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

 

Among Missouri adolescents 10 to 19 years old, non-fatal injury hospitalizations were 275.3 per 100,000 in 2017 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 provisional 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 85.0% from 2008 to 2018 (6.5 per 100,000 to 12.0 per 100,000). Comparatively, the national rate increased 67.0% from 2008 to 2017 (4.3 per 100,000 to 7.2 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 53 counties in Missouri. The coalitions address programs 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, driving courses, hosting educational events, and conducting media campaigns with prevention messages. In FFY18 these coalitions provided services to over 13,900 children and parents through over 180 teen safety educational events. There are several traffic safety and driving courses provided around the state that Safe Kids coalitions help promote. 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. This 90-minute evidence-based traffic safety program educates parents about Missouri’s Graduated Driver License (GDL) law. The goal of First Impact is to reduce new driver crashes, 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. First Impact features a video and discussion to promote the importance of parents and teens working together to reduce teen crashes, injuries, and fatalities. Ensuring parents understand the risks and responsibilities associated with driving is essential in preventing teen driving tragedies. The program is delivered by trained law enforcement officers and facilitators who coach parents by presenting key facts and proven strategies to help parents lower their teens’ crash risk by utilizing the Missouri GDL law. The Mercy Injury Prevention Center - Springfield offers the Alive at 25 Defensive Driving Course, which helps teach young adults to drive safely and responsibly. It is a highly interactive course developed by the National Safety Council 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 free 4-hour classroom course that teaches young drivers that there are consequences to their driving behavior and provides the tools for making positive choices. 

 

Violence Prevention

Missouri participated in the Child Safety Collaborative Innovation & Improvement Network (CoIIN) from November 2015 to May 2018. Missouri chose to focus on child passenger safety, suicide and self-harm prevention, and interpersonal violence prevention. Three workgroups were formed on these topics. CoIIN members included Department of Health and Senior Services (DHSS) staff from programs including adolescent health, injury prevention, women’s health, and home visiting. Other agencies involved included the Missouri Department of Transportation (MoDOT), Department of Mental Health (DMH), and Department of Elementary and Secondary Education (DESE).

 

The suicide and self-harm prevention workgroup of the CoIIN partnered with the DMH to improve implementation of evidence-based suicide prevention programs in schools across Missouri. The DMH staff from Prevention Resource Centers (PRC) are trained to conduct Signs of Suicide (SOS). PRCs are the primary source of technical assistance support for community coalitions with a goal to facilitate development of teams capable of making changes in substance use patterns in their community. The SOS is a universal, school-based depression awareness and suicide prevention program designed for middle school (ages 11–13) or high school (ages 13–17) students. The goals are to:

1. decrease suicide and suicide attempts by increasing student knowledge and adaptive attitudes about depression,
2. encourage personal help-seeking and/or help-seeking on behalf of a friend,
3. reduce the stigma of mental illness and acknowledge the importance of seeking help or treatment,
4. engage parents and school staff as partners in prevention through “gatekeeper” education, and
5. encourage schools to develop community-based partnerships to support student mental health. 

 

The DHSS provided DMH and the PRC staff with SOS kits (35 high school and 35 middle school). In FFY18 the PRC staff provided SOS training for 78 schools reaching 2,579 community members and school personnel.

 

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 MCH and Teen Pregnancy Prevention (TPP) grant funding to focus on positive youth development programs, such as the 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 the current work they are doing. The goals of SEL are more likely to be achieved when adults who work with youth understand how to incorporate and model SEL approaches. Seminars, which were provided to around 200 participants, encouraged both adults and agencies to include the protective factors and safe spaces required to encourage all youth to become successful adults.

 

The AHP continued to refine and develop training on Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) youth. These resources have been shared with the Council for Adolescent and School Health (CASH) and partners working on teen pregnancy prevention. AHP also completed a training of trainers that teaches foundational skills for teaching sex education. This training will be available to schools across Missouri throughout FY 2019.

 

The Section for Women’s Health currently supports the implementation of 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 through the Centers for Disease Control and Prevention. 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. The Green Dot strategy is evidence-based curriculum. In FY18, the Section for Women’s Health supported five middle schools and five colleges through these contracts.

 

Promote General/Traffic Safety

A total of 88 Local Public Health Agencies (LPHA) reported providing general safety education, 82 reported providing education on proper seat belt usage,  44 reported providing education on impaired/distracted driving, and 24 reported engaging in activities to promote safe use of ATVs. Traffic safety highlights included:

• Gasconade County Health Department partnered with First Impact to focus on providing education in schools related to safe driving, participated in and engaged community members in the MoDOT Buckle Up Phone Down challenge, and successfully engaged the Governor of Missouri to take the Buckle Up Phone Down pledge.
• Schuyler County Health Department provided education related to general distractive driving and texting and driving and held seat belt safety checks at the local high school.
• Wright County Health Department participated in Project Graduation to provide a safe environment for students in an effort to prevent injuries from students drinking and driving under the influence.

• Henry County Health Center rewarded teen drivers for wearing their seat belts at events held at three Henry County high schools.
• Dent County Health Department worked with emergency management personnel on safety initiatives to prevent adolescent motor vehicle accidents.

 

Prevent Unintentional Injury

A total of 82 LPHAs addressed home and school safety. Examples of this work included:

• Camden County Health Department continued their Water Safety efforts, partnered with the Missouri State Water Patrol and Make a Wish Boat Ride Program, and supported the Life Jacket Loaner Boxes in two locations. The boxes were stocked with life jackets for all ages to use as a loaner and return after use.
• Cass, Linn, and Montgomery county health departments provided Safe Sitter classes.
• Cooper County Public Health Center developed a survey to determine baseline knowledge regarding traumatic brain injury (TBI) and emailed the survey to 49 coaches, physical education instructors, school nurses, and school administrators. Survey results showed what was already in place at local schools and what was lacking related to prevention of TBIs.
• Dent County Health Department participated in a new community safety committee and helped provide a Community Safety Day.

 

Suicide/Violence/Substance Abuse Prevention

Multiple LPHAs targeted their efforts to address suicide, violence, and/or substance abuse prevention. In total, 44 LPHAs reported providing education, screening, and referral for adolescent suicide/self-harm; 32 reported providing mental health and counseling services and/or resources; 80 reported providing prescription drug abuse education, prevention, and intervention; 94 addressed child abuse and neglect; 54 addressed domestic violence; and 48 reported providing bullying prevention information and training. Highlights of this work included:

• Kansas City Health Department coordinated the Youth Violence Injury Prevention Program and provided education, curricula, and interactive classes for youth, teachers, and parents. Prevention topics ranged from dating violence to youth suicide prevention to bullying prevention, and from general health topics to addiction resources. The education was available to a wide range of youth audiences through schools, churches, youth-serving organizations, and others who work with youth in Kansas City.
• Montgomery County Health Department supported a motivational teen speaker for a school assembly and a parent involvement night and provided supplies to promote drug-free after school programs. The health department established a County Substance Use Prevention Coalition and submitted an outline to the MO Division of Behavioral Health for recognition of their work.

• Dallas County Health Department identified substance use and youth suicide as priority issues in their community and partnered with Burrell Mental Health Services and a local primary care provider to make contact with school counselors and offer to provide substance use training to students.
• Student surveys in Osage County showed an increase in the number of adolescents in schools who reported contemplating suicide. Osage County Health Department reached out to organizations and schools and showed the movie "The Ripple Effect" 18 times in their community.
• Franklin County Health Department took an active role in helping plan their county's first Teen Drug Summit to raise awareness regarding substance use among youth.
• Camden County Health Department identified substance use/overdose and suicide attempts and completions in adolescents as priority health issues and worked to make new connections, form new partnerships with community stakeholders, and strengthen existing partnerships related to adolescent substance use and suicide.
• Adair County Health Department led the effort to create the Adair County Opioid Coalition (ACOC). The coalition brought several prominent businesses and providers in the community together to work on one common goal and obtained support from local physician offices, EMS/First Responders, law enforcement, school leaders, county officials, mental health support providers, and pharmacies.
• The MCH Coordinator at Ralls County Health Department attended the 2nd Annual Regional Conference on Adolescent Health with session topics including: Recognizing and Responding to Risk; Building "Braveness"; and Responding to Youth Violence and Supporting Survivors. The MCH Coordinator shared the information gained with members of the HOPE Coalition and Light House Team.
• Dent County Health Department provided substance abuse prevention efforts in collaboration with the Prevention Coalition and reported increased community awareness of the risks of substance use and improved relationships with schools which resulted in increased opportunities to educate adolescents on the risks of substance use.
• St. Francois County Health Center and Washington County Health Department worked with community partners and stakeholders to increase awareness of substance use and overdose-related deaths.
• Newton County Health Department worked with the Newton County Community Coalition to address substance use among adolescents.

 

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.

 

Missouri students already show concerning trends in chronic disease risk factors. In 2017, 16.6% of high school and 10.3% of middle school students were obese. According to the Missouri High School Youth Risk Behavior Survey (2017), 46.2% of high school students were physically active at least 60 minutes per day on 5 or more days. According to the Missouri Youth Tobacco Survey (2017), 58.3% of middle school students were physically active at least 60 minutes per day on 5 or more days. Missouri adolescents ages 12-17 years, (21.6%) were physically active at least 60 minutes a day, every day compared to 18.5% nationally. Males were more likely to be physically active than females, 31.7% and 10.0%, respectively). Furthermore, 30.2% of high school, and 29.6% of middle school students drank sugary-sweetened beverages one or more times per day in the past seven days. Those who ate fruit or vegetables 5 times per day included 20.2% of middle school students and 13.8% of high school students. According to the National Survey of Children’s Health (NSCH) 2016-2017, Missouri adolescents ages 12-17 years, (16.4%) were physically active at least 60 minutes a day, every day compared to 18.2% nationally. Males were more likely to be physically active than females, 23.5% and 7.7%, respectively). Though not as great a divide, nationally males (22.7%) were also more commonly active than females (13.5%).

 

Missouri, in collaboration with both our internal and external partners, is working towards increasing 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.

 

In FY18, the Department of Health and Senior Services (DHSS) continued its partnership with the Springfield-Greene County Health Department to engage youth in nutrition and physical activity efforts in their local community through the Youth Health and Wellness Council (Council). The Council members are youth from the four units of the Boys and Girls Clubs of Springfield. The Council members developed an action plan using results from an assessment completed using the Community Health Living Index tool and information shared at a training in September 2017. The Council members worked on organizational nutrition policy, on-site gardens, and food insecurity. To address food insecurity, Council members created meal kits, which they distributed to 244 families in underserved areas in the city. They also made improvements to local parks including adding permanent stencil designs to encourage activity, Frisbee golf and tether ball equipment, and making playground improvements. Council members also focused on overcoming barriers to keeping youth engaged and committed in the Council. For example, they started using social media groups, which helped them add 10 new members this year and with planning fun activities for meetings.       

 

The School Health Program (SHP), with internal partners and the Department of Elementary and Secondary Education (DESE), facilitated a two-day training of trainers workshop to train a cadre of 25 individuals on the Centers for Disease Control and Prevention’s (CDC) School Health Index (SHI). The training, which occurred in August 2018, provided updates on recent revisions to the SHI and material on how to teach schools to implement the SHI. This group of trainers, representing schools, universities, hospitals and foundations from across the state, are available to school districts to train school staff on completing the SHI. Attendees included representatives from seven priority school districts participating in a CDC grant project (1801). All seven of these districts will be doing the SHI in the 2018-19 school year. SHP staff also shared information on available wellness resources and the updated SHI tool with 90 school nurse leaders attending the annual Lead School Nurse Collaborative (September 2018), as an effort to encourage more schools to utilize the SHI assessment for improving student health and wellness curriculum and school services. As schools completed the SHI, SHP and other Bureau of Community Health and Wellness (CHW) staff were available to provide technical assistance for them on implementing their plans.

 

SHP collaborated with partner programs to review and update the School Health Advisory Council (SHAC) Guidelines. The SHP shared the updated materials at the Lead School Nurse Collaborative (September 2018). Through encouraging schools to evaluate and energize the membership of their SHAC, the goal was for more inclusive representation in programs and school services that support the health and wellness of students and staff.

 

SHP and CHW held discussions with the Weight Management Clinic at Children’s Mercy Hospital-Kansas City to understand the needs and identify barriers for school nurses to work with overweight and obese students and their families. SHP 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.

 

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 National Survey of Children’s Health (NSCH) 2016-2017, 57.2% of Missouri children, ages 3-17 years, with a mental/behavioral condition received treatment or counseling compared with 50.7% nationally. Among those that received these mental health services, 64.8% were using Medicaid and 55.3% were privately insured in Missouri. This is greater than the national figures for private insurance (51.0%) and Medicaid recipients (50.9%). Missouri households with some college had a greater percentage of those who received mental health care (63.3%) than any educational attainment group nationally. In Missouri, the percentage of non-Hispanic Whites (58.1%) who received mental health care was greater than their national counterparts (52.3%). The percentage of two-parent married households in Missouri (59.3%) who received mental health care also exceeded the percentage nationally (50.1%). Nationally, children age 6-11 (47.0%) and 12-17 (56.8%) less frequently received mental health care than their Missouri counterparts (62.1% / 63.4%).

 

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 offered 4 hours of continuing education training for child care providers, 3 health promotions for children in child care, 2 hours of specialized consultation, and 6 technical consultations regarding well child care. By offering these services in FFY2018, the CCHC Program increased support of the mental health needs of children in the child care setting. 

 

Since mental health issues can begin well before adolescence, in FY2018 a new session titled “Building Resilient Children in the Child Care Setting 2.0” was developed by the Platte County Health Department for use in the CCHC program. This training includes a video titled “Resilience, the Biology of Stress and the Science of Hope.” Resilience is a one-hour documentary that delves into the science of ACES and the birth of a new movement to treat and prevent Toxic Stress. The training was offered to child care providers by the Columbia-Boone County Department of Public Health and Human Services and received the following responses:

 

• “I was raised in a physically, mentally, and emotionally abusive home. Thankfully, as an adult I have been able to overcome many of the bad effects it had on my life and was able to break the cycle as I raised my own children. However, as an adult I struggle with not having a good education due to parents who were not supportive in the learning process. I also struggle with fear that I might do something wrong and be judged for that. I struggle with low self-esteem. Even though I have these struggles, I feel I can be a strong encouragement and positive influence in the children’s lives that I am a part of. I feel this is very important information to be taught. Had my parents been given some of these tools and support, my childhood might have been different. I don’t think people realize how stress can affect a child in so many ways. Especially health related in their adult years. I felt this presentation was very informative. The proof is there that right treatment can change lives and it needs to start at a young age. Giving children the tools to learn how to express stress in their lives. I liked the idea of working on the issues instead of medicating the symptoms.”
• “As more and more of the organizations that provided trainings in the past experience funding cuts, it has become very hard to find enough hours to meet licensing requirements. This particular training on building resiliency in children is so important because I see in my care more and more children in crisis or stressful situations. I have a 2-year old (at the child care facility I work in) who is living with mom in a women’s shelter (dad in prison now). Last year three of my daycare kids had restraining orders on family members on file at my facility. I need tools to help me deal with these situations. These little ones need our help and we need the help and knowledge to BE that help!”

 

As indicated through these responses, the training provided to child care providers can benefit the adults receiving the training, the children they serve, as well as the parents who leave their children in their care.

 

All enrolled children from birth to age of kindergarten entry participating in the Genetics and Health 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 was an emerging concern across all population domains in Missouri, but especially among children and adolescents, and Local Public Health Agencies (LPHA) 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, 32 reported providing child and adolescent mental health and/or counseling resources and services and 106 reported having community partners who 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 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 to adddress child and adolescent mental health needs included:

 

• Taney County Health Department staff became trained in Youth Mental Health First Aid.
• The MCH Coordinator at Ralls County Health Department attended the 2nd Annual Regional Conference on Adolescent Health with session topics including: Recognizing and Responding to Risk; Building "Braveness"; and Responding to Youth Violence and Supporting Survivors. The MCH Coordinator shared the information gained with members of the HOPE Coalition and Leader In Me Lighthouse Team.
• Springfield-Greene County Health Department staff received Triple P positive parenting training.
• Platte County Health Department assisted Tri County Mental Health with the Youth Leadership conference. In total, 248 students attended the conference.  The health department, in collaboration with the Northland Coalition and 5 local coalitions located in Platte County, spent considerable time researching prevention strategies to lay the foundation for intervention opportunities throughout FFY2018. Representatives from 10 community leadership sectors in Platte County, including the health department, and prevention experts made up the steering committee that worked toward positive outcomes for Platte County youth. Based on MO Student Data, the prevention coalitions targeted multiple contexts to include the individual, family, school, and community through media campaigns and education of teens, parents, merchants/businesses, law enforcement, and school staff. Education included discussion of risk factors, not limited to but including the ACEs study, protective factors, opportunities to enhance resilience within youth and the community at large, SOS (Signs of Suicide), and Mental Health First Aid. Platte County coalitions aligned to facilitate a “trauma aware, trauma sensitive and trauma informed community” to build resilience and derail youth substance use and suicide ideology everywhere kids live, learn, work, and play.

• Platte County Health Department (PCHD) provided an on-site licensed mental health provider staff position for clients needing ongoing therapy and crisis intervention. The position was jointly supported by Tri County Mental Health and the Platte County Health Department. The health department provided monthly trainings to educate staff about "trauma-informed care" and "personal mental health and well-being" to make PCHD staff more trauma aware and trauma sensitive, with the goal to provide trauma-informed care in the health department’s Family Healthcare Clinic clients.

 

As part of the Nurse Education Webinar Series (NEWS), the School Health Program (SHP), sponsored with the University of Missouri Telehealth Network and the University of Missouri Sinclair School of Nursing-Nursing Outreach, a fall 2017 learning session focused on LGBTQ youth, and in particular, their unique challenges in access to health care and the role of the school nurse. Dr. Kenneth Haller from the St. Louis University School of Medicine and Cardinal Glennon Children’s Medical Center provided an hour-long educational program to school nurses. A total of 115 nurses completed the evaluation for continuing education (CE) credit for the live and archived program. In their evaluation, comments shared by participants included that many feel they are better prepared to support their LGBTQ students, especially if they have not yet been approached—they know those students are there, as well as have better self-awareness to improve their communication and cultural sensitivity within their practices.

Another session in the NEWS webinar series covered trauma-informed care in the school setting. The session was led by Dr. Patsy Carter from Department of Mental Health (DMH) and was well attended with 125 school nurses completing the evaluation for CE credit for both the live and archived viewing options. Most participants stated that they gained new insights in understanding the impact of trauma and how it comes out in student behaviors, and how they are thinking about getting the information out across their buildings and districts, for all staff.  

 

SHP, in partnership with Division of Social Services (DSS)-Children’s Division and DMH, initiated a Learning Community (LC) for developing trauma-informed schools.  The Learning Community kicked off with an invitation to school nurses interested in participating to submit an application. The project planned to host 40 school nurses for a 2-day in person workshop with a commitment to participate in monthly virtual meetings held throughout the school year. The project received over 100 applications in less than 2 hours. Through a selection process, the LC of school nurses was chosen and gathered in January 2018. The LC workshop included an introduction to the ACES study and provided the participants with the evidence-based materials from Creating a Trauma Responsive Missouri model. Monthly web-based meetings were held, with an average of 25 participants on each call. Each session included by Dr. Patsy Carter (as the program lead and content expert) sharing new materials and discussion by the school nurses sharing their projects applying the skills and knowledge they had gained from the project group. This project provided trauma responsive skills training to support these 40 nurses in 36 school districts to be better prepared to care for 70,380 students. When school nurses are trained in Trauma Responsiveness, they are better able to identify students in need of counseling and mental health services, and be a resource for the students and families to assist them to access the care and services.

 

Throughout the series of meetings, the nurses commonly shared that they changed their perspective to see the student, not the complaint, and reframe their approach to working with students, thus moving away from the ‘what’s wrong with you?’ mindset to instead thinking about ‘what’s happened to you?’ Many also reported that they shared their information in professional development programs with their district staff in school-wide trainings. At least 3 of the LC nurses were members of their district teams to attend an in-depth trauma institute over the summer. One school nurse had school sponsorship to attend the 2018 Fall Trauma-Informed School Conference in Sacramento, CA, and reported back that Missouri is ahead of the rest in our work on trauma-informed schools. Dr. Carter also commented that she has seen a growth in these nurses, that they are more confident in their ability to be able to support the whole-child needs of their students. These facilitated sessions were completed with a wrap up conversation November 2018. Participants shared their about their work and what is different now in their schools to support a trauma-informed environment for students as a result of participating in this learning community. 

 

• From a rural school district in southeast MO, the nurse shared that she presented at a back-to-school in-service to all of their staff and had the speaker Dr. Carter recommended talk to the secondary group and the elementary group. “Our school is going to continue to work on becoming Trauma Informed and it has opened many eyes on how to look at students differently and treat differently. We love this and thanks for your wonderful assistance and help.”
• “I feel like I've become much more empathetic to my more "difficult" students. I don't rush students out so much. I mean I want for them to get to class, but I also realize that if the students feel at ease with me I can help them more. I've made my office more "homey" feeling. Have alternative seating. I really felt that the webinars have helped to not forget about being trauma informed,” was shared by a southwest MO school nurse.
• Another shared that “This was such a great learning experience. The monthly webinars helped all the info we learned over the 3-day conference sink in. I am definitely looking at the kids in a different way, looking at the whole child, listening with my eyes. I have made my office more of a comfortable place to relax and unwind. I have cards for the kids to look at and show them how to deep breathe, self-regulate, and also (have) relaxation toys like stress balls, glitter wands, water motion toys. My elementary building is doing a school-wide Trauma training, all the teachers and staff are so interested in this, they have a plan to be fully Trauma Informed by end of 2019/20 school year. I learned to try and be involved in after school events so the kids can see me outside of the school day. We learned it is important to feel connected, feel trust and a sense of belonging, important for the kids to be a part of something bigger, so the teachers are planning on game clubs, student council etc.”
• From a school nurse in central MO, “We have a behavioral counselor on campus 3 days a week. We have 90 students signed up for services, as needed. It is a great resource. We are having a professional development day here in January 2019 with the entire staff for Trauma informed training. I feel like the training has helped me to see when a child needs further assistance than what they are asking for. Sometimes they need help and just don't know how to ask.”
• “I have really enjoyed the learning experience we have all shared. Like others said, I too have slowed down and do not have ‘back to class’ as the first goal. We have had School-wide Positive Behavioral Interventions and Supports (SWPBIS) for some time now. Great program. We have Ultimate Upstanders which recognizes students for taking the initiative to help other students without an adult initiating that help. Teachers, staff, and other students may fill out a paper to recognize students for helping. Positive Pals is in place to pair students with a staff member who will have one-on-one time daily (even if just for 5 min). As the school nurse, I do work more closely with teachers, the counselor, and principal than before to identify students who come to me that may have concerns other than just physical. (Our school) is in progress with staff training for trauma informed schools!”
• Another nurse shared, “I feel like we have helped so many more kids that maybe we would not have understood about before going through this program and being trauma informed. I looked through audio books on Amazon and chose to listen to "A Child Called It." This is a book I would have NEVER known to listen to prior to these meetings. Since listening to this book I opened my ears and eyes a little differently and I got an email that a girl that comes to me often was going to be in OSS (Out of School Suspension). I was shocked and talked with the principal and after looking into it and discussing what had happened, we found out that there was a ton going on at home that was similar to this horrific book. Since then, help has been in their home and the mother has been addressed. I thank God that people were put in my life to know to make me aware that this girl needed help... SO THANK YOU ALL!!!!”
• A small southwest MO school district nurse shared that she is adding tools to her health room, including a ‘calming corner’ with activities in mindfulness and stress relief. As she works to seek additional funding resources for her project, she will be tracking data from students, reviewing the reported pain levels in headaches and stomachaches before and after using the calming corner.

 

SHP added additional cohorts to the Enhancing School Health Services through Training, Education, Assistance, Mentorship, and Support (TEAMS) project, for school districts using the evidence-based framework to assess their health services policies and practices and develop an action plan. The framework also guided each cohort team through implementing and evaluating their work plan successes and challenges. Three sites initiated the project in late spring 2018; including St. Louis City public schools, Neosho School District, and Joplin Schools; with 23,854; 4,745; and 7,826 students respectively. In early summer, 5 additional districts were added: Bayless (1,703), Charleston R-I (955), Jennings (2,575), Ritenour (6,497) and Wentzville R-IV (16,375).  Care Coordination and provider engagement were identified as priority issues by these schools, with a range of focus on health and mental health concerns.

 

As a partner in the School-Based Health Center Task Force, SHP provided input and guidance with school and community partners to support student health services and supports. This group was influential with DSS/MO HealthNet (Missouri’s Medicaid) Division in their April 2018 policy to allow for behavioral/mental health services to be provided to students (outside of IDEA services) in the school as a place of service. This change will improve the access many students and families have to mental health care services. SHP will be following the MO HealthNet data to review the improved access and increased number of students benefiting from the system changes. SHP was also an active member of the ShowMe School Based Health Alliance, providing guidance and support to the many new school-based health clinics and mental health services across the state.

 

The Adolescent Health Program (AHP) continued to provide professional development funding in 2018, with a total of 16 LPHAs receiving over $10,000 to attend professional development opportunities. These opportunities included funding to attend conferences such as the Teen Pregnancy Prevention Partnership (TPPP) Conference and the Regional Adolescent Health Conference.

 

The AHP also worked with Wyman, Inc. to hold social emotional learning trainings around the state. More information on this is available under NPM #7 for Injury Hospitalization.

 

Another highlight is AHP's creation of an 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. Over 28,000 decks of cards have been dispensed with over $4 million worth of advertisements donated by Missouri Broadcasters Association since the campaign began. Responses received from the Connect with Me survey are listed below.

 

• “I used these in our wellness committee meeting for our district and the staff loved them. Nurses, administrators, counselors, and people of our community all gave positive feedback.”

• “We have more open and real conversations. It’s not just lecturing with eye rolling anymore.”
• “I love these cards!!! When I went into the Health Classes and used these with the kids you could tell that they just soak up all the attention and conversations that we were having. We live in a very poor community and so a lot of the kids come from very rough homes so they really enjoyed being able to have conversations. I was able to build relationships with a lot of the kids through these cards.”
• “My grandkids LOVED these! They know they can talk to me about anything but these cards really gave some great insight into WHAT to talk about. I could tell they felt empowered when asked some of the questions and I learned a few new things about them.”
• “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 the client to share personal struggles that have been hard to deal with and keep quiet about.”