When is the HEADSSS (Home, Education/Employment, Activities, Drugs, Sexuality, Suicide/Depression, Safety) interview indicated for a 12‑18‑year‑old adolescent?

HEADSSS Interview Indications for Adolescents Aged 12-18 Years

The HEADSSS psychosocial interview should be conducted at every annual well-visit for all adolescents aged 12-18 years, during any acute care hospitalization, and whenever clinical concern arises about mental health, risky behaviors, or psychosocial stressors. 1, 2, 3

Universal Screening Framework

The American Academy of Pediatrics endorses the HEADSSS framework as a validated psychosocial assessment tool specifically designed for adolescent healthcare encounters 1. This structured interview is indicated in the following clinical scenarios:

Routine Preventive Care

• Annual well-child visits for all adolescents aged 12-18 years represent the primary indication for HEADSSS assessment, as recommended by national guidelines 1, 2
• New patient evaluations in this age group should include comprehensive psychosocial screening using this framework 1

Acute Care Settings

• Any hospitalization of an adolescent should trigger HEADSSS assessment, following the "no-missed-opportunities" paradigm, since teenagers frequently underattend routine outpatient visits 3
• Hospital-based clinicians can use acute care encounters to provide preventive services and risk-stratify adolescents who might otherwise go unscreened 3

Targeted Clinical Concerns

• When clinical suspicion exists for mental health problems, substance use, risky sexual behavior, or other psychosocial concerns 2
• Adolescents with chronic health conditions face higher risk of mental health problems and warrant systematic psychosocial assessment 2, 4

Strategic Implementation Approach

Establishing the Interview Environment

• Interview the adolescent alone after excusing parents/guardians, typically during the physical examination portion of the visit 1
• Explain confidentiality clearly at the outset, specifying that information remains private unless there is immediate risk of harm to self or others 1
• Start with less threatening topics (Home, Education) before transitioning to more sensitive areas (Drugs, Sexuality, Suicide), which improves adolescent engagement and disclosure accuracy 1, 2

Framework Components

The HEADSSS acronym covers eight essential domains 1:

• H - Home environment
• E - Education and employment
• E - Eating behaviors
• A - Peer-related Activities
• D - Drugs and alcohol
• S - Sexuality
• S - Suicide/depression
• S - Safety from injury and violence

Integration with Depression Screening

• Combine HEADSSS with PHQ-9 screening starting at age 12 years, as the USPSTF recommends universal adolescent depression screening beginning at this age 5
• The suicide/depression component of HEADSSS should include direct questions such as "Have you ever thought about killing yourself or wished you were dead?" and "Have you ever done anything on purpose to hurt or kill yourself?" 6
• Never dismiss suicidal thoughts as unimportant; safety takes precedence over confidentiality when adolescents are at risk to themselves or others 6

High-Risk Populations Requiring Enhanced Assessment

Certain adolescent populations warrant particularly thorough HEADSSS evaluation 7:

• Homeless or runaway youth demonstrate higher rates of school dropout, depression, active suicidality, substance abuse, early sexual debut, sexual abuse, and HIV risk 7
• Adolescents presenting with behavioral changes, such as irritability (which may be the primary manifestation of depression rather than sadness), oppositional behavior, or loss of interest in previously enjoyed activities 6

Common Pitfalls to Avoid

• Do not confuse HEADSSS with HEADSS (which omits the "Eating" component) or SSHADESS (which adds a strength-based component at the beginning) 1
• Avoid conducting psychosocial screening without clear protocols for managing positive findings; screening alone without intervention pathways does not improve outcomes 5
• Do not rely solely on brief screening tools like PHQ-2 for suicide risk assessment, as they omit the suicide item and can miss patients with suicidal ideation 5
• Remember that adolescents may disclose more on self-administered surveys than in face-to-face interviews, particularly regarding sensitive topics like emotions, drug use, sex, and safety 4

Documentation and Follow-Up

• Digital self-report HEADSSS surveys can be initiated by non-trained staff and take approximately 15 minutes, showing significantly higher disclosure rates across all psychosocial categories compared to traditional interviews 4
• When risky behaviors or mental health concerns are identified, arrange appropriate counseling or intervention during the visit, with an outpatient follow-up plan established before discharge if in an inpatient setting 3
• Positive screens should trigger referrals to mental health and allied health professionals to provide at-risk youth with necessary support at early stages 8