A collaboration of programs and agencies, including the Delaware Division for Developmental Disabilities and the Delaware Department of Education, are interested in the nutritional and dietary needs and concerns of children with autism. During the past decade, a number of professionals, families, and advocates have raised numerous questions about the impact of nutrition and diet on the development of children with autism. Your assistance with determining these needs and concerns is critical.  Please take approximately 15 minutes to complete this survey.

All individual responses are anonymous and CONFIDENTIAL and are not available to program or state officials.

We welcome individuals from any country and state in the United States to take this survey!

The survey below is designed in three parts. 
Part I asks about your child and family. 
Part II asks about your child’s diet and nutrition, and some medical history. 
Part III is designed for families who have prepared special diets for their children. 

We also ask that you provide us with any comments you might have about nutrition, diet and autism. We thank you in advance for your responses. Please answer with as much detail as you would like.
 
If you have any questions, please contact the Center for Disabilities Studies at (302) 831-6974.  Thank you for your time!

What is your country of residence?

United States Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo (Brazzaville) Congo, Democratic Republic of the Costa Rica Croatia Cuba Cyprus Czech Republic Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic East Timor (Timor Timur) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Western Sahara Yemen Zambia Zimbabwe Other If other, please specify:

If you are from the United States of America, please specifiy what state you are from.

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands of the U.S. Virginia Washington West Virginia Wisconsin Wyoming

What is your child's birth month and year?

January February March April May June July August September October November December   1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Boy    Girl

African American  American Indian

Asian   Caucasian

Hispanic   Multicultural   

If other, please specify:

*This question is OPTIONAL. Responses to this question will be used ONLY to help determine whether the sample of respondents to this survey is racially/ethnically representative of the population of children receiving special education services in Delaware.

What is your child's medical diagnosis?

What is your child’s autism spectrum or autism related diagnosis? 

Aspergers Disorder Autism Spectrum Disorder Childhood Degenerative Disorder Pervasive Developmental Delay- Nonspecific Retts Syndrome Other

If other, please specify below:

What profession was the person who diagnosed your child (e.g., doctor, psychologist)?

Developmental Pediatrician Family Physician Neurologist Pediatrician Psychiatrist Psychologist Speech Language Pathologist Other

If other, please specify below:

What month and year was your child diagnosed?

January February March April May June July August September October November December   1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

How many children are in your family?     

Does or has your child taken medication(s)?  Yes    No

If, “yes,” please indicate type, start, and stop dates.

For example: Prescription X; January 4, 2004 to June 5, 2004

Does your child receive any other medical treatment(s)? Yes    No

If, “yes,” please indicate type, start, and stop dates.

For example: Treatment Y; April 14, 2003 to July 27, 2004

Please describe your child’s typical daily diet.         

Have you consulted with anyone about your child’s diet? Yes    No                                

If you answered “yes,” with what type of professional have you consulted? (e.g., dietician, doctor):

Does your child have food texture preferences? Yes    No   I don't know  

If you answered “yes,” what type of preferences does he or she have? (e.g., smooth, lumpy)

Does your child have food color preferences?   Yes    No    I don't know                  

If you answered “yes,” what colors does he or she prefer and not prefer?

Does your child have food temperature preferences? Yes    No   I don't know  

If you answered “yes,” what are his or her temperature preferences?

Does your child have any food allergies? Yes    No                                    

If you answered “yes,” what are these allergies, when did they start and what treatment was/is provided for them? 

Do types of food seem to affect your child’s behavior? Yes    No    I don't know       

If you answered “yes,” what types of food and how is his or her behavior affected? 

Does your child have trouble with constipation and/or diarrhea?   Yes    No     

If you answered “yes,” please describe the trouble and frequency.

Does your child have other stomach or gastrointestinal troubles? Yes    No   

If you answered “yes,” please describe the troubles and frequency.

Have you tried or used any homeopathic therapies with your child? Yes    No   

If you answered “yes,” please describe the types of homeopathic therapies you have tried.

Have you used a special diet or dietary supplements? Yes    No  

If no, please skip part three and click this link to complete the survey.

If yes, please fill in part three.

Please complete this section only if you have used a special diet or dietary supplements for your child. 

Please describe any special diet you have used for your child, including what the name, start date (month and year) and stop date (month and year) of the diet.  Please be sure to describe the diet.                     

Please describe any dietary supplements you have used for your child, including what the name, start date (month and year) and stop date (month and year) of the supplement.  Please be sure to describe the supplement.                     

How did you find out about your child’s diet or supplement?                                

How satisfied are/were you with your child’s special diet/supplement?        

Very     Somewhat    Not at all      

Very     Somewhat    Not at all   

How worthwhile is/was it to implement your child’s diet or supplement?      

Very     Somewhat    Not at all   

What support or information did/do you need to be able to implement your child’s special diet/supplement?

What benefits or advantages do/did you and your child gain from implementing your child’s special diet/supplement?    

What drawbacks or disadvantages do/did you and your child experience from implementing your child’s special diet/supplement?

Do you use or have you implemented a Gluten-free/casein-free (GFCF) diet for your child? Yes    No  

If you answered “yes,” please tell us about using the GFCF diet with your child.

Please add any additional comments you have about nutrition and diet and your child with autism.

Please tell us how you got here and why you are taking this survey? (This information will be used in the future development of surveys.)