Domain: Adolescent Health

Reporting for October 2021-September 2022

Objective

By 2025, increase the percentage of adolescents who received a preventative medical visit in the past year by 10%.

National Performance Measure

(NPM #10) Percent of adolescents, ages 12 through 17, with a preventive medical visit in the past year.

An annual preventive well visit can help adolescents adopt or maintain healthy habits and behaviors, avoid health‐damaging behaviors, manage chronic conditions, and prevent disease, including mental health issues. Additionally, they can play a role in preventing adolescent suicides.

Data from the 2020-2021 National Survey of Children’s Health (NSCH) (FY2022 indicator) shows that 70.7% of adolescents (ages 12 through 17) had a preventive medical visit in the past year. This is down from 75.5% of adolescents (ages 12 through 17) had a preventive medical visit in the past year in the 2019-2020 NCSH dataset.

Evidence-Informed Strategy Measure

(ESM 10.2) Percent of well-visits where depression screenings are occurring for Adolescents enrolled in Minnesota Health Care Programs (MHCP).

Although helping young people prevent depression, suicide, and other problems is a community-wide effort, primary care providers are well situated to discuss risks, provide screening, and offer interventions. Offering screening and follow-up at preventive visits helps ensure that young people receive mental health services and support.

For FY2022, the percentage of well-visits where depression screenings are occurring for adolescents enrolled in Minnesota Health Care Programs (MHCP) was at 66.7%. A total of 80,787 screenings took place.

Community-Identified Priority Need: Adolescent Suicide

Minnesota suicide prevention efforts are based on evidence that most suicides are preventable, mental illness is treatable, and recovery is possible with appropriate supports and intervention. The strongest suicide prevention efforts are multifactorial, requiring a combination of familial support, community connection, and behavioral health treatment. According to the 2022 Minnesota Student Survey, 29% of students reporting dealing with long-term (problems lasting 6 months or more) mental health problems (up from 23% in 2019 and 18% in 2016).

Minnesota has seen higher rates of suicide among youth than the national average for a long time. Suicide is the second leading cause of death among people ages 10-24, and is not experienced equally across age groups, genders, sexual orientations, race/ethnicities, or geography in Minnesota (see Figure 1).[1] Minnesota is closely tracking the changes in the suicide rate by race/ethnicity overtime. Based on 4-year averages (2016-2020) there have been some consistent trends. American Indian/Alaskan Native adolescents have had the highest suicide rates since 2014, with the average rate per 100,000 from 2016-2020 being 56.4%. This is significantly higher than the next highest average rate, which is Non-Hispanic White at 11.1%. The suicide rate has markedly increased for Black/African American and American Indian/Alaska Native adolescents, while steadily decreasing among non-Hispanic white adolescents. Historical and ongoing trauma, living in poverty, childhood adversity, lack of access to culturally relevant mental health services, and experiencing interpersonal violence are all experienced at higher rates among American Indian populations and are all associated with an increased risk of suicidal behavior. The disparities seen among American Indian youth in Minnesota is something we can’t ignore.

There is not one single path that leads to suicide. Many factors can increase the risk of suicidal thoughts and behaviors, such as childhood trauma and adversity, serious mental illness, physical illness, alcohol or other substance abuse, a painful loss, exposure to violence, social isolation, and easy access to lethal means. Factors such as meaningful relationships, coping skills and safe and supportive communities can decrease the risk of suicidal thoughts and behaviors. Adolescent suicide prevention efforts require improving access to comprehensive mental health services and building communities that support the mental well-being of youth and their families.

The COVID-19 pandemic magnified many of the barriers youth experience when trying to access the help they need. Limited access to mental health services and treatment may lead to self-harm, challenges with emotional regulation, and adaptive coping. A 2023 Kaiser Family Foundation analysis of data from the US Census Bureau’s Household Pulse Survey shows that the effects of the pandemic are still being felt, with nearly half of young adults (ages 18-24) reporting symptoms of anxiety and/or depressive disorder (49.9%).[2] Furthermore, the number of adolescents who have had serious thoughts of suicide have increased during the pandemic, with female highschoolers being particularly affected (with 24% having serious thoughts of suicide in 2019 compared to 30% in 2021).[3]

In any given year, 9% of Minnesotan school-aged children and youth experience severe emotional disturbance. The American Academy of Pediatrics (AAP), American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association declared a national children’s mental health emergency in October 2021 based on data from March to October 2020 showing emergency mental health emergencies rose 31% for youth ages 12-17 years and suspected suicide attempts increased nearly 51% among adolescents who identify as female ages 12-17 years. Identification of mental health problems improves with standardized screening. Half of all lifetime cases of mental illness begins by early adolescence. Substantial evidence shows that early mental health interventions help prevent behavior problems and poor school performance. 

Strategies and Activities

A.  Strategy A: Empower Youth, Young Adults, Families, and Communities to Meaningfully Engage in Creating Solutions to Prevent Suicide

1. State Level Activities
   1. Partner with MDH Suicide Prevention Unit (SPU) to Implement Identified Strategies from the MN Suicide Prevention State Plan

MDH coordinates the state’s suicide prevention efforts per Minnesota Statute, section 145.56 and in accordance with the State Suicide Prevention Plan. MDH SPU is the lead for Minnesota’s suicide prevention efforts and in partnership with others, including Title V staff, prioritize suicide prevention statewide. 

SPU serves as leader, convener, and connector for the Minnesota State Suicide Prevention Taskforce, a group made up of experts in mental health promotion, suicide prevention, intervention and postvention, and other state agencies. The Taskforce implements the State Suicide Prevention Plan and empowers communities to collaborate and implement comprehensive suicide prevention. During FFY 2022, the Taskforce’s membership grew to more than 85 members. 

The Taskforce is also responsible for developing and updating the State Suicide Prevention Plan and for ensuring its goals are communicated and met. The State Suicide Prevention Plan was revised over the 2022 calendar year and recently released in 2023. The current goals of the Minnesota Suicide Prevention Plan are to: 

• Increase individuals, organizations, and communities’ capacity to develop and implement a comprehensive approach to prevention suicide.
• Promote factors that offer protection for suicidal experiences across the individual, relationship, community, and societal levels.
• Identify and support individual’s wo are experiencing mental health challenges or who are having suicidal experiences.
• Strengthen access and delivery of care for mental health and suicide.
• Connect, heal, and restore hope to those impacted by suicide.
• Improve the timeliness and usefulness of data.

The Taskforce, along with its four active subcommittees and several ad-hoc committees are committed to moving suicide prevention efforts forward in Minnesota. The subcommittees have responsibility for implementing the goals and objectives laid out in the State Plan and are comprised of individuals interested in a specific topic related to one of the goals. The four primary subcommittees’ topics are: 

• Mental Health and Wellbeing – responsible for guiding the implementation of the mental health promotion and suicide prevention strategies. 
• Intervention – responsible for guiding the implementation of the suicide intervention strategies. 
• Postvention – responsible for guiding and implementing suicide postvention strategies. 
• Suicide Data Action Team (S-DAT) – responsible for guiding the implementation of the data-related goals and objectives of the State Plan. 
• A fifth sub-committee that has been meeting on-going is the communications committee; this committee has been and will continue to communicate suicide prevention, efforts, event, and opportunities to the grant regions across the state.
  2. Increase Help-Seeking Behaviors in Youth

MDH formed a partnership with the MDE and Kognito to launch the Minnesota Kognito At-Risk for Educators Mental Health Training Initiative (Kognito At-Risk). Kognito At-Risk is a series of three online interactive modules that help educators and other school staff at elementary, middle, and high school grade levels. It teaches staff how to identify warning signs of psychological distress, talk with students about their issues, build resilience, and increase connectedness. Kognito At-Risk also helps staff determine a student’s need for referral and, most importantly, motivate youth to seek help and assist youth with getting help. A total of 224 districts, including 1,222 schools, have participated in the roll out of At-Risk for educators. From those districts and schools, 33,255 individuals have completed the training. 

3. Partner to Implement the Minnesota Partnership for Adolescent and Young Adult Health (MNPAH) Strategic Plan

The MNPAH, convened by MDH, is a group of stakeholders representing state, county, schools, community agencies, faith organizations, and those working for and with young people. The MNPAH aims to support Minnesota’s overarching adolescent health goals, which are to: 

• Improve the health and well-being of all adolescents and young adults (ages 10-25 years old).
• Build and maintain strong partnerships with those interested in the health and well-being of young people.  

To address these goals and inspire action, the MNPAH developed a Strategic Plan in FFY 2020, with a set of priorities that include:

• ensuring access to high-quality teen-friendly health care.
• having a safe and secure place to live, learn, and play.
• developing positive connections with supportive adults.
• providing opportunities for youth to engage.
• uplifting adolescent and family-centered services.

Since the launch of the MNPAH strategic plan, Title V staff continue to promote and implement the plan through partners and communities statewide. During FFY 2022, staff met with Minnesota School Based Health Alliance, school districts, community clinics, and nursing students focusing on priorities to support adolescent and young adults in the communities they serve. Priorities identified with these partners included:

• physical and mental health support.
• supporting parents and caregivers.
• supportive schools and welcoming communities.
• addressing social determinants of health. 
  4. Train Providers on Adolescent and Young Adult Mental Health Screening

Suicide Prevention Training

Minnesota conducted 318 training sessions, which included gatekeeper training, general suicide prevention training, and Zero Suicide in FFY 2022. General gatekeeper trainings were provided to help identify youth who might be experiencing suicidal ideation or significant mental health distress and included the following: 

• Question, Persuade and Refer (QPR), an emergency mental health gatekeeper training intervention that teaches lay and professional gatekeepers to recognize and respond positively to someone exhibiting suicide warning signs and behaviors. Like CPR, QPR uses a “chain of survival” approach in which the gatekeeper learns to recognize early suicide warning signs, Question their meaning to determine suicide intent or desire, Persuade the person to accept or seek help, and Refer the person to appropriate resources. 
• Suicide Awareness for Everyone, TELL, ASK, LISTEN, KEEPSAFE (safeTALK) is a training that teaches participants to recognize and engage persons who might be having thoughts of suicide and to connect them with community resources trained in suicide intervention. SafeTALK stresses safety while challenging taboos that inhibit open talk about suicide. The training is delivered by a certified safeTALK instructor with a community support resource present in all trainings. Training is appropriate for high school youth and adults. 
• Applied Suicide Intervention Skills Training (ASIST) emphasis is on teaching suicide first-aid to help a person at risk stay safe and seek further help as needed. Participants learn to use a suicide intervention model to identify persons with thoughts of suicide, seek a shared understanding of reasons for dying and living, develop a safe plan based upon a review of risk, be prepared to do follow-up, and become involved in suicide-safer community networks. Participants also learn and practice skills in identifying and responding to people at immediate risk of suicide. 

Over 11,000 people participated in some form of suicide prevention training over the course of this reporting period. 

Pediatric Mental Health Access Program 

In September 2021, Minnesota was awarded an American Rescue Plan Act – Pediatric Mental Health Care Access – New Area Expansion grant from HRSA. Minnesota’s project aims to better equip primary care providers to screen for and respond to mental health concerns in children and adolescents, especially those from underserved populations such as those who identify as black, indigenous, or persons of color (BIPOC), those who are lesbian, gay, bisexual, transgender, and queer (LGBTQ), and those from rural areas. HRSA funds are being used to expand and enhance the reach of Minnesota’s statewide Psychiatric Assistance Line (PAL) service. PAL is a legislatively mandated triage, referral, and psychiatric consultation service available to health professionals, including pediatric primary care providers (PCPs). FastTracker is a mental health resource database that is used in conjunction with PAL to find mental health treatment and providers for people statewide.

During FFY 2022, a systems assessment with Wilder Foundation started to address the strengths of PAL and FastTracker and opportunities to expand, with a goal of completion in March 2023.

Child and Teen Checkups (C&TC)

C&TC provides best practices training to clinic systems, medical providers, and nurse practitioner students. In FFY 2022, this training includes guidance on screening for depression, the July 2022 American Academy of Pediatrics recommendation for screening for suicide during well visits, as well as information on recommended depression screening tools for adolescents, and referral resources including Fact Tracker and PALS. In FFY 2022, this training was provided to 58 family nurse practitioner students and four advanced practice registered nurses.

5. Provide Education for those that Work with Justice Involved Youth (JIY) in Community about the Importance of Mental Health Screening and Referral to Services

In partnership with the University of Minnesota School of Public Health, the C&TC program developed a Guide to Child and Teen Checkups/Preventive Health Care for Justice Involved Youth (PDF) available on the C&TC Special populations webpages. Additionally, C&TC provides training available upon request that covers the unique health challenges and needs of JIY and the importance of ensuring that Medicaid eligible youth receive appropriate screening, including mental health screening, during C&TC visits. 

6. Partner with Youth-Serving Community Organizations to Identify Policies and Practices to Support Adolescent Mental Health and Well-Being

In 2021, MDH launched the Reimagine Black Youth Mental Health Initiative in collaboration with the Brooklyn Bridge Alliance for Youth– supported through a federal grant from the Office of Minority Health. This is a policy demonstration grant that engages local partners to identify, assess, implement, and evaluation specific policies that will improve Black youth mental health. The Reimagine Black Youth Mental Health Initiative is set to continue through FFY 2026, and has three goals: 

•    Improve Black youth mental health. 

•    Design a process that includes Black youth and communities in policy development.  
•    Implement a Mental Health in All Policies Approach. 
  2. Local Public Health and Community Spotlight
     1. Promote Positive Youth Development and Help-Seeking Behaviors in Youth

With support from MDH and MN DHS C&TC, several counties provided community driven programming initiatives. One program provides outreach to parents on healthy youth development. Another county has developed programming in partnership with schools, community programs, and clinics to improve capacity for assisting youth in developing self-advocacy skills and break down the stigma on seeking care for mental health concerns.

B.  Strategy B: Expand and Improve Postvention Supports

1. State Level Activities
   1. Provide Support through Trainings and Technical Assistance to Communities Dealing with the Impact of a Death from Suicide

The shock and grief of a suicide often affects more than friends and families. A suicide has a devasting impact on a community, including friends, coworkers, schools as well as faith communities. Because knowing someone who has died by suicide is one of the highest risk factors for suicide, Minnesota has implemented postvention efforts to reduce suicide risk and promote healing in communities who have had a loss from suicide. 

Postvention trainings are ongoing and continue to be offered across the state in communities experiencing a loss from suicide. During this reporting period, Minnesota and its suicide prevention community grantees provided technical support monthly to communities across the state who are suffering losses from suicide within their communities. MDH also hosted The NAMI Connect Program Postvention Train the Trainer. The Connect Program is nationally recognized as a comprehensive model for planning and implementing suicide prevention and postvention practices. Minnesota’s suicide prevention partners, which include school staff, community mental health organizations, faith leaders, members of the MN State Suicide Prevention Taskforce Postvention Subcommittee, and the SPU staff at MDH attended the Connect Program Train-the-Trainer. 

The goal is to increase the number individuals who participate in the training and implementation process of postvention support within their communities.

C.  Strategy C: Reduce Access to Lethal Means

1. State Level Activities
   1. Partner with Providers and Others who Interact with Individuals At-Risk for Suicide to Routinely Assess for Access to Lethal Means

On May 10, 2022, Minnesota hosted a virtual Counseling on Access to Lethal Means (CALM) training for trainers – after a number of inquiries were received for this training. There was a total of 40 participants from across Minnesota. This opportunity has allowed agencies and communities to build capacity within their organization to provide CALM training ongoing.

D.  Additional Related Activities

1. State Level Activities
   1. Partner with Communities to Promote Healthy Youth Decision-Making Through Implementation of High Quality, Medically Accurate, and Evidence-Informed Programming

Minnesota Personal Responsibility Education Program (MN PREP)

MN PREP is a federally funded grant program that aims to create successful transitions from youth to adulthood through promoting healthy decisions and providing medically accurate, evidence-based quality sexual education to Minnesota young people ages 14-21. With efforts toward preventing pregnancy and sexually transmitted infections, MN PREP funds organizations through an open-competitive process who serves Minnesota most vulnerable youth populations at high-risk for teen pregnancy and sexually transmitted infections (STIs), including HIV/AIDS.

In FFY 2022, Minnesota provided oversight and training to six MN PREP grantees who serve youth populations, which include young people of color and American Indian youth; youth in foster care or aging out of foster care; in detention or on probation and in alternative learning centers; homeless or runaway youth; LGBTQ+ youth; and pregnant and parenting teens. Grantees were responsible for incorporating at least three of the following adulthood preparation topics in their programming: healthy relationships, healthy life skills, adolescent development, and/or financial literacy.

Minnesota Sexual Risk Avoidance Education Program – Minnesota Healthy Teen Initiative

Minnesota’s Healthy Teen Initiative (HTI) program, funded through the federal Title V State Sexual Risk Avoidance Education (SRAE) grant, links program participants to services provided by local community partners that support the safety and well-being of youth. Minnesota funded four HTI grantees who serve populations experiencing the greatest disparities in teen pregnancies and STIs. Grantees implemented high quality, medically accurate, evidence-based and informed programs to promote healthy youth development, abstinence, and to delay the onset of sexual activity in youth ages 10-14 – ultimately reaching over 500 youth during FFY 2022; with over 75% of youth participants indicating they were somewhat or much more likely to resist peer pressure after participating in MN SRAE programming. One grantee - St. James Public Schools – identified and referred students seen as at-risk for unhealthy decision-making regarding sexual and/or overall health and well-being to their district school social worker for assistance accessing support services.

Additionally, grantees implemented evidence-informed programs that reached over 500 parents of youth, as well as adult mentors who work with youth. One grantee – Better Together Hennepin – implemented the It’s That Easy curriculum to foster relationship building with youth, as well as to provide safe spaces for open conversations with youth about sex, technology use, and mental health. Parents, caregivers, and mentors attending these sessions expressed the need for more support in parenting and addressing mental health needs of youth as they continued to transition to in-person learning after being isolated for so long.

Additional MN PREP and MN SRAE/HTI activities included the following:

• Minnesota’s HTI program grantees promoted the annual “Let’s Talk Month” (LTM) initiative in October 2021. LTM is an opportunity for parents and youth to learn to communicate in an open honest manner about sexuality and other sensitive issues. MDH created a resource sheet and social media campaign with prompts and challenges for parents to start conversations with their youth. This campaign raised awareness about the impact these conversations have on youth to delay sex and avoid unintended pregnancy and/or STIs.
• MN PREP and MN SRAE program grantees provided sponsorship to the Adolescent Health Summer Institute, which was held virtually. The theme for the institute, “Promoting & Protecting Adolescent Mental Health” was held July 18-21, 2022. Attendees learned how parents and providers working with youth can discuss mental health with adolescents, identify influences, promote well-being, and help provide tools and strategies for maintain or achieving positive mental health. Special attention was given to how COVID-19 has affected the mental health landscape of adolescents. Funding also provided support for online learning platforms, materials, and other expenses associated with this training. 
  2. Support Communities by Increasing Access to Resources

A monthly newsletter was developed and distributed to help support communities and increase access to resources. Through interagency collaboration, SPU, MDH Mental Health Promotion and SHIP units, along with the MCH Section’s Mental Well-Being Coordinator, developed a toolkit #StayConnectedMN for distribution during Mental Health Awareness Month to support agencies in spreading the word about mental health services and normalizing help-seeking behaviors. The self-guided toolkit used easy to use messages and ready-made posts that applied to all audiences and were made available in five different languages. #StayConnectedMN was a 4-week communication campaign with simple messages and tips on how to support mental health and well-being. Each week had a different theme: 

• Week 1: Connect with yourself.  
• Week 2: Connect with others. 
• Week 3: Create a healthy environment.  
• Week 4: Know how to find help and support
  3. Promote and Train Communities and Agencies in Making Authentic Connections

MDH had planned to partner with Saint Paul-Ramsey County Public Health to provide the Making Authentic Connection (MAC) training, which centers the “why” and “how” to make positive connections with adolescents. This project was put on hold due to the COVID-19 pandemic and transition. MDH will revisit this activity in FFY 2023 with Saint Paul-Ramsey County Public Health to determine capacity for implementation.

4. Promote Positive Youth Development through C&TC

Mental health surveillance is required at all C&TCs for all ages. This includes obtaining the child and family’s mental health history and the child’s history of exposure to trauma. Mental health screening using an approved, standardized instrument is required for age 12 through 20 years. It is critical that children with identified concerns receive or be referred for specialized services. C&TC staff play a critical role by supporting health care providers that perform well child checks with up-to-date information on evidence based best practices screening recommendations and tools to successfully do screenings and refer children and adolescents to other services they need. 

This support is provided through direct technical assistance to medical providers, clinics, and higher education programs for medical providers in Minnesota through training that includes a component on mental health screening, diagnosis, support, and referral resources. The training is offered to C&TC coordinators and Minnesota Tribes – who provide information and trainings to all their local clinics – and medical providers and nurses who are contracted with Minnesota Department of Human Services to provide C&TC screening services. Individual C&TC coordinators do community outreach and quality improvement projects that include outreach to youth around recognizing mental health concerns and connecting to services. 

In FFY 2022, C&TC child health consultants trained 58 nurse practitioner students from four state university programs on providing C&TC components including adolescent health screening and identifying strength based protective factors, mental health screening, including recommended depression screening tools, and referral resources for identified mental health concerns.

2. Local Public Health and Community Spotlight
   1. Promote Healthy Youth Decision-Making Through Implementation of High Quality, Medically Accurate, and Evidence-Informed Programming

In FFY 2022, six MN PREP grantees delivered evidence-based curriculum to about 1,150 youth across 20 program sites in the Metro area and in Bemidji, including 150 youth in juvenile detention centers. Grantees primarily serve youth populations of color and American Indian youth; youth in foster care or aging out of foster care; youth in detention or on probation and in alternative learning centers; homeless or runaway youth; LGBTQ+ youth; and pregnant and parenting teens. Grantees were responsible for incorporating at least three of the following adulthood preparation topics in their programming: healthy relationships, healthy life skills, adolescent development, and/or financial literacy. Over 60% of participants statewide indicated they were somewhat or much more likely to make decisions to not use drugs or alcohol after they participated in MN PREP programming. Additionally, approximately 40% of participants indicated they were somewhat or much more likely to have a conversation with their parent about sex because of their participation in MN PREP.

The following are several examples of the activities that grantees led:

• One grantee, Evergreen Youth and Family Services, hosted events through their program Rock Sober to encourage sobriety and sober lifestyles. Events included sledding, bowling, and regular Friday night pizza parties to provide safe alternatives during times when youth are more likely to use substances.
• Another grantee, High School for Recording Arts, had a participant of their program contribute to a national video sponsored by FSBY. The video highlighted sexual education programming with youth experiencing homelessness, describing how adults can work with highly mobile and homeless youth.
• Minneapolis School Based Clinics held a Fast STI Testing event at a Minneapolis high school in an effort to lessen the stigma of STI testing and promote the school-based clinic, which offers physical, mental, and reproductive health services to students.

[1] Minnesota Resident Final Death File, 2021

[2] Kaiser Family Foundation

[3] KFF The Implications of COVID-19 for Mental Health and Substance Use, 2023