Adolescent Health

Annual Report Year

Priorities: 1) Improving adolescent access to and utilization of primary care and behavioral health services. 2) Enhancing positive youth development for adolescents to decrease high-risk behaviors (teen pregnancy, STIs, violence).

Adolescents in the District face a multitude of challenges including engaging in high risk behaviors that result in substance abuse, STI transmission, pregnancy and exposure to injuries. According to the 2019 YRBS data, 44% of high schoolers reported ever having sexual intercourse, with 7.9% reporting their first sexual encounter prior to the age of 13. In addition, adolescents and youth have been disproportionately affected by STI’s compared to other age groups. In the District, adolescents in the 13-17 year age group constitute the third highest rate of newly diagnosed cases of chlamydia and gonorrhea, with teens in the age group 18-19 second, and individuals in the 20-24 age range falling first. Bullying and other forms of interpersonal violence are also a significant problem in the District. These issues affect students at every level, from elementary school to high school. The District's public and public charter school system is comprised of 116 public schools (approximately 49,000 students) and 123 public charter schools (approximately 44,000 students). According to the 2019 Youth Risk Behavior Survey (YRBS) (n=10,648), over 12 percent of students reported being bullied at school in the previous school year. Additionally, with the increase of technology use, students are also susceptible to electronic bullying such as through texting or social media - 10.6% of high school students reported experiencing cyberbullying, an increase since 2012 (7.9%). In order to effectively address bullying in FY 19, Title V continued to fund the Office of Human Rights (OHR) to create a series of lessons to help middle school students learn how to use technology and social media in a healthy and supportive way. In addition, Title V funded the Wendt Center for Loss & Healing’s Resilient Scholars Project-School Based Program (RSP-SB) to provide high quality, evidence-based mental health services through group or individual therapy to children/adolescents (ages 6-17 years) suffering from affective disorders as a result of trauma and/or traumatic loss in DC Public and Public Charter Schools and community programs.

Goal 1: Decrease youth violence including bullying and partner violence.

In FY19, Title V continued to provide funding to the Office of Human Rights (OHR) to decrease incidents of bullying and other forms of interpersonal violence by creating a series of lessons to help middle school students learn how to use technology and social media in a healthy and supportive way. OHR partnered with Child Trends and adapted an existing evidence-informed curriculum aimed at reducing teen pregnancy, El Camino (“Program”), for use with DC middle school students to improve healthy relationship skills and prevent bullying and other forms of interpersonal conflict. The Program’s FY19 objectives were: 1) conduct a secondary pilot implementation of the one-hour lessons in the El Camino Healthy Relationships Curriculum (ten lessons total) by the end of school year 2018-2019; 2) assess satisfaction among school staff and students and changes in healthy relationship outcomes among students; and 3) develop training materials to allow the curriculum to be implemented beyond the project.

Driven by parent, educator and student feedback garnered in FY18, Child Trends made adjustments to the curriculum and focused its efforts on completing the secondary pilot at E.L. Haynes Public Charter School. Twelve youth—8th grade girls ages 13-14—were engaged to participate in the pilot of the curriculum. Child Trends provided two expert facilitators to guide the implementation of the curriculum (ten lessons) and collection of pre- and post-data from student participants and school staff. Typically, one facilitator would lead the lesson, while the other facilitator took notes on the extent to which the lesson went as planned, what activities and discussions were well-received, and what should be changed. After each pilot session, the pilot team debriefed with the extended research team to consider successes and challenges, and to prepare for the next pilot session. The pilot took place over twenty classroom sessions, splitting each of the ten lessons in the curriculum into two 30-minute sessions. Several challenges were experienced in FY19, such as:

• Shortened class period- due to the bell schedule and announcements, 30-minute sessions were cut down to 25-minute sessions. Facilitators eliminated certain activities to allow more time for high-priority activities and discussions;
• School schedule coordination and participant retention- spring break, field trips, testing, and graduation – impacted participation and retention levels; and
• Adequate data collection- only four of the 12 students participated in at least 75% of the sessions and only two students completed the pre- and post-survey.

By the end of FY19, OHR and Child Trends further revised the curriculum to incorporate feedback from facilitators and the host teacher. In supporting curriculum revisions, the host teacher focused on two items: timing of discussions and activities (i.e. can the activity be completed in the suggested time period?) and identifying discussions and activities that may need differentiation based on the grade of the participating student. In support of the development of training materials, the host teacher advised on accessibility, ease of use, and benefit to facilitators by providing a teacher’s perspective. Due to the challenges experience, Child Trends requested a no cost extension to conduct a tertiary and final pilot. Center City Public Charter School – Capitol Hill Campus was selected as the host site for the tertiary and final pilot of the curriculum with 6th – 8th grade students.

In FY 19, Title V funded the Wendt Center for Loss & Healing’s Resilient Scholars Project-School Based Program (RSP-SB) to provide high quality, evidence-based mental health services through group or individual therapy to children/adolescents (ages 6-17 years) who are suffering from affective disorders as a result of trauma and/or traumatic loss in DC Public and Public Charter Schools and community programs located primarily in Wards 1, 4, 5, 6, 7 and 8. In FY19, Wendt exceeded their target of 20 partnerships, with 23 formal school/community partners which resulted in referrals for 336 children/adolescents to participate in RSP-SB services. Of those referred, 83% (or 279) were enrolled in RSP-SB services. The remaining 17% of children/adolescents were not enrolled due to lack of consent from the referred child’s/adolescent’s parent/legal guardian to assess or ineligibility for services due to clinical reasons.

In FY19, a total of 692 group therapy sessions were provided, of which 640 occurred during School Year (SY) 2018-2019 and 52 during Summer 2019. Two hundred and twenty-one students participated in at least one session of group therapy and 64 students participated in at least one session of individual therapy. Ten children/adolescents were originally assigned and participated in group therapy but were transferred to individual therapy due to clinical or behavioral reasons. During FY19, 696 individual therapy sessions were provided – 12 were for children/adolescents who required one-on-one support outside of their participation in group therapy. Fifty-six children/adolescents who began either group or individual therapy were withdrawn from therapy. The reasons for withdrawal included: 1) student no longer attending the school or missed multiple sessions (e.g. schools did not allow students to participate during in-school suspension) (54%), 2) clinical or behavioral concerns (26%), and 3) student initiated withdrawal (20%).

On average, individual and group therapy participants demonstrated decreases in post-traumatic stress disorder (PTSD) and depressive symptoms as measured by the Structured Trauma-Related Experiences and Symptoms Screener (STRESS) and Mood and Feelings Questionnaire (MFQ), respectively. Participants also self-reported positive changes in their emotions, relationships, decision-making skills, and behaviors at the end of therapy. Sixty-eight children/adolescents were referred to additional services with the majority being other mental health supports (including Wendt’s office-based counseling), followed by primary medical care, dental care, housing programs, educational services, and after-school programs in order of volume. Thirty-one children/adolescents were referred to the Wendt Center’s annual grief camp (Camp Forget-Me-Not/Camp Erin DC). Moreover, parents/caregivers attended 53% of student psychosocial assessments conducted by RSP Clinicians/Interns at the start of services to determine eligibility for RSP-SB Services. The following successes pertain to parent/caregiver involvement:

• 196 parents/caregivers received supportive outreach from RSP Clinicians/Interns via telephone, email, or in-person;
• 96.5% of parents/caregivers were provided the RSP-SB Parent/Caregiver Project Manual; and
• at least one edition of the RSP-SB Newsletter was distributed to124 parents/caregivers.

In addition, RSP Clinicians/Interns provided approximately 97 clinical consultation/crisis support hours to school/community partner staff. Two hundred sixty school/community organization staff were trained on trauma, its effects on young people, and how to best support youth exposed to trauma with about 99% reporting that the training improved their understanding of trauma and their ability to support impacted children/adolescents.

Goal 2: Reduce sexually transmitted infections and unintended pregnancies.

In FY19, Title V staff continued to provide oversight of Teen Pregnancy Prevention (TPP) programs. DC Health believes that convening, coordinating, and integrating the multitude of teen pregnancy TPP programs in the District is critical to achieving Districtwide impact. Aligning with the Centers for Disease Control and Prevention's Community-Wide Teen Pregnancy Prevention Initiative framework, DC Health’s TPP programs aim to engage youth early in preventive health and reproductive life planning through a multi-component, community-wide approach. In FY19, seven organizations (Crittenton Services of Greater Washington, Sasha Bruce Youthworks, Big Brothers Big Sisters, Healthy Babies, Inc., Urban Institute, The Young Women’s Project (YWP) and Children’s National Medical Center (CNMC)) implemented teen pregnancy prevention (TPP) programs using evidence-based, evidence-informed or promising practice models primarily in Wards 5, 7 and 8. The TPP grantees served students at 23 DC Public Schools and 10 community-based sites and health centers. Each TPP sub-grantee used a community-wide teen pregnancy prevention model to incorporate reproductive life planning into their programming, this includes:

• increasing the availability of adolescent-friendly health services,
• creating sustainable community-clinical linkages for adolescent health services, and
• increasing access to long-acting reversible contraceptives (LARCs) among adolescents.

In partnership with Power to Decide, grantees initiated a pilot of One Key Question® (OKQ) at 3 sites. OKQ encourages providers who support women to routinely ask: “Would you like to become pregnant in the next year?” From there, providers can help women prepare for pregnancy or plan to prevent pregnancy. Helping adolescents actively consider reproductive health choices can help reduce the teen pregnancy rates and associated morbidities. In FY19, TPP experienced challenges that limited the number of participants reached, these included: coordinating with school schedules and changes to make sure students were available (i.e. testing dates, field trips, etc.), low student attendance rates in both school and community settings, unreliable participant or parent contact information, and solidifying and/or maintaining community partnerships. To enhance the quality and standard of services provided to students, TPP grantees participated in training and continuous quality improvement initiatives. Grantees evaluated programs utilizing (intake documents, pre- and post-surveys, and attendance records. Key accomplishments and points of program impact include:

• a 44% increase in birth control and condom use amongst sexually active participants (Crittenton),
• a 54% increase in  positive sexual health amongst sexually active youth- including use of condoms and LARCs (Healthy Babies),
• a 5% increase in the number of patients who received reproductive health services from the previous year (CNMC),
• a 70% increase in knowledge about where to access reproductive health services (Urban Institute),
• an 86% increase in  knowledge among program participants about STDs, HIV, AIDS and risk behaviors (Big Brothers Big Sisters),
• 2,808 clinical referrals from your educators (YWP)
• 39% of patient referrals to the reproductive health case manager initiated a contraceptive method (CNMC).
• a grantee partnership for STI and HIV testing (Urban Institute and Sasha Bruce).

During FY19, TPP grantees served a total of 1,457 male and female youth participants, ages 11-22 within Wards 5, 7 and 8 through community and school-based programming.

Goal 3: Increase access to and coordination of health systems.

Title V provides support for DC Health staff overseeing the locally funded School-Based Health Center Program (SBHC). The program aims to improve the physical, social, emotional, and behavioral health of students, as well as minimizes the effects of poverty and other adverse childhood experiences, enabling students to thrive in the classroom and beyond. SBHCs are operated by three DC Health grantees – Children’s National Medical Center, MedStar Health, and Unity Health Care, Inc. – with school-based health centers in seven DC Public high schools. SBHCs are open year-round and promote an adolescent-friendly approach due to evidence supporting the need for care to be accessible, equitable, acceptable, appropriate, comprehensive, effective, and efficient.

All providers must offer:

• Primary Care - Preventive medical care is available to students five days per week to include well child exams, immunizations and sports physicals. SBHC providers utilize a comprehensive risk assessment to identify attitudes, behaviors and environments that may affect an adolescent’s academic success. Students can access assistance from the SBHC for chronic diseases, substance use and acute care. For patients that do not elect the SBHC as their medical home, SBHC providers coordinate and communicate care with their primary care physician.  
• Reproductive Health Services - The SBHC uses The One Key Question® and provides life planning, reproductive care and contraceptive counseling and provision, including long-acting reversible contraceptives (subdermal implants and IUDs). Service offerings also include STI/STD screening, counseling and treatment. Prenatal care and IUD insertion is available at least once weekly.
• Oral Health Services - Preventive services including examinations, cleanings, sealants, topical fluoride treatments, education and counseling and basic operative services including fillings, scaling, deep cleanings, and pulpectomies. Acute care and consultation are available one full day per week.
• Behavioral Health - A mental health clinician provides behavioral health services on-site, at a minimum, one full day per week and conducts and/or ensures appropriate assessments, early intervention, treatment, counseling, and other psychiatric referrals are completed. In collaboration with DC Health, DC Public Schools (DCPS) and the Department of Behavioral Health (DBH), the SBHC establishes appropriate referral mechanisms to ensure student connection to behavioral health services, both within school and/or in the community.
• Linkages and referrals - Specialty or emergency health care services and social services not offered by the SBHC are referred out to a school or community resource.

In FY19, DC Health continued to implement One Key Question® (OKQ) in all school-based health centers (SBHCs) to identify an appropriate reproductive plan for students that can help women prepare for pregnancy or plan to prevent pregnancy. SBHC providers screened 1,841 students who were primarily young women, a 47% increase from FY18. As a result, 226 new SBHC female participants had a documented reproductive life plan.

The SBHC operators experienced challenges unique to the population served, which will continue to help inform future efforts and planning to best serve the students seeking care and services through the SBHCs. Challenges experienced included:

• high burden of mental health diagnoses - With a high burden of mental health diagnoses among high school students seeking services from the SBHCs, addressing needs were often a challenge in the absence of a Psychologist or Psychiatrist;
• outreach and enrollment of students - In an effort to increase enrollment, DC Health and SBHCs implemented an incentive-based enrollment campaign that offered a variety of rewards for patient referrals resulting in enrollment, school-wide enrollment drives and initiatives and increased publicity of SBHC services. However, these efforts did not yield the expected result of an increase in student enrollment;
• relocation to new spacing- Relocating to a new location presented unexpected limitations in clinic care;
• IT connectivity related issues- unexpected IT connectivity issues made it difficult to access information at times limiting the school-based health centers ability to provide services.

By the end of FY19, SBHCs had a collective total of 6,784 visits by 725 students. Chief reasons included 837 well child visits; 3,835 behavioral health visits; 2,392 sexual health/confidential reproductive health visits; 2,005 oral health screenings; 148 preventive oral health visit; and 204 asthma care visits. SBHCs also referred 154 students to social services.

Goal 4: Increase access and utilization of preventive oral health visits.

Title V provided oversight for the Oral Health Program (OHP) to ensure access and utilization of ongoing comprehensive primary dental services for DC residents. In FY19, OHP collaborated with the DC Health Primary Care Office (PCO) to implement the Community Dental Health Coordinator (CDHC) program in the District. The CDHC program aims to pilot a model of oral health integration into primary care and support services delivered to pregnant women and children 0-5 years of age and provide linkage to an oral health home.

During the fiscal year, OHP also continued to administer the School-Based Oral Health Program (SBOHP) with goals to increase access to preventive dental services for students ages 0 - 17 enrolled at the District’s LCDCs, public schools, and public charter schools who may not otherwise be using the dental care system. In FY19, OHP, along with DHCF, successfully launched a Managed Care Organization (MCO) notification form that activates the MCOs’ care coordination services when the SBOHP vendors identify a child with follow-up dental needs. Following a SBOHP clinical visit, forms are faxed to MCOs notifying them of students who require urgent or immediate follow-up care. The SBOHP also worked to increase the utilization of preventive oral health services among children and adolescents by targeting DCPS schools with low submission rates of oral health assessment forms, indicated by the Children’s School Services Report. OHP collaborated with the DC Health PCO office and successfully identified a sub-grantee to carry out the CDHC program model with the goal of linking pregnant women and children under five to oral health care. OHP experienced several staffing transitions however that impacted data collection, management, and oversight which prevented OHP from achieving many of their goals. The care coordination process and data did not adequately capture linkage to a dental home for all students and therefore requested data metrics, including number of children connected to a primary dental provider and percent of children referred to a dental resource were not able to be reported.

By the end of FY19, SBOHP served 2,330 unique children enrolled in 60 schools (26 DCPS, 21 PCS, and 13 LCDCs). Of the 2,330 students seen by SBOHP, 57 students were referred for urgent or immediate follow-up treatment. The outcome of those 57 referrals remains unknown due to limited data collection. The following diagnostic and preventive services were provided: dental screenings (N=2457), prophylaxis (N=2356), fluoride varnish (N=2345), and dental sealants (N=424). There were 127 children who received repeat cleanings during the school year in the same time period, likely an indication that these students could benefit from care coordination services and linkage to a dental home. Fifty-five percent of all schools covered by the SBOHP in FY19 were in HRSA’s Dental Health Professional Shortage Areas (Ward 7 & 8). Of those students who were served by SBOHP in FY19, (N=2330), 17% of children (N=398) had untreated caries. These children with untreated caries may have been seen in the SBOHP for the first time, developed new caries since the last SBOHP, or returned to SBOHP with caries. In addition, 73% of those children served in FY19 had Medicaid (N=1715), 18% had no dental insurance (N=428), and 12% had private insurance (N=300).