Social History and Interview

Why is the social history so important for adolescents?

Adolescent patients are at a unique stage in life: They are old enough to make decisions about their health and young enough for those decisions — often prone to lack of insight and concern about the long-term consequences — to have a significant impact. For example, 17-year-olds have enough autonomy to improve their diet but may not prioritize the long-term benefits of healthy nutrition and exercise over short-term satisfaction or convenience. Health-care providers have the opportunity to impact lifetime health by helping adolescents avoid substance use, encouraging safe sexual choices, diagnosing learning disorders, treating mood disorders, and encouraging a healthy relationship with food.

Because adolescents are often physically healthy, the primary goal of the annual visit is to help them reflect on behaviors that can improve or impede health and well-being, and then partner with them to support these healthy habits. When adolescents are managing chronic health conditions, it is equally important to address how health-related social behavior can negatively affect their health, especially because these behaviors may be overlooked by family and other providers focused on chronic disease management. Therefore, the social history can make up most of an annual well physical.

Confidentiality

Adolescents are less likely to be honest if they are worried that providers will share information about sensitive behaviors with family or friends, thus diminishing a clinician’s ability to be helpful. Teens should be informed about confidentiality and its limits at every visit. It may be helpful to include parents in the confidentiality discussion so that everyone understands that topics covered when a parent is out of the room will stay with the medical team unless an acute safety concern arises (e.g., hurting oneself, hurting others, or being hurt by others). State laws in the U.S. vary about what information can stay confidential, although safety concerns must always be reported to a parent or guardian. Therefore, it is critical to know local laws. An overview of minors’ consent law can be found here.

Electronic medical records and insurance billing are areas where confidentiality may be inadvertently broken. It is important to know the safeguards your institution and insurers use to protect patient information and be thoughtful about sharing information (e.g., in notes released online or documenting results).

While doing your best to provide a safe space in the clinical encounter, encourage adolescent patients to discuss sensitive topics with parents, assuming it is safe to do so.

Approaches to the Social Interview

Using a framework for addressing social factors that can influence a patient’s health and well-being offers an efficient way to identify areas of greatest concern, praise areas of success, and use these strengths to promote new challenges. Popular frameworks for the social history include the HEEADSSS psychosocial interview and the SSHADESS assessment (described below).

The HEEADSSS psychosocial interview: The HEEADSSS interview is a structured approach to adolescent psychosocial assessment. The acronym stands for Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety. To foster rapport and conversation, the interview starts with less personal questions and progresses to more-sensitive questions. If the adolescent takes the conversation in a different direction, follow the patient’s lead, and return to the framework as needed. The following table provides sample questions for each topic in the HEEADSSS interview.

(Source: Contemporary Pediatrics 2014. These materials are the sole and exclusive intellectual property of UBM LLC. All rights reserved. Reprinted with permission.)

(Source: Contemporary Pediatrics 2014. These materials are the sole and exclusive intellectual property of UBM LLC. All rights reserved. Reprinted with permission.)

Strength-Based Approaches to Social History

Regardless of the psychosocial assessment tool used, providers have a unique opportunity to help adolescents recognize their strengths, develop skills to build on these assets, and help them thrive as adults. Providers are more likely to offer meaningful and effective advice by emphasizing what patients do well, encouraging reflection on behaviors they would like to change, and offering guidance that is specific to the goals and desires of the patient.

The SSHADESS Screen (Strengths, School, Home, Activities, Drugs and Substance Use, Emotions, Sexuality, and Safety) is a strength-based approach to social history. SSHADESS is similar to HEEADSSS but begins by emphasizing a youth’s strengths to help increase their comfort with the interview and to promote confidence to change concerning behaviors.

Motivational interviewing: Motivational interviewing is a counseling approach designed to help individuals identify and overcome their ambivalence toward making positive changes in their lives. Motivational interviewing can be particularly effective when working with adolescents who may be resistant to change and struggle with feelings of uncertainty, fear, and self-doubt.

Conversations to elicit adolescents’ intrinsic desire for behavior change are often most effective when providers use motivational interviewing strategies that emphasize autonomy, provide information, use reflective statements to summarize and affirm, and ask questions to explore patients’ perspectives and ideas. These skills, which are grounded in careful listening and reflection, allow providers to focus the conversation on shared purpose, evoke desire and resources for change, recognize ambivalence, and, when the youth is ready, partner to provide advice and determine goals.

Promoting healthy adolescent development: Motivational interviewing can be used both to support behavior change and promote healthy adolescent development. Healthy adolescent development has been conceptualized as:

Many of these concepts are also encapsulated in the Circle of Courage Model for positive youth development based on Native American child-rearing principles. This framework conceptualizes the areas of development as belonging, mastery, independence, and generosity.

Substance Use Screening

Adolescents are developmentally vulnerable to substance use, which is a common but unhealthy way for them to fulfill a normal inclination for reward. This behavior may have significant immediate consequences and increase risk for a future substance use disorder. In the last decade, trends that contributed to substance use among youth included the emergence of vape devices and increased nicotine use, reduced perceptions of marijuana-related risks associated with legalization of commercial marijuana, and the availability of synthetic opioids, which has also led to a dramatic increase in adolescent overdose deaths.

Pediatricians have an opportunity to address substance use in primary care, yet time limitations, concerns about categorizing risk, insufficient substance use education, and limited referral resources for problematic use are barriers to comprehensive screening and brief intervention.

Fortunately, the American Academy of Pediatrics (AAP) has published policy statements and a clinical report on Screening, Brief Intervention, and Referral to Treatment (SBIRT) to provide pediatric-specific guidance on implementing substance use prevention, detection, assessment, and intervention practices in varied clinical settings. Multiple online and print resources are also available to help clinicians efficiently detect substance use, categorize risk, and formulate a response (see Additional Resources).

Multiple tools can be used to screen for adolescent alcohol, tobacco, and drug use, including:

• Screening to Brief Intervention (S2BI; see figure below)

• Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD)

• CRAFFT (Car, Relax, Alone, Forget, Family/Friends, Trouble)

These tools are meant to provide efficient yet comprehensive screening that is easily implemented in clinical situations and to stratify the level of substance use to guide appropriate interventions. Each provides feedback on an individual’s risk of substance use disorder that providers can use to structure a brief intervention as described below:

• If patients report no substance use, briefly praise them for their healthy choice. It may be helpful to note that a growing proportion of adolescents are making the choice to avoid substance use.

• If patients report occasional use, briefly evaluate consequences of use (e.g., trouble at school, changes in athletic performance) and discuss potential future negative effects of continuing use (e.g., friend/family disapproval, addiction).

• If patients are at high risk for a substance use disorder, endorse high-risk use (e.g., use of opioids, injection use, prior overdose), or have been unable to reduce substance use, motivational interviewing as described above can be used to promote behavior change or referral to specialized treatment may be warranted, both with close follow-up.

(Source: Substance Use Screening, Brief Intervention, and Referral to Treatment. Sharon J.L. Levy, MD, MPH, FAAP, and Janet F. Williams, MD, FAAP, Committee on Substance Use and Prevention. © Boston Children’s Hospital, 2018. All Rights Reserved. This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License.)