MARCH 21, 2006 FORMAT Form Approved

OMB No. 0930-0269

Expiration Date 09-30-2007

Public reporting burden for this collection of information is estimated to average 20 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. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports 

Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. 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. The control number for this project 

is 0930-0269.

DATE: |__|__| |__|__| |__|__|__|__| START TIME: |__|__| : |__|__| END TIME: |__|__| : |__|__|

MC_MO MC_DY MC_YR MC_START MC_END

MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| CHILD’S ID# |__|__|

MC_MOM MC_CHLD

EVALUATION PHASE: Intake |__|1 3-months |__|3 6-months |__|4 Discharge |__|6

MC_INTERVIEW_TYPE

PERSON COMPLETING |_______________| GRANT# TI |__|__|__|__|__|

MC_INTERVIEWER MC_SITE

MIDDLE CHILDHOOD DEVELOPMENTAL ASSESSMENT GUIDE

ASSESSING ACHIEVEMENTS FOR MIDDLE CHILDHOOD (AGES 6-10)

NOTE. This instrument is administered to children age 6 years, 1 day.

Please check YES or NO to indicate the correct response.

1. Responsibility for Good Health Habits Yes No N/A

MC_01A a. Can the child describe their health habits (bathing, brushing teeth,

clean clothes, etc)?.................................................................................... Yes 1 No 0 N/A -1

MC_01B b. Does the child state they are responsible for their health habits?................. Yes 1 No 0 N/A -1

2. Ability to Play in Groups

MC_02A a. Does the child play with 3 or more other children at times?.......................... Yes 1 No 0 N/A -1

MC_02B b. Is the child comfortable playing with 3 or more other children? .................... Yes 1 No 0 N/A -1

MC_02C c. Does the child like to play in groups?.......................................................... Yes 1 No 0 N/A -1

3. Development of One or More Close Friendships

MC_03A a. Can the child identify who their best friend is?............................................ Yes 1 No 0 N/A -1

MC_03B b. Can the child identify the kids they spend most of their time with? ............... Yes 1 No 0 N/A -1

4. Identification of Peer Groups

MC_04A a. Can the child say what group of people they fit in with?............................... Yes 1 No 0 N/A -1

MC_04B b. Is the peer group identified similar in age?.................................................. Yes 1 No 0 N/A -1

5. Competencies as a Member of a Family, Community, or Other Group

MC_05A a. Can the child describe how they fit in their family, neighborhood,

or other group?.......................................................................................... Yes 1 No 0 N/A -1

MC_05B b. Can the child identify the expectations they need to fulfill as

a member of the above groups?................................................................. Yes 1 No 0 N/A -1

6. Ability to Express Feelings

MC_06A a. Can the child share any feelings?............................................................... Yes 1 No 0 N/A -1

MC_06B b. Can the child share feelings about mother’s addiction? ............................... Yes 1 No 0 N/A -1

7. Belief in Capacity for Success

MC_07A a. Can the child identify something they wish to achieve or do well? ............... Yes 1 No 0 N/A -1

MC_07B b. Can the child state firmly that they will achieve it?....................................... Yes 1 No 0 N/A -1

2 0
Please check YES or NO to indicate the correct response.

8. Understanding of Right and Wrong Yes No N/A

MC_08A a. Does the child say it is not right to steal, harm others, or use alcohol

and drugs?................................................................................................ Yes 1 No 0 N/A -1

9. Awareness of Safety Rules

MC_09A a. Can the child describe how to cross the street? .......................................... Yes 1 No 0 N/A -1

MC_09B b. Does the child express the need to wear seatbelts?.................................... Yes 1 No 0 N/A -1

MC_09C c. Does the child wear helmets and pads when biking, skating, etc? ............... Yes 1 No 0 N/A -1

MC_09D d. Does the child know not to talk to strangers? .............................................. Yes 1 No 0 N/A -1

10. Ability to Read, Write, and Communicate Increasingly Complex and Creative Thoughts

MC_10A a. Can the child read and write?..................................................................... Yes 1 No 0 N/A -1

MC_10B b. Can the child say emergency telephone numbers? ..................................... Yes 1 No 0 N/A -1

MC_10C c. Can the child communicate feelings about mother being in treatment? ........ Yes 1 No 0 N/A -1

11. Responsibility for Homework

MC_11A a. Is the child in school?................................................................................. Yes 1 No 0 N/A -1

IF 11a = NO, END INTERVIEW

MC_11B b. Does the child do their homework?............................................................. Yes 1 No 0 N/A -1

12. School Achievement

MC_12A a. Is the child in the right grade for their age? ................................................. Yes 1 No 0 N/A -1

MC_12B b. Does the child get satisfactory, outstanding, As, Bs, or Cs, in school? ......... Yes 1 No 0 N/A -1

MC_12C c. Is the report of the child’s conduct in school satisfactory?............................ Yes 1 No 0 N/A -1

Please count the number of items on which child has a YES response ......................

MC_TOTAL_YES

SUMMARY SCORE

Please put a check mark by ONE of the following categories that appears to best describe this child’s achievements.

Score Number of domains having at least one YES response

MC_SCORE 1 1-4 Child approaching accomplishment of 1/3 of the 12 developmental achievements listed.

2 5-7 Child approaching accomplishment of 1/2 of the 12 developmental achievements listed.

3 8 Child accomplishing 2/3 of the 12 developmental achievements listed.

4 9-11 Child approaching accomplishment of almost all of the developmental achievements listed.

5 12 Child accomplishing all of the developmental achievements listed.

Copyright 2004 Karen Allen 

Not to be used without the written permission of Karen Allen, Ph.D.

MC – 2006.00