Detailed Assessment Measures

Attachment I2:
Detailed Assessment Measures

Research on the Efficacy and Feasibility of
Essentials for Parenting Toddlers and Preschoolers

Division of Violence Prevention
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention

Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
Public reporting burden of this collection of information is estimated to average 45 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-XXXX).

Detailed Assessment Measures
Instructions: Below is a series of phrases that describe children’s behavior. Please: (1) select the frequency describing how often the
behavior currently occurs with {ChildName} and (2) select either “yes” or “no” to indicate whether the behavior is currently a
problem.
Is this a problem for
you?

How often does this occur with {ChildName}?
Never

Sometimes

Always

Choose not
to answer

Yes

No

Choose
not to
answer

Dawdles in getting dressed

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Dawdles or lingers at
mealtime

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Has poor table manners

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Instructions: Below is a series of phrases that describe children’s behavior. Please: (1) select the frequency describing how often the
behavior currently occurs with {ChildName} and (2) select either “yes” or “no” to indicate whether the behavior is currently a
problem.
Is this a problem for
you?

How often does this occur with {ChildName}?
Never

Sometimes

Always

Choose not
to answer

Yes

No

Choose
not to
answer

Refuses to eat food
presented

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Refuses to do chores when
asked

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Is slow in getting ready for
bed

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Refuses to go to bed on time

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Attachment I2

Instructions: Below is a series of phrases that describe children’s behavior. Please: (1) select the frequency describing how often the
behavior currently occurs with {ChildName} and (2) select either “yes” or “no” to indicate whether the behavior is currently a
problem.
Is this a problem for
you?

How often does this occur with {ChildName}?
Never

Sometimes

Always

Choose not
to answer

Yes

No

Choose
not to
answer

Does not obey house rules
on {HIS/HER} own

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Refuses to obey until
threatened with punishment

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Acts defiant when told to do
something

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Argues with parents about
rules

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Gets angry when doesn’t
get{HIS/HER}own way

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Attachment I2

Instructions: Below is a series of phrases that describe children’s behavior. Please: (1) select the frequency describing how often the
behavior currently occurs with {ChildName} and (2) select either “yes” or “no” to indicate whether the behavior is currently a
problem.
Is this a problem for
you?

How often does this occur with { ChildName}?
Never

Sometimes

Always

Choose not
to answer

Yes

No

Choose
not to
answer

Has temper tantrums

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Sasses adults

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Whines

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Cries easily

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Yells or screams

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Hits parents

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Attachment I2

Instructions: Below is a series of phrases that describe children’s behavior. Please: (1) select the frequency describing how often the
behavior currently occurs with {ChildName} and (2) select either “yes” or “no” to indicate whether the behavior is currently a
problem.
Is this a problem for
you?

How often does this occur with {ChildName}?
Never

Sometimes

Always

Choose not
to answer

Yes

No

Choose
not to
answer

Destroys toys and other
objects

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Is careless with toys and
other objects

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Steals

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Lies

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Teases or provokes other
children

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Verbally fights with
friends{HIS/HER}own age

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Attachment I2

Instructions: Below is a series of phrases that describe children’s behavior. Please: (1) select the frequency describing how often the
behavior currently occurs with {ChildName} and (2) select either “yes” or “no” to indicate whether the behavior is currently a
problem.
Is this a problem for
you?

How often does this occur with {ChildName}?
Never

Sometimes

Always

Choose not
to answer

Yes

No

Choose
not to
answer

Verbally fights with sisters
or brothers

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Physically fights with
friends {HIS/HER} own age

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Physically fights with sisters
and brothers

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Constantly seeks attention

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Interrupts

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Is easily distracted

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Attachment I2

Instructions: Below is a series of phrases that describe children’s behavior. Please: (1) select the frequency describing how often the
behavior currently occurs with {ChildName} and (2) select either “yes” or “no” to indicate whether the behavior is currently a
problem.
Is this a problem for
you?

How often does this occur with {ChildName}?
Never

Sometimes

Always

Choose not
to answer

Yes

No

Choose
not to
answer

Has short attention span

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Fails to finish tasks or
projects

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Has difficulty entertaining
{HIM/HER}self alone

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Has difficulty concentrating
on one thing

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Is overactive or restless

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Wets the bed

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Attachment I2

Instructions: At one time or another, all children misbehave or do things that could be harmful, that are “wrong,” or that parents don’t
like. Examples include:
hitting someone
whining
not picking up toys
forgetting homework
throwing food
refusing to go to bed
having a tantrum
lying
wanting a cookie before dinner
running into the street
arguing back
coming home late
Parents have many different ways or styles of dealing with these types of problems. Below are items that describe some styles of
parenting.
Each item presents a parenting situation and two opposite ways of handling it. For each item, select the button on the scale that best
describes your style of parenting during the past two months in that situation with {ChildName}. If you always use one of the
approaches, select the button at that end of the scale. If you sometimes use one approach and sometimes the other, select a button in
between that best captures your style.
Here’s a SAMPLE ITEM that’s already filled in. The situation is meal time and the two different ways of handling the situation are “I
let my child decide how much to eat” and “I decide how much my child eats.” The parent in this example uses both approaches, but
lets her child decide how much to eat a bit more often than she decides how much her child eats, so she selected a button a bit more
toward the ‘let my child decide’ end.
SAMPLE ITEM:
At meal time…
I let my child decide how
much to eat.

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Attachment I2

I decide how much my
child eats.

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Choose not
to answer

0

Instructions: At one time or another, all children misbehave or do things that could be harmful, that are “wrong,” or that parents don’t
like. Parents have many different ways or styles of dealing with these types of problems. Below are items that describe some styles of
parenting.
For each item, select the degree on the scale that best describes your style of parenting during the past two months with {ChildName}.
When {ChildName} misbehaves…
I usually get into a long argument
with {ChildName} .

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I don’t get into an argument.

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Choose not to
answer

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(MALE PARENTS ONLY)
I threaten to do things that…
I know I won’t actually do.

I am sure I can carry out.

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Choose not to
answer

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When {ChildName} misbehaves…
I raise my voice or yell.

I speak to {ChildName} calmly.

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When there is a problem with {ChildName} …
things build up and I do things I
don’t mean to do.

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When {ChildName} doesn’t do what I ask…
I often let it go or end up doing it
myself.

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things don’t get out of hand.

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Choose not to
answer

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I take some other action.

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answer

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Choose not to
answer

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When I give a fair threat or warning…
I often don’t carry it out.

I always do what I said.

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Attachment I2

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answer

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Instructions: At one time or another, all children misbehave or do things that could be harmful, that are “wrong,” or that parents don’t
like. Parents have many different ways or styles of dealing with these types of problems. Below are items that describe some styles of
parenting.
For each item, select the degree on the scale that best describes your style of parenting during the past two months with {ChildName}
.
(FEMALE PARENTS ONLY)
If saying “No” doesn’t work…
I offer {ChildName} something
nice so {HE/SHE} will behave.

I take some other kind of action.

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answer

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When {ChildName} misbehaves…
I get so frustrated or angry that
{ChildName} can see I’m upset.

I handle it without getting upset.

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Choose not to
answer

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When I say {ChildName} can’t do something…
I let {ChildName} do it anyway.

I stick to what I said.

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answer

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When {ChildName} does something I don’t like, I insult {ChildName} , say mean things, or call {ChildName} names…
Choose not to
never or rarely.
most of the time.
answer

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If {ChildName} gets upset when I say “No”…
I back down and give in to
{ChildName} .

I stick to what I said.

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Attachment I2

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Read each statement carefully. Think about how you and {ChildName} generally get along. Tell us how well the statement describes
the way you usually act with {ChildName} .
Answer choices:
Not at all true (I do not do this)
A little true
Somewhat true

Moderately true
Quite a bit true
Very true (I often do this)

Example: I quarrel with my child.
If you spend a great deal of time quarreling with your child, you would select the space under “Very true (I often do
this)”.
If you never quarrel with your child, you would select the space under “Not at all true (I do not do this)”.
If you quarrel sometimes, but not much, you would select the space under “A little true” or “Somewhat true”.
If you quarrel often, but not all of the time, you would select the space under “Moderately true” or “Quite a bit true”.

I have pleasant conversations with
{ChildName} .
I try to teach {ChildName} new
things.
{ChildName} and I hug and/or
kiss each other.
I laugh with {ChildName} about
things we find funny.
{ChildName} and I spend time
playing games, doing crafts, or
doing other activities together.

Attachment I2

Not at all true
(I do not do
this)

A little true

Somewhat
true

Moderately
true

Quite a bit true

Very true
(I often do this)

Choose not
to answer

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Read each statement carefully. Think about how you and {Var: ChildName} generally get along. Tell us how well the statement
describes the way you usually act with {Var: ChildName}.

I listen to {ChildName} 's feelings
and try to understand them.
I thank or praise {ChildName} .
I offer to help, or help
{ChildName} with things
{HE/SHE} is doing.
I comfort {ChildName} when
{HE/SHE} seems scared, upset, or
unsure.
I hold or touch {ChildName} in an
affectionate way.

Attachment I2

Not at all true
(I do not do
this)

A little true

Somewhat
true

Moderately
true

Quite a bit true

Very true
(I often do this)

Choose not
to answer

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Instructions: Children often do things that are wrong, disobey, or make their parents angry. We would like to know what you have
done when {ChildName} did something wrong or made you upset or angry. Below is a list of things you might have done in the past
year. Please select how many times you did each of these things in the past year. If you did not do one of these things in the past
year, but it happened before then, select the box marked “Not this year, but has happened in the past.”
How many times in the past
year:
Have you shook
{HIM/HER}?
Have you hit {HIM/HER} on
the bottom with something
like a belt, hair brush, a stick
or some other hard object?
Have you spanked
{HIM/HER} on the bottom
with your bare hand?
Have you slapped
{HIM/HER} on the hand,
arm, or leg?
Have you pinched
{HIM/HER}?
Have you slapped
{HIM/HER}on the face or
head or ears?

Attachment I2

11-20
times

More than
20 times

Never

Not this year,
but has
happened in the
past

Choose not
to answer

1 time

2 times

3-5 times

6-10
times

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Instructions: Please read each statement and select the option that corresponds to how much you agree or disagree with each one.
Strongly agree

The problems of taking care of a child are easy to solve once
you know how your actions affect your child, an
understanding I have acquired.
I would make a fine model for a new parent to follow in
order to learn what he or she would need to know to be a
good parent.
Being a parent is manageable, and any problems are easily
solved.
I meet my own personal expectations for expertise in caring
for my child.
If anyone can find the answer to what is troubling my child, I
am the one.
Considering how long I’ve been a parent, I feel thoroughly
familiar with this role.
I honestly believe I have all the skills necessary to be a good
parent to my child.

Attachment I2

Strongly disagree

Choose not
to answer

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Instructions: At one time or another, all children misbehave or do things that could be harmful, that are wrong, or that parents don’t
like. Examples include:
hitting someone
whining
not cleaning room not doing homework
lying
refusing to go to bed arguing back
taking things that aren’t theirs
having a tantrum cursing
coming home late running into the street
Parents have many different ways of thinking about these types of problems, and may think differently about problems depending on
their specific children.
Please rate how much you would agree, in general, that the following reasons for misbehavior are true for {ChildName} ’s behavior
for the past two months:

Always true

Frequently
true

Sometimes
true

Occasionally
true

Rarely true

Never true

Choose
not to
answer

{ChildName} won’t listen.

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{ChildName} thinks that {HE/SHE} is the
boss.

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{ChildName} is headstrong.

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{ChildName} wants what {HE/SHE} wants
when {HE/SHE} wants it.

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{ChildName} purposely tries to get me angry.

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Attachment I2

Instructions: At one time or another, all children misbehave or do things that could be harmful, that are wrong, or that parents don’t
like. Parents have many different ways of thinking about these types of problems, and may think differently about problems depending
on their specific children.
Please rate how much you would agree, in general, that the following reasons for misbehavior are true for {ChildName} ’s behavior
for the past two months:

Always true

Frequently
true

Sometimes
true

Occasionally
true

Rarely true

Never true

Choose
not to
answer

{ChildName} tries to get my goat or push my
buttons.

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{ChildName} wants things {HIS/HER} way.

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{ChildName} is very demanding.

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{ChildName} likes to see how far {HE/SHE}
can push me.

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Attachment I2

Instructions: When a child does something wrong or makes a parent upset or angry, how often do you feel the following actions are
justified (that the actions are OK, appropriate, good, right)? Then, how likely is it that the action will solve the problem?

Is it justified for a parent to spank his or her child on the
bottom with a bare hand?
Will the parent’s spanking solve the problem?
Is it justified for a parent to slap his or her child on the
hand, arm, or leg?
Will the parent’s slapping solve the problem?

Attachment I2

Almost
always

Often

Sometimes

Rarely

Never

Choose not
to answer

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Instructions: Please select the degree to which you agree or disagree with the following statements. Your first reaction to each
question should be your answer.
Strongly agree

Somewhat
agree

Somewhat
disagree

Strongly
disagree

Choose not to
answer

Being a parent is harder than I thought it would be.

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I feel trapped by my responsibilities as a parent.

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I find that taking care of my child(ren) is much more work
than pleasure.
I often feel tired, worn out, or exhausted from raising a
family.

Attachment I2

Instructions: Please respond to each question or statement by selecting one option per row.

In the past 7 days...
I felt worthless……...
I felt helpless………
I felt depressed……
I felt hopeless………

Attachment I2

Never

Rarely

Sometimes

Often

Always

Choose not
to answer

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Instructions: Please respond to each question or statement by selecting one option per row.
In the past 7 days...
I felt fearful
I found it hard to focus on anything other than my
anxiety
My worries overwhelmed me
I felt uneasy

Attachment I2

Never

Rarely

Sometimes

Often

Always

Choose not
to answer

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Instructions: The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please select
how often you felt or thought a certain way.
Never

Almost
never

Sometimes

Fairly often

Very often

Choose not
to answer

In the last month, how often have you felt that you
were unable to control the important things in your
life?

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In the last month, how often have you felt confident
about your ability to handle your personal
problems?

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In the last month, how often have you felt that
things were going your way?

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In the last month, how often have you felt
difficulties were piling up so high that you could
not overcome them?

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Attachment I2

SOME ADDITIONAL QUESTIONS ABOUT YOU
1. What is your employment status? (choose one)
 Working for pay at a job or business
 Not working for pay but currently looking for paid work (skip next question)
 Not working for pay and not looking for a job (e.g., in school, retired, disabled, have family responsibilities, became
discouraged and gave up looking for a job). (skip next question)
2. On average, how many hours per week do you work for pay?
 Less than 35 hours per week
 35 hours or more per week
3. Are you currently enrolled in school?
 Yes, part-time
 Yes, full-time
 No
4. What is your highest level of education?
 8th grade or less
 some high school but no diploma or GED
 high school diploma or GED
 some college or post-secondary vocational courses
 vocational school diploma or 2-3 year college associate’s degree
 4-year college bachelor’s degree
 some graduate work but no degree
 master’s, professional, or doctoral degree (MA, MBA, PhD, JD, MD, etc.)
5. What is your marital/couple status?
 single, never married
 married
 divorced/separated
 widowed
 living with a partner
Attachment I2

 registered civil commitment or union
SOME QUESTIONS ABOUT YOUR SPOUSE OR PARTNER
ASK IF MARRIED OR PARTNERED
6. What is your spouse’s or partner’s employment status? (choose one)
 Working for pay at a job or business
 Not working for pay but currently looking for paid work (skip next question)
 Not working for pay and not looking for a job (e.g., in school, retired, disabled, have family responsibilities, became
discouraged and gave up looking for a job). (skip next question)
7. On average, how many hours per week does your spouse or partner work for pay?
 Less than 35 hours per week
 35 hours or more per week
8. Is your spouse or partner currently enrolled in school?
 Yes, part-time
 Yes, full-time
 No
9. What is the highest level of education your spouse or partner finished?
 8th grade or less
 some high school but no diploma or GED
 high school diploma or GED
 some college or post-secondary vocational courses
 vocational school diploma or 2-3 year college associate’s degree
 4-year college bachelor’s degree
 some graduate work but no degree
 master’s, professional, or doctoral degree (MA, MBA, PhD, JD, MD, etc.)

Attachment I2

SOME ADDITIONAL QUESTIONS ABOUT YOUR CHILD
Please answer both of the following questions about { CHILD NAME}’s Hispanic origin and race. For the purposes of this
survey, we do not consider Hispanic origin to be a race.
10. Is {CHILD NAME} of Hispanic, Latino or Spanish origin?
 Yes
 No
11. What is {CHILD NAME}’s race? You can choose more than one category.
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White

Attachment I2