Assessment

Working effectively with young people experiencing difficulties with alcohol requires the establishment of good rapport. Barriers to effective consultation with adolescents have been extensively described in the past two decades and can be classified into four broad categories: availability, accessibility, acceptability, and equity of health services. Concerns about confidentiality and privacy have been identified to be a particularly important barrier to seeking professional assistance among young people, who cite embarrassment, shame, uncertainty about access to a health professional without an adult as well as cost, as barriers to care.

Peak bodies recommend that a broad medical and psychosocial history that screens for health risk behaviours and mental health disorders is best practice for engaging effectively with young people. A systematic review suggests that this improves health outcomes in young people, although high quality evidence is still needed.

Confidentiality

A fundamental principle in working with young people is to actively reassure the young person about the confidentiality of the consultation and its limits.

Psychosocial History

A psychosocial history includes information about the social, cultural, educational and vocational background of the adolescent. There are different acronyms such as HEADDSSS that provide a framework for taking a broad psychosocial history from adolescents (see table below). In addition, with regard to alcohol, a family history of heavy alcohol or drug use also impacts on adolescents’ development. Apart from genetic factors, social and environmental factors, such as being exposed to a family culture that accepts heavy drinking, may contribute to the development of alcohol use disorders in the children of those who drink heavily.

Polysubstance use is common among young people and it is therefore important to screen for use of tobacco and other drugs in addition to alcohol (see Chapter 20). In Australia, fewer adolescents and young adults are taking up smoking and the average age at which a full cigarette was first smoked is now around 16.3 years in 2016 (from 14.2 years in 2001). Daily smoking has also at least halved between 2001 and 2016 in both males and females. Currently, use of electronic cigarettes is relatively low in Australia, but younger people are more likely to have tried e-cigarettes and there are concerns about the implications of this for public health. Young adults in their twenties are the most likely age group to use cannabis, and the average age of first cannabis use is around 18.7 years (NDSHS 2017). This group also continues to be the most likely to have used illicit drugs in the past year (28% in 2016) although this has declined from 35% in 2001 (NDSHS 2017).

The HEADSS Assessment

The HEADSS Assessment
The HEADSS mnemonic forms the basis for an assessment that provides a ‘psychosocial biopsy’, an opportunity to develop rapport, assess risk and provide a guide to any necessary interventions.
H HOME ENVIRONMENT Where do you live? Who lives with you? How does each member get along? Who could you go to if you needed help with a problem? Parent(s) jobs? Recent moves? Wanted to run away? Are there new people at home?
E EDUCATION/EMPLOYMENT What do you like/not like about school/work? What can you do well/what areas would you like to improve on? How do you get along with teachers/other students? How are your grades; any suspensions? Changes? Many young people experience bullying at school – have you ever had to put up with this?
E EATING/EXERCISE Do you have meals with your family? Who cooks at home? Are you worried about your weight? Do you think you are too thin or too fat? Sometimes when people are stressed, they can over eat/under eat. Have you ever experienced either of these? In general, what is your diet like? In screening more specifically for eating disorders, you may ask about body image, the use of laxatives, diuretics, vomiting or excessive exercise and rigid dietary restrictions to control weight.
A ACTIVITIES AND PEER RELATIONSHIPS With peers? (What do you do for fun? Where? When?) With family? Sports - regular exercise? Hobbies? Tell me about the parties you go to. Do you belong to any clubs? How much TV would you watch a night? Favourite music? Any trouble? Crimes? Arrests?
D DRUGS/CIGARETTES/ALCOHOL Many people at your age are starting to experiment with cigarettes/alcohol. Have any of your friends tried these or maybe other drugs like marijuana, snorting or injecting drugs, etc? How about you, have you tried any? What effects have you found? Do you have any regrets? How much are you taking, how often and has frequency increased recently?
S SEXUALITY Some people are getting involved in sexual relationships. Have you had a sexual experience with a guy or a girl, or both? Degree and types of sexual experience? Number of partners? Masturbation/ contraception? Knowledge about STDs Has anyone ever touched you in a way that’s made you feel uncomfortable or forced you into a sexual relationship? (History of sexual or physical abuse?) How do you feel about relationships in general/about your own sexuality?
S SUICIDE/DEPRESSION/MOOD SCREEN How do you feel about yourself at the moment on a scale of 1 to 10? What sort of things do you do if you are feeling sad/angry/hurt? Is there anyone you can talk to? Do you feel this way often? Some people who feel really down often feel like hurting themselves or even killing themselves. Have you ever felt this way? Have you ever tried to hurt yourself or take your own life? What have you tried? What prevented you from doing so? Do you feel the same way now? Have you a plan, etc.?
S SAFETY Sun protection, immunisation, carrying weapons; for example, have you ever needed to carry a weapon to protect yourself? Have you ever driven a car or driven with someone who was ‘over the limit’ or high on anything?
S SPIRITUALITY Beliefs, religion, music, what helps them relax, etc .What are you best at? Do you believe in another higher power? Does your family have any religious beliefs? Do you agree with them?

The HEADSS mnemonic forms the basis for an assessment that provides a ‘psychosocial biopsy’, an opportunity to develop rapport, assess risk and provide a guide to any necessary interventions.

H HOME ENVIRONMENT

Where do you live? Who lives with you? How does each member get along? Who could you go to if you needed help with a problem?
Parent(s) jobs? Recent moves? Wanted to run away? Are there new people at home?

E EDUCATION/EMPLOYMENT

What do you like/not like about school/work?
What can you do well/what areas would you like to improve on? How do you get along with teachers/other students?
How are your grades; any suspensions? Changes?
Many young people experience bullying at school – have you ever had to put up with this?

E EATING/EXERCISE

Do you have meals with your family? Who cooks at home?
Are you worried about your weight? Do you think you are too thin or too fat?
Sometimes when people are stressed, they can over eat/under eat. Have you ever
experienced either of these? In general, what is your diet like?
In screening more specifically for eating disorders, you may ask about body image, the use of laxatives, diuretics, vomiting or excessive exercise and rigid dietary restrictions to control weight.

A ACTIVITIES AND PEER RELATIONSHIPS

With peers? (What do you do for fun? Where? When?) With family?
Sports - regular exercise? Hobbies? Tell me about the parties you go to. Do you belong to any clubs? How much TV would you watch a night? Favourite music?
Any trouble? Crimes? Arrests?

D DRUGS/CIGARETTES/ALCOHOL

Many people at your age are starting to experiment with cigarettes/alcohol. Have any of your friends tried these or maybe other drugs like marijuana, snorting or injecting drugs, etc? How about you, have you tried any? What effects have you found? Do you have any regrets? How much are you taking, how often and has frequency increased recently?

S SEXUALITY

Some people are getting involved in sexual relationships. Have you had a sexual
experience with a guy or a girl, or both?
Degree and types of sexual experience? Number of partners? Masturbation/
contraception? Knowledge about STDs
Has anyone ever touched you in a way that’s made you feel uncomfortable or forced you into a sexual relationship? (History of sexual or physical abuse?) How do you feel about relationships in general/about your own sexuality?

S SUICIDE/DEPRESSION/MOOD SCREEN

How do you feel about yourself at the moment on a scale of 1 to 10? What sort of things do you do if you are feeling sad/angry/hurt?
Is there anyone you can talk to? Do you feel this way often?
Some people who feel really down often feel like hurting themselves or even killing themselves. Have you ever felt this way?
Have you ever tried to hurt yourself or take your own life? What have you tried?
What prevented you from doing so? Do you feel the same way now? Have you a plan, etc.?

S SAFETY

Sun protection, immunisation, carrying weapons; for example, have you ever needed to carry a weapon to protect yourself?
Have you ever driven a car or driven with someone who was ‘over the limit’ or high on anything?

S SPIRITUALITY

Beliefs, religion, music, what helps them relax, etc .What are you best at?
Do you believe in another higher power? Does your family have any religious beliefs? Do you agree with them?

Source: Adapted from Goldenring, J & Cohen, E 1988,‘Getting into adolescent heads’, Contemporary Paediatrics, vol. 5, pp. 75–90.

Chapter	Recommendation	Grade of recommendation
12.3	Screening and brief intervention for health risk behaviours (including alcohol and drug use) and mental health disorders may improve health outcomes of young people.	B