NPM #7 Injury Hospitalization – Reduce intentional and unintentional injuries among adolescents.

Among Missouri adolescents 10 to 19 years, non-fatal injury hospitalizations were 250.2 per 100,000 in 2018 compared to 274.9 per 100,000 in 2016. In 2017, the main causes of injury deaths among 10-19 year olds were motor vehicle accidents, homicide by firearms, and suicide by discharge of firearms. The leading causes of unintentional injury deaths in this age group were motor vehicle accidents, accidental poisoning, and drowning. Suicide is a persistent and increasing public health issue in Missouri. In 2017, the rate of suicide in Missouri was 24% higher than the national rate. According to 2018 Missouri Vital Statistics data, suicide remains the tenth leading cause of death for all ages among Missouri residents and the second leading cause of death among adolescents 10-19 years old. Additionally, the suicide rate among Missouri adolescents increased 56.0% from 2009 to 2019 provisional data (6.5 per 100,000 to 7.8 per 100,000). Comparatively, the national rate increased 58.0% from 2009 to 2018 (4.5 per 100,000 to 7.1 per 100,000). Youth suicide rates are higher in rural counties than more urban areas, presenting challenges for the provision of mental health services, as rural counties typically have fewer mental health resources available than urban counties. Multiple prevention strategies in Missouri were implemented to address unintentional and intentional injuries.

Injury Prevention

The Injury Prevention Program serves as the state lead for Safe Kids Worldwide and provides funding for 10 Safe Kids coalitions covering 59 counties in Missouri. The coalitions address topics such as teen driver safety, seat belt safety, pedestrian safety and other areas based on community needs. The coalitions offered a broad array of activities to achieve the performance goal, which included providing teen driver safety classes and hosting educational events, and conducting media campaigns with prevention messages. In FFY20 these coalitions provided services to over 2,600 children and parents through over 20 teen safety educational events.

Safe Kids coalitions help promote several traffic safety and driving courses provided around the state. First Impact is a program of ThinkFirst Missouri, a trauma prevention program of the University of Missouri School of Medicine, Department of Physical Medicine and Rehabilitation. The 90-minute evidence-based traffic safety program aims to reduce new driver crashes and resulting injuries and fatalities by increasing parental awareness and enforcement of Missouri’s Graduated Drivers License (GDL) law. First Impact provides the tools parents need to monitor, coach, and support their new teen driver. Trained law enforcement officers and facilitators deliver the program, which includes presenting key facts and proven strategies to help parents lower their teens’ crash risk by utilizing the Missouri GDL law. Teens Taking Action to Prevent Traffic Crashes (TRACTION), is a youth traffic safety leadership training program. The program includes a three-day conference to promote safe driving habits for youth and provide students and their adult advisors with the motivation, information, skills, and support necessary to develop a plan to address unsafe driving habits. The conference includes six workshops, docudrama training, team building, leadership training, and action planning. The Alliance of Southwest Missouri offers the National Safety Council’s Defensive Driving Course, a highly interactive course that helps young adults under the age of 25 take greater responsibility for their driving by focusing on behavior, judgement, and decision-making. This is a 4-hour, 6-hour or 8-hour classroom course that teaches young adults how to drive in a defensive manner. Some of the highlighted subjects contain training on: how to spot and evade head-on collisions, techniques to protect themselves against collisions with other drivers, distracted, drowsy, and impaired driving, the six deadly choices, how to avoid and protect oneself against road rage instances, Missouri law, and navigating highways, on/ off ramps, and heavy traffic.

Promote General/Traffic Safety

A total of 61 LPHAs reported providing general safety education, 66 reported providing education on proper seat belt usage, 61 reported providing education on impaired/distracted driving, and 40 reported engaging in activities to promote safe use of ATVs. Traffic safety highlights included:

• Gasconade County Health Department (GCHD) was able to place Buckle Up Phone Down messaging roadway signs in parking lots of schools and throughout the communities of Hermann, Rosebud, and Owensville. GCHD partnered with ThinkFirst for Teens who visited the Gasconade County R-1 School in March 2020 and provided education regarding risks associated with driving and safety tips for choices that prevent injury on the roadway. It was an impactful and meaningful presentation as the speaker shared her lived experience. The health department staff made “graduation bags” that included safe driving materials as well as safe driving promotional items (sunglasses, earbuds, cell phone charger, etc. – items that teens would take interest in). These items had the Buckle Up Phone Down message printed on them and served as a consistent messaging tool. These bags were given to graduating seniors who came to the school to pick up their diplomas. The health department distributed 130 bags to Owensville Seniors and 70 to Hermann Seniors.
• Macon County Health Department presented a teen driving safety proclamation to the county commissioners and all approved and stated their support for all efforts to increase teen driving safety. The health department continued to provide safe driving education via social media due to the COVID-19 pandemic making visiting schools in person not an option at this time. For example, they hosted a TikTok challenge which invited teens to create a safe driving message. First Impact Missouri (through University of Missouri) is now offering a FREE virtual 90-minute evidence-based traffic safety program that educates parents about Missouri’s GDL law. Attendance is perfect for parents of teen drivers ages 14-19, and new and soon to be drivers. Macon County Health Department shared these Zoom opportunities with their community. The Graphics Art class at Macon R-1 developed a teen safe driving billboard that is on display on Highway 63.
• Webster County Health Department created safe driving packets that included pamphlets from the Missouri Department of Transportation on seatbelt use, distracted driving, impaired driving, and the Missouri GDL. Packets also included a Parent-Teen Driving contract, information regarding driver education classes, an Arrive Alive bumper sticker and an in-car reminder to put the phone down and not text and drive. The education packets are being distributed to new license and permit holders through a partnership with the Marshfield Department of Motor Vehicles licensing office. Since February 2020, 135 packets have been distributed.

Prevent Unintentional Injury

A total of 48 LPHAs reported addressing home and school safety and 27 LPHAs reported addressing farm safety. Examples of this work included:

• Moniteau County Health Department, in partnership with the California Parks and Recreation director, implemented a requirement that all students playing flag football should wear mouth guards to prevent serious injury to the teeth and face. They also created an Unintentional Injury pamphlet that is being used in many capacities including during sports physicals. The California Newspaper included Farm Safety facts developed by the Missouri State Highway Patrol. The nurse practitioner who performed sports physicals at the health department also educated youth on injury prevention (seatbelt use, helmet use, farm equipment).

Violence Prevention

DHSS continues to have a strong focus on suicide prevention through its Violence Prevention Program. These activities are listed under SPM#8. 

The Adolescent Health Program (AHP) continued to participate in the interpersonal violence prevention workgroup, focusing on Social-Emotional Learning (SEL) through the training and expansion of the Teen Outreach Program (TOP) Clubs across Missouri. The AHP uses both Maternal Child Health (MCH) and Teen Pregnancy Prevention (TPP) grant funding to focus on positive youth development programs, such as TOP. TOP is a nine-month, mostly after school, evidence-based intervention (EBI) that teaches youth healthy behaviors, goal setting, self-efficacy, and community engagement.

The AHP continued to refine and develop training on Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) youth. These resources have, been presented at the MCSHC and are available for presentations at public and private partner meetings across the state.

Suicide/Violence/Substance Abuse Prevention

Multiple LPHAs targeted their efforts to address suicide, violence, and/or substance abuse prevention. In total, 78 LPHAs reported providing education, screening, and referral for adolescent suicide/self-harm; 91 reported providing mental health and counseling services and/or resources; 107 reported providing prescription drug abuse education, prevention, and intervention; 98 reported addressing child abuse and neglect; 56 reported addressing domestic violence; and 102 reported providing bullying prevention information and training. Highlights of this work included:

• Kansas City Health Department notes that Kansas City has adopted The KC Blueprint to reduce violence where people live, work and play. The strategic plan #ZeroReasonsWhy was selected for suicide prevention. The Kansas City Health Department continues to provide violence and suicide prevention education in classrooms and childcare centers on a regular basis- in 2020, they developed 5 new partnerships. The health department trained and provided resources and technical support to 10 additional partners who provide violence/suicide prevention education to youth using the AIM4Peace Life Skills Learning Program. These 10 new partners conducted 38 classes and educated 1409 youth, for a total of 26,884 youth over the last three years.
• Ralls County Health Department participated in the CHART teen health fair, providing education regarding suicide, risk factors, warning signs, how to help, and the suicide hotline number.
• Washington County health Department partnered with many local places of business which employ 15-19 year olds to establish policies that reflect a drug free workplace. In conjunction with the Washington County Ambulance District, the health department provided Naloxone training to 60 first responders. "Chasing the Dragon: The Life of an Opiate Addict," a documentary aimed at educating students and young adults about the dangers of addiction, is now being shown to all 7th grade health classes countywide.
• Platte County worked with one local school to implement a Naloxone policy and all school nursing staff have been trained at MS and HS in the Park Hill School district. All public schools and one private school in Platte County implemented the Signs of Suicide (SOS) program. This program screened 10,960 Platte County youth for depression and suicide. Platte County was instrumental in providing and organizing adult and youth mental health first aid trainings to the community and provided 64 trainings in 2020. Mailed Resilience: We Can Build it during Tough Times mailers to 32,974 families in Platte County. The mailer included resources for mental health, parenting, and local resource support. Youth of Platte County created projects titled,” Quarantine Chronicles,” that were shared with 4th-6th grade youth in the county.
• Lincoln County Health Department implemented Signs of Suicide (SOS) in schools within their county. A billboard was displayed addressing toxic stress, and a social media campaign was also started to address this issue.
• Montgomery County Health Department worked closely with all schools, and all schools now have policies/procedures in place for all staff to access referral forms, which including referral options for the school counselors available in each building. Montgomery County Health Department provided professional counseling services through Girls Town and Clarity Tele-Psych Services at the health department.
• The City of St. Joseph Health Department worked to train the community on ACEs and piloted an ACEs screening tool at Northwest Health Services. The health department also partnered with the company that schedules the ads that play at the movie theater and developed a 30 second video ad focused on ACEs and recovery to play before movies.
• The Laclede County Health Department developed an MCH Task Force comprised of 27 various stakeholders within the community. The health department staff provided Stewards of Children training to local agencies/organizations. Laclede County’s all-inclusive community resource guide, created in 1995, was updated in 2020 to include organizations that provide services specific to the MCH population. The health department was instrumental in creating parent resource kits that are shared with the Parents as Teachers Program, OB/GYNs, and hospital labor and delivery units. The Developing Nurturing Skills curriculum was used in local schools.

Please note that certain strategies in Missouri for NPM #7 impact both the child and adolescent populations. However, to avoid duplicative narrative, strategies were only listed in one or the other population domain. Please review the State Action Plan for Child Health in the annual report for additional information on programs and activities that addressed adolescent health.

SPM #4 Physical Activity – Percent of adolescents ages 12 through 17 who are physically active at least 60 minutes per day.

According to the NSCH 2018-2019 data, 15.3% of Missouri adolescents ages 12-17 years were physically active at least 60 minutes a day, every day, compared to 16.5% nationally. Males (16.4%) were more likely to meet this benchmark of physical activity than females (7.7%). This mirrored the national divide between males (21.7%) and females (13.1%) regarding physical activity. Households with some college education had the highest percentage in Missouri with 18.1%*, followed by college graduate (10.7%) and high school graduate (7.1%)* households. Those with private insurance in Missouri (11.3%) were less commonly meeting this measure than their national counterparts (15.1%). A greater proportion of children in two-parent married families (13.3%) were physically active for an hour daily than in single parent families (10.8%)*. A greater proportion of non-Hispanic Black Missourians (15.5%)* engaged in physical activity for an hour a day than their non-Hispanic White counterparts (13.5%).

Missouri, in collaboration with both our internal and external partners, is working to increase the percentage of adolescents who are physically active for at least 60 minutes per day. Obesity is complex and environmental and behavioral factors play a critical role. Missouri works to create policies and environments that encourage health-promoting behaviors.

As a partners on the CDC 1801 grant, the School Health Program (SHP) worked with the Department of Elementary and Secondary Education (DESE) and the MO Healthy Schools program, along with a cohort of local education agencies, to implement tools and best practices addressing nutrition and physical activity in the school setting. In the seven participating schools, the grant project team is implementing assessment and intervention tools to improve the school wellness environment (17,072 students).

DHSS staff partnered with Children’s Mercy, the University of Missouri Extension, and other agencies and organizations across the state including the Missouri Council on Activity and Nutrition (MOCAN) to identify and implement best-practice programs in schools and communities to promote opportunities for physical activity and access to nutritious foods. Program staff in the Bureau of Community Health and Wellness represent DHSS on the Healthy Weight Advisory Committee (HWAC), a MOCAN subcommittee whose purpose is to advance the recommendations of the former Children’s Services Commission Subcommittee for Childhood Obesity. These recommendations include both preventative and treatment interventions to address childhood obesity. DHSS staff also participated in the Coordinated School Health Coalition and Missouri Convergence Partnership.

Please note that certain strategies in Missouri for SPM #4 impact both the child and adolescent populations. However, to avoid duplication of the narrative, strategies were only listed in one or the other population domain. Please review the State Action Plan for Child Health in the annual report for additional information on programs and activities that address adolescent health.

* Interpret with caution due to sample size limitations.

SPM #8 Mental Health – Percent of children ages 3-17 with problems requiring counseling who received mental health care.

It is normal for children and adolescents to experience some emotional distress as they develop and mature. However, studies such as the Adverse Childhood Experiences (ACEs) show us that the toxic stress and challenges our young people face can have a drastic impact on their long-term health. In Missouri, according to the 2017 Youth Risk Behavior Survey (YRBS), 31.3% of youth in high school felt sad or hopeless almost every day for 2 weeks in the past year. Missouri is working to improve protective factors, access to mental health treatment, and the quality of staff and support services working with youth who have experienced trauma and multiple ACES. Impacting these areas can make a significant impact on future risky behaviors and chronic diseases.

According to the NSCH 2017-2018 data, 51.9% of Missouri children between 3-17 years, with a mental/behavioral condition received treatment or counseling compared with 50.3% nationally. Among those that received these mental health services, 57.4% were using Medicaid and 53.2% were privately insured in Missouri. This is greater than the national figures for private insurance (50.5%) and Medicaid recipients (50.9%). Missouri college graduate households had a greater percentage of those who received mental health care (57.4%)* than any educational attainment group nationally. In Missouri, the percentage of non-Hispanic Whites (53.2%)* who received mental health care was greater than it was nationally (52.0%). The percentage of two-parent married households in Missouri (60.5%) who received mental health care also exceeded the national percentage (49.9%). Nationally, children between 6-11 years (46.5%) and 12-17 years (56.5%) received mental health care generally less frequently than their Missouri counterparts (54.6%* and 55.9%* respectively).

According to the Association for Children’s Mental Health, mental health problems are common and often develop during childhood and adolescence, they are treatable, and early detection and intervention strategies work as they can improve resilience and the ability to succeed in school & life. Some of the activities reported in this section will address both the child and adolescent populations.

Title V activities specifically related to young children include the Child Care Health Consultation (CCHC) Program, which offered 12 hours of continuing education training for child care providers, 3 health promotions for children in child care, and 4 technical consultations regarding well child care. By offering these services in FFY2020, the CCHC Program increased support of the mental health needs of children in the child care setting. Additionally, the CCHC Program hosted a virtual event showing the documentary, Resilience: The Biology of Stress and the Science of Hope followed by a panel discussion regarding the documentary. The panelists included two child care health consultants from LPHAs currently contracting with the program and the Early Childhood Program Coordinator from DHSS. Participants in the event were other child care health consultants from contracting LPHAs.

All enrolled children from birth to kindergarten entry participating in the Genetics and Healthy Childhood (GHC) Home Visiting Programs are periodically screened throughout enrollment for social-emotional development using the Ages and Stages Questionnaire®: Social Emotional (ASQ:SE-3). All home visitors have been trained to provide assistance to caregivers in completing this screening, interpreting results to caregivers, providing recommended developmental activities for parents/children who score in the “monitoring” range and assisting families in accessing appropriate services.

Mental health issues were an emerging concern across all population domains in Missouri, but especially among children and adolescents, and LPHAs shared the concerns and addressed them at the local level within their communities. The MCH Services Program contract supported LPHAs providing screening and referral for child and adolescent mental health needs. Of the 114 LPHAs, 40 reported providing child and adolescent mental health and/or counseling resources and services, and 91 reported having community partners who provide mental health and/or counseling resources and services to children and adolescents. Several LPHAs collaborated with behavioral health partners and/or the University of Missouri Extension Services to participate in and/or provide Mental Health First Aid education. Christian County Health Department used MCH Services contract funding to help cover salary expenses for a full-time Licensed Professional Counselor for their MCH population. Individuals seeking counseling for suicide contemplation, unwanted pregnancy, rape, child abuse, parenting guidance, and a variety of other topics. LPHA activities that addressed child and adolescent mental health needs included:

• The Camden County Health Department has collaborated with the Council for Drug Free Youth and presented the TEAM CHALLENGE (which encourages trust, understanding, and acceptance among peers through communication with a strong substance-abuse prevention message targeting alcohol, marijuana, prescription drugs, heroin, and meth) to 8th grade students. The health department has sponsored some ad campaigns with the local radio station that gave a substance and suicide prevention message. One targeted the graduation class and one during Back to School. The health department also incorporated Naloxone education within their CPR/First Aid classes for childcare and healthcare providers.
• The Dallas County Health Department created a Dallas County Community Resource Guide that includes mental health and wellness resources. This list is updated as things change and progress. The crisis text line resource has been printed on business cards and magnets and distributed within Dallas County. A mental wellness campaign titled Mental Health Monday was done on the Dallas County Live Well Alliance and Dallas County Health Department Facebook pages. Trauma informed schools training opportunities were provided to Dallas County R-1 Schools. A Suicide Prevention lesson was given to Buffalo High School students. Students were provided with the Substance Abuse Prevention and Resource Guide, crisis text line information, and a journaling exercise. Dallas County R-1 School District is now providing counseling on-site for students. Dallas County R-1 School District were provided with suicide prevention training opportunities (QPR, Youth Mental Health First Aid, and Adult Mental Health First Aid).
• The City of St. Joseph Health Department collaborated with the local movie theater to provide a 30 second video message focused on ACE’s and recovery that was shown prior to the movie. The health department is collaborating with providers and the ACE’s screening tool is now being used by Northwest Health Services. The health department used Facebook to continue providing messages regarding coping skills, depression, ACE’s and recovery to their community. All Buchanan County High School students were given a bag that included a Teen Resource Guide and an ACE’s infographic. They also received guidance on building coping/resilience skills.
• Platte County has worked with one local school to implement a Naloxone policy and all school nursing staff have been trained at MS and HS in the Park Hill School district. All public schools and one private school in Platte County have implemented the Signs of Suicide (SOS) program. This program has screened 10,960 Platte County youth for depression and suicide. By providing 64 trainings in 2020, Platte County was instrumental in providing and organizing adult and youth mental health first aid trainings to the community. The health department mailed Resilience: We Can Build It during Tough Times mailers to 32,974 families in Platte County. The mailer included resources for mental health, parenting, and local resource support. Youth of Platte County created projects titled Quarantine Chronicles that were shared with 4th -6th grade youth in their county.

The SHP continues to participate on the advisory council for the Show-Me School-Based Health Alliance to support schools and communities to partner with their local providers and many FQHCs to improve access to mental health services through onsite and nearby clinics and provider services. With mental health services in physical proximity to classrooms, students have greater access to scheduling and maintaining access to mental health providers.

SHP supported professional development for school health services staff with online and collaborative learning opportunities. SHP completed a Trauma Informed Learning Community of Practice (Feb 2020), with participating school nurses (40) expressing they have plans to change practices and support their school environments. Evaluation comments included:

• “I learned great information in this training that has definitely impacted how I interact with students, parents, staff and pretty much anyone I encounter. I also really was taken aback at the data showing the connection between trauma and physical health. I look forward to how I can continue to share this information with other staff and work towards improvements in our district.”
• “Moberly Public Schools has now started our own Trauma Informed Learning Team to explore how we can incorporated Trauma Informed practices into our district. With the guidance and information I have received from this learning community- I have felt the support I needed to become an advocate for this in my district. As lead nurse for my district- I have been able to share this information with all of our nurses. We are now beginning to incorporate trauma assessment into our nursing assessments.”
• “I have shared a lot of the information with my direct supervisor to discuss ways in which this can be used district wide. I feel that at this time our district is Trauma Aware and working towards being fully Trauma Informed.”

SHP also hosted the annual Nurse Education Webinar Series (NEWS) covering topics in mental health. The series this year included three sessions specific to promoting youth mental health including: Mental Health: Challenges for our Youth (11/13/19), Caring for LGBTQ+ Youth (2/12/20), and Ask the Pharmacist: Updates on Psychiatric Medications at School (3/11/20). Each of these programs were offered in a live interactive webinar, and were also recorded and archived for later viewing.

Worth highlighting is AHP's on-going adult-child connectedness campaign called Connect with Me. This campaign, along with its Conversation Starter Cards, was developed to help parents, guardians, caregivers, and others who work with youth a chance to develop conversation skills to build connections with the youth in their lives. The cards cover a variety of topics including healthy relationships, mental health, substances, trauma, body image, and more. Adults can use these conversation starters to start discussing difficult topics with youth in order to better understand what is going on in their lives and to help them cope with changes and situations that are common. Over 45,000 decks of cards were distributed with over $5 million worth of advertisements donated by the Missouri Broadcasters Association since the campaign began. Responses received from the Connect with Me survey are listed below.

• “One of the cards asks who you would be if you could be anyone in the world. A client shared "I'd be a girl." It opened up a new dialog for him to share personal struggles that have been hard to deal with and keep quiet about.”
• “I learned things were different for the kids than I had assumed.”
• “They have helped my students open up about issues they are having.”
• “She liked them so much, she would pick up the cards and start the discussion process. I think she felt more comfortable after hearing from us.”

Multiple states have used Connect with Me as the basis for their own programming either by directly sharing the questions or by rebranding the cards for their own states. For this reason, and for sustainability, DHSS will begin the process of creating a phone app for Connect with Me, allowing further expansion of reach and important adolescent health related topic areas.

DHSS continues to sponsor and support professional development opportunities on mental health to those working with Missouri’s adolescent population. Lindsey Hammond, the Recovery and Resiliency Manager with Optum, provided evidence-based QPR Suicide Gatekeeper Training at the Missouri Coordinated School Health Conference (MCSHC) held in December 2018. The 1-hour training used innovative, practical, and proven strategies to help participants learn three steps for suicide prevention: QPR (question, persuade, and refer). Participants earned a certification if the 1-hour training was completed. Other mental health topics at MCSHC included abuse and neglect, trauma awareness, and resiliency.

DHSS joined the Missouri Suicide Prevention Network (MSPN), which leads statewide suicide prevention efforts. MSPN’s goal is to coordinate and develop implementation of the Missouri Suicide Prevention Plan. MSPN members provided recommendations and advice to support MSPN’s overall mission and work to eliminate the stigma of suicide, educate the community about suicide, and ultimately reduce the rate of suicide in Missouri.

In May 2020, DHSS began participating in the Child Safety Learning Collaborative. The Learning Collaborative facilitates state/jurisdiction implementation and spread of evidence-driven strategies and programs. These evidence-driven strategies and programs are aligned with injury-related Maternal and Child Health National Performance Measures. Missouri chose to focus on suicide and self-harm prevention. The Injury Prevention Program, in partnership with the Adolescent Health Program, has formed a workgroup including: the Department of Elementary and Secondary Education; public schools; the Association of Secondary School Principals; Wyman Inc.; school health; LPHAs; parents; and adolescents. The workgroup has begun developing a Mental Health Crisis Toolkit for families with youth experiencing a mental health crisis. The Society for the Prevention of Teen Suicide (SPTS) is currently piloting a version of this toolkit designed for use in emergency room settings. Missouri has been working with SPTS to develop a Missouri-specific resource for schools to use with youth and parents who are struggling thus providing resources to youth prior to requiring an emergency room visit. The programs will work with an already established group of school and health organizations to adapt this toolkit for implementation in Missouri counties. Missouri will pilot the toolkit in counties where the LPHAs chose adolescent mental health as their MCH priority issue. Once piloted and evaluated, this toolkit will provide families with comprehensive guidance in the midst of a mental health crisis.

* Interpret with caution due to sample size limitations.