Attachment E_Survey-Instrument

39

Attachment E

Survey Instrument

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Childhood Experiences Survey

On this survey, we will ask you some questions about your health, relationships, and behaviors. We will ask about these during 3 different time periods: now (as an adult), and thinking back to when you were a teenager and when you were a child.

You will also be asked to compare some different health experiences and to choose which you would prefer. Finally, we will ask some questions about your childhood experiences.

Your responses are very important to public health. Your answers will help us to improve the health of others in the future.

There are no right or wrong answers. We are only interested your experiences and opinions.

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Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Health, Relationships, and Behavior in the Past 30 Days

In the past 30 days how often did the following things happen…	Always	Often	Sometimes	Rarely	Never
I was so angry that I felt like throwing things, screaming at someone, or picking a fight
I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities
I felt depressed, afraid, or worthless
I felt like my emotions were out of control
I could not trust or maintain healthy relationships with other people
Illness, injuries, or accidents interfered with my daily activities
	Poor	Fair	Good	Very good	Excellent
In the past 30 days would you say that in general your health was…?

Health, Relationships, and Behavior during a Typical Month as an Adult

Now, please think about the same items during a typical month as an adult (since you turned age 18).

During a typical month as an adult how often did the following things happen…	Always	Often	Sometimes	Rarely	Never
I was so angry that I felt like throwing things, screaming at someone, or picking a fight
I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities
I felt depressed, afraid, or worthless
I felt like my emotions were out of control
I could not trust or maintain healthy relationships with other people
Illness, injuries, or accidents interfered with my daily activities
	Poor	Fair	Good	Very good	Excellent
During a typical month as an adult would you say that in general your health was…?

Health, Relationships, and Behavior as a Teenager (Ages 12-17)

Though it may feel like a long time ago, please think about the same items experienced during a typical month as a teenager (ages 12-17). This is about grades 7 and up in school.

During a typical month as a teenager how often did the following things happen…	Always	Often	Sometimes	Rarely	Never
I was so angry that I felt like throwing things, screaming at someone, or picking a fight
I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities
I felt depressed, afraid, or worthless
I felt like my emotions were out of control
I could not trust or maintain healthy relationships with other people
Illness, injuries, or accidents interfered with my daily activities
	Poor	Fair	Good	Very good	Excellent
During a typical month as a teenager would you say that in general your health was…?

Health, Relationships, and Behavior as a Child (Ages 5-11)

Last, please think about the same items experienced during a typical month as a child (ages 5-11). This is about grades K-6 in school.

During a typical month as a child how often did the following things happen…	Always	Often	Sometimes	Rarely	Never
I was so angry that I felt like throwing things, screaming at someone, or picking a fight
I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities
I felt depressed, afraid, or worthless
I felt like my emotions were out of control
I could not trust or maintain healthy relationships with other people
Illness, injuries, or accidents interfered with my daily activities
	Poor	Fair	Good	Very good	Excellent
During a typical month as a child would you say that in general your health was…?

Comparing Quality of Life as an Adult

Now we will ask you to compare different possible adult lives that you could experience today and into the future. These include the same aspects of health, relationships and behaviors that we just asked you about.

For each pair of lives A and B, we will ask which you would prefer. For example:

In Adult Life A:

• You would sometimes feel depressed, afraid or worthless

• You would have fair overall health

Or, in Adult Life B:

• You would never feel depressed, afraid, or worthless

• You would have excellent overall health

We will show these using dots, and displayed side-by-side in a table like this:

Aspects		Adult Life A	Adult Life B
Depressed, afraid, or worthless		Sometimes depressed	Never depressed
Overall health		Fair	Excellent

29. Would you prefer A or B?

• Adult Life A

• Adult Life B

There is one additional aspect: You would live in each life for the number of years shown from today, and then die.

Years you live from today, followed by death

Live for 8 years

Live for 7 years

29. Would you prefer A or B?

• Adult Life A

• Adult Life B

Next, we will add the other aspects of health and quality of life.

Note: electronic version of survey will have a “mouse over” option with fuller descriptors of each attribute (Aspect). Respondents will be reminded of this with a note on screen.

Adult Comparison #1

Imagine yourself now in Life A or Life B.

Aspects		Adult Life A	Adult Life B
Anger		Never angry	Never angry
Risky behaviors		Never risks health	Never risks health
Depressed, afraid, or worthless		Sometimes depressed	Never depressed
Emotions out of control		Never out of control	Never out of control
Relationship or trust problems		Never has problems	Never has problems
Illness, injuries, accidents, interfere with daily activities		Never interfered	Never interfered
Overall health		Fair	Excellent

29. Would you prefer A or B?

• Adult Life A

• Adult Life B

Now suppose you would live in each life for the number of years shown from today, then die.

Years you live from today, followed by death

Live for 8 years

Live for 7 years

29. Would you prefer A or B?

• Adult Life A

• Adult Life B

[Note: Respondents will be asked to answer 12 comparison questions total: 4 child, 4 teen, and 4 adult]

Adult Comparison #2

29. Similar to above. Values for each cell in the table will be determined by a random draw from a statistical algorithm (near-orthogonal D-efficient design, with good level balance, no or minimal overlap, no dominated pairs, etc.), which selects many dozen health states out of the total number of possibilities.

30. As above.

Adult Comparison #3

29. As above

30. As above

Adult Comparison #4

29. As above

30. As above

Comparing Quality of Life as a Teenager

Now we would like you to think about different possible teenage lives that you could have had while age 12-17, instead of the life that you actually lived. For each pair, please tell us which one has a better quality of life.

Teenage Comparison #1

Imagine yourself having lived Teenage Life A and Teenage Life B.

Aspects		Teenage Life A	Teenage Life B
Anger		Sometimes angry	Sometimes angry
Risky behaviors		Always risks health	Never risks health
Depressed, afraid, or worthless		Never depressed	Never depressed
Emotions out of control		Sometimes out of control	Never out of control
Relationship or trust problems		Never has problems	Never has problems
Illness, injuries, accidents, interfere with daily activities		Never interfered	Sometimes interfered
Overall health		Very good	Fair

29. Which life would you have rather lived through?

• Teenage Life A

• Teenage Life B

Now suppose your current adult life would be no different except for you would live for the number of years shown from today, then die.

Years you live from today, followed by death

Live for 6 years

Live for 10 years

29. Which life would you have rather lived through?

• Teenage Life A

• Teenage Life B

Teenage Comparison #2

29. Similar to above. Values for each cell in the table will be determined by a random draw from a statistical algorithm (near-orthogonal D-efficient design, with good level balance, no or minimal overlap, no dominated pairs, etc.), which selects many dozen health states out of the total number of possibilities.

30. As above

Teenage Comparison #3

29. As above

30. As above

Teenage Comparison #4

29. As above

30. As above

Comparing Quality of Life as a Child

Finally, we would like you to think about different possible childhood lives that you could have had while ages 5-11, instead of the life that you actually lived. For each pair, please tell us which one has a better quality of life.

Childhood Comparison #1

Imagine yourself having lived Child Life A and Child Life B.

Aspects		Child Life A	Child Life B
Anger		Never angry	Never angry
Risky behaviors		Never risks health	Never risks health
Depressed, afraid, or worthless		Rarely depressed	Never depressed
Emotions out of control		Rarely out of control	Never out of control
Relationship or trust problems		Never has problems	Never has problems
Illness, injuries, accidents, interfere with daily activities		Rarely interfered	Often interfered
Overall health		Good	Fair

29. Which life would you have rather lived through?

• Child Life A

• Child Life B

Now suppose your current adult life would be no different except for you would live for the number of years shown from today, then die.

Years you live from today, followed by death

Live for 8 years

Live for 6 years

29. Which life would you have rather lived through?

• Child Life A

• Child Life B

Childhood Comparison #2

29. Similar to above. Values for each cell in the table will be determined by a random draw from a statistical algorithm (near-orthogonal D-efficient design, with good level balance, no or minimal overlap, no dominated pairs, etc.), which selects many dozen health states out of the total number of possibilities.

30. As above

Childhood Comparison #3

29. As above

30. As above

Childhood Comparison #4

29. As above

30. As above

About You

Next, we have a few simple questions about you.

29. What is your gender?

• Female

• Male

29. What is the highest level of education you have completed?

• Less than high school

• Some high school

• High school degree or GED

• Some college but no degree

• Technical school

• 2-year college degree

• 4-year college degree

• Some graduate school but no degree

• Graduate or professional degree

29. Which of the following racial groups best describes you? Please check all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

29. Which of the following describes your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

29. How many children, if any, have you had? Please include all for which you are the parent or legal guardian.

• None (0 children)

• 1 child

• 2 children

• 3 children

• 4 children

• 5 children

• 6 or more children

29. What is your current marital status?

• Married

• Divorced

• Widowed

• Separated

• Never been married

29. What is your current employment status?

• Not employed

• Employed part-time

• Employed full-time

• Self-employed

29. What is your total household income before tax?

• None ($0)

• $1 - $12,500

• $12,501 - $25,000

• $25,001 - $50,000

• $50,001 - $75,000

• $75,001 - $100,000

• $100,001 - $125,000

• $125,001 - $150,000

• Over $150,000

• Not sure

29. Which of the following describes your health insurance? Please check all that apply.

• Private health insurance, often provided by an employer

• Medicaid or other public insurance

• TRICARE (military health)

• No health insurance

• Not sure

Childhood Experiences

For the last few sections of this survey, we would like to ask questions about your childhood experiences. Some of the questions may make you uncomfortable. We recommend that you complete this section of the survey in a private place.

You may also take a break at any time. You may close your web browser and resume the survey later if you choose.

Remember that you can refuse to answer any question by leaving it blank.

Please click here to continue.

These questions ask about some of your experiences growing up as a child and a teenager. Although these questions are of a personal nature, please try to answer as honestly as you can. For each question, place check the response that best describes how you feel.

When I was growing up …	Never True	Rarely True	Some-times True	Often True	Very Often True
I didn't have enough to eat.
I knew that there was someone to take care of me and protect me.
People in my family called me things like "stupid," "lazy," or "ugly."
My parents were too drunk or high to take care of the family.
There was someone in my family who helped me feel that I was important or special.
I had to wear dirty clothes.
I felt loved.
I thought that my parents wished I had never been born.
I got hit so hard by someone in my family that I had to see a doctor or go to the hospital.
There was nothing I wanted to change about my family.
People in my family hit me so hard that it left me with bruises or marks.
I was punished with a belt, a board, a cord, or some other hard object.
People in my family looked out for each other.
People in my family said hurtful or insulting things to me.
I believe that I was physically abused.
I had the perfect childhood.
I got hit or beaten so badly that it was noticed by someone like a teacher, neighbor, or doctor.
I felt that someone in my family hated me.
People in my family felt close to each other.
Someone tried to touch me in a sexual way, or tried to make me touch them.
Someone threatened to hurt me or tell lies about me unless I did something sexual with them.
I had the best family in the world.
Someone tried to make me do sexual things or watch sexual things.
Someone molested me.
I believe that I was emotionally abused.
There was someone to take me to the doctor if I needed it.
I believe that I was sexually abused.
My family was a source of strength and support.

[Programmer notes—not displayed on survey] Most items are scored 1-5 where “never true” is 1 and “very often true” is 5. Items 2, 5, 7, 13, 19, 26, and 28 are reverse scored where “never true” is 5 and “very often true” is 1. (Note: these numbers refer to the original CTQ, so here 2=Q47, etc.) Compute the following scores:

ea_score = Q3 + Q8 + Q14 + Q18 + Q25

pa_score = Q9 + Q11 + Q12 + Q15 + Q17

sa_score = Q20 + Q21 + Q23 + Q24 + Q27

en_score = Q5 + Q7 + Q13 + Q19 + Q28

pn_score = Q1 + Q2 + Q4 + Q6 + Q26

If ea_score>8 OR pa_score>7 OR sa_score>5 OR en_score>9 OR pn_score>7, then display the question text for all items for which the score(s) exceed the threshold and the following additional question:

29. Thinking about these childhood events in particular, approximately when did any of these events first begin to occur?

1. Before age 5

2. Ages 5-11

3. Ages 12-17, and not earlier

4. Don’t know or not sure

Other Experiences Before Age 18

You are now at the final section of the survey. To finish, we have a few other questions about your childhood before 18 years of age.

29. Were you ever put in foster care or put up for adoption?

• Yes

• No

29. When you were growing up, would you say your family was… ?

• Pretty well off

• About average financially

• Poor

29. For most of the time, did your family own their home?

• Yes

• No

• Not Sure

29. Did either of your parents or guardians ever receive public assistance, such as welfare, food stamps, or a food bank?

• Yes

• No

• Not Sure

29. What is the highest level of education that your mother (or main female caregiver) completed?

• Didn’t go to high school

• Some high school

• High school degree or GED

• Some college or technical school

• 4-year college degree or higher

• Not Sure

29. For most of the time, did your mother (or main female caregiver) work outside the home for pay?

• Yes

• No

• Not Sure

29. Was there a time of several months or more when your father (or main male caregiver) had no job?

• Yes

• No

• Not Sure

29. How old was your mother when you were born?

• 16 or younger

• 17-19

• 20-29

• 30-39

• 40 or older

29. Which of the following best describes your parents’ marital status before you were 18?

• Always married or lived together

• Married until widowed or death

• Separated or divorced

• Never lived together

29. Were you an only child?

• Yes

• No

29. Did you live with anyone who suffered from mental illness or depression?

• Yes

• No

• Not Sure

29. Did you live with anyone who was a problem drinker or alcoholic?

• Yes

• No

• Not Sure

29. Did you live with anyone who used illegal drugs?

• Yes

• No

• Not Sure

29. Did you live with anyone who went to prison or committed a serious crime?

• Yes

• No

• Not Sure

29. About how many times did you move residences, even in the same town?

• 0 to 2

• 3 to 5

• 6 to 9

• 10 or more

• Not sure

Thank you for your help with this survey. We appreciate your responses.

Childhood Trauma Questionnaire™: A Retrospective Self-Report (CTQ™). Copyright © 1998 NCS Pearson, Inc. Computer adaption copyright © 2010 NCS Pearson, Inc. Adapted and reproduced with permission. All rights reserved. Childhood Trauma Questionnaire” and “CTQ” are trademarks in the US and/or other countries of Pearson Education, Inc. or its affiliates.