Household Survey

Memories Can Heal

The Adverse Childhood Experiences Scale (ACE Test)

How can CHILDHOOD emotional baggage affect my ADULT LIFE? Answer the questions below to find out. Check all that apply:

Did You Grow Up in a Household with:

DIVORCE/SEPARATION OR ONE OR NO PARENTS

Were your parents ever separated or divorced during your first 18 years of life or did you grow up with one or both of your biological parents absent?

EMOTIONAL NEGLECT

During your first 18 years of life did you often feel that 1) there was no one in your family who helped you or made you feel important or special, 2) that you weren’t loved, 3) that people in your family didn’t look out for each other, 4) that people in your family didn’t feel close to each other, or 5) that your family was not a source of strength or support.

PHYSICAL NEGLECT

During your first 18 years of life did you sometimes 1) not have enough to eat, 2) not feel that there was someone there to take care of you and protect you, 3) think that your parents were too drunk or too high to take care of you, 4) have to wear dirty clothes or 5) not have someone there to take you to the doctor if I needed it.

MOTHER BEING MISTREATED

During your first 18 years of life did your father, stepfather or mother’s boyfriend often push, grab, slap or throw something at your mother? Did they often kick, bite, hit her with a fist or hit her with something hard? Did they ever repeatedly hit her over at least a few minutes or 2) threaten her with a knife or gun, or use a knife or gun to hurt her?

FAMILY EMOTIONAL PROBLEMS

During your first 18 years of life, was anyone in your household depressed or mentally ill or did anyone in your household attempt to commit suicide?

RECURRENT PHYSICAL ABUSE

During your first 18 years of life, did adults sometimes push, grab, slap, or throw something at you or hit you so hard that you had marks or were injured?

RECURRENT EMOTIONAL ABUSE

During your first 18 years of life, did adults often swear at you, insult you, put you down, threaten to hit you or throw something at you?

SEXUAL ABUSE

During your first 18 years of life, did any adult or much older child ever 1) touch or fondle your body in a sexual way, 2) have you touch their body in a sexual way, 3) attempt to have any type of sexual intercourse with you (oral, anal or vaginal) or 4) actually have any type of sexual intercourse with you (oral, anal, or vaginal)?

ALCOHOL OR SUBSTANCE ABUSE

During your first 18 years of life, did you live with anyone who was a problem drinker, alcoholic, or who used street drugs?

AN INCARCERATED HOUSEHOLD MEMBER

During your first 18 years of life, did anyone in your household go to prison?

This web questionnaire was adapted from a series of Adverse Childhood Experiences (ACE) studies completed over the past 10 years. These studies examine how traumatic childhood experiences affect adult health and well-being. For more information, or to see the references for each of the results above click here.

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This website is designed for general information only. The information presented at this site should not be construed to be formal advice nor the formation of a doctor/client relationship. All content copyright protected. Copyright 2006-2007, Memories Can Heal, David Russell, PhD. All Rights Reserved.