Autism Survey

1. Autism Survey

Christian Sarkine Autism Treatment Center, HANDS in Autism Team, 2005.
Adapted from Stone, W. (1987). Cross disciplinary perspecitves on autism. Journal of Pediatric Psychology, 21, 615-630.

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* Directions: Please answer the following questions on this survey as best you can. Do not spend too much time on any one question. For each of the following statements, check the number that best reflects how much you AGREE with each statement.

	Fully Agree	Mostly Agree	Somewhat Agree	Somewhat Disagree	Mostly Disagree	Fully Disagree
Autism is an emotional disorder.	Autism is an emotional disorder. Fully Agree	Autism is an emotional disorder. Mostly Agree	Autism is an emotional disorder. Somewhat Agree	Autism is an emotional disorder. Somewhat Disagree	Autism is an emotional disorder. Mostly Disagree	Autism is an emotional disorder. Fully Disagree
Early intervention can lead to significant gains in children’s social and communication skills.	Early intervention can lead to significant gains in children’s social and communication skills. Fully Agree	Early intervention can lead to significant gains in children’s social and communication skills. Mostly Agree	Early intervention can lead to significant gains in children’s social and communication skills. Somewhat Agree	Early intervention can lead to significant gains in children’s social and communication skills. Somewhat Disagree	Early intervention can lead to significant gains in children’s social and communication skills. Mostly Disagree	Early intervention can lead to significant gains in children’s social and communication skills. Fully Disagree
All children with autism display poor eye contact.	All children with autism display poor eye contact. Fully Agree	All children with autism display poor eye contact. Mostly Agree	All children with autism display poor eye contact. Somewhat Agree	All children with autism display poor eye contact. Somewhat Disagree	All children with autism display poor eye contact. Mostly Disagree	All children with autism display poor eye contact. Fully Disagree
Children with autism typically perform better when tasks are presented visually than when tasks are presented verbally.	Children with autism typically perform better when tasks are presented visually than when tasks are presented verbally. Fully Agree	Children with autism typically perform better when tasks are presented visually than when tasks are presented verbally. Mostly Agree	Children with autism typically perform better when tasks are presented visually than when tasks are presented verbally. Somewhat Agree	Children with autism typically perform better when tasks are presented visually than when tasks are presented verbally. Somewhat Disagree	Children with autism typically perform better when tasks are presented visually than when tasks are presented verbally. Mostly Disagree	Children with autism typically perform better when tasks are presented visually than when tasks are presented verbally. Fully Disagree
Problems with social relatedness that are present in autism are different from social problems seen in other psychiatric conditions.	Problems with social relatedness that are present in autism are different from social problems seen in other psychiatric conditions. Fully Agree	Problems with social relatedness that are present in autism are different from social problems seen in other psychiatric conditions. Mostly Agree	Problems with social relatedness that are present in autism are different from social problems seen in other psychiatric conditions. Somewhat Agree	Problems with social relatedness that are present in autism are different from social problems seen in other psychiatric conditions. Somewhat Disagree	Problems with social relatedness that are present in autism are different from social problems seen in other psychiatric conditions. Mostly Disagree	Problems with social relatedness that are present in autism are different from social problems seen in other psychiatric conditions. Fully Disagree
Autism is more frequently diagnosed in males than in females.	Autism is more frequently diagnosed in males than in females. Fully Agree	Autism is more frequently diagnosed in males than in females. Mostly Agree	Autism is more frequently diagnosed in males than in females. Somewhat Agree	Autism is more frequently diagnosed in males than in females. Somewhat Disagree	Autism is more frequently diagnosed in males than in females. Mostly Disagree	Autism is more frequently diagnosed in males than in females. Fully Disagree
Children with autism do not show attachments, even to parents/caregivers.	Children with autism do not show attachments, even to parents/caregivers. Fully Agree	Children with autism do not show attachments, even to parents/caregivers. Mostly Agree	Children with autism do not show attachments, even to parents/caregivers. Somewhat Agree	Children with autism do not show attachments, even to parents/caregivers. Somewhat Disagree	Children with autism do not show attachments, even to parents/caregivers. Mostly Disagree	Children with autism do not show attachments, even to parents/caregivers. Fully Disagree
Research indicates that sensory integration therapy is an effective treatment for autism and its symptoms.	Research indicates that sensory integration therapy is an effective treatment for autism and its symptoms. Fully Agree	Research indicates that sensory integration therapy is an effective treatment for autism and its symptoms. Mostly Agree	Research indicates that sensory integration therapy is an effective treatment for autism and its symptoms. Somewhat Agree	Research indicates that sensory integration therapy is an effective treatment for autism and its symptoms. Somewhat Disagree	Research indicates that sensory integration therapy is an effective treatment for autism and its symptoms. Mostly Disagree	Research indicates that sensory integration therapy is an effective treatment for autism and its symptoms. Fully Disagree
Children with autism are deliberately uncooperative.	Children with autism are deliberately uncooperative. Fully Agree	Children with autism are deliberately uncooperative. Mostly Agree	Children with autism are deliberately uncooperative. Somewhat Agree	Children with autism are deliberately uncooperative. Somewhat Disagree	Children with autism are deliberately uncooperative. Mostly Disagree	Children with autism are deliberately uncooperative. Fully Disagree
Most parents/caregivers of children with autism report their first concerns were related to the child’s social behavior.	Most parents/caregivers of children with autism report their first concerns were related to the child’s social behavior. Fully Agree	Most parents/caregivers of children with autism report their first concerns were related to the child’s social behavior. Mostly Agree	Most parents/caregivers of children with autism report their first concerns were related to the child’s social behavior. Somewhat Agree	Most parents/caregivers of children with autism report their first concerns were related to the child’s social behavior. Somewhat Disagree	Most parents/caregivers of children with autism report their first concerns were related to the child’s social behavior. Mostly Disagree	Most parents/caregivers of children with autism report their first concerns were related to the child’s social behavior. Fully Disagree
Autism tends to run in families.	Autism tends to run in families. Fully Agree	Autism tends to run in families. Mostly Agree	Autism tends to run in families. Somewhat Agree	Autism tends to run in families. Somewhat Disagree	Autism tends to run in families. Mostly Disagree	Autism tends to run in families. Fully Disagree
We now have treatments that can cure autism.	We now have treatments that can cure autism. Fully Agree	We now have treatments that can cure autism. Mostly Agree	We now have treatments that can cure autism. Somewhat Agree	We now have treatments that can cure autism. Somewhat Disagree	We now have treatments that can cure autism. Mostly Disagree	We now have treatments that can cure autism. Fully Disagree
Children with autism can grow up to live independently.	Children with autism can grow up to live independently. Fully Agree	Children with autism can grow up to live independently. Mostly Agree	Children with autism can grow up to live independently. Somewhat Agree	Children with autism can grow up to live independently. Somewhat Disagree	Children with autism can grow up to live independently. Mostly Disagree	Children with autism can grow up to live independently. Fully Disagree
There is one approach/program that works for all children with autism.	There is one approach/program that works for all children with autism. Fully Agree	There is one approach/program that works for all children with autism. Mostly Agree	There is one approach/program that works for all children with autism. Somewhat Agree	There is one approach/program that works for all children with autism. Somewhat Disagree	There is one approach/program that works for all children with autism. Mostly Disagree	There is one approach/program that works for all children with autism. Fully Disagree
It is important that all children diagnosed with autism receive some form of special education services at school.	It is important that all children diagnosed with autism receive some form of special education services at school. Fully Agree	It is important that all children diagnosed with autism receive some form of special education services at school. Mostly Agree	It is important that all children diagnosed with autism receive some form of special education services at school. Somewhat Agree	It is important that all children diagnosed with autism receive some form of special education services at school. Somewhat Disagree	It is important that all children diagnosed with autism receive some form of special education services at school. Mostly Disagree	It is important that all children diagnosed with autism receive some form of special education services at school. Fully Disagree
Autism occurs more commonly among higher socioeconomic and educational levels.	Autism occurs more commonly among higher socioeconomic and educational levels. Fully Agree	Autism occurs more commonly among higher socioeconomic and educational levels. Mostly Agree	Autism occurs more commonly among higher socioeconomic and educational levels. Somewhat Agree	Autism occurs more commonly among higher socioeconomic and educational levels. Somewhat Disagree	Autism occurs more commonly among higher socioeconomic and educational levels. Mostly Disagree	Autism occurs more commonly among higher socioeconomic and educational levels. Fully Disagree
Autism can be diagnosed as early as 18 months.	Autism can be diagnosed as early as 18 months. Fully Agree	Autism can be diagnosed as early as 18 months. Mostly Agree	Autism can be diagnosed as early as 18 months. Somewhat Agree	Autism can be diagnosed as early as 18 months. Somewhat Disagree	Autism can be diagnosed as early as 18 months. Mostly Disagree	Autism can be diagnosed as early as 18 months. Fully Disagree
With the proper treatment, most children diagnosed with autism eventually outgrow the disorder.	With the proper treatment, most children diagnosed with autism eventually outgrow the disorder. Fully Agree	With the proper treatment, most children diagnosed with autism eventually outgrow the disorder. Mostly Agree	With the proper treatment, most children diagnosed with autism eventually outgrow the disorder. Somewhat Agree	With the proper treatment, most children diagnosed with autism eventually outgrow the disorder. Somewhat Disagree	With the proper treatment, most children diagnosed with autism eventually outgrow the disorder. Mostly Disagree	With the proper treatment, most children diagnosed with autism eventually outgrow the disorder. Fully Disagree
Children with autism do not show affection.	Children with autism do not show affection. Fully Agree	Children with autism do not show affection. Mostly Agree	Children with autism do not show affection. Somewhat Agree	Children with autism do not show affection. Somewhat Disagree	Children with autism do not show affection. Mostly Disagree	Children with autism do not show affection. Fully Disagree
The need for routines and sameness is one of the earliest behavioral features of autism.	The need for routines and sameness is one of the earliest behavioral features of autism. Fully Agree	The need for routines and sameness is one of the earliest behavioral features of autism. Mostly Agree	The need for routines and sameness is one of the earliest behavioral features of autism. Somewhat Agree	The need for routines and sameness is one of the earliest behavioral features of autism. Somewhat Disagree	The need for routines and sameness is one of the earliest behavioral features of autism. Mostly Disagree	The need for routines and sameness is one of the earliest behavioral features of autism. Fully Disagree

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* To ensure that participants only complete the survey once, we ask that you provide a unique and confidential ID:

What are the first 2 letters of your mother's maiden name?

What is the number of the month you were born?

What are the first 2 letters of the city you were born in?

How or where did you hear about this survey?

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* Please provide the following:

Age

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* Gender:

Male

Female

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* What is your role?

Parent/Caregiver

Medical professional (MD, nurse)*

Educational personnel*

Licensed therapist (PhD, MSW, SLP)*

Other (please specify)

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* How many years of experience have you had with autism?

None

< 2 years

2-5 years

5 + years

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* For PARENTS/CAREGIVERS
What is your child's diagnosis?

Autism

Asperger's Disorder

PDD-NOS

Other (please specify)

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* For SERVICE PROVIDERS*

What percentage of your student/patient population falls in the autism spectrum?

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* Directions: Please answer the following questions on this survey as best you can. Do not spend too much time on any one question. For each of the following statements, check the number that best reflects how much you AGREE with each statement.

Question Title

* To ensure that participants only complete the survey once, we ask that you provide a unique and confidential ID:

Question Title

* Please provide the following:

Question Title

* Gender:

Question Title

* What is your role?

Question Title

* How many years of experience have you had with autism?

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* For PARENTS/CAREGIVERSWhat is your child's diagnosis?

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* For SERVICE PROVIDERS*

* For PARENTS/CAREGIVERS
What is your child's diagnosis?