Adverse Childhood Experiences (ACEs) are stressful or traumatic events, including abuse, neglect and household dysfunction that occur during childhood. These events can affect people of all

backgrounds and are strongly related to the development and prevalence of a wide range of health problems throughout a person’s lifespan. ACEs can have lasting, negative effects on health, well-being, and opportunity. These experiences can increase the risks of injury, sexually transmitted infections, maternal and child health problems, teen pregnancy, involvement in sex trafficking, and a wide range of chronic diseases and leading causes of death such as cancer, diabetes, heart disease, and suicide. ACEs and associated conditions, such as living in under-resourced or racially segregated neighborhoods, frequently moving, and experiencing food insecurity, can cause toxic stress (extended or prolonged stress). Toxic stress from ACEs can change brain development and affect such things as attention, decision-making, learning, and response to stress. Children and adolescents growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. These effects can also be passed on to their own children. Some children may face further exposure to toxic stress from historical and ongoing traumas due to systemic racism or the impacts of poverty resulting from limited educational and economic opportunities.

DPH sponsored a virtual technical assistance opportunity for SBHC coordinators, staff, and school personnel called Adverse Childhood Events, Trauma-Informed Care, and

School-Based Health Center Considerations for Screening. Over 140 partners participated. Objectives of the training were to understand Adverse Childhood Experiences and their impact on development, describe trauma-informed care, understand the importance of trauma-informed care in SBHCs, identify screening measures to operationalize in SBHCs, and to explain protocols and implementation considerations for SBHC practice.  During the upcoming school years DPH plans to hold a technical assistance meeting with SBHC coordinators and stuff to discuss how they have implemented ACES screeners into their practice. 

DPH funded SBHCs report programmatic data and information three times a year through survey monkey. Information on the number of individuals who received an ACEs screener, the number of individuals found to be at risk, and the number of individuals that were found at risk that were referred for follow up will continue to be collected.  The survey monkey report will be modified to collect information related to reimbursement specifically to see if SBHCs are receiving any for administering trauma screenings and which ones and if reimbursement is being provided for treatment. DPH will also ask specifically which social emotional screening tools are being used in the SBHCs, if students have been referred for service based on the screening and if there was follow through with students going to their referred appointments.

In the coming years DPH plans to distribute the 4 What’s Next program to the high schools funded by DPH that have a SBHC. The 4 What’s Next Program was purchased through a MCHBG Technical Assistance funding. Technical assistance was provided to the SBHCs from the Jordan Porco Foundation. The 4 What’s Next curriculum is a primary prevention program that builds resilience in high school students by giving them the tools to handle stress and distress now and in their future. Over the course of 5 modules, students learn and understand what distress looks like for them and develop or strengthen an internal focus of control related to their mental health and emotional wellbeing. They will gain skills for psychological resiliency such as coping skills and help-seeking and learn how to apply these skills to better manage conflict, time, and money as examples.

During the 2022 State Fiscal year the School Based Health Center Expansion Working Group, created under PA 21-35 Section 16, was charged with developing recommendations for the strategic expansion of school-based health center services in the state to address health needs in response to the pandemic, with a focus on expanding behavioral health services. The Working Group included representatives from the Appropriations and Public Health Committee’s along with state agency representatives and community providers. DPH Co-chaired the 20 plus member Working Group along with CEO, from Clifford Beers Clinic. 

The Working Group combined multiple databases and utilized the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) and Health Professional Shortages Areas (HPSA) to identify priority schools that presently do not have a school-based health center. The results showed 157 schools identified in 21 towns are recommended to be considered for potential SBHCs. The Working Group utilized the same methodology as noted above to identify SBHC sites that may be expanded or services to be added.  One option is to fund 36 sites located in 11 towns identified that have no Mental Health services. The second option would be to fund 124 sites located in 22 towns identified that have Mental Health and/or Medical services but are not offered full time. The CT Legislature awarded $10 million dollars in ARPA funding for FY 23 to address expansion of SBHC mental health services because of the PA 21-35 report.

Also, during the 2022 State Fiscal year the CDC Crisis Response Cooperative Agreement announced funding earmarked for the expansion of SBHCs to address the effects of the COVID-19 pandemic.  Funding is available July 1, 2021 to June 30, 2023.  Approximately $12 million is available for SBHCs. Site expansion utilizing the SVI from the CDC as well as workforce expansion of SBHCs will be addressed through this funding.  DPH is in the process of setting up a contract with the National School Based Alliance to assist with the activities related to this funding. The School Based Health Alliance is the premier provider of technical assistance, training, and consulting to the school-based health care field. They build the capacity of SBHCs to implement sustainable business practices, improve utilization, collect school-based health data, and provide enhanced services. 

AMCHP’s Innovation Hub (formerly Innovation Station) is an online platform that provides MCH professionals with tools and resources to explore, build, and share successful and effective practices from the maternal and child health (MCH) field. It is home to the MCH Innovations Database a searchable repository of “what’s working” in the field that improves the health and well-being of MCH populations. Practices in the database are assessed along a continuum and receive a designation of Cutting-Edge, Emerging, Promising, or Best practices depending on the amount of evidence demonstrating their work’s impact, among other criteria. In the Summer of 2020, our 4What’s Next program model and implementation strategy was accepted as a Cutting-Edge practice. Cutting-edge practices are generally housed in Innovation Station for two years.

Also, AMCHP began piloting a technical assistance cohort to support cutting-edge practices and work with individuals and organizations to help move the practice along the continuum to an Emerging, Promising, or Best Practice to stay in the database permanently.  There are two main components to this TA opportunity: 1) One-on-one check-ins between AMCHP staff and individual practices to track progress and provide tailored support, and 2) Training webinars on topics related to Innovation Station's criteria, with opportunities for peer-sharing. This training cohort is open to anyone supporting/working with their practice. This TA opportunity began in early 2021 and one of our MCH staff continues to take part in this TA opportunity.

DPH will partner with the School Based Health Centers to develop strategies to educate parents on the importance of well-child visits, including sending flyers/brochures out with annual enrollment packets and dissemination of information through local SBHC advisory boards. DPH will also partner to ensure SBHCs are engaged in health education activities on the individual and group levels and will provide direction and training regarding adherence to Bright Futures as a required standard for all DPH funded SBHCs. Outreach and health education through the School Based Health Centers will be inclusive of nutrition and physical activity. Strategies will be implemented to promote adolescent well-child visits, principally through the School Based Health Centers. DPH Title V will partner with the Medical Home Advisory Council, the CT Association of School Based Health Centers, and the School Based Health Center Advisory Committee to develop strategies to educate district and school administrators, and other local stakeholders about creating comprehensive local wellness policies that include creating a healthy school nutrition and physically active environment. Information will be shared with SBHCs on Medical Home Initiative extended services and respite to connect families to the services they may need for their children. A list of minimum standards for all SBHCs in CT was developed by the Advisory and initial plans for adoption into a regulatory structure are underway.

A DPH SBHC staff is the designated State Adolescent Health Coordinator who is a member of the National Network of State Adolescent Health Coordinators (NNSAHC), participates in community of practice calls focusing on different aspects of adolescent health and shares information on best practices, resources and educational opportunities with other state programs within and outside of DPH, SBHC staff, community providers and other interested parties.  SBHC staff also participate on a number of calls with the National SBHC Alliance and state partners. Trainings and resources from national and local partners will be sent out to SBHC staff regularly.

Due to COVID-19 CT schools and SBHCs have been operating in different ways the past couple of school years.  Some were open, others had a hybrid model or distance learning was used full time.  SBHCs continued to see students through telehealth visits and in person visits when they could.  For the 2022-2023 school year, schools plan to be open for all students and distance learning may be an option in some schools during a COVID-19 quarantine. SBHCs will continue working hard to provide medical and mental health services through telehealth and in person visits and assist with community need around COVID-19 testing and vaccination. 

CT Medical Home Initiative (CMHI) for CYSHCN Care coordinators will work with School Based Health Center staff to ensure families are accessing needed resources. Some care coordinators are embedded in pediatric practices while others spend time working to engage new practices with medical home and provide ongoing engagement with other involved practices. Care coordinators help families get appointment with specialists including dental services, acquire transportation to appointments, get respite funds, and facilitate insurance coverage for services. The coordinators help each family prioritize the specific needs, link them to support groups and food pantries, if necessary, in the area, help set up home therapy, and help with any difficulties or confusion the families might be having in getting services at school, including attending meetings at the school to help set up 504 plans. CMHI Care Coordinators along with staff from the CT Medical Home Initiative at FAVOR will reach out to School Based Health Centers staff to ensure they are connected to community resources, extended service funds for pharmaceutical and nutritional products, respite and other family identified needs.     

Care Coordination Collaboratives are comprised of care coordinators from all the sectors related to children: health, early care and education, family advocacy, law, home visiting programs, state agencies, and more. They come together to learn from one another, identify areas of shared need, develop inter-agency solutions to common problems, discuss emerging challenges and connect with others engaged in improving access to services for Children and Youth with Special Health Care Needs and vulnerable, at-risk children and their families. Connecticut has five regional care collaboratives. The Collaboratives range from meeting in their regions bimonthly to quarterly with some of the regions hosting electronic meetings for their group. The Collaborative meetings host speakers that highlight a wide range of topics as they related to CYSHCN, children and adolescents. These meetings also are a time where care coordinators can discuss some complex medical needs cases to help link to other services in the community.  DPH will connect SBHC staff to their regional care collaboratives. SBHC staff identified will be invited to attend the collaborative meetings to engage with other professionals and to gain knowledge on how to better connect the student they are seeing with resources in their community.

DPH will continue to promote the Educating Practices trainings to pediatric providers throughout the state.  In 2022, the program was transferred to the Connecticut Children’s Medical Center. The contractor will provide trainings on suicide prevention as well as develop and pilot a School Based Health Center Educating Practices module to inform pediatricians and their staff about School Based Health Centers in Connecticut, what services are provided at them, and how they can be utilized by their patients.

DPH Health Survey Unit staff will continue to represent the agency on the Preventing Adverse Childhood Experiences (PACE) Data to Action steering committee and data surveillance committee.  Staff collaborated with UConn Center for Prevention Evaluation and Statistics to develop the Adverse and Positive Childhood Experiences (ACE/PCE) Surveillance Capacity Assessment Technical Report.  This point-in-time surveillance capacity assessment was conducted as a foundational activity of CT PACE Data to Action initiative.  The goals of the assessment were to identify the data and indicators proposed for CT’s statewide adverse and positive childhood experiences (ACE/PCE) surveillance system, including exposure/incidence, risk and protective factors, subpopulations at risk, and social determinants of health (SDOH), as well as data access and sharing.

Connecticut has a growing number of state and local agencies involved in suicide prevention, intervention, and response.  CT has multi-pronged, coordinated suicide prevention efforts that cross programs at the CT DPH, CT Department of Mental Health and Addiction Services (DMHAS), CT Department of Children and Families (DCF), Wheeler Clinic, and United Way of CT/2-1-1 which operates the statewide suicide crisis lifeline (CT-NSPL).  In 2020, CT DPH was awarded a 5-year CDC Comprehensive Suicide Prevention grant that used the Public Health Approach for suicide prevention.  DPH staff involved in the federally funded CT Comprehensive Suicide Prevention Project have done extensive strategic planning to identify youth 10-17 years of age and young adults 18-24 years of age as most at-risk for nonfatal suicide attempts and self-directed violence.  The 2022-2023 Work Plan requires suicide prevention and intervention strategies to be implemented between 10/1/22 and 8/31/23. Examples of strategies that will impact youth 10-17 year-olds and 18-24 year-olds are: 1) Update/improve a state-level and local-level inventory of suicide prevention resources and identify gaps and opportunities in services for residents, including youth and young adults.  Notify partners of the gaps in resources, services, and policies. 2) Promote "Fresh Check Days" mental health awareness fairs at colleges and Army/Air Force National Guard for military recruits.  3) Improve communication between local school districts and state level agencies to facilitate timely, safe and supportive response to suicide of youth or trusted adults such as teachers and coaches. Local Health Departments will encourage school-based health centers to collaborate with and use mobile crisis under 2-1-1/9-8-8 crisis services upon identification of individuals at risk.  4) Promote and support suicide risk screening in health care and behavioral health systems.  This is currently being done at CT Children’s Medical Center.  5) Implement Gizmo's Pawesome Guide to Mental Health© Elementary Curriculum (www.Gizmo4MentalHealth.org).  Plans are being made to adapt the GIZMO curriculum for middle schools and high schools.  6) Promote the implementation of the 4-What's-Next Program in middle and high schools, which is a program for high-risk students to help to help build resilience in navigating and coping with them transition to new experiences in their lives, such as transition to high school or post-high school graduation.

As part of this project, CT DPH will continue these integrated collaborations, work to sustain the statewide 1 Word, 1 Voice, 1 Life awareness campaign and comprehensive statewide website: preventsuicidect.org, and implement the statewide five-year suicide prevention strategic plan, Connecticut’s Suicide Prevention Plan 2020-2025 (PLAN 2025).  In recent years, the statewide CT Suicide Advisory Board (CTSAB) has branched out to include five (5) Regional Suicide Advisory Boards (RSABs). Each RSAB is unique and self-autonomous but supports the overall vision of the statewide CTSAB and provides the local and regional infrastructure for activities. As part of the CDC-funded project, local health agencies will continue to engage with their region’s RSABs and local prevention councils to support suicide prevention, intervention, and response in their local jurisdictions.

According to CT Violent Death Reporting System data, the under 25-year-old age group comprises 10% of suicide decedents, but according to Emergency Department and hospitalization data, represent a large proportion of people who seek emergency medical treatment for suicide attempts (SA) and self-directed violent (SDV) behaviors. About three-times higher number of females (75%) under 20 years old incurred SA and SDV-related ED visits and in-patient stays (IPs) compared to males (25%) and past data have shown that nonfatal suicide risk is higher in Hispanic female adolescents.   When looking at trends over time from 2016 through 2018, there was an upward trend for Hispanic youth, for both males and females under 20 years old.

Injury and Violence prevention and surveillance staff regularly participates in CT Suicide Advisory Board (CT-SAB) meetings and share information with Title V staff. Title V will work to build its connection to the CT-SAB and increase awareness of SBHCs as a resource for suicide prevention and intervention.

PLAN 2025 is aligned with the National Strategy for Suicide Prevention and Healthy People 2020 and be designed to be accessible to everyone. Individuals, communities, institutions, and organizations are encouraged to use the plan as their working template to guide their efforts to prevent suicide attempts and deaths in CT. PLAN 2025 was launched in September 2020, and the vulnerable populations of focus include youth and young adults, in addition to middle-aged persons. Title V staff will continue to familiarize themselves with PLAN 2025 and disseminate it to MCH stakeholders, including SBHCs.

Title V staff will work with injury and violence epidemiologists to identify higher risk school districts based on rates of suicide/SA/SDV and behavioral health needs, and link school-based health center (SBHC) staff to their respective Regional Suicide Advisory Board (RSDB). The five (5) RSABs currently help strengthen regional, community, and partnering sector infrastructure, capacity, readiness, resources, and relationships to support mental health promotion and suicide prevention, intervention, and response. The RSABs promote the use of evidence-based practices, including the state suicide prevention campaign (1 Word 1 Voice 1 Life) co-branded with the National Suicide Prevention Lifeline (NSPL), to prevent SAs and deaths. The CT RSABs can help connect SBHCs to gatekeeper training for parents, school staff, and other youth serving organizations in the community. CT has extensive QPR training capacity, including in-person and virtual offerings and modules designed for custom audiences, such as law enforcement, schools and other youth serving organizations, and medical providers. All QPR trainings include mobile crisis and NSPL resources, and there is adequate capacity to respond to increased help-seeking behaviors that often follow gatekeeper training.

The statewide 1 Word 1 Voice 1 Life campaign, developed by the CT-Suicide Advisory Board, is intended to educate CT residents on how to recognize the warning signs of suicide, how to find the words to have a direct conversation with someone in crisis, and where to find professional help and resources, including the preventsuicidect.org web site, National Suicide Prevention Lifeline, and how to access statewide mobile crisis services. The CT Comprehensive Suicide Prevention project team communications specialists will be implementing newly developed mental health awareness and suicide prevention marketing designed to impact the continuum of emotional and mental health states.  It will be implemented in four (4) phases, with the first phase being emotional health awareness and finding ways to make yourself feel better and the last phase being to heavily promote crisis services, using call centers, and 9-8-8.  The materials will be available in both English and Spanish.  Title V distributes 1 Word suicide prevention awareness campaign materials throughout all programs. DPH will work with the United Way of CT to identify at least two strategies per year to disseminate the 1 Word campaign with a focus on reaching adolescents and young adults. 

CT saw a steep rise in deaths from prescription drug and illicit opioid overdoses between 2012 and 2021 and ranked among the top ten states with the highest rates of opioid-related overdose deaths. The impact of addiction on families is immeasurable. According to CT School Health Survey data, illicit drug use among Connecticut high school youth has significantly decreased over the last 10 years (2009-2019).  This downward trend was observed for marijuana use, age at first marijuana use (younger than 13 years of age), cocaine, heroin, methamphetamines, and ecstasy. The percentage of students who were offered, sold, or given illegal drugs on school property significantly declined from 28.9% in 2009 to 19.2% in 2019.  Just over 10% of high school students reported ever taking a prescription pain medicine without a doctor’s prescription or taking it differently than how a doctor told them to use it. In 2019, the prevalence for inappropriate use of a prescription pain medicine was highest for Hispanic youth and was significantly higher than non-Black students (14.3% compared to 8.0% (White) and 4.3% for non-Black Other Race).  In the coming grant year, the OIVP will continue to share prevention messaging and materials on youth and young adult use of prescription and illicit drugs with Title V staff and programs to address health disparities by sex, race, ethnicity, sexual orientation, and gender identity.

Interagency collaboration has been the hallmark of the efforts by state agencies in CT working towards the goal of reducing opioid related deaths and overdoses. CT DPH will continue to work together with its partners to reduce of the impact of prescription and illicit drug misuse in CT by utilizing:

1) Existing CT campaigns to reach adolescents: Over the last four years, CT has learned that opioid overdose prevention and awareness communications campaigns are best leveraged through the work of multiple state agencies and partners. Examples of complementary CT campaigns include: 1) the CT 'Change the Script' campaign focused on primary prevention as well as messages around naloxone; 2) the new LIVE LOUD/Harm Reduction campaign that explicitly educates on the dangers of Fentanyl is a statewide platform for messaging addressing opioid use disorder, including prevention, treatment, and recovery;  and 3) the DPH Naloxone + Overdose Response App (NORAsaves.com), a progressive website developed to be an interactive educational tool for CT residents to help advance the use of naloxone, provide education on opioids, and help prevent overdose deaths in the state.

2) Interagency advisory bodies to assess resource gaps: The CT Alcohol and Drug Policy Council (ADPC) is a legislatively mandated body comprised of representatives from all three branches of State government, consumer and advocacy groups, private service providers, individuals in recovery from addictions, and other stakeholders in a coordinated statewide response to alcohol, tobacco, and other drug (ATOD) use in CT. The Council, co-chaired by DMHAS and the Department of Children and Families (DCF), is charged with developing recommendations to address substance-use related priorities from all state agencies on behalf of CT citizens across the lifespan and from all regions of the state. The meetings are convened every other month at the CT Legislative Office Building. The Prevention subcommittee of the ADPC meets monthly. Staff from the DPH OIVP and IVSU regularly participate in this group. This is a statewide, multidisciplinary workgroup with a mission of recommending programs, and services to prevent the onset of illegal drug use, prescription drug misuse and proper storage and disposal; to reduce stigma, and to promote effective substance misuse prevention practices that enable communities and other organizations to apply prevention knowledge effectively.

The Office of Injury and Violence Prevention (OIVP), Opioid and Drug Overdose Prevention Program is helping CT combat the ongoing drug overdose epidemic, including conducting ongoing statewide surveillance of fatal and nonfatal drug overdoses. Injury and violence epidemiologists from the Injury and Violence Surveillance Unit (IVSU) disseminate local-level and statewide data reports to a broad array of state partners and stakeholders that capture drug overdose trends in CT to support the design of targeted community prevention strategies and evaluate state-level interventions. State stakeholders will include School-Based Health Centers, school districts, and college campuses. 

The Tobacco Control Program will continue to provide information and data to community and education partners in efforts to inform adolescents, youth, and young adults as well as their parents and educators about the hazards of vaping.  This information will include the latest available research and data on the use of various substances.  Materials to be provided include both generalized educational materials and state-specific data and resources that are available for use by Connecticut residents. The Tobacco Control Program will also continue to work with various community organizations to review and revise materials, answer questions, and offer technical assistance upon request.  Through active participation on the Vaping Resource Committee of the Prevention, Training, and Technical Assistance Service Center funded by the Department of Mental Health and Addiction Services, materials have been developed and disseminated for use by the regional behavioral health action organizations who in turn share with various local prevention councils, youth service bureaus, and community groups.  The Tobacco Control Program has developed materials and presentations that are available for a variety of audiences including schools, parent-teacher organizations, youth organizations and other interested parties. During the 2021-2022 school year, a youth cessation curriculum was made available to organizations including school staff, and also provided tobacco treatment specialist training free of charge for those interested in offering programs to Connecticut youth.

The Connecticut School Health Survey will continue to collect public health surveillance data to inform various child and adolescent health programs within and external to CT DPH. The school-based survey is known nationally as the Youth Risk Behavior Survey, or YRBS). Results from the 2021 CSHS will be posted online and shared with many stakeholders and data users within and outside of CT DPH. The 2023 CSHS will be administered in the spring of 2023 and collects information on ACEs and positive experiences to help inform Objectives 9.1 and 9.2 under Goal 9; adolescent well visit information to help inform Objective 9.3; tobacco, vaping and substance use behaviors to help inform Objective 9.4; and suicide risk and attempt data to help inform Objective 9.5. ACEs-related data from the 2021 CSHS will be analyzed and presented to the PACE Workgroup and included in the CDC annual report. The CSHS will be used to satisfy the surveillance requirements of Public Act 21-1, which will legalize retail marijuana, collecting data on youth cannabis use and abuse, impaired driving, attitudes, and perception of harm.

In the spring of 2022, the CDC released again the funding opportunity to YRBS funded states to help increase knowledge about Adverse Childhood Experiences (ACEs) using the YRBS data. Connecticut DPH applied for this supplemental funding with intentions to include the panel of ACEs-related questions in the 2023 CSHS. The ACEs data will continue to support the CDC Preventing Adverse Childhood Experiences (PACE) Data to Action grant, and prevention programs within and external to CT DPH.

The CSHS will continue to collect self-reported data on many topics including in-school and electronic bullying; dental visits; physical activity level; sedentary behavior; height and weight to calculate BMI, obesity, and overweight; alcohol, marijuana and illicit drug use, adequate sleep; and self-rated health status. 

During the 2022 CT legislative session, Public Act 22-87, An Act Concerning the Identification and Prevention of and Response to Adult Sexual Misconduct Against Children was enacted by the Governor. A section of this act requires CT DPH to administer the YRBS to public high schools, requires schools to participate in the survey (which has previously been voluntary, but will still allow for students and parents to opt-out), and requires the inclusion of questions on sexual abuse. Mandatory school participation will be of great consequence, as school participation has been historically low.  The increased access to high school students across the state will allow for more reliable health estimates from future YRBS data. 

The Behavioral Risk Factor Surveillance System (BRFSS) will continue to collect child and adolescent health information (age 0 to 17 years) from an adult proxy on a variety of topics including: child’s dental visit, dental decay, and dental sealants; breastfeeding history; physical inactivity (screen time including television viewing, use of electronic devices); nutrition; and self-reported height and weight to calculate BMI, obesity, and overweight.