The HEADSSS assessment is an internationally recognised tool used to structure the assessment of an adolescent patient, encompassing Home, Education/Employment, Activities, Drugs, Sex and relationships, Self harm and depression, Safety and abuse. The assessment starts with simple and easy questions about life to allow a rapport to be built, before delving into more personal and embarrassing aspects.
Adolescence is the transition period where a child becomes an adult. It encompasses the physical changes of puberty and the psychological and sociological changes associated with finding your identity and gaining independence from your parents/carers. It is difficult to attach an age category to this time period as different populations classify adolescence differently.
Adolescent medicine is a growing discipline in paediatrics1. The adolescent population (when defined as 10-20 year olds) in the UK is around 13-15% of the total population2, that’s approximately 8 or 9 million individuals. Where we have made staggering improvements in healthcare in infants and younger children, the same has not been achieved for adolescents1. It is an area where a lot of doctors, including paediatricians, can feel uncomfortable.
Communication must be adapted and it can be tricky to navigate ethical issues such as consent and confidentiality. The HEADSSS assessment is an internationally used tool to help give structure to an assessment of an adolescent patient.
Effectively communicating with adolescent patients takes time and building a rapport is essential. It can help to speak with the young person on their own. Before commencing a HEADSSS assessment, you should discuss confidentiality with the patient. You can assure them that you will keep your discussions confidential and only pass on information that they disclose without their permission if they or someone else is at risk of harm.3
This is a good way to start up a conversation and can gleam useful information; it gives you some idea of the social circumstances of the young person and involves questions that are not particularly probing to start building a rapport.
- Who lives at home?
- Do you have your own room?
- Do you fight with anyone at home?
- Is there anyone you particularly get on with?
- Who do they turn to when upset?
Education & Employment
Again, this can start with less intense questions about factual information and likes/dislikes then move into more personal areas, such as friendships and bullying.
- Do you go to school/college ?
- What subjects do you enjoy? What subjects don’t you like?
- Do you have a job? What sorts of hours do you work?
- What’s the best thing about working? What don’t you like so much?
- What would you like to do in the future?
- Who are your friends at school/work?
- Does anyone bully you?
This can be a great conversation starter and further build rapport. Try to know a bit about current movies/tv programmes/computer games/Youtubers/etc to share a little with the young person. Obesity is a growing problem in paediatrics so asking about physical exercise is a useful part of screening.
- What do you do in your spare time?
- How do you relax?
- What do you like doing with your friends?
- Do you participate in any sports/physical activity/exercise?
Drugs, smoking & alcohol
After asking the above questions, you should have started to develop a rapport and hopefully the young person may feel more comfortable answering some more probing questions. Using an opening statement can help encourage disclosure of sensitive information, for example, “some people around your age try smoking, alcohol or drugs, is this something you’ve experienced?”.
If they disclose that they are using any of the above substances, you can then ask more specific question to gauge their use and to elicit other pertinent information, such as who is supplying them with it. This is a particular concern in cases of suspected abuse, sexual exploitation, human trafficking or modern slavery. You can also at this point explore their understanding of the risks of taking these substances and if they have any motivation to quit.
- Some people your age try smoking, alcohol and drugs, is that something you’ve experienced?
- How much? How often?
- What does taking drugs/drinking alcohol do for you?
- Where do you get the money?
- Where/who do you get your drugs from?
- Does your alcohol use cause you any problems?
- Are you interested in cutting down or stopping?
- Is there anything I could do to help you with that? Would you like to see someone about that specifically?
Sex and relationships
Sexual health is a very large area of adolescent medicine and often gets overlooked as some doctors find it an uncomfortable question to ask. Equally, some young people are reluctant to talk to a professional about sex and relationships. It is important to be matter-of-fact and try not to show any embarrassment. If you remain relaxed and open, the young person will feel more confident in talking openly.
Try to be aware of your own assumptions and prejudices and use inclusive language whenever possible. This is another topic that can bring up examples of abuse, exploitation, human trafficking or modern slavery.
- Are you seeing anyone at the moment?
- Is that relationship with a boy or a girl?
- Some people your age start having sex, have you ever had sex?
- What contraception are you using?
- How do you handle intimate relationships? Do you feel pressure to go along with things that you’d rather not do?
- Does your partner give you things in exchange for sex or other physical acts?
Self-harm, depression and self-image
Depression in young people can be missed or misattributed to “mood swings” or “being a teenager”. The rates of suicide are increasing in adolescents4 and it is therefore important at this stage to address their mood.
- How is your mood at the moment?
- Do you ever feel sad or stressed? What do you do about that?
- What sorts of things make you feel low/sad/stressed?
- Have you ever thought about hurting yourself?
- Have you acted on those thoughts?
- Have you thought about ending your life?
Safety and abuse
It may not be necessary to ask every young person but is particularly important in cases of self-harm or substance misuse.
- Do you ever feel unsafe?
- Is there anyone in your life that you don’t feel safe around?
- Is anyone doing things to you that you don’t want them to? What sort of things?
- Does anyone put pressure on you to do things you don’t want to do?
- Is there anyone you can talk to about these things?
The assessment does not necessarily have to be completed in one sitting, it may take multiple conversations to build up the trust for the young person to disclose such personal information to you. Once a HEADSSS assessment is completed, it is important to document your findings in the notes and communicate appropriate information to other members of the healthcare team. Follow through on any offers of help or support you have made.
If concerns about the young person’s safety have been raised, you must explain to them that you need to pass that information on to the relevant agency. Reassure them that the main priority is their safety and establish what they will do in the meantime to help keep themselves safe.
|(1)||Payne D, Martin C, Viner R, Skinner R. Adolescent Medicine in Paediatric Practice. Archives of Disease in Childhood. 2005;90:1133-1137|
|(2)||Royal College of Paediatrics and Child Health. Bridging the gaps: healthcare for adolescents. Royal College of Paediatrics and Child Health, 2003.|
|(3)||Dr Damian Wood, Guideline for the use of the HEADSSS psychosocial assessment in young people. Nottingham Children’s Hospital Guidelines. Nottingham University Hospitals NHS Trust|
|(4)||McClure GM. Suicide in children and adolescents in England and Wales 1970–1998. Br J Psychiatry 2001;178:469–74.|
First draft: Dr Nicola Martin
Senior review: Dr Louise Ingram (Paediatric Specialist Registrar)