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. School-based health services serve as the principal vehicle for promotion of adolescent health services. 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 serve 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 a total student population of approximately 68,569, which is about 13% of Connecticut’s overall student population. Enrollment in these clinics is approximately 53% of the population or 36,555 students.  The number of visits to the SBHCs totaled 128,365 and the number of unduplicated students served was approximately 22,000. Approximately 22,000 students received one or more service visit per year (approximately 32% of the student population). A total of 18,017 students made 57,485 medical visits, an average of 3.2 visits per student. A total of 4,091 students made a total of 63,556 mental/behavioral health visits, an average of 15.5 visits per student. A total of 4,213 students made 7,324 dental visits, an average of 1.7 visits per student.

 

 

Source: 2021-2022 SBHC Year End Report (Q10) Number Unduplicated SBHC Students by Age-group that had at least one Medical, Mental Health or Dental Visit.

 

Source: 2022-2023 SBHC Period 1 Report (Q9) What is your school's population?

 

Source: SBHC Year-end reports. *2020-2021 data were reduced due to COVID restrictions.

 

Source: SBHC Year-end reports. *2020-2021 data were reduced due to COVID restrictions.

 

Source: SBHC Year-end reports. *2020-2021 data were reduced due to COVID restrictions.

 

Source: SBHC Year-end reports.

 

77% of clients have public or private insurance. DPH funded SBHCs that provided medical and behavioral health services bill and may be reimbursed for services.

 

During the 2021-2022 school year 33 mental health screening tools were used.  There were 4,517 physicals where a mental health screener was used.  Of those students who received physicals 779 were found to be at risk and 578 students were referred to SBHC mental health services. 10,887 mental health screeners were done at medical visits at the SBHCs.  Of those 1,262 students were found at risk and 617 students were referred to SBHC mental health services. There were 1,867 students who completed an ACEs screener.  Of these students 280 were found at risk and 179 students were referred for follow-up.

 

Most trends, successes, and challenges faced by the SBHCs in 2021-2022 were a direct effect of the COVID-19 pandemic. The increase in need for mental health services that the Country is seeing is very much reflected in the SBHCs. The majority of SBHCs saw an increased need in mental health services, primarily due to increased anxiety, depression, suicidal ideation, low self-esteem, behavioral issues, peer conflicts, hyperactivity, and difficulty with social skills. Along with other mental and behavioral issues that have been seen are an increase in somatic symptoms such as eating disorders, obesity, stomach aches, headaches and other physical symptoms that have increased absenteeism.

 

There was a significant increase in screening for mental and behavioral health issues which lead to more referrals to the mental health providers. There has been a decrease in the stigma associated with seeking mental health support, leading to more referrals done by other students and teachers. Many schools are still offering telehealth services for their patients to maximize the clinical reach of the staff. Despite this, the SBHCs have had a hard time meeting the demand resulting in waitlists.  Hiring mental health and medical staff to keep up with the demand has been challenging.

 

SBHCs expressed high absenteeism as a problem this school year. There were a few reasons for this including COVID outbreaks/quarantine and unusually high rates of other seasonal viruses/flu and stomatic illnesses. SBHCs struggled with the ever-changing rules for how to manage cases and/or outbreaks of COVID. Along with students, teachers also experienced high absenteeism rates.

 

Several schools experienced a large influx of immigrants, increasing the number of physicals and immunizations that needed to be done at the SBHC. This was in addition to the clinics trying to catch up on immunizations due to students missing appointments during the pandemic. Increase in vaccinations for flu and COVID-19 was considered a success. Many SBHCs did note an increase in the communication/collaboration with the school nurse and there was more support given to the SBHCs from school administration and teachers.

 

A statewide virtual school-based health conference sponsored by the Connecticut Association of School Based Health Centers (CASBHC) was held in the fall of 2022. The event “School Based Health Centers – Caring for the Whole Child”, was attended in person 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, Dr. Kerry Magro, an award winning autistic professional speaker and best-selling author, shared his story in his presentation, “Defining Special Needs: From Nonspeaking to Professional Speaker”. Other breakout workshop topics included: care for refugee and immigrant children, suicide prevention, self- care, dental care, violence, diabetes, misdiagnoses, emerging school infections, cis het clients, and Gizmo’s Pawesome guide to mental health.

 

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 and it was accepted as an Emerging Practice in 2022. 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. MCH Staff worked with our contractor to print 1,200 each in English and Spanish of the Gizmo books. We distributed Gizmo books to families through our Care Coordination sites. 

 

Suicide prevention, intervention, and response initiatives geared to youth and young adults ages 10 to 24 years old was a primary focus for DPH between July 2021 and June 2022. Injury and Violence Prevention and Surveillance staff regularly participated in monthly 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).  DPH Injury and Violence Prevention and Surveillance also prepared for the suicide crisis line transition from the 1-800 national suicide prevention lifeline to the three-digit 9-8-8. DPH worked with the United Way of CT to develop new video PSAs with updated content and print messaging and distributed it in venues such as social media sites like Facebook, Instagram, and Twitter. They also distributed these new images and other CT-SAB materials to youth and social services agencies and college campuses around the state. Title V distributes 1 Word suicide prevention awareness/9-8-8 campaign materials throughout all programs.

 

DPH continued to partner with CT Children’s to promote Educating Practices training on suicide prevention for pediatric providers.

 

The CT statewide Suicide Prevention Plan 2020-2025 was used as a framework to align surveillance and prevention strategies with the CT Comprehensive Suicide Prevention (CSP) Project awarded to DPH by the CDC in August 2020. Two of the disproportionately affected populations (DAP) of focus for the grant project are 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, three local health departments or districts (LHDs) and the corresponding Regional Behavioral Health Action organizations in their regions have started to implement and promote evidence-based suicide prevention and intervention strategies in their communities with a focus on the DAPS, especially those in the LGBTQ+ community and among Hispanic teen girls. In February 2022, the three LHDs began planning their strategies to implement and promote community-based initiatives, including among school-based children. 

 

New legislation (Section 1 of Public Act 21-46) in Connecticut went into effect July 2021 stating that local health departments and districts in Connecticut shall be trained in QPR Gatekeeper training by July 2022. Per the statute, LHD Directors are to identify eligible municipal employees for QPR training, including school personnel. On behalf of the CT Department of Children and Families, Wheeler Clinic held train the trainer sessions in Spring 2022 for LHDs to train selected LHD employees.       

 

The Suicide Crisis phone and text line was posted on additional high suicide risk locations (bridges, overpasses, railways, and multi-level parking garages). In the two years prior to July 2021, the Lethal Means subcommittee of the CT-SAB and CT Department of Transportation (DOT) have been communicating with over 10 communities’ Town Manager, Elected Official, Director of Health, and Local Prevention Council to install signs on bridges in their cities. 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.

 

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.  Although postponed in 2020, these trainings started up again late September 2021. Wheeler Clinic converted their in-person trainings to a virtual platform option.

 

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 85% 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. * 2020 provisional population was used to calculate the rates for 2020, 2021 and 2022 data 

 

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. These data also represent the first YRBS data collected since the start of the COVID-19 pandemic. Although most schools had returned to in-person instruction by that time, the time that some students spent out of school during the previous 12-month period likely impacted the health risk behavior estimates. Disruptions in daily life also remained common during the time of collection. The impact on health and risk behavior estimates due to the pandemic, remote learning, and shift to the fall semester was observed in CSHS 2021 results, and data need to be interpreted with caution when compared with previous years. With supplemental funding from CDC, and panel of Adverse Childhood Experiences (ACEs) related questions were collected in the 2021 CSHS.  CSHS 2021 results were disseminated in winter 2022, including annual estimates with 10-year trend report. Reports are 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 continued 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, Office of the Child Advocate 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.

 

The results from the 2019 CSHS estimated that about 44,000 Connecticut high school students used at least one tobacco product, including e-cigarettes, which are the most common type of tobacco products used by high school students in CT.  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. 

 

The 2021 CSHS could not replicate the weighted frequency for the reference of 44,000 students and the estimates and difficult to interpret because the survey was completed in the Fall which typically shows lower prevalence of risky behaviors. In addition, CSHS asks students about their behavior in the prior 12 months. In the fall of 2021 that time period would have included when COVID-19 precautions limited opportunities for social interaction both at school and extracurricular. The decreased prevalence may reflect the fact of limited access to tobacco products when students were remote learning at home.  The 2021 CSHS indicated that 10.6% of high school youth reported they had used electronic vapor products (EVPs), including e-cigarettes, vapes, vape pens, e-cigars, e-hookahs, hookah pens, and mods, such as JUUL, SMOK, Suorin, Vuse, and blu, on at least 1 day during the past 30 days (i.e., current EVP use). This represents approximately 15,600 students.  The drop in 2021 likely reflects significant factors unique to the 2021 CSHS administration. 

 

ACEs-related data from the 2021 CSHS have been analyzed and presented to the Preventing Adverse Childhood Experiences (PACE) Workgroup and included in the CDC annual report for the PACE Data-to-Action grant. The CSHS will be used to satisfy the surveillance requirements of Public Act 21-1, which will legalize adult-use cannabis, collecting data on youth cannabis use and abuse, impaired driving, attitudes, and perception of harm. The CSHS will also be used to satisfy Public Act 22-87, with data collection on adult sexual misconduct to a child.  This public act also requires school participation in the CSHS which will improve overall response rates and the ability to detect health disparities across all health-related and risk behavior topics. 

 

Source: 2021 CSHS/YRBS 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 CSHS/YRBS 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 CSHS/YRBS 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 2021 and prepared results for release in 2022.  2021 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 2021 BRFSS were released in late 2022 and posted to the DPH CT BRFSS web page which can be found at www.ct.gov/dph/BRFSS.  

 

Source: 2021 BRFSS and Trends.