Evaluations

The Adverse Childhood Experiences questionnaire helps to identify at risk youth for the development of mental health disorder.

Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score

While you were growing up, during your first 18 years of life:

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1. Did a parent or other adult in the household often …

Swear at you, insult you, put you down, or humiliate you?

or

Act in a way that made you afraid that you might be physically hurt?

Yes             No

If yes enter 1 ________

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2. Did a parent or other adult in the household often …

Push, grab, slap, or throw something at you?

or

Ever hit you so hard that you had marks or were injured?

Yes             No

If yes enter 1 ________

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3. Did an adult or person at least 5 years older than you ever…

Touch or fondle you or have you touch their body in a sexual way?

or

Try to or actually have oral, anal, or vaginal sex with you?

 Yes            No

If yes enter 1 ________

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4. Did you often feel that …

No one in your family loved you or thought you were important or special?

or

Your family didn’t look out for each other, feel close to each other, or support each other?

 Yes            No

If yes enter 1 ________

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5. Did you often feel that …

You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

or

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

 Yes            No

If yes enter 1 ________

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6. Were your parents ever separated or divorced?

Yes             No

If yes enter 1 ________

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7. Was your mother or stepmother:

Often pushed, grabbed, slapped, or had something thrown at her?

or

Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?

or

Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes             No

If yes enter 1 ________

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8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

Yes             No   

If yes enter 1 ________

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9. Was a household member depressed or mentally ill or did a household member attempt suicide?

Yes             No

If yes enter 1 ________

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10. Did a household member go to prison?

Yes             No

If yes enter 1 ________

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Now add up your “Yes” answers: _______ This is your ACE Score

As the ACE score increases so too does the correlation to health problems. This means that as the ACE score increases, so too does the risk for developing health conditions such as obesity, heart and lung disease, drug addictions, and depression. These individuals have a higher likelihood of having financial problems, intimate partner abuse, and psychological disturbances. If a score of 7 or higher is recorded on the ACE questionnaire, please take the PTSD-5 for further evaluation.

The PTSD-5 is a simple straightforward questionnaire that can help guide providers in evaluating the risk of youth for developing mental health disorders. A score of 3 or higher would necessitate professional follow up and suggests a higher likelihood of PTSD diagnosis.

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Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

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• a serious accident or fire

• a physical or sexual assault or abuse

• an earthquake or flood

• a war

• seeing someone be killed or seriously injured

• having a loved one die through homicide or suicide.

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Have you ever experienced this kind of event?
YES / NO

If no, screen total = 0. Please stop here.

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If yes, please answer the questions below.

In the past month, have you...

1. Had nightmares about the event(s) or thought about the event(s) when you did not want to? 
   YES / NO

2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? 
   YES / NO

3. Been constantly on guard, watchful, or easily startled?
   YES / NO

4. Felt numb or detached from people, activities, or your surroundings? 
   YES / NO

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
   YES / NO

If the score on the PTSD-5 is less than 3, continue to monitor symptoms. A referral to a health professional is at the discretion of the provider and client.

These screenings do not replace a physician's assessment or evaluation. In the event you are having thoughts of harming yourself or others or just feel you need emergent help, please dial 911 or seek out your nearest emergency department.