Appendix D Assessment Measures 12-22-10 PDF

Milwaukee Young Parenthood Study
Participant Assessment Tools
Appendix D MYPS Assessment Measures
Core Items and Demographics

AFL Baseline Evaluation
AFL Follow-Up Evaluation
Demographics
Stress and Coping
Perceived Stress Index
Parenting Stress Index
Everyday Discrimination Scale
Coping Self-Efficacy
Couple’s Relationship Variables
Conflict in Dating Relationships Inventory
Quality of Relationship Inventory
Parenting Measures
Caregiving Activities
Co-Parenting Relationship
Paternal-Infant Attachment Scale
Child Abuse Potential Inventory
Additional Risk and Protective Factors
CRAFFT
Past Trauma Screening items
Trauma Symptom Checklist-40
Other
Multigroup Ethnic Identity Measure
CRISYS
Consumer Assessment of Healthcare Providers/Systems
Brief Infant-Toddler Social and Emotional Assessment
Intervention: Therapist Client Intervention
Working Alliance (Client)
Working Alliance (Therapist)
Chart Review Worksheet

MYPS Time 1 Interview
MYPS time 4 Interview
1
Adolescent Family Life Care Programs Core Baseline Questionnaire (Time 1)

For Pregnant Teens
PRIVACY
We want you to know that:
1. Your answers to these questions will help us learn what people your age know, think, and do.
2. You may skip any questions you do not wish to answer. But we hope that you will answer as
many questions as you can.
3. Your answers will be combined with those of other teens. We will keep your answers private.
PLEASE DO NOT WRITE YOUR NAME ANYWHERE ON THIS SURVEY!
To be completed by project staff:

1. Client ID:
2. Site Number:
3. Today’s Date:
4. Site Name:
General Instructions
• Read all the answers before marking your choice. If none of the printed answer exactly applies
to you, black out the box beside the answer that best fits.
• Use a pencil to complete this survey
• Completely black out in the box beside your answer choice.
• If you make an error, erase it cleanly and them mark the box beside your correct answer choice.
• Do not make any stray marks
• PLEASE READ EACH QUESTION CAREFULLY.
Follow the directions for responding to each kind of question. These are:
2
3
About the Future

Think about the future and answer these questions:
1. How important is it to you to graduate high school? Or to graduate vocational or trade school?
MARK ONE
□ 1 Not important at all
□ 2 Somewhat important
□ 3 Very important
□ 4 Extremely important
□ 96 Already graduated
Answer the next question using a scale from 1 to 5. 1 is “not at all” and 5 is “a lot”
2. How much do you want to get more education or training? This could be college, vocational or
technical school, or a nursing certification.
MARK ONE
□ 1 Not at all
□ 2
□ 3
□ 4
□ 5 A lot
□ 97 Don’t Know
3. How important is it for you to get training to get the kind of job you want?
MARK ONE
□ 1 Not Important
□ 2
□ 3
□ 4
□ 5 Very Important
□ 97 Don’t Know
WHAT YOU THINK
4. Please mark how much you agree or disagree with this statement:
It is better for a person to get married than to go through life being single.
MARK ONE
□ 1 Strongly Agree
□ 2 Agree
□ 3 Neither Agree or Disagree
□ 4 Disagree
□ 5 Strongly Disagree
□ 97 Don’t Know
5. How much do you stay away from people who might get you into trouble?
MARK ONE
□ 1 Almost Never
□ 2 Some of the time
□ 3 Usually
□ 4 Almost Always
4
Please mark how much the following statements sound like you.
6. I think I should work to get something, if I really want it.
MARK ONE
□ 1 Not at all like me
□ 2 A little like me
□ 3 Mostly like me
□ 4 Very much like me
□ 97 Don’t Know
7. I make decisions to help me reach my goals.
MARK ONE
□ 97 Don’t Know
8. Some young women feel they are not ready to be a parent. For these women, I think adoption is
a good choice.
MARK ONE
□ 97 Don’t Know
The next question is about your mother or father. Or a person like a mother or father to you.
9. How often do you talk to your mother or father about your problems?
MARK ONE
□ 1 Almost never
□ 3 Usually
□ 4 Almost Always
□ 96 There is no person who is like a mother or father to me
ABOUT YOUR HEALTH
This next question is about your health.
10. These are some ways people try to avoid sexually transmitted diseases. What way(s) did you try
this month?
MARK ONE OR MORE
□ 1 No method used this month
□ 2 Abstinence (did not have sex this month)
□ 3 Condom
□ 4 Female condom, vaginal pouch
□ 5 Other Method (Describe_______________)
11. How many weeks or months pregnant are you
______1 Weeks or _________2 Months
12. Including this pregnancy, how many times have you been pregnant in your life?
MARK ONE
□ 1 Once
□ 2 Twice
□ 3 Three times
5
□ 4 More than three times

ABOUT YOU
These questions ask about you.
13. How old are you?
MARK ONE
□ 1 12 years old or younger
□ 2 13 years old
□ 3 14 years old
□ 4 15 years old
□ 5 16 years old
□ 6 17 years old
□ 7 18 years old
□ 8 19 years old or older
14. What is your marital status?
MARK ONE
□ 1 Single, never married (including living with someone or engaged)
□ 2 Married
□ 3 Separated or divorced
□ 4 Widowed
□ 5 Other (Describe______________)
15. Which of these statements best describes your relationship with the father of the baby you are
expecting?
MARK ONE
□ 1 We do not see or talk to each other
□ 2 We hardly ever see or talk to each other
□ 3 We are just friends
□ 4 We are involved in an on-again, off-again relationship
□ 5 We are romantically involved on a steady basis but are not married
□ 6 We are married (SKIP TO #19)
□ 7 Don’t know
IF YOU ARE MARRIED TO THE FATHER OF THE BABY YOU ARE EXPECTING, SKIP TO #19
16. Do you and the father of your baby have a legal agreement for child support, alimony, custody,
visitation, or where the child will live?
□ 1 Yes
□ 0 No
17. Does the father of your baby give you money, buy clothes for the baby, pay for doctor visits, or
provide other kinds of support?
□ 1 Yes
□ 0 No
18. Does the father of your baby do things to help you with your pregnancy? Some things may be to
provide transportation to the pre-natal clinic or help with chores.
□ 1 Yes
□ 0 No
19. Who do you live with now?
MARK ALL THAT APPLY
□ a. I live alone
□ b. With husband
□ c. With my mother (include stepmother)
6
□ d. With my father (include stepfather)

□ e. With baby’s father
□ f. With baby’s father’s mother
□ g. With baby’s father’s father
□ h. With partner
□ i. With other relatives
□ j. With friends
□ k. In a group home/institution
□ l. In a foster home
□ m. Other (Describe___________________)
20. Think about any children who may live with you. How many are under your care?
MARK ONE
□ 0 Zero (SKIP TO #22)
□ 1 One
□ 2 Two
□ 3 Three or more
21. How many of these children were born to you?
MARK ONE
□ 0 Zero
□ 1 One
□ 2 Two
□ 3 Three or more
22. Are you Hispanic or Latino?
□ 1 Yes
□ 0 No
23. Mark the box or boxes to describe your race.
MARK ONE OR MORE
□ 1 White
□ 2 Black or African American
□ 3 Asian
□ 4 Native Hawaiian or Other Pacific Islander
□ 5 American Indian or Alaska Native
□ 6 Other (Describe____________)
24. What is your current school status?
MARK ONE
□ 1 In school or GED program
□ 2 Graduated from high school or completed GED (SKIP TO #26)
□ 3 Dropped out of school
□ 4 Other (Describe______________)
25. IF YOU HAVE NOT FINISHED YOUR HIGH SCHOOL OR COMPLETED YOUR GED:
Do you want to have another baby before you finish high school?
□ 1 Yes
□ 0 No
□ 97 Don’t know
26. What is the highest grade you have completed?
MARK ONE
□ 1 8th grade or below
□ 2 9th grade
7
□ 3 10th grade
□ 4 11th grade
□ 5 12th grade
□ 6 Some college
□ 7 College degree or more
□ 97 Don’t know
27. Have you ever been in a job training program?
□ 1 Yes
□ 0 No (SKIP TO #29)
28. Did you ever complete a job training program?
MARK ONE
□ 1 Yes
□ 2 No and not in a job training program
□ 3 No and now in a job training
29. How many hours do you work per week?
WRITE 00 IF YOU DO NOT WORK
______________ Hours per week
30. Do you receive money or aid from any of the following sources?
MARK ALL THAT APPLY
□ a. Medicaid
□ b. Food stamps
□ c. WIC (Women, Infants, and Children) Program
□ d. TANF (Temporary Aid to Needy Families)
□ e. Social Security
□ f. Unemployment or Workers’ Compensation
□ g. Other public aid
□ h. Child support
□ i. My job
□ j. Husband or partner
□ k. Parent(s)
□ l. Other (Describe___________________)
31. What is your main source of financial support?
MARK ONE
□ 1 My job
□ 2 Husband or partner
□ 3 Parents
□ 4 Public aid
□ 5 Other relatives
□ 6 Other (Describe______________________)
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Adolescent Family Life Care Programs Core Follow-Up Questionnaire (Time 2-Time 4)
9
10
11
About the Future

Think about the future and answer these questions:
1. How important is it to you to graduate high school? Or to graduate vocational or trade school?
Mark ONE
□ 1 Not important at all
□ 2 Somewhat important
□ 3 Very important
□ 4 Extremely important
□ 96 Already graduated
Answer the next question using a scale from 1 to 5. 1 is “not at all” and 5 is “a lot.”
2. How much do you want to get more education or training? This could be college, vocational or
technical school, or a nursing certification.
Mark ONE
□ 1 Not at all
□ 2
□ 3
□ 4
□ 5 A lot
□ 97 Don’t Know
3. How important is it for you to get training to get the kind of job you want?
Mark ONE
□ 1 Not Important
□ 2
□ 3
□ 4
□ 5 Very Important
□ 97 Don’t Know
WHAT YOU THINK
4. Please mark how much you agree or disagree with this statement:
It is better for a person to get married than to go through life being single.
Mark ONE
□ 1 Strongly Agree
□ 2 Agree
□ 3 Neither Agree or Disagree
□ 4 Disagree
□ 5 Strongly Disagree
□ 97 Don’t Know
5. How much do you stay away from people who might get you into trouble?
Mark ONE
12
□ 1 Almost Never
□ 3 Usually
□ 4 Almost Always
Please mark how much the following statements sound like you.
6. I think I should work to get something, if I really want it.

Mark ONE
□ 97 Don’t Know
7. I make decisions to help me reach my goals.
Mark ONE
□ 97 Don’t Know
8. Some young women feel they are not ready to be a parent. For these women, I think adoption is
a good choice.
Mark ONE
□ 97 Don’t Know
The next question is about your mother or father or a person like a mother or father to you.
9. How often do you talk to your mother or father about your problems?
Mark ONE
□ 1 Almost never
□ 3 Usually
□ 4 Almost Always
□ 96 There is no person who is like a mother or father to me
ABOUT YOUR CHILD
These next questions are about the child you were pregnant with on_________________.
MM/DD/YY
10. Did this pregnancy end in live birth?
□ 1Yes
□ 0No (IF YOUR ANSWER IS “NO,” SKIP TO #30 ON PAGE 4.)
13
11. When was this child born? ___ ___ / ___ ___
MONTH / YEAR
12. An early birth is one that occurs at 36 weeks or earlier in pregnancy. As far as you know, did you
have an early birth?
Mark ONE
□ 1 Yes
□ 2 No
□ 97 Don’t Know
13. How much did this child weigh at birth?
Mark ONE
□ 1 5 ½ pounds or more
□ 2 Less than 5 ½ pounds
□ 97Don’t know
The next questions refer to the child born

___ ___ /___ ___
MONTH / YEAR
14. Did you breastfeed this child at all?

□ 1 Yes
15. How old was this child when you completely stopped breastfeeding him or her?
Mark ONE
□ 1 I am still breastfeeding
□ 2 Less than 1 month old
□ 3 1 month old to 2 months old
□ 4 3 months old or more
16. Is this child alive now?
□ 1 Yes
□ 0 No IF YOU ANSWERED “NO,” SKIP TO #30 ON PAGE 4.
17. This next question is about after the birth of this child. About how many times has this child had
a regular check up or “well-baby” visit? This is a visit to the doctor or nurse when your child is
not sick, but to get checked out or to get shots. Would you say . . .
Mark ONE
□ 1 Never (SKIP TO #19 ON PAGE 3)
□ 2 1–3 times
□ 3 4 or more times
□ 97 Don’t know
18. When was this child’s last “well-baby” visit?

Mark THE MOST RECENT
□ 1 Within the past 3 months
14

□ 4 More than a year ago
□ 97 Don’t know
19. Does this child live with you?

Mark ONE
□ 2 Yes
□ 1 Sometimes
□ 0 No
20. Where does this child live now?

Mark ONE
□ 1 With the child’s father
□ 2 With other relatives
□ 3 With adoptive family
□ 4 Other (Describe________________)
□ 97 Don’t know
21. Is this child 3 months old or older?

□ 1 Yes
22. Has this child had any of the following vaccinations/shots?
Yes No Don’t
MARK ON ANSWER FOR EACH Know
a. Diptheria, Tetanus, Pertussis (DTaP)
b. Inactivated Poliovirus (IPV)
c. Haemophilus influenzae type b (Hib)
d. Hepatitis B (HepB)
e. Pneumococcal (PCV)
f. Rotavirus (Rota)
IF YOUR CHILD DOES NOT LIVE WITH YOU, PLEASE SKIP TO #26 ON PAGE 4.
23. This next question is about the past four weeks. Has this child received any regular child care?
This could be a day care, nursery school, play group, babysitter, after school care, relatives, or
some other child care plan. (Regular” means at least once a week for a month or more.)
□ 1 Yes
24. Which of these has been your main child care provider in the past four weeks?
Mark ONE
□ 1 Child’s father/stepfather
□ 2 My brother/sister aged 13 years or older
□ 3 My brother/sister younger than 13 years old
15
□ 4 Child’s grandparent
□ 5 Other relative
□ 6 Non-relative or babysitter
□ 7 Nursery/preschool
□ 8 Family day care
□ 9________________________________________________________________
□ 10 Day care center referred by ________________________________________
□ 11 Other day care center not referred by ________________________________
□ 12 Other (Describe__________________________________________________)
□ 13 Child has not received regular child care in the past four weeks
25. How many hours a week is this child in child care?

This includes all the different plans that you use.
________ Hours
□ 97 MARK HERE IF YOU DON’T KNOW
26. Which of these statements best describes your relationship with your child’s father?
Mark ONE
□ 1 We do not talk to each other
□ 2 We hardly ever see or talk to each other
□ 3 We are just friends
□ 4 We are involved in an on-again, off-again relationship
□ 5 We are romantically involved on a steady basis but are not married
□ 6 We are married (SKIP TO #31)
□ 7 Don’t know
IF YOU ARE MARRIED TO THE FATHER OF YOUR CHILD, SKIP TO #31.
27. Do you and your child’s father have a legal agreement for child support, alimony, custody,
visitation, or where the child will live?
□ 1 Yes
□ 2 No
28. Does your child’s father give you money or buy clothes for your child? Or pay for doctor visits or
provide other kinds of support?
□ 1 Yes
□ 2 No
29. Does your child’s father help you in other ways, such as watching the child or helping with
chores?
□ 1 Yes
□ 2 No
30. What is your marital status?

Mark ONE
□ 1 Single, never married (including living with someone or engaged)
□ 2 Married
□ 3 Separated or divorced
□ 4 Widowed
16
□ 5 Other (Describe ______________________)
31. Who do you live with now?

Mark ALL THAT APPLY
□ a. I live alone
□ b. With husband
□ c. With my mother (including stepmother)
□ d. With my father (including stepfather)
□ e. With this child’s father
□ f. With this child’s father’s mother
□ g. With this child’s father’s father
□ h. With partner
□ i. With other relatives
□ j. With friends
□ k. In a group home/institution
□ l. In a foster home
□ m. Other (Describe ____________________)
ABOUT YOUR HEALTH

This next question is about your health.
32. These are some ways people try to avoid sexually transmitted diseases. What way(s) did you try
this month?
Mark ALL THAT APPLY
□ a. No method used this month
□ b. Abstinence (did not have sex this month)
□ c. Condom
□ d. Female condom, vaginal pouch
□ e. Other (Describe_______________)
33. Our records show that you were pregnant on

____________________.
MM/DD/YY
Have you been pregnant since that pregnancy ended?

□ 1 Yes
□ 2 No
34. Have you been pregnant since ____________________?

MM/DD/YY
□ 1 Yes
□ 2 No
35. These are some ways people try to avoid pregnancy.

What way(s) did you try this month?
Mark ALL THAT APPLY

□ a. DOES NOT APPLY – I am pregnant now
17
□ b. No method used this month

□ c. Abstinence (did not have sex this month)
□ d. Birth control pills
□ e. Condom
□ f. Withdrawal, pulling out
□ g. Depo-Provera, injectables (the shot)
□ h. Natural family planning (rhythm or safe period by calendar, temperature or cervical
mucus test)
□ i. Diaphragm
□ j. Female condom, vaginal pouch
□ k. Foam
□ l. Jelly or cream
□ m. Cervical cap
□ n. Suppository
□ o. Sponge
□ p. IUD
□ q. “Morning after” pills or emergency contraception
□ r. contraceptive patch
□ s. NuvaRing (Vaginal ring)
□ t. Implanon
□ u. Other method (Describe________________________)
36. Since ____________________, have you received . . .

MM / DD / YY
Mark ALL THAT APPLY
□ a. A pregnancy test?
□ b. An abortion?
□ c. Prenatal care?
□ d. Post pregnancy care?
ABOUT YOU
These questions ask about you.
37. What is your current school status?
Mark ONE
□ 1 In school or GED program
□ 2 Graduated from high school or completed GED (SKIP TO #39)
□ 3 Dropped out of school
□ 4 Other (Describe______________)
38. IF YOU HAVE NOT FINISHED YOUR HIGH SCHOOL OR COMPLETED YOUR GED:
Do you want to have another baby before you finish high school?
□ 1 Yes
□ 0 No
□ 97 Don’t know
39. What is the highest grade you have completed?
Mark ONE
□ 1 8th grade or below
□ 2 9th grade
18
th
□ 3 10 grade
th
□ 4 11 grade
th
□ 5 12 grade
□ 6 Some college
□ 7 College degree or more
□ 97 Don’t know
40. Have you ever been in a job training program?

□ 1 Yes
41. Did you ever complete a job training program?

Mark ONE
□ 1 Yes
□ 2 No and not in a job training program
□ 3 No and now in a job training
42. How many hours do you work per week?

WRITE 00 IF YOU DO NOT WORK
______________ Hours per week
43. Do you receive money or aid from any of the following sources?
Mark ALL THAT APPLY
□ a. Medicaid
□ b. Food stamps
□ c. WIC (Women, Infants, and Children) Program
□ d. TANF (Temporary Aid to Needy Families)
□ e. Social Security
□ f. Unemployment or Workers’ Compensation
□ g. Other public aid
□ h. Child support
□ i. My job
□ j. Husband or partner
□ k. Parent(s)
□ l. Other (Describe___________________)
44. What is your main source of financial support?

Mark ONE
□ 1 My job
□ 2 Husband or partner
□ 3 Parents
□ 4 Public aid
□ 5 Other relatives
□ 6 Other (Describe______________________)
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Other Demographics (Time 1 Only)
I am going to read a list of descriptions of parents’ relationships.

1. Tell me which best describes your biological mother:
□ Married to biological father
□ Married to someone other than your biological father
□ Divorced
□ Separated
□ Widowed
□ Never married
2. Tell me which best describes your biological father
□ Married to biological father
□ Married to someone other than your biological father
□ Divorced
□ Separated
□ Widowed
□ Never married
3. Do you have any other children?
□ No
□ Yes
4. If you have other children, how many other children do you have? __________________________
5. How often did you (or your partner) use birth control prior to becoming pregnant?
□ Never
□ Rarely
□ Sometimes
□ Often
□ All the time
6. These are some ways people try to avoid pregnancy.
What way(s) did you try before becoming pregnant.
Mark ALL THAT APPLY
□ No method used this month
□ Abstinence (did not have sex this month)
□ Birth control pills
□ Condom
□ Withdrawal, pulling out
□ Depo-Provera, injectables (the shot)
□ Natural family planning (rhythm or safe period by calendar, temperature or cervical
mucus test)
□ Diaphragm
□ Female condom, vaginal pouch
□ Foam
□ Jelly or cream
□ Cervical cap
□ Suppository
□ Sponge
□ IUD
□ “Morning after” pills or emergency contraception
□ contraceptive patch
20
□ NuvaRing (Vaginal ring)

□ Implanon
□ Other method (Describe________________________)
7. Where were you born? _________________________________
8. If outside the US, how old were you when you came to the US? _________________________
9. Where were your parents born?
□ Mother__________________________________
□ Father___________________________________
10. What language does your parent(s) speak at home most of the time? _____________________
11. Where do you go to see the doctor or midwife for prenatal care? __________________________
12. What is your baby’s due date? ________________________________
13. Have you ever received free or reduced lunch at school? (Check all that apply)
□ In grade school
□ In high school
□ Choose the statement that best describes your family's current money situation.
□
14. Choose the statement that best describes your family’s current money situation:
□ We have enough money to cover our basic needs (food, clothing, housing,
transportation, etc) and have some left for fun things.
□ We have enough money to cover our basic needs, but there is not much left for fun
things.
□ We struggle to have enough money to cover our basic needs and sometimes we don't
have enough for that.
□ We often don't have enough money to cover our basic needs (food, clothing, housing,
transportation, etc).
15. Imagine that this later pictures how American society is set up.
• At the top of the ladder are the people who are the best off—they have the most money,
the highest amount of school, and the jobs that bring the most respect.
• At the bottom are people who are the worst off—they have the least money, little or no
education, no jobs or jobs that no one wants.
Now think about your family. Please tell us where you think your family would be on this
ladder. Fill in the circle that best represents where your family would be on this ladder.
21
16. Now assume that the ladder is a way of picturing your school
• At the top of the ladder are the people in your school with the most respect, the highest
grades, and the highest standing.
• At the bottom of the ladder are the people who no one respects, no one wants to hang
around with and have the worst grades.
Where would you place yourself on this ladder? Fill in the circle that best represents where you
would be on this ladder.
22
Perceived Stress Scale-4 (Time 1-Time 4)
Instructions: The questions in this scale ask you about your feelings and thoughts during the last month.
In each case, please indicate with a check how often you felt or thought a certain way.
Never Almost Sometimes Fairly Very

Never Often Often
1. In the last month, how often have you felt that 0 1 2 3 4
you were unable to control the important things in
your life?
2. In the last month, how often have you felt 0 1 2 3 4
confident about your ability to handle your personal
problems?
3. In the last month, how often have you felt that 0 1 2 3 4
things were going your way?
4. In the last month, how often have you felt 0 1 2 3 4
difficulties were piling up so high that you could not
overcome them?
23
The Parenting Stress Index-Short Form (Time 2-Time 4)
Directions: Please read each of the following questions and respond by selecting how much you agree or
disagree with each statement.
Strongly Agree Not Disagree Strongly

Agree Sure Disagree
1. I often have the feeling that I cannot handle things 1 2 3 4 5
very well
2. I find myself giving up more of my life to meet my 1 2 3 4 5
children's needs than I ever expected.
3. I feel trapped by my responsibilities as a parent. 1 2 3 4 5
4. Since having this child I have been unable to do 1 2 3 4 5
new and different things.
5. Since having a child I feel that I am almost never 1 2 3 4 5
able to do things that I like to do.
6. I am unhappy with the last purchase of clothing I 1 2 3 4 5
made for myself.
7. There are quite a few things that bother me about 1 2 3 4 5
my life.
8. Having a child has caused more problems than I 1 2 3 4 5
expected in my relationship with my spouse
(male/female friend).
9. I feel alone and without friends 1 2 3 4 5
10. When I go to a party I usually expect not to enjoy 1 2 3 4 5
myself
11. I am not as interested in people as I used to be 1 2 3 4 5
12. I don't enjoy things as I used to. 1 2 3 4 5
13. My child rarely does things for me that make me
feel good
14. Sometimes I feel my child doesn't like me and 1 2 3 4 5
doesn't want to be close to me
15. My child smiles at me much less than I expected 1 2 3 4 5
16. When I do things for my child I get the feeling 1 2 3 4 5
that my efforts are not appreciated very much
17. When playing, my child doesn't often giggle or 1 2 3 4 5
laugh
18. My child doesn't seem to learn as quickly as most 1 2 3 4 5
children
19. My child doesn't seem to smile as much as most 1 2 3 4 5
children
20. My child is not able to do as much as I expected 1 2 3 4 5
21. It takes a long time and it is very hard for my 1 2 3 4 5
child to get used to new things.
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For the next statement, choose your response form the choices “1” to “5” below.
22. I feel that I am:
1. a very good parent,
2. a better than average parent,
3. an average parent,
4. a person who has some trouble being a parent.
5. not very good at being a parent.

Agree Sure Disagree
23. I expected to have closer and warmer feelings for my 1 2 3 4 5
child than I do and this bothers me
24. Sometimes my child does things that bother me just 1 2 3 4 5
to be mean
25. My child seems to cry or fuss more often than most 1 2 3 4 5
children
26. My child generally wakes up in a bad mood 1 2 3 4 5
27. I feel that my child is very moody and easily upset 1 2 3 4 5
28. My child does a few things which bother me a great 1 2 3 4 5
deal
29. My child reacts very strongly when something 1 2 3 4 5
happens that my child doesn't like
30. My child gets upset easily over the smallest thing 1 2 3 4 5
31. My child's sleeping or eating schedule was much 1 2 3 4 5
harder to establish than I expected
For the next statement, choose your responses from the choices “1” to “5” below
32. I have found that getting my child to do something
or stop doing something is: .................................................................................. 1 2 3 4 5
1. much harder than I expected,
2. somewhat harder than I expected,
3. about as hard as I expected,
4. somewhat easier than I expected,
5. much easier than I expected,
33. Think carefully and count the number of things which yourchild does that bothers you. For example:
dawdles, refuses to listen, overactive, cries, interrupts, fights, whines, etc.
Please fill in the number which includes the number of things you counted.
1. 1-3
2. 4-5
3. 6-7
4. 8-9
5. 10+
25

Agree Sure Disagree
34. There are some things my child does that 1 2 3 4 5
really bother me a lot.
35. My child turned out to be more of a problem 1 2 3 4 5
than I expected
36. My child makes more demands on me than 1 2 3 4 5
most children.
26
The Everyday Discrimination Scale (Time 1-Time 4)
Introduction: ‘‘In the following questions, we are interested in the way other people have treated you
or your beliefs about how other people have treated you. Can you tell me if any of the following has
ever happened to you:’’
Major Discrimination Yes No
1) At any time in your life, have you ever been unfairly fired? 1 2
2) For unfair reasons, have you ever not been hired for a job? 1 2
3) Have you ever been unfairly stopped, searched, questioned, physically threatened or 1 2
abused by the police?
4) Have you ever been unfairly discouraged by a teacher or advisor from continuing your 1 2
education?
5) Have you ever moved into a neighborhood where neighbors made life difficult for you 1 2
or your family?
For each situation to which the participant replied ‘‘yes,’’ the follow-up question was:
What do you think was the main reason for this experience?
• Your ancestry or national origins
• Your gender
• Your race
• Your age
• Your religion
• Your height or weight
• Your shade of skin color
• Your sexual orientation
• Your education or income level
• A physical disability
• Other
In your day-to-day life, how often have any of the following things happened to you?
27
Day-to-day unfair treatment 4 or more 2-3 Once Never

times times
1) You have been treated with less courtesy than other 1 2 3 4
people
2) You have been treated with less respect than other 1 2 3 4
people
3) You have received poorer service than other people at 1 2 3 4
restaurants or stores
4) People have acted as if they think you are not smart 1 2 3 4
5) People have acted as if they are afraid of you 1 2 3 4
6) People have acted as if they think you are dishonest 1 2 3 4
7) People have acted as if they’re better than you are 1 2 3 4
8) You have been called names or insulted 1 2 3 4
9) You have been threatened or harassed 1 2 3 4
10) You have been followed around in stores 1 2 3 4
Respondents who indicated any of these events occurred at least once were then asked one question,
covering all the situations:
What do you think was the main reason for this/these experience(s)?
• Your ancestry or national origins
• Your gender
• Your race
• Your age
• Your religion
• Your height or weight
• Your shade of skin color
• Your sexual orientation
• Your education or income level
• A physical disability
• Other
How did you respond to this/these experience(s)?

Please tell me if you did each of the following things.
Response to unfair treatment Yes No
1) Tried to do something about it 1 2
2) Accepted it as a fact of life 1 2
3) Worked harder to prove them wrong 1 2
4) Realized that you brought it on yourself 1 2
5) Talked to someone about how you were feeling 1 2
6) Expressed anger or got mad 1 2
7) Prayed about the situation 1 2
The Coping Self Efficacy Scale (Time 1-Time 4)
28
Cannot Moderately
do at certain Certain
all can do can do
0 1 2 3 4 5 6 7 8 9 10
For each of the following items, write a number from 0 - 10, using the scale above.
When things aren't going well for you, how confident are you that you can:
1. Keep from getting down in the dumps. 0 1 2 3 4 5 6 7 8 9 10

2. Talk positively to yourself. 0 1 2 3 4 5 6 7 8 9 10
3. Sort out what can be changed, and what can not be 0 1 2 3 4 5 6 7 8 9 10
changed.
4. Get emotional support from friends and family. 0 1 2 3 4 5 6 7 8 9 10
5. Find solutions to your most difficult problems. 0 1 2 3 4 5 6 7 8 9 10
6. Break an upsetting problem down into smaller parts. 0 1 2 3 4 5 6 7 8 9 10
7. Leave options open when things get stressful. 0 1 2 3 4 5 6 7 8 9 10
8. Make a plan of action and follow it when confronted with a 0 1 2 3 4 5 6 7 8 9 10
problem.
9. Develop new hobbies or recreations. 0 1 2 3 4 5 6 7 8 9 10
10. Take your mind off unpleasant thoughts. 0 1 2 3 4 5 6 7 8 9 10
11. Look for something good in a negative situation. 0 1 2 3 4 5 6 7 8 9 10
12. Keep from feeling sad. 0 1 2 3 4 5 6 7 8 9 10
13. See things from the other person's point of view during a 0 1 2 3 4 5 6 7 8 9 10
heated argument.
14. Try other solutions to your problems if your first solutions 0 1 2 3 4 5 6 7 8 9 10
don’t work.
15. Stop yourself from being upset by unpleasant thoughts. 0 1 2 3 4 5 6 7 8 9 10
16. Make new friends. 0 1 2 3 4 5 6 7 8 9 10
17. Get friends to help you with the things you need. 0 1 2 3 4 5 6 7 8 9 10
18. Do something positive for yourself when you are feeling 0 1 2 3 4 5 6 7 8 9 10
discouraged.
19. Make unpleasant thoughts go away. 0 1 2 3 4 5 6 7 8 9 10
20. Think about one part of the problem at a time. 0 1 2 3 4 5 6 7 8 9 10
21. Visualize a pleasant activity or place. 0 1 2 3 4 5 6 7 8 9 10
22. Keep yourself from feeling lonely. 0 1 2 3 4 5 6 7 8 9 10
23. Pray or meditate. 0 1 2 3 4 5 6 7 8 9 10
24. Get emotional support from community organizations or 0 1 2 3 4 5 6 7 8 9 10
resources.
25. Stand your ground and fight for what you want. 0 1 2 3 4 5 6 7 8 9 10
26. Resist the impulse to act hastily when under pressure. 0 1 2 3 4 5 6 7 8 9 10
29
Conflict in Adolescent Dating Relationships Inventory (Time 1-Time 4)
The Conflict in Adolescent Relationships Inventory (female version)

The following questions ask you about things that may have happened to you with your boyfriend while
you were having an argument. Check the box that is your best estimate of how often these things have
happened with your current or ex-boyfriend in the past year. Please remember that all answers are
confidential. As a guide use the following scale:
Never: this has never happened in your relationship
Seldom: this has happened only 1-2 times in your relationship
Sometimes: this has happened about 3-5 times in your relationship
Often: this has happened 6 times or more in your relationship
During a conflict or argument with my boyfriend in the past year:

Never Seldom Sometimes Often
1. I gave reasons for my side of the argument. 1 2 3 4
He gave reasons for his side of the argument. 1 2 3 4
3. I tried to turn his friends against him. 1 2 3 4
He tried to turn my friends against me. 1 2 3 4
4. I did something to make him feel jealous. 1 2 3 4
He did something to make me feel jealous. 1 2 3 4
5. I destroyed or threatened to destroy something he valued. 1 2 3 4
He destroyed or threatened to destroy something I valued. 1 2 3 4
6.I told him that I was partly to blame. 1 2 3 4
He told me that he was partly to blame. 1 2 3 4
7.I brought up something bad that he had done in the past 1 2 3 4
He brought up something bad that I had done in the past. 1 2 3 4
8.I threw something at him. 1 2 3 4
He threw something at me. 1 2 3 4
9. I said things just to make him angry. 1 2 3 4
He said things just to make me angry. 1 2 3 4
10.I gave reasons why I thought he was wrong. 1 2 3 4
He gave reasons why he thought I was wrong. 1 2 3 4
11. I agreed that he was partly right. 1 2 3 4
He agreed that I was partly right. 1 2 3 4
12. I spoke to him in a hostile or mean tone of voice. 1 2 3 4
He spoke to me in a hostile or mean tone of voice. 1 2 3 4
14. I offered a solution that I thought would make us both 1 2 3 4
happy.
He offered a solution that he thought would make us both 1 2 3 4
happy.
16. I put off talking until we calmed down. 1 2 3 4
He put off talking until we calmed down 1 2 3 4
17. I insulted him with put-downs. 1 2 3 4
He insulted me with put-downs. 1 2 3 4
18. I discussed the issue calmly. 1 2 3 4
He discussed the issue calmly. 1 2 3 4
20. 1 said things to his friends about him to turn them 1 2 3 4
30
against him.
He said things to my friends about me to turn them against 1 2 3 4
me.
21 I ridiculed or made fun of him in front of others. 1 2 3 4
He ridiculed or made fun of me in front of others. 1 2 3 4
22 I told him how upset I was. 1 2 3 4
He told me how upset he was. 1 2 3 4
23. I kept track of who he was with and where he was 1 2 3 4
He kept track of who I was with and where I was. 1 2 3 4
24. I blamed him for the problem. 1 2 3 4
He blamed me for the problem. 1 2 3 4
25. I kicked, hit or punched him. 1 2 3 4
He kicked, hit or punched me. 1 2 3 4
26. I left the room to cool down. 1 2 3 4
He left the room to cool down. 1 2 3 4
27. I gave in, just to avoid conflict 1 2 3 4
He gave in, just to avoid conflict 1 2 3 4
28.I accused him of flirting with another girl. 1 2 3 4
He accused me of flirting with another guy. 1 2 3 4
29. I deliberately tried to frighten him. 1 2 3 4
He deliberately tried to frighten me. 1 2 3 4
30. I slapped him or pulled his hair. 1 2 3 4
He slapped me or pulled my hair. 1 2 3 4
31. I threatened to hurt him 1 2 3 4
He threatened to hurt me. 1 2 3 4
32. I threatened to end the relationship. 1 2 3 4
He threatened to end the relationship. 1 2 3 4
33. I threatened to hit him or throw something at him. 1 2 3 4
He threatened to hit me or throw something at me. 1 2 3 4
34. I pushed, shoved, or shook him. 1 2 3 4
He pushed, shoved, or shook me. 1 2 3 4
35. I spread rumors about him. 1 2 3 4
He spread rumors about me. 1 2 3 4
31
Quality of Relationship Inventory (Time 1-Time 4)
Directions: You are now going to be asked a series of questions about your relationships with various
people in your life. In response to each question, please check one of the following boxes:
not at all
a little
some
a lot
Note: “Partner” refers to the mother or father of your baby
1) To what extent could you turn to the following people for advice about problems?
Your Father Your Mother Your Partner Partner’s Partner’s Other Parent
not at all not at all not at all Father Mother Figure:
a little a little a little not at all not at all
some some some a little a little not at all
a lot a lot a lot some some a little
a lot a lot some
a lot
2) How often do you need to work hard to avoid conflict with the following people?
a lot a lot some
a lot
3) To what extent could you turn to the following people for help with a problem?
a lot a lot some
a lot
4) How upset do the following people sometimes make you feel?
32
a lot a lot some
a lot
5) To what extent can you count on the following people to give you honest feedback, even if you
might not want to hear it?
a lot a lot some
a lot
6) How much do the following people make you feel guilty?
a lot a lot some
a lot
7) How much do you have to "give in" in your relationship with the following people?
a lot a lot some
a lot
8) To what extent can you count on the following people to help you if a family member very close to
you died?
a lot a lot some
a lot
9) How much do the following people want you to change?
33
a lot a lot some
a lot
10) How much more do you give than you get from your relationship with the following people?
a lot a lot some
a lot
11) How positive a role do the following people play in your life?
a lot a lot some
a lot
12) How significant is your relationship with the following people in your life?
a lot a lot some
a lot
13) How close will your relationship be with the following people in 10 years?
a lot a lot some
a lot
14) How much would you miss the following people if the two of you could not see or talk with each
other for a month?
34
a lot a lot some
a lot
15) How critical of you are the following people?
a lot a lot some
a lot
16) If you wanted to go out and do something this evening, how confident are you that the following
people would be willing to do something with you?
a lot a lot some
a lot
17) How responsible do you feel for the following people’s well-being?
a lot a lot some
a lot
18) How much do you depend on the following people?
a lot a lot some
a lot
19) To what extent can you count on following people to listen to you when you are very angry at
someone else?
35
a lot a lot some
a lot
20) How much would you like the following people to change?
a lot a lot some
a lot
21) How angry do the following people make you feel?
a lot a lot some
a lot
22) How much do you argue with the following people?
a lot a lot some
a lot
23) To what extent can you really count on the following people to distract you from your worries
when you feel under stress?
a lot a lot some
a lot
24) How often do the following people make you feel angry?
36
a lot a lot some
a lot
25) How often do the following people try to control or influence your life?
a lot a lot some
a lot
37
Fragile Families and Child Well-Being Study (Survey of New Parents) Mother’s One Year
Follow-Up Survey, Public Version
Fragile Families Caregiving Activities (Time 2-Time 4)
Now I would like to ask you some questions about things (YOUR PARTNER) does with (CHILD).
For each activity, please tell me how many days a week he/she does this in a typical week.
How many days does he/she usually (READ ITEM)?
Record Never as 0.
Days Per Week
Play games like “peek-a-boo” or “gotcha” with (CHILD) 0 1 2 3 4 5 6 7
Sing songs or nursery rhymes to (him/her) 0 1 2 3 4 5 6 7
Read stories to (CHILD) 0 1 2 3 4 5 6 7
Tell stories to (him/her) 0 1 2 3 4 5 6 7
Play inside with toys such as blocks or legos with (him/her) 0 1 2 3 4 5 6 7
Take (CHILD) to visit relatives 0 1 2 3 4 5 6 7
Change (his/her) diaper 0 1 2 3 4 5 6 7
Feed or give a bottle to (him/her) 0 1 2 3 4 5 6 7
Hug or show physical affection to (CHILD) 0 1 2 3 4 5 6 7
Put (CHILD) to bed 0 1 2 3 4 5 6 7
38
Now I would like to ask you some questions about things YOU do with (CHILD).
For each activity, please tell me how many days a week you do this in a typical week.
How many days do you usually (READ ITEM)?
Record Never as 0.
Days Per Week
Play games like “peek-a-boo” or “gotcha” with (CHILD) 0 1 2 3 4 5 6 7
Sing songs or nursery rhymes to (him/her) 0 1 2 3 4 5 6 7
Read stories to (CHILD) 0 1 2 3 4 5 6 7
Tell stories to (him/her) 0 1 2 3 4 5 6 7
Play inside with toys such as blocks or legos with (him/her) 0 1 2 3 4 5 6 7
Take (CHILD) to visit relatives 0 1 2 3 4 5 6 7
Change (his/her) diaper 0 1 2 3 4 5 6 7
Feed or give a bottle to (him/her) 0 1 2 3 4 5 6 7
Hug or show physical affection to (CHILD) 0 1 2 3 4 5 6 7
Put (CHILD) to bed 0 1 2 3 4 5 6 7
Fragile Families Caregiving Activities Additional Questions (Time 3 and Time 4 only)
C4. Sometimes children behave well and sometimes they don’t. In the past month, has (PARTNER)
spanked (CHILD) because he/she was misbehaving or acting up?
1) Yes 2) No -2) Don’t know
C4A. Did he/she do this…
1) Everyday or nearly everyday 2) A few times a week 3) A few times this past month
4) Only once or twice
C5. In the past month, how often has (PARTNER) spent one or more hours a day with (CHILD)?
4) Only once or twice 5) Not at all
39
C5A. How often do you think (PARTNER) should spend one or more hours a day with (CHILD)?
4) Only once or twice 5) Not at all
Do you think he spends too much time, not enough time, or just about the right amount of time with
(CHILD)?
1) Too Much 2) Not Enough 3) Just Right
C5B. Have you ever asked (PARTNER) to spend more time with (CHILD)?
1) Yes 2) No
Fragile Families Co Parenting Questions (Time 2-Time 4)
The following questions are about how parents work together in raising a child. Please tell me how often
the following statements are true for you and (PARTNER)?
(READ ITEM). Would you say it’s always true, sometimes true or rarely true?
Always Sometimes Rarely N/A

True True True
When (PARTNER) is with (CHILD), he acts like the
1 2 3 4
mother/father you want for your child
You can trust (PARTNER) to take good care of (CHILD) 1 2 3 4
He respects the schedules and rules you make for (CHILD) 1 2 3 4
He supports you in the way you want to raise (CHILD) 1 2 3 4
You and (PARTNER) talk about problems that come up with

1 2 3 4
raising (CHILD)
You can count on (PARTNER) for help when you need someone
1 2 3 4
to look after (CHILD) for a few hours
Fragile Families: Additional Co-Parenting Questions (Time 3 and Time 4 Only)

D3. If you had to go away for one week and could not take (CHILD) with you, how much would you trust
(FATHER) to take care of your child?
1) Very Much 2) Somewhat 3) Not at All
D3A. Could you trust anyone else to look after (CHILD)?
1) Yes 2) No
40
The Paternal-Infant Attachment Scale (Time 2-Time 4)
QUES1 When I am caring for the baby, I get feelings of annoyance or

irritation:
very frequently
frequently
occasionally
very rarely
never
QUES2 When I am caring for the baby I get feelings that the child is
deliberately being difficult or trying to upset me:
very frequently
frequently
occasionally
very rarely
never
QUES3 Over the last two weeks I would describe my feelings for the baby as:
dislike
no strong feelings towards the baby
slight affection
moderate affection
intense affection
41
QUES4 I can understand what my baby needs or wants:
almost always
usually
sometimes
rarely
almost never
QUES5 Regarding my overall level of interaction with the baby I believe I am:
much more involved than most fathers in my position
somewhat more involved than most fathers in my

position
involved to the same extent as most fathers in my

position
somewhat less involved than most fathers in my position
much less involved than most fathers in my position
QUES6 When I am with the baby I feel bored:
very frequently
frequently
occasionally
almost never
42
QUES7 When I am with the baby and other people are present I feel proud of
the baby:
very frequently
frequently
occasionally
almost never
QUES8 I try to involve myself as much as possible in child care and looking
after the baby:
this is true
this is untrue
QUES9 I find myself talking to people (other than my partner) about the baby:
many times each day
a few times each day
once or twice a day
rarely on any one day
QUES10 When I have to leave the baby:
I usually feel rather sad (or it's difficult to leave)
I often feel rather sad (or it's difficult to leave)
I have mixed feelings of both sadness and relief
I often feel rather relieved (and it's easy to leave)
I usually feel rather relieved (and it's easy to leave)
43
QUES11 When I am with the baby:
I always get a lot of enjoyment/satisfaction
I frequently get a lot of enjoyment/satisfaction
I occasionally get a lot of enjoyment/satisfaction
I very rarely get a lot of enjoyment/satisfaction

QUES12 When I am not with the baby, I find myself thinking about the baby:
almost all the time
very frequently
frequently
occasionally
not at all
QUES13 When I am with the baby:
I usually try to prolong the time I spend with him/her

Neither
I usually try to shorten the time I spend with him/her
QUES14 When I have been away from the baby for a while and I am about to be
with him/her again, I usually feel:
intense pleasure at the idea
moderate pleasure at the idea
mild pleasure at the idea
no feelings at all about the idea
negative feelings about the idea
44
QUES15 Over the past three months I have found myself just sitting looking at
the sleeping baby for periods of five minutes or more:
very frequently
frequently
a few times
not at all
QUES16 I now think of the baby as:
very much my own baby
a bit like my own baby
not yet really my own baby
QUES17 Regarding the things that we have had to give up because of the baby:
I find that I resent it quite a lot
I find that I resent it a moderate amount
I find that I resent it a bit
I don't resent it at all
QUES18 Over the past three months, I have felt that I do not have enough time
for myself or to pursue my own interests:
almost all the time
very frequently
occasionally
not at all
45
QUES19 Usually when I am with the baby:
I am very impatient
I am a bit impatient
I am moderately patient
I am extremely patient
46
Child Abuse Potential Inventory (Time 2-Time 4)
INSTRUCTIONS: The following questionnaire includes a series of statements which may be applied to
yourself. Read each of the statements and determine if you AGREE or DISAGREE with the statement-
check the best response. Be honest when giving your answers. Remember to read each statement: it is
important not to skip statements.
1. I have always been strong and healthy. Agree Disagree

2. I am a confused person. Agree Disagree
3. People expect too much from me. Agree Disagree
4. I am often mixed up. Agree Disagree
5. You cannot depend on others. Agree Disagree
6. I am a happy person. Agree Disagree
7. I am often angry inside. Agree Disagree
8. Sometimes I feel all alone in the world. Agree Disagree
9. Everything in a home should always be in its place. Agree Disagree
10. I often feel rejected. Agree Disagree
11. I am often lonely inside. Agree Disagree
12. Little boys should never learn sissy games. Agree Disagree
13. I often feel very frustrated. Agree Disagree
14. Sometimes I fear that I will lose control of myself. Agree Disagree
15. I sometimes wish that my father would have loved me more. Agree Disagree
16. My telephone number is unlisted. Agree Disagree
17. I sometimes worry that I will not have enough to eat. Agree Disagree
18. I am an unlucky person. Agree Disagree
19. I am usually a quiet person. Agree Disagree
20. Things have usually gone against me in life. Agree Disagree
21. I have a child who is bad. Agree Disagree
22. I sometimes feel worthless. Agree Disagree
23. I am sometimes very sad. Agree Disagree
24. I am often worried. Agree Disagree
25. A child should never talk back. Agree Disagree
26. I am often easily upset. Agree Disagree
27. I am often worried inside. Agree Disagree
28. People have caused me a lot of pain. Agree Disagree
29. Children should stay clean. Agree Disagree
30. I have a child who gets into trouble a lot. Agree Disagree
31. I find it hard to relax. Agree Disagree
32. These days a person doesn’t really know on whom one can count. Agree Disagree
33. My life is happy. Agree Disagree
34. I have a physical handicap. Agree Disagree
35. Children should have play clothes and good clothes. Agree Disagree
36. Other people do not understand how I feel. Agree Disagree
37. Children should be quiet and listen. Agree Disagree
38. I have several close friends in my neighborhood. Agree Disagree
39. I have headaches. Agree Disagree
40. I do not laugh very much. Agree Disagree
47
41. I have fears no one knows about. Agree Disagree

42. My family has problems getting along. Agree Disagree
43. Life often seems useless to me. Agree Disagree
44. People do not understand me. Agree Disagree
45. I often feel worthless. Agree Disagree
46. Other people have made my life unhappy. Agree Disagree
47. Sometimes I do not know why I act as I do. Agree Disagree
48. I have many personal problems. Agree Disagree
49. I often feel very upset. Agree Disagree
50. My life is good. Agree Disagree
51. A home should be spotless. Agree Disagree
52. I am easily upset by my problems. Agree Disagree
53. My parents did not understand me. Agree Disagree
54. Many things in life make me angry. Agree Disagree
55. My child has special problems. Agree Disagree
56. Children should be seen and not heard. Agree Disagree
57. I am often depressed. Agree Disagree
58. I am often upset. Agree Disagree
59. A good child keeps his toys and clothes neat and orderly. Agree Disagree
60. Children should always be neat. Agree Disagree
61. I have a child who is slow. Agree Disagree
62. A parent must use punishment if he wants to control a child’s behavior. Agree Disagree
63. Children should never cause trouble. Agree Disagree
64. A child needs very strict rules. Agree Disagree
65. I often feel better than others. Agree Disagree
66. I am often upset and do not know why. Agree Disagree
67. I have a good sex life. Agree Disagree
68. I often feel very alone. Agree Disagree
69. I often feel alone. Agree Disagree
70. Right now I am deeply in love. Agree Disagree
71. My family has many problems. Agree Disagree
72. Other people have made my life hard. Agree Disagree
73. I laugh some almost everyday. Agree Disagree
74. I sometimes worry that my needs will not be met. Agree Disagree
75. I often feel afraid. Agree Disagree
76. Children should never disobey. Agree Disagree
77. My family fights a lot. Agree Disagree
48
CRAFFT Screening Tool (Time 1-Time 4)

SELF
Please answer all questions honestly; your answers will be kept confidential.
Part A
In the past 12 months, did you:
1. Drink any alcohol (more than a few sips)?
□ Yes
□ No
2. Smoke any marijuana or hashish?
□ Yes
□ No
3. Use anything else to get high? “anything else” includes illegal drugs, over the counter and
prescription drugs, and things that you sniff or “huff”
□ Yes
□ No
Part B
1. Have you ever ridden in a car driven by someone (including yourself) who was “high” or had
been using alcohol or drugs?
□ Yes
□ No
2. Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
□ Yes
□ No
3. Do you ever use alcohol or drugs while you are by yourself, alone?
□ Yes
□ No
4. Do you ever forget things you did while using alcohol or drugs?
□ Yes
□ No
5. Do your family or friends ever tell you that you should cut down on your drinking or drug use?
□ Yes
□ No
6. Have you gotten into trouble while you were using alcohol or drugs?
□ Yes
□ No
PARTNER
Please answer all questions about your partner honestly; your answers will be kept confidential.
Part A
In the past 12 months, did your partner:
4. Drink any alcohol (more than a few sips)?
□ Yes
□ No
5. Smoke any marijuana or hashish?
□ Yes
49
□ No
6. Use anything else to get high? “anything else” includes illegal drugs, over the counter and
prescription drugs, and things that you sniff or “huff”
□ Yes
□ No
Part B
7. Has your partner ever ridden in a car driven by someone (including yourself) who was “high” or
had been using alcohol or drugs?
□ Yes
□ No
8. Does your partner ever use alcohol or drugs to relax, feel better about his/herself, or fit in?
□ Yes
□ No
9. Does your partner ever use alcohol or drugs while he/she is by his/herself, along?
□ Yes
□ No
10. Does your partner ever forget things he/she did while using alcohol or drugs?
□ Yes
□ No
11. Does your partner’s family or friends ever tell him/her that he/she should cut down on his/her
drinking or drug use?
□ Yes
□ No
12. Has your partner gotten into trouble while he/she was using alcohol or drugs?
□ Yes
□ No
50
Trauma Screening (Time 1-Time 4)
1. Is there anything that happened to you that was really bad or something else you saw that was
really scary?
□ Yes
□ No
a. When this happened, did you feel absolutely terrified?

□ Yes
□ No
b. Did you feel completely helpless?
□ Yes
□ No
□
Trauma Symptom Checklist (Time 1-Time 4)
How often have you experienced each of the following in the last two months?
0 = Never 3 = Often
1. Headaches 0 1 2 3
2. Insomnia (trouble getting to sleep) 0 1 2 3
3. Weight loss (without dieting) 0 1 2 3
4. Stomach problems 0 1 2 3
5. Sexual problems 0 1 2 3
6. Feeling isolated from others 0 1 2 3
7. "Flashbacks" (sudden, vivid, distracting memories) 0 1 2 3
8. Restless sleep 0 1 2 3
9. Low sex drive 0 1 2 3
10. Anxiety attacks 0 1 2 3
11. Sexual over activity 0 1 2 3
12. Loneliness 0 1 2 3
13. Nightmares 0 1 2 3
14. "Spacing out" (going away in your mind) 0 1 2 3
15. Sadness 0 1 2 3
16. Dizziness 0 1 2 3
17. Not feeling satisfied with your sex life 0 1 2 3
18. Trouble controlling your temper 0 1 2 3
19. Waking up early in the morning and can't get back to sleep 0 1 2 3
20. Uncontrollable crying 0 1 2 3
21. Fear of men 0 1 2 3
22. Not feeling rested in the morning 0 1 2 3
23. Having sex that you didn't enjoy 0 1 2 3
24. Trouble getting along with others 0 1 2 3
25. Memory problems 0 1 2 3
26. Desire to physically hurt yourself 0 1 2 3
27. Fear of women 0 1 2 3
28. Waking up in the middle of the night 0 1 2 3
51
29. Bad thoughts or feelings during sex 0 1 2 3

30. Passing out 0 1 2 3
31. Feeling that things are "unreal” 0 1 2 3
32. Unnecessary or over-frequent washing 0 1 2 3
33. Feelings of inferiority 0 1 2 3
34. Feeling tense all the time 0 1 2 3
35. Being confused about your sexual feelings 0 1 2 3
36. Desire to physically hurt others 0 1 2 3
37. Feelings of guilt 0 1 2 3
38. Feelings that you are not always in your body 0 1 2 3
39. Having trouble breathing 0 1 2 3
40. Sexual feelings when you shouldn't have them 0 1 2 3
52
Multigroup Ethnic Identity Measure (Time 1 Only)
In this country, people come from different cultures and have different words to describe different
customs of cultures of ethnic groups. Some examples of ethnic names are Mexican-Americans,
Hispanics, Black, Asian-Americans, American Indians, Anglo-Americans, and Whites.
Belonging to one or more ethnic groups, and the feelings associated with these groups, can have an
influence on various areas of our lives. The following questions will help us understand what your
attitudes and thoughts are in reference to your ethnic group.
In terms of ethnic groups, I consider myself:_________________
Disagree Slightly
Disagree Slightly Neutral Agree Agree
1. I have dedicated time to find out more about my
1 2 3 4 5
ethnic group, such as history, tradition and customs.
2. I am active in organizations or social groups
where the majority of its members are of my own 1 2 3 4 5
ethnic group.
3. I have a clear idea about what my ethnic group is
1 2 3 4 5
and what it means to me/
4. I have thought a lot about how my ethnic group
1 2 3 4 5
influences my life.
5. I am happy being a part of my ethnic group. 1 2 3 4 5
6. I feel I identify with the ethnic group I belong to. 1 2 3 4 5
7. I clearly understand what belonging to my ethnic
1 2 3 4 5
group means.
8. To learn more about my ethnic roots, I have
1 2 3 4 5
talked to others about my ethnic group.
9. I am proud of my ethnic group. 1 2 3 4 5
10. I participate in cultural activities from my own
ethnic group, for example, special foods, music and 1 2 3 4 5
customs.
11. I feel great affection toward my ethnic group. 1 2 3 4 5
12. I feel comfortable with my cultural heritage and
1 2 3 4 5
ethnic group.
13. My ethnicity is:

□ Asian, Asian-America, or Oriental
□ Black or African-American
□ Hispanic or Latin
□ European, Caucasian, White (Not Hispanic)
□ American Indian
□ Mexican
□ Mexican American
□ Mixed: my parents are of different ethnic groups
□ Other:_______
53
14. My father’s ethnic group is

□ American Indian
□ Mexican
□ Mixed: his parents are of different ethnic groups
□ Other:_______
15. My mother’s ethnic group is
□ American Indian
□ Mexican
□ Mixed: her parents are of different ethnic groups
□ Other:_______
54
Crisis in Family Systems (Time 1-Time 4)
Directions: For each of the following items, think about whether or not each situation has happened in
the past six months or not
Yes No
Did you go without food because you didn’t have the money to pay for it? 1 2
Was your telephone, electricity, or gas turned off? 1 2
Did you miss an appointment to have or change your plans because you had no 1 2
transportation to get there?
Did you have legal problems? 1 2
Did you drop out of school? 1 2
Did you get expelled from school? 1 2
Did a family member die? 1 2
Did a friend die? 1 2
Did you see violence? 1 2
Was anyone else in your household a victim of a crime? 1 2
Were you a victim of crime? 1 2
Did you(r partner) have a miscarriage? 1 2
Did you become ill? 1 2
Did another family member become ill? 1 2
Did you lose your housing? 1 2
Did you have trouble with your teacher(s)? 1 2
55
Consumer Assessment of Healthcare Providers and Systems (Time 3 and Time 4 Only)
Please answer the questions for the child listed on the envelope. Please do not answer for any other
children.
YOUR CHILD’S DOCTOR
1. Our records show that your child got care from the doctor named below in the last 12 months.
NAME OF DOCTOR LABEL GOES HERE
Is that right?
1
 Yes If Yes, Go to Question 2
2
 No If No, Go to Question 26
The questions in this survey booklet will refer to the doctor named in Question 1 as “this doctor.”
Please think of that doctor as you answer the survey.
2. Is this the doctor you usually see if your child needs a check-up or gets sick or hurt?
1
 Yes
2
 No
3. How long has your child been going to this doctor?

1
 Less than 6 months
2
 At least 6 months but less than 1 year
3
 At least 1 year but less than 3 years
4
 At least 3 years but less than 5 years
5
 5 years or more
YOUR CHILD’S CARE FROM THIS DOCTOR IN THE LAST 12 MONTHS

These questions ask about your child’s health care. Do not include care your child got when he or she
stayed overnight in a hospital. Do not include the times your child went for dental care visits.
4. In the last 12 months, how many times did your child visit this doctor for care?
1
 None If None, Go to
Question 26
2
 1 time
3
 2
4
 3
5
 4
6
 5 to 9
7
 10 or more times
5. In the last 12 months, did you phone this doctor’s office to get an appointment for your child for
an illness, injury or condition that needed care right away?
1
 Yes
2
 No If No, Go to Question 7 on Next Page
56
6. In the last 12 months, when you phoned this doctor’s office to get an appointment for care your
child needed right away, how often did you get an appointment as soon as you thought your
child needed?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
7. In the last 12 months, did you make any appointments for a check-up or routine care for your
child with this doctor?
1
 Yes
2
8. In the last 12 months, when you made an appointment for a check-up or routine care for your
child with this doctor, how often did you get an appointment as soon as you thought your child
needed?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
9. In the last 12 months, did you phone this doctor’s office with a medical question about your
child during regular office hours?
1
 Yes
2
10. In the last 12 months, when you phoned this doctor’s office during regular office hours, how
often did you get an answer to your medical question that same day?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
11. In the last 12 months, did you phone this doctor’s office with a medical question about your
child after regular office hours?
1
 Yes
2
 No If No, Go to Question 13 on Next Page
12. In the last 12 months, when you phoned this doctor’s office after regular office hours, how often
did you get an answer to your medical question as soon as you needed?
1
 Never
57
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
13. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how
often did your child see this doctor within 15 minutes of his or her appointment time?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
14. In the last 12 months, how often did this doctor explain things about your child’s health in a way
that was easy to understand?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
15. In the last 12 months, how often did this doctor listen carefully to you?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
16. In the last 12 months, did you talk with this doctor about any problems or concerns you had
about your child’s health?
1
 Yes
2
17. In the last 12 months, how often did this doctor give you easy to understand instructions about
taking care of these health problems or concerns?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
18. In the last 12 months, how often did this doctor seem to know the important information about
your child’s medical history?
58
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
19. In the last 12 months, how often did this doctor show respect for what you had to say?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
20. In the last 12 months, how often did this doctor spend enough time with your child?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
21. In the last 12 months, did this doctor order a blood test, x-ray or other test for your child?
1
 Yes
2
22. In the last 12 months, when this doctor ordered a blood test, x-ray or other test for your child,
how often did someone from this doctor’s office follow up to give you those results?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
23. Using any number from 0 to 10, where 0 is the worst doctor possible and 10 is the best doctor
possible, what number would you use to rate this doctor?
0
0 Worst doctor possible
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
 10 Best doctor possible
59
CLERKS AND RECEPTIONISTS AT THIS DOCTOR’S OFFICE
24. In the last 12 months, how often were clerks and receptionists at this doctor’s office as helpful as
you thought they should be?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
25. In the last 12 months, how often did clerks and receptionists at this doctor’s office treat you with
courtesy and respect?
1
 Never
2
 Almost Never
3
 Sometimes
4
 Usually
5
 Almost Always
6
 Always
60
Brief Infant-Toddler Social and Emotional Assessment (Time 3 and Time 4 Only)
*Note: The BITSEA has been ordered and will be submitted when it arrives. However, the ITSEA (longer
version from which the items are taken is included as a separate attachment)
61
The Working Alliance (All Intervention Sessions)
Working Alliance Inventory

Short Form (C)
DIRECTIONS: On the following pages are sentences that describe some of the different ways a person
might think or feel about the Young Parenthood Program staff member providing these parenting
support sessions. As you read through the sentences mentally insert the name of Young Parenthood
Program staff member in place of ____________ in the text.
Below each statement inside there is a seven point scale:
1 2 3 4 5 6 7
Never Rarely Occasionally Sometimes Often Very Often Always
If the statement describes the way you always feel (or think) circle the number 7; if it never applies to
you circle the number 1. Use the numbers in between to describe the variations between these
extremes.
This questionnaire is CONFIDENTIAL; neither your therapist nor the agency will see your answers.
Work fast, your first impressions are the ones we would like to see.
Thank you for your cooperation.
© A. O. Horvath, 1981, 1982; Revision Tracey & Kokotowitc 1989.
62
Role (circle): MOB FOB ID: _____ Session: ____ Date: _________
1. _______________ and I agree about the things I will need to do in this parenting support program.
1 2 3 4 5 6 7
2. What I am doing in this parenting support program gives me new ways of looking at parenthood.
1 2 3 4 5 6 7
3. I believe _______________ likes me.
1 2 3 4 5 6 7
4. _______________ does not understand what I am trying to accomplish in this parenting support program.
1 2 3 4 5 6 7
5. I am confident in _______________ 's ability to help me develop better co-parenting skills.
1 2 3 4 5 6 7
6. _______________ and I are working towards mutually agreed upon goals.
1 2 3 4 5 6 7
7. I feel that _______________ appreciates me.
1 2 3 4 5 6 7
8. We agree on what is important for me to work on regarding developing better co-parenting skills.
1 2 3 4 5 6 7
9. _______________ and I trust one another.
1 2 3 4 5 6 7
10. _______________ and I have different ideas on what my co-parenting issues are.
1 2 3 4 5 6 7
11. We have established a good understanding of the kind of changes that would be good for me.
1 2 3 4 5 6 7
63
12. I believe the way we are working on my co-parenting skills is correct.

1 2 3 4 5 6 7
64
Working Alliance Inventory

Short Form T
DIRECTIONS: On the following pages there are sentences that describe some of the different ways a
therapist might think or feel about his/her client(s). As you read the sentences mentally insert the name
of the couple you are working with in the place of ____________ in the text. Try to think about your
client as “a couple” rather than “two individuals.”
Below each statement inside there is a seven point scale:
1 2 3 4 5 6 7
If the statement describes the way you always feel (or think) circle the number 7; if it never applies to
you circle the number 1.
Use the numbers in between to describe the variations between these extremes.
This questionnaire is CONFIDENTIAL; neither the couple nor the agency will see your answers.
Work fast, your first impressions are the ones we would like to see.
Thank you for your cooperation.
© A. O. Horvath, 1981, 1984, 1991; based on revision by Tracey & Kokotowitc 1989.
65
Role (circle): MOB FOB ID: _____ Session: ____ Date: _________
1. _______________ and I agree about the steps to be taken to improve their co-parenting skills.
1 2 3 4 5 6 7
2. My client and I both feel confident about the usefulness of our current activity in these co-parenting
support sessions.
1 2 3 4 5 6 7
3. I believe _______________ likes me.
1 2 3 4 5 6 7
4. I have doubts about what we are trying to accomplish in these co-parenting support sessions.
1 2 3 4 5 6 7
5. I am confident in my ability to help _______________.
1 2 3 4 5 6 7
6. We are working towards mutually agreed upon goals.
1 2 3 4 5 6 7
7. I appreciate _______________ as a person.
1 2 3 4 5 6 7
8 We agree on what co-parenting skills are important for _______________ to work on.
1 2 3 4 5 6 7
9. _______________ and I have built a mutual trust.
1 2 3 4 5 6 7
10. _______________ and I have different ideas on what their co-parenting issue are.
1 2 3 4 5 6 7
66
11. We have established a good understanding between us of the kind of changes that would be good for
_______________.
1 2 3 4 5 6 7
12. _______________ believes the way we are working to improve their co-parenting skills is correct.
1 2 3 4 5 6 7
67
MYPS Infant and Maternal Health Outcomes Data Collection Sheet*

Can be collected from the Medical Record or Birth Certificate worksheet
Maternal Information
1. Date of first prenatal care visit (MM/DD/YYYY): __ No prenatal care

2. Date of last prenatal care visit (MM/DD/YYYY):
3. Total number of prenatal care visits for this pregnancy (if none, enter 0):
4. Did mother get WIC food for herself during this pregnancy? __ Yes __ No
5. Cigarette smoking before and during pregnancy

(for each time period, enter either the # of cigarettes or the # of packs of cigarettes smoked. If
NONE, enter 0)
Average # of cigarettes smoked per day
# of cigarettes # of packs
3 Months before pregnancy _____ OR _____
First 3 Months of pregnancy _____ OR _____
Second 3 Months of pregnancy _____ OR _____
Third trimester of pregnancy _____ OR _____
6. Principal source of payment for this delivery

___ private insurance
___ Medicaid
___ self-pay
___ Other (Specify) ____________________
7. Date last normal menses began (MM/DD/YYYY):
8. Risk factors in this pregnancy

Diabetes
__ Prepregnancy (Diagnosis prior to this pregnancy)
__ Gestational (Diagnosis in this pregnancy)
Hypertension
__ Prepregnancy (Chronic)
__ Gestational (PIH, preeclampsia)
__ Eclampsia
9. Infections present and/or treated during this pregnancy (Check all that apply)
__ Gonorrhea
__ Syphillis
__Chlamydia
__ Hepatitis B
__ Hepatitis C
__ None of the above
10. Obstetric Procedures (check all that apply)
68
__ Cervical cerclage
__ Tocolysis
External cephalic version:

__ Successful
__ Failed
11. Onset of labor (check all that apply)

__ premature rupture of the membranes (prolonged, > 12 hours)
__ precipitous labor (< 3 hours)
__ prolonged labor (>20 hours)
__ none of the above
12. Characteristics of labor and delivery (check all that apply)

__ induction of labor
__ augmentation of labor
__ non-vertex presentation
__ steroids (glucocorticoids) for fetal lung maturation received by the mother prior to delivery
__ antibiotics received by the mother during labor
__ clinical chorioamnionitis diagnosed during labor or maternal temperature ≥ 38°C (100.4°F)
__ moderate/heavy meconium staining of the amniotic fluid
__ fetal intolerance of labor such that one or more of the following actions was taken: in-utero
resuscitative measures, further fetal assessment, or operative delivery
__ epidural or spinal anesthesia during labor
__ none of the above
13. Method of delivery

A. Was delivery with forceps attempted but unsuccessful? __ Yes __ No
B. Was delivery with vacuum extraction attempted but unsuccessful? __ Yes __ No
C. Fetal presentation at birth __ Cephalic __ Breech __ Other
D. Final route and method of delivery (check one):
__ Vaginal/Spontaneous
__ Vaginal/Forceps
__ Vaginal/Vacuum
__ Cesarean
If cesarean, was a trial of labor attempted? __ Yes __ No
Newborn Information
14. Date of Birth (MM/DD/YYYY): ____________
15. Time of Birth (24 hour): ______________
16. Sex: __________________
17. Birthweight (ex: 9 grams 9 lb/oz; grams preferred, specify unit):

_____________________________________
18. Obstetric Estimate of Gestation: ________________(completed weeks)
69
19. Apgar Score:

Score at 5 minutes: _________________
If 5 minute score is less than 6,
Score at 10 minutes: _________________
20. Plurality – Single, Twin, Triplet, etc. (specify): _____________________________________
21. If not single birth, born first, second, third, etc. (specify):___________________________
22. Abnormal conditions of the Newborn

__ Assisted ventilation required immediately following delivery
__ Assisted ventilation required for more than 6 hours
__ NICU admission
__ Newborn given surfactant replacement therapy
__ Antibiotics received by the newborn for suspected neonatal sepsis
__ Seizure or serious neurologic dysfunction
__ Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid
organ hemorrhage which requires intervention)
__ None of the above
23. Congenital Abnormalities of the Newborn (check all that apply):

__ Anencephaly
__ Meningomyelocele/Spina bifida
__ Congenital diaphragmatic hernia
__ Omphalocele
__ Gastroschisis
__ Limb reduction defect (excluding congenital amputation and dwarfing syndromes)
__ Cleft lip with or without cleft palate
__ cleft palate alone
__ Down syndrome
__ Karyotype confirmed
__ Karyotype pending
__ Hypospadias
__ None of the anomalies listed above
24. Is infant living at time of report? __ Yes __ No __ Infant transferred, status unknown
25. Is the infant being breastfed at discharge? __ Yes __ No
Paternal Information
26. Is father’s name listed on the birth certificate? ____ Yes _____ No
Demographic Data
27. Is mother married? ___ Yes ___ No
If no, has paternity acknowledgement been signed in the hospital? __ Yes __ No
70
Education/Hispanic origin/race for mother & father: I am assuming you have this information elsewhere
& do not need it on this form
28. Place where birth occurred (check one):

__ hospital
__ freestanding birth center
__ Home birth: Planned to delivery at home? __ Yes __ No
__ Clinic/doctor’s office
__ Other (Specify) _____________________
*these measures are taken directly from the NCHS’ 2003 (most recent) birth certificate:
http://www.cdc.gov/nchs/data/dvs/birth11-03final-acc.pdf
71
Young Parenthood Study Baseline Interview Instructions
The goals of the first interview are as follows. We are using a semi-structured interview format for the following
reasons:
1) To help build rapport with study participants.
2) To allow for a in-depth investigation of key issues relevant to co parenting
3) To provide some degree of flexibility in what gets discussed.
Following the interview outline : Throughout the interview, you should closely follow the questions as outlined
below. However, you can deviate from the presented order if an issue comes up earlier in your conversation.
If you need to ask questions that have already been explicitly answered, acknowledge the repetitiveness, but
still ask. For example, if the adolescent spontaneously tell you that they never used birth control, when you get
to that part of the interview, you can say something like this: “You already sort of answered this question, but
let me go ahead and ask it again to see if you have anything to add.” Often this leads to a little more detail and
sometimes a completely different answer.
If the adolescent is all over the place, you may want to provide more structure. For example, you may want to
say "I'm going to ask you about ----- in a few minutes, but for the time being let's finish talking about -----.
Probing : It's important to probe some answers. For example, if the adolescent's response to a basic question
such as "could you describe your relationship with -----." is "I don't know", find some way of helping him/her to
be more definitive.
It is often useful to ask for specific examples, which might help to clarify a somewhat vague response.
When probing, it is very important that you don't make suggestions about what the adolescent might mean -
probes should be open ended - don't put your words into the adolescents mouth. Ask questions like "what was
that like for you?" "please tell me more about that" "what do you mean?".
72
MYPS INTERVIEW Time 1
I will be asking you a number of questions during the next hour or so. These questions cover many topics
surrounding becoming a parent and your family but will start with some basic background questions. I will be
recording this interview. This recording will only be used for the purposes of this study. If you do not
understand any of the questions I ask, please let me know and I try to rephrase or explain them.
In this interview, we will be talking about a co-parent. What I mean when I say co-parent is (partner name).
We don’t want to make assumptions about your involvement or relationship with (partner name) other than
that you will both be parents to this child.
How long have you known (partner)?
Are you currently involved in a steady relationship with (partner)?
How did you meet? Tell me the whole story of how your relationship got to where it is now.
Please describe your relationship with (partner)?
Please think of three words that will help me get an idea of what your relationship is like?
Now I am going to go back and ask you to explain why you chose those three words. One way to do this is for
you to give me an example of how your relationship is __________.
What are your feelings about (partner)? (or How do you feel about him or her?) (Probe for more than one
feeling)
How has your relationship changed since you found out she is pregnant (or that you are pregnant)?
Now I am going ask you to describe (partner’s) personality. Think of three words that describe (partner).
I am going to go back and ask you to explain why you chose those three words. One way to do this is for you to
give me an example of how he or she is __________.
Are there things about your partner that you wish you could change? (probe for examples)
Now please give me three words that (partner) would use to describe you.
Again, please give me an example for each word or explain why he or she might use that word to describe you.
73
Please describe a time or a situation when you felt really close to (partner)?
In what ways do you think your relationship with ______ will change over the next year?
In what ways would you like for it to change?
What could you do to make the relationship better?
What could your partner do to make the relationship better?
Conflict Resolution Questions
What kinds of things do you disagree about? Can you give me an example of a recent disagreement or
argument?
How do you think he or she feels about that?
Why do you think he or she feels that way?
What's your view about that issue?
How do you usually work things out when you have disagreements like this?
Are there any other issues you think that the two of you need to resolve?
What is the most serious fight or argument you have had with _____? What happened?
Have you ever gotten into a physical fight with _____? What happened? (who hit who? Was there injury?) How
did that get resolved?
Questions about pregnancy and parenting:
Was this a planned pregnancy?
(If yes) How did you and ---- make that decision?
What was your response to finding out that you are going to have a baby?
What are your feelings about becoming a parent?
Do you have any concerns (about becoming a parent)?
What do you think it will be like to co-parent with ---- (partner)?
Thinking ahead about 6 months, what do you think it will be like for the two of you to have a baby to take care
of together?
74
Can you describe how you imagine that will go?
What do you think your partner is going to be like as a parent?
Do you have any concerns (about his or her role as a parent)?
Questions about father.
What is (was) your father like? Please give me three words that describe him (and examples for each word).
Please describe your relationship with him? (Three words…examples)
Please describe a time or a situation when you felt really close to your father?
Does he know you are pregnant or expecting?

If yes:
How has your relationship changed since he found out you are pregnant (or your partner is pregnant?)
Questions about Mother
What is your mother like? Please give me three words that describe her (and examples for each word).
Please describe your relationship with her? (Three words…examples)
Please describe a time or a situation when you felt really close to your mother?
Does she know you are pregnant or expecting
If yes,
How has your relationship changed since she found out you are pregnant (or got ____ pregnant?)
Parent's Relationship
How would you describe your parent’s relationship? (ask for three words)
In what ways do you want your relationship with ---- to be different from your parents’ relationship? (ask for
examples)
In what ways do you want your relationship to be similar to your parents relationship (ask for details).
Ideas about Parenting
How do you think becoming a parent is going to change your life?
How will the baby be supported financially?
Who is going to take care of the baby (non-financial care and support)?
Questions about future of relationship
75
Where do you want this relationship to go in the future?
Have you and ------ discussed future plans?
What if things don't work out?
What do you think life would be like if you were no longer involved with her?
How do you think you would handle it?
How do you think she would handle it?
Have either of you been with other partners since you started going out?
If yes, how did the two of you work that out?
Services.
Are you currently in any sort of counseling or therapy?
Do you currently have any involvement with the courts or probation?
Are you receiving any help from a case manager, such as a social worker or nurse.
How about parenting classes?
Any counseling for drug or alcohol?
If yes to any of these, ask for details:
How many times have you met with someone?
When did you start?
Questions about success
I want to talk a little bit about being successful. Tell me about someone who you know who you think is
successful. What about their situation makes them successful in your mind?
So now we have a sense of a successful person you know, but let's talk more generally, maybe about other ways
of being successful or other kinds of success. How would you describe success for a (Black/Latino) who is 25
years old?
And now for whites….Does "success" mean something different for young people who are white?
Have you ever felt that being (Black/Latino) makes it difficult to reach your goals or be successful?
76
[If yes] Can you tell me about a specific time when you thought being Black/Latino got in the way of your
success?
Have you ever felt that young white people are able to reach their goals more easily? If yes…tell me about that.
Can you tell me about a moment in your life when you thought about this issue…the difference between
opportunities for whites and Blacks/Latinos?
Ending:
I've asked you a lot of questions about a lot of things, can you think of anything that I haven't asked you about
that you see as being important to understanding you?
Do you have any questions about this study?
77
Milwaukee Young Parenthood Study Interview: 6 Month Follow-up
INTRODUCTION: Today we’re going to be talking about how things have been going since the last
interview, which was when you were pregnant. We’ll begin by asking questions about your child and
your relationship with your child’s mother/father
In this interview, we will be talking about a co-parent. What I mean when I say co-parent is (partner
name). We don’t want to make assumptions about your involvement or relationship with (partner
name) other than that you will both be parents to (baby’s name).
Please start off by telling me about your child’s birth. How did that go? Please tell me the whole story.
What is the baby’s name?
Were there any complications for the baby? Complications can include things like the cord being
wrapped around (baby’s name) neck, he/she was not breathing or an emergency C section.
Where there any medical complications for you (if interviewing mother) …the mother (if interviewing
father)?
What was your first reaction to having (baby’s name)?
How are you feeling about having (baby’s name) now?
About your child:
I’d like to get a sense of your (baby’s name) personality… so, could you get us started by choosing 3
words (adjectives) that describe your him/her? (Pause while they list adjectives).
Now, let’s go over each word. Please give an example of something that made you say….. ________?
(Ask for a specific example for each adjective).
Now I would like you to choose 3 words that describe the relationship with your baby. (Pause while they
list words - Probe). I am not asking about you or your baby, but the relationship between you and
(baby’s name)…does that make sense?
Let’s go back over each word. Why did you say….. ________?
(Can you give me an example or something that will help me understand why you said XXX?).
About you as a parent:
Now I want to ask you about being a parent. Please choose 3 words that describe you as a parent? Let’s
go back over each word. What is it about being a parent that made you say….. ________? (Probe for a
specific events or example for each adjective).
Tell me about a time when – as a parent - you felt really angry or upset. (Probe, if necessary: Can you tell
me a little bit more about the situation?)
78
Tell me about a time when - as a parent - you felt happy or joyful. (Probe, if necessary: Can you tell me a
little bit more about the situation?)
How have you changed since the last time you were interviewed?
How has your life changed?
Are there things about yourself that you wish you could change?
What are your strengths as a parent?
What are your weaknesses as a parent?
Relationship with other parent of child:
Now I am going ask you to describe (partner’s name) as a parent. Think of three words that describe
him/her. Please explain why you chose those three words.
Has he/she (the father/mother) changed since the last time you were interviewed?
What are your feelings about (partner)?
Are there things about (partner’s name) that you wish you could change? (probe for examples)
Please tell me three words that will help me get an idea of what your relationship with XXX is like now?
Now I am going to go back and ask you to explain why you chose those three words.
Please describe how you and your partner work well together to take care of your baby?
Please tell me about a time when you and --- (name) were really “clicking” or felt close as co-parents.
What are some ways that you and (partner’s name) could do a better job of taking care of your baby
together?
Now please give me three words that (partner) would use to describe you. Again, please give me an
example for each word or explain why he or she might use that word to describe you.
What kinds of things do you and your baby’s other parent fight or disagree about?
Give me an example of a recent disagreement or argument about parenting or related to parenting?
How do you think he/she feels about that?
Why do you think he/she feels that way?
How do you usually work things out when you have disagreements?
79
What other things do you think the two of you need to work out?
What has been the most serious fight you've had with ________ since (baby’s name) was born? What
happened?
Have you gotten into a physical fight with ______ since the last time you were interviewed? What
happened?
What could you do to make your co-parenting relationship with your partner better?
What could (partner’s name) do to make the co-parenting relationship better?
Questions about future of the relationship
Couples go through lots of changes, we’re interested in what kind of relationship you are in now with
each other.What is your current relationship with (partner’s name)? Are you romantically involved, on
again off again, broken up, or don’t know (or other descriptor provided)?
What have you and ------ discussed about future plans?
Thinking about the future….what do you think your co-parenting relationship is going to be like in five
years?
Other services
When did you start?
Ending:
I have asked you a lot of questions. Is there anything I have not asked about, but should have in order to
understand you, particularly your experience as a parent?
80
What questions do you have about this study?
Thank You for being interviewed!!!
81
interview, which was when your child was around 6 months old.
name) other than that you will both be parents to (baby’s name).
Think back about six months ago and what your life was like six months ago. Now please tell me how
your life changed since the last time you were interviewed?
How are things better?
How are things worse?
About your child:
I’d like to get a sense of your baby’s personality… so, could you get us started by choosing 3 words
(adjectives) that describe your baby? (Pause while they list adjectives).
Now I would like you to choose 3 words that describe the relationship with your baby. (Pause while they
list words - Probe). I am not asking about you or your baby, but the relationship between you and your
baby…does that make sense?
Tell me about a time when, as a parent, you felt really angry or upset. (Probe, if necessary: Can you tell
Tell me about a time when, as a parent, you felt happy or joyful. (Probe, if necessary: Can you tell me a
little bit more about the situation?)
82
Now I am going ask you to describe your partner as a parent. Think of three words that describe
Are there things about your partner that you wish you could change? (probe for examples)
Please describe how you and your partner work well together to take care of your baby?
What are some ways that you and your partner could do a better job of taking care of your baby
together?
What kinds of things do you and your child’s other parent fight or disagree about?
What has been the most serious fight you've had with ________ since your child was born? What
happened?
Have you gotten into a physical fight with _________ since the last time you were interviewed? How did
that happen?
83
What could your partner do to make the co-parenting relationship better?
years?
If the couple is in a romantic relationship:
1. What if things don't work out?
2. How would you feel?
3. Who would you turn to?
4. How do you think you would handle it?
5. How do you think she/he would handle it?
6. Have either of you been with other people (sexually) since you were last interviewed? How has
that affected your relationship?
Other services
When did you start?
Ending:
84
85
interview, which was when your child was around 12 months old.
name) other than that you will both be parents to (child’s name).
Think back about 1 year ago and what your life was like 1 year ago. Now please tell me how your life
changed since the last time you were interviewed?
How are things better?
How are things worse?
About your child:
I’d like to get a sense of your child’s personality… so, could you get us started by choosing 3 words
(adjectives) that describe your baby? (Pause while they list adjectives).
Now I would like you to choose 3 words that describe the relationship with (child’s name). (Pause while
they list words - Probe). I am not asking about you or your child, but the relationship between you and
(child’s name)…does that make sense?
Describe a time in the last week when you and your child really “clicked”. Tell me more about that?
How did you feel? How do you think your child felt?
(Probe if necessary)
Describe a time in the last week when you and your child really weren’t “clicking”. Tell me more about
that time? How did you feel? How do you think your child felt? (Probe if necessary)
How do you think your relationship with your child is affecting his/her development or personality?
Thinking back to when you were a child, and your relationship with your parents, how does that
influence how you feel about being a parent now?
What things do you want to do the same and what things do you what to do differently as your mother
(in respect to the parenting she provided)?
How about your father? Same and different?
86
I’d like you to think of a time you and your child weren’t together and it was a bit stressful for either you
or your child. Can you describe it to me?
What kind of effect did it have on (child’s name) ?
What kind of effect did it have on you?
Has there been anything that has been a setback for (child’s name), like something that was really hard
for him or her to deal with?
Your child is a toddler and you’ve got some experience as a parent now. If you could do it all over again,
what would you change?
What would you keep exactly the same?
What kind of relationship do you think you will have with (child’s name) when he or she is your age?
What gives you the most joy in being a parent?
What is the hardest thing about being a parent?
What causes you to worry most about your child?
Tell me about a time when, as a parent, you felt really angry or upset. (Probe, if necessary: Can you tell
How did you handle these feelings?
How did this (event) affect your child? (or how do you think your child felt when this happened?)
How do you know when (child’s name) is upset? What does he/she do?
How does that make you feel?
When (child’s name) is upset what do you do?
Does your child ever feel hurt or unhappy because of something you did? Please tell me about that?
How did you respond to that?
About you:
87
How has becoming a parent changed you?
Now I am going ask you to describe (partner’s name) as a parent. Think of three words that describe
Are there things about (partner’s name) that you wish you could change? (probe for examples)
Please describe how you and (partner’s name) work well together to take care of your child?
What are some ways that you and (partner’s name) could do a better job of taking care of your baby
together?
What kinds of things do you and your child’s other parent fight or disagree about?
88
What has been the most serious fight you've had with ________ since your child was born? What
happened?
Have you gotten into a physical fight with _________ ? How did that happen?
What could (partner’s name) do to make the co-parenting relationship better?
years?
Other services
When did you start?
Questions about success
I want to talk a little bit about being successful. Tell me about someone who you know who you think is
successful. What about their situation makes them successful in your mind?
So now we have a sense of a successful person you know, but let's talk more generally, maybe about
other ways of being successful or other kinds of success. How would you describe success for a
(Black/Latino) who is 25 years old?
And now for whites….Does "success" mean something different for young people who are white?
89
Have you ever felt that being (Black/Latino) makes it difficult to reach your goals or be successful?
[If yes] Can you tell me about a specific time when you thought being Black/Latino got in the way of your
success?
Have you ever felt that young white people are able to reach their goals more easily? If yes…tell me
about that.
Can you tell me about a moment in your life when you thought about this issue…the difference between
opportunities for whites and Blacks/Latinos?
Ending:
90
# Parent triorm
- g TI S E A
(hild's
name D a t eb
o if r t h - l-l- Ageinmonths
-
mm 00 yy
Parent/Guardian
name D:tp romnlptpd I I S e xI B o y n G i r l
mm 00 yy
W a s y o u r c h i l d b o r n p r e m a t u r e l y ? I Yl feysensN, w o h a t w a s t h e e x p e c t e d d a t e o f b i r t /h ?
*/ * *
d i t ho t h eyr o u n cg h i l d r e(nn o ti n c l u d i nbgr o t h e a
I na t y p i c awl e e kh, o wm u c ht i m ed o e ys o u cr h i l ds p e n w r sn ds i s t e r s )- ? h o u r ps e rw e e k
D oy o uu s ea n yt y p eo f c h i l d c afroery o u cr h i l d ?n Y e sf l N o l f y e sh, o wm a n yh o u r ds oy o uu s ec h i l d c airnea t y p i c awl e e k ?- hours
D i dy o u cr h i l dh a v e
a n yp r o b l e ma st b i r t h ?n Y e sI N o l f y e sp, l e a seex p l a i n
This section contains statements about 12- to 36-month-old children. Many statements describe normal feelings
and behaviors, but some statements describe feelings and behaviors that may be a problem. Please do your best to
answer every statement.
Not SomewhatVery
true/ true/ true/
P i e a sr ier c l teh eC N E t e s c r i by ec su cr h i l r lb?e, h a v iionrt h eL A SM
r e s p 0 ntshea ib € sC I 0 l il H rarely sometimesoften
1. lsbothered
byloudnoises
orbright
lights. 0 1 2
2. Takes
a while
tofeelcomfortable (10minutes
innewplaces orm0re). 0 1 2
hurtsooftenthatyoucan't
3. Gets takey0ureyes
offhimorher. 0 1 2
4. Acts
aggressive
whenfrustrated. 0 1 2
5. lsquiet
0rless
active
innewsituations. 0 1 2
6. Gets whenleftwithanelvbabysitter.
upset (N:Never
used
babysitter/ 0 1 2
7. Responds
thefirsttimehisorhername
iscalled. 0 1 2
pleasure
8. 5hows when (forexample,
heorshesucceeds claps
forself). 0 l 2
9. Puts afterplaying.
toysaway 0 1 2
10.Seems
nervous,
tense,
orfearful. 0 1 2
11.lsrestless
andcan't
sitstill. 0 1 2
12.Gets rerywound playing.
uporsillywhen 0 r 2
,l3.
Actsbossy. 0 1 2
.l4.
lsconstantly
moving. 0 l 2
15.Dislikes
some
foods
because
ofhowtheyfeel. 0 1 2
16.Follows
rules. 0 1 2
17.lsbothered
bycertain (smells).
odors 0 ' l 2
18.Wakes
upatnight
andneeds
help
tofallasleep
again. 0 1 2
19.Getsupset leftwithafamiliar
when babysitter (N.Have
orrelative. notused
asitter
0rrelative
intheastmonth) 0 1 2
downwhenyousay"Shh."
20. Quiets 0 1 2
\ , . , . .i , , , i . I , . . . ; ,
rsBN 0l,5qEa7r3-7
rltPsychCorp C o p y r i g hOt 2 0 0 2b y Y a l eU n i v e r s i tayn dt h e U n i v e r s i toyf M a s s a c h u s e t t s .

A l l r i g h t sr e s e r v e dP. r i n t e di n t h e U n i t e dS t a t e so f A m e r i c a .
1 2 3 4 5 6 7 8 9 1 0 1 1 2 A BC D E ililillt
"1,*?j:,, S e t t i o nA r a n t i n u e d Not Somewhat Very
{!?'i.i.;
tl-:'ic-, true/ true/ true/
.l#45; i r l s 3 ii1l il1 l rr h eC l l ii q - { l ) 0 ri i! i\ai ri r e s i c i e l r - r i b pr: h" ;tul C* b' te h a v iio* ri h t i A 5 i i \ ' 4 0 N i H rarelv sometimes
often
orhasa tantrum
21.Cries untilheorsheisexhausted. 0 1 2
22. Refuses
toeatfoods
thatrequire
chewing. 0 ' l 2
t0getattenti0n
23. Misbehaves fromadults. 0 1 2
todoasyouask.
24.Tries 0 1 2
25. Plays f0r5 minutes
withtoys orlonger. 0 1 2
people
26. Hugs 0rpat.
witha squeeze (N:Physically
unable) 0 1 2 N
27.Has
started (like
heorshehadoutgrown
something
d0ing usea pacifier). 0 1 2
28. lsafraid
ofcertain
animals.
Whatanimal(s)? 0 1 2
2 9 . l sa f r a i d
o fc e r t a itnh i n g s . W ht a
h ti n g ( s ) ?
30. lsafraid ploces,

ofcertain likestores, parks,
elevators, Whatplace(s)?
orcars.
n i t ho t h epre o p l e .
3 1 .H a n g0 sny 0 u0 rw a n t s0b ei ny o ulra pw h e w 0 1 2
32. Rolls t0you(0rsomeone

a ballback else). (N:Physically
unable) 0 1 2
3 3 .H alse sfsu nt h a n
o t h ecrh i l d r e n . 0 l 2
34. Likes
being hugged,
cuddled, orkissed
byloved
ones. 0 1 2
35. lsveryloud.
Shouts a lot.
0rscreams 0 1 2
foryouwhen
36. Reaches youarenotholding
himorher. (N:Physically
unable) 0 1 2
37.Spits
outfood(s). 0 1 2
38. lsdisobedient (forexample,
ordefiant todoasyouask).
refuses 0 1 2
19.Cries getownway.
if doesn't 0 1 2
foryou(orother
40. Looks parent)
when
upset. 0 1 2
fromtoyt0toyfaster
41.Goes thanother
children
hisorherage. 0 1 2
42. Keeps
trying
even
when
something
ishard. 0 1 2
43. lssneaky. misbehavior.
Hides 0 1 2
atpicture
44. Looks books
byself. 0 1 2
45. Helps (forexample,
withdressing putsarminsleeve). 0 ' t 2
0nt0youwhen
46. [riesorhangs youtryt0 leave. 0 1 2
47.Worries
a lotorisveryserious. 0 1 2
48. Feels when
sick nervous
0rupset. 0 r 2
todogrown-up
49. Pretends likeshave.
things, 0 1 2
50. lsbothered
byhowsome feelonhisorherskin(forexample,
things clothing
seams, fabrics).
certain 0 1 2
51.Looks yousayhisorhername.
rightatyouwhen 0 1 2
ITSEA
P a r e nFt o r n r
SectionA cantinued liot SomewhatVery
true/ true/ true/
P l e a scei r c lteh e0 N Er e s p 0 nlshea tb e sdt e s c r i byeosu cr h i l d
s b e h a v iionrt h eL A SM
T0NiH rarely sometimesoften
52. Does
notreact
when
hurt.
53. lseasily
startled.
54. lsaffectionate
withloved
ones.
55. lswell-behaved.
you(orother
56. Prefers parent)
overother
adults.
57.Laughs
easily
ora lot.
58. lsstubborn.
59.Won'ttouch
some
objects
because
ofhowtheyfeel.
60. lshard
tosoothe
whenupset.
61.Runs inpublic
away places.
62. Sleeps
through
thenight.
63. 0ftengets
veryupset.
64. Gags
orchokes
onfood.
65. Wants
todothings
forself.
66. Points
toaskfor
something.
67. Points yousomething
toshow faraway.
68. lsbothered
bybeing (forexample,
inmotion swinging,
spinning,
being
tossed
intheair,orbouncing).
upgrouchy
69.Wakes orina badmood.
70. Has
trouble
falling
asleep
orstaying
asleep.
71. Tries youfeelbetter
tomake wheny0u're
upset.
72. Stays
stillwhile
being
changed,
dressed,
orbathed.
73. Has
trouble
calming
down
when
upset.
74. Demands
a lotofattention.
/5. Sits
for5 minutes youread
while a story.
76. lsworried
orupset
when someone
ishurt.
77.Iriesto"make-up"
aftermisbehaving.
beheldtogotosleep.
78. Must
79.lsimpatient
oreasily
frustrated.
80. lsinterested
inother
babies
andchildren.
81. Likes
figuring
things
out,likestacking
blocks.
82. Can fora longtime(n0tincluding
payattention TV).
83. lsaffectionate
withstrangers.
84. lsaware people's
ofother feelings.
85. When getsverystill,freezes,
upset, ordoesn't
move.
86. Has
trouble
adjusting
t0changes.
Sttl i,ttt ,,1 irtttlitttrLtl oli t/t.\-l h(t,<'..
ITSEA
P a r e nFt o r m 3
SectionA continued ilot SomewhatVery
tlue/ tru€/ true/
P l e a scei r c lteh e0 N Er e s p 0 nl shea tb e sdt e s c r i byeosu cr h i l d b' se h a v iionrt h eL A SM
T0NIH. rarery sometimesoften
ishurt(forexample,
s0me0ne
tohelpwhen
87.Tries gives
atoy). 0 1 2
,)
88. lsshywithnewadults. 0 1 L
heorshewants.
towaitforthings
89. lsable 0 1 2
')
a lot.
90. Cries 0 1
playful
91. lmitates youaskhimorherto.
when
sounds 0 1 2
')
else(forexample,
aresomething
thatobjects
92. Pretends uses asphone).
banana 0 1
rightaway.
newfoods
93.Accepts 0 1 2
94. Enjoys activities.

challenging 0 1 L
orfeeds
95. Hugs orstuffed
dolls animals. 0 1 2
-)
96. lsa perfectionist. 0 1
'I
orwaving
clapping
97.lmitates bye-bye. (N:Physlcally
unable) 0 2
when
98. lsnotafraid be.
should 0 1
orgives
99.Jokes youthings yousmile
tomake orlaugh. 0 1 2
orgrouchy.
100.lsirritable 0 1 2
,l
101.Pays
careful when
attention being
taught new.
something 0 2
102.Looks
unhappy anyreason.
orsadwithout 0 1 2
more
103.Sleeps hisorherage.
children
thanother 0 1 2
'I
toeat.
104.Refuses 0 I
105.lscurious newthings.
about 0 1 2
(nightteftlrs).
toyouforafewminutes
respond
anddoesn't 0 1 )
106.Wakes
upscreaming
1 0 7 l.s w h i n y o r f u s s yhwehoerns hi sen o f t i r e d . 0 1 2
108.Feels self.
badabout 0 1 2
109.lsa good
eater. 0 1 2
110.lsshywithnewchildren. 0 1 1
orruins
Breaks
111.lsdestructive. 0npurp0se.
things 0 1 2
tohave
112.Seems noenergy. 0 1
,l
orpouts.
angry
113.Gets 0 2
'I
ornightmares.
dreams
upfromscary
114.Wakes 0
1 1 5W
. antstosleepinsomeoneelse'sroomorbed. ( N . A l w a y s s h a r e s a r o o m0o r b e d1) 2
i 1 6 .H a s t e m p e r t a n t r u m s . 0 1 2
117.Hits, you(orother
orkicks
bites, parent). 0 1 2
118.lsa picky
eater. 0 1 I
atyoufromacross
back
119.Smiles a r00m. 0 1 2
')
withdrawn.
120.5eems 0 1
sad,
veryunhappy,
121.Seems ordepressed. 0 1 2
,l
when
122.0beys tostopbeing
asked aggressive. 0 I
T S E AP a r e nFt o r m
S e c t i o nA c o n t i n u e d Not SomewhatVery
true/ true/ true/
P l e a sc ei r c iteh e0 N Er e s p 0 nt5hea tb e sdt e s c r r byeosu cr h i l d b' se h a v iionrt h eL A 5 M
T 0NTH. rarely s0metimesoften
123.Refuses food(s)
toeatcertain for2 days
ormore. 0 1 I
124.Purposely tohurtyou(orother
tries parent). 0 1 2
'125.
Gets
upset
when asked
tochangeactivities. 0 1 I
126.Hurts (forexample,
selfonpurpose bangs
head). 0 1 2
t
\ Has your child begun to combine words, such as morejuice? Pleasecheck one box and follow the instructions next
to that box.
n Notyet Do not answer this section. Pleasego to Section C.
n Sometimes Please answer Items 1-5 below.
tr Often Please answer ltems 1-5 below.

l'lot SomewhatVery
true/ true/ true/
P l e a sc ei r r l teh e0 N tr e s p 0 nt5hea tb e sdt e s o i b cy ro u r h i l d 'bse h a v ironrt l r eL A SM
f 0NIH rarely sometimes
often
1. Repeats
thelastwords
ofsentences
orTVcommercials.
2. Swears.
3. Takes
awhile inunfamiliar
tospeak situations.
4. Talks
about
otherpeople's
feelings "Mommy
(like mad").
5. Ialks
about
things
thatarestrange,
scary,
0rdisgusting.
In the last month, did your child have any contact (more than 0 hours per week) with other young children
(not includingbrothers and sisters)? Please check one box and folbw the instructions next to that box.
tr No Do not answer this section. Go to Section D.
n Yes Pleaseanswer ltems 1-11 below.

Not SomewhatVery
true/ true/ tlue/
P l e a sc ei r c lteh e0 N Er e s p 0 ntsher tb e sdt e s c r i byeosu cr h i l d
s b e h a v iionrt h eL A SfTt 4 0 N I H rarelv sometimesoften
1. Takes
turns playing
when withothers. 0 1 - )
2. Tests
other toseeiftheywillgetangry.
children 0 1 2
3. Asks
forthings
nicely playing
when withchildren. 0 t t
4. Hits,
shoves,
kicks,
orbites (notincluding
children orsister).
brother 0 1 2
5. Has
atleast
onefavorite (achild).
friend 0 1 2
6. Picks
onorbullies
other
children. 0 1 2
7. Plays
wellwithother
children. 0 t l
8. Teases
other
children. 0 1 2
"house"
9. Plays withother
children. 0 1 2
10.Won'tletother play
children withhisorhergroup. 0 1 2
,l1.
Hurts
other 0npurp0se.
children 0 1
I
1
L
T S E AP a r e nF
t orm 5
The questionsin the next sectionask about feelingsand behaviorsthat can be problemsfor young children. Some
of the questionsmay be a bit hard to understandespeciallyif you have not seenthe behaviorin your child. Please
do your best to answerthem anYwaY.
Not SomewhatVety
true/ true/ true/
P l e a :cei r c ltei i e0 l ' i Er e s p 0 r rt shea tb e sdt e s c r i bveosu rc h i l d 'bse h a v i iontt h eL A SM
I 0NTH rarely sometimesoften
unaware
out.lstotally
1. Spaces happening
ofwhat's himorher.
around 0 1 2
(ontact.
physical
2. Avoids 0 1
eyecontact.
notmake 0 1 2
3. Does
1
4 . H a s a b o d y t i c o r t w i t ( h h e o r s h e s e e m s u n a b l e t o c o n t r o l ( f o r e x a m p l e , e y e s , m o u t h , n o s0e , 0 r l e1g s t w i t c h ) .
L
sounds heorsheseems unable tocontrol. 0 1 2

5. Makes
6. Holds foodincheeks. 0 1
7. Hurts onpurPose.
animals 0 1 2
getting
about
8. lsreryworried dirty. 0 1 L
orneat.
tobeclean
things
9. Needs 0 1
1 0 .P l a y s g a m e s w i t h o t h e r c h i l d r e n i n w h i c h t h e y l o o k a t o r t o u c h e a c h o t h e r ' s p r i v a t e p a r t s0. 1
11.Plays withownsexparts often andfora longtime. 0 1 2
ownhairout(such
12. Pulls aseyelashes, hair)'
orhead
eyebrows, 0 1 1
L
atyou,putsyourhand
looking
13.Without such
onobjects, aswind-up themwork.
tomake
toys, 0 1
bodY.
14.Worriesaboutown 0 1 L
,l
15.Puts
things order
inaspecial andover.
over 0 2
("p00ps").
movements
withownbowel
16. Plays 0 1
movements
bowel
17.Has (forexample,
heorsheshouldn't
where 0nthefloor). 0 1 2
("pees")
18. Urinates heorsheshouldn't.
where 0 1 2
pretend
outthesame
19.Acts theme giveonexomple
Please
overandover. below. 0 1 2
a particular
20. Repeats over
movement andover(likerocking,
spinning). giveanexomple
Pleose below'
orphrase
action
thesame
21. Repeats overandover. giveonexample
Pleose below.
P/ease
habits.
22. Hasverystrange below.
describe
23. Eats (likepaper

thatarenotedible
things
ordrinks orpaint).
Pleose below.
describe
Pleose
onthingsheorsheshouldn't.
Chews below.
describe
ParentForm
ITSEA
The following questions concern vour general f-eelingsabout your child's behavior.
1 . How worried ilre you about vour child's behavior, emotions, or relationships?
n N o t a t a l lw o r r i e d
n A l i t t l ew o r r i e d
n Worried
n Very worried
How worried rlre you about vour child's languagc dc."'clopment?
n N o t a t a l lw o r r i e d
if A little worried
[] Worried
n Very worried
ITSEA
P a r e nF
t orm

Appendix D Assessment Measures 12-22-10 PDF

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Informasi Dokumen

Judul Asli

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Format Tersedia

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Appendix D Assessment Measures 12-22-10 PDF

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Hak Cipta:

Format Tersedia

Milwaukee Young Parenthood Study

Participant Assessment Tools

Appendix D MYPS Assessment Measures

Core Items and Demographics

Chart Review Worksheet

Adolescent Family Life Care Programs Core Baseline Questionnaire (Time 1)

To be completed by project staff:

About the Future

□ 4 More than three times

□ d. With my father (include stepfather)

About the Future

WHAT YOU THINK

6. I think I should work to get something, if I really want it.

ABOUT YOUR CHILD

The next questions refer to the child born

14. Did you breastfeed this child at all?

16. Is this child alive now?

18. When was this child’s last “well-baby” visit?

□ 2 Within the past 6 months

19. Does this child live with you?

20. Where does this child live now?

21. Is this child 3 months old or older?

22. Has this child had any of the following vaccinations/shots?

25. How many hours a week is this child in child care?

30. What is your marital status?

□ 5 Other (Describe ______________________)

31. Who do you live with now?

ABOUT YOUR HEALTH

33. Our records show that you were pregnant on

Have you been pregnant since that pregnancy ended?

34. Have you been pregnant since ____________________?

35. These are some ways people try to avoid pregnancy.

Mark ALL THAT APPLY

□ b. No method used this month

36. Since ____________________, have you received . . .

40. Have you ever been in a job training program?

41. Did you ever complete a job training program?

42. How many hours do you work per week?

44. What is your main source of financial support?

Other Demographics (Time 1 Only)

I am going to read a list of descriptions of parents’ relationships.

□ NuvaRing (Vaginal ring)

Perceived Stress Scale-4 (Time 1-Time 4)

Never Almost Sometimes Fairly Very

The Parenting Stress Index-Short Form (Time 2-Time 4)

Strongly Agree Not Disagree Strongly

Strongly Agree Not Disagree Strongly

Strongly Agree Not Disagree Strongly

The Everyday Discrimination Scale (Time 1-Time 4)

Major Discrimination Yes No

Day-to-day unfair treatment 4 or more 2-3 Once Never

How did you respond to this/these experience(s)?

1. Keep from getting down in the dumps. 0 1 2 3 4 5 6 7 8 9 10

Conflict in Adolescent Dating Relationships Inventory (Time 1-Time 4)

The Conflict in Adolescent Relationships Inventory (female version)

During a conflict or argument with my boyfriend in the past year:

Quality of Relationship Inventory (Time 1-Time 4)

Note: “Partner” refers to the mother or father of your baby

4) How upset do the following people sometimes make you feel?

Fragile Families Caregiving Activities (Time 2-Time 4)

Days Per Week

Play games like “peek-a-boo” or “gotcha” with (CHILD) 0 1 2 3 4 5 6 7

Sing songs or nursery rhymes to (him/her) 0 1 2 3 4 5 6 7