Adolescent health: HEEADSSS psychosocial assessment in AU general practice

Adolescents in Australian general practice

Adolescence spans roughly 10–24 years and is the developmental window of highest psychosocial risk — and highest opportunity — in general practice. Mental and substance use disorders account for the largest share of disability in this age group, and most adult mental illness begins before age 25. Yet adolescents underutilise GP services: cost, embarrassment, concerns about confidentiality, and parental presence are the most frequently reported barriers.

Most presentations arrive as physical complaints. The underlying issue — depression, anxiety, substance use, sexual health, relationship, or identity concern — is rarely volunteered. A structured clinical framework addresses this: HEEADSSS, developed by Goldenring and Cohen and widely adopted in Australia, gives the practitioner a memorable, sequenced set of domains that moves from less sensitive to more sensitive territory within a single extended consultation. The RACGP Red Book recommends routine preventive activities in this age group at every opportunity, including mental health screening, substance use assessment, sexual health, immunisation review, BMI, and blood pressure.

The standard Australian approach is to see the young person alone for at least part of every consultation from age 12 onwards. This requires a short, sensitive conversation with the parent or guardian, framed as standard practice for adolescent care.

A. Core clinical — the AU general-practice framework

Setting up the consultation

The physical and social environment matters. Book a longer appointment (20–40 minutes) for a new adolescent patient or at annual review. Greet the young person first and use their preferred name. If a parent is present, explain: “It’s standard for me to spend some time with young people alone — I’ll come and get you shortly.”

Before the parent leaves, note any acute concerns. Once alone with the patient, open with a brief statement covering confidentiality:

“What we talk about stays between us. There are a few exceptions — if I’m worried you might be in serious danger, or if I’m concerned about the safety of a child, I may need to involve other people. I’ll always let you know if that’s the case.”

Keep language plain and free of clinical jargon. Use open questions. Validate responses without endorsing risk behaviour. Document the confidentiality discussion in your notes.

The HEEADSSS domains

H — Home. Who lives at home? Are there conflicts, recent moves, separations, or deaths in the family? Is there family violence, out-of-home care, or couch-surfing? Explore cultural background, language, religion, Aboriginal or Torres Strait Islander identity, and acceptance of the young person’s identity at home.

E — Education / Employment. What year are they in, and how is school going? Ask about bullying (in person and online), school refusal, truancy, suspensions, and learning difficulties. Explore career goals, part-time work, and the social environment at the workplace. Consider ADHD or autism spectrum disorder in young people with persistent school difficulties who have not been assessed.

E — Eating. “What does a typical day of eating look like for you?” Explore body image concerns, restriction, bingeing, purging, laxative or diet-pill use, and compulsive exercise. Use the SCOFF questionnaire (five questions; two or more positives warrant further assessment for an eating disorder) whenever there is any clinical concern.

A — Activities. Ask about friendships, sport, hobbies, arts, online gaming, and social media use. Explore risk-taking behaviours, extreme sport, and time spent online. Social media’s impact on sleep and mood is a common finding in this age group.

D — Drugs. Tobacco, e-cigarettes (vaping), alcohol, cannabis, prescription medications used recreationally, and illicit substances. Ask about use at home, school, and social events. Use the CRAFFT tool (Car, Relax, Alone, Forget, Family/Friends, Trouble — a score of 2 or above indicates higher-risk use) and AUDIT-C for alcohol. Explore friends’ use, since peer use is a strong predictor of the patient’s own use.

S — Sexuality. Use non-presumptive language: “Are you in a relationship at the moment? With someone of a similar gender, a different gender, or are you still figuring that out?” Ask about sexual activity, condom use, contraception, STI history, HPV vaccination status, and any unwanted sexual experiences. Explore gender identity and preferred pronouns. Ask about online safety — unwanted sexual contact, image-based abuse, and sexting.

S — Suicide / self-harm / depression / mental health. Ask directly about mood, sleep, concentration, and energy. Enquire about self-harm (past or current: cutting, burning, hitting) and suicidal thoughts, plan, or intent. A history of previous attempts and access to means must always be assessed. Use validated tools: the PHQ-9 (Adolescent version, 8 or above raises concern), K10, or GAD-7. See the suicidality assessment and safety planning guide for the full risk-stratification framework.

S — Safety. Family violence — witnessed or experienced. Bullying and cyberbullying. Driving — speed, alcohol, mobile phone use, seatbelts, peer-passenger risk. Online challenges, gambling, and weapons access. Work-related safety if employed.

Closing the interview

Summarise what you have heard. Acknowledge strengths and protective factors. Outline any concerns clearly. Agree on next steps — referral, a follow-up appointment, a safety plan, or simply an open door. Provide written information and relevant contact numbers (Headspace, Kids Helpline, and so on). Re-engage the parent at the end with an age- and consent-appropriate summary.

B. Evidence appraisal — structured screening in adolescent practice

Routine HEEADSSS use is associated with greater detection of psychosocial risk factors and increased connection to support services compared with unstructured consultations. The framework is endorsed by the NSW Health Youth Health Resource Kit, the RCH Melbourne Clinical Practice Guideline on engaging with adolescents, and the RACGP.

Mental health screening. PHQ-9 Adolescent, K10, and GAD-7 are validated and widely used in Australian general practice. A positive screen does not diagnose a disorder but flags the need for a fuller clinical interview and, where indicated, a management plan. Screening without a clear care pathway is of limited benefit — ensure referral options are in place before routinely screening.

Eating disorder screening. The SCOFF questionnaire has acceptable sensitivity and specificity in clinical settings; two or more positive responses should prompt a fuller eating disorder assessment. Medical instability (bradycardia, hypotension, electrolyte derangement, marked weight loss) warrants urgent paediatric or eating-disorder team review.

Substance use. Brief intervention — establishing rapport, asking permission to share information, providing balanced feedback, exploring ambivalence, and supporting behaviour change — has a consistent trial base for adolescent alcohol and cannabis use. Effect sizes are modest but replicated and cost-effective. Per eTG, brief intervention is first-line for hazardous use without dependence; dependence warrants referral to specialist youth drug and alcohol services.

Antidepressants in adolescent depression. Fluoxetine is the first-line agent per eTG in moderate-to-severe adolescent depression. Australian Product Information carries warnings regarding suicidality, particularly in the first weeks of treatment; fortnightly review for at least the first 4 weeks is recommended. Medication should be combined with psychotherapy wherever possible. Specialist input is advisable for initiation in most cases under 18.

Psychological therapies. Cognitive behavioural therapy and interpersonal therapy have robust evidence for adolescent depression and anxiety; both are first-line per eTG and the Royal Australian and New Zealand College of Psychiatrists. Family-based therapy (Maudsley approach) is first-line in adolescent anorexia nervosa. Access via the Better Access to Mental Health Care initiative (Mental Health Treatment Plan, up to 10 subsidised psychology sessions per calendar year; Eating Disorder Plan provides up to 40 sessions where criteria are met).

Vaping. Australian adolescent vaping rates rose sharply between 2018 and 2023. National regulatory reform from 2024 restricted the import and sale of disposable vapes and made nicotine-containing vapes available only on prescription for therapeutic use. Brief intervention using motivational interviewing is the current recommended approach; nicotine replacement therapy may be appropriate for nicotine-dependent young people.

C. Confidentiality, consent and mandatory reporting

Gillick / mature-minor competence

Common law in Australia — following the UK Gillick v West Norfolk and Wisbech Area Health Authority 1985 decision — permits a young person under 18 to consent to their own healthcare without parental knowledge or involvement if they have sufficient maturity and understanding to appreciate the nature, purpose, risks, benefits, alternatives, and consequences of the decision in question. Competence is decision-specific: a simpler, lower-risk decision (oral contraceptive pill, STI screen, mental health consultation) has a lower competence threshold than a high-risk or irreversible one.

In practice, Gillick competence supports confidential consultations regarding contraception, STI testing and treatment, mental health support, and management of minor illness. Document the competence assessment in your notes. For high-risk or complex decisions, consider involving a parent, guardian, or senior colleague. Refer to specialist services where the decision is beyond the scope of general practice.

Medicare card and billing privacy

At age 14, a young person can obtain their own Medicare card independent of a parent’s card. Proactively advising patients of this option at age 13–14 is a practical step to support consultation privacy. Medicare claims made on a shared family card may be visible to the cardholder; transitioning early removes this barrier.

My Health Record access: parents may access a child’s record until the child turns 14; from 14 onwards the young person controls access. Counsel patients about this, and ensure your practice’s My Health Record upload settings reflect age-appropriate privacy choices.

Mandatory reporting

Per the Australian Institute of Family Studies summary of mandatory reporting laws, doctors in all Australian states and territories are mandatory reporters. The reporting obligation arises when:

• There is reasonable suspicion (based on observation, disclosure, history, or physical examination) of child abuse — physical, sexual, emotional — or neglect.
• The child or young person is under 18.
• Several jurisdictions extend reporting obligations to exposure to domestic and family violence and to grooming behaviours.

The threshold is reasonable suspicion, not certainty or proof. You are not required to investigate; you are required to report when the threshold is met.

What to do:

1. Report to the relevant state authority (NSW: Child Protection Helpline 132 111; VIC: Child Protection Crisis Line 13 12 78; QLD: Child Safety Services 1800 177 135; and equivalent in other states and territories).
2. Document concerns, observations, threshold assessment, the decision reached, and follow-up plan in your notes.
3. Inform the family where it is safe to do so and where doing so does not create additional risk.
4. Continue ongoing care of the young person regardless of the outcome of the report.

A mandatory report does not destroy the therapeutic relationship if handled transparently and sensitively. Most young people understand the limits of confidentiality when they have been explained clearly from the outset.

D. Australian operations

MBS items

Adolescent consultations frequently warrant Level C or D billing (items 36 and 44 respectively) given the complexity and extended time required. Key MBS items:

• 23, 36, 44 — standard general-practice consultations (Level B, C, D by time)
• 715 — Aboriginal and Torres Strait Islander Health Assessment, with age-specific categories including 15–54 years; HEEADSSS is embedded in the youth version
• 2715 / 2717 — GP Mental Health Treatment Plan / Review; required to access Better Access psychology sessions
• 80000–80020 — Focussed Psychological Strategies by a GP with mental health skills training
• Eating Disorder Plan items (e.g., 90250 / 90251) — assessment and review; up to 40 psychology sessions and 20 dietitian sessions per calendar year
• IUD and contraceptive implant insertion — items 35503 / 35506 for LARC procedures
• STI pathology — rebated under the standard Medicare pathology schedule

PBS medications

• Fluoxetine — PBS-listed for adolescent depression; specialist initiation recommended under 18 in most product information
• Methylphenidate, dexamfetamine, lisdexamfetamine — Authority-required; psychiatrist or paediatrician initiation; GP continuation under formal shared-care arrangements
• Combined oral contraceptive pills, DMPA, Mirena (LNG-IUS), Implanon NXT (etonogestrel implant) — PBS-listed; Implanon NXT and Mirena require GP procedural training
• Nicotine replacement therapy (patch, gum, lozenge) — PBS-listed for nicotine dependence in patients 18 and over; off-label consideration in dependent adolescents under specialist guidance
• Naloxone — available free under the Take-Home Naloxone Program for opioid harm reduction; important for adolescents with opioid exposure or in contact with users

Crisis and referral services

Service	Who	Contact
Headspace	Mental health, substance, vocational, sexual health (12–25 yr)	headspace.org.au / centres nationally
eheadspace	Online / phone crisis + support (12–25 yr)	1800 650 890
Kids Helpline	All issues (5–25 yr); 24/7	1800 55 1800
13YARN	ATSI crisis; culturally safe	13 92 76
QLife	LGBTIQ+ peer support	1800 184 527
1800RESPECT	Sexual assault, domestic/family violence	1800 737 732
Lifeline	Crisis; all ages	13 11 14
CAMHS	Moderate-severe / acute risk	Via local health service
eSafety Commissioner	Image-based abuse, cyberbullying	esafety.gov.au
ReachOut.com	Youth-facing resources	au.reachout.com

Warm handovers — a brief phone call or a note to the receiving service, with the young person’s consent — improve uptake compared with providing a pamphlet alone.

E. Special populations

Aboriginal and Torres Strait Islander young people. Aboriginal and Torres Strait Islander youth experience higher rates of suicide, self-harm, family violence, and incarceration, driven by structural racism, intergenerational trauma, and socioeconomic disadvantage. Use MBS item 715 (Aboriginal and Torres Strait Islander Health Assessment, 15–24 year category) to structure the encounter. 13YARN (13 92 76) provides culturally safe crisis support and should be the first-line crisis service for this group. Engage local Aboriginal Community Controlled Health Organisations for culturally appropriate follow-up and wraparound support.

LGBTIQ+ young people. Sexual and gender minority youth experience higher rates of depression, anxiety, self-harm, and suicidal behaviour, largely driven by minority stress — discrimination, family rejection, and bullying. Use affirming language: ask for preferred name and pronouns. Do not assume gender or sexual orientation. Provide direct referral to inclusive services (QLife, Minus18, Twenty10, Thorne Harbour Health). For gender-affirming care in young people with gender dysphoria, refer to specialist multidisciplinary services (RCH Gender Service Melbourne, Westmead Gender Clinic Sydney, and equivalents) according to current Australian Standards of Care.

Young people in out-of-home care. This population has substantially elevated rates of mental health and developmental disorders, trauma exposure, and educational disadvantage. Health assessments are mandated for children entering care and at intervals thereafter. Trauma-informed care principles apply throughout.

Rural and remote young people. Access to Headspace, CAMHS, and specialist services may be substantially limited. Telehealth consultations (equivalently rebated for eligible MBS items), eheadspace, and Kids Helpline are critical pathways. Healthdirect provides consumer-facing triage and service-finder functions accessible nationwide.

When to escalate

Refer urgently or escalate to CAMHS or an emergency department when:

• Acute suicidality with a plan, intent, or access to means — initiate a safety plan and arrange emergency assessment
• Acute psychosis — same-day psychiatric review
• Severe eating disorder with medical instability (bradycardia below 50 bpm at rest, hypotension, syncope, marked electrolyte derangement, BMI below 15) — acute paediatric or eating-disorder team admission
• Suspected child abuse or family violence — mandatory report and safety planning with social work
• Sexual assault — forensic medical service; consider emergency contraception and post-exposure prophylaxis
• Acute substance overdose — ambulance; administer naloxone if opioid toxicity suspected
• Severe psychosocial deterioration (rapid school refusal, social withdrawal, marked weight loss, escalating self-harm) — urgent CAMHS or Headspace fast-track referral

For non-urgent concerns, document clearly and book a follow-up appointment within 2–4 weeks as a minimum safety net.

What this article is and is not

This is general health information drawn from current Australian clinical guidelines — RACGP Red Book, NSW Health Youth Health Resource Kit, RCH Melbourne CPGs, and eTG — for the purpose of patient education. It is not personal medical advice and does not create a doctor–patient relationship. Specific management decisions, including medication initiation and referral, are made between an individual patient and their own treating clinicians.

For consumer-friendly information: Healthdirect, ReachOut.com, Headspace, Beyond Blue.

For immediate support: Kids Helpline 1800 55 1800, Lifeline 13 11 14, Beyond Blue 1300 22 4636, 13YARN 13 92 76.

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Sources cited

1. RACGP Red Book — Preventive activities in adolescent health
2. NSW Health — Youth Health Resource Kit (HEEADSSS)
3. RCH Melbourne CPG — Engaging with and assessing the adolescent patient
4. Headspace — National Youth Mental Health Foundation
5. eheadspace — online and phone support
6. eTG complete — Adolescent mental health and substance use
7. Australian Institute of Family Studies — Mandatory reporting of child abuse and neglect
8. 13YARN — Aboriginal and Torres Strait Islander crisis support
9. Kids Helpline
10. QLife — LGBTIQ+ peer support
11. eSafety Commissioner
12. 1800RESPECT — sexual assault and family violence support
13. ReachOut.com — youth mental health
14. Lifeline — 13 11 14
15. Healthdirect — Adolescent health