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Using your HEADS-ED


Paediatric mental health (MH) admissions to emergency departments and hospitals are increasing worldwide, including in the UK, USA and Australia. COVID-19 has changed this somewhat, at least in the UK, with a decrease in presentations in the first national lockdown. As the UK and the rest of the world return to the “new normal” in 2021, it is likely that paediatric MH presentations could rise back to pre-covid levels. 

These presentations can be challenging to manage in the emergency department. A variety of tools have been developed to help with history taking and disposition, including the HEEADSSS, HEADS-ED, Risk of Suicide Questionnaire (RSQ) and many others. Here we take look at a recent paper looking at the utility of one of these scoring systems, the HEADS-ED.

Cappelli M, Zemek R, Polihronis C, Thibedeau NR, Kennedy A, Gray C, Jabbour M, Reid S, Cloutier P. The HEADS-ED: Evaluating the Clinical Use of a Brief, Action-Oriented, Pediatric Mental Health Screening Tool. Pediatr Emerg Care. 2020 Jan;36(1):9-15. doi: 10.1097/PEC.0000000000001180. PMID: 28538605

What is HEADS-ED?

The HEADS- ED was developed in 2012 as a tool specifically to obtain a psychosocial history from adolescents in the ED, when it was found found to predict psychiatric consult and admission to inpatient psychiatry with a sensitivity of 82% and a specificity of 87% (area under the receiver operator characteristic curve of 0.82, P < .01). This was a promising finding. 

What was the aim of the paper?

There was a composite primary aim:

  1. To examine the utility and decision validity of the HEADS-ED tool for Paediatric Emergency Department (PED) physicians in guiding consultations to psychiatry and crisis services for patients presenting with mental health concerns.
  2. To examine the concordance between PED physicians and crisis intervention workers (CIWs) in communicating the level of need and action required amongst a sub-sample for the patients. 

Where was the paper set?

This study was conducted in the PED at the Children’s Hospital of Eastern Ontario, Ottawa, a tertiary hospital with 70,000 annual visits a year. 3100 (4.5%) of these are related to mental health concerns. Approximately two-thirds of the MH patients are seen by the PED physicians who either discharge to the community or request a consultation with specialised MH services. Those who don’t need any medical care (other 1/3rd ) are referred directly to the CIWs.

What did they do? 

The HEADS-ED was added to the charts of every child aged 12 to 17 presenting to the ED with a MH concern, completed by the PED physicians. 

Only adolescents who had a complete HEADS-ED were included in the study. If they were younger than 12 or older than 17, or if their presentation was not with a MH concern, then they were excluded from the study.

What did they find? 

There were 2704 mental health presentations during the study period. After various exclusions for wrong age or incomplete or no HEADS-ED assessment, 639 adolescents were included in the study. Of those 140 (22%) were seen by the CIWs.

How good is HEADS-ED at predicting consultation or admission?

The study team looked at how well the screening tool corresponded to consultation for full psychiatric assessment and subsequent admission to inpatient care. 254 (39.7%) children and young people required a consultation by the CIW or psychiatrist. 96 (15.3%) were admitted. 

Chi-squared was applied to each of the seven HEADS-ED items to examine whether the scores correlated to request for consultation and subsequent admission.

  • Inpatient admission was highly associated with higher scores in education, activities and suicidality
  • Consultations with CIW or psychiatry was associated with higher mean HEADS-ED score (mean 6.91)
  • Those who did not need a consultation had a mean score 4.70 (n=254)
  • Those who were discharged had a lower mean score than those admitted (5.28 vs 7.21).

As the HEADS-ED score increased, the likelihood of admission did also. 

How reliable is the score at predicting admission?

  • A HEADS-ED score of 8 or more and a suicidality score of 2 led to 164% more requests for consults from the PED team (relative risk, 2.64; confidence interval, 2.28–3.06) 

How well did the PED and CIW scores correlated?

140 patients had the HEADS-ED completed by both PED physicians and CIWs. The PED physicians rated patients higher on all HEADS-ED items and composite scores compared with CIW; however, not all were statistically significant. 

Agreement on ratings ranged from 61.7% to 92.9% with the highest agreement being suicidality and lowest agreement being activities and peers.

Bottom line – Should I change my clinical practice after reading this paper?


The HEADS-ED can be useful in helping take a psychosocial history in adolescents in the PED.

This may help confer concern when referring to the MH team. It cannot currently be used as a risk assessment as this was a single centre site, in Canada. More work is needed to understand its external validity.  

Final words from Andy Tagg

Patients with mental health concerns are increasing in numbers. Rather than skip over them for something easy it is important that we all get comfortable with asking uncomfortable questions. One of the challenges of formal tools is that they rend to direct the conversation and turn it into a tickbox exercise rather than a free-flowinng conversation. Clinicians need to be able to jump from topic to topic as they develop rapport with the child or young person in front of them.

With four times as many exclusions as inclusions I wonder how well the clinicians did if they did not use the tool. My first instinct would be that clinical gestalt, in experienced clinicians, would be as useful, if not better than the HEADS-ED tool. Where I see the potential value is for those healthcare workers with less experience, that might need a little guidance along the way.


1. Lo CB, Bridge JA, Bridge JA, et al. Children’s mental health emergency department visits: 2007-2016. Pediatrics [Internet] 2020;145(6). Available from:

2. Irteja Islam M, Khanam R, Kabir E. The use of mental health services by Australian adolescents with mental disorders and suicidality: Findings from a nationwide cross-sectional survey. PLoS One [Internet] 2020 [cited 2021 Jan 3];15(4). Available from:

3. Lawrence D, Johnson S, Hafekost J, et al. The mental health of children and adolescents: Report on the second Australian child and adolescent survey of mental health and wellbeing [Internet]. Austrialian Government; 2015 [cited 2021 Jan 3]. Available from:$File/child2.pdf

4. Tolentino A, Symington L, Jordan F, Kinnear F, Jarvis M. Mental health presentations to a paediatric emergency department. Emerg Med Australas [Internet] 2020 [cited 2021 Jan 3];1742-6723.13669. Available from:

5. Williamson A, Skinner A, Falster K, Clapham K, Eades SJ, Banks E. Mental health-related emergency department presentations and hospital admissions in a cohort of urban Aboriginal children and adolescents in New South Wales, Australia: findings from SEARCH. BMJ Open [Internet] 2018 [cited 2021 Jan 3];8:23544. Available from:

6. UKParliment. Written questions and answers – Written questions, answers and statements – UK Parliament [Internet]. UIN 181292. 2018 [cited 2021 Jan 3];Available from:

7. Ougrin D. Debate: Emergency mental health presentations of young people during the COVID-19 lockdown. Child Adolesc Ment Health [Internet] 2020;25(3):171–2. Available from:

8. 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):e321-7. 

Other useful resources 

Andrew Tagg. Mental Health Screening, Don’t Forget the Bubbles, 2019. Available at:

Henry Goldstein. Adolescent Inpatient Psychiatry, Don’t Forget the Bubbles, 2017. Available at: 

Ester Sabel. The ABC of Self-Harm in Young People – A Psychiatric Approach to Resuscitation. 2019.  


  • Emergency Medicine Doctor with an interest in Paediatric Emergency Medicine. Interests in medical education, simulation, minor injuries, and mental health.

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