Introduction

Transitioning into adolescent hood is never easy and can be a rollercoaster ride. The period ranges from 12 to 18 years of age, which is the pubertal onset to being legally an adult and seen as independent in society. Generally, adolescents will be spending most of their transitioning at school, surrounded by classmates and friends, doing activities, being with families, et cetera. A lot happens during that transition, and teenagers have an increase in risk behaviours and psychological issues, which contribute to mortality and morbidity. Hence, when adolescents reach the healthcare system, it is imperative to do a HEADSS assessment as it is mostly opportunistically done.

More importantly, what is the HEADSS assessment? Written and spelt differently depending on the person doing it, the HEADSS (or HEEADSSSS) assessment is an easy mnemonic to screen the psychosocial factors of an adolescent. The age range has recently increased to 25 years of age as the HEADSS assessment is significant in young adults. The HEADSS framework is designed to start with less intimidating questions to highly personal questions. This strategy aids in engagement and completing a successful interview without the patient being overwhelmed too quickly by personal and intimate questions.

Remember that adolescents have the legal right to strict confidentiality, and reminding them of that fact is vital for a successful HEADSS assessment. For minors, use your best judgement to consider them as mature minors who can give reasonable and adequate informed consent.

HEEADSSSS

(H)ome

Start the HEADSS assessment by asking about their home situation. Focus on:

• Where do they live?

• Who is present at their home?

• What's the relationship with each member like?

• Have there been any recent changes? Such as new people or moves?

• Is it a stressful environment, or is there any violence?

(E)ducation & employment

• Where do they attend school (if they do attend school)? What grade do they attend, and how are they attendance to school?

• Ask what they enjoy at school and what they are good at. It is essential to look at what they have achieved and what they are proud of at school.

• Ask about their relationships with their teachers/colleagues. Is any bullying going on? If so, how are they coping?

• Are there any adults they can talk to at school about their feelings?

• Have there been any changes in grades?

• Have there been any disciplinary situations?

• What are their future plans after school?

• You can ask similar questions about their employment, such as where they attend, how their relationship with their boss/colleagues, performance, and so on.

(E)ating & exercise

• Ask about how the family eats at home. Does everyone eat together and how often, who are the cooks, is there a lot of variety?

• Ask if anyone is worried about their weight. You may prompt about if they are happy with their weight and how they see themselves. Have they noticed any recent changes? Have they tried any new type of diet?

• Ask if they enjoy sports, what is their favourite, and which are they best at? Get a history about their exercise and how often they do it.

• Take a menstrual history to complete.

(A)ctivities

Take some interest in what they enjoy as someone sharing their passion should always be appreciated.

• Ask what they like to do for fun in their spare time or any extracurricular activities outside of school.

• Are they involved in a club, organisation or part of a committee?

• Assess the amount of screen time spent on TV or other electronics.

• Who do they hang out with? What do they do together?

• Ask if their friends like to party, then prompt if they like to party.

(D)rugs & alcohol

A hot tip would be subtly set the scene before asking confronting questions. These could be said the following way: it's very typical for some young people your age to experience x, y, z. In your year, do people do x, y, z? Do you have any friends who do this too? What about yourself?

• Ask about their current medication usage.

• Does anybody in your family smoke cigarettes? Proceed to ask about cannabis and others. Elicit alcohol usage at home.

• Assess usage of recreational drugs such as marijuana, IV drugs, amphetamines and ecstasy. If so, find out how many times they use it, how much, how long, and how they afford it. Follow up on any regrets or negative consequences due to its usage.

(S)exuality & gender

The same approach can be used regarding sexuality and gender. If they are sexually active, the 5Ps method can be used to get a general sexual health history. See How to Take a Sexual Health History Efficiently and Effortlessly.

• Find out about their gender identity.

• Ask if they are in any romantic relationships.

• Ask about their sexuality and sexual experience, including previous STI(s) and screening, partners, practices, protection, previous pregnancies and pills.

• Ask about any uncomfortable situation and assess the possibility of sexual abuse.

(S)uicide, depression & self-harm

• It's a good start to ask about how they are currently feeling with a rating of 1-10. Elicit if they are stressed, feeling down, sad, and other feelings.

• You may want to follow up on how they are dealing/coping with those emotions. Do they have anybody they can trust and talk to about it? Find out how often they feel this way and for how long and intense these emotions are.

• Are they struggling to sleep? Are they being bullied which (includes online bullying)?

• Ask about suicide. Remember, you'll never know if you never ask; hence it is imperative to assess suicide risk. You may want to break the ice by saying that many people your age feel really down, and their way of coping is to harm themselves, some thinking of suicide and some going through the act of suicide. Have you ever felt this way? Have you tried to hurt yourself? You may want to elicit a coping response and ask what has prevented them from doing so. You may want to know how they are doing right now or if they have a plan in place. Finish by asking about their outlook on life and if they have any hope for the future.

(S)afety

Assess their safety and injury risk at home and school.

• Ask if there is any violence at home or in the community.

• Ask if they thought of carrying weapons to protect themselves.

• Assess their online safety.

• Mention that when using recreational drugs, unnecessary risks occur, such as drink driving. Have they been in a car with the driver under the influence of alcohol/drugs or have they been driving under the influence?

• What is their relationship with the justice system?

(S)trenght & spirituality

Get a sense of what they are good at and praise them for it. Too often, parents, teachers, and society focus on the weakness or faults of an adolescent and ignore their strengths.

• Ask how they would describe themselves.

• How would their best friend describe them?

• What do they excel at, or what interests them?

• Their relationship with religion, does the family go to a place of worship? What is their opinion on that subject?

• What are their beliefs?

• Who can they confide in, or who can they share happy/upsetting experiences with.

Performing the interview

Being prepared is critical in having a successful HEADSS assessment. Remember to be explicit about confidentiality and when it may be disclosed. Be nonjudgemental and avoid assuming and try personalised questions that come across as less intrusive. Parents can be asked about worries or concerns before leaving the consultation room. A guarding can be in the room at the beginning of the consultation and then dedicate time for the adolescent to be alone.

When examining, always have a chaperone present and ensure total privacy. If ever performing a Tanner staging, consider the adolescent to stage themselves with the help of picture staging. When done correctly and successfully, the HEADSS assessment can be fulfilling, especially when aiding adolescents into adulthood.

Take your time; the HEADSS assessment does not need to be done in one session, as many sessions can be done. Build rapport and document all findings. Follow up or refer if necessary.

Published 15th March 2022. Last reviewed 5th May 2022.

Reference

Dr Nicola Martin, Dr Louise Ingram. HEADSSS Assessment. Teach me Paediatrics website. https://teachmepaediatrics.com/community/holistic-care/headsss-assessment/. Updated July 24, 2018. Accessed May 15, 2022.

Headspace authors. Psychosocial assessment. Headspace website. https://headspace.org.au/professionals-and-educators/health-professionals/resources/psychological-assessment/. Accessed May 15, 2022.

Parker A, Hetrick S, Purcell R. Psychosocial assessment of young people: Refining and evaluating a youth friendly assessment interview. RACGP website. https://www.racgp.org.au/getattachment/9836132d-dcc3-4799-80e6-646c1fad212c/Psychosocial-assessment-of-young-people-refini-1.aspx. Updated August, 2010. Accessed May 15, 2022.

The Royal Children's Hospital Melbourne authors. Engaging with and assessing the adolescent patient. The Royal Children's Hospital Melbourne website. https://www.rch.org.au/clinicalguide/guideline_index/Engaging_with_and_assessing_the_adolescent_patient/. Updated September, 2019. Accessed May 15, 2022.