This article has been reproduced from the original version that appeared in print in Contemporary Pediatrics, July 1988.
For most young people, adolescence is a time of growth and development, not of illness. When illness occurs, it is often related to the increased risk-taking behavior that is part of the normal adolescent process of exploration.
Unfortunately, exploration can be dangerous. The major cause of mortality in adolescents is motor vehicle accidents, more than half related to drug or alcohol use. Next in importance are homicide and suicide. Other causes of morbidity in adolescents include unwanted pregnancy, high levels of sexually transmitted disease (STD), eating disorders, and syndromes related to stress and depression. All of these problems are not easily amenable to the intervention of a physiologically oriented physician. In fact, they may not even show up on the standard review of systems that physicians are taught to perform.
The physician who sees adolescents must be willing to take an adequate psychosocial history. If it is not done, there is no chance of spotting problems early and making a significant impact on morbidity and mortality.
While a fellow at Los Angeles Children’s Hospital, Dr. Cohen refined a system for organizing the psychosocial history that was developed in 1972 by Dr. Harvey Berman of Seattle. The system has been used successfully in Los Angeles and New York City. This method structures questions so as to maximize communication and minimize stress. The approach is known by the acronym HEADSS, which stands for Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression (Table 1).
We generally suggest restricting the psychosocial interview to those times when the adolescent is relatively well, since this is the best time to obtain information with low stress. However, if the adolescent is in crisis in your office, you will have no choice but to dig out the underlying information. Furthermore, illness is a double-edged sword; it increases vulnerability but at the same time may increase the potential for trusting and seeking help.
The note you strike at the outset may affect the entire outcome. Parents, family members, or other adults should not be present unless the adolescent specifically gives permission. If the parents are present before the interview, we always introduce ourselves to the adolescent first. In fact, we ask the adolescent to introduce us to the other people in the room. This gives the adolescent a clear message that we are interested primarily in him.
It is not reasonable to expect an adolescent to reveal personal information unless confidentiality can be assured (See “Ensuring Confidentiality”). We tell adolescents that we ask certain questions because the information is integral to our understanding of their health. With the exception of physical or sexual abuse, or suicidal or homicidal behavior or intent, we do not immediately reveal sensitive information to parents or authorities. It is our goal to have the teenager make these revelations himself.
Often we do not begin by asking, “Why are you here?” Rather, we start with innocuous conversation, often geared to an observation about the teenager. We may comment about clothing that sends a message or some factor about the teenager’s preferences that we have heard from others. Or, we may simply make a lighthearted comment about our own day or current events.
This initial banter allows the teenager to release tension and tell us something about himself of which he is proud. Doing so inspires confidence, imparts the message that we are concerned and will actually listen to him, and allows him to be “one up” on the interviewer for a brief period. This lightens up the atmosphere and allows good communication to begin.
Occasionally, we pick up a message from the teenager’s body language—indications that he or she is depressed, euphoric, frightened, or angry. Sometimes we make a comment on this perception. This approach may cut to the heart of the problem, allowing the teenager to express a feeling. The expression is almost always a beneficial experience and may lead to important conversation.