In the field of adolescent health, professionals need to master the act of effectual communication in order to understand adolescent development. Word specifics and the way the words are delivered can assist, enlighten, and win over behaviour at crucial and specified periods, assisting adolescents to develop health literacy, self-efficacy, and resilience (Cherry, 2017).
Psychosocial, behavioural and lifestyle problems are the major causes of morbidity and mortality among adolescents. These young adults may not present with, or express concerns directly about sexual health, relationships with significant others or mental health issues. Often, adolescents present with relatively minor issues or physical complaints such as a headache, tiredness, or stomach ache which may mask larger issues involving sexuality, depression, anxiety, eating disorders, drug use, issues with school, bullying concerns, and problems with family, friends or intimate partners. Nurses in community health school settings need to establish good communication and rapport skills and use systems at a school level to help students who frequently present for minor issues. (McMurray & Clendon, 2015)
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Adolescents facing difficulties may not fully understand what is happening to them and may be unable to articulate thoughts and feelings without medical professional help. It is common for adolescents to seek information and even self-diagnose using websites of varying reliability. Few will be aware of the range of services and support available to them via the school health nurse.
The ability to conduct a HEEADSSS adolescent psychosocial assessment is a key competency for nurses working in secondary schools.
HEEADSSS is an acronym, representing the following domains:
E Education and employment,
E Eating and exercise
A Activities and peer relationships, social media
D Drug use, including prescribed medications, cigarettes, alcohol, and other drugs
S Sexuality and gender
S Suicide and depression (including mood and possible psychiatric symptoms)
S Safety and spirituality
The adolescent stage (12–18 years old) is the period whereby a person develops from childhood to adulthood and the individual’s body and mind go through a number of changes that can be exciting, frightening, and confusing. During this stage, youth often have active social lives and experience pressure to experiment. These needs often result in different psychosocial issues (such as anxiety, depression, eating disorders and even suicide) that affect adolescents and lead to mental health issues that can be avoided with support. It is therefore crucial that at-risk adolescents are evaluated for psychosocial disorders by trained professionals working in the school setting (Levy, 2017).
The HEEADSSS adolescent psychosocial health assessment provides a structure for:
- Developing rapport with a young person while systematically gathering information about their world, including family, peers, school, culture, and their inner world.
- Developing a picture of the young person’s strengths and protective factors.
- Conducting a risk assessment and screening for specific risk issues.
- Identifying areas for intervention and prevention.
- Guiding health counseling, including commending and building on strengths, exploring options, planning actions, providing information, identifying the need for intervention and referral.
It should be noted that HEEADSSS is a guide and not to be seen in any form as a checklist.
The HEEADSSS format is designed to start with less sensitive areas of a young person’s life and move towards more sensitive areas. For some adolescents, however, the first domain (Home) can be a difficult and highly sensitive area:
- There may be conflict or violence in the home environment
- Adolescents from Culturally and Linguistically Diverse (CALD) backgrounds may initially feel uncomfortable talking about their parents and other family issues
- They may think that they do not have the right to complain or fear of being perceived as complaining about their parents
- Some adolescents may be living in out of home care arrangements.
Adolescents are often more willing to engage with these topics if health providers seek their permission to ask sensitive questions. Health professionals can use the third-person approach, which normalizes the process and lessens the impact of sensitive questions. They can progress from neutral to more sensitive topics—for example, if the young person mentions that they have a boyfriend or girlfriend, a further question might be to ask about their sexual activity level. When exploring the area of sexuality, the provider should not assume the young person’s sexual orientation; instead, they should adopt a gender-neutral and non-judgmental approach when asking sensitive questions (Levy, 2017).
Health promotion and positive development approaches involving adolescents take place over time and are subject to multiple contextual and societal factors during that time (Klein et al., 2014). Effective evaluation of such programming depends on a long-term commitment to tracking changes in life experiences and asset development, as opposed to measuring only efficacy outcomes. Some researchers have applied a unified approach, combining both qualitative and quantitative methods and procedures in the evaluation of long term, youth development programs (Montgomery et al., 2008). Holt (2009) suggests that combining varied research approaches can contribute to a better understanding of complex issues, allowing for cross-validation of research findings and compensate for the limitations inherent in each study design.
Evaluation of the Screening Policy
The HEADSSS assessment has been used successfully around the world in the adolescent health care field. This system has been used to facilitate effective communication and create a respectful and confidential environment where teenagers may feel more comfortable to obtain adequate health care.
Many adolescents do not recognise dangerous behaviour patterns as dangerous because they see their activities not as problems but as solutions. The Registered Nurses challenge is to explore these behaviours and the context in which the adolescent lives to develop realistic solutions with patient buy-in. The physician may be overwhelmed by the number of issues to be covered in the interview. It is obvious that every topic cannot be covered in a single visit, but the goal is to establish an entry point for open communication. Depending on the nature of the risk factors identified and the intervention to be established, the solution could either be to extend the initial visit or arrange a follow-up. Taking on a nonjudgmental approach during the psychosocial interview is crucial, so the adolescent feels they can trust and confide in the Nurse and feel safe and secure in further visits (Cherry,2017).
HEEADSSS may not be suitable for use with all adolescents. Alternative screening tools might be considered for adolescents with an intellectual disability.
Following the assessment process, the healthcare provider and adolescent and, where appropriate, their parents or carers, develop a management plan collaboratively. Actively engaging the young person in identifying what they want to work on and how they want to go about it, empowers them to be an active partner in their own health and wellbeing. It also increases the likelihood that they will follow through with the plan (Levy, 2017).
Involvement of Parents and Caregivers in the Management Plan
For many adolescents, parents are the main providers of physical and emotional support. For some adolescents, a carer such as a member of the extended family, or another trusted adult, will be their main source of support. Generally, management or treatment plans are more successful when parents or carers are involved (McMurray & Clendon, 2015).
From a medico-legal perspective, this also means considering the young person’s capacity for decision-making and informed consent. Providers should be sensitive to the concerns of parents from cultural backgrounds where healthcare may be viewed as a family matter.
Reliability of the HEEADSSS Screening
The HEEADSSS screening is carried out on all aspects of the adolescent’s life to ascertain the factors that are causing the adolescent’s psychosocial issues. When the assessment is done, it can show the adolescent not only the negative influences in their lives but also the positive influences. The screening is a comprehensive tool that yields objective results so that an accurate diagnosis can be made.
Adolescent Psychosocial Health Policy and Assessment
Having discovered the dangers of psychosocial disorders for youth, it is evident that this crucial problem needs to be taken seriously. Policies have been put in place to allow for the smooth running of such programs that help the youth in these kinds of situations. These policies target the primary caregivers that take on the responsibility for the health and wellbeing of these adolescents (Royal Australasian College of Physicians, 2000). Having policies in place allows for direction on how to handle these matters when they arise. It is crucial to create a safe environment for adolescents to come for help should they find themselves in these situations.
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There is a need to not just assess the mental health of the youth but also their emotional and behavioural issues. To do so, The Registered Nurse (RN) must obtain the adolescent’s psychosocial history. The HEEADSSS method is used to interview adolescents to obtain their psychosocial history focusing on the adolescent’s home environment, education, employment, eating habits, peer-related activities, drugs and alcohol, sexuality, suicide/depression and safety from injury or violence (Klein, Goldenring & Adelman, 2014). It is common for adolescents to be reluctant to discuss their health issues voluntarily. Using a routine psychosocial assessment is helpful in forming an understanding of context of behaviour and allows for an engagement between the patient and the RN. Using the HEEADSSS method allows the nurse to produce a management plan and the patient may also be more willing to be honest with a physician (The Royal Australasian College of Physicians, 2000). During the interview, the Registered Nurse should ensure the patient feels at ease while concentrating on the patient’s strengths and positive attributes (Klein et al., 2014). However, it is important to note that the HEEADSSS framework will only help to identify the psychosocial issues the adolescent is going through. Management options will squarely depend on the level of concern, the skills of the medical professional, and the available resources (The Royal Australasian College of Physicians, 2000).
Evidently, the issues adolescents are dealing with such as their need to fit in are leading them to engage in risky behaviours. Left unresolved these issues can lead adolescents to develop other mental health issues like depression, self-harm, and suicide (McMurray & Clendon, 2015). The community has a role to play in helping adolescents to fit in and handle their issues safely.
Schools likewise play a vital role in adolescent development. There is a need for balance between the school, home environment, and social networking. (Knight et al., 2002). Many students may find it hard to balance these three because they may not be used to handling all these aspects of life at once. Adolescence is the bridge between childhood and adulthood where a student starts to realise that there is more to life than just going to school and doing what their parents and the teachers expect of them. This realization leads to a level of independence which may be difficult for some adolescents to handle (Cherry, 2017). These new responsibilities coupled with other issues in school such as bullying may lead to serious mental health issues and influence the youth’s self-esteem. Investment needs to be made in counselling in schools and assuring the youth that problems can be worked out and they will eventually get over the issues (Levy, 2017).
Adolescence is the initial stage of adulthood therefore the community should be putting focus on mental health and ensuring this is upheld for the rest of life. Communities must invest in building public health policies, creating a supportive environment for adolescents, strengthening community action, reorienting health services, and developing the adolescent’s personal skills to boost confidence (McMurray & Clendon, 2015).
Other Methods of Adolescent Screening
Drug abuse is high on the list of factors affecting teenage mental health. HEEADSSS is an effective method for screening psychosocial problems affecting youth due to drug and substance abuse. However, in order to determine if there is drug abuse or the extent to which drugs have been abused medical professions can use the CRAFFT screening tool.
The CRAFFT screening tool has been designed to ascertain if an individual has engaged in substance-related risks. It uses a set of questions built upon six keywords: car, relax, alcohol, forget, friends, and trouble. The keywords are incorporated into questions to make it easy for an adolescent to answer the physician’s questions. There are six test questions for the six keywords involved. These questions are appropriate for adolescents by design and it screens for not just alcohol but also other forms of drugs and is most effective when administered under appropriate conditions.
One of the most useful aspects of the CRAFFT test is that the questions can be administered by the Registered Nurse during a general health interview or during a physical examination (Knight, Sherritt, Shrier, Harris & Chang, 2002).
Substance abuse is one of the biggest issues facing adolescents today and it has been noted to be one of the causes of both physical and mental health. Due to this realisation, it is prudent to ensure that adolescents receive medical care in ideal places for this screening and eventually allowing for early intervention (Knight et al., 2002).
The Role of HEEADSSS in Enhancing Adolescent Development
The HEEADSSS test is crucial in helping medical staff and parents of adolescents better understand how they can help the adolescent navigate their way through this vulnerable life stage.
If the adolescent is indulging in dangerous behaviour, it is up to the parents, counsellors, Education and medical staff to find ways to protect the adolescents from themselves. The HEEADSSS method enables the parties involved to explore the behaviours exhibited and understand the context in which the adolescents are operating and allowing them to develop realistic solutions (Klein et al., 2014). The HEEADSSS test further enables the Nurse to produce plans that help guide these adolescents to understand why they are behaving the way they are and coming up with ways to help them navigate out of different situations.
Adolescents who have gone through the screening are able to understand the consequences of their actions and feel empowered to seek support. They better understand that they are not alone facing these problems and most importantly that there are others going through the same. It further helps them to understand that there are people, who are willing to support the throughout (McMurray & Clendon, 2015). This knowledge is crucial in helping the adolescent have more confidence in themselves, which will help them have better judgment and decision-making capacity.
Referral options using an interdisciplinary approach are identified
Community health school nurses serve as a point of contact for the students. The nurse is able to carry out health assessments, provide appropriate treatment where needed as well as provide the first point of contact for students. Interventions and follow up of school children within the school setting is crucial. The student services team in a school work in collaboration to support both the educational and psychosocial wellbeing of students. Depending on assessment information, it may be necessary to provide appropriate referrals outside of the school. The school nurse may refer to the student’s general practitioner, mental health team in the community/in-patient units or other hospital and government services such as child protection and family services when appropriate (Cherry, 2017). The school nurse must work collaboratively to address the student’s health and wellness issues. Integrating knowledge and methods from different disciplines is all part of the interdisciplinary approach.
Recommendations for a Primary healthcare partnership model of practice
The role of Parents, Community and Health Nurses.
Adolescents do not exist in a vacuum, they have various people such as friends, family, and/or educators in their lives who love them and want them to succeed (Cherry, 2017). Parents can, however, end up overwhelmed and may need the support of other knowledgeable Adults. It is therefore crucial for school nurses and educators to play a role in prevention, identification, referral, and treatment of adolescents. The government and the local community have a role to play in supporting the parents and their adolescent children by availing resources to help in such situations like carrying out successful neighbourhood mobilisation. For this kind of mobilisation to be successful it must be carried out through at least four mediums: community organising and development, the collaboration of service delivery, implementing community-based programs, and finally the involvement of families in school governance and instruction (National Research Council, 1993).
Each initiative exists due to simple networking and partnership creation to resource holding. This is because it allows for the provision of services through the partnering of the state and the community. The Partnering of the state and community allows for the provision of services with each initiative existing due to simple networking and resource holding (Knight et al., 2002). Partnering is a method that works very well however it is not as successful when the state agencies are unable to instantly share authority with the community. Such programs are highly beneficial as they help families of adolescents who would otherwise lose out due to lack of resources because their parents are unable to afford the services. These community-based youth programs help the adolescents in their development journey by providing them with a sense of belonging, create crucial relationships, and develop interpersonal skills that allow them to grow (National Research Council,1993).
It is quite clear that adolescence is a crucial stage that does not just affect the youth but also the parents and the community at large. Screening systems such as HEEADSSS empower adolescents to get the help they need to cope with the issues that come with this stage of development. The adoption of the HEEADSSS screening system would go a long way in reducing occurrences of mental health issues because it allows for early detection. This detection system encourages preventative measures to be taken; thus, reducing the chance of serious issues like drug and alcohol addiction, sexually transmitted diseases, teenage pregnancies, and many other psychosocial problems. (McMurray & Clendon, 2015).
It is therefore important for governments to invest in community-based initiatives. By doing so, the youth will be able to open up more frequently about the issues that they are going through. This will in turn help parents and medical staff to note issues early on before they become serious and more complicated. It is crucial for schools to encourage the use of the HEEADSSS assessment tool to effectively help their students. In the end, the use of tools like HEEADSSS will empower the community to support these adolescents’ mental and emotional wellbeing.
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