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 year DPH plans to hold a technical assistance meeting with SBHC coordinators and stuff to discuss how they have implemented ACES screeners into their practice.  The training was also recorded and will be posted to the DPH SBHC webpage for SBHC staff to view.  DPH will be keeping track of views and conduct pre and posttest surveys.

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.

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 4 What’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 is taking 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 in order 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 this past school year.  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 2021-2022 school year, schools plan to be open for all students and distance learning may be an option in some schools. 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.  DPH anticipates a reduction in visit numbers during this uncertain time.

The Connecticut Department of Public Health (DPH), in collaboration with the Connecticut State Department of Education (CSDE), has received federal funding and plans to offer a no-cost weekly pooled COVID-19 screening testing to schools.  Through this program DPH and SDE are hoping to provide, with the help of a testing partner, weekly pooled testing to all unvaccinated K-12 students and staff in both public and private schools in several identified high-risk areas and weekly pooled testing to all unvaccinated K-6 students and staff in all public schools in the rest of the state.  Through testing cases may be identified sooner when screening testing is utilized, weekly surveillance testing of students and staff can help increase the time students spend in the classroom and reduce the number of days/times they are required to quarantine, screening testing reduces the risk of school-based COVID-19 transmission, and it allows parents, staff, and students to have confidence in school learning.  The DPH SBHC program and staff will assist with linking this testing program with SBHCs as needed.

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 Collaborative 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 in order 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 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. 

DPH Health Survey Unit staff will continue to represent the agency on the Connecticut Suicide Advisory Board (CTSAB) which meets monthly and continue to co-chair the Data to Action committee of the CTSAB, which meets quarterly. In hopes that in-person learning resumes statewide following the worst of the pandemic, DPH staff will resume their role with the Student Wellbeing committee of the CTSAB during this project year.

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 in order 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. 

CT saw a steep rise in deaths from prescription drug and opioid overdoses between 2012 and 2020 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 in order 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 on a monthly basis. 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 disposal; and to promote effective substance misuse prevention practices that enable communities and other organizations to apply prevention knowledge effectively.

3) Support for the CT Interscholastic Athletic Conference (CIAC) to deliver prevention campaign messaging to target student athletes and their families. The CIAC is the sole provider of access to CT’s student athletes for championship games, which attract huge numbers of adolescents and their families.  CIAC will include the CT Change the Script, opioid misuse and overdose prevention, campaign messages at events and provide outreach to coaches, athletic directors, school administration, and staff.

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.  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 websites: preventsuicidect.org and www.Gizmo4MentalHealth.org, and implement the newly updated 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 connect 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 familiarize themselves with the PLAN 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 RSAB. 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-SAB, 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, NSPL, and how to access statewide mobile crisis services. United Way has recently produced video PSAs that speak to suicide prevention among selected population groups, including one for Teens and is 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. 

For the federally funded CT DPH Comprehensive Suicide Prevention grant project, extensive strategic planning has identified 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 strategies that have been selected to be implemented in September 2021 are the Gizmo Mental Health Promotion curricula in selected elementary and middle schools in CT (4-6th grades) and the 4-What’s Next program in 7-8th graders and 11th-12th graders to help build resilience in navigating and coping with major transitions in the youths’ lives.

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. DPHs Tobacco Control Program will also work with various community organizations to review and revise materials, answer questions, and offer technical assistance upon request.  Through 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 2020-2021 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 CT youth.

The Connecticut School Health Survey will continue to collect public health surveillance data to inform various child and adolescent health programs within CT DPH and external partners too.  The school-based survey (known nationally as the YRBS) 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 and vaping behaviors to help inform Objective 9.4; and suicide risk and attempt data to help inform Objective 9.5.  Results from the 2021 CSHS will be posted online and shared with many stakeholders and data users within and outside of 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. 

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.