While the "excitement" of the Emergency Department that is seen on TV may make people think that the only skills we need are those that help us manage Critical Illnesses or Traumatic Injuries, as we have digested in prior Morsels (ex, Developmental Milestones, Formula Primer, Vegan Diets) all aspects of patient care are important for us to be adept at. One such vital aspect of pediatric emergency medicine is the appreciation of how psychosocial history impacts a patient's life and care. This is particularly true for vulnerable adolescents. As previously mentioned by Dr. Richardson, adolescents use the Emergency Department as their Primary Care resource often. Let's review an important tool to help us account for the impact of important psychosocial aspects in our adolescent patients in our ED - the HEADSS Assessment in the Ped ED:
THE HEADSS Assessment: An ED-focused HEADSS
The HEADSS assessment is a systematic approach to obtaining a psychosocial history from adolescents. Here is a streamlined version that we can apply easily in the ED:
- Home: Safe at home? Who lives in the home?
- Education: What school do you go to? Safe at school?
- Activities: What do you like to do for fun?
- Drugs: Have you smoked or vaped? Do you any kind of drugs, alcohol or pills to get high/drunk?
- Sex: Have you ever had sex with your mouth/vagina/penis/butt? Would you like confidential HIV/STD screening today? How do you prevent pregnancy? Would you be interested in birth control and/or condoms today?
- Suicide: Have you felt down or depressed in the last two weeks? Any thoughts of hurting yourself or others?
THE HEADSS Assessment: Important Points
Why we should talk to teens alone?
- Respect their personal privacy - Adolescents are more likely to seek care for sensitive issues when providers respect for their privacy.
- It is good practice - The standard of care is for providers to respect teen's autonomy as much as possible.
- Know your state's rules: The AAP has compiled a list of state-by-state policies.
But Doc, what do I say to the parents/guardians?
- While this may cause some apprehension, we should not allow this discomfort to prevent us from delivering the best care for our patients.
- Most parents will not only be comfortable with this, they will expect and appreciate it.
- Example: "I like to respect all of my patient's autonomy and to ensure that I am giving the best care to your child, I believe it is important to speak with her/him alone briefly. I would I'd like to talk to your teen about sex, drugs, and important things about her/his health. I will only share information with parents/guardians if I am worried about their safety. I may offer additional treatments if needed. Please wait in the waiting room and I will come to get you."
But Doc…. Why should I take the time to ask these awkward questions if I have the time?
- Social histories, especially in teens, can change our differential diagnoses and identify high-risk behaviors and safety concerns.
- Home
- A teen who lives with a romantic partner or a non-biological family member might be a red flag for human trafficking.
- For a 16-year-old girl who presents to the ED with a forearm fracture, asking confidentially about the home environment can help us differentiate an accidental vs. assault
- If we don't ask, we won't know
- Education
- Activities
- Take a brief opportunity to learn about your patients and connect with them
- Drugs
- For a teen with a history of vaping/cocaine use that their parents are not aware of, maybe this chest pain isn't "just" anxiety
- If we don't ask, we won't know!
- Sex
- 1/3 US high schoolers are having sex [Youth Risk Behavior Survey 2021]
- Adolescents with higher levels of risky sexual behavior are more likely to report the ED as their usual source of care. [Wilson, 2000]
- Is this dysuria a UTI or could this be chlamydia that could re-present with pelvic inflammatory disease next week?
- Could this flu-like illness if a patient who has multiple sex partners actually be HIV?
- If we don't ask, we won't know!!
- Suicidality
- Suicide is the 3rd leading cause of death in the USA for people 10-24 years.
- In a teen who presents with vomiting and abdominal pain, is this "just" viral gastroenteritis, or could this be a Tylenol overdose?
- Teens are more forthcoming privately
- If we don't ask, we won't know!!!
Moral of the Morsel
- This is our lane. Adolescent patients often rely on us in the ED as the source of their primary care.
- Be Vigilant! A HEADSS assessment can help broaden our differential and recognize badness
- Ignorance may not be blissful! If we don't ask, we won't know!
- It is a matter of Respect! Respect and Protect patient privacy - know your state's laws.
References:
Goldenring, J, Cohen, E (1988) Getting into adolescents heads. Contemporary Pediatrics, July: 75-80.
Cohen, E, MacKenzie, R.G., Yates, G.L. (1991). HEADSS, a psychosocial risk assessment instrument: Implications for designing effective intervention programs for runaway youth. Journal of Adolescent Health 12 (7): 539-544.
Cappelli M, Gray C, Zemek R, et al. The HEADS-ED: a rapid mental health screening tool for pediatric patients in the emergency department. Pediatrics. 2012;130(2):e321-e327. doi:10.1542/peds.2011-3798
Borowsky IW, Taliaferro LA, McMorris BJ. Suicidal thinking and behavior among youth involved in verbal and social bullying: Risk and protective factors. Journal of Adolescent Health 2013; 53:S4-S12.
Marianne Sharko, Rachael Jameson, Jessica S. Ancker, Lisa Krams, Emily C. Webber, S. Trent Rosenbloom; State-by-State Variability in Adolescent Privacy Laws. Pediatrics June 2022; 149 (6): e2021053458. 10.1542/peds.2021-053458
Szucs LE, Pampati S, Li J, et al. Impacts of the COVID-19 pandemic on sexual behaviors and receipt of sexual and reproductive health services among high school students—Youth Risk Behavior Survey, United States, 2021. In: Youth Risk Behavior Surveillance—United States, 2021. MMWR Suppl 2023;72(No. Suppl 1):55–65.
Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatr Adolesc Med. 2000;154(4):361–5.
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