Priority: Bullying and youth suicide prevention

Update on PM annual objectives:

NPM 7: Rate of hospitalization for non-fatal injury per 100,000 adolescents ages 10-19 was 237.8. The annual objective for reporting year 2019 was 227.0. The annual objective was not met. The annual indicator for NPM 7.2 represents calendar year 2017 hospitalizations. Colorado originally selected this NPM to focus on youth suicide hospitalizations. In 2017, Colorado experienced a small uptick in youth suicide hospitalizations, which contributes to the increase in overall youth injury hospitalizations. Colorado data from 2018 show a decrease in youth suicide hospitalizations. The annual objective for reporting year 2020 is 225.0.

ESM 7.2.2: Number of schools through collaborative state funding implementing Sources of Strength was 77. Since ESM 7.2.2 was newly developed in 2019, we are unable to compare it to an annual objective. The annual objective for reporting year 2020 is 85.

NPM 9: Percent of adolescents, ages 12 through 17, who are bullied or who bully others was 22.8%. The annual objective for reporting year 2019 was 22.5%. The annual objective was not quite met. The annual objective for reporting year 2020 is 22.0%.

ESM 9.3: Number of schools through collaborative state funding implementing Sources of Strength was 77. Since ESM 9.3 was newly developed in 2019, we are unable to compare it to an annual objective. The annual objective for reporting year 2020 is 85.

For this reporting period, MCH Block Grant dollars funded the Bullying and Youth Suicide Prevention Coordinator position to lead the implementation of connectedness and economic stability strategies outlined in the state action plan, as well as contracts with local public health agencies, schools, and school districts to implement local action plans for this priority. Additionally, MCH aligned with and leveraged funding from a research grant, Researching Sexual Violence Prevention using Resiliency, Strengths, Virality and Protective Factors (RSVP²), from the Centers for Disease Control and Prevention (CDC), and Colorado legislative funding to support school youth connectedness and advance the strategies outlined in the action plan. Implementation of connectedness and economic stability strategies expanded to 26 of the 64 counties throughout Colorado. The funded strategies and associated outcomes are summarized below. For a more detailed description, refer to the full state action plan.

According to the CDC, different types of violence are interconnected and often share the same root causes. An effective strategy to prevent multiple forms of violence is to utilize a shared risk and protective factor approach. This approach recognizes the overlapping causes of violence, as well as the factors that protect against the experience of violence. MCH, along with other programs across CDPHE, apply a shared risk and protective factor approach to prevent bullying and youth suicide by building school connectedness, community connectedness, and economic stability for youth. According to research in “Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence,” (CDC, 2014) connectedness and economic stability are protective for bullying, suicide, youth violence, teen dating violence, and child maltreatment.

Additionally, research identified in the Child Abuse and Neglect Technical Package by the CDC (2016) identifies policies: access to food, housing, and quality childcare, as well as paid family leave, as research-based strategies which build economic security for individuals and, therefore, families, and communities. Further, research identified in the Preventing Suicide Technical Package by the CDC (2017) identifies economic supports as a possible strategy to prevent suicide. Specific policies focused on livable wages, medical benefits, and other family assistance have shown an impact on rates of suicide. Though extensive research has not been done to show that these strategies directly reduce bullying and youth suicide, the research-based shared risk and protective factor approach supports the hypothesis that building economic security will prevent bullying and youth suicide.

The Bullying and Youth Suicide Prevention Coordinator supported school and community connectedness for youth and adults by promoting equity, school climate initiatives, teacher and staff trainings, policy and protocol development, and local adoption and implementation of Sources of Strength. The leveraging of MCH dollars, RSVP², and Colorado legislative funds resulted in the Bullying and Youth Suicide Prevention Coordinator supporting connectedness efforts with six local public health agencies, and 22 schools and school districts.

Local public health agencies implemented a variety of strategies to build connectedness with schools and their communities. Of the six agencies that prioritized bullying and youth suicide prevention, four of them worked with schools and districts to coordinate public health, school mental health and other community-based resources. For example, Northeast Colorado Health Department, which serves six counties and 21 school districts, developed a mental health resource matrix in collaboration with school districts and the community mental health center. This resource serves as a directory of mental health services available within the region. Community organizations and twelve school districts utilized this resource to refer and provide access to mental health services for youth. In order to identify resources for LGBTQ+ youth in Denver, Denver Public Health compiled a list of organizations and programs who provide mental health and suicide prevention services for LGBTQ+ youth. This list was developed to refer LGBTQ+ youth to safe and supportive programs and services.

In addition to these efforts, two local public health agencies worked with higher education institutions to develop curriculum to support building community connectedness. Jefferson County Public Health worked with the School of Mines, Red Rocks Community College, and Colorado Christian University, to plan for the development of a class curriculum on brain and mental health. This curriculum will be taught to current students at these schools starting in  2022. This curriculum may build connectedness through supporting conversations among peers and staff and increase awareness and access to community and school mental health services. El Paso County Public Health worked with the education department at the University of Colorado, Colorado Springs to plan for the development of a curriculum about adverse childhood experiences and trauma and how it impacts academic performance and student behavior. This curriculum will be provided to students majoring in education starting in 2022. Educating future teachers to utilize a trauma-informed approach demonstrates a norms change within the field, and may result in stronger abilities for teachers to be askable adults within school systems. The implementation of a trauma informed approach in education also supports children and youth to stay in and be connected to school.

To increase connectedness, schools and districts funded by a legislative grant program in the Office of Suicide Prevention implemented school climate initiatives.The Bullying and Youth Suicide Prevention Coordinator oversaw and provided technical assistance to 11 schools and districts. Initiatives funded by the grant program include: restorative practices, comprehensive sex education, and social-emotional learning programs. These programs seek to improve school climate by increasing the percent of youth who reported having a trusted adult in their life. LGBTQ+ people experience discrimination, stigma, and bias rooted in toxic heterosexual and cis gender social norms, which contributes to inequities in suicidal ideation, suicide attempts, depression, bullying, and sexual violence. Research by Proulx et al and Gegenfurtner et al has shown that comprehensive sex education inclusive of LGBTQ+ topics is specifically associated with reduced suicidal ideation, increased mental health, and decreased bullying among LGBTQ+ youth. It is also protective for youth of all identities regarding suicidal thoughts, depression, and suicide plans. The Bullying and Youth Suicide Prevention Coordinator and CDPHE colleagues wrote a Suicide Among Youth in Colorado report which included data and additional suicide and bullying prevention recommendations that are responsive to the inequitable LGBTQ+ health outcomes.

In addition to school climate initiatives, the legislative grant program funded school and district gatekeeper trainings such as Question Persuade Refer and Youth Mental Health First Aid, and supported the development of best practice policies and protocols for suicide prevention, intervention and postvention. Gatekeeper trainings are non-clinical trainings which teach attendees to identify risk factors and warning signs for someone who may be struggling; approach and engage those who may be struggling; and connect them with supportive resources and help. Schools and districts also reviewed and implemented best practice policies and protocols for suicide prevention and crisis response. The Bullying and Youth Suicide Prevention Coordinator in partnership with the Office of Suicide Prevention developed a series of webinars which synthesized best practice policies and protocols as well as prevention recommendations.

The number of schools implementing Sources of Strength through CDPHE collaborative funding in Colorado increased from 77 in the Fall of 2018 to 238 in the Spring of 2020. The implementation was funded through collaborative state funding from the Office of Suicide Prevention, Communities that Care, the Sexual Violence Prevention Program, and the Child Fatality Prevention System. Sources of Strength is an evidence-based program that has demonstrated an impact on youth suicide prevention. It is designed to prevent suicide by increasing help-seeking behaviors and connections between peers and caring adults. The Bullying and Youth Suicide Prevention Coordinator supported a CDC research grant focused on connectedness and enhancing the evidence-based for sexual violence, bullying,and suicide. This research grant supported the implementation of Sources of Strength in 20 high schools across Colorado. The Bullying and Youth Suicide Prevention Coordinator was part of a team that collected student surveys and worked with school staff to collect implementation data and school climate survey data. Data are currently being analyzed by research teams at the University of North Carolina, University of Rochester, and Texas Tech to evaluate the effectiveness of the shared risk and protective factor approach on multiple outcomes, including: sexual violence, bullying, and youth suicide. This research study will also support the field by identifying fidelity requirements to ensure successful implementation of Sources of Strength in schools. It is anticipated that the findings will be published in fall 2020.

Sources of Strength implementation was also supported by Boulder County Public Health. This local public health agency became Sources of Strength trainers and facilitated adult advisor and peer leader trainings in one school district, resulting in 12 schools, 59 adults, and 331 youth trained. Boulder County Public Health identified programmatic gaps and integrated positive youth development and equity into their Source of Strength trainings. Specifically, integrating positive youth development provided additional skills to adult leaders on how to be trusted adults for young people and support young people to become leaders. Additionally, Boulder County Public Health promoted sexual and gender equity in their trainings by educating adults and students on the importance of school and community environments which utilize affirming pronouns, names, and provide access to affirming bathrooms. Gender affirmation policies ensuring the use of one’s chosen name, chosen pronouns, and access to one’s preferred restroom and locker room, can help to create a supportive and safe environment. According to a recent study by Russell et al, the risk of suicidal behavior by transgender youth goes down by more than half for every additional context (e.g., at home, school, work, or with friends) in which their chosen name is used.

In order to promote economic stability the Bullying and Youth Suicide Prevention Coordinator facilitated and led the Office of Suicide Prevention’s Resiliency and Connectedness Commission Workgroup. As the facilitator, the Coordinator identified data, community resources, and strategies related to housing, income, and suicide prevention. The Resiliency and Connectedness Workgroup developed a one-pager related to housing that included community resources and partners to engage in suicide prevention efforts. A recent publication by Kaufman et al identified a link between minimum wage and suicide. The research study concluded that increases in minimum wage appeared to reduce the suicide rate among those with a high school education or less, and may reduce disparities between socioeconomic groups. This research resulted in the Resiliency and Connectedness Workgroup prioritizing income as the next area to develop prevention recommendations.

In addition to efforts at the state, one local public health agency working on the bullying and youth suicide prevention priority leveraged MCH funds to promote and increase the use of the earned income tax credit in their three-county region. Tri-County Health Department completed presentations with community serving organizations to increase the awareness and utilization of the earned income tax credit . A recent study by the Institute for Research on Labor and Employment found that “the minimum wage and the earned income tax credit represent the two most important policy levers for raising incomes for low wage workers” and found “evidence that minimum wages and earned income tax credits reduce non-drug suicides, especially among women.”

State and local experiences implementing strategies to support economic stability during this reporting period informed the identification and development of the new MCH priority focused on economic mobility in the 2021-2025 cycle.