As young people typically do not engage in health care services as frequently as people in other age groups, any encounter
should be considered as an opportunity to discuss their psychological and emotional wellbeing.
Performing a HEADS assessment
HEADS (sometimes referred to with multiple letters, e.g. HEEADDSSS) is a framework for a semi-structured interview conducted
during a consultation, which involves asking adolescents about their Home, Education and Employment, Eating and
Exercise, Activities and peers, Drugs and Alcohol, Depression and suicide, Sexual health, Safety and Strengths.Questions
covering these topics are flexible and intended to guide conversation rather than a rigid set of instructions
to follow (Table 2). Raising these issues may help a young person know that their clinician is interested
in their psychological and emotional health as well as their medical concerns. Even if a young person has no
particular concerns at that time, bringing up issues related to emotional wellbeing can build trust and act as
an invitation to discuss these issues in the future.
Clinicians will need to make a judgement based assessment of the psychological development and level of maturity of
the young person under their care in order to pitch their line of questioning and approach to the HEADS assessment at
an appropriate level. Questions should be framed in a way that avoids simple answers, such as “yes”, “no”, “ok”, “don’t
know”. For example, ask a question that requires a description rather than an opinion, such as: “What do you like about
school?” rather than “Do you like school?”.
There is no single correct way of performing a HEADS assessment; Table 2 highlights some of the topics that
can be discussed. Questions should be adapted to the circumstances of individual patients, and delivered in a
non-judgemental and informal way so that it does not sound like a test. If there is a particular presenting problem,
link as many of the questions as possible to this, e.g. exploring issues of sexual health or bullying.
Approaching the HEADS assessment:19
- Explain the purpose of the assessment so a young person does not wonder why they are being asked questions unrelated
to their visit, e.g. “I ask all the young people I see about how things are going in other areas of their
lives, because so many things are important for health, is that okay if we do that now?”
- Reiterate patient confidentiality
- Begin with topics that a young person is likely to find non-threatening: Starting with strengths and activities the
young person is good at can help ease into the conversation. Keep in mind that for many young people the
order of the questions may begin as non-threatening by starting the discussion with home and education environments before
moving onto topics they may be reluctant to discuss such as drug use and sex, but for some young people their home environment
may be a source of stress, so flexibility is important
- Asking about the activities of friends or peers can be an entry into sensitive topics such as drug use, i.e. “do any
of your friends smoke marijuana?”, “do you do it too?”
- Keep in mind that young people with depression may not label their experience as depression, and clinicians should
be alert for other signs such as a change in weight, altered behaviour or academic achievement at school, conflict with
others at home or other behavioural changes consistent with a diagnosis of depression20
- Record potential co-morbidities and the young person’s social, educational and family context in their notes 21
Closing off the HEADS assessment:
- Thank the young person for their answers and their honesty, reinforce their good health behaviours, remind them about
the confidentiality of their answers and ask if they have any questions
- Address any immediate safety issues which have been raised
- Reassure the young person – if it is appropriate, normalising their experience can help to place it in context so
that they do not feel like they are outliers or in some way unusual, e.g. body image concerns, “fitting in”, disagreements
with parents or uncertainty about sexuality
- Discuss which items they would like to address now. Acknowledge the emotional content of what they have told you before
introducing a logical potential solution; many young people are not yet fully able to use thoughts to control
- Make a plan with them for follow-up
N.B. Future articles in the mental health in young people series in Best Practice Journal will cover management strategies
for mental health problems identified during HEADS assessment.
A short video introduction to the HEADS assessment is available at:
For further information on HEADS assessment, see:
Screening for depression, suicide risk and substance use can be incorporated into the HEADS assessment
Depending on the information that is revealed from the HEADS assessment, further exploration of some topics may be warranted,
e.g. to examine feelings of depression or suicidal ideation or to assess for alcohol and drug misuse.
There are many different screening tools available for use in this situation; it is recommended that clinicians become
familiar with a few in particular that they are most comfortable using. Practices that use the bestpractice Decision
Support module for depression in young people can access a variety of these tools electronically.
The “depression in young people” module is nationally funded and available for any practice to install, free of charge.
For further information, see: www.bestpractice.net.nz/feat_mod_deprYoung.php
Research suggests that young people have a high acceptance rate for completing screening questions for psychosocial
issues in a self-administered format.22 Depending on the type of assessment tool being used, consider asking
the young person to go through the questions themselves in a private space, with the responses then reviewed by a clinician.
Keep in mind that some young people may have literacy issues or speak English as a second language so may require additional
help in completing the assessments.
Screening for depression and suicidal ideation
Evidence suggests that directly asking patients about depression and suicide is the best method for detecting and identifying
people at risk, rather than relying on patients to volunteer this information themselves.20
Examples of quick screening tools which show good sensitivity and specificity in research studies and are suitable for
use with young people in primary care include the Patient Health Questionnaire (PHQ-2) and Ask Suicide-Screening Questions
PHQ-2 consists of two questions: “Over the last two weeks, how often have you been bothered by either of the following
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
Responses can range from not at all (0 points), to several days (1 point), more than half the days (2 points) or nearly
every day (3 points). A combined score ≥3 across the two questions has a good sensitivity and specificity for detecting
young people with depression compared to more involved and lengthy screening questionnaires.23
ASQ involves asking young people:24
- In the past few weeks, have you wished you were dead?
- In the past few weeks, have you felt that you or your family would be better off if you were dead?
- In the past week, have you been having thoughts about killing yourself?
- Have you ever tried to kill yourself?
If the patient answers “yes” to Question 4, they should be asked how they tried to kill themselves and when. A “yes”
response to any of the questions would prompt further assessment and referral as appropriate.
Screening for alcohol and drug misuse
The CRAFFT screening tool is a validated method of detecting substance use problems in young people, and can be incorporated
into a conversation or used as a self-report questionnaire:25
- Have you ever been in car driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
- Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
- Do you ever use alcohol or drugs while you are alone?
- Do you ever forget things you did while using alcohol or drugs?
- Do your family or friends ever tell you that you should cut down on your drinking or drug use?
- Have you ever gotten into trouble while you were using alcohol or drugs?
Two or more “yes” answers indicate the need for a more detailed assessment.
The Substances and Choices Scale (SACS) is another tool that can be used to assess for misuse of alcohol and drugs in
young people. It can identify specific areas of concern that would prompt more in-depth assessment. As the tool measures
behaviour over the last month, it can also be used to monitor progress and outcomes during treatment for alcohol or substance
The young person can complete the SACS questionnaire themselves (the community version); there is also a more detailed
clinician version available. The main difference between the versions is that the community version only asks about alcohol
and cannabis use, with spaces to record other drug use. The clinician version names and asks about a wide range of substances.
When the clinician is administering the questionnaire, it is also recommended to ask about the use of other substances
not included on the list, such as herbal highs, party pills, sedatives and other latest “fad” drugs.
When the questionnaire is completed, the clinician can score the items to indicate whether further assessment or intervention
is indicated. When the questionnaire is used to monitor progress, the ticked boxes are connected with lines and the page
turned on its side to see the “SACS difficulties mountain range” and whether progress is “smooth” or “rocky”.
SACS was developed and validated in a New Zealand population, therefore is preferred to CRAFFT by some clinicians.
For an electronic version of SACS and a guide for administering and scoring the tool, see:
For further information on additional screening tools for mental health issues in young people, see: