An editorial in the latest American Academy of Pediatrics journal, Pediatrics, recommends adding an additional “S” to the HEADSSS acronym to become HEADS⁴. The revised acronym would equate to: home life, education, activities, drugs, sexual activity, safety, suicide and/or depression, and social media.

Highlights from the editorial:

• Because aberrant social media use may mirror addiction, management may warrant approaches typically used in substance abuse care, such as screening, brief intervention and referral to treatment.
• Social networking has emerged as a potentially addictive cornerstone of teenage life; it now warrants systematic assessment by practitioners.
• HEADSSS remains helpful, but the additional “S” for social media can operate as a tool for patient education and risk stratification.
• Social media questions should be implemented into the routine clinical assessment of adolescents.

A potential framework for questions to assess patients’ social media practices:

All pediatric patients > 11 years should be asked the following:

1. Which social media site and/or apps do you regularly use?
2. How long do you spend on social media sites and/or applications in a typical day?
   • Concerning response: > 120 minutes per day.
   • Practical tip: Most smartphones track the total time spent in each application. Ask the patient if they would be willing to follow these instructions to get a more accurate response.
     • iOS instructions: Settings -> Battery -> clock icon -> scroll down to “Battery Usage.” May also download the applications listed below from the App Store.
     • Android instructions: will need to download an application that tracks usage. Free options in the Google Play store include “QualityTime,” “BreakFree” and “Checky.”

3. Do you think you use social media too much?
   • If yes, ask if they have tried any strategies to remedy it.
4. Does viewing social media increase or decrease your self-confidence?
5. Have you personally experienced cyberbullying, sexting or an online user asking to have sexual relations with you?
   • Depending on the patient, the clinician may need to describe what these are.

If screening raises concern, potential next steps may include the following:

• Crafting a family media plan
• Follow-up appointments
• Behavioral health referral