Human Development

Adolescent confidentiality and HEEADSSS interview

Clinical Overview and When to Suspect Risk in Adolescents

— Adolescence: ages 11–21 per AAP/Bright Futures, spanning early (11–14), middle (15–17), and late (18–21) developmental stages

— HEEADSSS is a structured psychosocial screening interview: Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety

— Confidentiality is the cornerstone — adolescents who perceive confidential care are 3× more likely to disclose sensitive behaviors

— All well-adolescent visits annually per Bright Futures/USPSTF

— Sports physicals, pre-op clearance, contraceptive visits, mental health visits, ED visits for vague somatic complaints

— New behavioral change: declining grades, weight change, sleep disturbance, recurrent abdominal pain or headache without organic etiology

— After acute event: MVC, overdose, STI diagnosis, pregnancy test (positive or negative), assault, runaway episode

— Leading causes of adolescent mortality in the US: unintentional injury (mostly MVCs), suicide (#2), homicide (#3) — all behaviorally mediated

— ~17% of high schoolers seriously considered suicide in past year (YRBS); ~30% sexually active; ~22% current substance use

— Mental health visits doubled 2016–2022; firearm now leading cause of pediatric death overall

Definition and scope

When every visit warrants HEEADSSS

Epidemiology driving the screen

Step 3 management: At every adolescent encounter, dismiss the parent for at least part of the visit and explicitly state the confidentiality rule and its limits before asking sensitive questions. Document that this was done.

Board pearl: A 15-year-old brought in by mom for "fatigue" — the first correct step is to interview the patient alone with a confidentiality statement, not to order labs. Step 3 vignettes frequently bury the right answer in "speak to the patient privately" rather than in a diagnostic test.

Key distinction: Screening (HEEADSSS) is universal and risk-detection oriented; assessment (e.g., PHQ-9, CRAFFT, Columbia) is the next step when screening is positive — do not skip directly to deep assessment without the rapport-building structure.

Presentation Patterns and Key History

— Chief complaint often somatic: headache, abdominal pain, fatigue, "can't sleep," chest pain — with negative organic workup

— Behavioral red flags reported by parent: slipping grades, new peer group, locked phone, weight change, irritability, isolation

— Crisis presentation: overdose, suicide attempt, runaway, pregnancy, STI, MVC, school disciplinary action

— Home: who lives there, recent moves, conflict, firearms in home (always ask), foster/group home status

— Education/Employment: grades trend, attendance, suspensions, IEP/504, future plans, working hours

— Eating: body image, dieting, binge/purge, food insecurity — screen with SCOFF if concerns

— Activities: peers, structured activities, screen time, online relationships, gang involvement

— Drugs: tobacco/vaping, alcohol, cannabis, prescription misuse, IV use — use CRAFFT 2.1 (≥2 positive = high risk)

— Sexuality: orientation, gender identity, partners (number, gender), contraception, condom use, consent, history of abuse, sexting/exploitation

— Suicide/depression: PHQ-2 → PHQ-9-A; ask directly about ideation, plan, means, prior attempts

— Safety: seatbelts, helmets, driving under influence, dating violence, bullying (including cyber), firearm access

— "Many teens your age start to try alcohol or drugs — what's your experience been?"

— "Some people your age are attracted to boys, some to girls, some to both, some to neither — what's true for you?"

— Use third-person normalization to reduce shame; avoid leading questions

How the adolescent actually presents

Structuring HEEADSSS — start benign, escalate

CCS pearl: In a CCS-style adolescent case, order "Interview patient alone" and "Confidentiality discussion" as explicit actions before ordering screening instruments. Then sequence PHQ-9, CRAFFT, and GAD-7 as indicated.

Phrasing pearls (normalize before asking)

Board pearl: The single highest-yield question is direct: "Are you thinking about killing yourself?" Asking does not increase risk (well-established evidence) — and failure to ask is the test-wrong answer in suicide vignettes.

Physical Exam Findings and Developmental Assessment

— Affect, eye contact, grooming, engagement; parent-child interaction quality before separation

— Height/weight/BMI trajectory on growth chart — flattening or crossing percentiles is a clue to eating disorder, chronic disease, depression, or substance use

— Vital signs: bradycardia + orthostasis → anorexia; tachycardia/HTN → stimulants; hypothermia → severe malnutrition

— Document SMR for breast/genital and pubic hair; delayed puberty (no breast bud by 13 in girls, no testicular enlargement by 14 in boys) warrants workup

— Precocious puberty (<8 girls, <9 boys) requires endocrine evaluation

— Tanner stage drives anticipatory guidance more than chronologic age

— Eating: lanugo, parotid hypertrophy, Russell's sign (knuckle calluses), dental erosion, amenorrhea, acrocyanosis

— Drugs: track marks, nasal septum erosion, conjunctival injection, dental decay ("meth mouth"), nicotine staining, vape pod possession

— Safety/abuse: bruises in non-bony areas, patterned injuries, genital trauma, frenulum tears, multiple injuries in different stages of healing

— Self-harm: linear scars on forearms/thighs, often parallel; ask "can you tell me about these?"

— Sexuality: GU exam only when clinically indicated and with chaperone; offer same-sex examiner if requested

— Findings suggestive of abuse, pregnancy, or STI may not always be shared with the parent — depends on state law; never promise blanket confidentiality before knowing the issue

— Document exam findings objectively with measurements and photos (with consent) when abuse is suspected

General observation

Sexual maturity rating (Tanner staging)

Targeted exam clues to HEEADSSS domains

Step 3 management: A chaperone (separate from parent) must be offered for any sensitive exam, documented in the chart, and the adolescent's preference honored. The parent is not a substitute for a medical chaperone.

Confidentiality during exam

Board pearl: Bradycardia (HR <50) in a thin adolescent girl with amenorrhea = anorexia nervosa until proven otherwise, and admission criteria include HR <50 daytime/<45 nighttime, orthostasis, or <75% expected body weight.

Screening Instruments — Validated Tools to Pair with HEEADSSS

— PHQ-2 (2 items) → if positive, PHQ-9 Modified for Adolescents (PHQ-9-A); score ≥10 = moderate, ≥15 = moderately severe, ≥20 = severe

— Columbia Suicide Severity Rating Scale (C-SSRS) for risk stratification when SI endorsed

— USPSTF (2022): screen all adolescents 12–18 for major depressive disorder (Grade B) and anxiety (Grade B, ages 8–18)

— CRAFFT 2.1+N (Car, Relax, Alone, Forget, Family/Friends, Trouble; +N = nicotine): ≥2 yes = high-risk, brief intervention indicated

— AAP recommends annual screening starting at age 11; SBIRT framework (Screening, Brief Intervention, Referral to Treatment)

— SCOFF (≥2 of 5 = positive): Sick (vomit), Control, One stone (>14 lb) lost, Fat (feel), Food dominates life

— Order CMP, magnesium, phosphorus, EKG (QTc) when positive

— GAD-7 for generalized anxiety

— SCARED for pediatric anxiety subtypes

— PC-PTSD-5 for trauma screening

— HITS or HARK for intimate partner/dating violence

— CDC: annual chlamydia/gonorrhea screening for all sexually active females <25 and high-risk males; HIV testing 15–65 at least once

— Offer expedited partner therapy (EPT) where legal for chlamydia/gonorrhea

Depression and suicide

Substance use

Eating disorders

Anxiety and trauma

Sexual health and IPV

Step 3 management: A positive PHQ-9-A with active SI, plan, intent, or means access = emergency mental health evaluation, do not discharge home without safety assessment, means restriction counseling (especially firearms — Counseling Access to Lethal Means / CALM), and warm handoff.

Key distinction: Screening positive ≠ diagnosis. The PHQ-9-A and CRAFFT identify risk; DSM-5 criteria + clinical interview establish diagnosis. On boards, the next step after positive screen is usually structured assessment + safety planning, not immediate pharmacotherapy.

Board pearl: CRAFFT score ≥2 in a 16-year-old = brief motivational intervention in office + follow-up in 1–2 weeks, not automatic referral to rehab.

Confidentiality Law — What Minors Can Consent To

— Minors (<18 in most states) cannot consent to medical care — but every US state has exceptions for specific "sensitive services"

— Confidentiality ≠ absolute; tied to consent statute for that service

— STI testing and treatment — all states

— Contraception (most states; federally protected under Title X funded clinics regardless of state)

— Pregnancy care — most states; abortion access varies dramatically post-Dobbs

— Substance use treatment — federal 42 CFR Part 2 protects substance use records

— Mental health services — most states allow minor consent at age 12–16, often with session limits

— Age of consent for general medical care: typically 18, but mature minor doctrine recognized in many states

— HIV testing/treatment: most states allow minor consent

— HPV and other vaccines: state-dependent

— Gender-affirming care: highly state-variable and rapidly changing

— Married, military service, court-declared, or self-supporting/living independently (state-specific)

— Can consent to all medical care as an adult

— Suicidal ideation with plan/intent

— Homicidal ideation (Tarasoff duty in most states)

— Abuse or neglect — mandatory report to CPS

— Reportable communicable diseases to public health (not parents directly)

— Explanation of Benefits (EOB) sent to policyholder (parent) can inadvertently disclose confidential services

— Solutions: cash pay, Title X clinic, request confidential communication under HIPAA, state-specific minor consent laws

General principle

Universally confidential services (all 50 states, with variation)

Variable by state

Emancipated minor

Mandatory disclosure (confidentiality breaks)

Billing pitfall

Step 3 management: Open every adolescent visit with: "What we talk about is private. I won't share it with your parents — unless I'm worried someone is hurting you, you're going to hurt yourself, or you're going to hurt someone else. Then I have to tell someone to keep you safe."

Board pearl: A 16-year-old requests STI testing and asks you not to tell her parents — honor confidentiality in all 50 states. The parent's "right to know" does not override the minor consent statute for STIs.

Risk Stratification — Acting on a Positive HEEADSSS

— Low risk: anticipatory guidance, reinforcement of protective factors, return in 1 year

— Moderate risk: brief intervention in office, motivational interviewing, follow-up 2–4 weeks, consider referral

— High risk: immediate safety plan, same-day referral to mental health/SUD/social work, mandated reporting if applicable

— Imminent danger: ED transfer, do not leave alone, involve crisis team

— High acute risk: active SI + plan + intent + means access, or recent attempt → ED, 1:1 observation, psychiatric admission

— Moderate: SI without plan, prior attempt, multiple risk factors → safety plan, lethal means restriction, outpatient psych within 1 week, frequent check-ins

— Low: passive ideation, no plan, strong protective factors → safety plan, follow-up 2 weeks

— Connected adult (parent, coach, teacher, clergy)

— School engagement

— Future orientation

— Reasons for living (ask explicitly)

— Access to mental health care, lack of access to lethal means

— Firearms: remove from home or store locked, unloaded, separate from ammunition; offsite storage is best

— Medications: lock up or dispose of excess, especially acetaminophen, opioids, TCAs

— Document the conversation and parent agreement

— 5–15 min motivational interview, FRAMES model: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy

— For high-risk: referral to adolescent SUD program

Tiered response framework

Suicide risk stratification

Protective factors to assess and reinforce

Means restriction counseling (CALM)

Brief intervention for substance use (SBIRT)

CCS pearl: For an adolescent CCS case with active SI + plan, the correct sequence is: do not discharge → continuous observation → psychiatric consult → safety plan → admit to inpatient psychiatry. Ordering "discharge home with parent" fails the case.

Board pearl: Means restriction (especially firearm removal) is the single most evidence-based suicide prevention intervention for adolescents — higher yield than therapy initiation in the acute period.

Pharmacotherapy — When and What to Start in Adolescents

— First-line: fluoxetine (FDA approved ≥8 yr) or escitalopram (FDA approved ≥12 yr) for adolescent MDD

— Start low: fluoxetine 10 mg daily, increase to 20 mg after 1–2 weeks

— Black box warning: increased suicidality (esp. first 1–4 weeks); does not contraindicate use — but mandates close follow-up

— Follow-up: weekly × 4 weeks, biweekly × 4 weeks, then monthly; reassess PHQ-9-A at each visit

— Combination of SSRI + CBT > either alone (TADS trial)

— SSRIs first-line: sertraline, fluoxetine, escitalopram

— Avoid benzodiazepines in adolescents (dependence, disinhibition, overdose risk)

— Stimulants (methylphenidate, amphetamine) first-line; check baseline HR/BP, cardiac history (no routine ECG unless red flags per AHA/AAP)

— Non-stimulants: atomoxetine, guanfacine ER, clonidine ER — useful with tic disorder, substance use risk, or stimulant intolerance

— Opioid use disorder: buprenorphine FDA approved ≥16 yr; naltrexone for ≥18 yr; methadone limited <18

— Tobacco/nicotine: NRT off-label but supported; varenicline ≥16; bupropion off-label

— Alcohol use disorder: behavioral first-line in adolescents; pharmacotherapy off-label

— LARC (IUD, implant) is first-line for adolescents per AAP/ACOG — highest efficacy, no daily adherence

— Combined hormonal contraception fine if no contraindications (migraine with aura, smoking, VTE history)

— Emergency contraception: levonorgestrel OTC at any age, ulipristal Rx, copper IUD most effective

Depression

Anxiety

ADHD

Substance use disorders

Contraception

Step 3 management: Before starting an SSRI in an adolescent, document: discussion of black box warning with patient and parent, agreement on follow-up plan, removal of lethal means from home, and safety plan including crisis hotline (988).

Board pearl: Fluoxetine is the only SSRI with FDA approval for pediatric MDD down to age 8 — when the stem specifies a child <12, fluoxetine is the answer.

Motivational Interviewing and Brief Intervention Techniques

— Open-ended questions

— Affirmations

— Reflective listening

— Summaries

— Spirit: partnership, acceptance, compassion, evocation — not lecturing

— Precontemplation → contemplation → preparation → action → maintenance → (relapse)

— Match intervention to stage; trying to push a precontemplator to action backfires

— Ask: screen

— Advise: clear, personalized recommendation ("As your doctor, I recommend you stop vaping")

— Assess: readiness to change (0–10 scale)

— Assist: quit plan, resources, pharmacotherapy if indicated

— Arrange: follow-up within 1–2 weeks

— DARN-CAT: Desire, Ability, Reasons, Need → Commitment, Activation, Taking steps

— When you hear change talk, reflect and amplify it; avoid the "righting reflex"

— Pros and cons of changing vs. not changing

— Useful for ambivalence — the heart of MI

— Adolescent endorses weekend binge drinking — MI > confrontation

— Adolescent reports unprotected sex — MI to explore contraception readiness

— Adolescent with vaping — personalize harm (sports performance, cost, addiction)

— Restate confidentiality before each new sensitive topic if patient hesitates

— Offer to write down information rather than verbalize answers if more comfortable

Core MI principles (OARS + spirit)

Stages of change (Prochaska-DiClemente)

Brief intervention structure (5 A's)

Change talk to elicit and reinforce

Decisional balance

High-yield Step 3 scenarios

Confidentiality reinforcement during intervention

CCS pearl: "Counsel patient — substance use" and "Counsel patient — safe sex practices" are explicit CCS orders. Pair them with the relevant screening (e.g., GC/CT NAAT, HIV, urine pregnancy) and offer LARC or condoms in the same visit.

Board pearl: When asked "what is the most appropriate next step" for an adolescent with mild substance use, brief motivational intervention in the office beats "refer to rehab" and beats "drug test without consent." Drug testing without adolescent consent is generally not recommended by AAP — it damages trust and rarely changes outcomes.

Special Populations — Chronic Illness and Disability in Adolescents

— At higher risk for depression, substance use, risky sex, nonadherence

— Still need full HEEADSSS — disease focus often crowds out psychosocial screen

— Nonadherence frequently driven by HEEADSSS domains: depression, bullying, body image, peer pressure

— Begin transition planning at age 12–14

— Transfer to adult provider typically by age 18–22

— Six core elements: transition policy, tracking, readiness assessment, planning, transfer of care, transfer completion

— Confidentiality and consent assessed by decision-making capacity, not age alone

— Sexual health screening still required — high rates of sexual abuse in this population

— Guardianship status at 18 affects consent; address before age of majority

— SSRI dosing: start lower, titrate slower; sertraline and citalopram require hepatic dose adjustment

— Stimulant clearance unaffected by renal disease but cardiac comorbidity may limit use

— Contraception: avoid estrogen with significant hepatic disease or nephrotic-range proteinuria → progestin-only or IUD

— 4× higher suicide attempt rate vs. cisgender heterosexual peers

— Use chosen name and pronouns; ask, don't assume

— Screen for family rejection, housing instability, conversion practices exposure

— Gender-affirming care decisions involve patient, family, and multidisciplinary team

— High rates of trauma, mental health needs, school disruption

— Consent for medical care varies — agency, biological parent, or court depending on state

Adolescents with chronic disease (diabetes, asthma, IBD, sickle cell, CF, transplant, congenital heart disease)

Transition planning (Got Transition / AAP-AAFP-ACP)

Adolescents with intellectual or developmental disability

Adolescents with renal/hepatic impairment

LGBTQ+ adolescents

Adolescents in foster care

Step 3 management: For a 17-year-old with cystic fibrosis transitioning to adult care, schedule a joint pediatric-adult clinic visit, transfer the medical summary, and ensure first adult appointment is scheduled before the last pediatric visit. Document a transition readiness assessment.

Board pearl: LGBTQ+ status itself is not a mental illness — distress arises from minority stress and family rejection. Family acceptance is the strongest modifiable protective factor.

Special Populations — Pregnancy, Parenting Teens, and Pediatric Subgroups

— All states allow minor consent to pregnancy-related care (prenatal, labor/delivery)

— Abortion access: state-variable, parental involvement laws in many states (judicial bypass available)

— Higher risk for preterm birth, preeclampsia, anemia, postpartum depression, IPV

— Folic acid 400 mcg daily for all sexually active adolescents capable of pregnancy

— Screen for IPV at every prenatal visit (HITS, HARK)

— Once pregnant or parenting, adolescent typically gains decision-making authority for own and child's healthcare in most states (emancipation by parenthood varies)

— Postpartum: screen for depression at 1, 2, 4, 6 month visits (Edinburgh or PHQ-9)

— Contraception counseling started before delivery; LARC can be placed immediately postpartum

— Encourage school continuation; high rates of dropout

— Concrete thinking dominates — use simple language, avoid abstract risk framing

— Sexual activity at this age raises concern for abuse/exploitation; check age of partner

— Statutory rape laws vary — partner more than ~4 years older may trigger mandatory report

— Legal adult — full confidentiality and decision-making

— Still developmentally adolescent — frontal lobe maturation continues to ~25

— Transition out of pediatric care, college health, military, workforce

— Female athlete triad / RED-S: energy deficit, menstrual dysfunction, low bone density

— Screen for performance-enhancing drug use, eating disorder, concussion history

— Sudden cardiac death screen: AHA 14-element history + exam (ECG not routine in US)

Pregnant adolescent

Parenting adolescent

Early adolescent (11–14)

Late adolescent (18–21)

Athletes

Step 3 management: A 15-year-old presents pregnant, doesn't want parents told. In states with parental involvement laws for abortion only, prenatal care can proceed confidentially; counsel options neutrally (continue pregnancy, adoption, abortion where legal) and offer judicial bypass referral.

Board pearl: Sexual activity in a 12-year-old with an 18-year-old partner = mandatory report in most states regardless of consent — age differential triggers statutory rape statutes, and "consent" is legally invalid.

Complications and Adverse Outcomes of Missed Screening

— Completed suicide: most adolescents who die by suicide saw a medical provider within the prior month — missed opportunity

— MVC fatalities: alcohol, cannabis, distracted driving, no seatbelt — all HEEADSSS-screenable

— Overdose: rising rapidly with fentanyl-contaminated supply; counsel naloxone access

— Unintended pregnancy: highest rates in adolescents not offered LARC

— STI sequelae: PID, tubal infertility, ectopic pregnancy from undiagnosed chlamydia

— HIV: undiagnosed in ~50% of adolescents with infection

— Untreated MDD → chronic depression, comorbid substance use, academic failure, suicide

— Untreated eating disorder → cardiac arrhythmia, osteoporosis, death (highest mortality of psychiatric illnesses)

— Untreated anxiety → school avoidance, substance self-medication

— Earlier initiation = higher lifetime dependence risk (alcohol use before age 15 → 4× higher AUD risk)

— Adolescent brain particularly vulnerable to addiction neuroplasticity

— Continued sexual or physical abuse if not identified

— Human trafficking — red flags: tattoos branding, older "boyfriend," inconsistent story, controlled by accompanying adult, recurrent STIs

— Adolescent avoids care altogether after breach

— EOB-mediated disclosure → family conflict, eviction, violence

— Documentation of sensitive info in shared chart visible to parent portal

— 21st Century Cures Act mandates patient access to notes — adolescent records often dual-access by parent in pediatric portals

— Many EHRs allow adolescent-only segmented access starting age 12–13; configure proactively

Direct mortality consequences

Reproductive consequences

Mental health progression

Substance use trajectory

Abuse and exploitation

Iatrogenic harms from poor confidentiality

Patient portal pitfalls

Step 3 management: Before documenting sensitive HEEADSSS findings, verify your EHR's adolescent confidentiality settings. Use "confidential note" features or sensitive-data flags so parent portal access does not auto-disclose STI results, mental health diagnoses, or contraception.

Board pearl: A parent calls demanding the result of their 16-year-old's chlamydia test — you may not disclose without the adolescent's consent, even if parent is policyholder. Refer parent back to the adolescent.

When to Escalate — ED Transfer, Admission, Mandatory Reporting

— Active suicidal ideation with plan, intent, or means access

— Recent suicide attempt or self-injury requiring medical care

— Homicidal ideation with identified target

— Acute psychosis

— Acute intoxication or overdose

— Eating disorder with medical instability (HR <50, orthostasis, electrolyte abnormality, <75% expected body weight)

— Imminent risk that cannot be safely managed outpatient

— Failed outpatient stabilization

— Lack of supportive home environment for safety plan

— Need for medication initiation/observation in unsafe setting

— Suspected child abuse (physical, sexual, emotional, neglect) — reasonable suspicion, not proof, is the threshold

— All physicians are mandatory reporters in all 50 states

— Report even if adolescent asks you not to — confidentiality does not protect ongoing abuse

— Document factual findings, statements, and report; do not interrogate the suspected perpetrator

— Acute sexual assault → SANE exam, evidence collection within 72–120 hours, emergency contraception, HIV PEP, STI prophylaxis

— Human trafficking suspicion → National Human Trafficking Hotline, social work, do not confront accompanying adult

— Tarasoff duty (homicidal threat with identified target) — varies by state

— Adolescent medicine: complex eating disorder, gender-affirming care, complicated SUD

— Psychiatry: medication failure, complex comorbidity, severity escalation

— Social work: housing, food insecurity, abuse, custody disputes

Immediate ED/psychiatric transfer

Inpatient psychiatric admission criteria

Mandatory CPS report — when

Law enforcement involvement

Subspecialty consultation thresholds

CCS pearl: When a screening reveals active SI with plan, the CCS clock should advance with: continuous observation order, sitter at bedside, remove personal items (belts, shoelaces, sharps), psychiatry consult, and ED-to-inpatient psychiatric bed search. Do not order "discharge with outpatient follow-up."

Step 3 management: When you make a CPS report on a 14-year-old, tell the adolescent you are making the report and why, before they leave. Surprise reports damage therapeutic alliance and may put the adolescent at greater risk if they return home.

Board pearl: Reasonable suspicion of abuse is sufficient — you do not need to "be sure." Failure to report carries criminal and civil liability in all states.

Key Differentials — Overlapping Behavioral Syndromes

— Normal: transient, reactive to specific stressor, preserved function, retained interests

— MDD: ≥2 weeks, functional impairment, anhedonia, sleep/appetite/energy changes, hopelessness, SI

— Adolescents often present with irritability rather than sadness (DSM-5 allows irritable mood for pediatric MDD)

— Family history of bipolar

— Activation, decreased sleep need, grandiosity, hypersexuality

— SSRI monotherapy may unmask mania — ask about prior mood elevations before prescribing

— Mixed features in adolescents particularly common

— Overlap in concentration difficulty, sleep disturbance, irritability

— ADHD: symptoms since childhood, present across settings, no episodic mood component

— Anxiety: worry-driven concentration loss, somatic symptoms, avoidance behavior

— Comorbidity common (>50%)

— Cannabis/stimulant intoxication can mimic mania, psychosis

— Withdrawal can mimic depression, anxiety

— Re-evaluate mood/anxiety after 30 days sober when possible

— Anorexia (restricting vs. binge-purge): low weight + fear of fat

— Bulimia: normal/high weight + binge + purge

— Binge-eating disorder: binge without compensation

— ARFID: avoidance not driven by body image (sensory, fear of consequences)

— Atypical anorexia: all features except low weight — equally medically dangerous

— NSSI: intent to relieve distress, not to die; cutting, burning; still elevates future suicide risk

— Suicide attempt: intent to die; method, planning, lethality assessment

— Both require intervention; do not minimize NSSI as "just attention-seeking"

Depression vs. normal adolescent moodiness

Depression vs. bipolar disorder

Anxiety vs. depression vs. ADHD

Substance use vs. primary psychiatric disorder

Eating disorder subtypes

Suicide attempt vs. non-suicidal self-injury (NSSI)

Board pearl: A teen with new "depression" who is sleeping 4 hours, talking rapidly, spending impulsively, and hypersexual is not depressed — screen for bipolar/mania before any SSRI.

Key distinction: Adolescent MDD criteria allow irritable mood to substitute for depressed mood — this is a frequent test point and distinguishes pediatric from adult diagnostic criteria.

Key Differentials — Medical Mimics of Behavioral Presentations

— Hyperthyroidism: anxiety, insomnia, weight loss, tachycardia, tremor — check TSH

— Hypothyroidism: depression, fatigue, weight gain, constipation

— Adrenal insufficiency: fatigue, weight loss, hyperpigmentation

— Cushing's: mood lability, weight gain, striae

— Diabetes (new-onset or DKA): fatigue, irritability, weight loss, polyuria

— Seizures (especially absence or complex partial): "spacing out," declining grades — EEG

— Concussion / post-concussive syndrome: mood change, headache, sleep disturbance, cognitive slowing

— Migraine: missed school, irritability, somatic

— Multiple sclerosis (rare but possible in late adolescence): new neurologic + mood symptoms

— Mononucleosis: profound fatigue, depression-like

— HIV (acute or chronic): fatigue, weight loss, recurrent infection

— Lyme disease (in endemic area): fatigue, cognitive, mood

— Autoimmune encephalitis (anti-NMDA): psychosis, behavior change, seizures, dyskinesia

— Lupus: fatigue, cognitive, mood, multisystem

— Iron deficiency anemia: fatigue, poor concentration, pica

— B12 deficiency: mood, cognition (rare in adolescents unless vegan or IBD)

— Lead exposure (younger adolescents in older housing)

— Heavy metals, inhalant abuse, carbon monoxide

— Delayed sleep phase syndrome: classic adolescent — late sleep onset, hard wake, daytime fatigue masquerading as depression

— Obstructive sleep apnea: fatigue, irritability, poor performance (esp. with obesity)

— Narcolepsy: daytime sleepiness, cataplexy

Endocrine mimics

Neurologic mimics

Infectious/inflammatory

Nutritional/toxic

Sleep disorders

Step 3 management: Before diagnosing MDD in an adolescent with fatigue, weight change, or cognitive decline, screen with: CBC, ferritin, TSH, CMP, urine pregnancy (if applicable), HIV, urine drug screen, and sleep history. Don't anchor on psychiatric diagnosis.

Board pearl: New-onset psychosis + seizures + autonomic instability + dyskinesias in an adolescent female = anti-NMDA receptor encephalitis, often with ovarian teratoma. Don't call it primary psychiatric.

Anticipatory Guidance and Long-Term Prevention

— Safety: seatbelts every ride, no driving under influence, no riding with impaired driver, helmet use, firearm safety (lock storage, ammunition separate), water safety, online safety

— Nutrition/activity: 60 min daily activity, 5 servings fruit/veg, limit sugar-sweetened beverages, family meals

— Sleep: 8–10 hours per night (8–18 yr); consistent schedule; no screens 1 hour before bed

— Mental health: identify trusted adult, coping skills, crisis line 988

— Substance use: clear no-use message, family agreement, exit plan from unsafe situations

— Abstinence framed as one option, not the only counseling

— Dual protection: hormonal + condom

— PrEP for HIV: tenofovir/emtricitabine for high-risk adolescents (sexually active MSM, multiple partners, IDU); approved age ≥12 and ≥35 kg

— HPV vaccine at 11–12 (catch-up to 26); reduces cervical, anal, oropharyngeal cancers

— Meningococcal (MenACWY at 11–12, booster at 16; MenB shared decision-making 16–23)

— Graduated driver licensing — restrict night driving, passenger limits, no phone use

— Parent-teen driving contract evidence-based

— Sexting risks (legal, including child pornography statutes that can apply to minors photographing themselves)

— Cyberbullying — both victim and perpetrator screening

— Social media and depression — limit use, esp. nighttime

— After suicide attempt: continued therapy, medication adherence, means restriction, follow-up within 72 hours of discharge (Joint Commission)

— After STI: rescreen at 3 months (high reinfection rate), partner treatment

— After pregnancy: postpartum contraception (LARC immediately postpartum), depression screening

Annual visit core anticipatory guidance (Bright Futures)

Sexual health prevention

Driving safety

Digital citizenship

Secondary prevention after positive screen

Step 3 management: Post-psychiatric-discharge follow-up should occur within 7 days (ideally 72 hours for high-risk adolescents) — this is a HEDIS quality measure and a board favorite.

Board pearl: HPV vaccine series initiated before age 15 = 2 doses (0, 6–12 months); started ≥15 = 3 doses (0, 1–2, 6 months).

Follow-Up, Monitoring, and Care Coordination

— Mild depression on watchful waiting: 1–2 weeks

— SSRI initiation: weekly × 4, biweekly × 4, monthly thereafter (FDA black box monitoring)

— Post-suicide attempt: within 72 hours of hospital discharge, then weekly

— Substance use brief intervention: 1–2 weeks

— Eating disorder: weekly weights, vitals, labs (electrolytes, phosphorus) — phosphorus during refeeding

— Contraception initiation: 3-month visit, then annual; LARC requires no routine follow-up unless symptoms

— STI treatment: test of reinfection at 3 months for chlamydia/gonorrhea

— PHQ-9-A at each depression visit — track score trajectory

— GAD-7 for anxiety treatment

— CRAFFT or timeline followback for substance use

— Growth chart, vitals, electrolytes for eating disorders

— Therapist + prescriber communication (release of information from adolescent and parent for minors)

— School coordination: 504 plan, IEP, school counselor — requires adolescent and parent consent

— Care plan shared with primary, mental health, social work

— Warm handoff for transitions (pediatric to adult, inpatient to outpatient)

— Family-based treatment (FBT/Maudsley) is first-line for adolescent anorexia

— CBT and IPT for adolescent depression

— Family therapy for SUD, conduct issues, family conflict

— Confidentiality preserved within family-based work — discuss what is/isn't shared up front

— 988 Suicide and Crisis Lifeline (call/text)

— Crisis Text Line (text HOME to 741741)

— SAMHSA helpline 1-800-662-HELP

— Trevor Project (LGBTQ+) 1-866-488-7386

— RAINN 1-800-656-HOPE (sexual assault)

Cadence after positive screen

Outcome monitoring tools

Coordination of care

Family involvement

Rehab/counseling resources

Step 3 management: Document every follow-up plan with date, modality (in-person, telehealth), and contingency ("if symptoms worsen, call/return"). Provide 988 in writing at every visit where suicide risk is on the differential.

Board pearl: Family-based treatment, not individual therapy or hospitalization, is the first-line for medically stable adolescent anorexia — and outperforms individual therapy on weight restoration outcomes.

Ethical, Legal, and Patient Safety Considerations

— Imminent harm to self

— Imminent harm to others (Tarasoff duty in most states)

— Suspected abuse or neglect (mandatory CPS report)

— Reportable communicable diseases (to public health, not parents)

— Court order

— Minor assent + parental consent is the standard pediatric framework

— Sensitive services: minor consent alone (per state statute)

— Mature minor doctrine (state-variable): cognitively mature adolescent may consent to routine care

— Emancipated minor: full adult consent rights

— Patient portal: 21st Century Cures Act mandates access to notes, but adolescent records require segmented access — configure proactively

— EOB billing: parental insurance EOBs can disclose confidential services — direct adolescents to Title X clinics or HIPAA confidential communications request

— EHR documentation: use sensitive-data flags; avoid documenting STI/contraception/mental health in parent-visible sections when possible

— ED to outpatient: no follow-up scheduled, patient lost

— Pediatric to adult: medication errors, insurance lapses, missed appointments

— Inpatient psychiatric to outpatient: highest-risk window for suicide — 7-day follow-up is a quality measure and patient safety standard

— When they conflict (e.g., parent demands contraception not be prescribed), follow state law on minor consent and document the conversation; do not violate adolescent's confidential consent rights

— Avoid documenting third-party identifying information about partners, drug sources in adolescent's record

— Document conversations about confidentiality and its limits at the start of the visit

— Implicit bias affects screening rates — Black and Hispanic adolescents less likely to receive mental health referral despite equal symptom burden

— Use structured screening to reduce bias

Confidentiality boundaries — when to break

Informed consent and assent

Confidentiality breach risks in modern care

Transition-of-care risks

Parental rights vs. adolescent autonomy

Documentation pitfalls

Equity and bias

Step 3 management: A 16-year-old's mother demands the visit note from the patient portal showing the daughter was prescribed contraception. The correct action: explain confidentiality, do not release the confidential portion, ensure the EHR has segmented adolescent access, and refer the mother back to her daughter for conversation. Releasing the note violates state minor consent statute and HIPAA.

Board pearl: Confidentiality is not absolute — the three breaks (harm to self, harm to others, abuse) are universal across states and the most-tested element.

High-Yield Associations and Rapid-Fire Clinical Facts

• HEEADSSS mnemonic — exam favorite
— Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety
— Some versions add a third "S" for Strengths (assets-based)
• Confidentiality breaks (memorize)
— Harm to self	Harm to others	Abuse	reportable disease	court order
• First-line meds
— Adolescent MDD: fluoxetine (age ≥8) or escitalopram (age ≥12)
— Adolescent contraception: LARC (IUD or implant) first-line per AAP/ACOG
— Adolescent opioid use disorder: buprenorphine (≥16 yr)
— Adolescent ADHD: stimulants first-line; no routine ECG required
• Screening tools
— CRAFFT ≥2 → high risk
— PHQ-9 ≥10 → moderate; ≥20 → severe
— SCOFF ≥2 → eating disorder concern
— Columbia C-SSRS for suicide risk severity
• Vaccines at adolescent visits
— 11–12: Tdap, HPV, MenACWY
— 16: MenACWY booster; MenB shared decision
— Annual: influenza
— Catch-up: HPV through 26, hepatitis B, varicella, MMR
• Universally state-protected minor consent services
— STI testing/treatment, contraception, prenatal care, substance use treatment
• Mortality drivers (US adolescents)
— #1 Unintentional injury (MVCs, overdose)	#2 Suicide	#3 Homicide
— Firearms are leading cause of all pediatric deaths
• Anorexia admission criteria
— HR <50 daytime / <45 night, BP <90/45, orthostasis, T <96°F, <75% expected body weight, electrolyte abnormality, syncope, suicidality
• Statutory rape triggers
— Adult partner of a young adolescent → mandatory report regardless of "consent"
• Post-discharge psychiatric follow-up
— Within 7 days (HEDIS) — ideally 72 hours for high-risk
• HPV dosing
— Start <15: 2 doses	Start ≥15: 3 doses
• 988
— Suicide & Crisis Lifeline; call or text
• Board pearl: When a Step 3 stem opens with an adolescent in any context, the first reflex is: "Did the doctor talk to the patient alone with a confidentiality statement?" If not, that's the answer.
• Key distinction: Pediatric MDD allows irritable mood criterion; adult MDD requires depressed mood or anhedonia.

Board Question Stem Patterns

— Right answer: interview adolescent alone with confidentiality statement; HEEADSSS

— Wrong: order labs, prescribe medication, talk only to mom

— Right: test and treat confidentially in all 50 states; use cash/Title X to avoid EOB

— Wrong: require parental consent, notify parents

— Right: assess function of NSSI, screen for comorbid depression/anxiety, safety plan, outpatient mental health referral

— Wrong: dismiss as attention-seeking; inpatient psych unless SI present

— Right: continuous observation, psych eval, lethal means restriction (remove firearm), inpatient psychiatric admission

— Wrong: outpatient follow-up, prescribe SSRI and discharge

— Right: mandatory report (statutory rape regardless of "consent"); STI testing; pregnancy testing; contraception offer

— Wrong: maintain confidentiality without report

— Right: admit — medical instability from anorexia; check electrolytes, phosphorus, ECG (QTc); refeeding precautions

— Wrong: outpatient nutrition referral

— Right: protect confidential portion per state law; refer parent to adolescent

— Wrong: release full note

— Right: Tdap, HPV (2-dose schedule), MenACWY; HEEADSSS introduction

— Wrong: defer HPV

— Right: fluoxetine with black box warning discussion and close follow-up

— Wrong: benzodiazepine, TCA

— Right: within 7 days, ideally 72 hours

— Wrong: 1 month

— Right: brief motivational interview in office; offer cessation support

— Wrong: drug test, lecture, refer to rehab

Stem 1: "Mom brings in her 15-year-old daughter for 'attitude problems'..."

Stem 2: "16-year-old requests STI testing, doesn't want parents told"

Stem 3: "14-year-old reports cutting; not suicidal"

Stem 4: "17-year-old presents with active SI, plan to use father's firearm"

Stem 5: "13-year-old sexually active with 19-year-old partner"

Stem 6: "Thin 16-year-old with amenorrhea, HR 42, BMI 16"

Stem 7: "15-year-old, parent demands access to visit notes including contraception"

Stem 8: "12-year-old at well visit"

Stem 9: "Adolescent with new depression — first medication?"

Stem 10: "Discharged from inpatient psych after suicide attempt — when is follow-up?"

Stem 11: "Adolescent reports vaping — next step?"

CCS pearl: In adolescent CCS cases, the orders "Interview patient alone," "Discuss confidentiality," and stage-appropriate screening tools should appear in the first simulated minutes — before diagnostic orders.

Board pearl: When two answer choices both seem reasonable, the one that preserves adolescent autonomy and confidentiality while addressing safety is usually correct.

One-Line Recap

The adolescent visit is built around interviewing the patient alone, opening with an explicit confidentiality statement and its three limits (harm to self, harm to others, abuse), then systematically working through the HEEADSSS domains to detect risk early, deploying validated screening tools and stage-matched motivational interventions while respecting state-specific minor consent laws.

— Always interview the adolescent alone at every visit

— Open with confidentiality + its limits in plain language before sensitive questions

— Use HEEADSSS as the structured screen — annually and at any change in function

— Honor minor consent for STI testing, contraception, prenatal care, substance use treatment, and (most states) mental health

— Active SI with plan/intent/means → continuous observation, lethal means restriction, psychiatric evaluation, inpatient admission as needed

— Suspected abuse → mandatory CPS report regardless of adolescent's preference

— Statutory rape (significant age gap with young adolescent) → mandatory report

— Fluoxetine for adolescent MDD (≥8 yr) with black box warning + weekly follow-up × 4

— LARC as first-line contraception per AAP/ACOG

— Family-based treatment as first-line for adolescent anorexia

— SBIRT (brief motivational intervention) for any positive substance use screen

— 988 crisis line in every safety plan; post-psychiatric-discharge follow-up within 7 days

The four most-tested actions

The non-negotiable safety triad

First-line therapeutics worth memorizing

Step 3 management: When the stem features an adolescent, the first correct order is almost always to talk to the patient privately with a confidentiality statement — diagnostic and therapeutic interventions follow from what that conversation reveals, not from the parent's chief complaint.

Board pearl: Confidentiality is the therapeutic tool that unlocks accurate HEEADSSS data — protect it like a vital sign, and break it only for the three universal exceptions.