All the following questions refer to the time before you were 18 years of age. Now, looking back before you were 18 years of age…
Questions:
1. As a child, how often did your family experience serious financial problems?
- Never
- Rarely
- Sometimes
- Often
- Very Often
2. How often were you hungry because your family could not afford food?
- Never
- Rarely
- Sometimes
- Often
- Very Often
3. How often were you homeless when you were growing up?
(This means having to stay somewhere like a transitional housing program, a shelter, a hotel/motel paid by voucher, someone else’s home, a car or other vehicle, an abandoned building, anywhere outside, or anywhere else not meant for people to live.)
- Never
- Rarely
- Sometimes
- Often
- Very Often
4. How often did a parent or adult in your home ever swear at you, insult you, or put you down?
- Never
- Rarely
- Sometimes
- Often
- Very Often
5. How often were you bullied or severely teased by other children or adolescents? (This refers to bullying or teasing by children or adolescents of any age. It does not include experiences with adults or with siblings.)
- Never
- Rarely
- Sometimes
- Often
- Very Often
6. Before age 18, how often was there an adult in your household who tried hard to make sure your basic needs were met? By “basic needs” we mean food, shelter, clothing, and medical care. (This could be any adult in the household, not just a parent.)
- Never
- Rarely
- Sometimes
- Most of the Time
- Always
7. How often was there an adult in your household who made you feel safe and protected?
- Never
- Rarely
- Sometimes
- Most of the Time
- Always
8. Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking.
- Never
- Once
- More Than Once
9. How often did your parents or adults in your home ever slap, hit, beat, kick, or physically hurt each other?
- Never
- Once
- More Than Once
10. How often did an adult, or anyone at least 5 years older than you, touch you sexually, try to make you touch them sexually, or force you to have sex?
- Never
- Once
- More Than Once
11. Did you live with anyone who was depressed, mentally ill, or suicidal?
- Yes
- No
12. Did you live with anyone who was a problem drinker or alcoholic?
- Yes
- No
13. Did you live with anyone who used illegal street drugs or who abused prescription medications?
- Yes
- No
14. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
- Yes
- No
15. Were your parents separated or divorced?
- Yes
- No
16. Was either one of your parents absent from your life for a long period of time? Do not include absence due to death of parent.
- Yes
- No
17. Before age 18, did you experience the death of a parent, caregiver, or sibling?
- Yes
- No
18. Before age 18, were you ever the victim of a violent crime? This refers to any violent act that was perpetrated by someone other than a parent or household family member.
- Yes
- No
19. Overall, how uncomfortable did you feel answering the questions on this survey?
- Not at All
- Slightly
- Moderately
- Very
- Extremely
Adapted from Centers for Disease Control and Prevention. (2012). Behavioral Risk Factor Surveillance System Survey Questionnaire: Adverse Childhood Experiences Module. Atlanta, Georgia: Author.
For further information about this measure, contact: Dr. Joshua Mersky, University of Wisconsin-Milwaukee, mersky@uwm.edu