Survey of Feeding and Digestive Problems in Children with Autistic Spectrum Disorders (ASD): Comparison with non-ASD siblings
By filling out the following survey, you can help pediatricians and other health professionals learn more about certain problems in children with autistic spectrum disorders (ASDs).  Please click on the link below to read the Frequently Asked Questions explaining the purpose of the study and participant rights.

Instructions
Questions on the left (blue color) pertain to a child with ASD
when he/she was between the ages 3-12 years, even if he/she is older now.  Questions on the right (purple color) pertain to his/her sibling who does not have ASD (non-ASD child). 

Below are the instructions for completing this survey:

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4. What is your ASD child's diagnosis?                                                  
 
6. Was the diagnosis made by a medical professional?
 

7. Please check all that apply to your child's development

ASD child                                                                       
non-ASD child

8. Does your child have any of these neurological/developmental/genetic conditions? (Please check all that apply)

ASD child                                                                       
 
non-ASD child
 

9. Does your child have any medical conditions? (Please check all that apply)

ASD child                                                                       
 
non-ASD child
 

10. At what age did your child learn to use spoon/fork?

11. Duration of typical dinnertime with family at ages 3-12 years?

ASD child                                                                             
non-ASD child

12. Restricted diet at ages 3-12 years? (Please check all that apply)

ASD child                                                                             
non-ASD child

13. Strong preference for specific food colors, shapes, textures, or specific arrangement of food on the plate at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency         
            
non-ASD child
Duration

14. Insistence on eating with specific utensils/dishes at ages 3-12? (Please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency        
 
            
non-ASD child
Duration

15. Strong dislike/fear of specific food colors, shapes, textures, or arrangement on the plate at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency         
            
non-ASD child
Duration

16. Fear of eating new foods at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency     
    
            
non-ASD child
Duration

17. Ingestion of non-food items, such as paper, string, dirt, hair, at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency     
    
            
non-ASD child
Duration

18. Poor social mealtime behaviors (e.g. would not sit with family, temper tantrum during meal time, throwing food) at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency    
     
            
non-ASD child
Duration

19. Behavior outbursts during school lunch, requiring intervention by school personnel at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency     
    
            
non-ASD child
Duration

20. Able to start and finish meals with non-ASD children at the same table? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency    
     
            
non-ASD child
Duration

21. Unusual posturing (neck or trunk turning/bending/arching) during or after meals at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency         
            
non-ASD child
Duration

22. Oral-motor coordination problems (difficulty moving solid food inside mouth) at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency        
 
            
non-ASD child
Duration

23. At what age did your child get toilet training for daytime bowel movements?

24. Vomiting at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency     
    
            
non-ASD child
Duration

25. Diarrhea (more than 3 watery bowel movements per day) at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency        
 
            
non-ASD child
Duration

26. Constipation (more than 3 days between bowel movements) at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency         
            
non-ASD child
Duration

27. Soiling in underpants or withholding stool? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency   
      
            
non-ASD child
Duration

28. Inadequate/under weight or failure to thrive at ages 3-12 years?

ASD child                                                                            
non-ASD child

29. Difficulty swallowing solid food at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency         
            
non-ASD child
Duration

30. Reflux / indigestion/ GERD/ esophagitis at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency         
            
non-ASD child
Duration

31. If you selected “sometimes” or “often” in the previous question, what tests did your child have to confirm Reflux / indigestion/ GERD/ esophagitis at the age of 3-12 years? (please check all that apply)

ASD child                                                                           
 
non-ASD child
 

32. Food allergies at ages 3-12 years? (please check all that apply)

ASD child                                                                            
 
non-ASD child
 

33. Abdominal pain requiring a doctor visit at ages 3-12 years? (please answer both Frequency and Duration headings)

ASD child
Frequency                      
ASD child
Duration                                    
non-ASD child
Frequency         
            
non-ASD child
Duration

34. Celiac disease, proven by blood tests or by intestinal biopsy at ages 3-12 years?

ASD child                                                                            
 
non-ASD child
 

35. Eosinophilic esophagitis proven by biopsy at ages 3-12 years?

ASD child                                                                            
 
non-ASD child
 

36. Diseases of small or large intestine at ages 3-12 years?

ASD child                                                                            
 
non-ASD child
 

37. Gastrointestinal medications your child took for at least 1 month at ages 3-12 years (check all that apply)

ASD child                                                                            
 
non-ASD child
 

38. Who did your child see for his/her gastrointestinal problems at ages 3-12 years? (check all that apply)

ASD child                                                                            
 
non-ASD child
 

39. Is your child on Medicaid?

ASD child                                                                            
non-ASD child

40. Please estimate last year's total out-of-pocket medical, drug, education, P.T., O.T., and speech therapy expenditures for your child

ASD child                                                                            
non-ASD child

41. What is your total household income?

                                                                                 

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