Child Health

Plan for the application year: Oct 2022 - Sept 2023

Child maltreatment continues to be a top priority across multiple domains. For the current five-year cycle, the priority is, “increase the number of children who are living in safe, stable, nurturing environments.” This priority statement emphasizes protective factors and prevention, consistent with the Strengthening FamiliesTM protective factors framework, which promotes a common language and strengths based approach for working with families across systems.

NPM 7.1, the rate of hospitalization for non-fatal injury per 100,000 children, ages 0-9, is closely related to this priority. Assault is one of the leading causes of non-fatal hospitalized injuries among Alaskan infants less than age one and among the top ten leading causes among children ages 5-9 years each year. Many non-fatal injuries among young children are related to physical abuse and/or neglect by a caregiver. If WCFH’s collaborative work to reduce child maltreatment and improve overall child wellbeing is effective and scaled largely enough, we would expect to see a reduction in this indicator.

The ESM selected for this domain is the percent of preventable deaths due to injury reviewed by the MCDR with at least one prevention recommendation that is actionable (including a “who, what, when” component) and targets systems above the individual level. The Maternal Child Death Review Program (MCDR) is an evidence-based program partially funded by Title V which exists to prevent future deaths through a multidisciplinary expert review of all child deaths. Based on fatalities reviewed by MCDR during 2017-2021, 48% of infants (who were discharged from the hospital following birth), children, and youth experienced maltreatment at some point during their lives. Recommendations for the prevention of child fatalities are most useful when they include a specific action (“what”), a responsible party (“who”) and a timeframe for carrying out the action (“when”), and when such recommendations address agency and system actions as opposed to individual behaviors. Recommendations targeting systemic problems and promoting improved service delivery tend to have greater value than those focused on correcting individual behaviors, which can stigmatize and further marginalize groups of people experiencing disparities. MCDR continues to expand dissemination of recommendations through a variety of publications, presentations, and PSAs. When shared broadly, MCDR recommendations can help to inform initiatives, policies, and actions that prevent or reduce injuries and injury hospitalizations among children.

NPM Strategies:

7.1.1: Support and expand statewide systems (e.g., Help Me Grow, Learn and Grow, ILP, and home visiting programs) and resources for parents/caregivers, providers, educators, and community-based service agencies in use of standardized screening tools.

Although the most recent Early Childhood Comprehensive Systems (ECCS) federal grant program iteration has ended, WCFH will continue to collaborate with parents, providers, community organizations and Medicaid to increase awareness and use of the Ages and Stages Questionnaire (ASQ) as a standardized, parent-completed developmental screening tool. There have been improvements in the use of ASQ online screening in Alaska, and the gains made through the ECCS Grant have and will continue to be sustained through the facilitation of the Universal Developmental Screening Advisory Committee (UDSAC). The Early Childhood Systems Specialist facilitates this committee and the purpose of the UDSAC is to bring key stakeholders together to ensure that all children and their caregivers have access to developmental screening in Alaska. The Advisory Committee will accomplish this through:

1. Streamlining efforts to maximize efficiency
2. Coordinating data sharing
3. Ensuring access to training on developmental screening and screening tools for all voluntary or mandated screeners, including early childhood education, home visitors and health care providers
4. Providing stakeholder input on the statewide ASQ Online system
5. Increasing family-focused education on developmental screening

The UDSAC is a cross-sector and multi-stakeholder committee that will continue to meet the UDSAC goals through four active workgroups that will ensure that developmental screening efforts are sustained and equitable. Participants include Medicaid, Early Intervention, HMG-AK, Title V, MIECHV, home visitors, Tribal health, pediatric providers, and the Alaska Mental Health Trust Authority, Learn & Grow (childcare quality recognition and improvement system program), regional leaders for early childhood initiatives, and many others.

In recognition of the importance of monitoring and supporting the mental health of Alaska children, the UDSAC will also focus on the promotion and utilization of the ASQ-SE:2 and other standardized social emotional screening tools over the next few years.

HMG-AK is a system that connects children and families with the services they need. HMG-AK originally launched in the ECCS place-based communities and now accepts calls and referrals statewide. They have and will continue to grow and expand their outreach statewide by utilizing their growing staff and the in-house centralized access point (CAP). To support the relationship with all types of applicable providers, HMG-AK will continue to offer many free training opportunities. To increase the knowledge and use of developmental screening, they offer a free online developmental screening training, which includes a CYSHCN module. This training is for all types of providers (medical providers, home visitors, early childhood educators, etc.) who want to administer developmental screening appropriately. Certificates of Medical Education (CMEs) and an optional Maintenance of Certification Part 4 (MOC-4), a credit needed by physicians who are board certified in general and subspecialty pediatrics, will be offered. HMG-AK will also offer three training modules specifically for medical providers:

1. Developmental surveillance and screening, connecting families to services with Help Me Grow Alaska.
2. Postpartum depression and anxiety, opportunities in a pediatric setting.
3. Early relational health, opportunities in a pediatric setting.

These modules will also offer continuing education credits for medical professionals through partnership and accreditation with the Department of Health.

Providers will also continue to have access to the Strengthening Families toolkit for free on the HMG-AK website.

The director of HMG-AK is also the CDC Learn the Signs. Act Early Ambassador for Alaska and is currently working to update CDC milestone materials to reflect the Alaska population. This includes creating a developmental screening companion document to provide cultural context to westernized screeners such as the ASQ. In addition, HMG-AK and the Early Childhood Systems Specialist will continue to work on a project to build and pilot a developmental screening family engagement framework, to support Head Start agencies in the state to host culturally relevant and timely developmental screening for families in their communities. Learn and Grow has requested that an adaption of this document also be made available for childcare facilities statewide.

HMG-AK will also continue circulation of the updated the CDC Amazing Me! children’s books with Alaskan context and illustrations from Alaskan artists, as well as the updated CDC Milestone Moments booklets that are culturally functional for Alaskan families. These materials will be provided to any early childhood related organizations for free upon request.

7.1.2: Review all child deaths through the Alaska Maternal Child Death Review (MCDR), generate and promote actionable recommendations for all preventable deaths, increase awareness about MCDR program among the public, clinicians, and policymakers, and facilitate the implementation of recommendations.

MCDR is an evidence-based process for multidisciplinary review of all deaths among Alaskan infants, children, and adolescents from all causes. Review of child mortality is significantly funded through Title V. Whereas grant funds are available to support MCDR work specific to SUIDs and maternal mortality, there are no additional federal grant funds other than Title V to support mortality reviews for other deaths occurring among children. Given high rates of child maltreatment and the presence of abuse as a factor in many child deaths, the review committee includes child welfare experts. In addition to clinical and law enforcement records, MCDR gathers case histories from child protection agencies, including caregiver histories, to promote a deeper understanding of the role of ACEs and trauma in child deaths. MCDR also examines the role of substance use and other risk factors to provide qualitative and quantitative information to stakeholders. The MCDR staff team includes professionals who have prior work experience in the child protection field. The program strives to guide the program through reviews that are trauma-responsive and culturally sensitive, and which examine complex systemic factors that contribute to mortality disparities among children.

MCDR utilizes the Child Fatality Case Reporting System (CRS), including continued use of modules that captures life stressor information and COVID-19 pandemic impacts. These fields are useful in analyzing child fatality data from a health equity perspective as they provide insights into social determinants of health among children who died.

7.1.3: Support school nurses and counselors with injury prevention education and trauma informed care best practice information.

School nurses are on the forefront of injury prevention and stewardship of trauma informed environments that support students’ ability to navigate individual and collective stressors, so they are prepared to learn. School Health ECHOs will continue to provide information and support related to school health, including the mental health effects of the pandemic. In addition to school nurses, participants in School Health ECHOs also include counselors, administrative staff, district superintendents, teachers, and other school and public health personnel. In the past, average attendance has been between 80-120 participants per week. Sessions regularly include content on tools and resources to support mental health and wellbeing for students and staff alike, including training on trauma informed care, suicide prevention and substance misuse education for school staff.

The School Health Team, which facilitates collaboration between the Alaska Department of Education and Early Development, WCFH and other Division of Health offices including a Healthy Schools Specialist, and school districts, will continue to provide support for school district staff through individual training sessions, conference presentations and helping to ensure the availability of timely resources. The recently formed Office of School Health and Safety will help plan additional trainings and co-facilitate School Health ECHOs, which will continue bi-weekly starting in the fall of 2022.

7.1.4: Provide analytical and programmatic support for systems serving families and addressing child development, family violence, addiction, and mental health.

In partnership with the Centers for Safe Alaskans, the ALCANLink project applied for and obtained a grant from the American Public Health Association to further develop a prototype for a household challenges clinical prediction, diagnostic, and treatment/referral tool. This funding expanded on initial funding received the previous year to enhance the initial work developed. The project will collect information from clinical providers on what critical information must be included in a tool and how it can best integrate with delivery services. Targeted initially at the pregnancy period and offered in a clinical setting, a contractor will utilize the initial prototype, validated statistical models, literature review and cataloging of protective factors, and information obtained from clinical providers to build a testable tool. The tool will then be tested with the Nero Lab at the Centers for Safe Alaskans to complete development. Targeted providers and organizations will be identified to plan for testing the efficacy and utility of incorporating a prediction model that screens for pre-birth household challenges using state-specific population-based data.

7.1.5: Collect, analyze, and disseminate data to better understand child wellbeing in Alaska (e.g., ALCANLink, PRAMS, CUBS, education data sources, etc.).

Increasing the availability of comprehensive data from multiple sources is critical to documenting and measuring the interconnection of family, environment, and social factors that elevate negative and positive health outcomes for children. Through data visualization, data linkages and aggregation across sources, new informational products will be constructed and targeted to a more generalized audience. During the upcoming year, the CUBS program will add an additional two years of data (2020 and 2021) to an online R Shiny application launched in 2021. The original application allows users to query CUBS results from the full Phase 5 dataset (data collected 2015-2019). The new application includes trends, geographic data, and the ability to cross-tabulate any two variables in the dataset.

The MCH-Epidemiology Unit CSTE fellow will be completing a second year with the Unit. This individual will continue work started in 2021 developing an ACEs and trauma surveillance system for monitoring child wellbeing systematically over time. This project will centralize existing data and orchestrate the collection of new data. To tell the story of ACEs along an intergenerational trajectory, household challenges measured on PRAMS will be monitored, with references to recent publication linking pre-birth household challenge accumulation with increased early ACEs scores of offspring. Additionally, ACEs measured at age 3 years will be monitored over time. This score is constructed by linking CUBS data with child welfare data. Finally, a novel adult survey is being constructed, called Overcoming ACEs through Resilience (OARS). While the BRFSS survey was helpful for quantifying the magnitude of ACES in the adult population it is insufficient for developing a comprehensive prevention and intervention framework. The new adult survey will seek to understand ACEs in context of protections at each level of the socio-ecological framework and investigate the perceived impact of ACE components on individual lives.

The MCH Epi Unit will continue ongoing efforts to better understand child wellbeing while considering resilience and other protective factors in all analyses and publications. All analyses of CUBS and PRAMS data will attempt to highlight protective factors and evidence of resilience wherever possible. Building on initial studies that identified the importance of social supports as protections against child maltreatment, future analyses will seek to connect these social supports to early education outcomes and more extensive involvement with the child welfare system. Populations that leverage these supports will be investigated to determine if systems and other partners can use these data to identify and facilitate the development of these support structures.

The Phase 6 CUBS survey, which began data collection in 2020, includes more culturally diverse questions about supportive activities with the child (i.e., hiking, picking berries, fishing, and other outdoor activities) and will continue to ask questions about protective factors such as reading time and time spent with their father. Analyses may include continuing to explore the impact of the COVID-19 pandemic on the wellbeing of young children and their families in Alaska using data collected by CUBS in 2020 and 2021.

CUBS Phase 6 continues to include open-ended questions at the end of the survey, asking respondents to share resources they have used that they think other parents might like to know about, and to describe any resources or information that they wish they had to support them in raising their child. In 2021, the CUBS program began creating an annual summary of responses to these questions to share directly with appropriate partners and post online. These summaries will be posted on an annual basis as data collection is completed.

7.1.6: Continue to expand data sources for ALCANLink and increase the use in evaluating programs to better understand child health and development outcomes and identify specific populations in need of intervention.

After successfully updating the MOU between ALCANLink and DEED, data from the PAT programs have been integrated with education records and impact analyses are being conducted using the ALCANLink data as a population comparison (as well as matched subset analyses). This year efforts to integrate programmatic data to conduct evaluation of PAT and other home visiting programs will be prioritized.

The ASTHO funded project to link PRAMS with Medicaid will be completed. A short report and presentations are anticipated to describe the relationships observed among our PRAMS population on Medicaid and injury related health care utilization of the birth child by age two-years.

7.1.7: Partner with the Section of Chronic Disease Prevention and Health Promotion (CDPHP) and Tribal health systems on childhood injury prevention.

The Senior MCH-Epidemiologist will be ending his tenure as a co-chair of the Alaska Statewide Violence and Injury Prevention Partnership (ASVIPP). He has served for over 5 years in this “1-year” service and as such helped foster deep-rooted partnership and collaborations between WCFH, CDPHP, and Tribal health partners. The Senior MCH-Epidemiologist works closely with the CDPHP injury prevention program research analyst and will partner to develop statewide and regional child/adolescent injury profiles. Leading causes and factors contributing to injury will be described (e.g., suicide, motor vehicle, child maltreatment, and drowning) using multiple data sources, including those operated by MCH-Epi (MCDR, CUBS, PRAMS, ALCANLink).

With support from the Senior MCH-Epidemiologist, the Injury Prevention program received the CDC injury prevention grant for the first time. Over the course of this year, the MCH-Epi unit will support analytic and surveillance work related to ACEs, traumatic brain injury, and transportation Injuries. This work will focus on developing methods for surveillance, identifying sources, establishing protocols, conducting analyses, and writing reports.

7.1.8: Improve the reliability of maltreatment-related mortality classifications (particularly those related to child neglect and negligence) through a pilot study.

The Senior MCH Epidemiologist worked with a group of national experts to develop a public health classification definition and approach for consistent and reliable classification. This tool operationalized a public health approach to fatal maltreatment classification by establishing a standard for reviewing caregiver behavior based on well-established public health recommendations. Using the finalized tool, a research study was conducted to assess the accuracy and reliability of the tool when used by child death review partners outside the state of Alaska. The results of this study are currently being written up with publication anticipated in the early fall of 2022.