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

Among Missouri adolescents, 10 to 19 years old, non-fatal injury hospitalizations were 250.2 per 100,000 in 2018 compared to 274.9 per 100,000 in 2016. In 2017, the main causes of injury deaths among 10-19 year olds were motor vehicle accidents, homicide by firearms, and suicide by discharge of firearms. The leading causes of unintentional injury deaths in this age group were motor vehicle accidents, accidental poisoning, and drowning. Suicide is a persistent and increasing public health issue in Missouri. In 2017, the rate of suicide in Missouri was 24% higher than the national rate. According to 2018 Missouri Vital Statistics data, suicide remains the tenth leading cause of death for all ages among Missouri residents and the second leading cause of death among adolescents 10-19 years old. Additionally, the suicide rate among Missouri adolescents increased 56.0% from 2009 to 2019 provisional data (6.5 per 100,000 to 7.8 per 100,000). Comparatively, the national rate increased 58.0% from 2009 to 2018 (4.5 per 100,000 to 7.1 per 100,000). Youth suicide rates are higher in rural counties than more urban areas, presenting challenges for the provision of mental health services, as rural counties typically have fewer mental health resources available than do urban counties. Multiple strategies in Missouri were implemented to address unintentional and intentional injury prevention.

Injury Prevention

The Injury Prevention Program serves as the state lead for Safe Kids Worldwide and provides funding for nine Safe Kids coalitions covering 54 counties in Missouri. The coalitions address topics such as teen driver safety, seat belt safety, pedestrian safety and other areas based on community needs. The coalitions offered a broad array of activities to achieve the performance goal, which included providing teen driver safety classes and hosting educational events, and conducting media campaigns with prevention messages. In FFY19 these coalitions provided services to over 20,746 children and parents through over 122 teen safety educational events.

Safe Kids coalitions help promote several traffic safety and driving courses provided around the state. First Impact is a program of ThinkFirst Missouri, a trauma prevention program of the University of Missouri School of Medicine, Department of Physical Medicine and Rehabilitation. The 90-minute evidence-based traffic safety program aims to reduce new driver crashes and resulting injuries and fatalities, by increasing parental awareness and enforcement of Missouri’s GDL law. First Impact provides the tools parents need to monitor, coach, and support their new teen driver. Trained law enforcement officers and facilitators deliver the program, which includes presenting key facts and proven strategies to help parents lower their teens’ crash risk by utilizing the Missouri GDL law. TRACTION, Teens Taking Action to Prevent Traffic Crashes is a youth traffic safety leadership training program. The program includes a three-day conference to promote safe driving habits for youth and provide students and their adult advisors with the motivation, information, skills, and support necessary to develop a plan to address unsafe driving habits. The conference includes six workshops, docudrama training, team building, leadership training, and action planning. The Alliance of Southwest Missouri offers the National Safety Council’s Defensive Driving Course, a highly interactive course that helps young adults under the age of 25 take greater responsibility for their driving by focusing on behavior, judgement, and decision-making. This is a 4-hour, 6-hour or 8-hour classroom course that teaches young drivers about consequences to their driving behavior and provides the tools for making positive choices.

Promote General/Traffic Safety

A total of 88 LPHAs reported providing general safety education, 84 reported providing education on proper seat belt usage, 49 reported providing education on impaired/distracted driving, and 29 reported engaging in activities to promote safe use of ATVs. Traffic safety highlights included:

• Gasconade County Health Department (GCHD) partnered with the ThinkFirst Missouri program to provide education to area schools and parents related to safe driving, participated in many community events to promote the MoDOT Buckle Up Phone Down campaign; at the Gasconade County Fair, GCHD partnered with Missouri State Highway Patrol who provided the “Seat Belt Convincer” exhibit to demonstrate to attendees the importance of seat belt use.
• Macon County Health Department established a Teen Safe Driving Coalition, partnering with multiple multi-disciplinary organizations and developed a teen safe driving proclamation for Macon County in which all town mayors/officials pledged their commitment to endorse. As a result of these efforts, the county’s largest public school district agreed to participate in MoDOT’s It Only Takes One campaign, a competition between Missouri high schools that gives student groups the opportunity to educate teens, parents, and their community about the dangers teens face while driving.
• Vernon County Health Department conducted its first round of quarterly seat belt checks at four area high schools; a total of 342 students were surveyed, of which 79% were wearing seat belts. Every surveyed student received Smarties or Dum Dum suckers accordingly, each of which included one of a variety of seat belt safety statistic messages attached.
• Webster County Health Unit (WCHU) staff presented a Distracted Driving Course, which featured both classroom and hands on education, to 259 adolescents in the county. WCHU also developed a Safe Driving Resource Packet, which included information on distracted/impaired driving and seat belt safety as it relates to injury and fatality crashes. The packet was provided to every new permit and license holder who participated in the distracted driving course.

Prevent Unintentional Injury

A total of 85 LPHAs reported addressing home and school safety and 22 LPHAs reported addressing farm safety. Examples of this work included:

• Lewis County Health Department continued to participate in Farm Safety Day, an annual event held for fifth grade students in collaboration with MU Extension and many other community partners to provide safety information on a variety of topics including lawn mower/weed eater, animal handling, grain bin, electricity, water, and firearms.
• Cooper County Public Health Center presented education on head injury reduction during sporting activities and signs/symptoms of concussions to sixth grade students from all area schools, local athletic directors, coaches, YMCA director, and parents.
• Bates County Health Department supported a local bicycle helmet program, and provided education on a variety of topics including water safety, fire safety, farm safety, seat belt safety, prescription drug safety, and disaster preparedness.

Violence Prevention

DHSS intended to partner with the Department of Mental Health (DMH) to provide Signs of Suicide (SOS) training to schools, but due to changes in curriculum format (paper to online), this was not possible. Instead, DHSS researched new partnership opportunities and projects for addressing adolescent suicide prevention.

DHSS continues to sponsor and support professional development opportunities on mental health to those working with Missouri’s adolescent population. Lindsey Hammond, the Recovery and Resiliency Manager with Optum, provided evidence-based QPR Suicide Gatekeeper Training at the Missouri Coordinated School Health Conference (MCSHC) held in December 2018. The 1-hour training uses innovative, practical, and proven strategies to help participants learn three steps for suicide prevention: QPR (question, persuade, and refer). Participants earned a certification if the 1-hour training was completed. Other mental health topics at MCSHC included abuse and neglect, trauma awareness, and resiliency. 

In FY19, DHSS joined the Missouri Suicide Prevention Network (MSPN), who leads statewide suicide prevention efforts. MSPN’s goal is to coordinate and develop implementation of the Missouri Suicide Prevention Plan. MSPN members provided recommendations and advisement to support MSPN’s overall mission and work to eliminate the stigma of suicide, educate the community about suicide, and ultimately reduce the rate of suicide in Missouri.

The Adolescent Health Program (AHP) continued to participate on the interpersonal violence prevention workgroup, focusing on Social-Emotional Learning (SEL) through the training and expansion of the Teen Outreach Program (TOP) Clubs across Missouri. The AHP uses both Maternal Child Health (MCH) and Teen Pregnancy Prevention (TPP) grant funding to focus on positive youth development programs, such as TOP. TOP is a nine month, mostly after school, evidence-based intervention (EBI) that teaches youth healthy behaviors, goal setting, self-efficacy, and community engagement. AHP worked with the copyright holders of TOP, Wyman, Inc., to provide a range of professional development seminars to contractors and partners. These seminars, held around the state, educated those working with youth on how to help “youth to thrive” and emphasize SEL in their work. The goals of SEL are more likely to be achieved when adults who work with youth understand how to incorporate and model SEL approaches. After the success of these trainings during FFY2018, the AHP targeted outreach for additional trainings to domestic violence agencies and local public health agencies (LPHAs) to improve their youth outreach and programming. These seminars, which were provided to around 280 participants, encouraged both adults and agencies to include the protective factors and safe spaces required to encourage all youth to become successful adults. Staff involved with these partnerships were approved to present at two different national conferences in FFY 2020.

The AHP continued to refine and develop training on Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) youth. These resources have been presented at the MCSHC and are available for presentations at public and private partner meetings across the state.

The Section for Women’s Health currently supports the implementation of Shifting Boundaries and the Green Dot Violence Prevention Strategy with middle school and college populations through contracts with universities and non-profit organizations. These contracts are funded through the Rape Prevention and Education Grant and the Preventive Health and Health Services Block Grant through the Centers for Disease Control and Prevention. Shifting Boundaries seeks to change the built environment of the schools and school policies in order to reduce sexual violence, sexual harassment, and teen dating violence. The Green Dot strategy seeks to encourage active bystander behavior in order to reduce the rate of teen dating violence, domestic violence, sexual assault, rape, and stalking. Both are evidence-based curriculum. In FY19, the Section for Women’s Health supported seven middle schools and six colleges through these contracts.

Suicide/Violence/Substance Abuse Prevention

Multiple LPHAs targeted their efforts to address suicide, violence, and/or substance abuse prevention. In total, 49 LPHAs reported providing education, screening, and referral for adolescent suicide/self-harm; 34 reported providing mental health and counseling services and/or resources; 86 reported providing prescription drug abuse education, prevention, and intervention; 98 reported addressing child abuse and neglect; 54 reported addressing domestic violence; and 52 reported providing bullying prevention information and training. Highlights of this work included:

• Kansas City Health Department partnered with AIM4Peace Violence Prevention Program, a public health approach to reduce shootings and homicides and reverse the violence epidemic in Kansas City; the program focuses on neighborhood factors that most often contribute to violence and uses education and the sharing of real life experiences to those considered to be at highest risk of committing offenses about the effects violence and trauma can have on families. The partnership utilizes the AIM4Peace Life Skills Learning Program to offer community and school-based courses to prevent school delinquency and drop-outs, teach life skills (grades fifth through twelfth), educate about the dangers of gangs and/or street organizations, and provide personal development. 
• Ralls County Health Department provided education on suicide risks, signs of suicide, and mental health resources at several events including the local Teen Health Fair, Back to School Fair, and Red Ribbon Week.
• St. Louis City Department of Health (SLCDOH) participated with St. Louis Violence Prevention Commission to reduce crime by promoting and advocating for coordinated, well-resourced policies and supporting systems and interventions among area governments and agencies that service individuals and families most at risk of violent crime. SLCDOH facilitated Youth Violence Prevention Partnership (YVPP), a multi-sector collaborative that supports the public health approach to youth violence reduction in St. Louis; YVPP leads the Safe and Thriving Communities grant which developed a Community Safety Dashboard, a tool to support more informed decisions regarding the safety and well-being of St. Louisans, especially youth; it takes a holistic view of the community, including crime statistics along with data on community conditions and social determinants that relate to violence.
• Washington County Health Department (WCHD) established the Drug Prevention Coalition and partnered with a community grantee to combat opioid use in Washington County. As a result of WCHD staff approaching and educating local school administrative staff, all four school districts within the county adopted “Too Good for Drugs” curriculum developed by Prevention Consultants of Missouri – prior to this implementation, the county’s school districts had been without a drug prevention education program for many years.
• Platte County Health Department (PCHD) collaborated with Northland Coalition and Tri-County Mental Health Services, Inc. to assist all four of the county’s high schools and two of its middle schools in the adoption and implementation of the Signs of Suicide (SOS) program and SOS Trusted Adult Trainings resulting in the screening of over 10,000 students in seventh through twelfth grades and the training of over 3,300 school staff and parents in the 2018-2019 school year. In partnership with key area community groups, PCHD assisted in the development and implementation of the Handle with Care initiative to improve communication between law enforcement and schools when a child is present at a violent/traumatic scene (e.g. domestic violence, homicide, substance abuse) in an effort to help mitigate the toxic stress imposed on the child.
• Lincoln County Health Department collaborated with DART (Drugs Alcohol Reduction Team) to host the first Teen Drug Summit in which health department staff presented on teen coping skills and resilience.
• Montgomery County Health Department’s MCH Coordinator, after surveying the community to find no existing programs that provide education on resiliency, helped facilitate a partnership between the local school districts and the counselor at Missouri Girls Town; the partnership helped secure a grant that now allows the counselor to provide therapy sessions to elementary, middle, and high school students’ onsite.
• City of St. Joseph Health Department (CSJHD) contacted area middle school parent-teacher associations and other parent groups to explore opportunities to educate parents about the stresses youth face today and how parents can help their adolescents cope safely and successfully; as a result of their outreach efforts, CSJHD staff were able to present information at school health fairs, project graduation planning meetings, two First Impact classes, and several community outreach events.

Please note that certain strategies in Missouri for NPM #7 impact both the child and adolescent populations. However, to avoid duplicative narrative, strategies were only listed in one or the other population domain. Please review the State Action Plan for Child Health in the application for additional information on programs and activities that addressed adolescent health.

SPM #4 Physical Activity – Percent of adolescents ages 12 through 17 who are physically active at least 60 minutes per day.

According to the NSCH 2017-2018 data, 12.2% of Missouri adolescents ages 12-17 years were physically active at least 60 minutes a day, every day compared to 17.5% nationally. Males (16.4%) were more likely to meet this benchmark of physical activity than females (7.7%). This mirrored the national divide between males (21.7%) and females (13.1%) regarding physical activity. Households with some college education had the highest percentage in Missouri with 18.1%*, followed by college graduate (10.7%) and high school graduate (7.1%)* households. Those with private insurance in Missouri (11.3%) were less commonly meeting this measure than their national counterparts (15.1%). A greater proportion of children in two-parent married families (13.3%) were physically active for an hour daily than in single parent families (10.8%)*. A greater proportion of non-Hispanic Black Missourians (15.5%)* engaged in physical activity for an hour a day than their non-Hispanic White counterparts (13.5%).

Missouri, in collaboration with both our internal and external partners, is working to increase the percentage of adolescents who are physically active for at least 60 minutes per day. Obesity is complex and environmental and behavioral factors play a critical role. Missouri works to create policies and environments that encourage health-promoting behaviors.

The School Health Program (SHP), with internal partners assisted seven priority school districts participating in a CDC grant project (1801) with the completion of Centers for Disease Control and Prevention’s (CDC) School Health Index (SHI) and the Rudd Center’s Wellsat- Wellness Policy assessment tools. Results from these assessments were used to develop improvement plans related to student health and physical education. SHP and other Bureau of Community Health and Wellness (BCHW) staff were available to provide technical assistance on implementing their plans. CDC 1801 grant project schools implementing the SHI in the 18-19 school year included: Bayless (1,715 students), Charleston (915), Jennings (2,512), Kennett 39 (1,969), Ritenour (6,461), Senath-Hornersville C-8 (741) and University City (2,703).

SHP presented a session at the 2018 Coordinated School Health Coalition conference (11/29/18) along with the Adolescent Health Program to provide participants with the updated School Health Advisory Guide and discuss establishing and/or reenergizing existing School Health Advisory Councils. The session emphasized the need for the council to be representative and inclusive of the building population, and engage a student voice in promoting student and staff wellness. SHP also partnered to work with Dr. Carol Cox at Truman State University in developing resources for infusing physical activity ‘brain breaks’ into the school day. These tools are posted on the Department of Elementary and Secondary Education website to provide optimal access by school staff users; and the resources were shared with school nurse leaders in the monthly listserv mailing of News You Can Use. The materials are also scheduled to be presented at the annual Lead School Nurse Collaborative later in 2019.

DHSS staff participated with Children’s Mercy, the University of Missouri Extension, and other agencies and organizations across the state on MOCAN (Missouri Council on Activity and Nutrition) to identify and implement best-practice programs in schools and communities to promote opportunities for physical activity and access to nutritious foods. DHSS staff also participated in the Coordinated School Health Coalition.

Please note that certain strategies in Missouri for SPM #4 impact both the child and adolescent populations. However, to avoid duplication of the narrative, strategies were only listed in one or the other population domain. Please review the State Action Plan for Child Health in the application for additional information on programs and activities that address adolescent health.

SPM #8 Mental Health – Percent of children ages 3-17 with problems requiring counseling who received mental health care.

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 us that toxic stress and challenges our young people face can have a drastic impact on their long-term health. In Missouri, according to the 2017 Youth Risk Behavior Survey (YRBS), 31.3% of youth in high school felt sad or hopeless almost every day for 2 weeks in the past year. Missouri is working to improve protective factors, access to mental health treatment, and quality of staff and support services working with youth who have experienced trauma and multiple ACES. Impacting these areas can make a large impact on future risky behaviors and chronic diseases.

According to the NSCH 2017-2018 data, 51.9% of Missouri children, between 3-17 years old, with a mental/behavioral condition received treatment or counseling compared with 50.3% nationally. Among those that received these mental health services, 57.4% were using Medicaid and 53.2% were privately insured in Missouri. This is greater than the national figures for private insurance (50.5%) and Medicaid recipients (50.9%). Missouri college graduate households had a greater percentage of those who received mental health care (57.4%)* than any educational attainment group nationally. In Missouri, the percentage of non-Hispanic Whites (53.2%)* who received mental health care was greater than it was nationally (52.0%). The percentage of two-parent married households in Missouri (60.5%) who received mental health care also exceeded the national percentage (49.9%). Nationally, children between 6-11 years old (46.5%) and 12-17 years old (56.5%) less frequently received mental health care than their Missouri counterparts (54.6%* and 55.9%* respectively).

According to the Association for Children’s Mental Health, mental health problems are common and often develop during childhood and adolescence, they are treatable, and early detection and intervention strategies work as they can help improve resilience and the ability to succeed in school & life. Some of the activities reported in this section will address both the child and adolescent populations.

Title V activities specifically related to young children include the Child Care Health Consultation (CCHC) Program, which offered13 hours of continuing education training for child care providers, 1 health promotions for children in child care, 7 hours of specialized consultation, and 3 technical consultations regarding well child care. By offering these services in FFY2019, the CCHC Program increased support of the mental health needs of children in the child care setting. 

All enrolled children from birth to kindergarten entry participating in the Genetics and Healthy Childhood (GHC) Home Visiting Programs are periodically screened throughout enrollment for social-emotional development using the Ages and Stages Questionnaire®: Social Emotional (ASQ:SE-3). All home visitors have been trained to provide assistance to caregivers in completing this screening, interpreting results to caregivers, providing recommended developmental activities for parents/children who score in the “monitoring” range and assisting families in accessing services as appropriate.

Mental health issues were an emerging concern across all population domains in Missouri, but especially among children and adolescents, and LPHAs shared the concerns and addressed them at the local level within their communities. The MCH Services Program contract supported LPHAs providing screening and referral for child and adolescent mental health needs. Of the 114 LPHAs, 34 reported providing child and adolescent mental health and/or counseling resources and services, and 104 reported having community partners who are able to provide mental health and/or counseling resources and services to children and adolescents. Several LPHAs collaborated with behavioral health partners and/or the University of Missouri Extension Services to participate in and/or provide Mental Health First Aid education. Christian County Health Department used MCH Services contract funding to help cover the salary expenses for a full-time Licensed Professional Counselor for their MCH population, with individuals seeking counseling for suicide contemplation, unwanted pregnancy, rape, child abuse, parenting guidance, and a variety of other topics. LPHA activities that addressed child and adolescent mental health needs included:

• The MCH Coordinator at Camden County Health Department initiated conversations with local school officials regarding mental health awareness programs, resulting in one local school district incorporating a suicide awareness session in their workshop for teachers held prior to the beginning of the 2019-2020 school year.
• Dallas County Health Department staff received certification in Question, Persuade, and Refer (QPR) Gatekeeper Training for suicide prevention.
• City of St. Joseph Health Department provided and coordinated multiple trainings on Youth Mental Health First Aid and ACEs to local law enforcement and school district staff.
• Platte County Health Department (PCHD) collaborated with Northland Coalition and Tri-County Mental Health Services to host both the annual Northland Prevention Conference and the annual Youth Leadership Summit. A total of 290 individuals from all sectors of the community attended the Northland Prevention Conference and were educated on resilience, adolescent mental health, youth marijuana and vape use, mindfulness, and more. The Youth Leadership Summit was attended by 259 students. Following the summit, students of Youth with Vision created Resilience PSAs which were played throughout the metro area on two radio stations and social media outlets targeting youth. First responders and decision makers were educated by PCHD staff and other community partners on the Handle with Care initiative, which was created upon the success of other initiatives across the country, to improve communication between law enforcement and schools in Clay, Platte, and Ray counties regarding students impacted by traumatic events away from school. PCHD held two Youth Mental Health First Aid workshops open to the community in which a total of 50 community members attended.
• As a result of the prevention efforts of PCHD and other key community partners, each school district within Platte County now has an intervention crisis team which includes the incorporation of annual training of Signs of Suicide (SOS) program and the Trusted Adult program for all middle and high school employees. All public school districts within Platte County now also dedicate a minimum of two hours of professional development monthly to increase social-emotional development and learning for staff and students.

The SHP continued work with partners at Missouri Department of Mental Health and University of Missouri to again sponsor a Learning Community for school nurses to work toward becoming trauma informed schools. This second cohort of 40 school nurses and health room aides convened for a 2-day learning workshop (Feb 21-22, 2019) to review the Missouri Model for Trauma Informed Schools and create plans to implement practices. SHP hosted monthly web meetings for continued discussion and progress reporting for one year. Participants’ feedback about the project demonstrated success in providing participants with resources that supported trauma-informed care for students and faculty, and addressed some of the challenges in behavior and mental health they encounter.

Some of the learning and goals participants shared as they continue their journey included:

• “I want to know more about how to become an advocate for Trauma Informed in schools,” along with finding resources for “helping to educate my school staff to become trauma informed.” 
• Another said her hopes are for the school to start “Building resilience, and begin to implement a plan for adapting to a more trauma-informed culture.”
• Another said “I'm hoping that we can start implementing coping skills practice in classrooms every day.”
• Another nurse reported that she plans to offer “Mindfulness techniques for my administrators to do every day.”

They also shared some aha moments. For example, recognizing “what an important role I may play for a student,” that "It's not what is wrong with them, it's what has happened to them," to remember that “staff members, along with students, can be experiencing trauma as well,” and “To be more mindful of the fact that I can't fix a child's problem but I can be present.”

SHP partnered with Dr. Carol Cox at Truman State University in developing tools for ‘mindful moments’ to assist school nurses and staff in helping students feel less anxious/more in control. These just-in-time learning tools are posted on the Department of Elementary and Secondary Education website to provide optimal access by school staff users; and the resources were shared with school nurse leaders (102 school nurses) at the 2019 Lead School Nurse Collaborative. To help facilitate student access to mental health services, SHP serves as a member of the Show Me School Based Health Alliance of Missouri (SMSBHA) advisory board, and is working with member partners to expand access to care in school-based health care programs. Their provider programs include mental health along with health care services. These programs have increased in 2018-19 to be present in at least one school site in 50 of the 114 Missouri counties plus St. Louis City.

The SHP partnered with other Department of Health and Senior Services programs and the Missouri Department of Elementary and Secondary Education (DESE) to apply for CDC grant funding to support a project bringing together professional organizations as critical stakeholders in addressing the opioid crisis. The goal of this Community of Learning is to leverage efforts to address the opioid abuse and misuse epidemic in schools. The Missouri Combatting the Opioid Epidemic in Schools project (COPE) brought together content experts and school partners to understand the issues and develop action plans schools can implement in addressing the opioid epidemic in local communities. Partners from private health plans provided resources to get naloxone stocked in schools, school personnel and staff to be trained on medication administration, and school administration developed policies and practices for stocking the naloxone. To date, 93 school districts have received these stock doses and have policies in place to guide the practice. Through the partnerships in the COPE project, Opioid/Prescription Drug Misuse Prevention Education/Curriculum for grades K-12 has been posted on the DESE website for classroom use by schools. (https://kwelker.wixsite.com/opioideducation)

The Adolescent Health Program (AHP) worked on mental health through a continued partnership with Wyman, Inc. to hold social emotional learning trainings around the state. More information on this is available under NPM #7 for Injury Hospitalization.

Worth highlighting is AHP's on-going adult-child connectedness campaign called Connect with Me. This campaign, along with its Conversation Starter Cards, was developed to help parents, guardians, caregivers, and others who work with youth a chance to develop conversation skills to build connections with the youth in their lives. The cards cover a variety of topics including healthy relationships, mental health, substances, trauma, body image, and more. Adults can use these conversation starters to start discussing difficult topics with youth in order to better understand what is going on in their lives and to help them cope with changes and situations that are common. Around 40,000 decks of cards have been dispensed with over $5 million worth of advertisements donated by Missouri Broadcasters Association since the campaign began. Responses received from the Connect with Me survey are listed below.

• “One of the cards asks who you would be if you could be anyone in the world. A client shared "I'd be a girl." It opened up a new dialog for him to share personal struggles that have been hard to deal with and keep quiet about.”
• “I learned things were different for the kids than I had assumed.”
• “They have helped my students open up about issues they are having.”
• “She liked them so much, she would pick up the cards and start the discussion process. I think she felt more comfortable after hearing from us.”

* Interpret with caution due to sample size limitations.