Virtual Mentor. March 2005, Volume 7, Number 3.

Clinical Pearl

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HEADSS: The "Review of Systems" for Adolescents

An adolescent medicine fellow reviews the HEADSS assessment and provides a list of sample questions to ask adolescent patients when conducting a medical history.

Rachel Katzenellenbogen, MD

Most adolescents have few physical health problems, so their medical issues come from risky behaviors. As physicians, we need to ask about the context of a teen’s life, and the HEADSS assessment is a good guide [1]. HEADSS is an acronym for the topics that the physician wants to be sure to cover: home, education (ie, school), activities/employment, drugs, suicidality, and sex. Recently the HEADSS assessment was expanded to HEEADSSS [2] to include questions about eating and safety. I integrate safety into the other categories of the assessment, and I like to talk about eating and body image in the context of activities and exercise. Not all of the questions that follow need to be asked, but all subject areas should be covered; if a question is answered positively, continue the dialogue with follow-up questions (as noted in italics).

As always, it is important to discuss confidentiality and its legal boundaries when establishing rapport and before taking a history.

Home 
Where do you live? How long have you lived there? Who lives at home with you? Do you have any pets? Do you feel safe at home? Do you feel safe in your neighborhood? Are there any guns or other weapons at home? How are they stored? Do you have access to them? 

Education  (Note: Often teens are more comfortable answering questions about school than their home life, so you may choose to begin with these questions in your HEADSS assessment.)

Where do you go to school? Have you changed schools recently? What grade are you in? What do you like or not like about school? What is your favorite or least favorite class? Do you feel safe at school? What are your grades like? What were your grades like last year? Do you have an IEP (individual education plan) in place? What do you want to do after finishing school? 

Activities/Employment 
What do you do for fun? What do you and your friends do together? Do you have a best friend? Are you in any clubs or teams? Do you have a job? What is your workplace environment like? Do you drive? Do you exercise? Do you feel comfortable with your body or weight? Do you feel comfortable with your eating habits? Do you ever think about ways to lose weight? Do you ever eat in secret? Do you have a goal weight? What has been your highest weight? Your lowest weight? Have you ever thrown up to lose weight? Do you use diet pills or laxatives?  

Drugs (Note: Often teens are more willing to talk about their friends than themselves, so it can be helpful to start with those.)  

Do any of your friends smoke or drink? Do you know anyone who smokes or drinks? Have you ever tried? Have you ever used other drugs (cocaine, methamphetamine, ecstasy, heroin)? Have you ever used needles? How often do you drink or use drugs? Have you ever had a blackout? Have you ever done anything you later regretted when drinking?

(Note: A good screening tool to include for drug use is the CRAFFT Questions [3], a brief screening instrument for adolescent substance abuse—2 or more yes answers suggest a serious problem.)

Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
Do you ever use alcohol or drugs while you are by yourself, ALONE?
Do you FORGET things you did while using alcohol or drugs?
Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
Have you ever gotten into TROUBLE while you were using alcohol or drugs?

Suicidality
Have you ever been so sad you thought about hurting yourself? Have you ever tried? Do you feel sad now? Have you ever run away from home? Have you ever cut yourself intentionally? 

Sex
Have you ever dated anyone? Boys, girls, or both? Have you ever kissed anyone? Have you ever had sex? Oral sex? Anal sex? How many sexual partners have you had? How old were you when you first had sex? Has anyone ever touched you in a way you did not want to be touched or forced you to do something you did not want to do sexually? Are you dating anyone now? How old is he or she? Do you like your boyfriend or girlfriend? Do you feel safe with him or her? Does your boyfriend or girlfriend ever get jealous? Has he or she ever hit you or pushed you? Are you sexually active now? When did you last have sexual intercourse? Did you use a condom with your last sexual encounter? Have you ever had a sexually transmitted infection? Have you ever been tested for HIV? Have you ever been pregnant? Have you ever traded money or drugs for sex? 

References
1. Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr. 1988;5:75.
2. Goldenring JM, Rosen D. Getting into adolescent heads: an essential update. Contemp Pediatr. 2004;21:64.
3. Knight JR, Sherrif L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156:607-614. 

Rachel Katzenellenbogen, MD, is a third-year fellow in adolescent medicine/STD research at the University of Washington in Seattle. She is currently conducting research on human papillomavirus with D. Denise Galloway at the Fred Hutchinson Cancer Research Center.