NPM #7 Injury Hospitalization – Reduce intentional and unintentional injuries among children and adolescents

Please note that some of the strategies and activities listed below impact both the Child and Adolescent Health domains. To avoid duplication, the information will only be listed in this domain, for which it is anticipated to have a larger impact, but it should be noted that some strategies and activities may address a wider age range.

Among Missouri adolescents 10 to 19 years old, the rate of non-fatal injury hospitalizations was 277.3 per 100,000 in 2021 compared to 288.7 per 100,000 in 2020. The top three causes of injury deaths among Missourians ages 10 to 19 years old in 2020 were: 1) unintentional injuries, 2) homicide, and 3) suicide. Motor vehicle accidents were the number one cause of unintentional injury deaths in this age group, followed by accidental poisoning, and exposure to noxious substances. Suicide remains a public health issue of great significance in Missouri. For 2021, the overall suicide rate in Missouri for all ages was 18.7 per 100,000 compared to 14.0 per 100,000 for the US. According to 2021 Missouri Vital Statistics data, suicide was the 10th cause of death for all ages and the 3rd cause of death among adolescents 10-19 years old. Additionally, the 2021 suicide rate among Missouri adolescents aged 10-19 of 9.1 per 100,000 was higher than the 2020 rates (6.8 per 100,000) and the national rate (6.7 per 100,000). Suicide rates indicate higher risk in rural areas (Figure 5), presenting challenges for the provision of mental health services, as rural counties typically have fewer mental health resources than urban counties. Multiple prevention strategies in Missouri were implemented to address unintentional and intentional injuries.

The Bureau of Community Health and Wellness (BCHW) serves as the state lead for Safe Kids Worldwide and provides funding for 10 Safe Kids Coalitions. The coalitions, which are led by local public health agencies (LPHAs), non-profit entities, and local hospital systems, reach 60 counties to provide unintentional injury prevention services to children (0-19 years old). The coalitions offered a broad array of injury prevention educational activities for parents and children such as the National Safety Council’s Defensive Driving Course (DDC). Teens ages 14 and up were encouraged to take DDC and learn state and local traffic laws, distracted driving prevention, and safe driving practices. Other topics addressed safety in the areas of teen driving, sports, medication, fire, and water. Additional injury prevention activities included: hosting prescription drug take-back events, conducting media campaigns with prevention messages, and working with policy makers to address gaps in policies that could prevent injuries. The coalitions worked closely with law enforcement officers, firefighters and paramedics, medical professionals, educators, parents, businesses, public policymakers, and, most importantly, adolescents, to reinforce teen driver safety. The coalitions provided services to over 1,800 children and parents through 19 teen safety educational events. The Department of Health and Senior Services (DHSS) held quarterly conference calls with the Safe Kids coalitions. DHSS hosted the Safe Kids Missouri Leadership Workshop for all coalitions to gain knowledge of evidence-based interventions and network with other coalitions. Coalition leaders received information from the Brain Injury Association of Missouri, the Zero Suicide Prevention Program, Charlie’s House, Opioid PreventEd, and Catholic Charities of Central and Northern Missouri.

The Injury Prevention Program continued to build program capacity and partnered with current Safe Kids Coalitions to implement evidence-based programs, identify gaps in current services, and increase the number of partners supporting injury prevention programs. The Injury Prevention Program continued to strengthen collaboration with TEL-LINK and Text4baby to provide information and resources about car seats and seat belts. Family engagement continued to be a priority for Safe Kids coalitions and DHSS provided technical assistance to further that effort. The coalitions continued to incorporate families into coalition activities.

The Injury Prevention program coordinates the Missouri Injury and Violence Prevention Advisory Committee (MIVPAC), which provides expertise and guidance to the Injury Prevention Program and establishes injury prevention as a state priority. The committee consists of representatives from state, local and regional government agencies, non-government bodies, and consumers. The committee’s goal is to reduce the morbidity and mortality of children (0 -19 years old) due to injury and violence. MIVPAC completed and implemented its strategic plan. The plan includes strategies such as: utilizing the MIVPAC website to share and promote injury prevention initiatives, maintaining an updated list of MIVPAC members, sharing and promoting social media messages developed by MIVPAC members, providing monthly communication to committee members, partners, and families, promoting injury prevention events, and gathering data on intentional and unintentional injury.

The Adolescent Health Program (AHP) continued to implement evidence-based teen pregnancy prevention and positive youth development programs across Missouri’s highest-need areas in conjunction with the Personal Responsibility and Education Program (PREP) Grant and the Sexual Risk Avoidance Education (SRAE) Grant. These programs (Teen Outreach Program (TOP), and Making Proud Choices) continued to improve not only the knowledge of Missouri’s youth, but also their self-efficacy, health outcomes, and school outcomes.

The AHP continued working towards having adolescent input. The AHP team added an adolescent/youth voice in the Missouri Council for Adolescent and School Health (CASH). The AHP now requires Youth Advisory Councils (YAC) or youth advisors as part of all teen pregnancy prevention contracts. Each contractor was required to either start a YAC, add youth to an existing council, or hire youth as advisors to their agency this year. AHP continued to provide technical assistance and resources to contractors to grow skills related to developing YACs and youth advisors, as well as the youth/adult relationship education needed over the next few years. Columbia/Boone County Public Health & Human Services hired several youth community health workers (CHW). They have been invaluable assets to the program and the department. The youth CHWs have: 1) attended TOP club meetings and participated in ongoing discussions, 2) given input on youth-oriented campaigns, 3) helped revamp materials to better reach their peers, 4) highlighted needs that otherwise would have been overlooked, and 5) raised awareness on mental health after receiving the Youth Mental Health First Aid training. Moreover, other areas of the department have asked to utilize the youth CHWs, including in the community health assessment process. As a result of this work, one of the youth CHWs presented at the 2023 AMCHP conference.

The MCH Services Program continued to contract with the 19 LPHAs that identified the reduction of intentional and unintentional injuries among adolescents as a Priority Health Issue in their FFY 2022-2026 MCH work plans. The program continued to support LPHA efforts to prevent and reduce injury related to:

• Fire and water safety

Hickory County Health Department increased provider and individual knowledge by hosting a Fall Family Fun Festival (Picture below). The health department collaborated with community stakeholders to provide education and resources on various child health and safety priority issues including water safety. As a result, 25 women of childbearing age, and 45 children and adolescents increased their knowledge on water safety as evidenced by a verbal survey.

• Motor vehicle safety/accidents
• Child abuse and neglect
  • The MCH Services Program collaborated with MOKidsFirst and offered Darkness to Light’s Stewards of Children training to all LPHAs. Through real people and real stories, the training showed adults how to protect children. The framework of the training is built off the foundation of The 5 Steps of Protecting Children. 58 adults attended the training and reported increase in awareness and knowledge.
• Violence
  • The Kansas City (KC) Health Department provided advocacy training and support services to 57 parents through the Parent Leadership Training Institute. During the institute, a staff member at the Kansa City Health Department created a children’s book titled “Just Like Me.” In addition, the health department helped eight youth serving organizations incorporate evidence-based education and trained 14 youth serving organizations to implement the violence prevention curricula and KC Blueprint strategies. They also subcontracted with youth ambassadors to establish a social media presence on Facebook, Instagram, Tik-Tok, and Snapchat. The youths created and shared violence prevention messages that reached about 15,968 youths.
• Lead poisoning

Young Children Specific

The Child Care Health Consultation (CCHC) Program provided consultations and trainings for child care providers and health promotion for children in child care on a variety of injury prevention topics to promote safe child care environments, encourage healthy and safe behaviors, and prevent injuries among children. Consultations for child care providers assisted in the assessment of healthy and safe environments using evidence-based tools, development and review of policies, implementation of health and safety procedures, promoting active supervision, and utilizing safe and developmentally appropriate equipment in the indoor and outdoor environments of the child care facility. Training and consultation topics included abuse and neglect, mandated reporting, shaken baby syndrome, emergency preparedness, CPR/First Aid, medication administration, poisoning prevention, lead poisoning prevention, fire safety, gun safety, Halloween safety, injury prevention, motor vehicle and car seat safety, outdoor and playground safety, safe sleep, stranger safety, water safety, and sun safety. The CCHC Program provided a total of 1,638.5 hours of consultation and training for child care providers, and 346 hours of health promotion presentations for children in child care on safety and injury prevention. CCHC Program services continued to provide children in child care with meaningful experiences regarding health and safety and injury prevention that can be implemented in their lives outside the child care facility, and provided educational materials for their parents/guardians. All CCHC program services continued to be inclusive and promote family involvement in all services. The capacity for LPHAs to provide CCHC Program services was severely impacted by the COVID-19 pandemic.

Safe Kids Coalitions addressed priorities including child passenger safety, bicycle safety, crib safety, TV and furniture tip-over, pedestrian safety, poisoning, farm safety, and other areas based on community needs. The coalitions offered a broad array of activities including: providing cribs and car seats, offering parent education on child safety, conducting car seat checks, certification training for child passenger safety technicians (CPST), conducting media campaigns with prevention messages, and working with policymakers to address gaps in policies that could prevent injuries. The coalitions provided services to over 68,500 children and parents through over 800 educational events. Over 2,600 child safety seats were distributed, and over 3,000 car seat checks were conducted.

The DHSS Injury Prevention Program Manager represented District 5 (Central District) on the Missouri Child Passenger Safety Advisory Committee. Responsibilities included: maintaining regular contact with all CPSTs/inspection stations in the district, being available to sign off on seats for CPST/instructor recertification, mentoring new instructors, being the main point of contact when the Missouri Department of Transportation orders car seats for the area inspection stations, recruiting new inspection stations, and attending CPS Advisory Committee meetings. The MCH Director, Injury Prevention Program Manager, MCH Program Manager, and MCH District Nurse Consultants continued to partner with safety advocates to prevent intentional and unintentional injuries. They served on statewide and regional safety coalitions such as the Missouri Coalition for Roadway Safety state and regional coalitions and the Occupant Safety Subcommittee. Additionally, the MCH Director continued to participate on the Missouri Brain Injury Advisory Council, MIVPAC, and CASH.

The Childhood Lead Poisoning Prevention Program (CLPPP) continued to provide education and support to LPHAs, health care providers, and families of children under the age of six years old through identification, reduction and remediation of potential lead hazards. To further support messaging on child-related topics, the CLPPP focused on building relationships with other child health and wellness focused agencies through the creation of a Lead Advisory Committee. The CLPPP continued to promote childhood blood lead screening and testing, and efforts led to 63,091 blood lead tests reported for children under six years of age, an increase of 10,636 from FFY 2021. In FFY 2022, five children were reported to have undergone chelation therapy.

SPM #2 Suicide and Self-Harm – Promote Protective Factors for Youth and Families

It is normal for children and adolescents to experience some emotional distress as they develop and mature. However, studies such as the Adverse Childhood Experiences (ACEs) show that the toxic stress and the challenges young people face can have a significant impact on their long-term health. According to the 2021 Youth Risk Behavior Surveillance Survey (YRBSS), 32.5% of high school students in Missouri reported being sad or hopeless almost every day for two or more weeks in a row, causing them to withdraw from activities in the last 12 months. According to the National Survey of Children’s Health (NSCH) 2020-2021 data, 44.5% of Missouri children between 3-17 years old who had a mental/behavioral condition received treatment or counseling from a mental health professional in the last 12 months compared to 51.6% nationally. Among children that were publicly insured only, 41.2% received treatment or counseling, which is lower in comparison to 51.8% nationally. There were comparable percentages among children with private health insurance only, with 48.6% in Missouri and 53.1% nationally. Missouri college graduate households had a greater percentage of children 3-17 years old who received treatment or counseling (56.5%) than any educational attainment group for which there is data at both the state and national level. Among children from households with some college or technical school, 35.8% received treatment or counseling compared to 49.3% at the national level. Among Non-Hispanic White children with a mental/behavioral condition, 48.2% of Missouri children received treatment or counseling, which was slightly lower than the 53.1% nationally. For Missouri children with a mental/behavioral condition in a household with two, currently married parents, fewer children (43.9%) received services compared to nationwide (51.8%). The proportion of children (6-11 years) that received treatment or counseling was similar in Missouri (45.4%) and nationally (45.7%). Among 12-17 year olds, a lower percentage of Missouri (48.8%) children received counseling or treatment than nationwide (58.1%). Partners across Missouri worked to improve protective factors, access to mental health treatment, and the quality of support services and staff working with youth who have experienced trauma and multiple ACES.

The School Health Program (SHP) continued to partner with the Department of Mental Health (DMH), Department of Social Services (DSS), Department of Elementary and Secondary Education (DESE), and other organizations to identify training and resources and to facilitate a connection with school districts across Missouri. The SHP supported professional development for school health staff to implement trauma informed approaches and best practice recommendations for creating safe spaces for all students to attend school, including LGBTQ and other at-risk students. One of the webinar topics was “COVID-19, Trauma and How to Help the Student Cope.” (Picture below shows a slide from the presentation.) In addition, they shared an evidence-based brief on components of a trauma informed school health office. The SHP staff also shared simple posters on calming strategies, making positive connections with students, and mental wellness. Feedback from school nurses showed they value the tools, as they are quick and easy to implement. 

Through the Show Me School Based Health Alliance partnership, the SHP supported school based clinics to provide services including mental and behavioral health on school campuses or near schools. These school based clinic services are effective in providing comprehensive care especially when they are established in partnership with a Federally Qualified Health Center (FQHC).

The Adolescent Health Program (AHP) continued to focus on Social-Emotional Learning (SEL), protective factors and Positive Youth Development (PYD) through implementing TOP Clubs across Missouri. TOP participants build connectedness with their facilitators, schools and communities. These implementation sites continue to be inclusive, safe spaces with caring, responsive and knowledgeable facilitators. More than 95% participants reported feeling physically safe at TOP and that their facilitators support and care about them. In the 2021-2022 academic year, over 600 youth from 30 communities participated in TOP. As part of the program, the youth gave back to their communities and completed nearly 13,000 hours of community service learning (CSL). CSL options are chosen by the youth and vary from community to community, but some choices have included working at the foodbank, volunteering with youth or elderly, teacher appreciation, food drives, or just spreading kindness (Marquand Zion picture below).

The AHP piloted a new program with long-time partner, Wyman, Inc. This program, Teen Connection Project (TCP), focuses on building communication skills, SEL, and developing connections between high school aged youth and the peers and adults in their lives. These protective factors meld well with achieving the goals of Missouri’s Title V Block Grant. Wyman has piloted this program, including a rigorous evaluation, in parts of Missouri and across the country. With external funding, three schools piloted TCP and 55 youth completed the program. 

The AHP continued to work on adult/child relationships through the Connect with Me campaign. This campaign encourages parents/guardians, teachers, coaches, and all adults to have stronger relationships and deeper conversations with the youth they care about. Topics covered in the conversation starter cards for this campaign include trauma, healthy body image, and taking action. In FFY22, the cards included a mental health and diversity section.  The AHP continued working to expand this campaign to include a phone app, which will expand the programs outreach capabilities and the variety of topics available. The app will be launched in 2023.

Missouri is part of the National Network of State Adolescent Health Coordinators (NNSAHC), a community and resource to communicate ideas, build knowledge, and share expertise. Missouri’s SAHC served as the NNSAHC President through the spring of 2023. The SAHC reached out to this network to gather ideas on addressing adolescent mental health and suicide prevention, and the idea for a mental health toolkit was sparked.

DHSS participated in the second cohort of the Children’s Safety Networks Child Safety Learning Collaborative (CSLC) to reduce fatal and serious injuries among infants, children, and adolescents. The CSLC concluded in October 2021. The CSLC strategy team, which included the MCH Director, the Injury Prevention Program Manager, the AHP Manager, and the Manager of Trauma-Informed Treatment at the DMH, continued to collaborate to improve Missouri’s efforts to address suicide and self-harm. The Injury Prevention Program, in partnership with the AHP, are piloting the Mental Health Crisis Toolkit for Missouri families. The toolkit provides comprehensive guidance on helping youth experiencing a mental health crisis. DHSS distributed more than 900 toolkits to 14 school districts. These schools/districts will continue to provide the toolkit to parents and guardians of youth that the school personnel feel may be experiencing a mental health crisis. School personnel and families are being asked to complete a survey requesting feedback on the effectiveness of the toolkit, its components, as well as any additions that would be helpful.

The MCH Services Program supported LPHAs and/or community partner efforts to provide education, screening, and referral for adolescent mental health needs. The program continued to contract with the 30 LPHAs that identified prevention and reduction of suicide and/or self-harm among their local adolescent populations as a Priority Health Issue in their FFY 2022-2026 MCH work plans. These efforts include, but are not limited to, preventing substance use, preventing and reducing the impact of toxic stress, and building resiliency. Examples of LPHA contract activities included:

• The City of Independence, Montgomery, Gasconade, Pettis, Nodaway, and Ray County Health Departments increased provider and community education by increasing the number of certified Youth Mental Health and First Aid instructors within their counties. This has increased trainings offered to parents, grandparents, school staff, childcare and medical providers and anyone else who provides services to adolescents and their families.
• Montgomery County Health Department has increased the number of children and women of childbearing age that receive mental health resources and counseling services by partnering with Missouri Girls Town Foundation to provide free counselling sessions once a week at the health Department. Ninety-eight free counseling sessions were provided to youth and women of childbearing age. 

• Jefferson County Health Department increased community and individual knowledge in regards to mental health by creating the Jefferson County Teen Coalition Group. The group meets to discuss health and wellness issues they observe in their schools and develop an advocacy plan to address them. The health department uses various social media platforms and digital engagement to reach the community. Lastly, the health department implemented the Healthy Choices Program, a five-week teen wellness program focusing on all aspects of wellness (physical, emotional, and resiliency). This program included many aspects of learning how to make healthy decisions. Topics highlighted included: identifying common stressors in daily life and finding coping skills to deal with stressors, physical activity options, how to shop healthy, how to read nutrition labels, and more. This was implemented in one school district in collaboration with the PE teacher and reached the entire 7th grade class.
• The City of Independence and Christian County Health Departments increased community awareness of mental health by developing mental wellness messaging. The City of Independence placed two billboards within the county, while Christian County used a digital billboard that rotates several mental health messages.
• Andrew County Health Department increased and strengthened collaboration across youth serving agencies, specifically by collaborating with schools, law enforcement, and first responders to implement the Handle with Care Program. This program enables law enforcement and first responders to notify schools that a child may have been exposed to trauma and to handle them with care. Trauma may include anytime a child is present when: a household member is arrested, a search warrant is served in their residence, a drug/alcohol overdose or death/suicide of a family member occurs, and/or when a child experiences incidents such as domestic or community violence, physical and/or sexual abuse, house fires, and car wrecks.

The Child Care Consultation (CCHC) Program provided 230.25 hours of trainings and consultations to help child care providers identify children with mental health needs, promote evidence based protective factors for youth and families, and address mental illness in children in child care prior to reaching adolescence. Training topics for child care providers that focused on mental health and wellness of children included trauma-informed care, resilience, identification of depression and anxiety in preschool aged children, divorce, grief, separation anxiety, social and emotional learning and development, positive behavior support, positive discipline, developing healthy relationships, and substance abuse awareness. Training topics for child care providers that focused on staff mental health and wellness included suicide prevention and awareness, trauma-informed care, resilience, self-care, stress management, the relationship between physical health and mental health, substance use awareness and prevention, and de-escalation in times of crisis. Consultations with child care providers promoted the implementation of policies and procedures that optimize the mental health of staff and children, and provided referrals to outside resources. As a result of these trainings and consultations, child care providers have increased access to information and resources that promote early identification of mental health needs and protective factors that can be implemented for children, child care providers, and families.

The CCHC Program also provided 111.25 hours of health promotion of mental health among children in child care. Topics included bullying, emotional expression and regulation, anger management, sleep, screen time, empathy, self-esteem, celebrating differences and diversity, and living tobacco and drug free. As a result, children in child care were provided with meaningful experiences and coping strategies to benefit their lives inside and outside of the child care setting to enhance their ability to promote their own mental health and the mental health of their peers. CCHC Program services also continued to provide evidence-based mental health resources for families of children in child care, and encouraged family participation during all CCHC Program services. The capacity for LPHAs to provide CCHC Program services was severely impacted by the COVID-19 pandemic.