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.

Click Here to read the Frequently Asked Questions about the survey.

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:

If you have …	and …	then …
A child with ASD	No other children	Answer blue questions only
A child with ASD	1 or more children without ASD	Answer both blue and purple questions. Of your children without ASD, please pick the child closest by age to the child with ASD.
No child with ASD	1 or more children without ASD	Answer purple questions only. Please pick the oldest child.

Please note: if you have more than one child with ASD, we would love to have the info on all of them. Could you please kindly complete the blue questions for each child separately? We understand this may seem a repetitive task but we would greatly appreciate your help.

At the end, please remember to click on "Submit" button, or your data will be lost and we will not get any info.

Start

1. City (if outside the US, please type in both your city and country here)

State

2. Current age of your ASD Child

2. Current age of your non-ASD Child

3. Gender of your ASD child

3. Gender of your non-ASD child

4. What is your ASD child's diagnosis?

5. Age at the time of diagnosis.

6. Was the diagnosis made by a medical professional?

Yes

No (by whom?) No (by whom?)

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

Uncertain

No

Yes (specify) Yes (specify)

non-ASD child

Uncertain

No

Yes (specify) Yes (specify)

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

ASD child

non-ASD child

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?

ASD child

non-ASD child

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

Yes

No

Uncertain

non-ASD child

Yes

No

Uncertain

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

Yes

No

Uncertain Uncertain

non-ASD child

Yes

No

Uncertain Uncertain

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

ASD child

Yes

No

Uncertain Uncertain

non-ASD child

Yes

No

Uncertain Uncertain

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

ASD child

Yes

No

Uncertain Uncertain

non-ASD child

Yes

No

Uncertain Uncertain

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

Yes

No

Not applicable (outside US)

non-ASD child

Yes

No

Not applicable (outside US)

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?

Less than $25,000

$25,000 - $49,000

$50,000 - $75,000

More than $75,000

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Please provide your feedback on this questionnaire’s design, user-friendliness, and whether any questions seemed unclear or confusing. We value your opinion and suggestions. Thank you for your time.

up to 30 minutes	61-90 minutes
31-45 minutes	more than 90 minutes
46-60 minutes

up to 30 minutes	61-90 minutes
31-45 minutes	more than 90 minutes
46-60 minutes

Gluten-free	Soy-free
Dairy (casein)-free	Carbohydrate diet
Candida diet	Uncertain
Rotation diet	No diet restrictions
Feingold diet

Gluten-free	Soy-free
Dairy (casein)-free	Carbohydrate diet
Candida diet	Uncertain
Rotation diet	No diet restrictions
Feingold diet

Barium swallow	pH probe
Endoscopy	Biopsy
Videofluoroscopy	Not applicable
Uncertain	No tests
Other Other

Milk	Eggs
Citrus	Wheat
Yeast	Corn
Uncertain	No allergies
Other Other

Zantac	Pepcid
Prevacid	Prilosec
Flagyl	Laxatives (e.g. Miralax, etc.)
Not applicable	Other Other