Background: What is HEADSSS?
Adolescence is a challenging time when many emotional and physical changes take place. Most adolescents make it through their teenage years and enter adulthood without major trauma. However, for some teenagers this may be a very dangerous time of experimentation. Physicians play an important role in helping with this transition. Many physicians find it difficult to discuss sensitive issues with adolescents. HEADSSS is a screening tool to assess risks that can be used for all adolescents. It provides a systematic approach to the adolescent interview progressing from the least threatening topics to the most personal and sensitive subjects. The acronym stands for: Home, Education/Employment, Activities, Drugs, Sexuality, Suicide, and Safety. This interview format is flexible and can be catered to all adolescents.
Adolescents are very concerned about privacy and thus the failure to establish trust and rapport can create huge boundaries when interviewing. It is very important to outline the rules of confidentiality at the beginning of the interview to both adolescents and their parents and other caregivers. It is also essential that the adolescent understand that established confidentiality is not absolute. In circumstances where there is imminent harm to the patient or others such as suicide or homicide, confidentiality may be broken. A useful way to ensure patients understand confidentiality is to ask them to explain their understanding of confidentiality. This should be followed by your confidentiality statement. Also remember that it is very important to have some alone time with the adolescent in order to give the patient time to discuss topics that may be too sensitive or embarrassing to disclose in front of their parents.
Assumptions and Judgments
Physicians may have certain belief systems that may lead them to making assumptions about youth. It is extremely important not to make any assumptions and ask non-judgmental questions in order to build rapport and trust with the adolescent.
The HEADSSS interview
H = Home and Environment
Questions about home set the tone for the rest of the interview and are asked in order to establish whether or not the patient is living in a safe and supportive environment. You want to know how the patient feels about where they live and who they live with. If the patient is not living at home, you want to explore whether they are able to meet their basic life needs. If the adolescent does not have a place to live, it is suitable to ask if they are interested in referral to shelters and social work. As with all questions in the HEADSS interview attempt to make questions developmentally appropriate.
- Who lives at home with you? Where are you living?
- Are you happy with your living situation? Do you feel safe?
- Are your parents together? If not, where are they?
- Is there anything you would like to change about your family?
E = Education/Employment
Questions about home and employment are asked in order to discover whether or not the patient is in school and/or working. For youth in school, it is important to ask about their grade level and if it is age appropriate, the grades they receive, their friends at school and their overall view of school in general. For employment you want to obtain information on the type of work they do, their career aspirations, and if they enjoy work. If youth are not in school find out their education level, why they stopped going to school and if they plan on going back to school in the future.
- Are you in school? What grade are you in? How are your grades?
- What do you like best and least about school? What is your favourite subject?
- What do you want to do when you finish school?
- Do you work? Have you worked in the past?
- How do you get along with your teachers and employers?
Note that “E” can also stand for Eating and Exercise; questions about these topics should be asked if you suspect eating disorders.
A = Activities
Questions about activities are critical to building rapport and some of these questions may have been asked at the beginning of the interview. The goal of asking about activities is to understand day to day life of the adolescent. Ask youth about what they do for fun and how they spend their spare time. Asking about friends and social groups can reveal how socially integrated the teen may or may not be in addition to learning about risks associated with certain social groups.
- What do you do when you are not at school or working?
- Do you spend time with your family? What do you do?
- Do you have one best friend or a few friends? Who do you trust?
- Do you have any regular sports? Hobbies? What is your favourite music?
- Have you ever been involved with the police? Have you been charged?
D = Drugs
Questions about drugs and other substances may be difficult to ask about and it is often useful to start the discussion by normalizing the topic of substance use. For example, “Many teens I see have experimented with drugs and alcohol at some point. Have you?” You may also want to start by saying: “We always ask everyone these questions.” You want to find out how substance use has impacted the patient’s relationships, accomplishments and overall well being. If substance use is established it is important to determine the type of drug use as well as quantity and frequency. It is also useful to ask youth if they believe they have a problem with substance use and if so, if they would like help.
- When you go out to parties with your friends, do the people you hang out with drink alcohol or smoke? Do you? How often? How much?
- Have you or your friends ever tried any other drugs? What types?
- How do you pay for your alcohol, cigarettes, or drugs?
- Do you use any drugs regularly? Have you ever used a needle?
S = Sexuality
Most interviewers find sexuality the most difficult portion of the HEADSSS interview. This may be the first time an adolescent has ever openly disclosed their sexual feelings to anyone. The goal is to determine whether their sexual feelings and activity endanger their well being. Explore any risk taking behaviour such as lack of protection, number of partners and prostitution. It is important to discuss the patient’s feelings regarding their sexual identity. It may be helpful to review the limits of confidentiality at this point and then continue to ask about present and past sexual relationships.
- Have you ever been in a relationship? What was it like? How long?
- Have you ever had sex? When was the first time you had sex?
- Was it a good experience? Are you using contraception? What type?
- How many partners have you had? Have you ever been pregnant?
- What do you know about STDs and prevention?
- Has anyone ever tried to force you into anything sexual against your will?
- Do you have questions any about sex?
S = Suicide, Depression and Homicide
A common approach to suicide and depression are to ask general questions about past and present states of mind. However, it is also important to ask direct questions about suicide to determine if the patient is currently suicidal. Remember that adolescents who are depressed or suicidal may present differently from adults – changes in school performance, boredom, acting-out and health risk behaviours and decreased self-esteem. They may also appear “happy” on the surface but are actually experiencing depression and thoughts of suicide and/or homicide. Ask about sleeping patterns, eating habits, history of suicide attempts, depression, preoccupation with death, hopeless/helpless feelings and history of psychosocial/emotional trauma.
- Have you been depressed lately? What does being depressed mean to you?
- What do you do when you get depressed? Have you been hospitalized?
- Has anyone in your family ever been depressed? Committed suicide?
- Have you ever tried to hurt yourself? How?
- Have you ever felt like killing yourself? What happened?
- Do you feel suicidal now? Do you have a plan?
- Have you ever felt like hurting someone else?
S = Safety
It is important to ask questions regarding an adolescent’s safety at school, home and during his/her free time. Asking specifically about violence, driving under the influence of alcohol or drugs, and all forms of abuse are critical aspects of this section of the HEADSSS interview.
- Have you ever been seriously injured? How?
- Do you always wear a seatbelt in the car?
- Have you ever ridden in a car with someone who was drunk or high?
- Is there any violence in your home? In your school?
- Have you ever been picked on or bullied?
- Have you ever felt the need to carry a weapon to protect yourself?
It may also be useful to ask thought provoking questions such as: “If I could grant you any 3 wishes, what would they be?” or “If you could be any animal in the world, what would you be and why?” These questions can provide additional clinical information that can be important in developing a therapeutic plan. When ending the interview, it is also a good idea to ask them to sum up their life in one word or ask them what they see when they look in the mirror. Remember to acknowledge both positive and negative behaviours; adolescents enjoy been seen in a positive light and your interview will benefit from this positive reinforcement.
Keep in mind that HEADSSS is a risk assessment screening tool. Problems revealed during the interview must be followed up. Adolescents may be referred to individuals prepared to deal with these issues in greater depth if you are unable to. If the adolescent is involved in health risk taking behaviour, it is your job to help the patient understand that these behaviours are problems and that together you can develop strategies for dealing with them. Provide any educational material adolescents may benefit from. Finally, always give adolescents a chance to address any concerns that were not covered in the interview and remember to remind them they are welcome to come back at all times if they want to.
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H.E.A.D.S.S. – A Psychosocial Interview for Adolescents. www.bcchildrens.ca/NR/rdonlyres/6E51B8A4-8B88-4D4F-A7D9-13CB9F46E1D6/11051/headss20assessment20guide1.pdf
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Slotnick J. HEADSS Handbook. Division of Adolescent Medicine, Children’s Hospital of Los Angeles
Writer: Anne Marie Jekyll
Edited by: Jeff Bishop