HEEADSSS Assessment – OSCE Guide

Introduction

An important consideration when taking a medical history from a young person (12-25 years) is identifying health risks and behaviours unique to this age group.

We know that such factors can have a profound and cumulative impact on the life course, influencing long-term physical and mental well-being, the development of chronic conditions, educational achievement, socio-economic development and the attainment of life goals.^1,2

Thorough, sensitive, and appropriate psychosocial assessment can then be key to identifying strengths and risks for young people and supporting interventions that promote current and future physical and mental health.³ This is where the tailored approach of the HEEADSSS assessment is very useful.

The traditional assessment progresses from addressing less sensitive topics to more sensitive issues, as outlined by the acronym:

• Home
• Education and employment
• Eating and exercise
• Activities, hobbies, and peer relationships
• Drugs and alcohol
• Sexual activity, sexuality, and gender identity
• Suicide, self-harm, depression, mood, and sleeping patterns
• Safety

This conversation generally takes place as a face-to-face, semi-structured interview with the young person, understanding that such a conversation does inevitably encounter barriers, including the clinician’s lack of familiarity and confidence with assessments and staff and patient time pressures.⁴

As such, developing skills in sensitive and empathetic communication with young people is key to creating a confidential and respectful space where young people can disclose information perceived as important to their lives.³

The interview

A HEEADSSS assessment forms a valuable part of the discussion when first meeting a young person, and similar questions can then be used to identify new stressors and assess overall well-being in the future.⁵

First introduce yourself to the adolescent to make clear that the young person is the patient. It’s imperative that at the beginning of the conversation, we help the young person feel comfortable and confident in their conversation with you.

Be respectful of a young person’s affirmed gender identity, name, and pronouns. When in doubt, ask! Continuously misgendering someone (using the wrong gender pronouns or name) can be upsetting and unsupportive. It is as simple as asking, “What gender pronouns do you use?” “What name should I use?”.⁶

Then, try having the adolescent introduce the other people in the room. Parents, family members, or other involved adults should ideally not be present during the HEEADSSS interview as a parent or carer’s presence is likely to limit how much sensitive information the patient will provide.

This does not mean that parents should be ignored. Always ask them whether they have any concerns and reassure them of further interaction once the interview is over.

Be certain to explain the purpose, such as: “We speak privately with our patients about stressors that are more common for young people so they can begin to take responsibility for their health care needs.” With explanation, adults generally accept the need for confidential care.

Confidentiality becomes another important aspect of a HEEADSSS assessment and should be addressed before jumping into the interview, with a line such as: “During this visit, I’ll ask you some very personal questions to best help you. I promise that whatever you say will be kept private between us and not be passed along to your parents or anybody else outside this clinic, unless you give permission.”

Importantly, the young person should be aware: “The only exception would be in a circumstance in which a disclosure to someone is required by law – like if you’re at risk of hurting yourself or someone else is hurting you.”

From this point, nothing about the HEEADSSS interview, including the order of questioning, should ever be treated rigidly. Each young person should receive a tailored approach.⁷

Home

• Who lives with you? Tell me about your family or the people who are important to you.
• Where do you live? Can you describe where you live, like your house or apartment?
• How would you describe your relationships with the people you live with?
• Is there someone at home or in your support network you feel comfortable talking to about stress?
• Has anyone new come to live with you recently?
• Has anyone recently left your household?
• Do you have any devices at home, like a phone or computer? How do you use them?
• Have you experienced any big changes lately, like moving to a new place or living away from home?
• Have you ever felt unsafe or experienced any violence at home?

Education and employment

• How would you describe your school? Do you feel safe there? Why or why not?
• Have you ever experienced bullying at school?
• Do you feel included and like you belong at school?
• Is there a teacher or another adult at school you trust and feel comfortable talking to about important things?
• How are your grades going? Are there any subjects you’re finding challenging?
• Have there been any recent changes or events at school that have affected you?
• What do you want to do after school? Do you have any goals for your education or career?
• Are you working part-time? Where do you work, and how many hours do you work each week?

Further exploration

• How many days have you missed from school recently?
• Have you changed schools in the past few years?
• Can you tell me about your friends at school?
• Have you ever repeated a class or grade?
• Have you ever been suspended or expelled?
• Have you ever thought about leaving school early?
• How well do you get along with people at school or work?
• Have your responsibilities at work increased recently?
• What are your favourite subjects at school?
• Are there any subjects you don’t enjoy as much?

Eating and exercise

• Do you ever feel stressed about your weight or how your body looks? Can you tell me more about how it makes you feel?
• Have you noticed any changes in your weight lately?
• Have you tried to change your eating habits or diet in the past year? What did you do, and how often?

Further exploration

• What do you like and not like about your body?
• Have you tried anything else to manage your weight?
• Can you tell me about your exercise routine?
• What do you think a healthy diet looks like?
• How does your current eating compare to what you think is healthy?
• How would you feel if you gained or lost 5kg?
• Do you ever feel like your eating is out of control?
• Have you ever used medication or supplements to try to lose weight?

Activities hobbies, and peer relationships

• What activities do you enjoy doing in your free time? How do you hang out with your friends and family, and where do you usually go?
• Do you spend a lot of time online? What do you like to do on the internet?
• About how much time do you spend each day using devices like computers, TVs, or phones?
• Do you ever feel like you want to spend less time on screens or online activities?
• Have you ever had any negative experiences with social media that you’d like to talk about?

Further exploration

• Do you play any sports or participate in physical activities?
• Do you attend any religious or spiritual events regularly?
• Have you ever sent messages or posted things online that you later regretted?
• What kinds of books do you enjoy reading for fun?
• How do you feel after playing video games?
• What music genres or artists do you like to listen to?

Drugs and alcohol

• Some young people try smoking, vaping, drugs, or alcohol. Have you heard about friends who have tried these?
• Have you tried smoking, vaping, drugs, or alcohol? If yes, can you tell me more about it, like how often, how much, and who you were with?
• How do drugs, smoking, or drinking affect you? What do you and your friends do when you use them?
• Have you noticed yourself using more drugs or alcohol lately?
• Where do you get cigarettes, drugs, or alcohol from? Do you buy them, and how do you get money for them?
• Does anyone in your family smoke, drink alcohol, or use drugs?

Further exploration

• Is there a history of alcohol or drug problems in your family?
• Do you ever drink or use drugs alone?
• Have you ever been in a car with someone who was high or had used drugs or alcohol?
• Do you use alcohol or drugs to feel better or fit in?
• Do you forget things you did while using drugs or alcohol?
• Have your family or friends ever said you should cut down on drinking or drug use?
• Have you ever gotten into trouble while using drugs or alcohol?

Sexual activity, sexuality, and gender identity

• Have you ever felt attracted to someone or had romantic feelings for someone else?
• How would you describe your sexual orientation? For example, do you see yourself as queer, heterosexual, or somewhere else on the spectrum?
• Have you ever been in a relationship that included sexual activity, like kissing or touching?

Further exploration

• Do you find your sexual activities enjoyable?
• Have any of your relationships been violent or involved coercion?
• What does the term “safer sex” mean to you?
• Have you ever been forced or pressured into doing something sexual that you didn’t want to do?
• Have you ever been touched sexually in a way that you didn’t want?
• How many sexual partners have you had?
• What contraception are you using, if any?
• Do you use condoms every time you have intercourse? Or use other forms of protection?
• Have you ever been pregnant or worried about pregnancy? Or worried about getting someone pregnant?
• Have you ever had a sexually transmitted infection or been concerned about one?

Suicide, self-harm, depression, mood, and sleeping patterns

• On a scale of 1 to 10, how would you rate your mood recently? Can you tell me more about why you feel that way?
• Do you find yourself feeling stressed or anxious more often than usual, or more than you’d like to feel?
• Have you been feeling sadder or down more often than usual?
• Do you often feel bored or like there’s not much that interests you?
• Have you been having trouble falling asleep or staying asleep?
• Have you thought a lot about hurting yourself or someone else?

Further exploration

• Does it seem like you’ve lost interest in activities you used to enjoy?
• Have you been spending less time with friends than you used to?
• Do you prefer being alone most of the time?
• Have you ever tried to harm yourself or kill yourself?
• Have you ever used self-harm (like cutting) as a way to calm down or feel better?
• Have you started using alcohol or drugs to relax, calm down, or feel better?

Safety

• Have you ever had a serious injury? Can you tell me how it happened?
• Do you know anyone who has been seriously injured? What happened to them?
• Do you make sure to always wear a seatbelt when you’re in a car?
• Have you ever met someone in person that you first met online? Or do you plan to meet someone like that?
• Have you ever sent a text message while driving? When was the last time?
• Have you ever been in a car with a driver who was drunk or high? When was this, and has it happened more than once?
• Do you experience or witness a lot of violence at home, school, in your neighbourhood, or among your friends?

Further exploration

• Do you use safety equipment like helmets for bike riding or skateboarding?
• Have you ever been in a car or motorcycle accident? What happened?
• Have you ever been bullied or picked on? Is it still a problem?
• Have you been in physical fights at school or in your neighbourhood? Is this still happening?
• Have you ever felt like you needed to carry a weapon for protection?
• Do you still feel that way? Have you ever been in trouble with the law?

After the consultation 

As you conclude the HEEADSSS assessment conversation with a young person, ensuring the discussion ends on a supportive and empathetic note is important.

Summarise the key points discussed during the interview. Validate the young person’s experiences and feelings, acknowledging the courage it takes to share personal information.

• “Thank you for sharing with me today. It’s clear that you’re dealing with a lot, and it’s important to remember that you’re not alone.”

If there are any concerns or areas that require follow-up, discuss potential next steps with the young person. This may include referrals to appropriate professionals or resources, as well as ongoing support strategies.

• “Let’s think about what we’ve discussed and what steps we can take next to make sure you have the help and resources you need.”

It remains important to gain consent from the young person before proceeding with any referrals or further actions, including speaking to their parents or carers. Ensure they understand the purpose and potential outcomes of onward referrals or support plans.

Respect the young person’s wish to keep certain aspects of their life private or personal within the boundaries of confidentiality outlined at the beginning of the conversation.

It is important to document the HEEADSSS assessment findings in a sensitive and confidential manner. This will allow topics or concerns to be revisited in the future.

When done well, the HEEADSSS framework is a thorough, sensitive, and appropriate psychosocial assessment tool. It can be key to identifying strengths and risks for young people and aid in supporting interventions, enabling healthcare practitioners to ensure current and future physical and mental health.

References

1. WHO. (2001). The second decade: improving Adolescent Health and Development. Geneva: World Health Organization.
2. Australian Research Alliance for Children and Youth. (2014). The Nest Action Agenda. Canberra: ARACY.
3. Waller, Bailey, Zolfaghari, Ho, Feuerlicht, Ross, & Steinbeck. (2023). Psychosocial assessment of adolescents and young adults in paediatric hospital settings: patient and staff perspectives on implementation of the e-HEEADSSS. BMC Health Serv Res, 23(683).
4. Saw, Smit, Silva, Bulsara, & Nguyen. (2022). Service evaluation and retrospective audit of electronic HEEADSSS (e-HEEADSSS) screening device in paediatric inpatient service in Western Australia. International Journal of Adolescent Medicine and Health, 34(6), 401-409. 
5. The Sydney Children’s Hospital Network . (2024). HEEADSSS 3.0 interview for adolescents. Available from: [LINK]
6. Hager, A. (2014). Supporting Gender Identity: A Beginner’s Guide for Friends, Family, and University Staff. Available from: [LINK]
7. Klein, D., Goldenring, J., & Padelman, W. (2014). HEEADSSS 3.0: the psychosocial interview for adolescents updated for a new century fueled by media. Contemporary Pediatrics.