Insights in Public Health

Over the past two decades, the State of Hawai‘i has worked to overhaul its Mental Health Services for Children and Adolescents and to provide comprehensive evidence-informed services for children and families through a system of care (SOC) approach. Despite major accomplishments, the state continues to struggle to achieve results for certain populations. This article will describe recent and on-going efforts by a grant-funded initiative to address the special needs of one of these groups: girls who have experienced significant trauma. This initiative includes a strong evaluation component that is linked to a large national data collection effort by the Substance Abuse and Mental Health Services Administration (SAMHSA). It is expected that results of the evaluation will be published in the near future.

Similar to children's mental health service systems across the country, Hawai‘i has been challenged by the need to join efforts to serve youth across mental health, child welfare, education, and juvenile justice systems. The Hawai‘i State Department of Health's (DOH) Child and Adolescent Mental Health Division (CAMHD) recognized that the need for coordinated efforts and an effective system of care approach is particularly acute in the area of understanding, engaging, and serving girls with histories of trauma. This group is at the greatest risk compared to any other population for suicide, self-harm, running away, truancy, pregnancy, prostitution, and further victimization.^1–4 CAMHD data show that between 18% and 44% of girls with identified trauma histories are served in out-of-home treatment settings. These girls also present a major dilemma to the juvenile justice system. They are often seen in court due to “status offenses” such as truancy or running away, and they end up in detention facilities or being incarcerated despite having engaged in minimal criminal behavior. These girls often enter the “revolving door” of systems, moving in and out of residential placements, hospitalization, foster care, incarceration, and re-exposure to violence.²

Recognition of the specialized needs of this population led CAMHD leaders to apply for federal funding to test a service model specifically designed for girls exposed to trauma. Project Kealahou was designed to address a number of gaps in the standard care available to such girls in Hawai‘i by:

• Systematically identifying girls exposed to trauma and recognizing that many of their behavioral issues are rooted in trauma;

• Addressing trauma issues, including behavioral problems rooted in trauma, through individualized plans of care and a systems-of-care approach;

• Utilizing gender-responsive and culturally relevant engagement and social support practices that involve families and extended families;

• Providing adequate evidence-based treatment approaches for trauma;

• Developing effective mechanisms to build cross-agency service integration and collaboration, in order to overcome interagency conflicts and fragmented care.

Beginning in 2010, CAMHD became one of 29 sites across the United States to receive funding under the auspices of a six-year (2010–2016) Cooperative Agreement with SAMHSA as part of the Children's Mental Health Initiative's (CMHI) system of care program. Approximately twenty full-time-equivalent positions have been created within CAMHD to implement the Project in three of O‘ahu's four CAMHD service catchment areas, ie, East Honolulu, Windward O‘ahu, and Central O‘ahu.

System of Care Approach

Systems of care mark an important departure from traditional mental health service delivery in that they require systems to embrace the core values of being child-centered, family-focused, community-based, and culturally competent.⁶ In addition, systems of care reflect the core value-based principles of (1) individualized and strength-based services; (2) readily available services in least restrictive environments; (3) integrated and coordinated services, with collaboration from families and service providers; and (4) early identification and intervention.⁷ The SOC movement is more than coordinated services, it is a philosophy that supports helping each child reach their full potential by recognizing the importance of family, community, and schools to address the multiple and complex needs of children in a culturally competent and coordinated manner. In Hawai‘i, as in other jurisdictions across the country, child-serving agencies have developed separate models of care with differing mandates that often result in a “silo” effect. Youth and families with complex needs do not fit neatly into the silos; what often results is fragmented care as each agency is only concerned with their specific mandates.⁸ A true SOC must breakdown the silos and plan across agencies to support youth with serious mental health needs and their families in meeting their needs and achieving their goals.

Imperative Need for Gender-Specific, Trauma-Informed Systems of Care

National research suggests that girls are at greater risk than their male counterparts for particular life stressors.^9–11 These include specific events such as sexual abuse, which may require interventions tailored to the unique psychosocial and interpersonal characteristics of girls. Girls who have histories of trauma resulting in emotional and behavioral symptoms pose a service delivery challenge to mental health, education, child welfare, and juvenile justice systems. They are at greater risk than boys for running away, truancy, suicide, teen pregnancy, prostitution, and further victimization despite intervention efforts.^12,13

Furthermore, there is a growing body of literature detailing the links between violent victimization, abuse, posttraumatic stress disorder, and arrests/involvement in the juvenile justice system, in turn leading to a host of other issues, including suicide, and increased rates of pregnancy. ^10,15–18 These patterns of behavior are often indicative of underlying familial discord, trauma histories, and general emotional and/or behavioral dysregulation, which require intensive treatment and support.^13,19,20

Research from multiple disciplines suggests that attending to the ways in which gender differentially impacts emotional and behavioral outcomes for boys and girls may be a key to developing more effective efforts to improve the lives of young people.^21–23 For instance, recognizing a girl's need to find a safe environment and cultivate close relationships may be integral to designing successful programming for girls. Additionally, the American Psychological Association's Guidelines for Psychological Practice with Girls and Women (2007) recommend that mental health professionals and juvenile justice systems focus more attention on the interaction between gender and culture.²⁴

Changes Being Implemented

Hawai‘i's SOC initiative is called Project Kealahou, which in the Hawaiian language means “the new pathway.” This new pathway builds common trauma-informed practices across Hawai‘i's child-serving systems and moves the service system forward to address the complex needs of girls who have trauma histories. The project builds on CAMHD's existing partnerships and practices by adding components which are largely missing from the current system in order to create opportunities to change life trajectories of girls who have been traumatized.

Project Kealahou embodies system of care practices and a strengths-based, coordinated effort across system partners, including:

• Systematic identification of girls with trauma issues across child serving agencies;

• Provision of comprehensive mental health and trauma assessments;

• Utilization of a wrap-around approach for comprehensive coordinated service planning that is family-driven and youth-guided; assurance that each agency plan is fully integrated into each girl's coordinated service plan;

• Coordinated intensive case management across all involved agencies and support needs;

• Ready access to comprehensive, effective, and accountable evidence-based, trauma-focused, culturally-informed services and supports;

• Fostering of culturally-informed service approaches, assured through a Cultural Specialist;

• Full involvement of families and youth in both services and project implementation through roles in evaluation, governance, peer partner and parent partner supports;

• Employment of blended project staffing that includes clinicians, intensive case managers, family and youth partners, and a liaison to the O‘ahu probation officers;

• Partnering with other child-serving agencies to work towards blended/braided funding and shared administrative approaches;

• Development of gender and trauma-informed practices and policies across public agencies and the community.

Project Kealahou is coordinated by DOH-CAMHD with strong partnerships with the Department of Education (DOE), Family Court (FC), Office of Youth Services (OYS), the Department of Human Services- Child Welfare Services (CWS), Hawai‘i Families as Allies (HFAA), the University of Hawai‘i (UH) and provider agencies. Project Kealahou aims to partner with CAMHD, DOE, FC, OYS and CWS to build sustainable pathways for the delivery of cross-agency care management, through mechanisms such as promoting multi-agency case planning processes, cross-agency workforce development training and data sharing agreements. Along with these child serving agencies, family members and youth are full partners in the governance of the project, developing and implementing the strategic goals of the project and evaluating the progress and success of the project's initiatives. Representatives from each of these entities participated in the development of the initial grant proposal for the project, and a focus group was conducted with detained girls to inform strategies for building a viable trauma-informed system of care.

Target Population

The target population for this project is girls with serious emotional disturbances and significant trauma histories in the child welfare, juvenile justice, educational, and mental health systems in the Central, Windward, and East Honolulu catchment areas of the island of O‘ahu. Previously CMHI-grant funded areas of Leeward O‘ahu and West Honolulu (Farrington, Roosevelt and McKinley school complexes) are ineligible for these services due to the requirements of the grant program. Girls ages 11–18 will be accepted into the program, and they may stay in the program until age 21.

Project Kealahou is planning to enroll up to 500 participants over 5 years of services implementation, with referrals coming primarily from the four major child-serving agencies: CAMHD, Juvenile Justice (ie, Family Court, Girls Court, Youth Corrections and Probation), Department of Education (DOE), and Child Welfare Services (CWS). Through Project Kealahou, these four child-serving agencies and community partners will increase their awareness of the role of trauma in youth's emotional/behavioral difficulties, their understanding of the importance of family and youth engagement, their ability to assure youth's access to appropriate services including culturally relevant services, and their knowledge about appropriate services and supports to be provided.

Implementation Plan

Project Kealahou is working to address the gaps in our current system for girls with histories of trauma on two levels. (1) At the direct service level, Project Kealahou is working to develop and enhance mental health services for traumatized girls. (2) At the larger system level, Project Kealahou is working to improve the degree of integration, collaboration and shared understanding of trauma among major state agencies involved in caring for these girls. Table 1 contains a project summary illustrating the direct service level and system level interventions, and describing the overall project implementation plan.

Table 1.

Project Kealahou (PK) Objectives

GAPS	How the Project works with Girls	How the Project works with the System
Traumatized girls are under-identified and the role of trauma in youth's difficulties is not well-understood.	Outreach/social marketing to all agencies and relevant cultural groups for referrals. Trauma screening for all referred girls.	PK and Governing Council assure shared training inunderstanding trauma for staff across a range of child-serving agencies.
Youth and Family are not engaged consistently and don't drive treatment.	Engagement process includes peer and family support specialists. Female staff works with the youth. Project staff works with other service providers to increase engagement.	PK and Governing Council explore and recommend models of cross-agency shared care coordination.
Cross-agency collaboration is perfunctory; girls' treatment is stalled because multi-agency teams can't agree.	PK clinical staff works with service providers to facilitate effective team work in stuck or contentious cases.	PK co-trains Family Court along with clinical staff. PK provides cross agency training on: system-of-care principles, strength-based approaches and trauma-informed care.
Most mental health providers are not trained in and do not utilize effective evidence-based trauma treatment approaches.	PK/CAMHD staff and other providers receive training in Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). Expert consultants provide on-going support to trained clinicians.	Training capacity is established within the state to provideon-going training in TF-CBT. Training is provided to DOE and the private practice community to assure access to trauma treatment in lower levels of care.
Services are not culturally resonant for the population served.	PK staff represents a range of ethnic and cultural backgrounds. PK Cultural Specialist works with clinical staff to modify the program's approach for Hawai‘i's cultural groups.	Governing council membership is chosen to assure wide range of cultural perspectives. Outreach to engage groups with strong ethnic or cultural ties to specific parts of the community.
Lack of advocacy by youth and “youth voice.” Treatment Plans are not “youth guided.”	A paid “Peer Support Specialist” helps girls “own” their plans and guide their teams. Peer Specialists “at the table” in all project decision-making. Peer Specialists receive active support from PK Youth Coordinator.	Youth are members of the Governing Council and are compensated for their time in council meetings. Peer Specialists are co-trainers with other project staff at cross-agency training events to represent youth perspectives on agency practices.
Lack of interventions that are effective and gender-responsive.	Girls Circle groups provided in all three regions. Project develops links with local youth development groups (YWCA Hula Halau, Paddling groups, etc) and involves girls in pro-social activities. Project staff is mostly female. Quality and safety of relationships is a priority. Girls have choices about whom they will work with in therapy and which program they will attend.	Governing council explores ways to develop increased access to community-based activities for youth receiving help from social service agencies. PK provides training on gender-responsive programming across agencies.

Evaluation Plan

The wide variety of information being gathered for this project can be summarized into five major categories. First, population information addresses the characteristics of the youth and families that are served. Second, service information is compiled regarding the type and amount of direct care services used by children, youth, and families. Third, financial information is gathered about the cost of services. Fourth, system information is collected about the quality and operations of the infrastructure needed to support and sustain the enhanced youth and family services. Finally, outcome information is examined to determine the extent to which services provided lead to improvements in the functioning and satisfaction of youth and families.

Data from the evaluation of Project Kealahou will be used to improve service systems by examining several domains of performance in comparison to national results (from other currently and formerly funded CMHI sites) regarding satisfaction with services, clinical outcomes, juvenile justice encounters, school functioning, caregiver strain, and family life. The evaluation of data will lead to an increase in quality of service delivery by providing information on which services are more likely to lead to positive outcomes for girls and where service gaps still exist. Evaluation data along with feedback gathered through process evaluation efforts from family members and stakeholders will also be used to develop local policies to create a better system of care for girls with trauma and to ensure sustainability of the trauma-informed system of care beyond the 6-year project.