first born, second born, etc)
4. What is your ethnic background?
Caucasian
African American
Latino/Hispanic
5. What is the biological father's ethnic background?
6. Has this child been diagnosed by a physician, (neuro)psychologist or other professional with Autism, Pervasive Developmental Disorder (PDD), Asperger's, or any other neurological/neuropsychological disorder? No Yes
If yes, what was the specific diagnosis
7. Has your child been diagnosed with a comorbid disorder? (learning disorder, bipolar disorder) No Yes
If yes, what disorder has your child been diagnosed with
8. What is your child's dominant hand?
Left Right
Left
Right
Does not have a dominant hand
9. Does your child have food cravings? No Yes
If yes, what specific cravings does your child have?
10. Does your child have food aversions? No Yes
If yes, what specific aversions does your child have?
11. Does your child have food allergies? No Yes
If yes, what specific food allergies do they have?
12. Please check all of the problems that your child had during the first six months after birth
Cholic Trouble conforming to your body when picked up Rocking back and forth when sitting on the floor
Cholic
Trouble conforming to your body when picked up
Rocking back and forth when sitting on the floor
Headbanging
Biting him/herself
13. Does your child have skin problems or rashes? No Yes
If yes, what kind of skin problems?
Background Information
14. What is your highest educational level?
Did not graduate high school High school graduate GED (General Degree)
Did not graduate high school
High school graduate
GED (General Degree)
Some College
College Graduate
Other
15. Dad's highest education level
16. Have you or anyone in your immediate family (biological parents and grandparents, brother, sister, aunts/uncles, cousins) been diagnosed with the following (check all that apply)
Schizophrenia Autism/Aspergers
Schizophrenia
Autism/Aspergers
Major Depression
Learning Disorders/Dyslexia
17. List who has been diagnosed and what diagnoses they were given?
18. If you were diagnosed with any of the disorders above, were you taking medications for it while pregnant? No N/A Yes taking
Prenatal
19. How old were you when you gave birth to this child?
20. Have you ever had a miscarriage? No Yes
If yes, how many miscarriages did you have before the birth of this child?
21. How far along in your pregnancy did you begin prenatal care?
22. In what geographical region did you live during your first three months of pregnancy?
What kind of area was this (urban, rural, industrial)
23. In what geographical region did you live during the first three months after your child was born?
24. Did you live within 20 miles of high voltage power lines while pregnant with this child? No Yes Don't Know
25. What was your occupation during the first three months of your pregnancy?
26. What was the biological father's occupation at the time?
27. Did you have any infections during the first three months of this pregnancy? No Yes
If yes, what kind of infection did you have?
28. Did you take any medications for your infection(s)? No Yes, I took
29. Was it flu season or were you exposed to the flu during the first three months of pregnancy? No Yes
30. Did you get a viral or bacterial infection during the first three months of pregnancy? No Yes
31. Were you exposed to Rubella/Measles during your first three months of pregnancy? No Yes
32. Did you have an upper respiratory infection during the first three months of pregnancy? No Yes
33. Did you have skin problems or rashes during your first three months of pregnancy? No Yes
34. Did you take Terbutaline (for asthma or for stopping contractions) while pregnant? No Yes
35. In the first three months of your pregnancy how well did you wash your fruits and vegetables before eating them?
rarely washed them ran them under water
rarely washed them
ran them under water
washed them with soap
scrubbed them with soap
36. During the first three months of your pregnancy, how often did you eat fish?
Never 1-2 times per week 3-4 times per week
Never
1-2 times per week
3-4 times per week
4-5 times per week
Greater than 5 times per week
If you ate fish during your first three months of pregnancy, what kind of fish did you eat most often?
37. Did you smoke during your first three months of your pregnancy? No Yes
38. Did you drink alcohol or take recreational drugs during the first three months of your pregnancy? No Yes, I took
Prenatal Stress
39. During the first three months of this pregnancy, how often did you have major health, financial, family, or social concerns? (examples: about your pregnancy, medical treatment, paying for the baby, family problems, bills, etc)
Never Rarely Sometimes
Rarely
Sometimes
Often
Always
40. On a scale from 1-5, how stressful were your health, financial, family, or social concerns if 1=Not at all stressful, 3=Somewhat stressful, and 5=Extremely Stressful?
Morning Sickness
41. Did you feel nauseous during your first three months of pregnancy? No Yes
42. Did you vomit during the first three months of your pregnancy? No Yes
43. How often did you vomit?
I never vomited in the first three months of pregnancy Less than once per day Once per day
I never vomited in the first three months of pregnancy
Less than once per day
Once per day
2-3 times per day
3-4 times per day
Greater than 4 times per day
44. Was your vomiting related to the pregnancy? No Yes Don't Know
45. Were you sensitive to smells during your first three months of this pregnancy? No Yes
46. Did you have any food or drink cravings during your first three months of pregnancy? No Yes
If you answered yes to having cravings during the first 3 months of pregnancy, check all the food groups and indicate the specific items you craved in the box below? If you did not have cravings, go to question 47.
Meat products, like fish, chicken, or eggs Vegetables Alcohol Spicy foods Dairy foods like milk, or ice cream
Meat products, like fish, chicken, or eggs
Vegetables
Alcohol
Spicy foods
Dairy foods like milk, or ice cream
Sweets (candy or chocolate)
Grains and starches
Fruit juices
47. Did you have any aversions to foods, drinks, or smells in the first 3 months of your pregnancy? No Yes
If you said yes you had aversions during the first 3 months of your pregnancy check all the food groups and list the specific items you found aversive? If you did not have aversions, skip to question 48.
Delivery
48. What type of delivery did you have with this child
Cesarean Normal Vaginal Induced vaginal
Cesarean
Normal Vaginal
Induced vaginal
Induced but had a Cesarean
Breech delivery
Vacuum delivery
49. How many weeks did you carry this child before giving birth?
50. Were there any complications at birth? No Yes If yes, what were they?
If your labor was induced, at what week was it induced? How was it induced How much time passed between inducement and the birth of your child
If your labor was induced, at what week was it induced?
How was it induced
How much time passed between inducement and the birth of your child
51. How long were you in labor?
52. How much did your child weigh at birth? pounds
Ear Infections
53. Did you child experience ear infections (If they didn't experience ear infections, skip to question 58)? No Yes
54. If yes, at what age did they begin?
55. How many ear infections has your child experienced (how often did your child get ear infections)?
56. Did your child ever require tubes? (Or were they doctor recommended?) No Yes
If they did have tubes, at what age did he/she first get them? How many sets of tubes have they had?
If they did have tubes, at what age did he/she first get them?
How many sets of tubes have they had?
57. Has your child experienced any hearing loss as a result of ear infections or tubes? No Yes
Language Development
58. How has your child's speech developed?
Language development is normal My child developed a few words then lost those words My child developed a few words, then lost those words, but language is normal now
Language development is normal
My child developed a few words then lost those words
My child developed a few words, then lost those words, but language is normal now
My child's language never developed normally
My child is too young to determine whether their language is normal or abnormal
59. Which of the following licensed credentialed specialist has your child been assessed or treated by? Also indicate how old your child was when they first went to the specialist and how long they have been seeing them.
Behavioral Analyst (what age & how long) Physical Therapist (what age & how long) Occupational therapist (what age & how long) Pediatric Neurologist (what age & how long) Developmental Pediatrician (what age & how long)
Behavioral Analyst (what age & how long)
Physical Therapist (what age & how long)
Occupational therapist (what age & how long)
Pediatric Neurologist (what age & how long)
Developmental Pediatrician (what age & how long)
Speech and Language Pathologist (what age & how long)
Psychologist (what age & how long)
Psychiatrist (what age & how long)
Other licensed specialist (what age & how long)
60. Which interventions or treatments has your child been exposed to? Also indicate at what age this treatment began and how long they have been receiving this treatment.
Applied Behavioral Analysis ( ABA )
Medication
Other therapies (Gluten free, casein free diets, Chelation, vitamin supplements )
Thank-you for taking the time to complete the survey. Please make sure to include a valid email address so we can send you the set of free behavioral programs. Also, send this link to friends and family with children age 10 and under.