(questions in bold are most essential)
Before you start screening, it is important to build trust with your adolescent patient in order to develop a therapeutic relationship and foster honest responses. In order to build trust, consider:
- Interview the adolescent patient without their parents in the room. At times it might be difficult to ask parents to leave the exam room, but below is one approach:
“Your child is getting older and teenagers sometimes have things on their mind that they want to keep private. We like to give teens a chance to talk to their doctor (or other health care provider) alone so they can bring up these concerns. I put some time aside at each appointment to talk to them individually about their health concerns, decisions and behaviors. Afterwards, I can bring you back into the room and we can wrap up the appointment together.”
- Clearly explain your confidentiality policy right from the start. Accepted practice is that providers will only break confidentiality if and when an adolescent states that they want to harm themselves or others or that someone is harming them ( in most states, if not all, we are mandated reporters for abuse and neglect). You can explain this by saying:
“As your doctor, I respect your confidentiality. This means that the things we talk about will just stay between the two of us. (It is important to note that in hospitals or clinics, information is documented and goes into charts or electronic records that are accessible to the institution. Or there may be other team members involved in the treatment. It is better to say “The information does not leave the hospital” or will stay among the team” or something that reflects the real situation). It is important that you feel comfortable talking about important things so that I can give you medical advice and recommendations based your specific situation. The only exception to my ability to keep your information confidential is if you tell me you are going to harm yourself or others or if someone is harming you. As your doctor, I want to keep you and everyone healthy so if you have thoughts or intentions to harm yourself or others, then I would have to tell the appropriate people to prevent that from happening. Do you have any questions about this?”
- The order of the questions is important – especially for males – moving from most neutral to most severe symptoms. Also, the order in which the disorders are queried is important, going from least severe and most common to most serious. Questions should aim to target the most universal symptoms of each diagnostic category.
- Use the HEADDSSS approach because it goes from least to most invasive questioning fostering increasing trust as the encounter proceeds:
H: Home (who lives at home, dynamics, concerns, smokers in the home)
E: Education/Employment (school, grade, grades/evaluations, learning disabilities, bullying/harassment, jobs)
A: Activities (sports, clubs, what do they do with their free time)
D: Drugs (alcohol, smoking, marijuana, IV drug use, anabolic steroid , supplement use, medication misuse)
D: Developmental Concerns (independence, autonomy, judgment, appropriate socializing, risk-taking)
S: Safety (including access to firearms, gang involvement, intimate partner violence)
S: Sex (gender identity, sexual orientation, current relationship, comprehensive sexual history, contraception use/understanding)
S: Suicidality (and Mood/Anxiety Assessment)
Do you have friends who are concerned about their weight? Are you concerned about your body (image) or weight? Have you gained or lost weight recently? Do you know how to tell if you are too heavy, too light, or just right? How do you feel right now? Are their foods you try to avoid? Why? Do you avoid fats? Do you know that your body needs to metabolize fats to function normally and to not get any fat can lead to medical problems? Do you do anything to change your weight? Have you ever dieted? Have you ever restricted your diet, tried to eat less, or skipped meals in order to lose weight? Have you ever made yourself vomit in an effort to lose weight? Do you Calorie count or always look at nutrition labels before eating foods? Why? Does anyone you know? Do you take pills, laxatives, vitamins or any other supplements or medications to change your body shape or to change your appetite? Does anyone you know? Do you ever over-indulge or over-eat? How often? Do you think this is a problem for you? Why? Do you use steroids or sports supplements (such as powdered protein or creatine drinks) to make yourself stronger? Does anyone you know? Do you participate in sports or exercise regularly? How much? Why do you exercise? Do you exercise solely for the reason of losing weight or burning off calories? What would you do if you had a problem with your eating or you were concerned that a friend had a problem? Do you know anyone who has a problem with their eating? Have you talked to them about it or tried to get help for them? Do you ever feel guilty about your eating? How often do you feel this way? Why? Adapted from Abigail H. Natenshon, http://www.empoweredparents.com Do you participate in sports? |
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Are you in a romantic relationship? Have you ever been? Have your friends started dating? Have you been on a date? What kinds of things do you do on dates? Have any of your relationships ever been sexual relationship? What does it mean to you to be in a “sexual relationship”? Do you have any friends in sexual relationships? Have you ever had sex? How old were you the first time you had sex? Do you have any specific concerns related to relationship, dating, sex, or sexuality? Where do you get information about sex? Have you talked about sex in school/health class? With your friends? With your parents or any family members? Do you trust the information you receive? Do you have any questions? |
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Have your partners been female, male or both? How would you describe your sexuality and sexual orientation? Is there a term that you prefer I use? Have you ever liked someone of the same-sex? Do you know that straight people can have same-sex attractions, especially in adolescents? Do you know anyone who is gay, lesbian, bisexual, asexual, questioning or queer (LGBAQQ)? Do you have any friends or do any of your friends have parents who are LGBAQQ? What challenges do they face? Are you being bullied or teased because of your real or perceived sexual orientation? Do you know anyone who has been? Has anyone spread rumors about your sexual orientation? Are you afraid for your safety at all? (If pt has same sex attractions or identifies as LGBAQQ): (If pt has same sex attractions or identifies as LGBAQQ): (If pt has same sex attractions or identifies as LGBAQQ): Are you having any thoughts of wanting to hurt or kill yourself? |
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Do you have any concerns about your gender? How do you define your gender? Do you have the sense that your body does not match your gender identity? Have you ever been bullied or teased about your real or perceived gender? Do you known anyone who is? Has anyone spread rumors about your gender? Are you afraid for your safety at all? (If pt identifies as transgender): (If pt identifies as transgender): (If pt identifies as Female-to-Male transgender or Male-to-Female): (If pt identifies as Female-to-Male transgender): Are you having any thoughts of wanting to hurt or kill yourself? |
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How many sexual partners have you had? What kind of sex do you have? Have you ever had anal or oral sex? What do you know about STIs/STDs? What do you know about HIV/AIDS? What is your plan to prevent yourself from getting STIs/STDs and HIV/AIDS? Do you think you are at risk for an STI/STD or HIV/AIDS? Why? Have you ever been tested or treated? Do you know where you can get testing? Would you like to get tested for STIs/STDs and HIV/AIDS? Do you ever talk to your partner about their STI/STD and HIV/AIDS status? Has your partner been tested? How do you know? Have you talked about getting tested together? If you have female partners, are you aware that birth control (such as “the pill” or IUD, etc.) does not prevent STIs/STDs or HIV/AIDS? Do you know how to use condoms? Do you have condoms? Did you use condoms every single time you have had sex, including anal and oral sex? Do you know where you can get them? Has anything ever gotten in the way of using condoms? Have you ever had sex while you were intoxicated (drunk or high)? Have you ever had sex for money, drugs, gifts or other things? |
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Reproductive Life Plan & Pregnancy Prevention/Preconception Care |
Do you know how to use condoms? Do you have condoms? Did you condoms them every single time you have had sex, including anal and oral sex? Do you know where you can get them? Has anything ever gotten in the way of using condoms? (For male patient who report having sex with men) Have you ever had a sexual relationship with a woman? Have you ever gotten someone pregnant? Are you worried that could happen? Why? What are you and your female partners using for birth control? Have you talked to your female partners about what they are using? Do you know what options are available to girls? Do you know what options are available to boys? Are you satisfied with the methods you have chosen? Do you know what “Plan B” is? Do you know that if your female partners want “Plan B” that you, as a guy, can buy it for them? Do you know how to get it? Have you ever thought about having a family? Have you thought about being a father? How does being a father fit with your other goals and aspirations (e.g. going to college, getting a job, etc.)? Do you know anyone your age who is a father? What challenges do they face? Have you ever used a condom? |
Do your partners respect you? What does it mean for them to respect you? Did they ever hurt you in any way? Are your sexual activities enjoyable? Are you ever forced to do things you do not want to? What does “safe sex” mean? Have you ever heard of the term “relationship violence”? Do you know anyone who has been in a violent relationship? Have you ever been in a violent relationship? Have you ever heard of the term “rape”? Do you know that violence and rape affect both men and women, and can occur in all relationships including gay and straight ones? Have you ever experienced relationship violence or rape? Have you ever had sex while you were intoxicated (drunk or high)? Do you know that if you have sex with someone who cannot say “no” because they are intoxicated (or for any other reason) that it can be considered rape? Have you ever had sex for money, drugs, gifts or other things? |
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Do you feel safe at home, school, in your community/neighborhood, and online? Who do you get along with at home? How is conflict resolved at home? When people argue in your house, what happens? Do arguments or fights ever become physical? Do you know anyone who is bullied or who is a bully? How would you respond if you witness someone being bullied? Have you ever been bullied or bullied someone else? Are you on Facebook, or any social networks? Have you ever seen mean things or rumors online about your friends? Have people spread rumors about you online? Do you know what “sexting” is and have you ever done “sexting”? Do you ever talk to people you do not know? Do you use online dating sites? How do you keep yourself safe online? Are you involved in a gang? Is there a lot of violence in your school? In your neighborhood? Among your friends? Are there gangs in your school or community? Do you feel like you ever have been physically, sexually, or emotionally abused? Has anyone ever touched you inappropriately? Do people ever say things about you that make you feel bad about yourself? Has anyone ever hit, slapped or punched you? Are there guns in your home? Are they locked? Can you access them? Have you ever felt the need to carry a weapon such as a knife or gun? Do you carry a weapon? Why? Have you ever been arrested? What for? Have you ever thought about hurting or killing someone else? Have you been in a fight recently? Why? |
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What do you like to do for fun/after school? Have you ever had a serious injury or motor vehicle accident? Have any of your friends? What happened? How could it have been prevented? Do you know what the #1 cause of teenage deaths is? (Accidental injuries, specifically motor vehicle accidents where teens are not wearing their seatbelt) Do you always wear a seatbelt? Do you always wear a helmet on your….(bike, skateboard, ATV, snowboard, when skiing, etc)? Do wear a mouthguard when you play contact sports? Do you drive (with or without) a license? Are you planning to learn? How? Have you ever driven with someone who was drunk or high? How often? If Yes, then follow with remainder of CRAFFT screen (see Substance abuse section below). |
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Have you EVER tried [insert items below]? How much do you use this substance? How often? When did you start? Why do you use them?
Do you know anyone who uses tobacco, alcohol or drugs? Does anyone in your family have a problem now or in the past with drugs or alcohol? Have you ever taken medications out of the medicine cabinet (prescribed to you or someone else) and taken them in order to get a high? Where do you get information about drugs? Have you talked about sex in school/health class? With your friends? With your parents or any family members? Do you trust the information you receive? Do you have any questions? CRAFFT Screen for Adolescents: If no to all three, only ask the “C” question. If yes to any, then ask all CRAFFT questions: Do you know anyone who uses tobacco, alcohol or drugs? |
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Do you have trouble concentrating or staying focused? If so, when do you notice this the most? (in school? When doing homework? When watching a movie? Do you get distracted easily? Do you have difficulty finishing tasks, like homework? Do you have trouble starting tasks 9do you procrastinate)? Do you have trouble organizing (your time, your belongings, prioritizing things you have to do)? Do you have trouble sitting still? Do you feel restless inside? Do you have trouble waiting (in line, for your turn in a conversation)? Are you forgetful (forget to take your homework to school, forget where you put things)? When you were in elementary school, did your teachers comment that you were disorganized or not doing your best? Are there times or activities that you stay focused on for hours at a time? (i.e. video games) |
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Do you see or hear things that other people do not see or hear? Do you ever feel that people are following you or trying to hurt you? Do you have special powers, abilities (e.g. ability to read others’ minds), or status? When you hear the radio, watch TV, use a computer, or read, do you feel that there are messages intended just for you? Do you ever hear someone speaking to you even if there is no one around? Do you ever see fleeting shapes or shadows? Do you ever hear unusual noises or someone calling your name? |
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Do you ever feel the opposite of depressed—very cheerful, happy, productive? Does it last more than a week and impact your relationships, school work, and ability to function? Do you find that during these periods you do not need much sleep to feel rested? Do your thoughts race? Do you sometimes feel too good or cheerful for a long time? During those times do you have trouble sleeping? Do you ever have extreme mood swings? Like you feel very very happy or very very irritable, and other times when you feel extremely depressed, like it's hard to function? |
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Do you have any trouble sleeping (falling asleep, waking up in the night, waking up too early, sleeping too much, nightmares)? How is your appetite (loss of appetite, overeating)? Are you having any trouble concentrating? How is your mood, in general? Are there times when you feel down, sad, angry, irritable? When you feel this way, do you know what is causing it? How long does it last? What do you do to feel better? Have you lost interest in things that you used to enjoy? Do you feel like things will get better? Do you have any thoughts of wanting to hurt yourself? (If so, have you ever done so? If so, when and how?) If positive response, probe with self-injury questions in Suicidal and Self-Injurious Behaviors below. Have you ever thought that you didn’t want to live anymore or wanted to end your life? If so, how recently have you felt that way? If suicidal ideation is present, probe with the suicidal ideation questions in the Suicidal and Self-Injurious Behaviors section below. NOTE: Active suicidal thoughts, particularly with a plan, necessitate an emergency evaluation for possible hospitalization. If the thoughts are passive (no intent or plan, like “sometimes I wish I was dead.”) this at least necessitates a safety plan incorporating involving others who can be of support, emergency numbers to call, and strategies to get the person through until help arrives. The provider may need to call an ambulance or fill out a commitment paper to get the person to an emergency department where they can be assessed for admission to a hospital. |
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Do you worry a lot? Is it hard for you to control? Does this worrying affect your relationships, school work, extracurricular involvements or ability to function? Do you ever have episode of intense fear for no apparent reason when you don’t expect it? Do you feel tense or nervous to the point that it gets in the way of you doing things? Have you ever felt panicky or had a panic attack? (describe symptoms: heart pounding, shortness of breath, sweating, nausea, chest tightness, tingling in extremities, feeling of going crazy or fear that you are dying) If so, how often and in what circumstances? (panic disorder) |
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Do you have any habits that you do that are not necessary, but you do them anyway? If so, what are they (handwashing? Counting? Checking)? Do you have thoughts that you don’t want but they keep coming back? If so, what are they? Do the thoughts or behaviors interfere with your daily life? |
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Do you ever become so upset that you make or act upon threats to hurt other people, animals, or property? Do you tend to get in a lot of physical fights? Do you find that you often resort to threats and violence to solve problems? If you do hurt someone, do you feel bad about it afterwards? Are you having any thoughts of wanting to hurt or kill anyone else? Have you ever been arrested? For what? Do you frequently have run-ins with law enforcement? Do you sometimes do things that you wish you had not done on an impulse? Are you frequently getting into conflicts with others or into trouble with authorities? Do you ever feel out of control? How quickly do you get very angry? Do you have trouble controlling your anger? Do you ever get in fights? hurt others? punch walls? Do you ever get so angry that you black out? |
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NOTE: Self-injurious and suicidal ideation screening may be a part of a screen for depressive disorders, discussed in the Depressive Disorder section above. If a full depressive disorder screen is not done, the following screen should be. Do you have any thoughts of wanting to hurt yourself? (If so, have you ever done so? If so, when and how?) If positive response, probe with the following questions:
Have you ever thought that you didn’t want to live anymore or wanted to end your life? If so, how recently have you felt that way? If suicidal ideation is present, probe with the questions below:
NOTE: Active suicidal thoughts, particularly with a plan, necessitate an emergency evaluation for possible hospitalization. If the thoughts are passive (no intent or plan, like “sometimes I wish I was dead.”) this at least necessitates a safety plan incorporating involving others who can be of support, emergency numbers to call, and strategies to get the person through until help arrives. The provider may need to call an ambulance or fill out a commitment paper to get the person to an emergency department where they can be assessed for admission to a hospital. |
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Have you ever been abused, neglected, or in a situation where you were seriously injured or your life was in danger? Do you think about it a lot? Do you experience thoughts, images, or dreams related to this event? Do you avoid reminders of this event? |
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