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Available 24/7 by phone call, text, or online. Also has support for deaf or hard of hearing. Provides support to all veterans and their families and loved ones. Funded by U.S. Department of Veterans Affairs

Patti Furguson

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24/7, confidential crisis support for Veterans and their loved ones. Contact the Veterans Crisis Line: Dial 988 then Press 1, chat online, or text 838255.

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This is staffed 24/7 with trained counselors for anyone needing help

Stefanie Smith

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This website provides risk factors for teenage suicide and signs for family to look out for. It has a lot of education and resources available.

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares.

Teen Suicides: What Are the Risk Factors?

Temperament, family and community all play a role

Nadine Kaslow, PhD

One of the myths about suicidal talk, and actual suicide attempts, in young people is that they are just a bid for attention or "a cry for help." Kids who talk or write about killing themselves are dismissed as overly dramatic-obviously they don't mean it! But a threat of suicide should never be dismissed, even from a kid who cries "Wolf!" so many times it's tempting to stop taking her seriously. It's important to respond to threats and other warning signs in a serious and thoughtful manner. They don't automatically mean that a child is going to attempt suicide. But it's a chance you can't take.

When thinking about this, it helps to understand what factors make a young person more or less likely to consider or attempt suicide. What do we know about young people who try to kill themselves, or who actually die by suicide? Let's take a look at both the risk factors-things that increase the likelihood that a child will engage in suicidal behavior-and the protective factors, or things that reduce the risk.

If a child has a lot of risk factors and hardly any protective factors you need to be extremely concerned about him. On the other hand, if he has a fair number of risk factors but a lot of protective factors you may be somewhat less concerned, although you still, of course, need to be concerned.

Here are some key suicide risk factors:

A recent or serious loss. This might include the death of a family member, a friend or a pet. The separation or a divorce of parents, or a breakup with a boyfriend or a girlfriend, can also be felt as a profound loss, along with a parent losing a job, or the family losing their home.

A psychiatric disorder, particularly a mood disorder like depression, or a trauma- and stress-related disorder.

Prior suicide attempts increase risk for another suicide attempt.

Alcohol and other substance use disorders, as well as getting into a lot of trouble, having disciplinary problems, engaging in a lot of high-risk behaviors.

Struggling with sexual orientation in an environment that is not respectful or accepting of that orientation. The issue is not whether a child is gay or lesbian, but whether he or she is struggling to come out in an unsupportive environment.

A family history of suicide is something that can be really significant and concerning, as is a history of domestic violence, child abuse or neglect.

Lack of social support. A child who doesn't feel support from significant adults in her life, as well as her friends, can become so isolated that suicide seems to present the only way out of her problems.

Bullying. We know that being a victim of bullying is a risk factor, but there's also some evidence that kids who are bullies may be at increased risk for suicidal behavior.

Access to lethal means, like firearms and pills.

Stigma associated with asking for help. One of the things we know is that the more hopeless and helpless people feel, the more likely they are to choose to hurt themselves or end their life. Similarly, if they feel a lot of guilt or shame, or if they feel worthless or have low self-esteem.

Barriers to accessing services: Difficulties in getting much-needed services include lack of bilingual service providers, unreliable transportation, and the financial cost of services.

Cultural and religious beliefs that suicide is a noble way to resolve a personal dilemma.

But what about protective factors, things that can mitigate the risk of engaging in suicidal behavior?

Here are some key protective factors:

Good problem-solving abilities. Kids who are able to see a problem and figure out effective ways to manage it, to resolve conflicts in non-violent ways, are at lower risk.

Strong connections. The stronger the connections kids have to their families, to their friends, and to people in the community, the less likely they are to harm themselves. Partly, that's because they feel loved and supported, and partly because they have people to turn to when they're struggling and feel really challenged.

Restricted access to highly lethal means of suicide.

Cultural and religious beliefs that discourage suicide and that support self-preservation.

Relatively easy access to appropriate clinical intervention, whether that be psychotherapy, individual, group, family therapy, or medication if indicated.

Effective care for mental, physical, and substance use disorders. Good medical and mental health care involves ongoing relationships, making kids feel connected to professionals who take care of them and are available to them.

So what do you do if your child fits the profile of someone at risk for youth suicide? Warning signs of suicide to be alert to include changes in personality or behavior that might not be obviously related to suicide. When a teenager becomes sad, more withdrawn, more irritable, anxious, tired, or apathetic-things that used to be fun aren't fun anymore-you should be concerned. Changes in sleep patterns or eating habits can also be red flags.

Acting erratically, or recklessly is also a warning sign. If a teen starts making really poor judgments, or he starts doing things that are harmful to himself or other people, like bullying or fighting, it can be a sign that he is spinning out of control.

And, finally, if a child is talking about dying, you should always pay attention. "I wish I was dead." "I just want to disappear." "Maybe I should jump off that building." "Maybe I should shoot myself." "You'd all be better off if I wasn't around." When you hear this kind of talk, it's important to take it seriously-even if you can't imagine your child meaning it seriously.

What to do? The first thing to do is talk.
For more information and resources on suicide, see the APA's suicide help page.

Nadine Kaslow, PhD, is a psychologist who was the 2014 President of the American Psychological Association. She is the Vice ... Read Bio

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Teen Suicides: What Are the Risk Factors? - Child Mind Institute

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Temperament, family and community all play a role Nadine Kaslow, PhD One of the myths about suicidal talk, and actual suicide attempts, in young people is that they are just a bid for attention or "a cry for help."

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This website provides information on a Elder abuse task force to combat abuse, neglect and financial exploitation of the elderly in KY.

Lizzy napoli

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The United States Attorney's Office for the Eastern District of Kentucky, in partnership with the United States Attorney's Office for the Western District of Kentucky and in coordination with the United States Department of Justice Civil Division, has launched an Elder Justice Task Force to combat neglect, abuse, and financial exploitation of seniors occurring in Kentucky.

The Task Force brings together federal, state, and local agencies involved in protecting the elderly. Task Force members include the Kentucky Attorney General's Office, Kentucky Cabinet for Health and Family Services, Kentucky Long-Term Care Ombudsman, Kentucky Department for Financial Services, Kentucky State Police, Jefferson County and Fayette County Commonwealth Attorney's Offices, Office of Inspector General for the U.S. Department of Health and Human Services, Federal Bureau of Investigation, Internal Revenue Service, U.S. Postal Service, U.S. Department of Veteran Affairs, U.S. Secret Service, and U.S. Social Security Administration, among others.

As part of this initiative, the office is actively engaged in efforts to:
Other Elder Justice Resources
The United States Attorney's Office is primarily a legal office and not an investigative agency. Please keep in mind that this office cannot represent you in any matter. therefore, you may need to consult and retain your own attorney.
Enforcement Efforts By The Office
Below you can read more about the office's enforcement efforts relating to elder justice in the Eastern District of Kentucky:
https://www.justice.gov/usao-edky/pr/erlanger-nursing-home-and-united-states-government-settle-civil-allegations https://www.justice.gov/usao-edky/pr/somerset-optometrist-found-liable-false-claims-act

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The United States Attorney's Office for the Eastern District of Kentucky, in partnership with the United States Attorney's Office for the Western District of Kentucky and in coordination with the United States Department of Justice Civil Division, has launched an Elder Justice Task Force to combat neglect, abuse, and financial exploitation of seniors occurring in Kentucky.

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This website and resource promotes healthy families by giving parents the tools they need to help their families through difficult transitions such as divorce. Beech Acres offers classes and mediation services to help parents get through difficult transitions to strengthen their family unit. They also focus on grandparents being caregivers and offer mental health services for children.
Tracy Thompson-Lang

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Because kids don't come with instruction manuals.

Beech Acres Parenting Center provides families with parenting programs, services, and expert resources for every stage of life. If you'd like more information about our programs and services, talk to one of our Parent Connections specialists who can recommend a program that's right for you and your family.

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Beech Acres Parenting Center provides families with parenting programs, services, and expert resources for every stage of life. If you'd like more information about our programs and services, talk to one of our Parent Connections specialists who can recommend a program that's right for you and your family.

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This website helps connect individuals in need with mental health treatment or addiction treatment needs.

MEREDITH FOSTER

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Oftentimes, people don't seek help for their mental health and/or addiction issues because they don't have the necessary funds in their budget. Thus, they have to make the choice to bypass treatment in order to take care of other expenses that meet their immediate needs-paying for housing, keeping utilities on, and feeding their families.

This is especially true these days, when studies have found that more than half of all Americans have less than $1,000 in their savings and checking combined. Additionally, almost two-thirds are unable to pay their credit card balances every month, which means they're borrowing more than they can pay and leaving no room for recovery-related expenses.

Fortunately, there are mental health and addiction resources available at no cost at all. Some are informative, meant to educate you about the illness or addiction so you know exactly what it is and how others have successfully overcome it. Others are action-based, supplying you with the tools or exercises necessary to begin to live a better life.

Regardless of which type you choose to access, remember that help is available and that it doesn't have to cost a thing.

MENTAL HEALTH DISORDER RESOURCES

The National Alliance on Mental Illness reports that one out of every five people struggle with some type of mental illness, and one out of 25 is battling a condition severe enough that it impacts their everyday "normal" life activities. If you have been diagnosed with a mental health condition or have not been diagnosed, yet believe that you may have one, here are some online guides and resources that can help.

Depression/Loss

Depression and Bipolar Support Alliance: This organization has a ton of depression-specific information on their website, whether you're searching for yourself or someone else. They also have training and events centered on this condition (as well as bipolar disorder), so you can pick the option that suits you best. The site features a wellness section, too, where you can read about research related to depression and learn some of the tools that can help ease it. Additionally, there are links to peer groups, enabling you to find local support with a click of the mouse.

The Center for Complicated Grief: Are you struggling with the loss of a loved one? If so, the Center for Complicated Grief's website provides information so you can better understand your grief, helping you to realize that you're not alone. It also contains links to various self-treatment options, some of which you can do right now to begin feeling better. For instance, they have an article about practicing self-compassion, an action you can take that can help you begin to work through the emotions related to your loss in a positive way.

IMAlive: This site is intended to help people who are either in crisis or considering suicide. Just click on the tab and you're able to chat immediately with a trained professional: someone who will listen as you talk about what is happening in your life; someone who can help you come up with viable and worthy solutions to whatever is causing your angst. Their goal is to provide you with the help you need so you can work through what is going on and learn to enjoy life again.

American Foundation for Suicide Prevention: If you feel like hurting yourself and think that having a support group may help, this website can help you find one in or near your area. It offers access to meeting locations in the U.S., Canada, China, Australia, and Brazil, giving you many different options regardless of where you live, work, or travel to.

Stress & Anxiety

American Institute of Stress: Realistically, everyone has stress on some level, but sometimes it can feel like too much. So, if you're looking to learn more about what stress is, how it affects you, and how to get rid of it, this website can help. It also has special sections for military personnel, offering help on a more personalized level for those who have served our country.

Anxiety and Depression Association of America (ADAA): Find support groups dedicated specifically for those who have anxiety and depression disorders using the simple online search. Some are offered in-person (with locations in the U.S., Canada, Australia, and South Africa), whereas others are conducted over the internet or by phone. The option is yours.

Post-Traumatic Stress Disorder (PTSD)

National Center for PTSD: If you have PTSD or think you may have it, the U.S. Department of Veterans Affairs (VA) can connect you with a PTSD peer-support group in your area. This enables you to meet and get to know people around you who are also suffering with PTSD, helping you learn what works best when it comes to relieving its effects.

Sidran Institute: For individuals struggling with PTSD (as well as their friends and family), visiting the Sidran Institute's website offers hope via trauma workshops, informative articles, and web links. It also provides tools designed to alleviate the stress, tension, fear, and depression common with this particular condition. It supplies a number of tips for PTSD sufferers when it comes to dealing with events that can add to this condition, such as holidays, parenting, health, and more.

Eating/Body Image Disorders

Overeaters Anonymous: Whether you overeat, under-eat, eat compulsively, binge, or purge, Overeaters Anonymous' website offers a variety of different services that can help you overcome your unhealthy food-related behaviors. From finding a local meeting full of others who feel the same to locating virtual workshops which provide support and inspiration, this site is loaded with information.

National Association of Anorexia Nervosa and Associated Disorders (ANAD): Access this website and you'll find support groups, helplines, treatment centers, and other resources designed to help overcome a variety of eating disorders. You can also request a Recovery Mentor or Grocery Buddy right on their homepage, giving you that one-on-one person who can help make your recovery a greater success.

Body Dysmorphic Disorder (BDD) Foundation: This foundation provides free online information and resources for individuals with a "disabling preoccupation with perceived defects or flaws in appearance." On their site you can learn more about BDD, take a couple different questionnaires to help you figure out if you may have it, and gain access to many different links that will connect you with other available resources for body-related issues.

Other Mental Disorder Resources

Healing from BPD (Borderline Personality Disorder): This website offers a chat room for people with borderline personality disorder. Experts who treat this specific mental health condition are in the room as well. That makes it a good place to share your thoughts about BPD, ask any questions you may have, and find helpful ideas for better dealing with the challenges you face.

International OCD (Obsessive Compulsive Disorder) Foundation: If you have obsessive compulsive disorder, this site can connect you to a variety of different resources available to you-from area programs to local support groups. This enables you to get help in the way that feels the most comfortable and appropriate for you.

Co-Dependents Anonymous (CoDA): This website provides information and literature designed to help individuals develop healthier relationships. It does this by explaining what codependence is and how to overcome it, providing you with support as you make the transition.

Emotions Anonymous (EA): EA offers supportive meetings for people who struggle with their emotions, providing a greater sense of well-being as a result. Their philosophy is, "We may each have different symptoms, but the underlying emotions are the same or similar." Thus, attending their meetings-whether in person, virtually, or over the phone-enables you to connect with others on a basic emotional level as you work together to make a positive change.

ADDICTION RESOURCES

The American Society of Addiction Medicine (ASAM) shares that addiction is a disease which affects a person's brain as it relates to reward, memory, and motivation. ASAM further states that it is also "characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one's behaviors and interpersonal relationships, and a dysfunctional emotional response."

Many different forms of addiction exist. Below, you can find out more about some of them and the online resources that may be able to help, should they apply to you or someone you love.

Alcohol Addiction

Alcoholics Anonymous (AA): Arguably the most well-known organization for overcoming alcohol addiction, Alcoholics Anonymous' website explains what they can do with their 12-step program when it comes to beating this particular addiction. It also gives you the option of finding an AA group in your area, making it easier than ever to locate people who can support you in your journey toward lifelong sobriety.

Al-Anon: It isn't just alcoholics who struggle with the negative effects of alcohol addiction; family and friends often have a difficult time, too. Al-Anon is a group designed specifically for them. It provides a safe and supportive place to share their concerns, stories, and experiences in an effort to help each other better cope with the impact addiction is having on their lives.

LifeRing: If AA's recovery model isn't of interest to you, LifeRing is another alcohol addiction self-treatment option. With focus on the Sober Self (the name they use to reference their belief that "in every addict there exists the desire to find lasting sobriety"), they strive to make that persona more powerful than the Addict Self (the part that wants control and leads to substance use and abuse). They do this through face-to-face meetings, online meetings, email groups, and forums, and the information for all of these is on their site.

Drug Addiction

Narcotics Anonymous (NA): If you struggle with narcotic addiction, NA's website can connect you to the recovery resources that make the most sense for you. You can find literature and other materials created by both members and experts, news related to NA workshops and projects, and a "Find a Meeting" option so you can locate meeting venues in and around your geographic area.

Marijuana Anonymous (MA): This online resource contains information for marijuana addicts and the people who love them. You can connect with others who are working hard to overcome their reliance on marijuana. You also have the option of downloading their app, giving you unlimited and immediate access to help right from your computer or mobile device.

Cocaine Anonymous (CA): If cocaine is the drug causing problems in your life, CA is there to help. On their website, you'll find information about cocaine addiction itself (what it is and how it came to be an issue), how CA can help in the recovery process, and where you can locate local CA meetings if you feel that support groups are the help you need.

Crystal Meth Anonymous: Just like the other 12-step groups, this one offers the same type of supportive services for individuals who struggle with addiction. The only difference is that this one is for people who abuse crystal meth. Use their site to find the meetings closest to you, enabling you to choose one that best suits your needs.

Nar-Anon: Nar-Anon's website is a great resource for friends and family members of narcotics addicts. In addition to offering their own 12-step program for loved ones, they also have links to a number of different pieces of literature on narcotics addiction to learn more about it and its effects.

Gambling Addiction

Gamblers Anonymous: Gambling addiction isn't talked about as frequently as alcohol or drug addiction, but it's an addiction nonetheless. Gamblers Anonymous is one viable option for help, because their website contains information about gambling addiction, a questionnaire you can take to determine whether you're a compulsive gambler, and various meeting locations and gambling resources to aid in your recovery.

Gambling Therapy: This online group is designed to provide email support, access to forums, and connection to online support groups for individuals who are addicted to gambling. Click on the resources tab and you'll find links to gambling information and groups across the globe who can help.

Pornography/Sex Addiction

Sex Addicts Anonymous (SAA): SAA is a group for individuals who are addicted to sex (whether diagnosed or not), and they have one goal: to offer "a message of hope to anyone who suffers from sex addiction." Their website offers information about sex addiction, explains how SAA works, and shares how to locate a meeting near you. You can also download their newsletter, The Outer Circle, directly from their site.

PsychForums' Sexual Addiction Forum: If you're looking for help for your sex addiction and prefer to use forums, then PsychForums may be the website for you. It hosts thousands of different sex-related topics, enabling you to either search out answers to your questions or to seek help from others by asking some of your own.

Youth Pornography Addiction Center: This organization is dedicated to helping parents who have teens that may be addicted to pornographic materials. From disrupting patterns early to finding effective treatment options, this site strives to make it easier for you to help your child overcome this issue while they're still young and better able to reverse their problematic behaviors.

Other Addiction Resources

Smokefree.gov: Nicotine addiction can be just as troublesome as other conditions, especially because it affects your physical health. If you're interested in learning how to effectively give up your cigarette habit for good, this site is a great online resource. You can find tips for quitting, daily challenges that make it easier to quit, access to a quit plan designed specifically for you, and encouragement and support via text messages sent right to your mobile phone.

SMART Recovery: If you're not a big fan of the 12-step model, SMART Recovery offers another option through their 4-Point Program. The four points are: building and maintaining motivation; coping with urges; managing thoughts, feelings, and behaviors; and living a balanced life. Also, they aren't as spirituality based as the 12-step programs, concentrating on self-empowerment instead.

MENTAL HEALTH & ADDICTION COMBINED

Sometimes, mental health issues and addiction go hand-in-hand. Either addictive substances are used in an effort to self-medicate, or the use of substances creates mental health concerns. A few organizations exist that are capable of providing information and support for these types of dual diagnosis situations.

Dual Recovery Anonymous (DRA): DRA offers help and support for individuals who are dependent on chemicals and have some type of mental illness. They do this via a 12-step program focused on "relapse prevention and actively improving the quality of our lives." On their site, you'll find information about dual recovery itself, meeting formats, and more.

Dual Diagnosis: Whether you're looking for information or a local support group to join for your two-sided issues, Dual Diagnosis offers both. They also have links to articles, research, and other resources that are relevant to dual diagnosis and recovery.

We're Here to Help!

If you want to learn more about what resources are available for your specific mental health and/or addiction issues, give us a call today at 800-570-3670. Our trained and compassionate staff is here to assist you with finding the best treatment options for you-no matter what type of budget you're working with!

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Free Mental Health and Addiction Resources

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Oftentimes, people don't seek help for their mental health and/or addiction issues because they don't have the necessary funds in their budget. Thus, they have to make the choice to bypass treatment in order to take care of other expenses that meet their immediate needs-paying for housing, keeping utilities on, and feeding their families.

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This website is a resource to promote education in order to prevent bullying from occurring and learning what you and I can do to help!
Jessie Shell

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Stop Bullying on the Spot

When adults respond quickly and consistently to bullying behavior they send the message that it is not acceptable. Research shows this can stop bullying behavior over time.

Parents, school staff, and other adults in the community can help kids prevent bullying by talking about it, building a safe school environment, and creating a community-wide bullying prevention strategy.

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StopBullying.gov provides information from various government agencies on bullying, cyberbullying, prevention and response.

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This website is for teens to learn about what 🤬 do the body and brain by interactive games and kid friendly reading. It also provides resources for parents and teachers.
Jennifer Brooks

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Other Resources

Clinical Trials

Clinical trials are research studies in human volunteers conducted to answer specific health questions. Learn about the NIDA-sponsored clinical trials available to you

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Parents & Educators | National Institute on Drug Abuse

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Find science-based education materials and conversation starters to educate young people about drug use and health.

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This is a small, local enterprise dedicated to getting men and women out of addiction and established in a sober life at the same time.  Christian-based. Funding is from donations from ReUse Centers, Cincy Gutter Boys, The Bridge Church, and individuals.
Kris Frank

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Reset is a Christ-centered, voluntary program for men and women in the Greater Cincinnati area that desire to radically change their lives.

Our mission is to provide an opportunity for men and women to learn a better way of dealing with life issues so that they can experience their true purpose in life.

Our program consists of five key components that are essential to helping men and women break the destructive patterns in their lives that lead to addictions, lost opportunities, and (re-)incarceration. Those five key components are dignified housing, employment opportunities, growth opportunities, hope for the future, and Biblical truth.

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Reset Ministries | Radical Recovery, Lasting Lifechange

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Reset is a Christ-centered, voluntary program for men and women in the Greater Cincinnati area that desire to radically change their lives. Our mission is to provide an opportunity for men and women to learn a better way of dealing with life issues so that they can experience their true purpose in life.

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Reaching At-Risk Populations in an Emergency

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Reaching At-Risk Populations in an Emergency

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During emergencies it is a challenge to identify and locate at risk groups. Grass root networks in communities support efforts to keep this population safe.
https://emergency.cdc.gov/workbook/index.asp
Funded by Federal money through the presidents annual budget request,contracts and grants.
Carroll Ober

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Cat Barber
Southeastern Indiana Economic Opportunity Corporation (SIEOC) is a huge resource to vulnerable populations in Southeastern Indiana.  One of their many programs is the Individual Development Account (IDA) program.  A program  designed to help low-income individuals save money.  If enrollees meet the small savings requirement, the program will triple-match their savings.  Giving the individual $3 for every $1 saved.

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This article talks about how people with a mental health issues is looked at in society. The fact that they are looked down upon and in a different way causes them to be considered a vulnerable population. The article also gives ways that the lives of those with mental health could improve with help from others in society.

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WHO | Mental health, poverty and development

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People with mental and psychosocial disabilities are a vulnerable group as a result of the way they are treated by society. They are subjected to stigma and discrimination on a daily basis, and they experience extremely high rates of physical and sexual victimization.

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Baby Steps is a program funded through St Elizabeth Foundation that specializes in working with pregnant women and new mothers that used substances during their pregnancy. It helps find treatment and resources, understand the risks of newborn withdrawal, and educates mothers on how to stay sober after delivery.
Emily Shepard

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St. Elizabeth Healthcare - Baby Steps Program

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Suicide Risk in Youth with Intellectual Disability: The Challenges of Screening

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Suicide Risk in Youth with Intellectual Disability: The Challenges of Screening

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This article talks about the children and adolescents with intellectual disabilities are often diagnosed with co-morbid psychiatric disorders and may be at risk for suicide. The difficulty in screening these individuals.

Funded by: NCBI

Ivy Smock

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J Dev Behav Pediatr. Author manuscript; available in PMC 2013 Jun 1.

Published in final edited form as:

Erica Ludi, BS, Elizabeth D. Ballard, MA, Rachel Greenbaum, PhD, Maryland Pao, MD, Jeffrey Bridge, PhD, William Reynolds, PhD, and Lisa Horowitz, PhD, MPH

Abstract

Children and adolescents with intellectual disabilities (ID), often diagnosed with co-morbid psychiatric disorders, are a vulnerable population who may be at risk for developing suicidal thoughts and behaviors. Previous research has demonstrated that direct suicide screening can rapidly and effectively detect suicide risk and facilitate further clinical evaluation and management. Currently, there are no measures that screen for suicide risk designed specifically for individuals with ID. A review of the literature was conducted: 1) to estimate the prevalence of suicidal thoughts, behaviors and deaths by suicide in children and adolescents with ID; 2) to describe associations between youth with ID and suicide risk; 3) to identify the limitations of commonly used suicide screening measures developed for non-ID youth. The literature review confirms that suicide risk exists in this population; youth with ID think about, attempt and die by suicide. Standardized suicide risk screening is challenged by the lack of measures developed for this population. A summary of the findings is followed by a discussion of the practical clinical considerations surrounding the assessment of suicide risk in youth with ID.

Keywords: youth suicide, intellectual disability, developmental delay, suicide screening, assessment

INTRODUCTION

Youth who present with suicidal thoughts and behaviors create high anxiety for clinicians. When the child or adolescent has comorbid ID, like Johnny, the clinician's concern is heightened. Triage and management of emergency situations, like the above vignette, require specially trained multidisciplinary staff to manage the crisis together with patients and family. When screening patients with ID, clinicians often find themselves at a loss as to how to directly ask the patient about current suicidal thoughts, past suicidal behavior, plan formulation and access to means. Suicide screening measures developed specifically for youth with intellectual disability do not exist.

At one time, it was suggested that lower levels of intellectual functioning protected individuals from suicidal thoughts and behaviors.1 However, studies and case reports have suggested that young people with ID think about, attempt and die by suicide. The purpose of this paper is threefold: 1) To summarize the literature on prevalence rates of suicidal ideation and suicidal behaviors in children and adolescents with ID; 2) To identify risk factors, including comorbid psychiatric disorders and immediate psychosocial stressors that are associated with suicidal ideation/suicidal behavior (SI/SB) in children and adolescents with ID; and 3) To discuss practical strategies for assessing suicide risk in the ID population, including the limitations of suicide assessment instruments developed for non-ID youth.

Definition and prevalence of Intellectual Disability

The American Association on Intellectual and Developmental Disabilities (formerly the American Association on Mental Retardation) defines an Intellectual Disability (ID) (formerly termed mental retardation) as "a disability characterized by significant limitations in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills...originating before age 18."2 It is estimated that 1-3% of the population, or seven to eight million Americans, have an Intellectual Disability3 with approximately 614,000 persons, ages 3-21 years, requiring special education in school.4,5 Typically, the ID population is divided into four categories: mild (85%), moderate (10%), severe (3-4%) or profound (1-2%).6 The ID population is widely divergent in level of intellectual functioning as well as developmental strengths, including social interaction and verbal expression. On one end of the spectrum, people with mild ID (IQ 55-70) can achieve academic skills in the sixth grade range and can generally work, marry and raise families. In contrast, individuals with profound ID (IQ < 25) are characterized by pervasive cognitive, motor and communicative impairments and usually require complete care throughout life.6 Of note, language usage has changed over the last four decades. Many terms have been used to describe this population: "intellectual disability," "mental retardation (MR)," "retardate," "developmental delay" and "developmental disability (DD)." "Mental retardation" and "retardate" are no longer acceptable terms. For this paper, the term intellectual disability will be used, with the exception of the description of a few older studies.

A Population at Risk for Comorbid Mental Health Problems

Children and adolescents with ID are vulnerable to developing comorbid psychiatric conditions. Studies have shown that 30-64% of children and adolescents with ID develop comorbid mental health disorders, a rate of 2.8-4.5 times that of their peers in the general population, including higher rates of depression, anxiety and psychosis.7-11 Persons with ID have been reported to experience more abuse, neglect, social disadvantage, challenging family circumstances, stigma, peer neglect and peer exclusion than persons without such disabilities.12-14 The "dual diagnosis15"of mental illness and ID is often missed by clinicians due to a general under-identification of emotional and mental health problems in persons with ID16,17 Given the common occurrence of this diagnostic overshadowing along with the cognitive, physical and psychiatric vulnerabilities outlined above, persons with ID are likely to be at increased risk for undetected suicidal thoughts and behaviors.

Suicide Risk in non-ID Youth

Suicide is the third leading cause of death for youth worldwide. In 2007, in the United States, 4,324 young people under the age of 24 years killed themselves.18 Even more common than death by suicide are suicidal thoughts and behavior. The latest Center for Disease Control and Prevention survey data revealed that 14% of high school students seriously considered killing themselves and 6% attempted suicide in the previous year, 2% requiring medical attention.19 Some of the most common risk factors for suicide are previous attempt, mental illness, interpersonal discord and poor physical health.20 There are a plethora of studies examining suicide risk in youth. However, the majority do not specifically address the issue of suicide risk in youth with ID; in fact, many times youth with ID are excluded.

Screening for Suicide Risk

The American Association of Pediatrics and the National Strategy for Suicide Prevention suggest screening for suicide risk as a method of suicide prevention in the general population.21-23 Screening may identify children and adolescents at risk for suicide and connect them with critical mental health treatments.21,24 Screening instruments typically query for critical risk factors such as current and past suicidal thoughts and behavior, since these are predictive of future suicide attempts25-27and death by suicide.28-31 Yet, the risk factors for youth with ID may not be the same as those established with a non-ID population. Assessment in the ID population may look different. It is unclear how to best screen youth with ID for suicide risk given the lack of guidance that exists.

In summary, youth with ID are a heterogeneous group of individuals with varying levels of intellectual and adaptive functioning. They tend to develop co-morbid psychopathology at higher rates than their peers in the general population. Since no suicide screening instruments have been created specifically for this population, youth with ID are at risk for undetected suicidal thoughts and behaviors. This paper seeks to raise awareness of suicide risk in youth with ID by summarizing prevalence reports, identifying risk factors, and evaluating current suicide screening measures.

LITERATURE SEARCH STRATEGY

In order to report the prevalence of SI/SB in youth with ID and to identify reported associations and correlations, a review of the literature was conducted by using language (English) and year restrictions (1960 to present) in six widely-used electronic databases: PubMed, Scopus, OVID, PsycInfo, Web of Science and Cochrane Library. Combinations of the following key words were utilized: "suicide," "suicidal," "youth," "children," "adolescents," "intellectual disability," "developmentally delayed," "mentally retarded" and "mental retardation." Studies that focused on adults or non-suicidal self-injury were excluded because self-injurious behavior with intent to die was the focus of this review. The results were synthesized with data from the literature on suicide screening in non-ID youth and assessment of psychopathology in youth with ID.

Prevalence of SI/SB in Youth with ID

The search strategies identified 188 articles. Of those, 175 (93%) were excluded because they focused on adults, did not specifically address SI/SB in youth with ID or focused on self-injury without intent to die. Therefore, 13 articles were identified that describe suicidal ideation and behavior in children and adolescents with ID: one comprehensive literature review,32 three prospective studies, three chart reviews and six published case reports. For a summary of key findings from the prospective studies, chart reviews and case reports, see Tables 1, 2 and 3, respectively.

Table 1 presents the prospective studies. Overall, reported prevalence of SI/SB was limited to youth with psychiatric comorbidities and estimated to be between 17-60%. Two of the prospective studies directly assessed the youth with ID.33,34 The two studies revealed rates of SI between 22-60%, compared with approximately 20% in the general population at the concurrent time period.35 They report history of behaviors to be between 17- 48%, as compared to 8% in the general population.35 In contrast, Koskentausta found that none of the parents of children with ID reported "suicidal talks" as a problem behavior for their children.36 The chart reviews in Table 2 estimate the prevalence of SI/SB to be around 20-42%. Two chart reviews37,38 do not discuss how the patients were assessed for suicide risk and found a prevalence of approximately 20%. The third chart review looked at parent report and measured prevalence of SI and "gestures" to be 42%.39 Overall, the prospective studies and the chart reviews suggest that SI/SB are present at a higher rate in samples of adolescent psychiatric patients with "MR" or ID, but reports vary by source and assessment method.

The six published case reports of patients with ID and SB are summarized in Table 3. Three40-42 describe attempt methods and stressors similar to those seen in the general adolescent suicide literature (i.e. hanging, cutting, etc)20 and three1,43,44 report on more unusual attempts (i.e. biting electrical wire, swallowing coins, refusing to eat). The case reports in this review highlight the varied manifestations of SI/SB in this population. The description of some unusual behaviors indicates that suicidal intent or the wish to die may present in a more atypical manner in this population. Such differences in clinical presentations would have important implications for the development of a screening instrument.

Variables Correlated with Suicide Risk in Youth with ID

The prospective studies and chart reviews cited in this paper identify variables associated with suicide risk in youth with ID. The most commonly reported are higher IQ, co-morbid Axis 1 disorders and recent psychosocial stressors.33,34,37,38,39

Association with Intelligence Quotient (IQ)

A number of studies have found that higher levels of intellectual and adaptive functioning can be associated with suicidal ideation and behavior in samples of individuals with ID.1,33,37,38,40 For instance, Carlson et al.33 compared IQ scores of suicidal versus non-suicidal adolescents and found that performance IQ of the suicidal adolescents was an average of 12 points higher than the non-suicidal individuals (p=.025). Similarly, Sternlicht et al.,40 who reviewed medical files of patients with "MR" at a psychiatric institution, found that the average IQ of their suicidal patients was within the "mildly retarded" range. However, some of the IQ scores (range: 16-79) of the suicidal adolescents and adults in their study fell within the "profoundly retarded" range (25 or below). Therefore, the findings are somewhat inconclusive as to whether there is a clear association with higher IQ.

Occurrence of SI/SB and Comorbid Axis I Disorder in patients with ID

Similar to youth in the general population, comorbid psychiatric disorders, like depressive disorders, post traumatic stress disorder (PTSD) and oppositional defiant disorder (ODD), have been found to correlate with SI and SB in psychiatric patients with ID.33,37,38 Carlson et al.33 observed that 67% of a sample of adolescents with MR and DD who expressed SI met criteria for a mood disorder; whereas, none in the non-suicidal group could be classified as having a mood disorder (p<.001). Similarly, Hardan et al.37 found sadness, somatization and eating disturbances were observed significantly more frequently in the suicidal group versus the non-suicidal group (p=.001, p=.033, p<.01, respectively).

Association with Immediate Stressors

Specific immediate stressors have been associated with individuals with ID expressing SI or manifesting SB. Walters et al.38 found that 36.7% of their suicidal population had experienced significant familial loss, including death, adoption or out of home placement. They also discovered that a substantial proportion of the suicidal patients had been abused physically (46%), sexually (10.5%) or both (26%). Other studies examining psychosocial stressors in suicidal versus non-suicidal individuals with ID reported that suicidal individuals experienced less family and social support, less reciprocity in relationships, greater rejection, more comorbid physical disabilities, greater stress, loneliness and isolation.5,41,45,46 These findings are limited by the use of correlation analyses, consequently the direction or causality of the relationship is difficult to extrapolate. However, as a result of this research, it has been suggested that screening procedures and suicide prevention include a focus on family bereavement, abuse and interpersonal distress.5

Evaluation of Existing Suicide Screening Instruments

Suicide screening measures designed specifically for the ID population do not exist. In an effort to examine current resources for clinicians wanting to assess suicide risk in their clients with ID, six commonly utilized suicide screening instruments and three sets of suicide screening items from longer depression evaluations for non-ID youth were identified through comprehensive assessment review articles.47,48 Evaluation criteria were established through discussion with suicide risk assessment researchers, child psychiatrists and pediatric psychologists. Each measure was evaluated for application in an ID population using the following six factors: the number of items, validated age range, response format, grammatical tense, time recall period and exclusion of individuals with ID from validation studies. Published validation studies and information from the comprehensive reviews were utilized to extract content for the evaluation. Moreover, each instrument developer was contacted by e-mail to confirm details about participant inclusion/exclusion and language of questions. Results are presented in Table 4. Specifically, many instruments are written in the past tense and have response formats with 4 or more choices. Moreover, several validation studies were done with adolescents in 6 th grade or higher and did not include individuals with ID. The following section outlines the instrument limitations in more detail.

Suicide Screening Instrument Limitations

Clinicians wanting to screen youth with ID for SI/SB utilizing instruments developed for non-ID youth are challenged by the following characteristics of the measures:

Reading Comprehension Level

Many screening questionnaires require the individual to be at an advanced grade level (6 th grade or higher), requesting that the individual read the questions or statements to themselves and respond accordingly. This can be problematic since many children and adolescents experience delays and limitations in oral language development and reading capacity and tend to read and comprehend at an elementary grade level.63

Receptive language skills

Even if an assessment is read aloud, it may include complex sentences and vocabulary. Long sentences and polysyllabic words can be difficult for an individual with ID to understand. Furthermore, many self-report measures are not intended to be read aloud, which in turn, could affect the responses.

Complex response formats

Suicide assessments often contain elaborate response formats in order to determine the timing or the severity of a suicidal thought or behavior. The participant is often asked to choose between 4 or more response options. For some instruments, the response format changes throughout the questionnaire, which can be confusing. Many individuals with ID can complete multiple choice tests, but do best with fewer and consistent choice options (2 to 3).64-66

Abstract thinking

As discussed previously, it is known that past suicidal ideation and behavior predict future behavior. 25,26,28-30 Such an assessment requires recollection of discrete past events and thoughts. Many assessments ask questions in past tense or may require an understanding of the abstract concept of time. Memory skill deficits may inhibit retrieval of past thoughts and behaviors since individuals with ID tend to be more oriented to present time and place.63

Informant component

Sometimes the warning signs for youth with ID can present differently than the signs for youth without ID. For instance, a regression in functional skill level or outward behaviors that differ from one's usual temperament can signal distress in a person with ID.67 Stereotypic and repetitive behaviors also tend to increase in frequency with agitated or irritable mood in this population. It is essential for the clinician to obtain as much information as possible regarding the individual's baseline personality, affect, behavior, capacity and skill level in order to accurately assess the divergence.68 Many times, behavioral changes or functional regression are more easily observed. Therefore, it is important to conduct behavior change assessments in this population that utilize an objective informant, such as a parent/guardian or teacher. For the above reasons, existing instruments created for non-ID youth appear to be severely limited for use in children and adolescents with ID at this time.

CONCLUSION

Children and adolescents with ID present some unique challenges for suicide risk assessment. A review of the literature suggests that children and adolescents with ID are at risk for suicidal thoughts, behaviors and death by suicide, with rates as high as 42%. Studies have identified slightly higher IQ, co-morbid psychiatric disorders and recent psychosocial stressors as correlates of suicide risk in the ID population. Previous studies and reviews have suggested healthcare providers routinely assess for suicide risk and depression in youth with ID;32,37 however, standardized evaluation of suicidal thoughts and behaviors is challenged by the lack of appropriate measures.

CLINICAL GUIDANCE

Some guidance for clinicians on generally assessing psychopathology in persons with ID has been developed. For example, in 2007, the National Association for the Dually Diagnosed published the Diagnostic Manual-Intellectual Disability: A Clinical Guide for Diagnosis of Mental Disorders in Persons with Intellectual Disability. In this manual, clinicians adapted the DSM-IV-TR for adults with ID highlighting similarities and differences in symptomatology for each disorder. Chapters for mood disorders like Major Depressive Disorder and Bipolar I Disorder are included; however, assessment of suicidal ideation is briefly discussed in one paragraph of a chapter on assessment. The paragraph emphasizes the importance of exploring self-threatening statements and behavior and limiting access to lethal means such as guns and pills, but does not provide guidance on the specific language to utilize during the suicide assessment. In addition, a number of mental health screening measures have been developed to assess psychopathology in individuals with ID. Some of the most commonly used are the Reiss Scales for Children's Dual Diagnosis,69 Nisonger Child Behavior Rating Form,70,71 the Mini Psychiatric Assessment Schedule for Adults with Developmental Disability (Mini-PAS-ADD),72 the Diagnostic Assessment for the Severely Handicapped-II (DASH-II)73 and the Assessment of Dual Diagnosis74 (ADD).75,76 While some of these measures allude to self-injurious behavior, they assess for non-suicidal self-injury such as biting or picking at wounds. The Nisonger Form is a parent-report questionnaire. Out of 66 items, there are two items assessing self-harm, asking the parent to rate "threatens to harm self" or "physically harms or hurts self on purpose" on a four-point problem scale.70

When assessing youth with ID for psychopathology in general, the parent or caregiver is commonly considered the most reliable primary data source.77 While parent corroboration is important, it may not be sufficient, as sometimes suicidal behavior and thoughts are unrecognized by caregivers. For example, in a study of SI/SB in adults with ID, the majority (16/23 or 70%) of the suicidal patients were not identified as suicidal by relatives or caregivers.78 This could in part be due to the fact that warning signs for youth with ID (i.e. changes in normal behavior, rather than verbalized statements) can be harder to distinguish and are not directly assessed. Therefore, an instrument that captures both patient and caregiver points of view on SI/SB and abnormal behaviors is critical in a population with ID.

FUTURE DIRECTIONS

A suicide risk screening instrument specifically designed to evaluate children and adolescents with ID would greatly aid clinicians in a variety of settings. Developing a single measure will be a challenge given the wide range of cognitive abilities seen in this population. While such a measure is perhaps best utilized in a group with an IQ in the mild to moderate range (IQ 75-45), clearly more advanced expressive/verbal abilities make it easier to assess the child. It is possible that an IQ subscale measure such as verbal reasoning or comprehension as compared to a performance measure, such as block design, may be a predictor of the feasibility of a suicide measure.

In general, a suicide screening instrument developed for youth with ID in the future would ideally include simplified verbal self-report, short yes or no questions read aloud or modified statements from the Childhood Depression Inventory.53 Questions or statements would be more oriented to current time and place. Moreover, it will need to include informant components (from teachers and caregivers) that collectively assess current and past suicidal ideation and behavior (any past attempts). Parent/guardian observation of troubling behavior changes or regression of functional skill level (over the past 2 to 3 months) would also be an important component (such as language from the Vineland).79 While an instrument that takes into consideration all these limitations will be helpful, clinical judgment will still be necessary, as is the case assessing any population. Careful clinical studies will need to be done with trained clinicians familiar with the uneven intellect and challenging emotional and social development seen in these youth to understand these complicated assessments. Importantly, suicide screening in youth with ID is only a first step. Careful consideration of how healthcare providers will manage patients who endorse suicidal thoughts or behaviors on a screening instrument is imperative. With a suicide screening instrument designed specifically for individuals with ID, perhaps Johnny, the case example described above, could have proactively received a more comprehensive assessment and earlier intervention before his situation became a clinic emergency.

​

A 16 year old boy, Johnny, with moderate intellectual disability (ID) tells his mother that he wants to jump off a bridge and runs towards the front door of the house. As he pulls on the door, he stomps his feet and yells "I want to die" repetitively. With the physical appearance and strength of a man, Johnny behaves in a way that is difficult for his mother to manage safely when he is upset. After an hour, she is finally able to coax him into the car and bring him to the community health center where he has been in psychotherapy for the past three months. He continues to say that he wants to jump off a bridge and tries to extricate himself from his mother's grip. The front desk personnel are unable to reach the child's usual therapist. As a result, the psychiatry attending on call, security officers, and social workers are contacted emergently to assess and manage the treatment of this adolescent. The mother reports a recent death in the family and that her son has experienced prolonged episodes of screaming and crying that are atypical for him. He has become increasingly irritable and aggressive over the past week, culminating in an attack on a classmate and a teacher's aid, with whom he normally gets along well. Soon after, Johnny began threatening to hurt himself, saying the whole family would be better off without him. Review of Johnny's chart reveals recordings of irritability and depression but no information on previous suicide assessment. It is difficult for the clinicians to gain a clear idea of whether Johnny understands death or the concept of killing himself, but they recognize that he is experiencing a significant amount of emotional distress. The clinicians begin the challenging process of formulating a realistic safety-management plan for Johnny.

Acknowledgments

Disclosure: This work was supported in part by the National Institute of Mental Health.

Footnotes

COI: There are no conflicts of interest to report.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Contributor Information

Erica Ludi, Office of the Clinical Director, National Institute of Mental Health, Bethesda Maryland.

Elizabeth D. Ballard, Department of Psychology, Catholic University, Washington, DC.

Rachel Greenbaum, Children's Mental Health Team, Surrey Place Centre, Toronto, Ontario, Canada.

Maryland Pao, Office of the Clinical Director, National Institute of Mental Health, Bethesda Maryland.

Jeffrey Bridge, The Research Institute, Nationwide Children's Hospital, Columbus, OH.

William Reynolds, Department of Psychology, Humboldt State University, Arcata, CA.

Lisa Horowitz, Office of the Clinical Director, National Institute of Mental Health, Bethesda, MD.

REFERENCES

3. American Association on Intellectual and Developmental Disabilities 2009 http://www.aamr.org.

18. Centers for Disease Control and Prevention . Web-based Injury Statistics Query and Reporting System (WISQARS) [Online] National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (producer); 2008. Available from: URL: [ www.cdc.gov/ncipc/wisqars. [2011 Dec 6] Google Scholar]

47. Goldston D. Assessment of suicidal behaviors and risk among children and adolescents. 2000. Technical report submitted to NIMH under Contract No, 263. MD-909995.

52. Shaffer D, Wilcox H, Lucas C, et al. The development of a screening instrument for teens at risk for suicide.. Poster presented at the meeting of the Academy of Child and Adolescent Psychiatry; New York, NY. 1996. [ Google Scholar]

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Suicide Risk in Youth with Intellectual Disability: The Challenges of Screening

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J Dev Behav Pediatr. Author manuscript; available in PMC 2013 Jun 1. Published in final edited form as: Erica Ludi, BS, Elizabeth D. Ballard, MA, Rachel Greenbaum, PhD, Maryland Pao, MD, Jeffrey Bridge, PhD, William Reynolds, PhD, and Lisa Horowitz, PhD, MPH Children and adolescents with intellectual disabilities (ID), often diagnosed with co-morbid psychiatric disorders, are a vulnerable population who may be at risk for developing suicidal thoughts and behaviors.

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Ensuring Access to Quality Health Care in Vulnerable Communities

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Ensuring Access to Quality Health Care in Vulnerable Communities

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It is so important that hospitals and other health care organizations build and keep a strong linkages with a diverse group of community stakeholders to ensure that the needs of vulnerable communities are supported in the future.

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Abstract

For millions of Americans living in vulnerable rural and urban communities, their hospital is an important, and often their only, source of health care. As transformation in the hospital and health care field continues, some communities may be at risk of losing access to health care services and the opportunities and resources they need to improve and maintain their health. Integrated, comprehensive strategies to reform health care delivery and payment, within which vulnerable communities can make individual choices based on their needs, support structures, and preferences, are needed.

In this Invited Commentary, the authors outline characteristics and parameters of vulnerable communities as well as the essential health care services that hospitals should strive to maintain locally identified by the American Hospital Association Task Force on Ensuring Access in Vulnerable Communities. They also describe four of nine emerging strategies-recommended by the task force-to reform health care delivery and payment and allow hospitals to provide the essential health care services, along with implementation barriers and how to address them. While this Invited Commentary focuses on vulnerable communities, the four highlighted strategies (addressing the social determinants of health, adopting new and innovative virtual care strategies, designing global budgets, and using inpatient/outpatient transformation strategy), as well as the other five strategies, may have broader applicability for all communities.

Every day, hospitals and health systems are navigating the challenges and opportunities of a constantly changing health care environment. At the American Hospital Association (AHA), we have been focusing on meeting the demands of today and tomorrow by redefining the hospital-or the "H"-to best serve patients and communities, create new models of care and collaboration, address affordability and value, and advance health in the United States.

To advance the health of all patients and all communities, the AHA developed our Path Forward, with a commitment in five areas: access, value, partners, well-being, and coordination. The health care field must work to ensure that all individuals have access to affordable and equitable health, behavioral, and social services; provide increased value to individuals; embrace the diversity of individuals and serve as partners in their health, including connecting with them in ways that make sense in the digital age; focus on well-being and partnerships with community organizations; and coordinate and integrate care.

About one in four Americans, or 77 million people, have multiple chronic conditions, and spending on patients with multiple chronic conditions across the United States consumes 71% of all health care dollars throughout all settings. Part of redefining the "H" means adjusting to this new reality-a reality of helping patients with multiple chronic conditions take charge of their health.

Redefining the "H" also requires a focus on quality improvement, population health management, and the shift from volume to value. Ultimately, this transformation will foster seamless coordination of care and integration of services to manage populations effectively, which leads to better outcomes and value for patients and health care providers.

We feel strongly that quality and performance improvements are a critical answer to addressing environmental shifts and challenges in health care. Providing high-quality care is a goal that will not waver even as the structure of the national health care system is in flux, as it is the cornerstone of health care organizations.

Quality Care for Vulnerable Populations and All Communities

For millions of Americans living in vulnerable rural and urban communities, their hospital is an important, and often their only, source of health care. As transformation in the hospital and health care field continues, some communities may be at risk of losing access to health care services and the opportunities and resources they need to improve and maintain their health. Although there are special payment programs currently in place that attempt to account for the unique circumstances of vulnerable communities, what is urgently needed are integrated, comprehensive strategies to reform health care delivery and payment within which vulnerable communities can make individual choices based on their needs, support structures, and preferences.

To this end, health care providers and payers must work together to develop strategies that can preserve and enhance health care services for all Americans. In 2015, the AHA's Board of Trustees created the AHA Task Force on Ensuring Access in Vulnerable Communities to examine ways in which hospitals and health systems can help ensure access to health care services in vulnerable communities and to identify challenges to doing so. The task force considered a number of integrated, comprehensive strategies that were emerging to reform health care delivery and payment. The ultimate goal of the task force's work is to provide vulnerable communities and the hospitals that serve them with the tools necessary to determine what the essential health care services they should strive to maintain locally are and what delivery system options will allow them to do so.

In this Invited Commentary, we outline characteristics and parameters of vulnerable communities as well as what we consider to be the essential health care services. We then describe some of the strategies recommended by the task force to reform health care delivery and payment to allow hospitals to provide the essential health care services, along with implementation barriers and how to address them. Although our focus here is on vulnerable communities, these strategies may have broader applicability for all communities.

Characteristics and Parameters of Vulnerable Communities

There is no defined set of factors that can determine whether a community is vulnerable. The AHA task force created a list of characteristics and parameters of vulnerable rural and urban communities. One or more of these characteristics or parameters may be sufficient to identify a vulnerable community:

lack of access to primary care services;

poor economy, high unemployment rates, and limited economic resources;

high rates of uninsurance and underinsurance;

cultural differences that may pose challenges, such as social, cultural, and linguistic barriers that may prevent patients from accessing care;

low education or health literacy levels; and

environmental challenges, which include unsafe streets; asthma exacerbated by air pollution, leading to unnecessary hospitalizations; housing instability, leading to environmental allergens causing symptoms that may result in inappropriate testing; and minimal or no spaces for physical activity or exercise.

In addition, certain characteristics or parameters may be unique to rural and urban communities. For example, characteristics or parameters of vulnerable rural communities may include a declining and aging population, the inability to attract new businesses, and business closures, while characteristics or parameters of vulnerable urban communities may include a lack of access to such basic needs as food, shelter, and clothing and a disproportionately high disease burden.

Essential Health Care Services for All

Across communities, the range of health care services needed and the ability of individuals to access health care services varies widely. The AHA task force recommends that access to a baseline level of high-quality, safe, and effective services should be preserved and protected within all communities. These essential health care services are:

psychiatric and substance use treatment services,

emergency department and observation care,

a robust referral structure to provide all individuals in the community with access to the full spectrum of health care services.

Part of ensuring access to these essential health care services for vulnerable communities is ensuring that care is equitable and culturally competent. Health care organizations must keep working to eliminate health and health care disparities, which still exist for far too many individuals from racial, ethnic, and cultural minorities. Doing so will require collecting race, ethnicity, language preference, and other sociodemographic data and using those data to stratify quality metrics; increasing cultural competency training for all clinicians and employees; and increasing diversity in health care leadership and governance.

Without diversity and heath equity, there is no quality. Quality, cost, equity, diversity, and community health are inextricably linked. By 2050, one in two residents of the United States is projected to self-identify as either African American, American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander, Hispanic/Latino, or multiracial, according to the U.S. Census Bureau. Yet, sociodemographic and socioeconomic characteristics continue to determine an individual's access to safe, quality care, and as the definition of diversity evolves to include gender identity, sexual orientation, and socioeconomic, veteran, and disability status, more people are affected.

To address the health care inequities that continue to persist for far too many individuals, a growing number of hospitals and health systems are playing an anchor role in communities. As an example, more than 1,500 hospitals, roughly 25% of all U.S. hospitals, have pledged to take action on specific goals to eliminate health care disparities, led by the AHA's Institute for Diversity and Health Equity.

Strategies for Ensuring Health Care Access

The AHA task force identified nine emerging strategies, each of which offers the opportunity for hospitals and communities to ensure that vulnerable populations have access to the essential health care services (described in detail in the task force report). Figure lists these emerging strategies and indicates which of the essential health care services the task force suggested each strategy could address.

In the remainder of this section, we outline four of the nine strategies. These four strategies are the ones that the AHA believes could have the broadest and most immediate impact.

Addressing the social determinants of health

The task force grappled with the reality that in vulnerable communities, even if quality care is available, the social determinants of health (SDOH; see Figure ) may prevent individuals from being able to access health care or achieve health goals.

Although there are many ways health care providers could engage to help address the underlying social conditions affecting their patients, the task force identified three general paths:

1. Screening and information: Providers systematically screen patients for health-related social needs and discuss the impact these challenges may have on their health with them.

2. Navigation: Providers offer navigation services to assist patients in accessing community services.

3. Alignment: Providers partner with community stakeholders to more closely align local services with the needs of patients.

(More information about this strategy, including a series of resources on the role that hospitals and health systems can play in addressing the SDOH, is available on the AHA website.)

Critical to addressing the SDOH is catalyzing cooperation and partnership among health care providers and community-based organizations. To that end, the AHA brought together more than 15 state hospital associations and state health department collaborators to design opportunities to work on violence, the opioid epidemic, and other issues underpinned by the SDOH.

Clinicians also have a key role in collaborations to address these issues. Although clinicians have begun to receive more education and gain experience in enhanced delivery care models and population health management, many lack education and experience collaborating with community-based organizations and addressing situations that illustrate the health impact of clinical-community linkages. For example, clinicians can work with local school districts and public health departments to increase access to primary care and dental services for children and families in underserved neighborhoods. Such clinical-community linkages can help reduce emergency department visits, promote preventive care and healthy behaviors, and connect patients to local organizations to address their specific social needs. Additionally, residency programs have not widely incorporated training on the SDOH into their curricula.

To meet the changing needs of the health care landscape and address health care disparities, residency training programs and health systems can play a role in creating a culture supportive of physicians developing skills and training to recognize and address the SDOH. More than 50% of U.S. medical schools are revising their undergraduate curricula to meet the demands of a dynamic health care system, including learning about the SDOH. For example, a recent publication from the Association of American Medical Colleges compiles a series of interesting articles about how medical schools and teaching hospitals are working to address the SDOH and achieve health equity.

Adopting new and innovative virtual care strategies

The AHA task force believed that virtual care strategies would allow vulnerable communities, particularly those that have difficulty recruiting or retaining an adequate health care workforce, the opportunity to maintain or supplement access to health care services. One virtual care strategy, which provides health care remotely by means of telecommunication technologies, is telehealth. Through videoconferencing, remote monitoring, electronic consults, and wireless communications, telehealth expands patient access to health care services and offers a wide range of benefits, such as:

immediate, around-the-clock access to physicians, specialists, and other health care providers that otherwise would not be available in many communities;

the ability to perform remote monitoring without requiring patients to leave their homes; and

less expensive and more convenient care options for patients.

Therefore, virtual care strategies, such as telehealth, can be used to fill the need for essential health care services in a variety of specialty areas and across diverse patient populations. Currently, smartphones, tablets, and computers can be used to connect patients and physicians directly, but as technology advances, the number of modes through which virtual care can be provided will increase.

Designing global budget payments

The task force also looked at new payment models, such as global budget payments, that could be designed to provide financial certainty for hospitals in vulnerable rural and urban communities. Many factors must be considered when designing these models, including, among other things, the payment levels, types of health care providers and payers that will participate, types of services to be included, and selection of appropriate quality metrics. However, ultimately, global budget payments have the potential to offer providers the flexibility to create a unique plan that meets mandated budgets and that allows them the ability and autonomy to create solutions that work for their communities.

Using inpatient/outpatient transformation strategy

The task force also recommended that an inpatient/outpatient transformation strategy would allow hospitals to more closely align the services they offer with those needed by their communities. That is, hospitals would conduct a detailed assessment of the level of inpatient and outpatient services needed in their community. Then they would take the following three steps to achieve better alignment:

1. reduce inpatient capacity to a level that closely reflects the community's need for acute inpatient beds;

2. shift resources to enhance outpatient and primary care services offered to the community as needed; and

Barriers and Resources to Address Them

For each of the nine strategies, barriers to implementation include limited federal funding, restrictive federal regulations, and a lack of collaboration and buy-in from community stakeholders (including public health departments, educational and faith-based organizations, government agencies, fire and police departments, local businesses and service organizations, and other health care organizations). Even with federal policy changes, vulnerable communities and the hospitals that serve them may not have the resources needed to successfully adapt emerging strategies on their own. Some resources for overcoming barriers include applying for grants and establishing learning networks to share information and ideas. However, the most important resource may be hospital-community partnerships.

The building of hospital-community partnerships can bring together a variety of individuals and organizations to address implementation barriers and make a bigger impact than either the hospital or a community organization could do on its own. This collaborative approach is effective because different stakeholders are addressing similar issues and serving the same populations; thus working together creates an opportunity to align efforts, reduce duplication, optimize financial resources, and, ultimately, improve the overall health and well-being of the community.

The AHA's Health Research & Educational Trust, with support from the Robert Wood Johnson Foundation, developed A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health, which includes practical tools, worksheets, and actionable strategies to build consensus and accountability within a partnership. An accompanying compendium of case studies describes nine communities with vulnerable patient populations that have developed and sustained successful hospital-community partnerships, many with multiple stakeholders.

The AHA has also designed a Community Conversations Toolkit, which can be used to engage community members in discussions related to health services offered in the community. The toolkit offers ways to focus the engagement of specific stakeholders, including patients, clinicians, and hospital leaders, through community conversation events, social media, and the use of a community health assessment. The toolkit also gathers several AHA resources that address community engagement into one place.

Working Together for Integration and Transformation

It is more important than ever that hospitals and other health care organizations build and maintain strong linkages with a diverse group of community stakeholders to ensure that the needs of vulnerable communities are supported in the future. Collaboration through community health assessments and other strategic endeavors will be vital as a foundation for identifying health priorities and aligning efforts to address them. In addition, hospitals and other community stakeholders will need to work together to identify barriers that could prevent populations from achieving good health, unite around shared goals, and work collaboratively to implement changes that promote a healthier community, while also developing a sustainable business model. Improving access to care and the value of care in vulnerable communities will involve developing innovative ways to use limited resources and to transform care for changing communities.

Acknowledgments:

The authors thank Cynthia Greising for her editorial assistance with this Invited Commentary.

Footnotes

Editor's Note: This New Conversations contribution is part of the journal's ongoing conversation on social justice, health disparities, and meeting the needs of our most vulnerable and underserved populations.

To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal's website ( http://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=61), follow the discussion on AM Rounds ( academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type "New Conversations" (see Dr. Sklar's announcement of the current topic in the November 2017 issue for submission instructions and for more information about this feature).

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

References

Reference cited in Figure 2 only

# data[].attributes.attachment_link.title
Ensuring Access to Quality Health Care in Vulnerable Communities

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For millions of Americans living in vulnerable rural and urban communities, their hospital is an important, and often their only, source of health care. As transformation in the hospital and health care field continues, some communities may be at risk ...

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Local Health Departments and vulnerable  population 

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Local Health Departments and vulnerable  population 

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Local Health Departments capacity must be increased to fulfill those roles and responsibilities, especially in meeting the needs of vulnerable populations

Jennifer Smith

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Provides children and adults with intellectual and/or developmental disabilities and other barriers with services to reach their maximum potential (New Perceptions, 2019). Some of those services include speech, physical and occupational therapy for children up to age 3, to get them ready for school. They have work training programs for adults. They help adults to find work and provide some packaging and assembly work as well. There are many other services offered through New Perceptions as well. They have a couple teams each year for the special Olympics. Our Dayton high school students played their basketball team last year. It was wonderful seeing our students lift these people up and make them so happy!!

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New Perceptions provides children and adults with intellectual and/or developmental disabilities and other barriers with services to reach their maximum potential. Seven hundred sixty one (761) individuals from Boone, Campbell, Carroll, Gallatin, Grant, Kenton, Owen and Pendleton counties of Northern Kentucky are served annually. We believe in the ability of our participants; guiding and providing them with the confidence and tools necessary to reach their goals.

Children up to age 3 are offered physical, occupational, and speech therapy to assist them in preparation for school. Three programs are offered for adults including The Work Center which offers participants assembly and packaging work, Supported Employment which offers support and skill development needed to succeed in community workplaces, and The Learning Center which offers classroom-style learning, art programming, and adult day services.

Mission/Vision/Values

The following statements shape our work, are the underlying strength of our organization and the basis for evaluating our strategic goals, programs, and partnership with the community.

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New Perceptions provides children and adults with intellectual and/or developmental disabilities and other barriers with services to reach their maximum potential. Seven hundred sixty one (761) individuals from Boone, Campbell, Carroll, Gallatin, Grant, Kenton, Owen and Pendleton counties of Northern Kentucky are served annually.

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Helps to guide adults and children with  multiple disabilities and help them reach their full potential.
Funded by the Dorothy Wood Foundation.
Private donors and business's

Leo Gripshover

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Redwood provides enriching educational, therapeutic, and vocational services to children and adults with disabilities

# data[].attributes.headline
The Watershed Addiction Treatment Programs 

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The Watershed Addiction Treatment Programs 

# data[].attributes.body
The Watershed offers medical, counseling and educational services to help those in need of alcohol and drug recovery. There is a 24/7 free help hotline to available. Recovery location options are Florida or Texas.
Funded by The Watershed.
Rachel Manter

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Dr. Mario Stefan has been working as a medical doctor at The Watershed Addiction Treatment Program for eight years. He cares for the non-psychiatric medical needs of Watershed patients. Dr. Stefan received his early medical training overseas, and after graduation ...

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Inpatient Drug Rehab & Addiction Treatment for Alcohol & Drug Addiction

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Inpatient Drug Rehab & Addiction Treatment for Alcohol & Drug Addiction, at The Watershed in Florida & Texas. Services include medical detox center, inpatient drug rehab center & aftercare. Over 55,000 people helped since 1998. Joint Commission Approved & LegitScript Certified.

# data[].attributes.body
Maternal and Child health is a concern for every person pregnant. Some women have unplanned pregnancies and with that, they may not have the funds to be able to support the child. This website will help a pregnant mother find programs, such as WIC and SNAP, to help her and her child to stay healthy during and after pregnancy. Also located on this website, are the list of the immunizations required for children.

Michelle Murphy

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Division of Maternal And Child Health - Cabinet for Health and Family Services

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Transitions is a place that offers residential and outpatient therapies for substance abuse. They provide wrap-around services based on what an individual needs are. They do this by substance use disorder education and counseling, mental health therapy, case management, and supported employment.  They offer this therapy to men and women struggling with substance abuse. Transitions is a non-profit charity.  They have many organizations involved to keep this place going.
The services provided are funded or administered by: US Department of Housing and Urban Development, Kentucky Department of Corrections, Kentucky Housing Corporation, Federal Bureau of Prisons, Northern Kentucky Regional Mental Health/Mental Retardation Board, Northern Kentucky Area Development District, Fiscal Courts of Boone Kenton and Campbell Counties, Other Government Agencies Foundations, and Individual Donors and Businesses.

Amanda Wurtz

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Parent center hub is a website that was set up to assist parents with finding resources in their area. It is a central “Hub” of information and products created for the network of Parent Centers serving families of children with disabilities.

All the materials found on the CPIR Hub have been created and archived for Parent Centers around the country to help them provide support and services to the families they serve.

Vulnerable population served: children and disabled children.

This website was produced under U.S. Department of Education, Office of Special Education Programs.

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All the materials found on the CPIR Hub have been created and archived for Parent Centers around the country to help them provide support and services to the families they serve. The CPIR employs a user-centered process, gathering the perspectives of our experienced audience-Parent Center staff members and other experts-every step of the way, to create products and services that increase Parent Centers' knowledge and capacity in specific domains.

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Camp Possible is a therapeutic camp for children ages 6-12 who struggle with behavioral/mental health issues. Campers attend for 8 weeks during their summer break. They participate in traditional and non-traditional group therapy sessions which provide opportunities to practice new skills in pro-social camp activities. Each week a new character trait will be presented with opportunities to build skills around the trait. At Camp Possible children practice skills such as anger management, self-esteem, peer relations, taking direction, interacting with adults, and more. Trained clinical staff take children into the community to practice in real-life settings that are safe and kid-friendly.
Funded by the Talbert House
Ashley McFann

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Provides support to individuals during a crisis 24 hours a day, 7 days a week. Also lists resources for youth, disaster survivors, Native Americans, veterans, loss survivors, LGBTQ+, attempt survivors, deaf/HOH, and Spanish speaking individuals.
Funded by the federal Substance Abuse and Mental Health Services Administration (SAMHSA).
Michelle Chambers

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WHO Mental Health, Poverty, and Development 

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WHO Mental Health, Poverty, and Development 

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World Health Organization-Mental Health Development. This Article describes issues with vulnerable mental health populations.
Funded by WHO.
DUSTIN WOLFE

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WHO | Mental health, poverty and development

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People with mental and psychosocial disabilities are a vulnerable group as a result of the way they are treated by society. They are subjected to stigma and discrimination on a daily basis, and they experience extremely high rates of physical and sexual victimization.

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End the cycle of child abuse by promoting individual well-being and healthy family relationships.
-Family Nurturing Center mission statement
Funded through corporate sponsorship of fundraising events (e.g., St. E), partner organizations like United Way & Kentucky Child Victims' Trust Fund, and private donations.

Pam Frink

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Programs of the Family Nurturing Center

The Family Nurturing Center offers many programs and services to serve the families of the tri-state area. You can read some of the testimonials from people we have served here.

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Programs of the Family Nurturing Center The Family Nurturing Center offers many programs and services to serve the families of the tri-state area. You can read some of the testimonials from people we have served here.

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Mental health disease is prevalent and this community is undeserved. Healthy People 2020 is addressing this issue.See link below
https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders
Funded by the Robert Wood Johnson Foundation
Carroll Ober

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Example of how to post:
Online resource to find a psychologist - Rebeca Tacy
Funded by subscriptions and advertising

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Psychology Today: Health, Help, Happiness + Find a Therapist

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View the latest from the world of psychology: from behavioral research to practical guidance on relationships, mental health and addiction. Find help from our directory of therapists, psychologists and counselors.