Treatment Effectiveness Survey

Dear Parent:
Parent experience is an extremely valuable, yet rarely used, source of information for assessing alternative means of treatment. The Autism Research Institute needs your help in evaluating the various forms of therapy, including drugs, which are used in treating autism.

PLEASE HELP by completing this form. We will summarize the results in easy-to-understand form, for publication on the Internet, the ARI newsletter, the ASA Advocate, and elsewhere.

The more data we collect, the more meaningful the results will be. So, parents, please complete this form.

Thank you,
Bernard Rimland, Ph.D. and Steve Edelson, Ph.D.

Today's Date [use format: mo/da/yr]:

Parent's Name (first, last):
/

Address1:
Address2:
City: , State: Zipcode/Postal code:
Country [if outside U.S.]:

Telephone: Fax:
E-mail: <==Please enter your e-mail address

Child in ARI files? Yes No Unknown

Child's Name

Date of Birth [format: mo/da/yr; e.g., 09/25/98]: Age:

Sex of Child: Boy Girl

Age Autism Started (months):
[If started at birth, please type 'at birth.']

Diagnosis: You may check more than one diagnosis.

Autism Asperger Syndrome PDD-NOS Landau-Kleffner Syndrome Other
If you checked 'Other,' please specify:

Seizures? Never Infrequently Often

Level of Functioning: Low Moderate High

SELECT A LETTER TO RATE TREATMENT EFFECTIVENESS:

A = Definitely Helped; B = Moderate Improvement; C = Possibly Helped;
D = No Definite Effect; E = Little Worse; F = Much Worse

I. Drugs

(* For anti-seizure drugs, use first line to rate the behavior, second line for seizure control)

ACTOS A B C D E F
Aderall A B C D E F
Amphetamine A B C D E F
Anafranil A B C D E F
Antibiotics A B C D E F
Antifungal -- Diflucan A B C D E F
Antifungal -- Nystatin A B C D E F
Atarax A B C D E F
Benedryl A B C D E F
Beta Blocker A B C D E F
Buspar A B C D E F
Chloral Hydrate A B C D E F
Clonidine A B C D E F
Clozapine A B C D E F
Cogentin A B C D E F
Cylert A B C D E F
Deanol A B C D E F
*Depakene (behavior) A B C D E F
*Depakene (seizure) A B C D E F
Desipramine A B C D E F
*Dilantin (behavior) A B C D E F
*Dilantin (seizure) A B C D E F
Felbatol A B C D E F
Fenfluramine A B C D E F
Halcion A B C D E F
Haldol A B C D E F
*Klonapin (behavior) A B C D E F
*Klonapin (seizure) A B C D E F
Lithium A B C D E F
Luvox A B C D E F
Mellaril A B C D E F
*Mysoline (behavior) A B C D E F
*Mysoline (seizure) A B C D E F
Naltrexone A B C D E F
Naltrexone (low dose) A B C D E F
Pentoxifylline A B C D E F
Paxil A B C D E F
Pepcid A B C D E F
Phenergan A B C D E F
*Phenobarbital (behavior) A B C D E F
*Phenobarbital (seizure) A B C D E F
Prolixin A B C D E F
Prozac A B C D E F
Risperdal A B C D E F
Ritalin A B C D E F
R-THPB A B C D E F
Secretin: Intravenous A B C D E F
Secretin: Transdermal A B C D E F
Stelazine A B C D E F
*Tegretol (behavior) A B C D E F
*Tegretol (seizure) A B C D E F
Thorazine A B C D E F
Tofranil A B C D E F
Valium A B C D E F
Valtrex A B C D E F
*Zarontin (behavior) A B C D E F
*Zarontin (seizure) A B C D E F
Zoloft A B C D E F
Other: A B C D E F
Other: A B C D E F
Other: A B C D E F

II. Supplements


Calcium A B C D E F
Cod liver oil A B C D E F
Cod liver oil with
Bethanocol (Urocholine) 		A B C D E F
Colostrum A B C D E F
Digestive enzymes A B C D E F
DMG A B C D E F
Fatty acids A B C D E F
Folic acid A B C D E F
Melatonin A B C D E F
P5P A B C D E F
SAMe A B C D E F
St. John's Wort A B C D E F
TMG A B C D E F
Vitamin A A B C D E F
Vitamin B3 A B C D E F
Vitamin B6/magnesium A B C D E F
Vitamin B12 (Oral) A B C D E F
Methyl B12 (Nasal) A B C D E F
Methyl B12 (Subcutaneous) A B C D E F
Vitamin C A B C D E F
Zinc A B C D E F
5HTP A B C D E F
Other: A B C D E F
Other: A B C D E F
Other: A B C D E F

III. Diets


Candida Diet A B C D E F
Feingold Diet A B C D E F
Gluten/Casein-Free A B C D E F
Low Oxalate Diet A B C D E F
Rotation Diet A B C D E F
Removed Chocolate A B C D E F
Removed Diary A B C D E F
Removed Eggs A B C D E F
Removed Sugar A B C D E F
Removed Wheat A B C D E F
Specific Carbohydrate Diet (SCD) A B C D E F
Other: A B C D E F
Other: A B C D E F
Other: A B C D E F

IV. Misc. Therapies/Conditions


Behavior modification A B C D E F
Berard AIT A B C D E F
Floortime A B C D E F
Food allergy treatments A B C D E F
Heavy Metal Detox. (chelation) A B C D E F
High fever A B C D E F
Homeopathy A B C D E F
Hyperbaric Oxygen (HBO) A B C D E F
IVIG A B C D E F
MT Promoter A B C D E F
NAET A B C D E F
Neurofeedback A B C D E F
Occupational therapy A B C D E F
Options Program ("Son Rise"): child's speech A B C D E F
Options Program ("Son Rise"): child's behavior A B C D E F
Options Program ("Son Rise"): parent's attitude A B C D E F
Patterning (Doman/Delacato) A B C D E F
Sensory integration A B C D E F
Social skills training A B C D E F
Speech therapy A B C D E F
Relationship Development Intervention (RDI) A B C D E F
Steroids A B C D E F
Tomatis program A B C D E F
Transfer factor A B C D E F
Vaccination A B C D E F
Do you feel your child was injured by a vaccine? Yes No Maybe
If so, which vaccine?
At what age?
Other: A B C D E F
Other: A B C D E F
Other: A B C D E F