MARCH 15, 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: |__|__| : |__|__|

AC_MO AC_DY AC_YR AC_START AC_END

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

AC_MOM AC_CHLD

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

AC_INTERVIEW_TYPE

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

AC_INTERVIEWER AC_SITE

ADOLESCENT CHILDHOOD DEVELOPMENTAL ASSESSMENT GUIDE

ASSESSING ACHIEVEMENTS FOR ADOLESCENT CHILDHOOD (AGES 11-17)

Please check YES or NO to indicate the correct response.

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

AC_01A a. Does the adolescent practice good personal hygiene? ................................ Yes 1 No 0 N/A -1

AC_01B b. Does the adolescent eat more fruits, nuts, grains, and vegetables

than fast foods?......................................................................................... Yes 1 No 0 N/A -1

AC_01C c. Does the adolescent have regular doctor visits?.......................................... Yes 1 No 0 N/A -1

AC_01D d. Does the adolescent have regular dentist visits? ......................................... Yes 1 No 0 N/A -1

AC_01E e. Does the adolescent exercise regularly or play sports?................................ Yes 1 No 0 N/A -1

2. Physical, Emotional, Sexual Growth and Development

AC_02A a. Can the adolescent identify expected body changes?.................................. Yes 1 No 0 N/A -1

AC_02B b. Can the adolescent share feelings about mother being in treatment?........... Yes 1 No 0 N/A -1

AC_02C c. Is the adolescent able to discuss concerns regarding sexuality

(body development)? ................................................................................. Yes 1 No 0 N/A -1

3. Social and Conflict Resolution Skills

AC_03A a. Does the adolescent spend time with at least two other people

each day?.................................................................................................. Yes 1 No 0 N/A -1

AC_03B b. Can the adolescent state what things they do to solve disagreements

between themselves and others, or between two other people? .................. Yes 1 No 0 N/A -1

4. Good Peer Relationships with the Same and Opposite Sex

AC_04A a. Is the adolescent comfortable with peers of the same sex?.......................... Yes 1 No 0 N/A -1

AC_04B b. Is the adolescent comfortable with peers of the opposite sex?..................... Yes 1 No 0 N/A -1

AC_04C c. Does the adolescent state they can make decisions without

responding to pressure from peers/friends? ................................................ Yes 1 No 0 N/A -1

5. Capacity for Intimacy

AC_05A a. Does the adolescent express ‘special feelings’ for someone else?............... Yes 1 No 0 N/A -1

AC_05B b. Does the adolescent state that they are capable of sharing certain

conversation and secrets with someone else? ............................................ Yes 1 No 0 N/A -1

2 0
2

6. Sexual Identity and Responsible Sexual Behavior Yes No N/A

AC_06A a. Does the adolescent state they have sexual thoughts and dreams?............. Yes 1 No 0 N/A -1

AC_06B b. Does the adolescent state their sexual impulses are under control?............. Yes 1 No 0 N/A -1

AC_06C c. Does the adolescent practice no sex or safe sex with condoms? ................. Yes 1 No 0 N/A -1

7. Coping Skills and Strategies

AC_07A a. Can the adolescent identify what stresses them out?................................... Yes 1 No 0 N/A -1

AC_07B b. Can the adolescent identify what they do that is positive, healthy,

legal, and/or safe to deal with feelings or situations?................................... Yes 1 No 0 N/A -1

AC_07C c. Can the adolescent identify what they do to cope with their mother’s

addiction?.................................................................................................. Yes 1 No 0 N/A -1

8. Appropriate Level of Autonomy

AC_08A a. Does the adolescent state that they are allowed to make choices

regarding their behavior? ........................................................................... Yes 1 No 0 N/A -1

AC_08B b. Does the adolescent state that they are given a range of choices

by their parents from which to choose?....................................................... Yes 1 No 0 N/A -1

AC_08C c. Does the adolescent make decisions and choices for themselves,

their siblings, and their addicted parents?................................................... Yes 1 No 0 N/A -1

9. Personal Value System

AC_09A a. Is the adolescent able to identify what things are valuable to them?............. Yes 1 No 0 N/A -1

AC_09B b. Is the adolescent able to identify what has shaped or helped to

determine what they value?........................................................................ Yes 1 No 0 N/A -1

10. Progression from Concrete to Abstract Thinking

AC_10A a. Can the adolescent identify who the current President and Vice President

of the United States are?............................................................................ Yes 1 No 0 N/A -1

AC_10B b. Can the adolescent identify the importance of voting? ................................. Yes 1 No 0 N/A -1

11. Academic and Career Goals

AC_11A a. Does the adolescent know what the highest grade of education is 

that they want to complete?........................................................................ Yes 1 No 0 N/A -1

AC_11B b. Does the adolescent know what they want to ‘be’ when they grow up,

or what they want to do as a job? ............................................................... Yes 1 No 0 N/A -1

12. Educational or Vocational Competence

AC_12A a. Is the adolescent currently enrolled in school? ............................................ Yes 1 No 0 N/A -1

AC_12B b. Is the adolescent in the correct grade for their age? .................................... Yes 1 No 0 N/A -1

AC_12C c. Is the adolescent receiving As, Bs, or Cs in school?.................................... Yes 1 No 0 N/A -1

AC_12D d. If not in school, is the adolescent being successful

in a vocational training program?................................................................ Yes 1 No 0 N/A -1

AC_12E e. Is the report of the adolescent’s conduct in the educational

setting satisfactory? ................................................................................... Yes 1 No 0 N/A -1

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

AC_TOTAL_YES
3

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

AC_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.

AC--2006.00