OMB #: 0970-0555
Expiration Date: 09/30/2021
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National Survey of Child and Adolescent Well-Being
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Survey of Family Well-Being
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RTI International PO Box 12194 Research Triangle Park, North Carolina 27709l USA Sponsored by: Administration for Children and Families Conducted by: RTI International |
Instrument 1: Survey of Adopted Youth, Young Adults, and Adults (SAY)
Note: This survey will begin immediately following the consent procedure included in Attachment G.
Section A: Demographics
INTROA: This first set of questions will ask some basic information about you. Remember, people with many different backgrounds and types of families will be completing this survey. For this reason, we try to ask about lots of different possible family members, including birth or biological parents, adoptive parents, foster parents, grandparents, other relatives and siblings.
A1. What is your age?
________________ years old
A2. Where do you live now….?
At my birth or biological parent(s)’ house, apartment or condo
At my adoptive parent(s)’ house, apartment, or condo
At my own house, apartment, condo, dormitory, or military barracks
At another adoptive family member’s house, apartment, or condo
At another birth or biological family member’s house, apartment, or condo
At a foster parent(s)’ house, apartment, or condo
At a group home or residential treatment facility
I do not have a home right now, for example, I am living inside my car, an abandoned building, on the street, in a park, in a shelter, or am couch surfing
Other (please specify): _____________________
A3. For the next question, “school” refers to a junior high or middle school, a high school, a college or university, or a technical or vocational or GED program. “School” also refers to homeschool. Are you currently attending school?
Yes
No
A4. What is the highest level of school you have completed?
Less than 11th grade
12th grade
GED
College, university, technical, or vocational school
Graduate or professional degree
Other (please specify) _______________
A5. Are you Spanish, Hispanic, or Latino?
1. Yes
2. No
A6. What is your race? Select all that apply.
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or other Pacific Islander
5. White
6. Other
A7. What sex were you assigned at birth, on your original birth certificate?
1. Male
2. Female
3. Don’t know
A8. How do you describe yourself? 1. Male
2. Female
3. Transgender
4. Do not identify as male, female, or transgender
A8a. Which pronoun do you use to describe yourself, he, she, or they? We will refer to you by this pronoun throughout the survey.
He
She
They
A9. Which of the following best represents how you think of yourself?
Straight or heterosexual
Lesbian or gay
Bisexual
Other
Don’t know
A10. What is your date of birth?
mm/dd/yyyy
Section B: Adoption History
INTROB: Now we would like to ask you about your overall life experience.
B11. Adoption is a process where a person legally assumes the parenting of another child born to someone else. Have you ever been legally adopted?
Yes
No
B11a. [If B11=Yes] How many times have you been adopted?
________________ times
[If B11=1 and if B11a>1] You indicated you were adopted [FILL B5a NUMBER OF TIMES] times, however for the remainder of the survey, focus on your last or most recent adoption.
B12. [If B11=1] How old were you when you were adopted? Your best guess is fine.
_______________ years old
B13. [If B11= 1] How long did you know your adoptive parent(s) before the adoption process started?
I didn’t know my adoptive parent(s) before the adoption process
Less than 6 months
6 months to 1 year
More than 1 year to 3 years
More than 3 years
All my life or as long as I can remember
B13a. [If B11= 1 and B13>1] How close did you feel to your adoptive parent(s) before the adoption process started?
2. Very close
3. Moderately close
4. Slightly close
5. Not at all close
6. I was too young to remember
B13b [If B11=1] Do you have other birth or biological siblings who were adopted by the same family?
Yes
No
B13c [If B11= 1 and B13>1] What was your relationship to your adoptive parent(s) before your adoption?
Birth or biological grandparent(s)
Another birth or biological relative, like an aunt, uncle, or cousin
Non-relative foster parent(s)
Other (please specify)
B14. [If B11= 1] Open adoption is when adoptive parents allow contact between birth or biological parents and child. Was [if A1<18-“Is”] your adoption an “open adoption”?
Yes
No
Don’t know
B15. [If B11=1] Do [if A1>=18-“When you were a child, did”] you have contact with your birth or biological mother?
Yes
No
B16. [If B15= 1] How supportive were [if A1<18-“are”] your adoptive parents of your contact with your birth or biological mother?
2. Supportive
3. Not very supportive
4. I never discussed contact with my birth or biological mother
B17. [If B15=1] How satisfied were [if A1<18-“are”] you with the ongoing contact you had [if A1<18-“have”] with your birth or biological mother [ifA1>=18-“as a child”]?
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
B15a. [If B11=1] Do [if A1>=18-“When you were a child, did”] you have contact with your birth or biological father?
Yes
No
B16a. [If B15a= 1] How supportive were [if A1<18-“are”] your adoptive parents of your contact with your birth or biological father?
1. Very supportive
2. Supportive
3. Not very supportive
4. We never discussed contact with my birth or biological father
B17a. [If B15a=1] How satisfied are [if A1<18-“are”] you with the ongoing contact you had [if A1<18-“have”] with your birth or biological father [ifA1>=18-“as a child”]?
Note: These childhood family structures and characteristics will be gathered from available NSCAW I or NSCAW II secondary data. For this reason, these constructs are not included in the current survey.
Child race/ethnicity
Child sex and gender identify (when available)
Child date of birth
Primary parents/caregivers during childhood
Number of siblings during childhood
Biological vs. adopted relationship to family members
Note: These characteristics of the adoptive parent(s) will be gathered from available NSCAW I or NSCAW II secondary data. For this reason, these constructs are not included in the current survey.
Parent gender/race
Marital status; if divorced, child age at time of divorce
Prior relationship to adoptive parent before adoption (kin, former foster parent, new relationship)
B18. [If A2 does not equal 1 “in my adoptive parent(s) home”] How old were you when you stopped living with your [adoptive] parent(s)?
_________________ years old
[If question A2 is not “In my parent(s) home”]
[If B11=Yes, use “adoptive parents”; otherwise use “parents”]
B19. Why did you stop living with your [adoptive] parent(s)? Please answer Yes or No for each option. Answer “Yes” if it was one of the main reasons you left home.
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Yes |
No |
B19a. To get a job, to join the military, or to attend school, college, or another educational program |
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B19b. To get married or move in with a boyfriend, girlfriend, or significant other |
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B19c. My [adoptive] parent(s) asked me to leave their home, apartment, or condo |
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B19d. To move in with my birth or biological family [do not include this response option if B11=no] |
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B19e. To move in with another [adoptive] family member |
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B19f. To get group home or residential services to manage emotions, behaviors, drug, and/or alcohol problems |
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B19g. My gender identity or sexual orientation was not accepted by my [adoptive] parent(s) |
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My racial or ethnic identity was not accepted by my [adoptive] parents |
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B19h. Other (please specify):________________________ |
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Please give a brief description of what was going on when you left home:
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
B20. Who lives with you now? Please answer Yes or No for each option.
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Yes |
No |
B20a. Birth or biological mother |
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B20b. Birth or biological father |
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B20c. Adoptive mother |
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B20d. Adoptive father |
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B20e. Adoptive sister or brother |
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B20f. Birth or biological sister or brother |
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B20g. Spouse |
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B20h. My own child(ren) |
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B20i. Boyfriend, girlfriend, or other romantic partner |
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B20j. Other relative |
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B20k. Other non-relative (please specify): ______________ |
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Section C: Post Adoption Instability Experiences
[If B11=2, the phrase “after your adoption,” will be deleted and references to “adoptive parent(s)” will be replaced only with “parent(s)”]
INTROC: [If B11=1 and A1>=18 years] Next, we want to ask you about some life experiences.
C21a._1. First, think about important events in your life before you turned 18. What is one event in your life before you turned 18 that you remember well? Please provide a brief description, for example, had a special birthday or met your best friend.
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
C21b._1. Now, think about important events in your life that happened after your adoption, but before you turned 18. What is one event after your adoption, but before you turned 18 that you remember well? Please provide a brief description, for example, learned to drive or met my first boyfriend, girlfriend, or romantic partner.
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
[If B11=1 and A1<18 years] Next, we want to ask you about some life experiences after your adoption.
C21a_2. First, think about important events in your life that happened after your adoption. What is one event after your adoption that you remember well? Please provide a brief description, for example, moved to a different school or met your best friend.
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
[If B11= 2 and A1>=18 years] Next, we want to ask you about events before you turned 18.
C21a_3. First, think about important events in your life before you turned 18. What is one event in your life before you turned 18 that you remember well? Please provide a brief description, for example, moved to a different school or met your best friend.
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
[If B11= 2 and A1<18 years] Next, we want to ask you about events during your childhood.
C21a_4. First, think about important events in your life up to this point. What is one event in your life that you remember well? Please provide a brief description, for example, moved to a different school or met your best friend.
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
[DISPLAY AS INTRO BEFORE C22 only if B11=1] We are interested in learning whether there were times when you did not live with your adoptive parent(s) after your adoption, but before you turned 18. We will ask you separately about times you may have left your adoptive home to live in foster care, a group home or residential treatment center, juvenile detention, or to live with other relatives. We realize that you may have lived in many of these places before coming to live with your adoptive parent(s). Or, you may have lived in these places while living with your parent(s) before your adoption was finalized. For this interview, we are only interested in learning about whether there were times when you did not live with your parents after your adoption was finalized [if A2>=18 years-“and before you turned 18 years old”].
[DISPLAY AS INTRO BEFORE C22 only if B11=2] We are interested in learning whether there were times during your childhood when you did not live with your parent(s). We will ask you separately about times you may have left your home to live in foster care, a group home or residential treatment center, juvenile detention, or to live with other relatives. For this interview, we are only interested in learning about whether there were times when you did not live with your parents [if A2>=18 years-“before you turned 18 years old”].
C22. First, I want to ask you about time in foster care. Here, foster care refers to a child living with a foster parent who is not related to the child, for example, not living with their grandparent or some other relative and not living in a group home. [After your adoption], did you ever spend time in foster care?
Yes
No
C23. [If C22=1] With how many different foster families have you lived [after your adoption]?
___________________ families
C24. [If C22= 1; If C23>1, insert “first”] How old were you when you [first] moved from your [adoptive] parent(s)’ home to live with a foster family?
___________________ years old
C24a. [If C22=1; If C23>1, insert “first”] How long did you live with this [first] foster family after you moved from your [adoptive] parent(s)’ home?
Less than 2 months
2 to 6 months
More than 6 months to 1 year
More than 1 year to 3 years
More than 3 years to 5 years
More than 5 years
C25. [If C22= 1; If C23>1, insert “first”] When you [first] moved from your [adoptive] parent(s)’ home to a foster family, did you still have contact with…? Please answer Yes, No, or Not Applicable (NA) for each option.
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Yes |
No |
Not applicable |
C25a. Your adoptive parent(s) |
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C25b. Your adoptive sibling(s) |
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C25c. Your birth or biological parent(s) |
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C25d. Your birth or biological sibling(s) |
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C25e. Other relatives |
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C26. [If C22= 1; If C23>1, insert “first”] Next, we would like to understand what was going on in your [adoptive] family when you [first] moved from your [adoptive] parent(s)’ home to a foster family. Which of the following describes your family situation at that time? Please answer Yes or No for each option.
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Yes |
No |
C26a. You did not feel accepted by your [adoptive] family |
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C26b. You did not feel safe in your home because of violence or abuse |
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C26c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
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C26d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
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C26e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
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C26f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
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C26g. You needed help to manage your drinking or drug use |
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C26h. Your gender identity or sexual orientation was not accepted |
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C26i. Your racial or ethnic identity was not accepted |
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C26j. Other (please specify) |
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C27. [If C22= Yes; If C23>1, insert “first”] During the time when you [first] moved from your [adoptive] parent(s)’ home to a foster family, did you receive any of the following services? Please answer Yes or No for each option.
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Yes |
No |
C27a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
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C27b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
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C27c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
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C27d. Drug or alcohol treatment services |
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C27e. Job training or support with independent living or other life skills |
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C27f. Other (please specify): ______________ |
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C28. [If C22=1] Did you ever return to live with your [adoptive] family?
C28a. [if C28=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C24b. [If C22=1; If C23>1] How much total time did you spend in foster care after you moved from your [adoptive] parent(s)’ home?
Less than 2 months
2 to 6 months
More than 6 months to 1 year
More than 1 year to 3 years
More than 3 years to 5 years
[IF B13c=1, use “another”]
C29. [After your adoption], did you ever live without your [adoptive] parent(s) in a [another] grandparent’s home? [A1>=18 years: Please think only about those times that happened before you turned 18 years old.]
Yes
No
C29a. [If C29=1and B11= 2] Was this grandparent your…?
Adoptive grandparent
Birth or biological grandparent
C30. [If C29=1] How many times have you gone to live without your [adoptive] parent(s) in a grandparent’s home?
______________________ times
C30a. [If C29= 1; If C30>1, insert “first”] How old were you when you [first] moved from your [adoptive] parent(s)’ home to live with your grandparent?
___________________ years old
C31. [If C29= 1; If C30>1, insert “the first time” otherwise use “when”] When you [first] went to stay at this grandparent’s home, did you still have contact with …? Please answer Yes, No, or Not applicable for each option.
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Yes |
No |
Not applicable |
C31a. Your adoptive parent(s) |
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C31b. Your adoptive sibling(s) |
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C31c. Your birth or biological parent(s) |
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C31d. Your birth or biological sibling(s) |
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C31e. Other relatives |
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C32. [If C29= 1; If C30>1 insert ‘first’] Next, we would like to understand what was going on in your [adoptive] family when you [first] went to live in this grandparent’s home without your [adoptive] parents. Which of the following describes your family situation at that time? Please answer Yes or No for each option
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Yes |
No |
C32a. You did not feel accepted by your [adoptive] family |
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C32b. You did not feel safe in your home because of violence or abuse |
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C32c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
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C32d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
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C32e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
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C32f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
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C32g. You needed help to manage your drinking or drug use |
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C32h. Your gender identity or sexual orientation was not accepted |
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C32i. Your racial or ethnic identity was not accepted |
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C32j. Other (please specify) |
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C33. [If C29= 1; If C30>1 insert ‘first’] During the time when you [first] went to live in this grandparent’s home without your [adoptive] parent(s), did you receive any of the following services? Please answer Yes or No for each option.
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Yes |
No |
C33a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
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C33b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
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C33c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
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C33d. Drug or alcohol treatment services |
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C33e. Job training or support with independent living or other life skills |
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C33f. Other (please specify): ______________ |
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C34. [If C29= 1] Did you ever return to live with your [adoptive] family?
Yes
No
C34a. [if C34=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C35. [If C29=1, use “another relative’s home”] [After your adoption], did you ever live without your [adoptive] parents in [another] relative’s home? [Please do not include your grandparent’s home.] [A1>=18 years: Please think only about those times that happened before you turned 18 years old].
Yes
No
C36. [If C35= 1] Who was this relative?
Adoptive aunt, uncle or cousin
Birth or biological aunt, uncle or cousin
Birth or biological sister or brother
Adoptive sister or brother
Birth or biological parent
Another relative (please specify): ______________________
C37. [If C35= 1] How many times have you gone to live without your [adoptive parents] in a relative’s home?
______________________ times
C38. [If C35= 1; If C37>1 insert “the first time” otherwise use “when’] How old were you [the first time/when] you moved from your [adoptive] parent(s)’ home to a relative’s home?
_____________________ years old
C39. [If C35= 1; If C37>1 insert “first”] When you [first] went to stay at a relative’s home, did you still have contact with…? Please answer Yes, No, or Not applicable for each option.
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Yes |
No |
Not applicable |
C39a. Your adoptive parent(s) |
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C39b. Your adoptive sibling(s) |
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C39c. Your birth or biological parent(s) |
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C39d. Your birth or biological sibling(s) |
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C39e. Other relatives |
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C40. [If C35= 1; If C37>1 insert “first”] Next, we would like to understand what was going on in your adoptive family when you [first] moved from your [adoptive] parent(s)’ home to a relative’s home. Which of the following describes your family situation at that time? Please answer Yes or No for each option.
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Yes |
No |
C40a. You did not feel accepted by your [adoptive] family |
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C40b. You did not feel safe in your home because of violence or abuse |
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C40c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
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C40d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
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C40e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
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C40f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
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C40g. You needed help to manage your drinking or drug use |
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C40h. Your gender identity or sexual orientation was not accepted |
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C40i. Your racial or ethnic identity was not accepted |
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C40j. Other (please specify) |
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C41. [If C35= 1; If C37>1 insert ‘first’] During the time when you [first] moved from your [adoptive] parent(s)’ home to a relative’s home, did you receive any of the following services? Please answer Yes or No for each option.
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Yes |
No |
C41a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
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C41b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
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C41c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
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C41d. Drug or alcohol treatment services |
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C41e. Job training or support with independent living or other life skills |
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C41f. Other (please specify): ______________ |
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C42. [If C35= 1] Did you ever return to live with your [adoptive] family?
Yes
No
C42a. [if C42=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C43. [After your adoption], did you ever live without your [adoptive] parent(s) at another adult’s home, for example, an older friend’s home, with a friend’s family or parent(s), with a boyfriend or girlfriend or romantic partner’s parent(s), or in a neighbor’s home)? [A1>=18 years: Please think only about those times that happened before you turned 18 years old.]
Yes
No
C44. [If C43= 1] How many times have you gone to live at another adult’s home without your [adoptive] parent(s)?
___________________ times
C45. [If C43= 1; If C44>1 insert ‘first’] How old were you when you [first] went to live in another adult’s home without your [adoptive] parent(s)?
__________________ years old
C46. [If C43= 1; If C44>1 insert ‘first’] When you [first] went to live at another adult’s home, did you still have contact with….? Please answer Yes, No, or Not applicable for each option.
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Yes |
No |
Not applicable |
C46a. Your adoptive parent(s) |
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C46b. Your adoptive sibling(s) |
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C46c. Your birth or biological parent(s) |
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C46d. Your birth or biological sibling(s) |
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C46e. Other relatives |
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C47. [If C43= 1, If C44>1 insert ‘first’] Next, we would like to understand what was going on in your family when you [first] moved from your [adoptive] parents’ home to another adult caregiver’s home. Which of the following describes your family situation at that time? Please answer Yes or No for each option.
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Yes |
No |
C47a. You did not feel accepted by your [adoptive] family |
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C47b. You did not feel safe in your home because of violence or abuse |
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C47c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
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C47d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
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C47e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
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C47f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
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C47g. You needed help to manage your drinking or drug use |
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C47h. Your gender identity or sexual orientation was not accepted |
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C47i. Your racial or ethnic identity was not accepted |
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C47j. Other (please specify) |
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C48. [If C43= 1; If C44>1 insert ‘first’] During the time when you [first] moved from your [adoptive] parents’ home to another adult caregiver’s home, did you receive any of the following services? Please answer Yes or No for each option.
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Yes |
No |
C48a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
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C48b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
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C48c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
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C48d. Drug or alcohol treatment services |
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C48e. Job training or support with independent living or other life skills |
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C48f. Other (please specify): ______________ |
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C49. [If C43= 1] Did you ever return to live with your [adoptive] family?
Yes
No
C49a. [if C49=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C50. Running away is defined in the following way: a minor leaving home for over 24 hours or going missing for more than 24 hours and their parent or guardian not knowing where he/she/they was/were. [After your adoption] did you ever run away from your [adoptive] parents’ home? [A1>=18 years]
Yes
No
C51. [If C50= 1] [After your adoption], how many times have you run away from your [adoptive] parent(s)’ home?
_____________________ times
C52. [If C50=1; If C51>1 insert ‘the first time’] How old were you [the first time] you ran away from your [adoptive] parent(s)’ home?
____________________ years old
C53. [If C50= 1; If C51>1 insert ‘first’] When you [first] ran away from your [adoptive] parent(s), did you still have contact with …? Please answer Yes, No, or Not applicable for each option.
|
Yes |
No |
Not applicable |
C53a. Your adoptive parent(s) |
|
|
|
C53b. Your adoptive sibling(s) |
|
|
|
C53c. Your birth or biological parent(s) |
|
|
|
C53d. Your birth or biological sibling(s) |
|
|
|
C53e. Other relatives |
|
|
|
C54. [If C50= 1; If C51>1 insert ‘first’] Next, we would like to understand what was going on in your [adoptive] family when you [first] ran away. Which of the following describes your family situation at that time? Please answer Yes or No for each option.
|
Yes |
No |
C54a. You did not feel accepted by your [adoptive] family |
|
|
C54b. You did not feel safe in your home because of violence or abuse |
|
|
C54c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
|
|
C54d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
|
|
C54e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
|
|
C54f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
|
|
C54g. You needed help to manage your drinking or drug use |
|
|
C54h. Your gender identity or sexual orientation was not accepted |
|
|
C54i. Your racial or ethnic identity was not accepted |
|
|
C54j. Other (please specify) |
|
|
C55. [If C50= 1; If C51>1 insert ‘first’] During the time when you [first] ran away from your [adoptive] parent(s)’ home, did you receive any of the following services? Please answer Yes or No for each option.
|
Yes |
No |
C55a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
|
|
C55b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
|
|
C55c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
|
|
C55d. Drug or alcohol treatment services |
|
|
C55e. Job training or support with independent living or other life skills |
|
|
C55f. Other (please specify): ______________ |
|
|
C56. [If C50= 1] Did you ever return to live with your [adoptive] family?
Yes
No
C56a. [if C56=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C57. [After your adoption], was there ever a time when you spent one or more nights homeless without your [adoptive] parents, for example, living inside a car, an abandoned building, on the street, in a park, in a shelter, or couch surfing? [A1>=18 years: Please think only about those times that happened before you turned 18 years old.]
Yes
No
C58. [If C57= 1] How many separate times have you spent one or more nights homeless without your [adoptive] parents?
______________________ times
C59. [If C57= 1; If C58>1 insert “the first time” otherwise, insert “when”] How old were you [the first time/when] you spent a night homeless without your [adoptive] parent(s)?
______________________ years old
C60. [If C57= 1; If C58>1 insert “first”] When you [first] spent one or more nights homeless without your [adoptive] parent(s), did you still have contact with….? Please answer Yes, No, or Not applicable for each answer choice.
|
Yes |
No |
Not applicable |
C60a. Your [adoptive] parent(s) |
|
|
|
C60b. Your [adoptive] sibling(s) |
|
|
|
C60c. Your birth or biological parent(s) |
|
|
|
C60d. Your birth or biological sibling(s) |
|
|
|
C60e. Other relatives |
|
|
|
C61. [If C57= 1; If C58>1 insert “first”] Next, we would like to understand what was going on in your [adoptive] family when you [first] became homeless. Which of the following describes your family situation at that time? Please answer Yes or No for each option.
|
Yes |
No |
C61a. You did not feel accepted by your [adoptive] family |
|
|
C61b. You did not feel safe in your home because of violence or abuse |
|
|
C61c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
|
|
C61d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
|
|
C61e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
|
|
C61f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
|
|
C61g. You needed help to manage your drinking or drug use |
|
|
C61h. Your gender identity or sexual orientation was not accepted |
|
|
C61i. Your racial or ethnic identity was not accepted |
|
|
C61j. Other (please specify) |
|
|
C62. [If C50= 1; If C51>1 insert ‘first’] During the time when you [first] spent one or more nights homeless without your [adoptive] parent(s), did you receive any of the following services? Please answer Yes or No for each option.
|
Yes |
No |
C62a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
|
|
C62b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
|
|
C62c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
|
|
C62d. Drug or alcohol treatment services |
|
|
C62e. Job training or support with independent living or other life skills |
|
|
C62f. Other (please specify): ______________ |
|
|
C63. [If C50= 1] Did you ever return to live with your [adoptive] family?
Yes
No
C63a. [if C63=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C64. [After your adoption], did you ever spend at least one night in juvenile detention or have you ever taken into custody for an illegal or delinquent offense? [A1>=18 years: Please think only about those times that happened before you turned 18 years old.]
Yes
No
C65. [If C64= 1]
How many times have you spent at least one night in detention?
__________________ times
How many times have you been taken into custody?
__________________ times
C66. [If C64= 1; If C65a or C65b>1 insert “the first time’] How old were you [the first time] when you spent at least one night in detention or were taken into custody?
_______________________ years old
C67. [If C64= 1; If C65a or C65b>1 insert ‘first’] When you [first] spent at least one night in detention or were taken into custody, did you still have contact with….? Please answer Yes, No, or Not applicable for each option.
|
Yes |
No |
Not applicable |
C67a. Your adoptive parent(s) |
|
|
|
C67b. Your adoptive sibling(s) |
|
|
|
C67c. Your birth or biological parent(s) |
|
|
|
C67d. Your birth or biological sibling(s) |
|
|
|
C67e. Other relatives |
|
|
|
C68. [If C64= 1; If C65a or C65b>1 insert ‘first’] Next, we would like to understand what was going on in your [adoptive] family when you [first] spent at least one night in detention or were taken into custody. Which of the following describes your family situation at that time? Please answer Yes or No for each option.
|
Yes |
No |
C68a. You did not feel accepted by your [adoptive] family |
|
|
C68b. You did not feel safe in your home because of violence or abuse |
|
|
C68c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
|
|
C68d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
|
|
C68e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
|
|
C68f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
|
|
C68g. You needed help to manage your drinking or drug use |
|
|
C68h. Your gender identity or sexual orientation was not accepted |
|
|
C68i. Your racial or ethnic identity was not accepted |
|
|
C68j. Other (please specify) |
|
|
C69. [If C64= 1; If C65a or C65b>1 insert ‘first’] During the time when you [first] spent at least one night in detention or were taken into custody, did you receive any of the following services? Please answer Yes or No for each option.
|
Yes |
No |
C69a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
|
|
C69b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
|
|
C69c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
|
|
C69d. Drug or alcohol treatment services |
|
|
C69e. Job training or support with independent living or other life skills |
|
|
C69f. Other (please specify): ______________ |
|
|
C70. [If C64= 1] Did you ever return to live with your [adoptive] family?
Yes
No
C70a. [if C70=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C71. Transitional housing is a temporary accommodation before permanent housing. [After your adoption], did you ever live in a transitional housing program without your [adoptive] parent(s)? [A1>=18 years: Please think only about those times that happened before you turned 18 years old.]
Yes
No
C72. [f C71= 1] How many times have you gone to live in a transitional housing program without your [adoptive] parent(s)?
_____________________ times
C73. [If C71= 1; If C72>1 insert ‘first’] How old were you when you [first] moved from your [adoptive] parent(s)’ home to live in a transitional housing program?
____________________ years old
C74. [If C71= 1; If C72>1 insert ‘first’] When you [first] moved from your [adoptive] parent(s)’ home to live in a transitional housing program, did you still have contact with…? Please answer Yes, No, or Not applicable for each option.
|
Yes |
No |
Not applicable |
C74a. Your adoptive parent(s) |
|
|
|
C74b. Your adoptive sibling(s) |
|
|
|
C74c. Your birth or biological parent(s) |
|
|
|
C74d. Your birth or biological sibling(s) |
|
|
|
C74e. Other relatives |
|
|
|
C75. [If C71= 1; If C72>1 insert ‘first’] Next, we would like to understand what was going on in your adoptive family when you [first] moved from your [adoptive] parent(s)’ home to a transitional housing program. Which of the following describes your family situation at that time? Please answer Yes or No for each option.
|
Yes |
No |
C75a. You did not feel accepted by your [adoptive] family |
|
|
C75b. You did not feel safe in your home because of violence or abuse |
|
|
C75c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
|
|
C75d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
|
|
C75e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
|
|
C75f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
|
|
C75g. You needed help to manage your drinking or drug use |
|
|
C75h. Your gender identity or sexual orientation was not accepted |
|
|
C75i. Your racial or ethnic identity was not accepted |
|
|
C26j. Other (please specify) |
|
|
C76. [If C71= 1; If C72>1 insert ‘first’] During the time when you [first] moved from your [adoptive] parent(s)’ home to a transitional housing program, did you receive any of the following services? Please answer Yes or No for each option.
|
Yes |
No |
C76a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
|
|
C76b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
|
|
C76c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
|
|
C76d. Drug or alcohol treatment services |
|
|
C76e. Job training or support with independent living or other life skills |
|
|
C76f. Other (please specify): ______________ |
|
|
C77. [If C71= 1] Did you ever return to live with your [adoptive] family?
Yes
No
C77a. [if C77=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C78. A group home is a residence intended to serve as an alternative to a family foster home. Homes normally house 4 to 12 youth, offering the use of community resources, including employment, health care, education, and recreational opportunities. A residential treatment center is a 24-hour inpatient facility that provides a range of therapeutic and support services for children by a team of professionals. [After your adoption], did you ever live in a group home or a residential treatment center? [A1>=18 years: Please think only about those times that happened before you turned 18 years old.]
Yes
No
C79. [If C78= 1] How many separate times have you lived in a group home or residential treatment center [after you were adopted]?
_______________________ times
C80. [If C78= 1; If C79>1 insert ‘first’] How old were you when you [first] moved from your [adoptive] parents’ home to a group home or residential treatment center?
_____________________ years old
C81. [If C78= 1; If C79>1 insert ‘first’] When you [first] moved from your [adoptive] parent(s)’ home to a group home or residential treatment center, did you still have contact with…? Please answer Yes, No, or Not applicable for each option.
|
Yes |
No |
Not applicable |
C81a. Your adoptive parent(s) |
|
|
|
C81b. Your adoptive sibling(s) |
|
|
|
C81c. Your birth or biological parent(s) |
|
|
|
C81d. Your birth or biological sibling(s) |
|
|
|
C81e. Other relatives |
|
|
|
C82. [If C78= 1; If C79>1 insert ‘first’] Next, we would like to understand what was going on in your [adoptive] family when you [first] moved from your [adoptive] parent(s)’ home to a group home or residential treatment center. Which of the following describes your family situation at that time? Please answer Yes or No for each option.
|
Yes |
No |
C82a. You did not feel accepted by your [adoptive] family |
|
|
C82b. You did not feel safe in your home because of violence or abuse |
|
|
C82c. You did not feel safe in your home because of another family member’s mental health, drug, or alcohol problems |
|
|
C82d. Your [adoptive] parent(s) did not allow you to live at home, for example, they locked you out or threw you out of their home |
|
|
C82e. Your [adoptive] parent(s) or another family member did not feel safe in the home because of your behavior, for example, you were harming your parent, sibling, or pet |
|
|
C82f. You needed help to manage your emotions or behaviors, such as school problems, not following rules, or having suicidal thoughts |
|
|
C82g. You needed help to manage your drinking or drug use |
|
|
C82h. Your gender identity or sexual orientation was not accepted |
|
|
C82i. Your racial or ethnic identity was not accepted |
|
|
C82j. Other (please specify) |
|
|
C83. [If C78= 1; If C79>1 insert ‘first’] During the time when you [first] moved from your [adoptive] parent(s)’ home to a group home or residential treatment center, did you receive any of the following services? Please answer Yes or No for each option.
|
Yes |
No |
C83a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
|
|
C83b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
|
|
C83c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
|
|
C83d. Drug or alcohol treatment services |
|
|
C83e. Job training or support with independent living or other life skills |
|
|
C83f. Other (please specify): ______________ |
|
|
C84. [If C78= 1] Did you ever return to live with your [adoptive] family?
Yes
No
C84a. [if C84=2] Did you continue to keep in contact with anyone from your [adoptive] family?
Yes
No
C85. [If A1 > =18 years] After you turned 18 years old, did you ever spend at least one night homeless, for example, living inside your car, an abandoned building, on the street, in a park, in a shelter, or couch surfing?
Yes
No
C85a. [If C85=2] During the past 12 months, have you spent at least 1 night homeless, for example, living inside your car, an abandoned building, on the street, in a park, in a shelter, or couch surfing?
Yes
No
C86. [If A1 > =18 years] After you turned 18 years old, did you ever spend at least one night in detention, jail, or prison?
Yes
No
C86a. [If A1<18 or C86=1] During the past 12 months, have you spent at least one night in detention, jail, or prison?
Yes
No
C87. [If A1>= 18 years and C73<18] After you turned 18 years old, did you ever live in a transitional housing program?
Yes
No
C87a. [If A1<18 or C87=1] During the past 12 months, have you lived in a transitional housing program?
Yes
No
C88. [If A1>=18 years and C80<18] After you turned 18 years old, did you ever live in a group home or a residential treatment center?
Yes
No
C88a. [If A1<18 or C88=1] During the past 12 months, have you lived in a group home or a residential treatment center?
[If for any instability episode “Did you ever return to live with your [adoptive] family?” =Yes AND B11=Yes]
C89. When we asked you about things that may have happened in your life, such as running away or going to live somewhere without your [adoptive] parent(s), you told us that you returned to live with your [adoptive] family.
Tell us more about why you returned to live with your [adoptive] family?
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
Section D: Post Adoption Services and Support
INTROD: The next questions will ask you about services and supports that you may have needed or received.
[If B11=Yes, all questions.]
[If B11= No, remove “after your adoption.”]
[If A1>=18, insert “Before you turned 18”]
D90. [Before you turned 18] [after your adoption], did you feel you needed any of the following services, regardless of whether they were offered to you? Please answer yes or no for each option.
|
Yes |
No |
D90a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
|
|
D90b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
|
|
D90c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
|
|
D90d. Drug or alcohol treatment services |
|
|
D90e. Healthcare services, for example from a pediatrician or primary care physician |
|
|
D90f. Job training or support with independent living or other life skills |
|
|
D90g. Other (please specify): ______________ |
|
|
D91. [Before you turned 18] [after your adoption], did you ever receive any of the following services? Please answer Yes or No for each option.
|
Yes |
No |
D91a. Mental health services, for example, individual, group, or family therapy, inpatient care, or home-based services |
|
|
D91b. Educational supports, for example, Individualized Education Plan, 504 plan, special education classes, tutoring, or support to help with changing schools |
|
|
D91c. Support group, in-person, online, or by phone with others who were adopted or moved from an adoptive home |
|
|
D91d. Drug or alcohol treatment services |
|
|
D91e. Healthcare services, for example from a pediatrician or primary care physician |
|
|
D91f. Job training or support with independent living or other life skills |
|
|
D91g. Other (please specify): ______________ |
|
|
D92. [If yes to any type of service in D91] How helpful was/were the service(s) overall?
Very helpful
Helpful
Not helpful
D93. Were there any other services that you would have liked to have received?
1. Yes
2. No
[IF YES] Please describe them here.
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
D94. [If “yes” to service need in D90 and “no” to service receipt in D91] Why do you think you did not get the services you needed?
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
D95. [If “yes” to service need in D90 and “yes” to service receipt in D91] What do you think helped you get the services you received?
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
D96. [If B11=Yes] Was your adoption ever terminated or legally ended by a court order?
Yes, my adoptive parents’ rights were terminated
Yes, I was legally emancipated with a court order before I turned 18 years old
No, my adoptive parents’ rights were not terminated, instead we just ended our relationship on our own
No
D97. [If D96=yes] When was your adoption terminated? Please provide an approximate date.
___________________[Fill date– MM/DD/YYYY]
Section E: Family Relationships
INTROE: These next questions ask about your family relationships.
[If B11=Yes, all questions]
[If B11= No, replace “adoptive parent” with only “parent.”]
E96. How many living [adoptive] parents do you have?
__________________ parents
[If E96=0 SKIP TO E103]
E97. [If E96>1 include: First, think about one of your [adoptive] parents] [First, think about one of your [adoptive] parents.] How close do you currently feel to this [adoptive] parent?
1. Extremely close
2. Very close
3. Moderately close
4. Slightly close
5. Not at all close
E98. [If E96>1, use “first”] Thinking about this same parent, about how often do you see or have contact with them?
Never
A few times a year
A few times a month
About once a week
Several times a week
Every day
E99. [If A1 > =18 years and B12<18] [If E96>1, use “first”] During your childhood, before you turned 18 years old, how close did you feel to your [first] [adoptive] parent?
Extremely close
Very close
Moderately close
Slightly close
Not at all close
E99a. [If E96>1, use “first”] Is this [first] [adoptive] parent Spanish, Hispanic, or Latino?
1. Yes
2. No
E99b. [If E96>1, use “first”] What is this [first] [adoptive] parent’s race? Select all that apply.
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or other Pacific Islander
5. White
6. Other
E100. [If E96>1] Now think about your other [adoptive] parent. How close do you currently feel to your second [adoptive] parent?
Extremely close
Very close
Moderately close
Slightly close
Not at all close
E101. [If E96>1] Thinking about this same parent, about how often do you see or have contact with them?
E102. [If E96>1 and If A1 >= 18 years and B12<18] During your childhood, before you turned 18 years old, how close did you feel to your second [adoptive] parent?
Extremely close
Very close
Moderately close
Slightly close
Not at all close
E102a. [If E96>1, use “second”] Is this [second] [adoptive] parent Spanish, Hispanic, or Latino?
1. Yes
2. No
E102b. [If E96>1, use “second”] What is this [second] [adoptive] parent’s race? Select all that apply.
1. American Indian or Alaska Native
2. Asian
3. Black or African American
4. Native Hawaiian or other Pacific Islander
5. White
6. Other
E103. [If B11=1 and if E96>=1] Thinking about your adoptive family now, how much do you feel that you belong?
Completely
Very much
A moderate amount
A little
Not at all
E104. Thinking about the next five years, how hopeful are you about your future?
Extremely hopeful
Very hopeful
Moderately hopeful
Slightly hopeful
Not at all hopeful
E105. How supportive are your [adoptive] parents of your future plans?
Extremely supportive
Very supportive
Moderately supportive
Slightly supportive
E106. [If B11=yes] Do you know the identity of at least one of your birth or biological parents?
Yes
No
E106a. [If E106= 1] How many birth or biological parents’ identities do you know?
1
2
E107. [If E106=1; if E106a>1, use [first] and introduction text below:] [For these next set of questions first think about the birth or biological parent that you feel the closest to.]
How close do you currently feel to your [first] birth or biological parent?
Extremely close
Very close
Moderately close
Slightly close
Not at all close
E108. [If E106=1] Thinking of this same birth or biological parent, about how often do you see or have contact with them?
Never
A few times a year
Once or twice a month
About once a week
Several times a week
Every day
E109. [If A1 > =18 years and if E106=Yes; if E106a>1, use ‘first’] During your childhood, before you turned 18 years old, how close did you feel to your [first] birth or biological parent?
Extremely close
Very close
Moderately close
Slightly close
Not at all close
E110. [If E106=1 and E106a>1] Do you know your second birth or biological parent?
Yes
No
E111. [If E106=1 and E106a>1] How close do you currently feel to your second birth or biological parent?
Extremely close
Very close
Moderately close
Slightly close
Not at all close
E112. [If E106=1 and E106a>1] Thinking of this same parent, about how often do you see or have contact with them?
Never
A few times a year
Once or twice a month
About once a week
Several times a week
Every day
E113. [If A1 > =18 years and if E106a>1] During your childhood (before you turned 18 years old), how close did you feel to your second birth or biological parent?
Extremely close
Very close
Moderately close
Slightly close
Not at all close
E114.
[If B11=1 and if A1 < 18 years old] Do you have any birth or biological sibling(s) who do not live with you now?
OR
[if B11=1 and A1>= 18 years old or older] Before you turned 18, did you have any birth or biological sibling(s) who did not live with you?
Yes
No
Don’t know
E115.
[If A1<18 years] Do you have any adoptive sibling(s) who do not live with you now?
OR
[If A1 >=18 years] Before you turned 18, did you have any adoptive sibling(s) who did not live with you?
Yes
No
E116. [If B11=1] Are there other members of your birth or biological family such as aunts, uncles, or cousins, who do not live with you, but with whom you keep in touch?
Yes
No
E117. [If B11=1 and if E106=yes] Thinking about your birth or biological family now, how much do you feel that you belong?
Completely
Very much
A moderate amount
A little
Not at all
Section F: Adoption Motivations/Experience
[If B11=Yes]
INTROF: Now we would like to understand more about your adoption experience.
F118. Now think back to the time when you were adopted. At that time, were you involved in the decision about being adopted?
Yes
No, I was too young to understand what was going on
No, but I wanted to be part of this family
No, and I did not want to be a part of this family
F119. [Skip if F118= 2, 3, or 4] Did you want to be adopted by this family?
Yes
No
F120. [If F119= 1 OR F118=3] Why did you want to be adopted by this family? Please answer Yes or No for each option.
|
Yes |
No |
F120a. To have a stable family |
|
|
F120b. To have long-term family relationships |
|
|
F120c. To have someone that loves and cares about me |
|
|
F120d. To have someone I can count on |
|
|
F120e. To have a home |
|
|
F120f. To have a stable school and neighborhood |
|
|
F120g. To be able to go to college |
|
|
F120h. To have siblings |
|
|
F120i. Other (please specify): ________________________ |
|
|
F121. [If F119= 2 or F118= 4] What are some reasons you did not want to be adopted by this family? Please answer Yes or No for each option.
|
Yes |
No |
F121a. I wanted to go back to biological or birth family |
|
|
F121b. I wanted to go back to my neighborhood |
|
|
F121c. I wanted to go back to your cultural roots |
|
|
F121d. This family was not a good fit |
|
|
F121e. Other (please specify): _____________________ |
|
|
F122. Are you aware of a court proceeding that made your adoption legal?
Yes
No
F123. [If F122= 1] Were you involved with the court proceedings?
Yes
No
I cannot remember
F124. Did anyone talk with you about being adopted by this family?
Yes
No
F124a. [if F124=1] Who talked to you about being adopted by this family? Please select all that apply.
Birth or biological parent
Adoptive parent
Caseworker
Someone else (please specify): _________________
F125. Thinking about why you were adopted, do you think that any of these reasons were part of your parent(s)’ decision to adopt you? Please answer Yes or No for each option.
|
Yes |
No |
F125a. My adoptive parent(s) loved me |
|
|
F125b. I was already part of our family as a relative or foster child |
|
|
F125c. My adoptive parent(s) were unable to have a birth or biological child |
|
|
F125d. My adoptive parent(s) wanted to expand their family |
|
|
F125e. My adoptive parent(s) wanted a sibling for their other child(ren) |
|
|
F125f. My adoptive parent(s) had already adopted my sibling(s) |
|
|
F125g. My adoptive parent(s) knew me before the adoption and wanted to help me |
|
|
F125h. My adoptive parent(s), or someone close to them, had previously been adopted |
|
|
F125i. My adoptive parent(s) wanted to help a child in need of a permanent family. |
|
|
F125j. Other reason? (please specify): __________________ |
|
|
Section G: Perceptions of Childhood Family Cohesion/Functioning
If B11=Yes, all questions
If B11= No, replace “adoptive family” with only “family.” And, replace “adoptive parent” with only “parent.”
INTROG1: [If A1>=18, use ‘before you turned 18’ and ‘was’] For the next set of statements, think of your experiences during your childhood [If A1>=18-“before you turned 18”]. Please think about all members of your [adoptive] family when answering these questions. Select how often each statement is [was] true for your [adoptive] family.
G126. In my [adoptive] family, we talk about problems. [If A2>=18 years: In my [adoptive] family, we talked about problems.]
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
G127. When we argue, my [adoptive] family listens to “both sides of the story.” [If A2>=18 years: When we argued, my [adoptive] family listened to “both sides of the story”.]
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
G128. In my [adoptive] family, we take time to listen to each other. [If A2>=18 years: In my [adoptive] family, we took time to listen to each other.]
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
G129. My [adoptive] family pulls together when things are stressful. [If A2>=18 years: My [adoptive] family pulled together when things were stressful.]
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
G130. My [adoptive] family is able to solve our problems. [If A2>=18 years: My [adoptive] family was able to solve our problems.]
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
INTROG2: [If A1>=18, use ‘before you turned 18’ and ‘felt’] For the next set of statements, think of your experiences during your childhood [A1>=18-“before you turned 18”]. Please think about the [adoptive] parent to whom you feel [felt] the closest. Please indicate how often each of the following is true for you.
G131. I am happy when I am with my [adoptive] parent. [If A2>=18 years: I was happy when I was with my [adoptive] parent.]
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
G132. My [adoptive] parent and I are very close to each other. [If A2>=18 years: My [adoptive] parent and I were very close to each other.]
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
G133. My [adoptive] parent is a comfort to me when I am upset. [If A2>=18 years: My [adoptive] parent was a comfort to me when I was upset.]
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
G134. I spend time with my [adoptive] parent doing what he/she/they likes to do. [If A2>=18 years: I spent time with my [adoptive] parent doing what he/she/they likes to do].
Never
Very rarely
Rarely
About half the time
Frequently
Very frequently
Always
G135. How warm is your relationship with your [adoptive] parent? [If A2>=18 years: How warm was your relationship with your [adoptive] parent?].
Not at all warm
Slightly warm
Moderately warm
Very warm
Extremely warm
[If B11=No, SKIP]
G136. If you knew everything about your [adoptive] family that you now know, would you want to be adopted by this this family?
Definitely not
Probably not
Maybe
Probably
Definitely
[If B11=No SKIP]
G137.
[If A1<18 years and D95=No] How often do you think about ending your adoption?
OR
[If A1>=18 years] Before you were 18, how often did you think about ending your adoption?
Never
Rarely
Sometimes
Usually
Always
Section H: Health and Mental Health Status
INTROH: The next questions ask about your health.
H138. In general, would you say your health is...?
Excellent
Very good
Good
Fair
Poor
H139. Do you think you have a problem with your own mental health? Please include any emotional, behavioral, learning, or attention problems.
Yes
No
H140. Do you think you have a problem with your own drug or alcohol use? Please include any alcohol or drug abuse problems.
Yes
No
H141. [If A1>=18] During your childhood, before you turned 18 years old, did you have a problem with your own mental health? Please include any emotional, behavioral, learning, or attention problems.
Yes
No
H142. [If A1>=18] During your childhood, before you turned 18 years old, did you have a problem with your own drug or alcohol use? Please include any alcohol or drug abuse problems.
Yes
No
H143. Now I have a few questions about your personal experiences with COVID-19, the disease caused by the novel coronavirus.
How much has COVID-19 changed your family income or employment situation?
No change.
Mild. There has been a small change, but I can still meet my basic needs and pay bills.
Moderate. I have had to make cuts, but I can still meet my basic needs and pay my bills.
Severe. I am unable to meet my basic needs or pay my bills.
H144. How much has COVID-19 changed your access to extended family and non-family social supports?
No change.
Mild. I continue my visits with social distancing, regular phone calls, video calls or social media contacts.
Moderate. I have lost in-person and remote contact with a few people, but not all of my supports.
Severe. I have lost all in-person and remote contact with my supports.
H145. How much stress have you experienced due to COVID-19?
None.
Mild. I worry occasionally or experience minor stress-related symptoms, such as feeling a little anxious, sad, or angry; or having mild trouble sleeping
Moderate. I worry frequently or experience moderate stress-related symptoms, such as feeling moderately anxious, sad, or angry; or having moderate or occasional trouble sleeping
Severe. I worry all the time or experience severe stress-related symptoms, such as feeling extremely anxious, sad or angry; or having severe or frequent trouble sleeping
H146. How much stress or disagreement is there in your family due to COVID-19?
None.
Mild. My family members are occasionally short-tempered with one another; but there is no physical violence.
Moderate. My family members are frequently short-tempered with one another; or children in my home get in physical fights with one another.
Severe. My family members are frequently short-tempered with one another; or adults in my home throw things at one another, knock over furniture, hit or harm one another.
Section I: Support
INTROI: Think of people you can go to if you want to talk to someone about something personal - for instance, if you had something on your mind that was worrying you or making you feel down.
I147. Currently, how many people do you feel you can you go to if you want to talk about something personal?
No one
1
2
3
4
5 or more
I148. [If question I147 ≠ “no one”] Who are the people you can talk to about something personal related to you? Please answer yes or no for each option.
|
Yes |
No |
I148a. Adoptive parent |
|
|
I148b. Birth or biological parent |
|
|
I148c. Foster parent |
|
|
I148d. Other adoptive relative |
|
|
I148e. Other birth or biological relative |
|
|
I148f. Spouse or partner |
|
|
I148g. Mentor or other community member such as a caseworker or social worker, teacher, or coach |
|
|
I148h. Friend, peer, or coworker |
|
|
I148i. Therapist, counselor, or doctor |
|
|
I148j. Lawyer or court-appointed special advocate, such as CASA |
|
|
I148k. Other (please specify): |
|
|
I149. When you run into challenges, who is your primary source of support or help?
Adoptive parent or guardian
Birth or biological parent
Foster parent
Another adoptive relative
Another birth or biological relative
Spouse or partner
Mentor or other community member such as a caseworker or social worker, teacher, or coach
Friend, peer, or coworker
Therapist, counselor, or doctor
Lawyer or court-appointed special advocate, such as CASA
Other (please specify): ______________________
Section J: Open Ended Question
INTROJ: This is our last question.
J150. Is there anything else about your [adoption] experience that you would like to share?
1 Yes
2 No
[IF YES] What would you like to share?
[TEXT BOX FOR AN OPEN-ENDED RESPONSE]
SAY, Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Domanico, Rose |
File Modified | 0000-00-00 |
File Created | 2021-08-11 |