Screening Adolescent Health

Screening Adolescent Health

Structures the comprehensive adolescent well-visit (ages 11-21) using the HEEADSSS psychosocial interview framework, Bright Futures anticipatory guidance, confidential risk-behavior screening, and age-appropriate preventive service delivery including immunizations, laboratory screening, and mental health assessment.

Why This Skill Exists

Adolescents have the lowest healthcare utilization rate of any pediatric age group despite bearing the highest burden of risk behaviors — substance use, unprotected sex, self-harm, and reckless driving. The HEEADSSS framework (Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, Safety) is the gold standard for structured psychosocial assessment but requires deliberate confidentiality protocols to elicit truthful responses. This skill ensures every adolescent encounter covers required preventive services, builds rapport through confidential time, and applies validated screening tools for the conditions that drive adolescent morbidity and mortality.

Checkpoint A — Intake Verification

Required Intake Questions (Pre-Confidential, With Parent Present)

1. What is the adolescent's age and grade level?
2. What concerns does the parent/guardian have?
3. What is the family medical history (obesity, diabetes, cardiovascular disease, mental health, substance use)?
4. What is the immunization status (see managing-immunization-schedules skill)?
5. Is there a history of chronic conditions or hospitalizations?

Confidentiality Setup (CRITICAL)

• Explain confidentiality to BOTH parent and adolescent at the start of the visit
• State explicitly: "I'm going to spend some time talking with [patient] alone. This is routine for teen visits. What you share with me is confidential unless I'm worried about safety — like someone hurting you, you hurting yourself, or you hurting someone else."
• Document that confidentiality was explained and agreed upon
• Know your state's minor consent laws for: contraception, STI testing/treatment, substance abuse treatment, mental health services

Required Documents

• Prior well-visit notes
• Immunization record
• School records or IEP/504 if applicable
• Any completed pre-visit screening questionnaires (PHQ-A, CRAFFT, GAPS)

Step 1 — HEEADSSS Psychosocial Interview

Conduct the following interview domains with the adolescent alone (confidential time):

H — Home

• "Who lives at home with you?"
• "How do you get along with the people at home?"
• "Have you ever felt unsafe at home?"
• "Have you recently moved or had changes in your living situation?"
• Red flags: homelessness, foster care transitions, domestic violence, parental substance use

E — Education/Employment

• "What grade are you in? How are your grades?"
• "Have you ever been held back, suspended, or expelled?"
• "Do you have a job? How many hours per week?"
• "Do you feel safe at school?"
• Red flags: dropping grades, truancy, bullying (victim or perpetrator), work > 20 hrs/week interfering with school

E — Eating

• "Are you happy with your weight? Are you trying to lose or gain weight?"
• "Do you ever skip meals, make yourself throw up, or use laxatives or diet pills?"
• "How many meals do you eat per day?"
• Screen: SCOFF questionnaire if disordered eating suspected (score ≥ 2 = positive)
• Red flags: BMI extremes, body dysmorphia, purging behaviors, excessive exercise

A — Activities

• "What do you do for fun? Who do you spend time with?"
• "How much time do you spend on screens/social media per day?"
• "Are you involved in sports, clubs, or community activities?"
• "Do you have access to firearms at home?"
• Red flags: social isolation, excessive screen time (> 4 hrs recreational), firearm access without safe storage

D — Drugs

• "Have you ever tried alcohol, cigarettes, vaping, marijuana, or other drugs?"
• Administer CRAFFT 2.1 screening tool:
  • Part A: past 12-month use of alcohol, marijuana, other substances, vaping/tobacco
  • Part B (if any "yes" in Part A, or for all patients ≥ 12):
    1. Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?
    2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
    3. Do you ever use alcohol or drugs while you are by yourself, or Alone?
    4. Do you ever Forget things you did while using alcohol or drugs?
    5. Do your Family or friends ever tell you that you should cut down on your drinking or drug use?
    6. Have you ever gotten into Trouble while you were using alcohol or drugs?
  • Score ≥ 2: positive screen → brief intervention and possible referral (SBIRT)

S — Sexuality

• "Are you in a relationship? Have you ever been in a romantic relationship?"
• "Have you ever had sex (oral, vaginal, anal)?"
• If sexually active: "Do you use condoms? What birth control method?"
• "Have you ever been pressured or forced into sexual activity?"
• "Are you attracted to males, females, both, or are you not sure?"
• Screen for STIs if sexually active: chlamydia/gonorrhea (annually for sexually active females ≤ 25; all MSM), HIV (at least once for ages 15-18 per USPSTF)
• Provide LARC counseling (IUDs, implants) per AAP for sexually active adolescents

S — Suicide/Depression/Self-Harm

• Administer PHQ-A (Patient Health Questionnaire for Adolescents) or PHQ-2 as screen
  • PHQ-2 ≥ 3: administer full PHQ-9
  • PHQ-9 ≥ 10: moderate depression — initiate treatment discussion
  • PHQ-9 ≥ 20: severe — urgent behavioral health referral
• Ask directly: "Have you ever thought about hurting yourself or ending your life?"
• If yes: assess plan, means, intent, and timeline using Columbia Suicide Severity Rating Scale (C-SSRS)
• Red flags requiring immediate action: active suicidal ideation with plan/means, self-harm scars, recent attempt

S — Safety

• "Do you always wear a seatbelt?"
• "Do you text while driving?"
• "Have you ever been in a physical fight?"
• "Do you have access to guns at home?"
• "Is there anyone in your life who has hurt you or who you're afraid of?"
• Firearms: counsel on safe storage (AAP recommends no guns in homes with children; if present, locked/unloaded/stored separately from ammunition)

Step 2 — Preventive Services Delivery

Immunizations Due at Adolescent Visits

• Tdap (11-12 years)
• HPV series (11-12 years, catch-up through 26)
• MenACWY (11-12 years, booster at 16)
• MenB (16-23 years, shared clinical decision)
• Annual influenza
• COVID-19 per current ACIP schedule

Laboratory Screening

Vision and Hearing

• Vision screening at 11-14, 15-17, 18-21 per Bright Futures
• Hearing screening once during adolescence per Bright Futures

Step 3 — Anticipatory Guidance

Provide age-appropriate counseling on:

• Nutrition: calcium (1300 mg/day for ages 9-18), iron (menstruating females), balanced diet
• Physical activity: ≥ 60 minutes moderate-to-vigorous daily
• Sleep: 8-10 hours for ages 13-18 per AAP; limit electronics before bed
• Driving safety: graduated licensing, no distracted/impaired driving
• Social media: discuss cyberbullying, online predators, screen time limits
• Consent and healthy relationships: boundary-setting, recognizing abuse
• Academic planning: school engagement, future goals

Checkpoint B — Adolescent Health Screening Review

• Confidentiality explained to both parent and patient; documented
• HEEADSSS assessment completed across all 8 domains
• CRAFFT 2.1 administered and scored (if any substance use history)
• PHQ-A or PHQ-2/9 administered and scored
• Suicide risk assessment completed if PHQ positive or clinical concern
• Immunizations reviewed and administered (or refusal documented)
• Laboratory screening ordered per guidelines
• STI screening offered if sexually active
• Contraception counseled if applicable
• Anticipatory guidance provided and documented
• Safety assessment (firearms, seatbelts, violence) completed
• Referrals placed for any positive screens (behavioral health, substance use, nutrition)
• Follow-up plan communicated
• All [VERIFY] flags resolved or escalated

Quality Audit

Guidelines

• Follow AAP Bright Futures 4th Edition for adolescent periodicity schedule and anticipatory guidance
• Use HEEADSSS framework (Goldenring & Rosen, updated) for psychosocial interview
• Administer CRAFFT 2.1 per AAP/SBIRT (Screening, Brief Intervention, Referral to Treatment) model
• Use PHQ-A (or PHQ-2 → PHQ-9 sequential approach) per USPSTF depression screening recommendation for ages 12-18
• Apply Columbia Suicide Severity Rating Scale (C-SSRS) for positive suicide screens
• Follow ACIP immunization schedule for adolescents 11-18
• Follow USPSTF recommendations for HIV screening (grade A, ages 15-65)
• Follow AAP policy on firearm injury prevention and counseling
• Confidentiality: follow state minor consent laws; break confidentiality only for: imminent danger to self, imminent danger to others, suspected abuse/neglect, reportable communicable diseases per state law
• SCOFF questionnaire for eating disorder screening: validated for ages 12+
• This skill produces clinical screening documentation; it does not replace clinical judgment