Expand your HEADS, follow the THRxEADS!

Abstract

Adolescence can be a particularly challenging period for individuals with a chronic health condition or disability. We present a new mnemonic, THRxEADS (T for Transition, H for Home, Rx for Medication and Treatment, E for Education and Eating, A for Activities and Affect, D for Drugs and S for Sexuality), which can be used as a complement to the adolescent HEADS (Home–Education–Activities–Drugs–Sexuality) assessment. THRxEADS may serve as a clinical tool to explore key issues that are often not covered in subspecialty clinic visits such as transition, coping, adherence and understanding of illness, as they apply to youth with special health care needs. THRxEADS may be used as a vehicle to highlight successes and to promote resilience. It may also be used as an educational tool with medical trainees to allow a deeper understanding of the realities of adolescents with chronic health care needs. A short list of sample chronic illness and disability-specific questions is provided.

Since the mid-1970s when the HEADS acronym was first introduced, this assessment heuristic has evolved to become an evidence-based approach to assessing and monitoring adolescent health care (1). From the initial five-letter acronym (Home–Education–Activity–Drugs–Sexuality), HEADS has expanded considerably through the years to integrate additional areas of review, including Eating/Diet, Safety/Security and Suicidality/Depression (2). More recently, Ginsburg has suggested a strength-based variation of the HEADS assessment: SHADESS, where the first ‘S’ stands for ‘strength’ (3). Further, in our era of social media, the HEADS assessment also allows an examiner to target topics such as cyberbullying, cyber-dependence and review of inappropriate web content, all important factors in adolescent health (4).

An increasing number of children with chronic illness or disability are surviving into adolescence and adulthood. The physical, social, cognitive and emotional impacts of chronic disease in adolescence are diverse and well documented (5). In this commentary, we introduce a complement to the HEADS assessment specifically for adolescents with chronic illness and disability. We suggest the use of the acronym, THRxEADS, to incorporate four key elements for this population: transition, medication/treatment, coping/understanding of illness and adherence to treatments. We believe that THRxEADS will help structure interviews with adolescents with chronic health conditions in a way that can highlight both challenges and successes. The different components of the acronym can be reordered to facilitate flow and to help build a therapeutic alliance during the interview (i.e., starting with gentler items such as H for Home or E for Education and ending with more confidential, and potentially more delicate, items such as D for Drugs or S for Sexuality). THRxEADS can also be used as a teaching tool for medical trainees. Table 1 provides examples of questions specific to youth with special health care needs that can be added to the usual HEADS assessment.

Table 1.

THRxEADS—chronic illness and disability-specific questions

Parameters	Sample questions
T – Transition	What is your condition?
	Can you explain the important things about your condition in three or four sentences?
	How much of your health care is your responsibility?
	What do you need to do to get ready for adult health care?
	What kind of services will you need to find in the adult system?
H – Home	Are there any issues with housing and your health? (accessibility/allergens/others)
	Do you have concerns about how your condition affects your family’s function?
	Who knows about your condition? (family members/friends)
	If you live in more than one home, are there differences in the way you take care of your condition in the two homes?
R x – Medication and Treatment	What medications do you take? What are the dosages?
	Who is in charge of your medication? What is your role?
	How do your medications/treatments fit in your routine during the week/weekend?
	What happens when you miss a dose?
	What do you like and dislike about your medication?
E – Education and Eating	Does your condition make things different or difficult for you at school?
	Is there someone you can talk to or go see for help/support at school?
	How often do you have to miss school because of your condition?
	How does your condition or medications affect your diet and appetite?
	Does your condition affect how your body looks? In what way?
A – Activities and Affect	Does your condition get in the way of participating in activities that your friends do?
	Do you have friends or talk to people who have similar health/disability issues?
	Do you use the internet to connect with other teens with health conditions or learn about your condition?
	Does your condition affect your sleep?
	Does your condition make you sad, angry or anxious?
	Have you ever had suicidal thoughts or tried to hurt yourself because of your condition?
D – Drugs	What do you know about the effect of alcohol/cigarettes/street drugs on your condition or treatments?
	Do you ever use alcohol/cigarettes/street drugs to treat your condition, symptoms or medication side effects?
S – Sexuality	What do you know about the effect of your condition on your sexual health?
	Are there any limits on contraception you can use because of your condition?
	Have you talked about the genetics of your condition? (i.e., can it be passed on to your children?)

SETTING THE STAGE

The optimal timing for a first adolescent assessment varies but it can be helpful to have a standard age at which to begin asking adolescence-specific questions, as adolescents with some conditions (such as cystic fibrosis or chronic kidney disease) may appear younger than their age and not be perceived as teenagers. The first use of THRxEADS, with adolescents and parents present, leads parents to be reassured about what will happen when adolescents are examined alone and highlights the shift in their child’s role in their health care as they approach transfer to adult care. Giving youth an opportunity to speak confidentially with a health care provider (HCP) at a future session or during each session also demonstrates the importance of this role change while allowing HCPs to address sensitive issues.

T FOR TRANSITION

Transition to adult care is not just about self-management, although this is an important part of the process. In the years before transfer, HCPs should encourage adolescents’ autonomy while acknowledging the importance of effective interdependent relationships with key allies and collaborators (6), including parents. Transition to adult care can be a very worrisome time for both teens and parents. There is a risk for information to be lost in transfer (7). By preparing for transfer early on, parents can allow for a smoother transition and foster autonomy, confidence and responsibility in their adolescents, all of which are essential for a successful transition.

H FOR HOME

A multitude of chronic health-related issues can arise in the home, including conflicts with parents or siblings, financial strains and accessibility. Differences in emotional and logistical support between parents are common, particularly when there are two or more households. Parental involvement can have an important impact on the adolescent’s physical and psychological well-being. While having to rely on parents for various aspects of care may be perceived as burdensome for some, spending time with parents in the context of a chronic condition can provide an opportunity to strengthen parent–teen relationships (8).

Rx FOR MEDICATION AND TREATMENT

For many adolescents diagnosed with a chronic illness, treatment and medication can be both life-saving and a source of great frustration. Many teenagers have low levels of adherence to treatment at some point or another, which can lead to conflict in the family, morbidity with repeated hospitalizations and tension with the health care team (9). Asking adolescents about their medications and treatments such as catheterizations or physical therapy, in a nonthreatening, nonjudgemental way, is essential to learn about their level of involvement and whether they have challenges with adherence. Adolescents should be recognized for being adherent with their treatments and encouraged to ask questions about the impacts and side effects of their medications.

E FOR EDUCATION AND EATING

Chronic illness in teens is accompanied by an increased risk of absenteeism, bullying and educational difficulties in school (10). HCPs should explore their patient’s short- and long-term aspirations and help them advocate for services and supports needed to thrive at school.

Eating, weight and body image preoccupations are other important elements to be explored in the context of chronic illness and medication side effects. Body image issues may relate to obesity, striae, low weight or early/delayed puberty.

A FOR ACTIVITIES AND AFFECT

Adolescents with chronic conditions may have additional cognitive limitations, physical limitations or both, preventing them from participating in activities (11). This can place them at increased risk of social isolation, poor self-esteem and technology/media overuse. This is also an opportunity to discuss appropriate and helpful ways to use media to increase health literacy and social connectedness (12).

The experience of a chronic illness is unique to each individual. Living and coping with a chronic illness may be particularly challenging at a time when the sense of self is still consolidating. Teens with chronic health conditions are at increased risk of having sleep, mood and anxiety-related difficulties (13). HCPs should be familiar with screening instruments for anxiety/depression and be able to offer support in the case of sleep difficulties, low mood, anxiety, self-harm and suicidal ideation.

D FOR DRUGS

Some illnesses and treatment regimens place youth at a higher risk for negative health outcomes when combined with tobacco, alcohol and other substances. As with their same-aged peers, youth with a chronic illness often have the desire to experiment, or to ‘fit in’ by using illicit drugs. Providing adolescents a safe space to ask questions about substance use and directing them toward accessible and reliable resources for further information are essential. This is especially important as this topic is very frequently omitted in the context of busy clinic visits (14).

S FOR SEXUALITY

Adolescents with a chronic condition might question their ability to engage in normal sexual activity (15). Others might wonder if their fertility is different or altered. Youth must be offered an attentive ear to discuss such sensitive issues, in addition to gender identity and sexual orientation. It is important to address contraception, puberty and sexuality in order to normalize this component of development and encourage the development of a healthy identity.

TAKE-HOME MESSAGES

The THRxEADS mnemonic may be an accessible means to better understand the multifaceted lives of adolescents with chronic illnesses. With a particular emphasis on transition, medication/treatment, coping and adherence, we feel that THRxEADS is a powerful tool to foster autonomy, strength and resilience in youth with health conditions. It can also serve as a useful teaching tool for trainees. In using the THRxEADS model, one must be mindful that working with any adolescent requires patience and adaptability. Adolescents are spontaneous and surprising: do not forget to be flexible, open-minded and … follow the THRxEADS!