Getting into adolescent heads

This article has been reproduced from the original version that appeared in print in Contemporary Pediatrics, July 1988.

For most young people, adolescence is a time of growth and development, not of illness. When illness occurs, it is often related to the increased risk-taking behavior that is part of the normal adolescent process of exploration.

Unfortunately, exploration can be dangerous. The major cause of mortality in adolescents is motor vehicle accidents, more than half related to drug or alcohol use. Next in importance are homicide and suicide. Other causes of morbidity in adolescents include unwanted pregnancy, high levels of sexually transmitted disease (STD), eating disorders, and syndromes related to stress and depression. All of these problems are not easily amenable to the intervention of a physiologically oriented physician. In fact, they may not even show up on the standard review of systems that physicians are taught to perform.

The physician who sees adolescents must be willing to take an adequate psychosocial history. If it is not done, there is no chance of spotting problems early and making a significant impact on morbidity and mortality.

While a fellow at Los Angeles Children’s Hospital, Dr. Cohen refined a system for organizing the psychosocial history that was developed in 1972 by Dr. Harvey Berman of Seattle. The system has been used successfully in Los Angeles and New York City. This method structures questions so as to maximize communication and minimize stress. The approach is known by the acronym HEADSS, which stands for Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression (Table 1).

We generally suggest restricting the psychosocial interview to those times when the adolescent is relatively well, since this is the best time to obtain information with low stress. However, if the adolescent is in crisis in your office, you will have no choice but to dig out the underlying information. Furthermore, illness is a double-edged sword; it increases vulnerability but at the same time may increase the potential for trusting and seeking help.

Assuring confidentiality

The note you strike at the outset may affect the entire outcome. Parents, family members, or other adults should not be present unless the adolescent specifically gives permission. If the parents are present before the interview, we always introduce ourselves to the adolescent first. In fact, we ask the adolescent to introduce us to the other people in the room. This gives the adolescent a clear message that we are interested primarily in him.

It is not reasonable to expect an adolescent to reveal personal information unless confidentiality can be assured (See “Ensuring Confidentiality”). We tell adolescents that we ask certain questions because the information is integral to our understanding of their health. With the exception of physical or sexual abuse, or suicidal or homicidal behavior or intent, we do not immediately reveal sensitive information to parents or authorities. It is our goal to have the teenager make these revelations himself.

Often we do not begin by asking, “Why are you here?” Rather, we start with innocuous conversation, often geared to an observation about the teenager. We may comment about clothing that sends a message or some factor about the teenager’s preferences that we have heard from others. Or, we may simply make a lighthearted comment about our own day or current events.

This initial banter allows the teenager to release tension and tell us something about himself of which he is proud. Doing so inspires confidence, imparts the message that we are concerned and will actually listen to him, and allows him to be “one up” on the interviewer for a brief period. This lightens up the atmosphere and allows good communication to begin.

Occasionally, we pick up a message from the teenager’s body language-indications that he or she is depressed, euphoric, frightened, or angry. Sometimes we make a comment on this perception. This approach may cut to the heart of the problem, allowing the teenager to express a feeling. The expression is almost always a beneficial experience and may lead to important conversation.

The history begins at Home

Asking about home is the least threatening line of questioning and is completely expected. It is important not to make assumptions and to try as often as possible to ask open-ended questions (Table 2).

It is a mistake, for example, to say, “Tell me about your mom and dad.” This question assumes that the patient lives with both a mother and father. You may not know that a parent died recently or that a divorce is in the works. Start by asking, “Where do you live?” or, “Tell me about your living situation.” This can be followed by, “Who lives with you?” These questions allow the adolescent to describe exactly what is important to him at home. Then go on to find out what relationships are like at home and whether there has been a recent change-moving, running away, being institutionalized, or having someone join or leave the household. These events are extremely stressful to teens, who need a stable environment to accomplish the tasks of separating from parents, connecting with peers, and developing a positive self-image.

Most teenage problems with sexuality, drug use, risk taking, and psychological difficulty stem in part from some problem with relationships at home. Young people tend to get into trouble when they do not have the support, caring, and respect that enables them to resist adverse peer pressure and to seek counsel from trusted adults.

It is useful to ask whom the teen can trust to discuss difficult personal matters. You might have to give hypothetical examples. If the teen cannot talk to and trust anyone at home, this is an important finding and one that, in our experience, is all too frequent. Such lack of trust in relatives is an automatic setup for other psychosocial difficulties.

Education and employment come next

Most of the teen’s time that is not spent in the home is spent at school. Young people expect to be asked about their education and are seldom threatened by the discussion. Most have come to some terms with their school performance; if they have not, this in itself may be a serious problem.

Many interviewers make the mistake of not trying to get a deep enough history about school, taking statements at face value. A common error is to ask, “How are you doing in school?” Especially in younger teens, the answer is invariably “okay,” “fine,” or “good.” These words carry no meaning. You must be willing to follow up: “What do you mean by okay?”

We suggest asking, “Tell me about school-what do you like about it and what don’t you like?” In this way we elicit both strengths and weaknesses. We also ask for grade averages. We are particularly concerned to find out if the teenager has had a recent change in performance level. A change in academic performance correlates highly with other psychosocial problems and with risk of suicide attempts or acting-out behaviors. It may also indicate an underlying learning disorder. This is especially true at transition points such as sixth and ninth grades, when students who have been able to compensate for learning disorders may have sudden difficulty keeping up with leaps in performance expectation. We also ask what relationships are like in school and what extracurricular activities the young person is involved in.

The older the teenager, the more we expect some plans for future education and employment. Early adolescents may have vague ideas about the future, but these should begin to solidify in 11th and 12th grades.

In certain inner-city and high-risk populations, we ask if they actually attend school. In the South Bronx, the chronic absenteeism rate ranges from 15% to 20% with “overabsenteeism” exceeding 40% at times. We are also concerned about the fact that many young people are “passed along” from grade to grade even though they are not capable of basic reading and writing skills. We ask all high-risk groups whether they have any difficulty reading, and we occasionally test young people with grade-specific reading and writing paragraphs. It also may be useful to check how many schools, and new sets of friends, the student has had to confront in the last four years.

As young people enter middle and late adolescence, they may develop an employment history through summer jobs or part-time work. Some practitioners may be seeing young people who are employed full-time. We can thus substitute the word “employment” for “education” as the E in HEADSS. We ask the same kinds of questions-number of jobs held, job strengths and weaknesses, satisfaction levels, nature of relationships at work, goals, and any recent or frequent changes in employment. For younger teens who are employed part-time, you might want to take the employment history under the Activities section above.

Looking at peer Activities

When adolescents are not at home or in school, they tend to be with their peers. The peer group is particularly important in early and middle adolescence when young people are learning to separate from their parents. At this point they derive much of their identity and self-esteem from peer activities. We usually begin by asking, “Tell me what you do with your friends” or “What do you do for fun?” We press them for specifics if they don’t show any extrafamilial or extracurricular activity patterns. We also ask them to give us names and characteristics of friends. Some young people tell us they have friends but cannot readily name names and joint activities. These teens may be hiding the fact that they are isolated and depressed. We also look for any indication that friendships are changing. The patient may have joined a higher risk peer group or begun to drift away from peers, indicating potential isolation and thus depression and suicide risk.

If you take this kind of history often enough, you will become concerned with teens who cannot describe their activities beyond “hanging out.” They may be at higher risk than teens who have favorite activities with friends, such as sports, dancing, hobbies, games, or even shopping.

We also ask young people to tell us how much reading they do for fun. The young people who read outside of classroom requirements are generally doing better in school and at home and have a better prognosis for going on to college or full employment. We also ask about the kinds of television programs they watch and the amount of time spent watching TV. Young people who watch TV for more than two hours a day may be using it to avoid homework or interaction with peers. For others, TV becomes a mesmerizing fantasy drug. Inordinate use of TV may indicate a troubled family system where TV is used to bypass interfamilial conflict. It may also indicate a lack of parental control. Young “couch potatoes” are also at risk for obesity.

If young people are of driving age, it is important to ask if they drive, if they have their own car, who pays for the car, and whether they and their passengers use seat belts. Since the number one cause of mortality in adolescence is auto accidents, we remind teenagers who are not using seat belts that buckling up is imperative.

On to Drugs

We repeat the confidentiality statement as we come to private matters: drugs and sex. We say that we will be extending confidentiality within the limits mentioned and warn that the next questions will be more personal.

The drug history must be sensitive and frank. With younger adolescents, we usually approach the topic obliquely: “We have discussed what you do with your friends for having fun. I know that some young people your age experiment with drugs. Do any of your friends use drugs (or get high)?” Young adolescents are quite willing to tell us about their friends when they would not tell us so readily about themselves.

We next observe that when young people get together there is considerable pressure to be one of the crowd. We ask, “Have your friends ever tried to get you to use drugs?” Often the young person will sheepishly admit that he has tried something, which leads to a discussion of under what circumstances, which drugs, how often, and how much. In middle-to-late adolescence, it may be sufficient to ask directly about drug use, without reference to friends.

We also ask about alcohol abuse, since alcohol is the number one drug problem in adolescence. We ask about tobacco as well, since most teens do not consider smoking or chewing tobacco to be a form of drug use. We specifically make sure that young people understand that cigarettes and alcohol are both addicting drugs.

We also want to know whether the adolescent is taking risks, such as driving under the influence of substances or riding with someone who is intoxicated. Our first goal in counseling is to prevent such overtly dangerous activities and then to determine if substance abuse is a significant problem or a passing experiment. To do this, we must look at the adolescent’s drug use in terms of the overall psychosocial picture and determine whether it is causing physiologic risk or interfering with social growth. If drug use is more than occasional, we work with the adolescent to help make some changes in life-style, ideally developing some form of contract and following up on it. (See, “Are you ready to deal with the pot-smoking patient?” Contemporary Pediatrics, April 1987.)

As long as a drug-using adolescent agrees to work with us on his drug problem, we do not reveal drug abuse unless suicidal or homicidal behavior is involved, such as driving under the influence. It is still our eventual goal, whenever possible, to have the adolescent reveal the nature of his drug use to his parents. We offer to serve as mediators of that process.

The Sexual history

We then approach the adolescent on the most threatening and most personal area-the sexual history. Especially with younger adolescents, we approach gently, again from the point of view of friends. We may observe, “We have talked about some of the friends you hang out with. Are there any of your friends with whom you have had a sexual relationship?” The open-endedness allows adolescents to tell us that they are having experiences with the same sex, opposite sex, or both. In older adolescents we may simply say, “Most young people of your age are beginning sexual explorations. Since sexual activity can affect your health, I am interested in finding out as much as I can. Can you tell me about your sex life?” This is open-ended and allows the teenager to elaborate.

We always try to obtain a complete sexual history, asking what patients are doing, when, where, and with whom. We never ask, “And are you having sex with someone?” because the definition of “having sex” is subjective and even culturally defined. We rather ask exactly what activity is taking place. If the teenager is reluctant or wonders why we are asking these questions, we restate our concern about pregnancy and STDs. We always ask teenagers about their knowledge of fertility and sexually transmitted infections. We may comment, “I know that this may be embarrassing for you, but it is very important. We ask these questions of all adolescents.” We also may say, “Many adolescents do not have anyone knowledgeable to talk to about sex. Please take this opportunity to ask any questions or voice any concerns you may have.”

It is important not to assume that adolescents who are having sexual intercourse are enjoying it. We ask about comfort with sexuality and whether sexual contact is truly enjoyable. Many young females, but also a surprising number of males, do not enjoy sexual activity because they are tense about it and feel as if they are being forced into undesired situations by peer pressure. Often we can serve as trustworthy adults who give them permission not to be sexually active until they are feeling more comfortable.

We are always careful to ask teens if they have ever had uncomfortable sexual experiences, such as being touched sexually when they did not want to be touched, at any time in their life. Given the burgeoning reports of child and adolescent sexual abuse, it is important to take this history. If it is not asked for, particularly in young males, it will not be forthcoming.

The history of abuse may not come out on the first interview, but the very fact that you ask and show interest gives the teen a chance to trust you and to reveal the facts at a later time. It is surprising how often adolescents have a “sigh reaction,” where they take a deep breath and say to themselves, “I think I am going to trust” and reveal one of their deep, dark secrets (drugs, alcohol use, sexual problems, abuse). You may be able to establish enough rapport so that the teenager will trust you with the most sensitive details.

The greatest impediment to an adequate sexual history is not embarrassed teens who refuse to confide in their doctor. Rather, we find that the problem lies with doctors who are uncomfortable with sexuality and do not wish to take a good sexual history. If you cannot become knowledgeable about and comfortable with sexuality, don’t see teenagers. You must be capable of frank, nonjudgmental counseling. This does not mean you cannot offer opinions, feelings, and advice if they are clearly labeled. It only implies that you have to be as comfortable with sex as you are with diarrhea. Remember, most people are not comfortable with either!

Screening for Suicide/depression

We suggest that every psychosocial interview seek to identify elements that correlate with anxiety or depression, the frequent precursors to adolescent suicide. Many of the items in the suicide screen (Table 3) have already been determined in the psychosocial history: severe family problems, changes in school performance, changes in friendship patterns, preoccupation with death in media or dress, sexual acting out, and drug, alcohol, and cigarette abuse.

Other items to seek include a family history of psychological problems or suicide or a history of similar behavior in close friends or relatives. In addition, we ask whether any family members use drugs, alcohol, and cigarettes. There is a high correlation between psychological disturbances and a family history of substance abuse.

We also suggest asking about two areas that are often forgotten-sleeping and eating habits. Teenagers who are anxious or depressed have difficulty falling asleep. Generally, it takes them more than 30 minutes to fall asleep, and often more than one hour. Though many adolescents have occasional sleep problems, difficulties occurring more than once or twice a month are significant. Even if adolescents are hiding other parts of the history and refusing to trust, they will often reveal a sleep disturbance. Sleep problems tend to make adolescents feel miserable in the morning and are a considerable nuisance to the otherwise healthy and active adolescent.

Some adolescents increase their total amount of sleep considerably when depressed. These adolescents are not difficult to discern since they also have the body language of depression: reduced affect, reduced eye contact, and difficulty in interviewing because of helplessness and hopelessness. They may refuse to communicate in anything more than whispers or mumbles.

The second important factor is nutrition. Frequent fad dieting, crash diets, anorexic or bulimic behavior, and obesity with significant overeating or binging are all indicators of significant psychological distress, potentially depression, and certainly problems with self-esteem. Nutritional disturbances may be a precursor for suicidal behavior. Young people who put themselves at risk need nutritional and psychological counseling. It is important to note that 60% of normal-weight females in the United States believe they are overweight! This misperception may lead not only to serious problems with self-esteem and eating disorders but also to increased anxiety and depression.

Wrapping it up

We often end the interview by asking teenagers to sum up their life in one word or to give us the overall “weather report” for their life (sunny with a few clouds, very sunny with highs all the time, cloudy with rain likely, etc.). Or, we may ask them to tell what they see when they look in the mirror each day. We specifically look for teenagers who tell us they are “bored.” Boredom in adolescents often indicates that the patient is depressed. Adolescence may be trying, challenging, and nerve-wracking, but it can never be boring. When the word is used by adolescents, it is a significant red flag.

We also ask teens to tell us whom they can trust and confide in if there are problems in their life, and why they trust that person. This is especially important if we have not already identified a trusted adult in the family. We always tell the adolescent that he or she now has another adult-the physician-who can be trusted to help with knotty problems and to answer thorny questions honestly. We indicate that we are interested in them as whole persons, someone who wants to help them lead a fuller, healthier life.

We give teenagers an opportunity to express any concerns we have not covered, and we ask for feedback about the interview. If they later remember anything they have forgotten to tell us, we remind them that they are welcome to call at any time or to come back in to talk about it.

For teenagers who demonstrate significant risk factors, we relate our concerns. We ask if they are willing to change their lives or are interested in learning more about ways to deal with their problems. This leads to a discussion of potential follow-up and therapeutic interventions.

Many adolescents do not recognize dangerous life-style patterns because they see their activities not as problems but as solutions. Our challenge lies in helping the adolescent to see dysfunctional behaviors as problems and helping to develop better strategies for dealing with them.

If the adolescent’s life is going well, we say so. In most cases we can identify strengths and potential or real weaknesses and discuss both in order to offer a balanced view.

We ask if there is any information we can provide on any of the topics we have discussed, especially the issues of sexuality and drugs. We try to provide whatever educational materials young people are interested in.

The psychosocial history can be done in 15 to 30 minutes, depending on the nature of risk factors identified, the amount of discussion and education needed, and the intervention to be arranged. You may not be able to get all the information on a first interview. Moreover, the teen may not reveal all at the first encounter. But using this method, you may be able to get a handle on those teens you need to see again for further evaluation.

So try getting into the HEADSS of your adolescent patients. We think you’ll be glad you made the effort.

The authors are interested in hearing from readers about the HEADSS interview-both problems and good points. They also ask readers to share any other techniques they find useful in dealing with adolescent patients.

Ensuring confidentiality

All adolescents should be told about confidentiality at the beginning of the interview and again just before taking the drug abuse and sexual history. Each physician must determine the nature of his own confidentiality statement. There are two schools of thought.

One school acknowledges to teens that there may be some legislated and ethical limits on confidentiality.

For example: “In this interview I will ask you some very personal questions in order to get to know you better. The answers may be very important to your health. But because the answers are sensitive and personal, I promise they will be confidential-that means just between you and me. I will not tell your parents, your teachers, or other authorities about them unless you give me permission. The only exception is that if I find that you or anyone else has been physically harmed or is about to be physically harmed, I am required to take immediate action. What we say remains in this room until you say otherwise, unless one of my partners needs to know in order to care for you while I’m away. They make the same promises of confidentiality. I hope that you will trust me with the truth about these difficult questions.”

The limits here are not explicitly spelled out unless the patient asks for examples, in which case you may mention homicide, suicide, physical or sexual abuse, or the potential for any of them. Some authorities spell these out explicitly.

The second school of thought does not favor specifying limits. Adherents point out that almost universally when suicidal, homicidal, or abuse behavior is revealed to the doctor, it is basically a cry for help and the patient will be relieved rather than angry when you say this matter cannot be kept secret.

Either approach can work. In both cases, most sexual and drug abuse information is kept confidential initially. A controversy exists over where to draw the line with severe drug abuse that is either suicidal or de facto homicidal behavior.

Some thoughts on office questionnaires

Many pediatricians do psychosocial screening of adolescents by using office questionnaires. The most innovative and effective screening methods involve interaction with a computer, which young people seem to enjoy. While these may be useful, we find there is no substitute for direct communication. The psychosocial interview described in the accompanying article helps to establish rapport and trust and elicits vital information, such as body language, that cannot be revealed by a questionnaire. Furthermore, many of our adolescents do not answer questionnaires or even anonymous computer questions fully, especially when it comes to sensitive issues such as sex and drugs. They need to be convinced through person-to-person communication that it is safe to make revelations in these areas. Questionnaires can get you started, but you still need to do a well-organized psychosocial interview.

-John M. Goldenring, MD, MPH

DR. GOLDENRING is in the private practice of pediatrics and adolescent medicine in Thousand Oaks, Calif. He teaches at Ventura County Medical Center, Ventura, Calif., and Cedars Sinai-UCLA Medical Center, Los Angeles.

DR. COHEN is associate clinical professor of family medicine and pediatrics at the University of Southern California School of Medicine. He is director of the USC Introduction to Clinical Medicine course and medical director of the High Risk Youth Project of Los Angeles Children’s Hospital.