Adolescent Health – Annual Report

At the onset of adolescence, children develop the ability to understand abstract concepts, question values, develop a more mature sense of identity, and learn to establish personal relationships. The physical changes at this age are dramatic, as boys and girls gradually grow into men and women. With this in mind, Guam Title V selected NPM # 10 – Percent of Adolescents, ages 12 to 17, with a Preventive Medical Visit.

The Medicaid Program’s benefit for children and adolescents is known as Early and Periodic Screening, Diagnostic and Treatment (EPDST) services. EPDST provides a comprehensive array of prevention, diagnostic, and treatment services for low-income infants, children, and adolescents. These screenings are designed to identify health and developmental issues as early as possible. The goal of EPDST is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting. State Medicaid agencies are required to inform all Medicaid-eligible individuals under age 21 that EPSDT services are available and of the need for age-appropriate immunizations and provide or arrange for the provision of screening services for all children.

The annual preventive health care visit provides the opportunity for early screening, diagnosis, and intervention, effective treatment, or referrals to decrease morbidity and mortality, and establish effective communication between patient and provider.

The American Academy of Pediatrics and Bright Futures recommend annual well-care visits during adolescence to promote healthy behaviors, prevent risky ones, and detect conditions that can interfere with a teen's physical, social, and emotional development. Comprehensive well care includes a physical exam; immunizations; screening; developmental assessment; oral health risk assessment; and referral for specialized care if necessary.

There has been a decrease in those eligible for services under EPDST and those receiving actual screenings in the adolescent population. This may due to the fact that the majority of youth feel healthy and they do not recognize the need for annual health screenings.

From 2015 to 2018, the percent of ten to fourteen year old individuals having an actual screening decreased by 2.4%, whereas in the fifteen to eighteen year old and nineteen to twenty year old groups having an actual screening increased by 13% and 50% respectively. This may be due to the relatively high number of Family Practice physicians verses Pediatricians working at the Community Health Center (CHC), in addition to the fact that the CHC have extended hours of operation and are open on the weekends.

Nearly 80 million people in the U.S. are currently infected with some type of human papillomavirus (HPV), a common virus transmitted through sexual contact. Every year in the United States, 33,700 women, and men are diagnosed with a cancer caused by HPV infection. Although cervical cancer is the most well-known of the cancers caused by HPV, there are five other types of HPV cancer. Cervical cancer is the only type of HPV cancer with a recommended screening test. The other types of HPV cancers may not be detected until they cause health problems. HPV vaccination could prevent more than 90% of HPV cancers—31,200 cases every year—from ever developing.

HPV vaccines are given as a series of three shots (two if the child is eleven or twelve) over six months. CDC recommends the HPV vaccine for preteen boys and girls aged eleven or twelve, so they are protected before being exposed to the virus. Two vaccines (Cervarix and Gardasil) protect against cervical cancers in women. Gardasil also protects against genital warts and cancers of the anus, vagina, and vulva. Both vaccines are available for females.

More than half of Guam adolescents have received at least one dose of HPV vaccine; however less than half have received three doses (or two doses if the first HPV vaccine dose was given after age 15).

The general lack of knowledge about HPV may explain why the risk of acquiring HPV, or of developing a HPV-related disease, is commonly under-estimated, both at the individual and societal levels. Such a low perception of risk is likely to impair community demand for HPV vaccination. The perception of parents about HPV vaccines is also critical to HPV vaccination success, because parental consent is required to administer HPV vaccines to minor children. Some media attention has centered on the possibility that the sexual nature of HPV transmission may significantly hinder parental acceptance of the vaccine, which would lead to under-utilization.

The Guam Department of Education School Health Counselors in collaboration with Guam Cancer Care and the Department of Public Health and Social Services Immunization Program has launched a school-based immunization program focused on cancer prevention and HPV vaccination. The voluntary immunization program aids in the fight against cancer and will expose children to vaccines that can help prevent a range of vaccine-preventable disease. In particular, children ages nine to seventeen years old who obtain parental consent will be able to receive the HPV vaccine at their respective school site.

According to the National Campaign to Prevent Teen and Unplanned Pregnancy, each year approximately 750,000 teenage girls become pregnant. The rate of pregnancy among US teenagers has been steadily dropping, but it is still higher than almost all industrialized countries.

Guam’s teen birth rates are high compared to the US teen birth rates. Guam’s teen birth rate was 39.5 per 1,000 females aged fifteen to nineteen years in 2017; in 2018 the rate of teen birth was 33.9 per 1,000, a decrease of 15.2%. However, in 2017 Guam’s teen birth rate was 71% higher than the US’s teen birth rate.

The Personal Responsibility Education Program (PREP) replicates evidence-based teen pregnancy prevention model Be Proud/Be Responsible in all Guam public high schools, with the intent to change behavior and delay sexual activity, increase condom or conceptive use for those who are sexually active, and reduce unintended pregnancy. For the school year 2017-18, the program was delivered to approximately 5,000 students, primarily in 9th and 10th grade.

Bullying

Bullying is unwanted aggressive behavior, either physical or verbal, among children where there is an actual or perceived imbalance of power. True bullying involves aggression that is repeated or has the potential to be repeated. Bullying has been linked to many negative outcomes including criminal violence, mental health impacts, substance abuse, and suicide. Victims often suffer from anxiety and depression, physical ailments, and decreased academic achievement. Perpetrators often engage in violent and abusive behavior as adults, abuse drugs or alcohol, and engage in other risky behaviors. Bystanders or those who witness acts of bullying, are also more likely to have mental health problems, suffer from depression and anxiety, and engage in substance abuse.

Our data gathering efforts included an evaluation of responses to bullying and mental health questions included in the latest Youth Risk Behavior Survey (YRBS). Data from the Guam 2017 survey for high school students tell us that the percent of children aged twelve through seventeen who report being bullied on school property was 16.3%, which was down 3.6% from 2015. A break down by gender shows a decrease of 7.2% in the number of female students who reported being bullied from 20.1% in 2015 to 18.7% in 2017. Furthermore, there was a decrease of 5% in male students who reported being bullied from 14.2% in 2015 to 13.5% in 2017.

Cyberbullying is bullying that takes place over digital devices like cell phones, computers, and tablets. Cyberbullying can occur through SMS, Text, and apps, or online in social media, forums, or gaming where people can view, participate in, or share content. Cyberbullying includes sending, posting, or sharing negative, harmful, false, or mean content about someone else. It can include sharing personal or private information about someone else causing embarrassment or humiliation. Some cyberbullying crosses the line into unlawful or criminal behavior.

The most common places where cyberbullying occurs are Social Media, such as Facebook, Instagram, Snapchat, and Twitter; SMS (Short Message Service) also known as Text Message sent through devices;  Instant Message (via devices, email provider services, apps, and social media messaging features) and Email.

With the prevalence of social media and digital forums, strangers as well as acquaintances can often view comments, photos, posts, and content shared by individuals. The content an individual shares online – both their personal content as well as any negative, mean, or hurtful content – creates a kind of permanent public record of their views, activities, and behavior. This public record can be thought of as an online reputation, which may be accessible to schools, employers, colleges, clubs, and others who may be researching an individual now or in the future. Cyberbullying can harm the online reputations of everyone involved – not just the person being bullied, but those doing the bullying or participating in it. 

In 2018, the Guam Department of Education (GDOE) reported 30 incidents of cyberbullying and sexting in school year 2017/18. The percent of high school students who report being cyberbullied stands at 13.1% according to the 2017 Guam YRBS, which is down from 13.3% in 2015. A breakdown by gender shows the percentage of females who reported being cyberbullied was 16.3% in 2017, which represents a decline of 17.8% from 2015. High school males who reported being cyberbullied increased 25% (29.9%) from 7.7% in 2015 to 10% in 2017.

In the United States, an estimated 3.2 million youth (ages 8-18) are Lesbian, Gay, Bisexual, Transgender, and Questioning/Queer (LGBTQ). Among older youth, approximately 8% or 1.6 million youth (in grades 9-12) identify as LGBTQ, and nearly 1% or 150,000 youth (ages 13-17) identify as transgender.

While trying to deal with all the challenges of being a LGBTQ, teens also have to deal with harassment, threats, and violence directed at them on a daily basis. LGBTQ youth are nearly twice as likely to be called names, verbally harassed or physically assaulted at school compared to their non-LGBTQ peers.

Results from the Guam 2017 Youth Risk Behavior Survey show that more Guam high school students who self-identify as lesbian, gay, or bisexual (LGB) report having been bullied on school property (31%) and cyberbullied (19.8%) in the past year, than their heterosexual peers (16.3% and 13.3%, respectively). The survey also showed that more LGB students (18.5%) than heterosexual students (8.8%) reported not going to school because of safety concerns. Among students who identified as “not sure” of their sexual orientation, they also reported being bullied on school property (25.4%), being cyberbullied (26%), and not going to school because of safety concerns (24.7%). Bullying puts youth at increased risk for depression, suicidal ideation, misuse of drugs and alcohol, risky sexual behavior, and can affect academics as well. For LGBTQ youth, that risk is even higher.

Results from the Guam 2017 Youth Risk Behavior Survey show that Guam high school students were more likely to report feeling sad and hopeless (almost every day for 2 or more weeks so that they stopped doing some usual activities during the 12 months before the survey) than their US counterparts. In 2017, 50.2% of Guam females reported having felt sad and hopeless in the past 12 month compared to 41.1% of US females, 29.4% of Guam males, and 21.4% of US males. Low self-esteem and depression is a vicious cycle with long-term implications. Depression may predispose an individual to have impaired social and communication skills, which in turn might lead to victimization by peers.

From 2009 to 2017, for both Guam and the nation, female high school students were more likely than male high school students to report having seriously considered attempting suicide in the past 12 months. Guam students were more likely than their US counterparts to report considering suicide. In 2017, 26.2% of Guam high school students seriously considered attempting suicide in the past 12 month before the survey, compared to 17.2% nationally; 33.5% of females seriously considered attempting suicide versus 17.7% of males.  In 2017, 20.6% of Guam high school students attempted suicide one or more times during the 12 months before the survey, compared to 7.4% nationally. Females were more likely than males to report attempting suicide (25.6% and 14.6% in 2017, respectively).

It is devastating to note that in Guam’s 2017 YRBS that 63.9% of LGB youth reported depressive symptoms, such as sadness or hopelessness for two weeks or more that interfere with their usual activities compared to 36.3% of non-LGB youth. Over four in ten (43.6%) of Guam’s LBG youth, compared with close to three in ten in ten (26.2%) non-LGB youth, ever seriously considered attempting suicide, and 40% of Guam’s LGB youth attempted suicide according to Guam’s YRBS, compared to 20.6% of Guam’s non-LGB youth. Among youth who attempted suicide in 2017, the percentage of attempts resulting in injury, poisoning, or overdose that required treatment by a doctor or nurse was over twice that of non-LGB youth (12% vs 5.8%).

In the United States, suicide is the 10th leading cause of death for all ages. More than one person dies by suicide every 15 minutes in the United States.[1] In 2011, over 8 million adults reported having serious thoughts about suicide and over 1 million reported a suicide attempt. [2]

Unfortunately, the picture of suicide on Guam is similar. Suicide is also among the top ten leading causes of death on Guam. Suicides, however, are just the tip of the iceberg. For every suicide committed, there are many more hospitalizations or emergency department visits for self-inflicted injuries. This statistic fails to capture the number of people who only seek outpatient care following a suicide attempt or do not seek medical treatment at all. 

For years 2013-2018, there were 68 suicide deaths among Guam children aged 10 through 24 years. Males comprise the majority (75%) of suicide deaths. Although more females attempt suicide than males, males are approximately four times more likely to die from suicide.[3]

The lethality of the method used determines the differences between a non-fatal attempt and a death by suicide. Firearm and hanging victims have less of a chance for survival than those using a less lethal method, such as poisoning. Suicide by hanging was the leading cause of death by suicide from 2011-2018. Use of firearms was the 2nd leading method.

Hanging may have been chosen for two main reasons: the anticipated nature of a death from hanging, and accessibility. Those who favored hanging anticipated a certain rapid and painless death with little awareness of dying and believed it was a “clean” method that would not damage the body or leave harrowing images for others. Materials for hanging were easily accessed and individuals may have considered it “simple” to perform without the need for planning or technical knowledge. Hanging is seen as the quickest and easiest method with few barriers to completion and is sometimes adopted despite not being the first choice.

For the year 2013- 2018, Guam recorded seven suicide deaths to children 10 – 14 years of age. The causes of death were Asphyxia due to Hanging (6)  and Overdose (1). Very little is known about childhood suicide. There has been a recent wave of research and writing on adolescent suicide, but only a few observed articles on suicide risk in preteens. Until recently, it was believed that children never committed suicide. Most adults want to believe that early childhood is an idyllic time of happiness and carefree living. Even among adults who recognize that childhood for some children can be troubled by stress and pain, most believe that children are not capable of making life-and-death decisions such as suicide.

It should be noted that although suicide is underreported among all age groups, this is particularly true for children. Children seldom leave suicide notes, and they typically have less access to suicidal methods (e.g., guns, pills, etc.). When child suicides do occur, they often are typically reported as accidents. It is impossible to know whether Guam’s children killed themselves intentionally or whether they understood the finality of the decision.

The risk and protective factors related to suicidal ideation among college students in Guam remains unknown. The purpose of a University of Guam study was to identify the rates of suicidal ideation and suicide attempt, and explore the risk and protective factors of suicidal ideation among college students in Guam. Two hundred and seven (207) college students at the University of Guam were surveyed. The rate of suicidal ideation and suicide attempts was 10.2% and 8.2%, respectively. In analyses of the survey data, previous suicide attempts, shorter period of living in Guam, high scores on cultural difference and negative affect, and low scores on family meaning were identified as independent predictors of suicidal ideation.

In 2005, the University of Guam's Isa Psychological Services Center applied for and received a three-year grant through the Garrett Lee Smith Memorial Act. This grant supported the creation of the I Pinangon Campus Suicide Prevention program, which has provided suicide prevention services to the university community, including students and their families, faculty, administrators, and staff. In 2008, Isa Psychological Services Center received another three-year grant through the Garrett Lee Smith Memorial Act to support the enhancement, expansion, and institutionalization of campus suicide prevention services through a variety of infrastructure development strategies. Since the inception of the grant in 2005, I Pinangon has reached over 7,000 participants from the university community through gatekeeper training, mental health screening, and other outreach events.

Project Inspire held an inaugural charity gala to raise funds for mental health awareness and suicide prevention, while promoting local artists. The LIFE, CAMERA, ACTION! event brought together organizations hoping to bridge the gap between the arts and mental health in a unique way never before seen and involving our youth. While the event was inspired by a personal tragedy, its goal is to bring hope to those suffering through a medium many of our youth are familiar with: the arts.

Earlier in the year, Project Inspire and the production team lost one of their key members to suicide. The late cinematographer was honored at the event. Throughout 2019, Project Inspire will release public service announcements, focusing on saving lives, and teaching residents how to get help that is available. The group will create messages with the guidance of Guam Behavioral Health and Wellness Center.

Prevention of suicide is not the exclusive responsibility of any one sector of society. Schools can create cultures in which young people feel it is healthy to talk through emotional and other difficulties. General practitioners can restrict the number of tablets prescribed to those at risk of overdose. Accident and Emergency staff can ensure all young people who have attempted suicide receive specialist mental health assessment. In addition, each of us can pay close attention to the overall mental health of our loved ones to reduce the risks of them taking their lives.

The Guam Behavioral Health and Wellness Center launched "Focus on Life," a media campaign that aims on raising the awareness for the need to address the issue of suicide on Guam. This film features survivors, trained caregivers and suicide prevention resources who speak of the pain that suicide had caused or may cause our people, and how we can live through those pains so that it will not happen again.

Guam Behavioral Health and Wellness Center operates the Crisis Hotline. The Crisis Hotline (CHL) project, comprised of one full-time staff and coverage provided by staff of the Adult Inpatient Unit, started as an information help line for Desert Storm and from this tumult was recognized a need for a 24-hour telephone "counseling" service to the island community.

The purpose of the Crisis Hotline is to assist individuals experiencing crises, through staff and volunteers having undergone comprehensive training in crisis intervention, and a strong networking system with other governmental agencies and private organizations.

Approximately 320 calls come through the Crisis Hotline every month. The spectrum of crisis calls range from a youngster needing help with his homework to suicide. The most prevalent calls are relationship problems, most of which are compounded by depression.

Island Girl Power hosted a “Focus on Life” carnival in September 2018. Island Girl Power is a local prevention program, focused on offering positive activities and role models for young girls and their families. The annual event was an opportunity for the community to visit the Island Girl Power facilities and learn more about their prevention programs, including awareness campaigns for suicide and underage drinking. The organization distributed 500-suicide awareness ribbons at the event.

Despite the island’s welcoming culture, members of Guam’s lesbian, gay, bisexual, and transgender (LGBT) community often struggle for acceptance. In a 2015 health survey, 37% of the LGBT community had experienced being bullied and 25% spoke of suicide. To address this, Guam Behavioral Health and Wellness Center (GBHWC) collaborated with Guam’s Alternative Lifestyles Association (GALA) to provide a range of behavioral health to the LGBT community. With additional support from GDOE, GALA brings health awareness, substance abuse prevention, and youth empowerment programs to schools and community centers. Their programming includes Storytelling for Empowerment, an evidence-based substance abuse and suicide prevention curriculum; a health and wellness program; and a Summer Power Camp that includes arts and crafts, physical fitness, and substance abuse and wellness workshops for school-age youth.

GALA relies on strong collaboration with a wide range of schools and community partners – including the University of Guam, Title V MCH, victim advocacy services, village mayors – to identify youth who could benefits from their services.

Since its partnership with the GBHWC GALA has implemented its programs in one high school and three middle schools, serving northern and central villages. Approximately 350 youth have participated in their community based Storytelling for Empowerment workshops, and in the 2017-2018 school year, 260 youth participated in their school and summer camp programs.

By establishing a presence in schools and communities, GALA has also educated parents, teachers, schools administrators, and other adults on the behavioral health needs of LGBT youth, including the increased risk of substance misuse and suicide.

[1] US, DHHS, 2012

[2] SAMSHA, NSDUH Report, 2011

[3] SAMSHA, NSDUH Report, 2011