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Childhood Disabilities: Early Identification and Intervention

 

PDQ

Parental Development Questionnaire

This questionnaire is intended to help parents, guardians and physicians record observations about a child's behavior. The results of this questionnaire cannot be considered a diagnosis, but may indicate the need for referral, further testing and intervention.

Physician Information Personal Information
Name Child's name
Practice name Parent's/Guardian's name
Address Address
City City
State Zip State Zip
Phone Phone
Child's date of birth
Child's age now
Child's sex male female
Date(s) of observation

How to use this questionnaire

Use this questionnaire to record how often you see your child behave in the ways described on the next page. Before you begin, read through the entire list of behaviors to make sure you know which behaviors to look for.

Watch your child over a six-hour period in his or her natural setting, for example at home or day care. Take your time. You can watch your child for several days if necessary.

Using the rating scale on the following page, circle the number which best indicates how often, if ever, your child behaves this way.

Rating Scale

0 Never saw You have never seen your child behaving this way.
1 Rarely saw You saw your child behave this way 1-2 times in 6 hours.
2 Sometimes saw You saw your child behave this way 3-4 times in 6 hours.
3 Frequently saw You saw your child behave this way 5 or more times in 6 hours.

 

Nbr. Question Never Rarely Sometimes Frequently
1 Avoids making and/or holding eye contact when spoken to. 0 1 2 3
2 Flaps hands or fingers in front of face or at sides. 0 1 2 3
3 Becomes upset when routines are changed. 0 1 2 3
4 Uses toys or objects inappropriately (spins wheels, takes toys apart). 0 1 2 3
5 Lines objects in orderly manner and becomes upset when order is disrupted 0 1 2 3
6 Gets too engaged in toys or books and is distressed when interrupted. 0 1 2 3
7 Fails to point out objects of interest to him/her. 0 1 2 3
8 Is physically remote (does not want hugs, kisses, cuddling). 0 1 2 3
9 Does not have system of gesturing (pointing, waving) 0 1 2 3
10 Does not exhibit reasonable fear (wanders away, runs to street). 0 1 2 3
11 Slaps, hits or bites self or in other ways attempts to injure self. 0 1 2 3
12 Whirls or spins in circles. 0 1 2 3
13 Walks on tiptoes while moving or standing. 0 1 2 3
14 Gazes into space and seems lost to reality. 0 1 2 3
15 Does not engage in imaginative play activities. 0 1 2 3
16 Does not imitate children or adults during play. 0 1 2 3
17 Responds to anger and frustration with tantrums. 0 1 2 3
18 Holds hands to ears to shield noises that don't seem to bother others. 0 1 2 3
19 Does not carry out simple commands or requests. 0 1 2 3
20 Becomes very agitated and uncomfortable in noisy or crowded places. 0 1 2 3
21 Leads parent by hand toward needed item. 0 1 2 3
22 Uses parent's hands to open bags or containers. 0 1 2 3
23 Pays attention to sounds or songs more than to people speaking. 0 1 2 3
If your child is verbal or uses other forms of communication (i.e. signing or PECS), look for the following behaviors.
24 Does not use language to answer questions. 0 1 2 3
25 Repeats words, phrases or sounds for pleasure without engaging others. 0 1 2 3
26 Has good speech, but speaks to no one in particular (without eye contact). 0 1 2 3
Regarding the following behavior, consider your child's behavior over the last several weeks or months.
27 Says a word one time only, and/or has lost previously acquired language. 0 1 2 3

Score Summary

Add all the numbers you circled and write the total in the box.  
  • A score from 0-10 indicates no need for referral or further testing.
  • A score from 11-25 indicates a mild, but present situation, which should be discussed with a physician for possible referral.
  • A score above 25 indicates a strong need for referral and possible intervention.

Parents' or Guardians' Comments

To provide a more complete picture of your child, please write down any information that you feel might help Physicians or others understand your child. Include information about positive as well as troublesome behavior.

If you need additional information, please contact the NACA toll free at (877) 928-8476. Or contact http: www.yautism.com .

 

 

 

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