According to the World Health Organization, young people between the ages of 10 and 19 years are often thought of as a healthy group. However, many do die prematurely due to illnesses that are either preventable or treatable. Maine tracks these issues through two performance measures: adolescent (ages 12-17) bullying; and unmet mental health needs of adolescents.

Performance Measure: Percent of adolescents, ages 12 through 17 years, who are bullied or who bully others.

Despite increased attention to the need for prevention and intervention, bullying and harassment remain common experiences for children and adolescents. According to the 2018 National Survey of Children’s Health (NSCH), 18% of adolescents, aged 12-17 years old bullied others and almost half (47.5%) were bullied in the previous 12 months. The percent of Maine children who have bullied others is about the same as the U.S. (15.7%). The percent of Maine adolescents who had been bullied is significantly higher than the U.S. percentage of 40% and only 13 states had a higher percentage of parents reporting that their child had been bullied.

Based on Maine Integrated Youth Health Survey (MIYHS) data, the percent of high school students reporting that they were bullied on school property and the percent who have been electronically bullied had been declining, but in 2019 both percentages increased slightly, but not significantly. Schools and communities are increasingly recognizing the impact of bullying and harassment on students’ education success and mental and physical health. The Maine Department of Education (DOE) provides ongoing training and technical assistance for school systems on implementation of required comprehensive model bullying and harassment prevention policies and procedures as well as trainings in other areas of best practice bullying prevention (http://maine.gov/doe/bullying). The Maine Center for Disease Control and Prevention (Maine CDC) supports best practices in addressing bullying and harassment behavior in school settings, including integration of restorative justice practices.

We know that some groups are disproportionately affected by bullying. Almost two of three (63%) of children with special health care needs are bullied, picked on, or excluded by other children.[1] Students who are American Indian/Alaska Native (33%), Native Hawaiian/Pacific Islander (39%), or multiracial (29%) are more likely to be bullied than students who are white (23%).[2] Students who identify as gay, lesbian or bisexual have even higher rates of bullying and harassment with 37% of gay/lesbian youth and 37% of bisexual high school youth reporting being bullied at school in the past year.2 Almost half (44%) of high school youth who identify as transgender were bullied at school in the past year.2 It is also problematic that many youth report relatively low confidence in the ability of adults to respond supportively to bullying and harassment. Only 32% of high school students believe that adults in their school address conflict, negative language and bullying in positive ways to help students.2

Over the 2015-2020 period of this Strengths and Needs Assessment, Maine CDC and the Adolescent Health and Injury Prevention (AHIP) Program focused on primary prevention of bullying and harassment through interventions that addressed underlying risk and protective factors, with a focus on social and emotional skill building. The AHIP Program partnered with the Maine Youth Action Network (MYAN) to promote youth leadership and positive youth development, including youth-led initiatives focused on improving school climate and reducing bullying and harassment. Youth received training and engaged in assessing their schools and communities to identify opportunities for change, using the Youth Participatory Action Research model. Youth then developed and took action on projects with the support of adult advisors. All MYAN programming is based on the principles of social and emotional learning, which are protective in reducing bullying and harassment and enhancing resiliency for youth. During FY20, MYAN provided training to 1820 youth, including ongoing engagement with 986 young people through groups working on local action projects. Maine exceeded our objective of 700 (number of youth receiving support from MYAN). The shift from in-person training during the pandemic allowed for greater virtual engagement as well as an increase in the statewide infrastructure around youth engagement.

Over the past five years, Maine CDC and the MYAN conducted significant outreach to increase engagement among youth who are often disproportionately at risk of experiencing bullying and harassment. During the COVID-19 pandemic, many lesbian, gay, bisexual, and transgender (LGBT) youth reported experiencing negative effects from isolation and lack of family support. MYAN partnered with OUT Maine, an organization serving LGBT youth in Mid-Coast Maine, to host regular virtual drop-in sessions and ongoing engagement, such as online gaming groups. These initiatives were planned and led by youth, building leadership skills while fostering connection and community support.

The AHIP Program identified youth engaged by the MYAN as our evidence-based strategy measure (ESM) recognizing that social and emotional learning skills and connections with caring adults are primary factors in preventing bullying and harassment and promoting resiliency. While Maine CDC can provide data on youth directly impacted by MYAN programming, it is difficult to truly capture the impact on school climate and support. For these reasons, Maine CDC closely monitors data from the MIYHS on protective factors such as support from teachers, safety at school, and connections to caring adults.

In addition to working with young people through the MYAN, Maine CDC invested in evidence-based interventions to teach social and emotional skills in school settings. The Maine CDC Tobacco and Substance Use Prevention Program worked with 50 schools across the state to implement Second Step, a social and emotional learning curriculum for Pre K-grade 8 students that has been demonstrated to reduce bullying and harassment as well as substance use behaviors. The Maine CDC AHIP Program began implementing Sources of Strength, a resiliency-building intervention demonstrated to increase connections with peers and supportive adults. Maines’ Safe Schools’ offered an online bullying prevention professional development course. The Creating Safe Maine Schools Resource Guide and other best practice resources are available through the Maine DOE bullying prevention webpage (https://www.maine.gov/doe/schools/safeschools/bullying).

For the past five years, the number of high school students who report being bullied at school in the past 12 months has remained stable (MIYHS). While Maine CDC is committed to reducing experiences of bullying and harassment among young people, we recognize that many of our primary prevention strategies, such as Second Step in elementary schools, may take time to demonstrate outcomes. However, we believe that investments in these upstream prevention strategies have the potential to create significant long-lasting reductions in bullying and harassment, while also having positive outcomes in other areas of wellbeing for Maine students.

The COVID-19 pandemic required adaptation of many planned strategies for FY20. As schools shifted from in-person learning in the Spring of 2020 to completely online, it was a challenge for the AHIP Program to implement school-based initiatives such as Sources of Strength. However, the AHIP Program worked with community partners and schools to make available a virtual Sources of Strength program for fall of 2020. The MYAN created multiple opportunities for engaging youth through virtual projects. MYAN also implemented web-based trainings focused on increasing the use of restorative practices in school settings. Restorative practices emphasize creating a supportive school climate, fostering connection between youth and adults and addressing conflict in ways that maintain relationships and promote change.

To support implementation of social and emotional learning (SEL) in schools, the Maine DOE hired a SEL Specialist in January 2020 to focus on SEL resources, support schools and be the primary contact for supporting schools with bullying related issues. Stakeholders from Maine DOE, Maine CDC and supporting partners were convened to provide input and guidance on this project. In response to COVID-19, amid school’s shifting to remote learning, the Maine DOE Office of School and Student Supports (O3S) offered schools support for SEL practices and directed them to available resources. Over 2000 contact hours were awarded to educators attending support sessions for SEL throughout the spring.

Maine DOE provided school personnel trainings on understanding trauma and trauma-informed practices at in-person regional events, as well as virtual and asynchronously and as part of the Maine DOE Health Promotion Program conference. Over 4500 contact hours were awarded for the events.

Performance Measure (State): Percent of adolescents, ages 12 through 17, with unmet mental health needs

While efforts targeting adolescents often focus on their physical health, unmet mental health needs among teens has a significant impact on their current well-being, and a lasting effect on their future. According to the 2018-2019 NSCH, 9.6% of Maine adolescents aged 12-17 years currently have depression; this is slightly more than the national average of 7.0%. About 22% have problems with anxiety, which is significantly higher than the national average of 12.6%, and 9% have behavioral or conduct problems (vs. 6.4% nationally).

Unrecognized or unmet mental health needs can affect all aspects of adolescents’ wellbeing and may put them at higher risk for academic failure, substance use, and suicide. Even if youth and families recognize the need for mental health services, youth face additional barriers to care. Maine is a rural state, and a lack of transportation or long wait times make it difficult to access the behavioral health providers specializing in care for adolescents. About 17% of Maine children received treatment or counseling from a mental health professional in the previous 12 months. Among Maine high school students, 1 in 3 (32%) reported feelings of sadness or hopelessness that lasted two or more weeks, yet only 25% of those students ever sought help from an adult.[3]

Maine continued to see concerning trends related to youth mental health over the five-year period (2015-2020). The AHIP Program focused on increasing access to care, preventing suicide deaths and attempts through the use of evidence-based prevention practices, and supporting resiliency-building youth engagement strategies. Co-location of behavioral health services in school settings is an effective way to reduce barriers to access for mental health care. Maine CDC supports 15 School Based Health Center (SBHC) clinics that offer medical and behavioral health services to middle and high school students. School Based Health Center providers conduct health risk assessments with young people that include screening for depression and other behavioral health conditions. Over the past five years, SBHC providers reported an increase in demand for mental health care among the students they serve. As a result, Maine CDC added supplemental funding to SBHC contracts in 2019 to support behavioral health services for uninsured or underinsured youth. School closures due to COVID-19 presented an additional access challenge; however, all SBHCs successfully implemented telehealth services and were particularly effective in providing ongoing behavioral health visits during the pandemic. After schools closed for in-person learning in March of 2020 SBHCs provided an additional 1719 encounters (visits), of which 94% were for mental health. In total, the SBHCs provided ongoing mental health care to 412 students in the 2019-20 school year.

In addition to youth engagement activities for bullying and harassment prevention, the MYAN supported multiple Youth Policy Boards and local youth action groups focused on mental health awareness and stigma reduction. Several groups chose to focus on increasing awareness of mental health services available in their local schools and communities. The MYAN Statewide Youth Policy Board used the framework of Youth Participatory Action Research to gather data from fellow students about awareness of mental health resources in their schools with an emphasis on students’ perception of the accessibility and effectiveness of services and how well adults in schools supported students in need. Youth Policy Board members analyzed their findings and created a report with recommendations, including increased mental health education for faculty, increased access to resources and mental health professionals in schools and open dialogue between students and faculty about mental health. The Youth Policy Board presented on these findings to leadership staff at Maine CDC, Maine DOE, the DHHS Commissioner’s Office and the Maine Children’s Cabinet.

Reducing suicide deaths and serious attempts among youth is a longstanding priority for the Maine CDC. Suicide is the second leading cause of death among Maine youth aged 10-19 years. Maine’s youth suicide rate in 2017-2019 was 14.5 deaths per 100,000 youth aged 15-19 years, which was the highest youth suicide rate in New England, and is in the top quartile of state youth suicide rates. Youth suicide rates in Maine have been trending up over the past 10 years. According to data from the MIYHS, the number of high school students who seriously considered attempting suicide in the past year increased significantly between 2009 and 2019 (12.5% in 2009 to 16.4% in 2017). Provisional data from 2020 does not suggest that there were more suicide deaths among youth in 2020 compared to 2019. Maine’s AHIP program is closely monitoring suicide deaths among youth monthly. In addition, we are working with Maine’s syndromic surveillance staff to monitor ED visits for suicide ideation and attempts. These data indicate that there was an overall decrease in ED visits during 2020 due to COVID-19, but the proportion of these deaths attributable to suicide was higher than in previous years. This work is funded by the federal CDC’s Emergency Department Surveillance of Non-Fatal Suicide Related Outcomes grant. This work involves using syndromic data to monitor and disseminate data on suicide-related ED visits and work with partners to use these data for prevention and intervention activities.

The reasons for Maine’s relatively high youth suicide rate are multiple and complex; as in many rural states, Maine’s youth face barriers to receiving mental health care, and few providers in Maine specialize in treating adolescents. Maine CDC is committed to improving early identification of youth at risk of suicide and reducing barriers to care.

Maine CDC and the AHIP Program are committed to expanding suicide prevention resources throughout Maine including increasing the use of evidence-based prevention interventions. The AHIP Program partnered with NAMI-Maine on the Maine Statewide Suicide Prevention Training Program which provided professional development to educators and youth-serving organizations on identification, support, referral and care coordination for young people at increased risk of suicide. The Maine Suicide Prevention Training Program reached over 820 school staff and community providers.

In June of 2019, the AHIP Program was awarded a Garret Lee Smith Youth Suicide Prevention grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). Under this grant Maine CDC expanded training and technical assistance to schools on early identification and intervention for students with unmet mental health needs. Additionally, this grant funds Youth and Family Navigators, who provide direct support and connections to care for youth at increased risk of suicide and their families. In partnership with NAMI-Maine and the Maine Youth Action Network, AHIP worked with 13 schools across the state to implement Sources of Strength (https://sourcesofstrength.org/), an evidence-based program that has been demonstrated to increase resiliency, help-seeking and connections to caring adults. Maine CDC also continued to prioritize the use of suicide-prevention best practices in medical and behavioral health settings. The AHIP Program expanded the number of clinical systems implementing the Zero Suicide model (https://zerosuicide.edc.org/) by four additional sites. All organizations complete a self-assessment and create quality improvement action plans to increase screening, intervention, treatment and care coordination for individuals at risk of suicide in their care.

Maine CDC continued to implement suicide prevention interventions for youth in schools and community settings. During FY20 the AHIP Program partnered with the Association of State and Territorial Health Officers (ASTHO) and the US CDC to develop a series of community planning tools that support Maine’s state suicide prevention plan. As part of this project, AHIP will partner with the Maine Resiliency Building Network to create a series of resources focused on increasing the number of youth who feel connected to their community. This will include development of a “Community Conversations” guide and engaging stakeholders throughout the state in discussing what community resources are needed to ensure that Maine youth can thrive and succeed.

The MYAN engaged youth in community change projects focused on mental health and wellbeing. In addition to the Youth Policy Boards and Youth Taking Action groups, MYAN supported schools implementing the Sources of Strength initiative.

Maine DOE Health Education and Physical Education Consultants worked with the AHIP Program and NAMI-Maine to deliver at least three regional trainings for the combined stress management and suicide prevention curriculum lessons and high school Lifelines Suicide Prevention lessons for middle and high school educators. The state law requiring all school personnel to receive suicide awareness and prevention training every five years, as well as designating trained gatekeepers in all school districts, requires ongoing training provided by NAMI-Maine. The law was amended to require all Maine schools to put locally developed protocols for suicide prevention, intervention and postvention in place for the 2019-2020 school year. NAMI-Maine continued to offer protocol development training to support all Maine schools in reaching this requirement by the end of the 2019-2020 school year. In response to COVID-19 and the shift to remote learning, educators were offered professional development sessions to support suicide prevention education and supports in the new remote learning setting as well as resources and supports for ongoing self-care for students.

The 2007 Health Education and Physical Education standards within the Maine Learning Results commenced a revision process in the fall of 2019. The steering committee comprised of a variety of stakeholders met through June 2020. The revision will incorporate newly enacted laws on mental health, child sexual abuse prevention and affirmative consent. The committee planned to recruit teachers to be a part of the writing team in the summer of 2020; this was delayed until Summer 2021 due to the COVID-19 pandemic.

Members of the Maine DOE Office of School and Student Supports participated on the Governor’s Opioid Prevention and Intervention Task Force as well as the sub-committee for identifying education resources for substance-use prevention efforts. The recommendations from the sub-committee included more qualified instructors for PreK – diploma health education, so that more students receive quality skills-based health education instruction that includes substance use prevention, mental health and components of social emotional learning, as well as a requirement for social emotional learning for all adult educators.

[1] National Survey of Children’s Health, 2018-2019.

[2] Maine Integrated Youth Health Survey, High school, 2019.

[3] Maine Integrated Youth Health Survey, High school, 2019.