1 Survey

Appendix A A.2.1.i–11

Source: Visits: 6 month Mode: Self-administered (Mail-in) Estimated Time:		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

6 Month Mother Questionnaire

6 months and 12 months

Instructions

1	This booklet contains questions about how you feel, your baby’s behavior and how you and your partner divide the duties of raising your baby.
2	Use a No. 2 pencil or a blue or black ink pen only. Do not use a felt-tipped pen or a red ink pen.
3	Make solid marks that fill the oval completely. Do not use a or an to record an answer.
4	If you need to change an answer, be sure to erase or mark out the unwanted marks completely.
5	Mark only one response for each question, unless otherwise directed.

Q1. The first question is a series of items about how you currently feel.

The following are statements that people have used to describe themselves. Read each statement and fill in the response to indicate how you feel right now, that is, at this moment. There are no right or wrong answers. Do not spend too much time on any one statement, but give the answer which seems to best describe your present feelings.

Right now, at this moment:	NOT AT ALL	SOMEWHAT	MODERATELY SO	VERY MUCH SO
a. I feel calm	O	O	O	O
b. I feel secure	O	O	O	O
c. I am tense	O	O	O	O
d. I feel strained	O	O	O	O
e. I feel at ease	O	O	O	O
f. I feel upset	O	O	O	O
g. I am presently worrying over possible misfortunes	O	O	O	O
h. I feel satisfied	O	O	O	O
i. I feel frightened	O	O	O	O
j. I feel comfortable	O	O	O	O
k. I feel self-confident	O	O	O	O
l. I feel nervous	O	O	O	O
m. I am jittery	O	O	O	O
n. I feel indecisive	O	O	O	O
o. I am relaxed	O	O	O	O
p. I feel content	O	O	O	O
q. I am worried	O	O	O	O
r. I feel confused	O	O	O	O
s. I feel steady	O	O	O	O
t. I feel pleasant	O	O	O	O

Q2. The next question is a series of items about how you generally feel.

The following are statements which people have used to describe themselves. Read each statement and fill in the response to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statement, but give the answer which seems to best describe your feelings.

Generally:	NOT AT ALL	SOMEWHAT	MODERATELY SO	VERY MUCH SO
a. I feel pleasant	O	O	O	O
b. I feel nervous and restless	O	O	O	O
c. I feel satisfied with myself	O	O	O	O
d. I wish I could be as happy as others seem to be	O	O	O	O
e. I feel like a failure	O	O	O	O
f. I feel rested	O	O	O	O
g. I am “calm, cool, and collected”	O	O	O	O
h. I feel that difficulties are piling up so that I cannot overcome them	O	O	O	O
i. I worry too much over something that really doesn’t matter	O	O	O	O
j. I am happy	O	O	O	O
k. I have disturbing thoughts	O	O	O	O
l. I lack self-confidence	O	O	O	O
m. I feel secure	O	O	O	O
n. I make decisions easily	O	O	O	O
o. I feel inadequate	O	O	O	O
p. I am content	O	O	O	O
q. Some unimportant thought runs through my mind and bothers me	O	O	O	O
r. I take disappointments so keenly that I can’t put them out of my mind	O	O	O	O
s. I am a steady person	O	O	O	O
t. I get in a state of tension or turmoil as I think over my recent concerns and interests	O	O	O	O

3. The next question is about activities with which parents may spend their time. Please indicate how much you and your partner are involved in the following activities. If you and your partner are not involved in a particular activity record as “Not applicable.”

	Partner’s “job”	Mostly partner’s “job”	We share it “equally”	Mostly my “job”	My “job”	Not applicable
a. Changing your child’s diapers	O	O	O	O	O	O
b. Giving your child a bath	O	O	O	O	O	O
c. Taking your child to sitter or day care	O	O	O	O	O	O
d. Feeding your child	O	O	O	O	O	O
e. Taking your child to doctor’s visits	O	O	O	O	O	O
f. Buying toys for your child	O	O	O	O	O	O
g. Attending to your child when he/she cries	O	O	O	O	O	O
h. Dressing your child	O	O	O	O	O	O
i. Getting up at night to attend to your child	O	O	O	O	O	O
j. Putting your child to bed	O	O	O	O	O	O
k. Making child-care arrangements (scheduling day care or sitters)	O	O	O	O	O	O
l. Doing your child’s laundry	O	O	O	O	O	O
m. Reading to your child	O	O	O	O	O	O
n. Buying clothes for your child	O	O	O	O	O	O
o. Playing with your child	O	O	O	O	O	O
p. Talking to your child	O	O	O	O	O	O
q. Taking your child on outings	O	O	O	O	O	O

4. The following questions ask you to choose an answer which best describes your feelings. While you may not find an answer that exactly states your feelings, please choose the answer which comes closest to describing how you feel. Your first reaction to each question should be your answer. Please indicate the degree to which you agree or disagree with the following statements. If you are not sure, please select “Not Sure.”

	Strongly Disagree	Disagree	Not Sure	Agree	Strongly Agree
a. When my baby came home from the hospital, I had doubtful feelings about my ability to handle being a parent.	O	O	O	O	O
b. Being a parent is harder than I thought it would be.	O	O	O	O	O
c. I feel capable and on top of things when I am caring for my baby.	O	O	O	O	O
d. I can’t make decisions without help.	O	O	O	O	O
e. I have had many more problems caring for my baby than I expected.	O	O	O	O	O
f. I enjoy being a parent.	O	O	O	O	O
g. I feel that I am successful most of the time when I try to get my baby to do or not do something.	O	O	O	O	O
h. Since I brought this baby home from the hospital, I find that I am not able to take care of this baby as well as I thought I could. I need help.	O	O	O	O	O
i. I often have the feeling that I cannot handle things very well.	O	O	O	O	O
j. It takes a long time for parents to develop close, warm feelings for their babies.	O	O	O	O	O
k. I expected to have closer and warmer feelings for my baby than I do and this bothers me.	O	O	O	O	O
l. Sometimes my baby does things just to be mean, and that bothers me.	O	O	O	O	O
m. When I was young, I never felt comfortable holding or taking care of babies.	O	O	O	O	O
n. My baby knows I am his or her parent and wants me more than other people.	O	O	O	O	O
o. The number of children I have now is too many.	O	O	O	O	O

Q3. Continued

	Strongly Disagree	Disagree	Not Sure	Agree	Strongly Agree
p. Most of my life is spent doing things for my baby.	O	O	O	O	O
q. I find myself giving up more of my life to meet my baby’s needs than I ever expected.	O	O	O	O	O
r. I feel trapped by my responsibilities as a parent.	O	O	O	O	O
s. I often feel that my baby’s needs control my life.	O	O	O	O	O
t. Since having this child, I have been unable to do new and different things.	O	O	O	O	O
u. Since having a baby I feel that I am almost never able to do things that I like to do.	O	O	O	O	O
v. It is hard to find a place in our home where I can go to be by myself.	O	O	O	O	O

4. For these next questions, please select the best answer.

a. When I think about myself as a parent, I believe:

O I can handle anything that happens

O I can handle most things pretty well

O Sometimes I have doubts, but find that I handle most things without any problems

O I have some doubts about being able to handle things

O I don’t think I handle things very well

b. I feel that I am:

O A very good parent

O A better-than-average parent

O An average parent

O A person who has some trouble being a parent

O Not very good at being a parent

c. How easy is it for you to understand your child’s wants or needs?

O Very easy

O Easy

O Somewhat difficult

O It is very hard

O I usually can’t figure out what the problem is

5. The next questions ask about different types of baby behaviors. As you read each description of the baby’s behavior, please indicate how often your baby did this during the LAST WEEK (the past 7 days). Record as “Does Not Apply” if you did not see the baby in the situation described during the last week.

a. During feeding, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Lie or sit quietly?	O	O	O	O	O	O	O	O
Squirm or kick?	O	O	O	O	O	O	O	O
Wave arms?	O	O	O	O	O	O	O	O

b. During sleep, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Toss about in the crib?	O	O	O	O	O	O	O	O
Move from the middle to the end of the crib?	O	O	O	O	O	O	O	O
Sleep in one position only?	O	O	O	O	O	O	O	O

c. When being dressed or undressed during the last week, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Wave her/his arms and kick?	O	O	O	O	O	O	O	O
Squirm and/or try to roll away?	O	O	O	O	O	O	O	O

d. When put into the bath water, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Splash or kick?	O	O	O	O	O	O	O	O
Turn her/his body and/or squirm?	O	O	O	O	O	O	O	O

e. When placed on his/her back, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Wave arms and kick?	O	O	O	O	O	O	O	O
Squirm and/or turn body?	O	O	O	O	O	O	O	O

f. When placed in an infant seat or car seat, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Wave arms and kick?	O	O	O	O	O	O	O	O
Squirm and/or turn body?	O	O	O	O	O	O	O	O
Lie or sit quietly?	O	O	O	O	O	O	O	O

g. How often during the last week did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Cry or show distress at a change in parent’s appearance (glasses off, shower cap on, etc.)?	O	O	O	O	O	O	O	O
Startle at a sudden change in body position (e.g., when moved suddenly)?	O	O	O	O	O	O	O	O
Startle to a sudden or loud noise?	O	O	O	O	O	O	O	O

The following questions are about the last two weeks.

h. During the last two weeks, when introduced to an unfamiliar adult, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Cling to a parent?	O	O	O	O	O	O	O	O
Refuse to go to the unfamiliar person?	O	O	O	O	O	O	O	O
Hang back from the adult?	O	O	O	O	O	O	O	O
Never “warm up” to the unfamiliar adult?	O	O	O	O	O	O	O	O

i. When in the presence of several unfamiliar adults, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Cling to a parent?	O	O	O	O	O	O	O	O
Cry?	O	O	O	O	O	O	O	O
Continue to be upset for 10 minutes or longer?	O	O	O	O	O	O	O	O

j. When visiting a new place, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Show distress for the first few minutes?	O	O	O	O	O	O	O	O
Continue to be upset for 10 minutes or more?	O	O	O	O	O	O	O	O

k. When the study child was approached by an unfamiliar person when you and he/she were out (for example, shopping), how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Show distress?	O	O	O	O	O	O	O	O
Cry?	O	O	O	O	O	O	O	O

l. When an unfamiliar person came to your home or apartment, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Allow her/himself to be picked up without protest?	O	O	O	O	O	O	O	O
Cry when the visitor attempted to pick her/him up?	O	O	O	O	O	O	O	O

m. When the study child saw a toy she/he wanted, how often in the past week did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Get very excited about getting it?	O	O	O	O	O	O	O	O
Immediately go after it?	O	O	O	O	O	O	O	O

n. When given a new toy, how often in the past week did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Get very excited about getting it?	O	O	O	O	O	O	O	O
Immediately go after it?	O	O	O	O	O	O	O	O
Seem not to get very excited about it?	O	O	O	O	O	O	O	O

o. How often during the last week did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Move quickly toward new objects?	O	O	O	O	O	O	O	O
Show a strong desire for something she/he wanted?	O	O	O	O	O	O	O	O
Seem excited when you or other adults acted in an excited manner around her/him?	O	O	O	O	O	O	O	O

p. In the last two weeks, when visiting a new place, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Get excited about exploring new surroundings?	O	O	O	O	O	O	O	O
Move about actively when she/he is exploring new surroundings?	O	O	O	O	O	O	O	O

q. In the last two weeks, when familiar relatives/friends visited, how often did your baby:

	Never	Very Rarely	Less Than Half the Time	About Half the Time	More Than Half the Time	Almost Always	Always	Does Not Apply
Get excited?	O	O	O	O	O	O	O	O
Seem indifferent?	O	O	O	O	O	O	O	O