The CT Title V program recognizes the value of providing adolescents with appropriate, comprehensive, and timely health care. We also recognize the importance of effective transition to all aspects of adult life, including health care and related services. In addressing the needs of adolescents, the CT Title V program strategies emphasize supporting Adolescent Wellness (including comprehensive well child visits) and process improvement for the transition to adult life – inclusive of the identification of primary care providers for Youth with Special Health Care Needs. The School Based Health Centers were used as an infrastructure in promoting comprehensive adolescent well child visits, developmental assessment, risk assessment and behavioral health screening, anticipatory guidance, and Body Mass Index (BMI) screening and intervention.

 

School Based Health Centers (SBHC) are free standing medical clinics located within or on the grounds of schools and are licensed as outpatient clinics or as hospital satellites. They offer accessible medical, mental health and/or dental services to all students enrolled in the school regardless of ability to pay/insurance status. Services provided to students include but are not limited to: diagnosis and treatment of acute injuries and illnesses, managing and monitoring chronic disease, physical exams, administering immunizations, prescribing and dispensing medications, laboratory testing, health education, promotion and risk reduction activities, crisis intervention, individual, group and family counseling, outreach, oral health (in some locations), referral and follow-up for specialty care, and linkages to community based providers. SBHC staff work collaboratively with schools, parents, and the community to ensure that students are healthy and ready to learn. SBHCS support students by providing a safe place to talk about sensitive issues such as depression, family problems, relationships, and substance abuse, support the school environment by helping children stay in school reducing absenteeism and by identifying and addressing health problems that may interfere in the learning process, and support families by allowing parents to stay at work while attending to their child’s routine health care needs also resulting in fewer ED visits.

 

Mental health services are a priority within the SBHCs and experienced adolescent health clinical staff who provide mental/behavioral health services. Mental/behavioral health services include, but are not limited to - assessment, diagnosis and treatment of psychological, social and emotional problems, crisis intervention, individual/group/family counseling, psycho-social education, advocacy and case management, outreach to students at risk and referral to community-based providers to address needs outside the scope of SBHC practice.

 

DPH supported 90 school-based health service sites in 27 communities statewide through a state budget line item as well as MCHBG funds. Included are 78 School Based Health Centers (SBHC) and 12 Expanded School Health (ESH) sites. SBHCs served students, Pre-Kindergarten through grade 12, and are in elementary, middle, and high schools.

 

The school-based health centers serve as the principal vehicle for promotion and improvement of adolescent health services. The 90 DPH supported SBHCs had total student population of approximately 67,200, which is about 13% of Connecticut’s overall student population. Enrollment in these clinics is approximately 54% of the population or 36,000.  The number of visits to the SBHCs totaled more than 80,000 and the number of unduplicated students served was approximately 13,000. Approximately 12,900 students received one or more service visit per year (approximately 19% of the student population). A total of 9,831 students made 25,711 medical visits, an average of 2.6 visits per student. A total of 4,515 students made a total of 51,182 mental/behavioral health visits, an average of 11.3 visits per student. A total of 1,674 students made 2,880 dental visits, an average of 1.7 visits per student.

 

 

Source: 2020-2021 DPH SBHC 1st Period Report.  Q9. What is your School Population?

 

Source: 2020-2021 DPH SBHC Year End Reports.

* 2019-2020 and 2020-2021 Numbers are severely reduced due to COVID-19 and school closures

 

Source: 2020-2021 DPH SBHC Year End Reports.

* 2019-2020 and 2020-2021 Numbers are severely reduced due to COVID-19 and school closures

 

 

 

 

 

Source: 2020-2021 DPH SBHC Year End Reports.

* 2019-2020 and 2020-2021 Numbers are severely reduced due to COVID-19 and school closures

 

75% of SBHC clients have public or private insurance. DPH funded SBHCs that provided medical and behavioral health services bill and may be reimbursed for services.

 

Source: 2020-2021 DPH SBHC Year End Report

 

During the 2020-2021 school year most of Connecticut schools operated in a hybrid model with some portions of the school year fully virtual due to the COVID-19 pandemic. COVID-19 impacted the school year, reducing student’s access to care at the SBHC.  This resulted in low SBHC visit rates due to a decrease with students being in-person.

 

The hybrid school format had a lot of negative effects on the students. Students had difficulty shifting from the in-school to virtual model and struggled with routine at home. Absenteeism and academic problems were a worrisome trend, heightened by the pandemic and distance learning.  Many reported symptoms of depression, anxiety, and loneliness due to the uncertainty of the COVID-19 pandemic. Students experienced anxiety and stress around managing online learning and navigating the online learning world as well as personal/family issues during covid.  Students often worried about their relatives getting sick and students expressed their concerns about the violence in their own community and nationally. Students struggled with not being able to see friends, loneliness and for some suicidal ideation.  Students lacked energy and motivation to engage in schoolwork, were frustrated, distracted, and developed behavioral issues related to distance learning.  It was especially difficult for a lot of the students in the bilingual program to adapt to distance learning. The lack of fluency of English, deficits in technology knowledge, and limited access to good internet connection made the process of distance learning frustrating for many students and parents. 

 

Mental health became a focus during the COVID-19 pandemic. SBHCs reported an increase in depression, anxiety, trauma and ADHD.  Students reported an increase in social isolation, lack of motivation, increased fatigue, and difficulty in their daily structure navigating in home/in school learning. Students in high school had heightened stress related to academic pressure, college acceptances, and workload. Students in younger grade levels shared trends specific to imbalances of routine, lack of motivation, and report of social stressors especially with new COVID-19 social distancing barriers in the classroom.  Clinicians had difficulty running group sessions due to social distancing guidelines and trouble connecting with clients who struggled or refused telehealth services. The ACES screening tool and Depression Screen helped providers monitor psychosomatic illnesses. School based referrals have increased this reporting period, with family and self-referral also continuing to occur.

 

Medical visits were difficult to maintain since there is only so much that could be done remotely through telehealth while students were home learning. Trends included increase in obesity due to lack of physical activity, poor sleep and eating habits while at home, which impacted overall health and learning, increase in food insecurity and more families seeking resources, overdue vaccines, and physicals, decrease access to healthcare, and less social interaction with peers.  Students reported feeling extreme amounts of stress due to managing school, family life, friends, and other personal relationships. The amount of stress due to COVID was varied with some students stating that hybrid learning made their school load easier to manage and other commented that the hybrid model made school and home life much more difficult. Fewer sick visits during this year which may be a result of masking, social distancing, or at home learning. In attempt to keep up with providing access to care some SBHCs held flu vaccination clinics and other primary care services outside for students and their families. Others referred to Community Health Centers or were able to stay open at the school site even when school was virtual. SBHC staff also assisted with COVID activities in the community.

 

SBHCs did have some successes when it came to COVID-19.  After initial set up, many telehealth visits were successful with no breaks in coverage for the students. The ability to reach parents through the phone or computer increased parent contact and involvement in treatment planning.  Parents engaged more frequently by text with the providers. Some students thrived in quarantine and learning at home since in person school was the source of their anxiety.  Many schools continued with free lunch for students.

Source: DPH SBHC 2019-2020 3rd Period Reports through 2020-2021 3rd Period Reports.

 

Source: DPH SBHC 2019-2020 3rd Period Reports through 2020-2021 3rd Period Reports.

 

A statewide virtual school-based health conference sponsored by the Connecticut Association of School Based Health Centers (CASBHC) was held in the fall of 2020. The event “Healing From The Inside Out”, was attended virtually by more than 180 participants including: school personnel, nurses, physicians, mental health clinicians, state agency personnel, and other stakeholders with an interest in adolescent health. The keynote speaker, Kevin Hines, “Cracked Not Broken” author spoke about his true story of surviving and thriving after a suicide attempt off the Golden Gate Bridge. Other breakout workshop topics included: mindfulness, PREP, eating disorders, human trafficking, PANDAS, violent encounters, motivational interviewing and suicide risk assessment and intervention.

 

In the Spring of 2022, a Title V staff member along with staff from CT United Way and Department of Mental Health and Addiction Services (DHMAS) worked on submitting Gizmo Initiative to AMCHP’s Innovation Hub as a Best Practice. Gizmo Initiative is a fun, flexible, turn-key curriculum for elementary youth that introduces the Gizmo’s Pawesome Guide to Mental Health (Guide) using an animated Power Point of the Guide, implementer discussion guide, and required and optional activities for youth. It may be implemented in various settings, such as public/ private/ parochial/ therapeutic schools, treatment locations, camps, and before or after school programs. The curriculum strives to help youth, their trusted adults, and the settings in which they live support their mental health and social emotional learning and create a greater sense of individual and community connectedness thereby strengthening their mental wellness and reducing their risk of many negative health outcomes, but most importantly poor mental health and suicide. The Guide was developed to respond to a critical youth suicide prevention and mental health promotion education and service gap evidenced by the Connecticut data, and to support youth mental health literacy. Utilizing the evidence-based Safety Plan (Stanley and Brown, 2012) as the framework, the Guide introduces mental health and wellness knowledge and skills to youth at an early age with the hope that they may keep and apply what they learn for a lifetime to help them stay healthy and safe. These include: 1. What is mental health; 2. Mental health is equally as important as physical health; 3. Daily activities that support mental health wellness; 4. How to identify when mental health needs attention; 5. Internal and external healthy coping strategies that support mental health; 6. How to identify and connect with trusted adults; and 7. Resources to share with trusted adults. Time: The curriculum is made up of five (5) segments that may be implemented over a 50-minute period at once, or across multiple days for no more than two consecutive weeks.

 

Suicide prevention had been a focus among adolescents, and more recently to a broader group of youth and young adults ages 10 to 24 years old. Injury and Violence Prevention and Surveillance staff regularly participated in CT Suicide Advisory Board (CT-SAB) meetings (virtual meetings as of March 2020) and shared information with Title V staff.  The statewide 1 Word 1 Voice 1 Life campaign, developed by the CT-SAB, is intended to educate Connecticut residents on how to recognize the warning signs of suicide, how to find the words to have a direct conversation with someone in crisis, and where to find professional help and resources, including the preventsuicidect.org web site and the Suicide Prevention Crisis Line at 2-1-1 (text 741-741). Title V distributes 1 Word suicide prevention awareness campaign materials throughout all programs. DPH worked with the United Way of CT to distribute the 1 Word campaign via animated video PSAs and print messaging in various venues such as youth and social services agencies and college campuses around the state as well as outdoor advertising at Yard Goats minor league baseball games at Dunkin’ Donuts Park.  

 

DPH continued to partner with Child Health and Development Institute and CT Children’s Medical Center to promote Educating Practices training on suicide prevention for pediatric providers.

 

In September 2020, the CT statewide Suicide Prevention Plan 2020-2025 was launched, and the Plan was used as a framework to align surveillance and prevention strategies with the CT Comprehensive Suicide Prevention (CSP) Project awarded by the CDC in August 2020.  Two of the targeted vulnerable populations for the grant project are the 10 to 17 year-olds and 18 to 24 year-olds, who both have higher suicide attempt rates compared to the rest of the population. Since the start of the CSP Project in September 2020, DPH’s partners have worked to identify and onboard three local health departments (LHDs) to start and promote existing suicide prevention and intervention strategies in their communities with a focus on the vulnerable populations, especially those in the LGBTQ+ community and among Hispanic teen girls. 

 

The Suicide Crisis phone and text line was posted on additional high suicide risk locations (bridges, overpasses, railways, and multi-level parking garages). Since July 2019, the Lethal Means subcommittee of the CT-SAB and CT Department of Transportation (DOT) have been communicating with 10 communities’ Town Manager, Elected Official, Director of Health, and Local Prevention Council to install signs on a bridge in their city. To date, three communities successfully posted signage on local bridges and overpasses. Several other communities are pursuing signage and working with the DOT to apply for an encroachment permit.  In September 2021, it was reported that there was a new signage being pursued in six CT town/city train stations and 50 signs with QR codes were sent to a parking garage. Also, radio ad space for suicide prevention was purchased on three CT radio stations WDRC- AM, WDRC-FM, and WMRQ-FM HD2 from 12/09/2019 - 06/30/2020 and continued through the remainder of 2020.

 

DPH supports the suicide-crisis information and referral line through United Way’s 211 Infoline and partnered with Department of Mental Health and Addiction Services (DMHAS) and Department of Children and Families (DCF) to provide sustainability to crisis line services, of critical importance related to the national Zero Suicide model. Additionally, DPH in consultation with the CT-SAB worked with Wheeler Clinic to plan trainings that address the risk factors related to suicide ideations and the reduction of stigma in mental health help seeking. Like last year’s activities, Wheeler Clinic planned to offer one training course of “Assessing and Managing Suicide Risk: Core Competencies for Behavioral Health Professionals (AMSR),” a one-day 6.5 hr. training for behavioral health professionals, and two suicide prevention webinar trainings, “Recognizing and Responding to Suicide Risk: Essential Skills for Primary Care Practitioners (RRSR-PC)” for primary care providers of adults, young adults (18-24), and youth (RRSR-PC-Y).  RRSR-PC-Y webinar participants will learn how to work with parents of at-risk youth.  These trainings were postponed, partly due to COVID-19, and are planned to start up again late September 2021. Wheeler Clinic also worked to convert their in-person trainings to a virtual platform.

 

Source: CT Violent Death Reporting System

 

The DPH Office of Injury and Violence Prevention (OIVP), Opioid and Drug Overdose Prevention Program is helping CT combat the ongoing opioid epidemic. Since April 2019, DMHAS and DPH have been involved with two (2) statewide resources, the LIVE LOUD (Live Life with Opioid Use Disorder) multi-media campaign (liveloud.org) combined with Fentanyl risk awareness and harm reduction and the CT Naloxone + Overdose Response App (NORAsaves.com) or NORA. In CT, opioids were involved in 95% of the drug overdose deaths, and among all opioid-involved deaths, about 90% of those are caused by Fentanyl overdose.  These fentanyl percentages are higher in CT that most parts of the U.S., so much education and awareness is needed to those with opioid use disorder. The statewide public awareness campaign, called Change the Script, which launched in February 2018 to help communities, health care providers, pharmacists and individuals address the opioid crisis, is also ongoing and points people to drugfreect.org. CT values interagency collaboration and seeks to ensure sustained statewide, multi-agency education and awareness campaigns that align with the CT Opioid REsponse (CORE) Initiative, a strategic plan which lays out a series of actions designed to rapidly reduce opioid-related overdose deaths in CT. Change the Script was chosen as the theme of the campaign to speak to the need to change public perception and thinking about drug dependence and acknowledge addiction as a chronic brain disease. The campaign also seeks to address the stigma associated with opioid misuse, which often prevents a person or their loved ones from seeking help. A variety of marketing strategies were developed to address several different demographic audiences, including adolescents. Change the Script messages were and continue to be disseminated across the state through a variety of mass media mediums.

 

Source: Office of the Chief Medical Examiner, Connecticut

 

One area of interest is Neonatal Abstinence Syndrome (NAS) surveillance and related education and targeted interventions. Title V and OIVP staff sit on the CT Perinatal Quality Collaborative, led by the CT Hospital Association, which focused on NAS education and cross system collaboration as well as participating in the Substance Exposed Infants-Fetal Alcohol Spectrum Disorder working group.

 

The CT Youth Risk Behavior Survey (YRBS), which is administered as the “Connecticut School Health Survey” (CSHS) is a school-based surveillance system designed by the Centers for Disease Control and Prevention and collects data on substance use and abuse including alcohol, mental health, well-visits, physical activity and nutrition, obesity and overweight, sleep, violence and injury, sexual behaviors, as well as positive or protective factors. Due to the impact of COVID-19 in Connecticut on schools during the 2020-2021 school year, the CSHS was not administered during the spring of 2021, but delayed until the fall of 2021 when widescale in-person learning resumed.  The impact on health and risk behavior estimates due to the pandemic, remote learning, and shift to the fall semester is unknown and data will likely need to be interpreted with caution.  With supplemental funding from CDC, and panel of Adverse Childhood Experiences (ACEs) related questions were collected in the 2021 CSHS. CSHS 2021 results will be prepared for dissemination in summer 2022, including annual estimates, a trend report, a health and academics report, sexual minority risk report. Reports will be posted online and shared with stakeholders and partners. Results from the CSHS can be found at www.ct.gov/dph/CSHS. 

 

Adolescent health data from the CSHS continues to support the work of adolescent health programs within DPH, as well as programs in other organizations that promote adolescent well-being, including the CT Department of Education, Department of Mental Health and Addiction Services, and Department of Children and Families and non-governmental agencies such as the Connecticut Alliance to End Sexual Violence, Connecticut Coalition to End Homelessness, the CT Suicide Advisory Board, and the CT Children’s Injury Prevention Center.

 

About 44,000 Connecticut high school students use at least one tobacco product, including e-cigarettes, which are the most common type of tobacco products used by high school students in CT. Every year in CT, 800 youth under 18 years of age become new daily smokers, and nearly 5,000 Connecticut adults die prematurely from their own smoking.  Vaping has been marketed to youth as a safer alternative to cigarettes and other tobacco products. As a result, while cigarette smoking among CT high school students decreased from 25.6% in 2000 to 3.7% in 2019, the use of vaping products, such as e-cigarettes, more than tripled from 7.2% in 2015 to 27% in 2019, according to 2019 CT Youth Risk Behavior Survey (YRBS) data.

 

In 2021, we could not replicate the weighted frequency for the reference of 44,000 students and the estimates from the 2021 YRBS are preliminary and difficult to interpret because the survey was completed in the Fall which typically shows lower prevalence of risky behaviors.

 

Source: 2021 Youth Risk Behavior Survey Preliminary Results. *On at least 1 day during the 30 days before the survey; “tobacco” includes cigarettes, cigars, e-cigarettes, hookahs (waterpipes), chewing tobacco, snuff, snus, dip and pipes. †F>M; 11th>9th (Based on t-test analysis, p < 0.05). Note: This graph contains weighted results.

 

 

Source: 2021 Youth Risk Behavior Survey Preliminary Results. *On at least 1 day during the 30 days before the survey; includes e-cigarettes and other vaping products. †F>M; 11th>9th, 12th >9th,; B>A, H>A, W>A (Based on t-test analysis, p < 0.05). Note: This graph contains weighted results.

 

Source: 2021 Youth Risk Behavior Survey Preliminary Results. *Indoors or outdoors, on at least 1 day during the 7 days before the survey. †F>M; 10th>9h; 12th>9h; H>A, H>B, W>A, W>B (Based on t-test analysis, p < 0.05). Note: This graph contains weighted results.

 

The CT Behavioral Risk Factor Surveillance System (BRFSS) concluded data collection for calendar year 2019 and prepared results for release in 2020.  Both the 2019 and 2020 CT BRFSS collected child health information (age 0 to 17 years) from an adult proxy on the following topics:  child’s dental visit, dental decay, and dental sealants; breastfeeding; physical inactivity (screen time including television viewing, use of electronic devices) ; nutrition; and self-reported height and weight to calculate BMI, obesity, and overweight.  Results from the CT 2019 BRFSS were released in late 2020 and posted to the DPH CT BRFSS web page which can be found at www.ct.gov/dph/BRFSS.  

 

Source: 2020 BRFSS and Trends.