ACEPLUS-SR English

ACE+SR: ACE+ Self-Report Rating Scale
ACE+SR is a rating scale that will ask you to provide information about your behaviour
when you were (a) a young child (by the age of 12 years old) and (b) in the last six
months.
To jog your memory to think back to your childhood years, it is helpful to look through any
photographs that were taken at that time and/or childhood documents (such as school,
educational, social care or health reports) you may have. If you have any documents like
these, please send copies of them back with the completed ACE+SR scale.
Date of Completion: _____________________________
Name: _____________________________
Date of Birth: _____________________________
Please complete the following questions by circling one answer only (never, rarely,
sometimes, often or don’t know) relating to your functioning or behaviour (1) as a child
(by the age of 12 years old) and (2) in the last six months.
Next, with reference to the rating you have provided (never, rarely, sometimes or
often), please provide (a) specific examples of the behaviour, (b) how it impacted on
your personal, social, educational and/or occupational activities, and (c) whether
adjustments had to be made to manage or prevent any problems that arose.
We also ask about behaviour over the last 6 months because as a person grows up, a
problem or difficulty may lessen or present differently (hence the examples may differ
and/or how difficulties may impact on their behaviour, activities and relationships). In
some cases, the difficulty may persist, but its impact is lowered due to adjustments
and strategies that are applied (by the person themselves or by others around them).
Please provide as much information as possible, using a separate page if necessary.
© Psychology Services Limited: https://www.psychology-services.uk.com 1

C1: As a CHILD, did you fail to give close attention to details or make careless mistakes Never Rarely Sometimes Often
(e.g. difficulty concentrating on boring or repetitive tasks)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacted on your
activities and relationships as a child and (c) whether adjustments had to be made to manage or prevent any problems that arose.
P1: Over the last 6 MONTHS, have you failed to give close attention to details or made Never Rarely Sometimes Often
careless mistakes (e.g. difficulty concentrating on boring or repetitive tasks)? DK
With reference to the rating you have given (never, rarely, sometimes or often), please (a) detail examples of the behaviour, (b) how this impacts on your
activities and relationships at the present time and (c) whether adjustments have to be made to manage or prevent any problems that arise.
C2: As a CHILD, did you fail to sustain attention in tasks or activities (e.g. maintaining Never Rarely Sometimes Often
your focus over a long period when concentrating on tasks)? DK
P2: Over the last 6 MONTHS, have you failed to sustain attention in tasks or activities Never Rarely Sometimes Often
(e.g. maintaining your focus over a long period when concentrating on tasks)? DK

C3: As a CHILD, did you not listen to what was being said to you (e.g. difficulty Never Rarely Sometimes Often
concentrating on what people said to you, even when speaking to you directly)? DK
P3: Over the last 6 MONTHS, have you not listened to what is being said to you (e.g. Never Rarely Sometimes Often
difficulty concentrating on what people say, even when speaking to you directly)? DK
C4: As a CHILD, did you fail to follow through on instructions or finish tasks (e.g. not Never Rarely Sometimes Often
completing chores or schoolwork, taking ‘short-cuts’ and missing things out)? DK
P4: Over the last 6 MONTHS, have you failed to follow through on instructions or finish Never Rarely Sometimes Often
tasks (e.g. not completing work, taking ‘short-cuts’ and missing things out)? DK

C5: As a CHILD, did you struggle to organise tasks and activities (e.g. difficulty structuring Never Rarely Sometimes Often
and planning tasks on your own, missing deadlines)? DK
P5: Over the last 6 MONTHS, have you struggled to organise tasks and activities (e.g. Never Rarely Sometimes Often
difficulty structuring and planning tasks on your own, missing deadlines)? DK
C6: As a CHILD, did you avoid or strongly dislike tasks requiring sustained mental effort Never Rarely Sometimes Often
(e.g. you delayed or were reluctant to start tasks that took a lot of thought)? DK
P6: Over the last 6 MONTHS, have you avoided or strongly disliked tasks requiring Never Rarely Sometimes Often
sustained mental effort (e.g. delay or reluctant to start tasks that take a lot of thought)? DK

C7: As a CHILD, did you lose things necessary for certain tasks or activities (e.g. misplaced Never Rarely Sometimes Often
or had difficulty finding things you needed at home or school)? DK
P7: Over the last 6 MONTHS, have you lost things necessary for certain tasks or activities Never Rarely Sometimes Often
(e.g. misplaced or had difficulty finding things you need at home or work)? DK
C8: As a CHILD, were you easily distracted by things going on around you (e.g. by noise or Never Rarely Sometimes Often
activities going on around you in the environment)? DK
P8: Over the last 6 MONTHS, have you been easily distracted by things going on around Never Rarely Sometimes Often
you (e.g. by noise or activities going on around you in the environment)? DK

C9: As a CHILD, were you forgetful in your daily activities (e.g. forgetting items you Never Rarely Sometimes Often
needed for activities or things you must do)? DK
P9: Over the last 6 MONTHS, have you been forgetful in your daily activities (e.g. Never Rarely Sometimes Often
forgetting items you needed for activities, forgetting appointments or meetings)? DK
C10: As a CHILD, did you fidget with your hands or feet or squirm about when sitting Never Rarely Sometimes Often
down (e.g. couldn’t sit still, wriggled in chair, fiddled with items, distracted others)? DK
P10: Over the last 6 MONTHS, have you felt restless or fidgety (e.g. unable to settle, Never Rarely Sometimes Often
fidgeting with hands, legs or feet, fiddling with items, distracting others)? DK

C11: As a CHILD, did you leave your seat in situations where you were expected to Never Rarely Sometimes Often
remain seated (e.g. in class, places of worship, the cinema, on public transport)? DK
P11: Over the last 6 MONTHS, have you left your seat in situations where you are Never Rarely Sometimes Often
expected to remain seated (e.g. in meetings at work, places of worship, the cinema)? DK
C12: As a CHILD, were you hyperactive (e.g. overly active, running in roads and corridors, Never Rarely Sometimes Often
climbing things without consideration for others or your own safety)? DK
P12: Over the last 6 MONTHS, have you felt restless or physically agitated inside (e.g. a Never Rarely Sometimes Often
constant need to be active, pacing, struggling to unwind, settle and relax)? DK

C13: As a CHILD, were you a noisy child who struggled to get on with activities quietly Never Rarely Sometimes Often
(e.g. could not settle and play quietly, talked or shouted out during quiet time)? DK
P13: Over the last 6 MONTHS, have you been a noisy person who struggles to get on with Never Rarely Sometimes Often
activities quietly (e.g. can’t settle, talk when watching TV or at the cinema)? DK
C14: As a CHILD, were you persistently active and ‘on the go’ (e.g. wherever you were or Never Rarely Sometimes Often
whatever you were doing, like a whirlwind, needing constant supervision)? DK
P14: Over the last 6 MONTHS, have you been persistently active, busy and ‘on the go’ Never Rarely Sometimes Often
(e.g. always busy, excessively driven, doing things at a frantic pace, can’t switch off)? DK

C15: As a CHILD, did you interrupt others who were speaking (e.g. impatiently blurting Never Rarely Sometimes Often
out thoughts or answers, not waiting your turn to speak)? DK
P15: Over the last 6 MONTHS, have you interrupted others who are speaking (e.g. talking Never Rarely Sometimes Often
over people, finishing their sentences, not waiting your turn to speak? DK
C16: As a CHILD, did you have difficulty waiting in turn when turn-taking was expected Never Rarely Sometimes Often
(e.g. waiting in line, waiting for your turn in sports, games or group situations)? DK
P16: Over the last 6 MONTHS, have you had difficulty waiting in turn when turn-taking is Never Rarely Sometimes Often
expected (e.g. waiting in line, at road junctions, in sports or games)? DK

C17: As a CHILD, did you interrupt or intrude on others (e.g. on conversations, the private Never Rarely Sometimes Often
space or activities of others, not adhering to social boundaries)? DK
P17: Over the last 6 MONTHS, have you interrupted or intruded on others (e.g. on Never Rarely Sometimes Often
conversations, private space or activities of others, not adhering to social boundaries)? DK
C18: As a CHILD, did you talk excessively even at times when this was inappropriate (e.g. Never Rarely Sometimes Often
persistent chattering, without constraint, dominating conversation)? DK
P18: Over the last 6 MONTHS, have you talked excessively even when this is Never Rarely Sometimes Often
inappropriate (e.g. persistent chattering, without constraint, dominating conversation)? DK
Thank you for completing ACE+SR - please check you have completed the rating for each
item (never, rarely, sometimes, often or don’t know).

ACEPLUS-SR English

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ACEPLUS-SR English

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ACE+SR: ACE+ Self-Report Rating Scale

Date of Completion: _____________________________

Date of Birth: _____________________________

Please provide as much information as possible, using a separate page if necessary.

© Psychology Services Limited: https://www.psychology-services.uk.com 1

© Psychology Services Limited: https://www.psychology-services.uk.com 2

© Psychology Services Limited: https://www.psychology-services.uk.com 3

© Psychology Services Limited: https://www.psychology-services.uk.com 4

© Psychology Services Limited: https://www.psychology-services.uk.com 5

© Psychology Services Limited: https://www.psychology-services.uk.com 6

© Psychology Services Limited: https://www.psychology-services.uk.com 7

© Psychology Services Limited: https://www.psychology-services.uk.com 8

© Psychology Services Limited: https://www.psychology-services.uk.com 9

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