HEEADSSS

HEEADSSS 3.0
The psychosocial interview for adolescents
updated for a new century fueled by media
DAVID A KLEIN, MD, MPH; JOHN M GOLDENRING, MD, MPH, JD; AND WILLIAM P ADELMAN, MD

The HEEADSSS psychosocial interview is a practical, time-tested

strategy that pediatricians can use to evaluate how their teenaged
patients are coping with the pressures of daily living, especially now in
the context of electronic and social media.

F
or most teenagers, a psychosocial history is at implicated in deadly motor vehicle crashes in the
least as important as the physical exam. This age group. In fact, unintentional injuries, homicide,
essential psychosocial history can be obtained and suicide are among the leading causes of adoles-
using the HEEADSSS method of interviewing cent deaths in the United States, and are the top 3
adolescents. The HEEADSSS interview focuses on causes for those aged 15 years and older.3
assessment of the Home environment, Education Moreover, consequences of adolescents’ stressors
and employment, Eating, peer-related Activities, may include obesity, eating disorders, depression, or
Drugs, Sexuality, Suicide/depression, and Safety other mental health problems. These issues are not
from injury and violence (Table 1).1,2 easily identified or addressed using a strictly physi-
Because adolescence is a time of growth and ologic orientation.
development when threats to health can arise, these Without an adequate psychosocial history, one is
threats are often related to physical and social explo- unlikely to spot problems early enough to signifi-
ration. For example, sexual exploration may lead cantly reduce adolescent morbidity and mortality.
to sexually transmitted infections or unintended The HEEADSSS interview is a practical, time-tested
pregnancies. Experimentation with drugs or alcohol strategy that physicians can use to obtain a “psycho-
is another cause of morbidity and mortality that is social review of systems” for adolescent patients.

DR KLEIN is an adolescent medicine fellow, Department of Pediatrics, San Antonio Military Medical Center, Fort Sam Houston, Texas.
DR GOLDENRING is an adolescent medicine specialist, medical director, and a medical-legal consultant, Oceanside, California. DR ADELMAN
is an adolescent medicine specialist and associate professor, Department of Pediatrics, Uniformed Services University of the Health Sciences,
Bethesda, Maryland. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as
reflecting the views of the US Air Force, the US Army, or the US military at large. The authors have nothing to disclose in regard to affiliations with or
financial interests in any organizations that may have an interest in any part of this article.

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 Since the second version of HEEADSSS was cre-
ated in 2004, nearly all teenagers have obtained DISCUSSING CONFIDENTIALITY
access to the Internet and three-quarters of them
use cell phones and send text messages.4-7 This uti- You may say, for example: “During this visit, I’ll ask you
lization of media profoundly affects the lives of some very personal questions to best help you. I promise that
adolescents; media may now contribute to 10% to whatever you say will be kept private between us, and not
20% of any specific health problem.7 Thus, questions be passed along to your parents or anybody else outside this
office, unless you give permission.”
on new media use are critically important and are
included in this HEEADSSS 3.0 update. In addition, Clinicians may end the introduction with:
this update emphasizes a strengths-based approach “The only exception would be in a circumstance in which a
to the adolescent interview to foster patient- disclosure to someone is required by law.” Some specify the
physician rapport and successful interventions. circumstances (eg, the patient is planning to kill or seriously
injure himself or someone else; or the patient is experiencing,
or is planning to commit, physical or sexual abuse or neglect).
How to use the psychosocial screen
You should begin spending time alone with your Other clinicians prefer a nonqualified ending:
patients at whatever age they first exhibit the “If you tell me something that is so bad for your health that
psychosocial changes associated with puberty. I think it is best to get somebody else involved in your care,
Generally, it is preferable to conduct the psycho- like a parent or another doctor, I will tell you that. If you
social interview when the adolescent is relatively disagree, then together we can discuss the way to proceed.”
This method reinforces the strength of the physician-patient
well.8 Nonetheless, situations of crisis or illness may
relationship.
sometimes facilitate effective history taking because
vulnerability may foster trusting relationships. At Each physician must determine what limits on confidentiality
every visit, the adolescent should be assessed for are prescribed by the laws of the particular state in which the
new stressors and overall well-being. physician practices.a State-by-state confidentiality guidelines
are available from the Guttmacher Institute (www.guttmacher.
org) and from the National Center for Adolescent Health and
Working with parents Law (www.adolescenthealthlaw.org).
If the parents are present, first introduce yourself to
the adolescent to make clear that the teenager is the REFERENCE

patient. Then try having the adolescent introduce a

Guttmacher Institute. State policies in brief. An overview of minors’
consent law. http://www.guttmacher.org/statecenter/spibs/spib_
the other people in the room. Parents, family mem- OMCL.pdf. Updated December 1, 2013. Accessed December 4, 2013.
bers, or other involved adults should not be present
during the HEEADSSS interview because a parent’s
presence is likely to limit how much sensitive infor- Making a good beginning
mation the patient will provide. Allowing a parent Starting the interview with nonthreatening conver-
to sit in on the interview also makes it more difficult sation about the patient’s hobbies or current events
to exclude him or her at subsequent visits when the may help to ease anxiety, foster rapport and trust,
patient may have more private issues to discuss. and encourage disclosure. Then you might say: “I
This does not mean that parents should be would like to take a few minutes to see how you
ignored. Before asking adults to leave the room, are handling stress and whether your behaviors are
always ask whether they have any concerns and safe.”10,11 Once young people start talking, they are
assure them of further interaction once the inter- likely to keep talking. You will succeed better, how-
view is over. Be certain to explain the purpose, such ever, if you explain the concept and limitations of
as: “We speak privately with our patients about confidentiality as part of this initial conversation.12,13
stressors that may appear during adolescence so (See “Discussing confidentiality,” above.)
they can practice taking responsibility for their The beauty of HEEADSSS is that by using the
health care needs.” With explanation, adults accept acronym, you can naturally proceed from very
the need for confidential care.9 important but usually less threatening questions

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Table 1 The HEEADSSS psychosocial interview for adolescents

Questions if time permits or
Potential first-line questions if situation warrants exploration

Home Who lives with you? Where do you live? Have you moved recently?
What are relationships like at home? Have you ever had to live away from home? (Why?)
Can you talk to anyone at home about stress? (Who?) Have you ever run away? (Why?)
Is there anyone new at home? Has someone left recently? Is there any physical violence at home?
Do you have a smart phone or computer at home? In
your room? What do you use it for? (May ask this in the
activities section.)

Education Tell me about school. How many days have you missed from school this month/
and Is your school a safe place? (Why?) Have you been quarter/semester?
employment bullied at school? Have you changed schools in the past few years?
Do you feel connected to your school? Do you feel as if Tell me about your friends at school.
you belong? Have you ever had to repeat a class/grade?
Are there adults at school you feel you could talk to Have you ever been suspended? Expelled? Have you ever
about something important? (Who?) considered dropping out?
Do you have any failing grades? Any recent changes? How well do you get along with the people at school? Work?
What are your future education/employment plans/ Have your responsibilities at work increased?
goals? What are your favorite subjects at school? Your least favorite
Are you working? Where? How much? subjects?

Eating Does your weight or body shape cause you any stress? If What do you like and not like about your body?
so, tell me about it. Have you done anything else to try to manage your
Have there been any recent changes in your weight? weight?
Have you dieted in the last year? How? How often? Tell me about your exercise routine.
What do you think would be a healthy diet? How does that
compare to your current eating patterns?
What would it be like if you gained (lost) 10 lb?
Does it ever seem as though your eating is out of control?
Have you ever taken diet pills?

Activities What do you do for fun? How do you spend time with Do you participate in any sports?
friends? Family? (With whom, where, when?) Do you regularly attend religious or spiritual activities?
Some teenagers tell me that they spend much of their Have you messaged photos or texts that you have later
free time online. What types of things do you use the regretted?
Internet for? Can you think of a friend who was harmed by spending time
How many hours do you spend on any given day in online?
front of a screen, such as a computer, TV, or phone? Do How often do you view pornography (or nude images or
you wish you spent less time on these things? videos) online?
What types of books do you read for fun?
How do you feel after playing video games?
What music do you like to listen to?

Drugs Do any of your friends or family members use Is there any history of alcohol or drug problems in your
tobacco? Alcohol? Other drugs? family?
Do you use tobacco or electronic cigarettes? Does anyone at home use tobacco?
Alcohol? Other drugs, energy drinks, steroids, or Do you ever drink or use drugs when you’re alone?
medications not prescribed to you? (Assess frequency, intensity, patterns of use or abuse,
and how patient obtains or pays for drugs, alcohol, or
tobacco.)
(Ask the CRAFFT questions in Table 5, page 25.)

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Questions if time permits or

Potential first-line questions if situation warrants exploration

Sexuality Have you ever been in a romantic relationship? Tell Are your sexual activities enjoyable?
me about the people that you’ve dated. Have any of your relationships been violent?
Have any of your relationships ever been sexual What does the term “safer sex” mean to you?
relationships (such as involving kissing or Have you ever sent unclothed pictures of yourself on
touching)? e-mail or the Internet?
Are you attracted to anyone now? OR: Tell me Have you ever been forced or pressured into doing
about your sexual life. something sexual that you didn’t want to do?
Are you interested in boys? Girls? Both? Not yet Have you ever been touched sexually in a way that you
sure? didn’t want?
Have you ever been raped, on a date or any other time?
How many sexual partners have you had altogether?
(Girls) Have you ever been pregnant or worried that you
may be pregnant?
(Boys) Have you ever gotten someone pregnant or
worried that might have happened?
What are you using for birth control? Are you satisfied
with your method?
Do you use condoms every time you have intercourse?
What gets in the way?
Have you ever had a sexually transmitted infection or
worried that you had an infection?

Suicide/ Do you feel “stressed” or anxious more than usual Tell me about a time when you felt sad while using
depression (or more than you prefer to feel)? social media sites like Facebook.
Do you feel sad or down more than usual? Does it seem that you’ve lost interest in things that you
Are you “bored” much of the time? used to really enjoy?
Are you having trouble getting to sleep? Do you find yourself spending less time with friends?
Have you thought a lot about hurting yourself or Would you rather just be by yourself most of the time?
someone else? Have you ever tried to kill yourself?
Tell me about a time when someone picked on you Have you ever had to hurt yourself (by cutting yourself,
or made you feel uncomfortable online. for example) to calm down or feel better?
(Consider the PHQ-2 screening tool [Table 6, page Have you started using alcohol or drugs to help you
26] to supplement.) relax, calm down, or feel better?

Safety Have you ever been seriously injured? (How?) How Do you use safety equipment for sports and/or other
about anyone else you know? physical activities (for example, helmets for biking or
Do you always wear a seatbelt in the car? skateboarding)?
Have you ever met in person (or plan to meet) with Have you ever been in a car or motorcycle accident?
anyone whom you first encountered online? (What happened?)
When was the last time you sent a text message Have you ever been picked on or bullied? Is that still a
while driving? problem?
Tell me about a time when you have ridden with a Have you gotten into physical fights in school or your
driver who was drunk or high. When? How often? neighborhood? Are you still getting into fights?
Is there a lot of violence at your home or school? In Have you ever felt that you had to carry a knife, gun, or
your neighborhood? Among your friends? other weapon to protect yourself? Do you still feel that
way?
Have you ever been incarcerated?

Abbreviations: CRAFFT, Car, Relax, Alone, Forget, Friends, Trouble; HEEADSSS, Home, Education and employment, Eating, Activities,
Drugs, Sexuality, Suicide/depression, Safety; PHQ-2, Patient Health Questionnaire 2.
Adapted from Goldenring JM, et al1; Goldenring JM, et al.2

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first screening for markers of strength and resiliency

Table 2 Characteristics of resilient to use throughout the rest of the visit (Table 2).1,10,14
teenagers Consider: “To help me get to know you, tell me
Home Connected, caring parents or family
something about yourself that makes you proud” or
members “Tell me how your friends describe you.”10 This may
Acceptance of responsibility be postponed when patients are anxious to address
Chores their psychosocial concerns; however, positive fac-
Care of siblings or other relatives tors may mitigate risks or point to productive inter-
Education and Better than average school performance ventions or an improved outlook.10,11,14
employment Feelings of connection to school While counseling about risks you have uncov-
Limited employment (<20 hr/wk) ered, be certain to assess the patient’s readiness to
Strong participation in extracurricular, change, the context of the patient’s situation, oppor-
school-related activities, including sports
tunities to praise the patient for significant accom-
Activities Leadership among peers plishments or avoiding risks, and implementation
Religious affiliation of patient-created solutions and coping strategies
Drugs Pledge to abstain (Table 3).1,10,14
Refusal skills
Consider starting at Home
Sexuality Pledge to abstain
Questions about the teenager’s home environment
Refusal skills
Consistently responsible sexual behavior
are generally expected and are a good beginning
for the psychosocial interview. Instead of making
Suicidality No personal history of attempted suicide assumptions, ask open-ended questions if possible
No family history of attempted or
accomplished suicide
(Table 4).1 It is a mistake, for example, to say “Tell
Access to a confidant me about your mom and dad,” which assumes that
Successful coping skills the patient lives with 2 parents and that the parents
Substance free are of different genders. Rather, start by asking
“Where do you live?” or “Tell me about your living
Safety Seat belt and helmet use
Conflict resolution skills situation.” Then ask: “Who lives with you?” These
Substance free questions allow the adolescent to describe what is
Refusal to ride in cars with potentially most important in his or her home setting.
intoxicated driver Proceed by asking what relationships are like at
Goldenring JM, et al1; Ginsburg KR10; Resnick MD, et al.14 home and whether there has been a recent change:
moving, running away, divorce, or having someone
join or leave the household. Such events are often
to those most often considered highly personal. extremely stressful to teenagers, who prefer a stable
Nothing about the HEEADSSS interview, however, environment in which to undertake the develop-
including the order of questioning should ever be mental tasks of adolescence, such as separating from
treated rigidly. Although teenagers typically feel parents, connecting with peers, and developing a
comfortable progressing in the order of the acro- positive self-image.
nym, be aware of clues from the chief complaint Because media-related morbidity can be reduced
or previous interactions that would modify your by enlisting parental supervision, it is important to
approach. For example, the home environment may screen for the patient’s home use (especially bed-
be much more stressful to some adolescents than room use) of computers, TVs, video games, smart
any issues they may have about sexuality. phones, or other media devices.7 (See “Screening for
Remember to search for the patient’s strengths media use and misuse,” page 24.)
because positive attributes suggest the presence of It is extremely useful to ask in whom the teen-
resilience. 8,10,11 In fact, some experts recommend ager trusts to confide. Connection to supportive

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questioning. Instead, try asking: “Tell me about

Table 3 A strengths-based approach school. What do you like about it, and what don’t
you like?”
When talking to adolescents, search for positives in the
Search for the patient’s degree of connectedness
history. Approaches based on risk factors alone may
induce feelings of shame and deter patient engagement.
to the school and education; high connectedness
It also sets low expectations—absence of risk factors predicts lower rates of substance use, early sexual
does not equate to success. Here are some tips: initiation, violence, school absenteeism, and other
causes of adolescent morbidity.14 Connectedness

1 Identify strengths early so that they can be “built

on” when motivating the patient to change or when
encouraging ongoing success. An alternative acronym,
is specifically increased not only by educational
commitment and adult mentorship but also by peer
SSHADESS, accounts for this strategy.10 group belonging and a safe environment.15 Be cer-
tain to inquire about involvement in extracurricu-

2 Look for examples of past difficulties that your

patient has successfully overcome. The ability to
adapt to and overcome adversity is known as resilience and
lar activities and occurrences of bullying.
Ask specifically about academic performance
is highly protective against a wide range of bad outcomes. (generally measured by grades). Declining academic
performance correlates highly with psychosocial

3 Praise when praise is warranted! Many adolescents,

especially those at high risk, never hear any praise
from adults!
problems, such as drug use or suicide risk, and
may indicate an underlying learning or attention
disorder.

4 Use reflective listening and pause. This allows

the teenager time to confirm and expand on his or
her thoughts.
When an adolescent lives in a high-risk environ-
ment, begin the school section of the interview by
ascertaining whether he or she regularly attends

5 Create a comfortable, trusting, nonjudgmental

setting that communicates respect. Consider: “I
want you to feel comfortable coming to me for health
school. In some inner-city areas, the absentee-
ism rate for teenagers ranges from 15% to 40%.16
It also may be helpful to check how many schools
information and comfortable telling me what is going on and new sets of friends the student has adapted to
in your life.”
in recent years. This is particularly important in

6 Share your concerns. It is acceptable to gently

challenge your patient by saying, for example, “I’m
worried that daily marijuana use may be a barrier to your
military families for whom moving is often a way
of life.17
The older the teenager, the more you should
achieving your goal of serving in the military.”
expect him or her to have some plans for future
Abbreviation: SSHADESS, Strengths, School, Home, Activities, Drugs/substance education or employment. Ask teenagers who are
abuse, Emotion/depression, Sexuality, Safety.
Goldenring JM, et al1; Ginsburg KR10; Resnick MD, et al.14
employed part time whether the work is intru-
sive and if economic circumstances necessi-
tate it. Working more than 20 hours a week has
adults—parents or others—is highly protective been associated with negative outcomes of emo-
against many health risks and high-risk behaviors.14 tional distress and substance use.14 When inter-
It is also important to remember to praise solid rela- viewing adolescents who are employed full time,
tionships with adults and assumption of responsi- inquire about their strengths and weaknesses on
bilities at home. the job, satisfaction level, nature of relationships
at work, goals, and recent or frequent changes
E is for Education and Employment in employment.
Most young people expect questions about their Again, remember to look for and praise successes
education and are seldom threatened by them. A at school and at work. Such successes include not
common error is to ask “How are you doing in only academic ones but also leadership and achieve-
school?” Invariably, the patient will simply ment in extracurricular school activities or in
answer “fine” or “good,” necessitating additional the workplace.

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Table 4 Opening lines, poor and better

Category Poor Better
“Do you get along with
Home “Where do you live and who lives there with you? (No assumptions made.)
your mom and dad?”

“How are you doing in “Tell me about school.” OR: “What do you enjoy about school? What do you
Education
school?” dislike? (Open-ended; harder to answer “OK.”)

“Tell me what you think about your weight and shape.” OR: “Tell me about
Eating “What do you eat?”
what you like and don’t like about your body.” (Open-ended; can’t answer “OK.”)

“Do you have any

Activities “What do you and your friends like to do for fun?” (Open-ended.)
activities outside school?”

“What kinds of drugs have you seen around your school or at parties?” OR: “Do any of
Drugs “Do you use drugs?”
your friends use drugs or alcohol?” (Less personal; eases into a difficult discussion.)

“You told me you’ve been going out with Steve for the past 3 months. Has
Sexuality “Have you ever had sex?” your relationship become sexual?” (Context makes question seem less
intrusive.) OR: “Are you attracted to anyone currently?” (Nonjudgmental.)
From Goldenring JM, et al.1

E is also for Eating any stress? If so, tell me about it.” Then follow with
Adolescents often have unhealthy eating habits, specific questions about diet, eating habits, nutri-
and the prevalence of obesity and eating disorders tional knowledge and beliefs, and pathologic dieting
continues to increase, so questions about nutri- behaviors. Remember how much eating and exercise
tion are important. Aim to help all adolescents behaviors are influenced by genetic inheritance and
develop healthy eating (and exercise) habits that can by behavior modeled in the family or media. In 2010,
be maintained over a lifetime. there were at least 100 easily discoverable pro-anorexia
Obesity, which greatly increases the likelihood of websites encouraging and guiding disordered eating
developing diabetes and heart disease, is now clearly behaviors.21 Media “apps” for calorie counting are
recognized to begin in childhood and adolescence.18 widely available and these can be used to increase
Sedentary adolescents often snack continually health and/or contribute to pathologic behavior.
during the time that they spend in front of media Remember, of course, to praise good diet and
devices, compounding their risk. Simple strategies, exercise choices whenever you find them.
such as recommending appropriate portion sizes,
eliminating sugared soda and fast food, and limiting Looking at peer-related Activities
screen time, can be helpful in improving adolescent When adolescents or young adults are not at home, in
eating habits and overall health.7,19 school, or at work, they tend to be with their peers. As
Physicians should also attempt to identify ado- a prelude to more sensitive HEEADSSS questions, it
lescents whose eating habits may signal body image is wise to have the patient tell you about what things
or self-esteem problems, psychologic distress, or he or she really enjoys. Adolescents derive much of
depression. Frequent dieting, compulsive exercise, their identity and self-esteem from peer activities.
and purging are all of concern. At least half of nor- Begin by asking: “Tell me what you do with your
mal-weight young women surveyed in the United friends” or “What do you do for fun?” Be concerned
States believe they are overweight.20 about teenagers who cannot readily name friends
Use this question, for example: “As I ask all my or describe their activities beyond “hanging out.”
patients—does your weight or body shape cause you They may be at higher risk than teenagers who

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talk about specific activities with friends, such as

SCREENING FOR MEDIA sports, dancing, hobbies, games, or even shopping.
USE AND MISUSE Adolescents who say they are “bored all the time”
may be depressed.
Improved media access can lead to positive, prosocial Ask teenagers about the nature and quantity of
outcomes such as empathy, acceptance of diversity, social their use of television, computers, video games,
group acceptability, and respect for the elderly.a.b Clinicians and mobile media devices. Nearly one-third of high
are now also faced with identifying how the concerning
school students surveyed in a large nationwide study
aspects of the media age—cyberbullying, sexting, driving
while texting, online solicitation, Internet addiction (eg, played video or computer games for 3 hours or lon-
video games), and media-related depression (eg, Facebook ger on the average school day.22 You may uncover a
depression), to name a few—are affecting virtually every lack of parental connection and control, an avoid-
aspect of adolescent patients’ psychosocial and physical well- ance of homework or family/peer interaction, or
being. addictive behavior. Seek the specifics when inter-
Adolescents now spend 7 to 11 hours per day with different viewing an adolescent who endorses constant text
media, far from the maximum 1 to 2 hours typically messaging or social media posting. This behavior
recommended.a One quarter of teenagers are “cell-mostly” may be detrimental (eg, leading to sexting, texting
Internet users, stating that they mostly go online from
while driving, or media-related depression) and/or
their cell phones.c This suggests an unprecedented level of
unsupervised Internet access. One-quarter of adolescents it may be protective (as when used to connect with a
experience electronic bullying and one-third text while health peer group that is otherwise unavailable).
driving.d,e Those bullied online are more likely to report
pervasive fear (in multiple environments) than those On to Drugs
traditionally bullied.f In addition, pornography is available The drug history is sensitive. For patients in early
by typing a few key words into a search engine. Failing to
identify associated risk behaviors will miss opportunities to
adolescence, approach the topic obliquely: “We talked
improve health outcomes. about what you and your friends do to have fun.
Do any of your friends use drugs or alcohol (or get
Try to add “media” or “Internet” literacy in discussion
drunk or high)?” Young adolescents who would not
with parents and patients. This can include topics such
as co-viewing to foster communication and accurate readily talk about their own drug or alcohol use are
interpretation of content, as well as setting limits (eg, parental often very willing to tell about such behavior by their
controls, time using media, or access to media in one’s friends. Next you might ask: “Tell me about a time
bedroom). that you felt pressured by friends to use drugs or alco-
R E F E R E N C E S hol, if any.” The answer may lead to a discussion of
specific circumstances and types of substances tried.
a.
  S trasburger VC, Jordan AB, Donnerstein E. Children, adolescents, and
the media: health effects. Pediatr Clin North Am. 2012;59(3):533-587. You may be able to ask older adolescents about
b.
  Donnerstein E. The Internet. In: Strasburger VC, Wilson BJ, drugs more directly. To elicit the most information,
Jordan AB. Children, Adolescents, and the Media. 3rd ed. Thousand
Oaks, CA: Sage; 2013.
you need to know the latest trends of substance use
c.
  Madden M, Lenhart A, Duggan M, Cortesi S, Gasser U. Teens and within the patient’s specific community. Substances
Technology 2013. Washington, DC: Pew Internet & American Life used may include, for example, new synthetic can-
Project; 2013. http://www.pewinternet.org/Reports/2013/Teens-
and-Tech.aspx. Accessed December 4, 2013. nabinoids, caffeine-containing energy drinks, ana-
d.
  Nielsen Co. State of the media: TV usage trends: Q3 and Q4 2010. bolic steroids, and prescription medications such as
New York: Nielsen Co; 2011. http://www.nielsen.com/us/en/re-
ports/2011/state-of-the-media-tv-usage-trends-q3-and-q4-2010.html. opioids, benzodiazepines, and stimulants.
Accessed December 4, 2013. Also, ask specifically about tobacco and ciga-
e.
  Lenhart A, Ling R, Campbell S, Purcell K. Teens and mobile phones.
Washington, DC: Pew Internet & American Life Project; 2010. http:// rettes, including electronic cigarettes (inhaled doses
pewinternet.org/~/media/Files/Reports/2010/PIP-Teens-and- of nicotine), because many teenagers do not con-
Mobile-2010-with-topline.pdf. Accessed December 4, 2013.
f.
  Hatzenbuehler ML. The social environment and suicide attempts in
sider chewing tobacco or smoking to be a form of
lesbian, gay, and bisexual youth. Pediatrics. 2011;127(5):896-903. drug use. Be sure to find out whether the adolescent
drives while under the influence of drugs or alcohol
and/or rides with drivers who are intoxicated.

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Explaining harms—without also evaluating

readiness to change, acknowledging perceived ben- Table 5 The CRAFFT questions
efits to substance use, using motivational inter-
Two or more “Yes” answers suggest high risk of a serious
viewing techniques, and establishing trust and substance-use problem or a substance-use disorder.
rapport—will likely not suffice to induce behav-
ioral change. CRAFFT (Car, Relax, Alone, Forget,
Friends, Trouble) is a brief, validated, office-friendly C Have you ever ridden in a Car driven by someone who
was high or had been using drugs or alcohol?

screening test useful in initially assessing the sub-

stance-using teenager (Table 5).23
R Do you ever use alcohol or drugs to Relax, feel better
about yourself, or fit in?

The goal of obtaining a drug history is usually to

have the adolescent reveal the nature of problematic
A Do you ever use drugs or alcohol when you are
Alone?

substance use to his or her parents or guardians

(with your facilitation, if the patient desires) so that
F Do you Forget things you did while using drugs or
alcohol?

these caregivers can provide the patient with a more

robust support system and foster additional treat-
F Do your family and Friends ever tell you that you
should cut down your drinking or drug use?

ment. Alternatively, substance use can remain con-

fidential as long as there is no clear and immediate
T Have you ever gotten into Trouble while using drugs
or alcohol?

threat to the patient. Abbreviation: CRAFFT, Car, Relax, Alone, Forget, Friends, Trouble.
Knight JR, et al.23

Sexuality
The sexual history may be the most sensitive part contraception, and sexually transmitted infec-
of the interview. It may benefit rapport to seek per- tions, given that many teenagers use the Internet
mission before proceeding: “Do you mind if I ask and social media as their primary sex educators.
you a few more personal questions to learn how I You might add: “Many people do not have any-
can best assist you?” It is also helpful to expressly one knowledgeable to talk to about sex. We’re
acknowledge the discomfort most patients feel about always happy to answer any questions you have.”
discussing this topic. Say, for example: “I know that And remember, adolescents may forgo contracep-
this may be embarrassing for you, but I ask these tive or reproductive services if they think (rightly or
questions of all my teenaged patients to make sure I wrongly) that parental notification is mandatory.12,13
can give my best advice.” Do not assume that adolescents who are having
Especially with younger adolescents, you might sexual experiences are comfortable about it. You
observe: “Tell me about any of your friends who are may say: “Some of my patients tell me they feel pres-
starting to be in romantic relationships.” To older sured or coerced into having sex. Have you ever felt
adolescents, simply say: “Tell me about any romantic this way?” Sometimes, you can serve as a trustwor-
relationships you’ve been involved in.” The open- thy adult who gives adolescents permission to avoid
endedness of such questions allows adolescents to sexual activity until they are more comfortable with
tell whether they are having relationships with peo- engaging in it. A history of abuse (if any) may not
ple of the same sex, the opposite sex, or both. come out in the first interview, but the very fact that
From asking about relationships, it is a short step you show interest establishes rapport and may lead
to asking about sexual relationships: “Since sex- the patient to reveal the facts at a later time.
ual activity can affect your health, please tell me In today’s Internet-linked world, sexual materi-
whether any of your relationships involved kiss- als of all kinds are easily available. You may wish
ing or touching.” If so, inquire about other sexual to ask teenagers about what sexual information and
behaviors. Whether to screen for sexually transmit- materials they have accessed online and how much
ted infections, pregnancy, abuse, and other sequelae and how often. Again, some experimentation with
of sexual activity depends on the details. this is likely normal, but excessive use of such sites
Ask patients about their knowledge of fertility, or accessing unusual or violent sexual content may

ContemporaryPediatrics.com J an u ary 2 0 1 4 C O N T E M P O R A R Y P E D I AT R I C S 25
 H E EADSSS

Table 6 Patient Health Questionnaire 2

A score of 3 or greater has good sensitivity and specificity for detecting major depression in adolescents.

OVER THE PAST 2 WEEKS, HOW

OFTEN HAVE YOU BEEN BOTHERED MORE THAN NEARLY
BY ANY OF THE FOLLOWING? NOT AT ALL SEVERAL DAYS HALF THE DAYS EVERY DAY

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

Richardson LP, et al.25

indicate a risky behavior.7 found that lesbian, gay, and bisexual (LGB) adoles-
Sometimes the greatest impediment to obtain- cents were more likely than heterosexual teenagers
ing an adequate sexual history is a physician’s own to have attempted suicide in the previous 12 months
discomfort with sexuality. With practice, these (21.5% vs 4.2%, respectively). 26 The likelihood of
questions become easier to ask without appearing attempting suicide was 20% higher for LGB teen-
judgmental. You can offer advice and personal opin- agers in unsupportive environments than in sup-
ions, but only if the teenager solicits them and only portive environments. Sexual minority adolescents
if you clearly label them as such. benefit greatly from clinician-provided support, as
well as a safe place for asking questions.
Screening for Suicide and Some adolescents who are not contemplating sui-
depression cide nevertheless harm themselves. Teenagers who
Adolescents should be screened for depression when engage in cutting describe it as a mood-stabilizing
systems are in place to ensure accurate diagnosis, behavior; in these situations a careful risk assess-
psychotherapy, and follow-up. 24 Teenagers often ment is important.
exhibit depression as boredom, irritability, anxi-
ety, moodiness, sleep disturbance, and social with- S for Safety
drawal. Many are more willing to admit to “stress” Injuries, suicide, and homicide—the major causes of
than to overt depression or sadness. The Patient morbidity and mortality in adolescents—are a con-
Health Questionnaire 2 (PHQ-2), a 2-item survey, stant environmental reality for many young people.
may be used as an initial screening tool for depres- Antecedents such as bullying, domestic and school
sion in adolescents at each visit (Table 6).25 violence, gang involvement, sexual abuse, online
When depression seems likely, ask directly and solicitation, and access to weapons must be identified
clearly about self-harm. Asking about suicidal behav- in the psychosocial history. Family violence, which
ior does not precipitate or trigger it, and clinicians increases the risk for teenaged violence several-fold,
should not be reluctant to question patients unambig- occurs in all social and economic classes, as does
uously: “You’ve told me that you’ve been feeling bad dating violence, which is reported by as many as 25%
lately. Have you felt so bad that you’ve thought seri- of teenaged and young adult women.27,28
ously about harming yourself?” Adolescents attempt Proceed to questions about the threats most preva-
suicide more often than we realize, so physicians lent in the patient’s community. In some settings,
should not be surprised if a teenager has contemplated these threats may be school violence and guns; in
or even attempted it. Past suicide attempts are a strong other settings, these may be sports injuries, sexual
risk factor for future attempts and future suicide. The violence, or risk taking related to motor vehicles. Then
clinical question is: How serious is the ideation, plan- ask about any other threats. Avoid letting assumptions
ning, or actual behavior? based on the patient’s racial, ethnic, or socioeconomic
Pay attention to sexual orientation. A recent study status lead you to skip taking parts of the history.

26 C O N T E M P O R A R Y P E D I AT R I C S J an u ary 2 0 1 4
 H E EADSSS

Find out what strategies the patient uses for self- future visits. You may say: “I’m here for you, and
protection, conf lict resolution, and avoidance of I want you to feel comfortable confiding in me.
violence. (No gangs? How about local bullies? Is If you have something personal to talk about,
there an abusive partner or parent?) Know the I’ll try to give you my best advice and answer
school-based and community organizations in your your questions.”
area that offer programs on conflict resolution and Many adolescents do not recognize dangerous
violence avoidance so that you can make special- behavior patterns as dangerous because they see
ized referrals. Many young people respond to vio- their activities not as problems but as solutions.
lence with violence because that is all they know Your challenge is to explore these behaviors and the
from their homes, streets, and media. Before offer- context in which the adolescent lives, and to develop
ing concrete solutions, ask adolescents whether realistic solutions with patient buy-in.10,11 Depending
they can think of ways to avoid violence using their on the nature of the risk factors identified and the
reported strengths. intervention to be established, you can either extend
the initial visit or arrange a follow-up.
Wrapping it up Finally, by now you may be overwhelmed by the
You may end the psychosocial interview by asking amount of issues to be covered in this interview
adolescents to tell you in whom they can trust and and wonder how to do this in a limited time. Of
confide if they have problems. Emphasize that your course, you cannot cover every aspect in a sin-
approach is nonjudgmental and that you welcome gle visit, but your goal is to establish an effective

A C O N T E M P O R A R Y P E D I AT R I C S R E S O U R C E C E N T E R

HEEADSSS 3.0: THE PSYCHOSOCIAL INTERVIEW FOR

ADOLESCENTS UPDATED FOR A NEW CENTURY FUELED BY MEDIA
As part of our commitment to providing the pediatric
practitioner with practical clinical information and tools that
are immediately applicable to incorporate into daily practice,
Contemporary Pediatrics is launching a series of topic-specific
Resource Centers. Resource Centers comprehensively cover a
single clinical topic and include articles, tools, videos, links to
CME, and more.

Since HEEADSSS, the psychosocial exam for adolescents, is such

a critical part of the field of adolescent medicine and for the
training of pediatric residents, the Contemporary Pediatrics
HEEADSSS Resource Center is dedicated to imparting clinicians
with the considerations, rationale, and clinical flexibility of
this assessment in a single site that can serve as a starting
point for students, residents, and teachers alike. Access this
Resource Center’s tools, videos, and articles in support of
the HEEADSSS goal of fostering patient-physician rapport, at
ContemporaryPediatrics.com/HEEADSSSresourcecenter

ContemporaryPediatrics.com J an u ary 2 0 1 4 C O N T E M P O R A R Y P E D I AT R I C S 27
 H E EADSSS

relationship in each case and leave the remaining 12. Jones RK, Purcell A, Singh S, Finer LB. Adolescents’ reports of paren-
tal knowledge of adolescents’ use of sexual health services and their
questions for a later visit. You should feel free to reactions to mandated parental notification for prescription contracep-
add or remove priority questions based on the tion. JAMA. 2005;293(3):340-348.
needs of your patient population. In other words, 13. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of
make HEEADSSS your own. physician confidentiality assurances on adolescents’ willingness to
disclose information and seek future health care. A randomized control
Try getting into the HEEADSSS of your ado- trial. JAMA. 1997;278(12):1029-1034.
lescent patients. Your effort may have a lifelong 14. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from
impact. harm. Findings from the National Longitudinal Study on Adolescent
Health. JAMA. 1997;278(10):823-832.
Dedication 15. Centers for Disease Control and Prevention. School Connectedness:
Strategies for Increasing Protective Factors Among Youth. Atlanta,
This manuscript is dedicated to the memory of GA: US Department of Health and Human Services; 2009. http://
David Rosen, MD, and Eric Cohen, MD, for their www.cdc.gov/healthyyouth/adolescenthealth/pdf/connectedness.
significant contributions to previous versions of the pdf. Accessed December 4, 2013.

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Know From Nationally Available Data. Baltimore, MD: Johns Hopkins
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New York: Nielsen Co; 2011. http://www.nielsen.com/us/en/ Nutrition Examination Survey III. Arch Pediatr Adolesc Med.
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