by: Mario Cappelli, PhD and Paula Cloutier, MA

Affiliations:  1Children’s Hospital of Eastern Ontario (CHEO), 2CHEO Research Institute, 3University of Ottawa

What is the HEADS-ED?

The HEADS-ED is a brief mental health screening tool that helps physicians to obtain a psychosocial history to aid in making decisions regarding patient disposition (e.g., admission, discharge, or requesting specialized mental health consultation).   The tool was designed by a multidisciplinary clinical and research team to match the existing psychosocial “HEADS” interview 5 as closely as possible by adapting it for emergency department (ED) use and adding a scoring component to assist with decision-making. Seven items representing specific components of the patient history are included (Home, Education, Activities & peers, Drugs & Alcohol, Suicidality, Emotions & behaviours, and Discharge resources).  Each item is rated according to three action levels: No action needed, Needs action but not immediate, and Needs immediate action. The levels were developed from the communimetrics theory of measurement which emphasizes the use of non-arbitrary levels that translate immediately into action.6  The levels are used to inform and facilitate decisions regarding patient disposition.

Why it was initially developed?  

Recent research shows that pediatric mental health presentations to the Emergency Department (ED) are increasing in Canada and the US.1,2 In order for physicians to use a screening tool in the ED, it must be brief, clinically intuitive, easy to complete and score, and help guide their decision making. Currently, there is no standard of practice or tool for physicians or non-mental health specialists to help guide the assessment and disposition of mental health ED presentations. The lack of an available mental health screening tool has been identified as a significant barrier by ED physicians in providing appropriate care,3 which would indicate that current mental health screening tools are not meeting their needs.

Completing the HEADS-ED:  

The HEADS-ED can be used to guide the psychosocial assessment and can be completed within a few minutes by a health care practitioner (physician or nurse) or allied health professional (crisis worker, school counselor) following the assessment.  It is available in a paper and pencil version or online at  The online version provides details about the tool, training videos and a mental health resource library (Figures 1-3).  It also has the functionality to help guide clinician decision making by 1) immediately providing a meaningful score; 2) suggesting if a consultation with a mental health professional may be required; and 3) identifying appropriate local community resources based on the needs identified in the ED to facilitate continuity of care.  An example of the website tailored for the National Capitol Region of Canada can be found at

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Who is eligible?

The HEADS-ED was initially developed for use with children and adolescents between the ages of 6 and 18 years presenting to the ED for mental health care. Its use has expanded to school boards and mental health centralized intake services.

What is the evidence so far?  

The reliability and validity of the HEADS-ED has been established in two separate samples of pediatric patients presenting to the ED with mental health concerns7,8.  There are many barriers at the individual and system level that influence the successful integration of new practices and evidence-based research in clinical settings. To help understand the barriers for implementing the HEADS-ED, we conducted focus groups with participants from 6 different EDs across 2 provinces (Ontario and Nova Scotia) using the Theoretical Domains Framework.9-10 The study findings indicate that tailored implementation strategies are needed when using the tool in ED settings by taking into account site specific requirements. This methodology can serve as an implementation model for other services wanting to implement the tool.

What can be expected in the future?

The HEADS-ED currently is part of an Emergency Department Mental Health Clinical Pathway designed for a seamless transition from ED services to follow-up community services and is currently being implemented and evaluated in Ontario, Canada.11  We have also partnered with an academic team of healthcare providers in order to tailor and evaluate the tool for use in primary care settings.  A version for children under the age of 6 years old is also in development.

◊ A video describing the HEADS-ED tool and the website is available at:

◊ For more information visit HEADS-ED or email Paula at or Mario at

◊ To download the HEADS-ED form in English and French, click HERE.

1.  American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians and Pediatric Emergency Medicine Committee, Dolan MA, Mace SE. Pediatric mental health emergencies in the emergency medical services system. Pediatrics. 2006; 118(4):1764–1767
2.  Newton AS, Ali S, Johnson DW, et al. A 4-year review of pediatric mental health emergencies in Alberta. Can J Emeg Med. 2009; 11(5): 447-454.
3.  Habis A, Tall L, Smith J, et al. Pediatric emergency medicine physicians’ current practices and beliefs regarding mental health screening. Pediatr Emerg Care. 2007; 23(6):387–393
4.  Betz ME, Sullivan AF, Manton AP, et al. Knowledge, attitudes, and practices of the emergency department providers in the care of suicidal patients. Depression and Anxiety. 2013; 30:1005-12; doi:10.1002/da.22071
5.  Goldenring JM, Rosen DS. Getting into adolescent heads:  an essential update.  Contemporary Pediatrics. 2004; 21:64-90
6. Lyons JS. Communimetrics: A Communication Theory of Measurement in Human Service Settings. London New York: Springer; 2009.
7. Cappelli M, Gray C, Zemek R, et al. The HEADS-ED: A rapid mental health screening tool for pediatric patients in the Emergency Department. Pediatrics. 2012; 130(2):130:e321-e327
8. Cappelli, M., Zemek, R., Polihronis, C., Thibedeau, N.R., Kennedy, A., Gray, C., Jabbour, M., Reid, S., Cloutier, P. (Accepted, Jan 2017).  Evaluating the HEADS-ED:  A brief, action oriented, clinically intuitive, pediatric mental health screening tool. Pediatric Emergency Care.
9. Michie S, Johnston M, Abraham C, et al. “Psychological Theory” Group. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26–33.
10. MacWilliams K, Curran J, Racek J, et al. Barriers and facilitators to implementing the HEADS-ED: a rapid screening tool for pediatric patients in emergency departments. Pediatr Emerg Car; 2016.  doi:10.1097/PEC.0000000000000651
11. Improving transitions in care for children and youth with mental health concerns. Available at: Updated 2015. Accessed March 18, 2016.

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