Parent Questionnaire



University of Massachusetts Lowell, Department of Psychology

Research investigation to identify the challenges faced by parents of those with an autism spectrum disorder.

Parent Questionnaire

Note: You do not have to answer questions that you would rather not and can just leave those blank.

General Information

1. How old are you?

2. Are you male or female?

1____Male 2____Female

3. What is your race? Mark one or more races to indicate how you consider yourself:

____ White

____ Black, African American, African, Negro

____ American Indian or Alaska Native

____ Asian, Asian-American

____ Native Hawaiian, Samoan, or other Pacific Islander

____ Other Asian – write in race:

____ Other race – Please print name of race:

4. What is your current marital status?

___ Married/Live with partner ___Widowed ___ Divorced/separated

___ Single, never married

5. What is the highest grade or year of school that have you completed?

1____Never attended school

2____Grades 1 through 4

3____Grades 5 through 8

4____Grades 9 through 11 (some high school, no diploma)

5____Grade 12: high school graduate or equivalent (such as GED)

6____ Some college but no degree

7____ Diploma or certificate from a vocational, technical, trade or business school beyond the High School level

8____ College: Associate degree (academic, occupational or vocational program)

9____ College: Bachelors degree (for example: BA, AB, BS)

10___ Master's degree (for example: MA, MS, MEng, MEd, MSW, MBA)

11___ Professional school degree (for example: MD, DDS, DVM, LLB, JD)

12___ Doctorate degree (for example: PhD, ScD, EdD)

6. In the last 12 months, about how much was your household’s total income, before

taxes, from all sources? (includes child support, other family member’s jobs, tips and bonuses, alimony, pensions, welfare, SSI, and any other income)

Less than $10,000 ____ $60,000 - $69,999 ____

$10,000 - $19,999 ____ $70,000 - $79,999 ____

$20,000 - $29,999 ____ $80,000 - $89,999 ____

$30,000 - $39,999 ____ $90,000 - $99,999 ____

$40,000 - $49,999 ____ $100,000 – or greater ____

$50,000 - $59,999 ____

7. Do you or your family own your home / pay rent / other?

___ Own ___ Pay rent ___ Other: __________________________

8. Are you employed?

____Part Time _____Full time ____Unemployed and seeking for job

____Unemployed and not seeking for job (e.g., housewife/husband)

_____Retired

9. How many children are you raising in your family (oldest to youngest)?

| |Gender |Age |Specific Diagnosis (or typically developing |If diagnosed when was |

| | | | |diagnosed (year) |

|1 |M/F | | | |

|2 |M/F | | | |

|3 |M/F | | | |

|4 |M/F | | | |

|5 |M/F | | | |

|6 |M/F | | | |

|7 |M/F | | | |

|8 |M/F | | | |

Listed below are people and groups that are often helpful to families. Part A of the questionnaire asks you to indicate how helpful each source is to your family. Please check the response that best describes how helpful the source has been to your family. If a source of help has not been available to your family during this period of time, check Not Available.

Part B asks you to indicate how satisfied you are with the helpfulness of each source of support.

10. PART A

| |0 |1 |3 |4 |5 |

| |Not |Not at All |Sometimes |Generally |Very |

| |Available |Helpful |Helpful |Helpful |Helpful |

|1. acceptance of your child from family members. | | | | | |

|2. acceptance of your child from friends. | | | | | |

|3. acceptance of your child from society in general. | | | | | |

|4. knowledge and awareness in society of autism spectrum disorders | | | | | |

|(ASD). | | | | | |

|5. knowledge and awareness among professionals (e.g. teachers, | | | | | |

|aides, doctors, psychologists etc.) of ASD. | | | | | |

|6. the effects of having a child with ASD on your career/employment | | | | | |

|7. the effects of having a child with ASD on your marriage / | | | | | |

|partnership. | | | | | |

|8. the effects of having a child with ASD on your social life | | | | | |

|9. your own ability to cope with the demands of raising a child with| | | | | |

|ASD. | | | | | |

|10. your feelings of stress. | | | | | |

|11. your feelings of anxiety. | | | | | |

|12. your feelings of depression. | | | | | |

|13. your feelings of anger | | | | | |

|14. your feeling ofguilt | | | | | |

|15 your feeling of sadness | | | | | |

|16. your feeling of hopelessness | | | | | |

|17. your feeling of loneliness | | | | | |

|18. your feeling of isolation | | | | | |

10. PART D

This part asks whether you were concerned about any of the issues listed in the table when your child was younger, perhaps between the ages of 5-10 years.

| |1 |3 |4 |5 |6 |

| |Not at All |Slightly |Quite Concerned |Very |Extremely |

| |Concerned |Concerned | |Concerned |Concerned |

|1. acceptance of your child from family members. | | | | | |

|2. acceptance of your child from friends. | | | | | |

|3. acceptance of your child from society in general. | | | | | |

|4. knowledge and awareness in society of autism spectrum disorders | | | | | |

|(ASD). | | | | | |

|5. knowledge and awareness among professionals (e.g. teachers, | | | | | |

|aides, doctors, psychologists etc.) of ASD. | | | | | |

|6. the effects of having a child with ASD on your career/employment | | | | | |

|7. the effects of having a child with ASD on your marriage / | | | | | |

|partnership. | | | | | |

|8. the effects of having a child with ASD on your social life | | | | | |

|9. your own ability to cope with the demands of raising a child with| | | | | |

|ASD. | | | | | |

|10. your feelings of stress. | | | | | |

|11. your feelings of anxiety. | | | | | |

|12. your feelings of depression. | | | | | |

|13. your feelings of anger | | | | | |

|14. your feeling of guilt | | | | | |

|15 your feeling of sadness | | | | | |

|16. your feeling of hopelessness | | | | | |

|17. your feeling of loneliness | | | | | |

|18. your feeling of isolation | | | | | |

11. How has having a child with ASD impacted your life? Please check to what extent you agree with the following statements:

| |1 |2 |3 |4 |

| |Strongly agree |Slightly agree |Slightly |Strongly disagree |

| | | |disagree | |

|1.Having a child with ASD has changed my perspective on life | | | | |

|2.I have a more positive outlook on life than I did before I had my child. | | | | |

|3. I take fewer things for granted than I used to before I had my child. | | | | |

|4.Having a child with ASD has positively impacted my career | | | | |

|5. I have less employment opportunities than I used to | | | | |

|6. I become frustrated more easily. | | | | |

|7. I have become a better person. | | | | |

|8. Having a child with ASD has changed how I view people | | | | |

|9. I have less friends (social experiences) than I used to | | | | |

|10. I have more patience with others. | | | | |

|11. I have more respect for others. | | | | |

|12. I “don’t sweat the small stuff” like I used to. | | | | |

|13. I am less spiritual and / or religious than I used to be. | | | | |

|14. I am more open-minded. | | | | |

|15. I have become a weaker person. | | | | |

|16. Having a child with ASD has negatively impacted my financial situation | | | | |

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