Background

Adolescence is generally a healthy life stage. However, death between the ages of 10–24 (2349 in 2014 in the UK) is often from preventable causes. Young men die more frequently than young women, and the major cause of death in this age group is road traffic accidents. Death from suicide is also a significant contributor, as is cancer. Adolescents have the highest mortality rate in the 0–24 age bracket when infants are excluded. Whereas boys between ages 15 and 24 are at a higher risk than girls of the same age.1 2

Adolescents have specific health and psychosocial needs that should be addressed at each consultation; ideally, directly with the young person, no longer through their parents such as in paediatric practice.3 It is also a time when life long health behaviours are set and mental health illnesses emerge (see figure 1).

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Figure 1

Structure of HEEADSSS interview.

This paper proposes the reviewed Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidal ideation and Safety (HEEADSSS) assessment as a gold standard in obtaining a developmentally appropriate psychosocial history from young people.4 5 The information gathered can then be used in order to provide appropriate support to the young person.

Introducing the interview

This psychosocial interview can be used in several ways. It can be used in its fuller format when there are concerns or known risk taking such as someone who has taken an overdose. It can also be used in clinics when seeing adolescents with chronic illness, in particular when there is non-adherence or poor disease management. It can be used in very much shortened form when time is constrained, merely asking how things are at home or school and each area. This also gives a message that you are there to talk about those things should the young person wish to confide in you at a later date.6

It is important to build a relationship of trust with the young person in order to foster rapport and encourage disclosure. Ice breaking, also termed ‘problem-free talk’, such as discussing hobbies and recent events, is important to show the adolescents that you value them as a person with interests and strengths, not just a patient.

It is important to make clear to both parent and patient that seeing the young person alone is routine and will allow them to start taking responsibility for their own health. These will not only increase independence for the teenager but encourage them to freely speak about their worries and health concerns.

A discussion about what confidentiality entails can be assumed once you are alone with the young person. State the circumstances in which you may need to break confidentiality such as if the young person is in danger or could put someone else at risk. It should also be clear that if we have concerns about their safety we would let them know to whom we would need to disclose and include them in the decision-making about who to tell and how.1 7 Use box 1 as a guide.

The interview

The interview is a structured opportunity to engage with the young person and learn about their identity, strengths and protective factors at an appropriate developmental level.4

The questioning style needs to be open to allow the young person to express themselves fluently. Guide questions have been suggested to each part of the interview and they should be used to either generally screen each section or go into more detail if indicated. The questions are aimed at guiding the interview. A brief scan of each area can subsequently be used whenever the adolescent is seen, offering a safe place to talk. The questions are provided as a guide to having a conversation where advice can be given when needed and appropriate next steps can be agreed with the young person when necessary.

Throughout the different sections it is useful to establish protective factors that make the young person resilient and able to deal with difficulties. It is also important to learn of characteristics of the individual that could put them at higher risk of harm8 9 (see box 2).

Home

The interview can begin with a discussion of the adolescents’ home and the environment where they live.

• Where do they live and with whom? How is life at home?

• Ask about people who are not in the home, for example, one of the parents, other important family members.

• Is there anyone new at home? Has someone left recently?

• Can you talk to anyone at home about stress? Who?

• Recent life events. Physical and social environment.

• Sleep pattern? Is sleep refreshing? What time to sleep? What time to wake up? Night waking?

• How often you stay awake past midnight? With whom?

• Do your friends stay up late? Night waking? Naps?

• Have you ever moved or had to live away from home? If so, why?

• Have you ever run away? (Why?)

• Is there physical violence at home? Have you taken part of or been victim of violence at home?

Education/employment

Prompt the young person to tell you about school/work life.

• Tell me about school? What school? What year?

• Is your school a safe place? Why/ how? Have you ever been bullied at school?

• Do you have a best friend, a group of friends or prefer your own company?

• Do you feel comfortable in your school? Do you feel as if you belong?

• Are there adults in school you could talk to about something important?

• Any special educational needs? What are your best subjects? Do you have any failing grades?

• Any recent changes?

• Tell me about how you see the future and what do you want to do?

• How are you going to achieve that? Any financial restraints?

Eating

Unhealthy eating habits are common in adolescence and can evolve into serious mental health conditions such as eating disorders. Discussing eating habits and nutrition, together with exercise, could help set up a healthier lifestyle.

• Does your shape or body cause you any stress? If so tell me about it …

• Have there been any recent changes to your weight?

• Have you dieted in the last year? How often? Ever taken dieting pills?

• Tell me about your exercise routine.

• What would you think is a healthy diet? How does that compare to your diet?

• What it would be like if you gained (lost) 10 lb?

• Does it ever seem like your eating is out of control?

• Do you ever make yourself sick?

Activities

Learning about things they enjoy doing with friends and family or alone will allow an understanding of their strengths and difficulties.

• What do you enjoy doing for fun? How do you spend time with friends? (With whom, where, when?)

• Many teenagers tell me they spend much of their free time online. What type of things do you use the internet and smart phone for? (see box 3)

• How many hours do you spend on a given day in front of a screen, computer, TV or phone?

• Do you participate in sport? What sport?

• What music do you listen to?

• What type of books you read?

• Do you regularly participate in religious or spiritual activities?

• Have you messaged photos or texts that you have later regretted?

• Can you think of a friend who was harmed by spending time online?

• How do you feel after playing video games? How often and how long do you spend playing video games?

Drugs

• Do any of your friends/family members smoke tobacco? Take drugs? Drink alcohol?

• Do you use tobacco or electronic cigarettes? Drugs? Energy drinks, steroids or other medications not prescribed to you?

• Is there any history of tobacco, alcohol or drug problems in your family?

• How did you start taking drugs/smoking/drinking alcohol?

• Do you ever drink or use drugs when you are alone? (assess frequency, intensity, patterns of use and abuse and how patient obtains or pays for drugs alcohol or tobacco) (see box 4).

Sexuality

This part of the interview is very private, thus might be difficult for the young person to engage in these questions. It is important they are treated with respect and you may choose to ask the young person permission to proceed. Questions such as ‘Do you mind if I ask you a few more personal questions …’ or … ‘This might be embarrassing but I ask these questions to all my teenage patients to make sure I can give best advice’ might be appropriate.

• Tell me about your sexual life. Or …  Are you attracted to anyone now?

• Are you interested in boys? Girls? Both? Or you are not yet sure?

• Have you ever been in a sexual relationship? Tell me about the people you’ve dated.

• Concerns about sex (pregnancy, sexually transmitted disease) contraception menstruation.

• Are your sexual activities enjoyable?

• Have any of your relationships been violent?

• What does the term ‘safe sex’ mean to you?

• Have you ever been touched or forced into sexual activities that you didn’t want?

• How did you feel afterwards? Are you still in contact with this person? Have you told anyone?

Suicide/low mood

Young people are more likely to admit stress and anxiety than symptoms of depression. Mental health disorders often have its onset during adolescence.

• Do you feel stressed or anxious more than usual?

• Do you feel sad or down more than usual?

• Are you bored a lot?

• Are you having trouble going to sleep?

• Have you thought about hurting others or yourself?

• Tell me about the time that someone picked on you or made you feel uncomfortable online.

• Tell me about a time where you felt sad while using social media like Facebook.

• Does it seem like you lost interest in things that you used to enjoy?

• Do you find yourself spending less time with friends? You rather just be by yourself?

• Have you ever tried to kill yourself?

• Have you started to use drugs or alcohol to make you feel better?

Table 1 can be used as a screening tool.

Safety

Morbidity and mortality in this age group is mainly from injuries, suicide and homicide. It is important to assess how the patient copes with danger and what strategies they have to cope with high-risk environments and behaviours.

• Have you ever been seriously injured in a car accident? How about anyone you know?

• Do you always wear a seat belt in the car?

• Have you ever met in person with anyone whom you first met online?

• When was the last time you sent a text message while driving?

• Tell me about the last time you have ridden with a driver that was drunk or high. When? How often?

• Is there violence in your school? In your neighbourhood? Among your friends? Within your couple?

• Have you ever been in prison?

• Do you use safety equipment for sports and/or other physical activities?

• Have you ever been picked on or bullied? Is this still a problem?

• Do you or have you into a physical fight at school or your neighbourhood? Are you still getting into fights?

• Have you ever felt that you had to carry a knife, gun or other weapon in your pocket to defend yourself? Do you still feel this way?

Wrap-up the interview

It is useful to sum up and reflect back to show you have understood them with the positive factors as well as the difficulties.5 The discussion can be very therapeutic.

To end the interview, check the young person has someone in whom they can confide if they have a problem. Let the young person know that you are here and they can come back to you if they need further advice. Direct the young person to the appropriate services if they need sexual health, psychology or other professional’s advice.

It is important to realise that you cannot get all this information in a very short consultation and you might need to explore different aspects of the young person’s psychosocial situation in further encounters. What is important is to gather as much information as possible, while listening and prioritising the major difficulties for the adolescent.4

Summary

Taking time to talk to young people independently is a very useful way to screen for risk factors and offer them the advice that would be most helpful. Empowering young people to take responsibility for their health will allow them to use the appropriate health services and lead healthier lives.4 5

Talking freely about their real concerns and gaining a clear understanding of their needs is paramount for young people. Once the standard is set to obtain a psychosocial history routinely, it becomes easier for the health professional to build bridges with this large group of patients and to help keep them safe from preventable causes of mortality and morbidity.1