FAPCI. Functioning after Pediatric Cochlear Implantation. Parent/Caregiver Survey

Transcription

1 FAPCI Functioning after Pediatric Cochlear Implantation Parent/Caregiver Survey Frank R. Lin M.D., Kristin Ceh M.Ed CED, Deborah Bervinchak M.A., John Niparko M.D. Parent/Caregiver name Relationship to child Child s name Child s birthdate / / Month Day Year Today s Date FAPCI v

2 Directions: This survey is about behaviors and activities that your child may do at home. Please read each item and then review all the available responses. Circle the ONE response that best describes your child s behavior and activities over the LAST FOUR WEEKS. To change a response, place an X through it and circle your new choice. Here is an example of a question: 1) How much of your child s speech (any sounds or words that your child produces) can you understand? A. Almost none (0-4%) B. A little (5-24%) C. Some (25-49%). D. Most (50-95%) E. Almost all (96-100%) If an item is unclear or more than one response applies, circle the ONE best answer and write comments next to the item. Definitions: Certain words and phrases used throughout the survey are defined here: Age-appropriate: The appropriate level for your child based on his/her chronological age (your child s age in years). Visual cues: Consist of cued speech, sign language, or gestures. FAPCI v

3 Reminder: Visual cues refer to cued speech, sign language, or gestures. For Questions 1-9: How often does your child? (Grammar is not important.) 1) Respond to phrases that s/he overhears from a nearby conversation? (For example, your child overhears you say ice cream and responds by becoming excited, signing ice cream, or saying I want some! ) 2) Appropriately answer simple questions presented in SPOKEN language WITHOUT visual cues? (For example, your child nods/signs/speaks when asked Do you want juice or milk? or Do you want to watch a movie? ) 3) Talk about his/her experiences during the day or about a past event using simple SPOKEN sentences? (for example, I ate a hot dog, Me and Mom play soccer. ) 4) Ask simple questions using SPOKEN language? (for example, Can I more milk?, Can you read me story? ) 5) Use the past tense in SPOKEN language? (for example, I talked to Grandma, I ate French fry ) 6) Use the negative in a 2-3 word SPOKEN phrase? (for example, Me no want, Don t do that ) 7) Correctly use pronouns in SPOKEN language? (for example, We go to school, She took it ) 8) Correctly use prepositions in SPOKEN language? (for example, My toy is under the bed, My cup is on the table ) 9) Initiate a spoken conversation with another child? (For example, your child tells a classmate about his/her new toy.) FAPCI v

4 10) How many age-appropriate items would your child be able to IDENTIFY with SPOKEN language when they are pointed to? (For example, you point to a tomato/chair/phone and ask What s this? ) A. Almost none of the objects (0-4%) B. Few of the objects (5-24%) C. Some of the objects (25-49%) D. Most of the objects (50-95%) E. Almost all of the objects (96-100%) 11) How much of your child s speech (any sounds or words that your child produces) would an adult who is not familiar with your child understand? A. Almost none (0-4%) B. A little (5-24%) C. Some (25-49%) D. Most (50-95%) E. Almost all (96-100%) 12) How does your child typically respond when greeted by a familiar person? (For example, your child sees Grandma or a close friend of the family.) Your child greets the person using A. Only gestures or facial expressions (for example, waving hi, smiling) B. Only sign language C. 1 spoken word/word approximation (for example, Hi. ) D. 2 or 3 spoken words (for example, Hi, Uncle Frank ) E. Complex spoken language (for example, Hi Grandma, will you read me a book? ) 13) How many people s names does your child use in SPOKEN language? (For example, your child says Mom, Grandma, Uncle Frank ) A. None (for example, your child may only use names in sign language) B. 1-2 (for example, Mama, Dada) C. 3-5 (for example, Mama, Dada and other close family members such as brothers/sisters) D (for example, close family members and some other familiar relatives/friends) E. >10 (for example, names of almost all familiar people who your child is in contact with) 14) Which statement best describes your child s singing? (for example, Itsy-bitsy spider, Row, row, row your boat ) A. I have not heard my child sing. B. My child hums or sings without using words. C. My child sings with a few understandable words. D. My child sings with mostly understandable words, but does NOT have pitch. E. My child sings with mostly understandable words and has SOME pitch. Hint: Pitch refers to hitting the right notes or being in tune. FAPCI v

5 15) What is the MAIN way that your child communicates his/her wants when NOT coached by an adult? (For example, your child wants milk, needs to go to the bathroom, or is too hot in his/her jacket) Your child uses A. Gestures with or without vocalizations (for example, crying when too hot in his/her jacket; pointing to a cookie and grunting) B. Sign language with or without vocalizations (for example, using the sign for cookie) C. 1 spoken word/word approximation with or without sign language (for example, saying milk and using the corresponding sign) D. 2 or 3 simple spoken words with or without sign language (for example, Cookie, please, I want cookie, Me hot ) E. Complex spoken language (for example, Can I please have a cookie after I finish my dinner?, I need to go the bathroom ) For Questions 16-17: How many of the following types of words/phrases does your child use in SPOKEN language? Grammar is not important. 16) - What (for example, your child says What?! or What that? ) - Where (for example, Where is it?, Where my toy? ) - Why (for example, Why do we have to? ) - Inversion questions (for example, Are we there yet? ) - Which (for example, Which mine?) A. None B. 1 C. 2 D. 3 E ) - Words to describe color or size (for example, your child says red ball or big car ) - Numbers to describe how many (for example, three dogs, two cars) - Words to describe quantity (for example, lots of cars, all gone, many) - Plural endings (for example, cars, books, cookies) - Possessive endings (for example, Nick s toy, Mom s car) A. None B. 1 C. 2 D. 3 E. 4-5 FAPCI v

6 For Questions 18-21: Which statement best describes your child s understanding of SPOKEN language WITHOUT visual cues in the following situations? 18) When riding in a car, my child is able to understand A. No spoken language in this situation B. His/her name (for example, by looking up, smiling, vocalizing) C. One to two word statements (for example, Look, Police car ) D. Simple questions & commands (for example, Get your book., Are you hungry? ) E. Complex questions & commands (for example, What did you do at school?, What do you want to do when we get home? ) 19) When listening from a different room of the house, my child is able to understand A. No spoken language in this situation OR we do not communicate this way. B. His/her name (for example, by yelling back What? or coming to try and find you) C. One to two word statements (for example, Bedtime. ) D. Simple questions & commands (for example, Clean up your room., Are you hungry? ) E. Complex questions & commands (for example, What do you want for lunch?, Please put away your toys and come here. ) 20) When in a noisy environment (for example, while speaking face-to-face with your child at a birthday party), my child is able to understand A. No spoken language in this situation B. His/her name (for example, by looking up, smiling, vocalizing) C. One to two word statements (for example, Line up, Take a balloon ) D. Simple questions & commands (for example, Do you want cake?, Do you want to play? ) E. Complex questions & commands (for example, Where do you want to sit?, Finish your painting and let s get some cake. ) FAPCI v

7 21) When using the telephone with a familiar caller (for example, with a parent or grandparent), my child is able to understand A. No spoken language on the phone OR s/he has not begun to use the telephone. B. His/her name & simple words (for example, understanding Hello and responding by saying Hi ) C. Simple questions if they are spoken slowly and clearly (for example, How are you? ) D. Simple questions if they are spoken at a natural pace (for example, at the same pace as in a face-to-face conversation) E. Complex questions if they are spoken slowly or at a natural pace (for example, What did you do at school today?, What animals did you see at the zoo? ) 22) Given an UNLIMITED set of possible choices, how many age-appropriate items would your child be able to POINT TO when they are presented in SPOKEN language WITHOUT visual cues? (For example, when in the kitchen, you ask Where s the oven? your backpack? the dog? ) A. Almost none of the objects (0-4%) B. Few of the objects (5-24%) C. Some of the objects (25-49%) D. Most of the objects (50-95%) E. Almost all of the objects (96-100%) Reminder: Visual cues refer to cued speech, sign language, or gestures. 23) How many age-appropriate 2-step SPOKEN commands presented WITHOUT visual cues does your child understand? (for example, Put on your shoes and jacket, Put away your toys and wash your hands ) A. None B. 1-2 C. 3-5 D E. More than STOP HERE Incomplete = Subtotals Page 3 Page 4 Page 5 Page 6 Page 7 FAPCI Total FAPCI v