Tagg, A. Mental Health Screening, Don't Forget the Bubbles, 2019. Available at:
This post accompanies the talk I gave at the adolescent health session of the Australasian College for Emergency Medicine Annual Scientific Meeting in Hobart.
Why is asking about mental health important?
According to the World Health Organisation, mental health disorders account for 16% of the global disease burden for illness and injury in those aged between 10 and 19 years of age. A study by Horowitz et al. looking at all adolescents presenting to an emergency department with non-psychiatric problems found that ~5.6% had suicidal ideation. 40% of those children (over 16) who have completed suicide had been to hospital with suicidal ideation in the previous year. Spotting them before they get to the point of no return is of vital importance.
In Australia 1 in 7 of 4 to 17 year olds are currently experiencing mental health problems and in the state of Victoria the number of adolescents presenting to the emergency department with problems appears to be increasing exponentially. According to Hiscock et al. the number of children presenting with mental health problems has increased by 46% from 2008-9 (n=5988) to 2015-16 (n= 8726) whilst the number of presentations due to physical problems has only increased by 13% over the same time frame.
Why don’t we do it?
It may seem, in the time poor world of the emergency department, as if it is just too hard to ask in depth questions about psychosocial problems. Most of us have had no formal training in what to ask and may be afraid that we don’t know what to do with the answers we are given. In one study at Evelina Children’s Hospital in London only 3% of teenagers had some form of psychosocial assessment. Introduction of a HEADSS proforma and an education session boosted this to 35%.
The history of the HEADS screening tool
Eric Cohen created the initial HEADS tool in the late ’80s as a refinement of something designed by Henry Berman in 1972. Extra letters were then added as the impact of modern day life was recognised as a major cause of morbidity and mortality.
Before we get started
Some of the questions we ask can be quite probing so it is important to gain trust before we launch into a HEADSS screen. As children transition to adulthood and pass through that awkward teen phase it is a great opportunity to talk to them about their healthcare, on their own. Parents might not like it, they might think you are hiding something from them but this consultation is about the patient (in the main) and what they need. They need to be given a safe space to open up and talk and that just cannot happen if they feel they might be judged. I explain the process to the parents then send them off to get a cup of tea. Once they have left earshot, only then can we begin.
I think it’s important that we can have an open discussion about what’s on your mind and so I’ve asked your Mum to step out for a bit. Some of the questions I’m going to ask you might seem a bit personal and if you don’t feel comfortable answering them that’s okay
Everything that you say in here is just between you and me, nobody else, with just a couple of exceptions. There are some things that, by law, I have to act on. If I think you are unsafe or at risk of harming someone then I have to say something. Everything else is between us. Do you understand?
In order to establish trust I start with talking about confidentiality and how anything* they might say is completely confidential, that I will not repeat anything they have said to their parents without their permission. Having made that statement I’ll use the HEEADSSS screening tool to guide my line of inquiry.
When using the tool though you it is worth parking some of your fundamentally privileged assumptions in that back car park that is miles from the ED and you are afraid to walk to on your own at night, and throw away the key.
- Not all children live at home with their mum and dad.
- Not all children go to school
- Not all children are heterosexual.
The Me first education and training resource from GOSH has some great examples of child centred language.
When asking about mental health it is not always a case of mother knows best. One study found that 1 in 13 (7.7%) of children questioned met DSM IV criteria for a recognised mental illness when they rated themselves. When their parents filled in the same survey they only met criteria 4.7% of the time.
- 1 in 10 (10%) adolescents have ever self-harmed.
- 1 in 13 (7.5%) had seriously considered suicide.
- 1 in 20 (5.2%) had actually made a plan.
- 1 in 40 (2.4%) have tried.
*It is important to recognise the times when this confidentiality must be broken – in cases of suspected abuse, for example.
The nitty gritty
As with all forms of history taking the way we ask a question determined the quality of the answer we get. Open-ended screening questions with enough time allowed (without interruption) for honest reflection and answers should be followed by more fact-finding probing questions.
is for HOME and homelife – that place that they spend their days when they are not at school or hanging around with mates.
Tell me a bit about your Mum and Dad?
Do you get on with your Mum and Dad?
Where do you live?
Who lives there with you?
What are things like at home?
What are the rules like at home?
What kind of things do you argue about the most?
Can you talk to anyone at home about stress?
is for EDUCATION or EMPLOYMENT.
How are you doing at school?
Are you in school?
Does your school feel like a safe place?
Have you ever been bullied at school?
What are you good at?
What is hard for you?
How much school have you missed this year?
School students that are having an episode of major depression have missed around 28 days of school and the vast majority (62.8%) have been bullied in the classroom, in the playground, or online.
is also for EATING and EXERCISE.
What do you eat?
Do you worry about the shape of your body or your weight?
What do you like or not like about your body?
Do you try things to manage your weight?
Have you ever made yourself throw up to lose weight?
Are any of your family or friends worried about your weight or your attitude towards your body?
is for ACTIVITIES.
Do you have any activities outside of school?
What do you do for fun?
What do you do with your free time?
What do you do with your friends?
What does a usual day involve for you?
How much TV do you watch? What are your favourite shows?
Some teenagers tell me they spend a lot of their free time online – what do you use the internet for?
It seems that teens at the latter end of the last century spent a lot of their free time outside, doing sports or playing with friends. Socialization now takes place inside in front of a computer screen or on the phone with over 90% of teens using social media apps such as Snapchat, Facebook and Instagram. Time spent in pursuit of ‘likes’ and ‘favourites’ is time spent in self-reflection and comparison with photoshopped perfection. It is no wonder that they find themselves falling short. There is a marked association between social media use and depressive symptoms.
It is worth mentioning at this point that social media can also be a force for good. Artificial intelligence can scour the big data of social media posts and identify words that are linked with suicidal ideation or intention. Once the algorithm has spotted the red flags you will be targeted, not with adverts for things you don’t really need, but for suicide prevention an mental health hotlines. This does raise huge questions about data privacy and fair use in this world of Big Brother.
is for those things our parents warn us about – DRUGS.
Do you do drugs?
What kind of drugs have you seen around school or at parties?Many young people experiment with drink or drugs. Have you or your friends ever tried them?
What have you tried?
And if they are taking something it is worth considering delving deeper to find out if they might have a substance use disorder. We all remember the CAGE mnemonic from medical school but our about using the CRAFFT?
One of the major differences between the CAGE and CRAFFT questions is that the latter also considers drugs other than alcohol.
is for SEX.
Have you ever had sex?
Tell me about your girlfriend?
Have you ever been involved in a romantic relationship?
Have any of your relationships been sexual ones?
How do you see yourself in terms of sexual preference? Are you interested in boys, girls, both, or not sure?
Have you ever had an experience in the past that you did not feel comfortable with?
and what we are all worried about – SUICIDALITY.
Do you ever feel stressed or anxious?
Do you feel sad or down more than usual?
Have you thought a lot about hurting yourself or other people?
According to the WHO the pooled estimate of completed suicides across all genders, countries and ages 10-19 is 3.77 per 100,000 population. Whilst the UK is at the lower end of the spectrum with 2.35 per 100,o00, New Zealand is one of the top three countries in terms of suicide rate at 9.36 per 100,000. What is even more concerning is that this rate appears falsely low due to the age spread. The rate of suicide in adolescent males (15-19) is a staggering 17.6 per 100,000! A number of theories have been put forward to explain the disproportionately high rate in young Māori males including intergenerational trauma, cultural isolation and identity confusion.
During the complex psychosocial development that takes place in teenage years thoughts of suicide progress to acts. It is beyond the scope of this post to cover all aspects of suicide risk assessment suffice to say you need to ask. There might be breadcrumbs in the assessment that you should follow. Poor sleep might presage anxiety or depression – both are linked with sleep disturbance.
is also what we are aiming for – SAFETY.
Have you ever deliberately harmed or injured yourself?
Have you ever put yourself in unsafe situations – risky driving, unsafe sex, that kind of thing?<
Do you belong to a group or gang?
Have you ever been in trouble with the police?
It is not so much about places of safety but how likely they are to engage in risk taking behavior – do they wear their seatbelt, make dodgy online dating choices?
What’s the alternative?
Unlike the world of Connor Macleod of the Clan Macleod, there can be more than one assessment tool. Each has their merits.
The HEADS-ED tool comprises of some of the key elements of the HEADSS screen, taking away a lot of the ambiguity thus making it easier to score. Because it also contains elements related to discharge strategies and resources it has been shown to be highly sensitive (82%) and specific (87%) in determining which adolescents need further psychiatric input in an inpatient setting. It’s based on some much longer screening tools such as the Childhood Acuity of Psychiatric Illness (CAPI) scale and the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH 3.0) scale.
It has been used as a tool in patients aged 12-16 years of age with triage complaints directly related to mental health concerns. These include anxiety, bizarre behaviour, depression, deliberate self-harm and suicidal behaviour. There is little data on how it works as a screening tool in the general teenage population. You can head to the HEADSS-ED online portal for a self-assessment version. It has pretty good inter-rate reliability compared to some of the other tools. As score more than 7 and a suicidality score of 2 has been linked with a sixfold increase in likelihood for admission.
The Headspace modification
Headspace is an Australian service that provides mental health support for clients between 12 and 25 years of age – over the phone, online and in person.. They have modified the HEEADSSS tool to add anxiety, psychosis and mania. One of the more useful additions is something we should all be using. It encourages a wrap-up summary of both the patient’s strengths and goals. An interview that only focuses on the negative aspects of a teens life might be seen as a form of de-motivational interviewing. The summary encompasses the 4 Ps – Predisposing factors, Precipitating factors, Perpetuating factors and Protective factors.
Chadia, Amari and Kaufman came up with this new century version of the traditional tool to encompass Transition, Home, Rx (medication), Education and eating, Activities, Drugs and Sexuality. The transition component considers those teens with chronic disease – such as diabetes or CF – that are coming to the end of their time in child-centred care.
The Ask Suicide Screening Questions toolkit was developed from a grant by the National Institute of Mental Health (NIMH) and comprises of just four questions. A positive response to any one question identified 97% of youths (10-21) at risk of attempting suicide. What are those questions?
- In the past few weeks have you ever wished you were dead?
- In the past few weeks have you ever felt your family would be better off if you were dead?
- In the past week have you ever had thoughts of killing yourself?
- Have you ever tried to kill yourself?
- Are you thinking of killing yourself right now?
Whilst these questions may appear blunt there is plenty of evidence to suggest that asking a suicidal person if they are contemplating an attempt is unlikely to push them over the edge.
It might be easier to take the problem out of the hands of individual clinicians who are afraid to ask questions. Innovative use of an iPad to pose the screening questions has proven useful with the end-users feeling comfortable about answering questions. This might be a useful lead-in to the conversation followed by more in-depth, and effective, face-to-face interaction.
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