Effects of trauma‐informed approaches in schools: A systematic review

Background Exposure to different types of trauma have been associated with varying types and complexity of adverse outcomes, including adverse effects on cognitive functioning, attention, memory, academic performance, and school‐related behaviors. Given the growing research on trauma and increased knowledge about the prevalence, consequences and costs associated with trauma, there have been increased efforts at the local, state and federal levels to make systems “trauma‐informed” (Lang et al., 2015). Indeed, federal legislation has been proposed to advance trauma‐informed practice, with approximately 49 bills introduced between 1973 and 2015 that explicitly mentioned trauma‐informed practice, with more than half introduced in 2015 alone (Purtle & Lewis, 2017). The promotion and provision of trauma‐informed approaches in school settings in particular is growing at a rapid rate across the United States. At least 17 states have implemented trauma‐informed approaches at the school, district, and even state‐wide levels (Overstreet & Chafouleas, 2016). This rapid increase in the growth of trauma‐informed approaches in schools has been fueled by a number of local, state, and federal initiatives and increasing support by education related organizations. While the intent of creating trauma‐informed approaches in schools is a noble one, relatively little is known about the benefits, costs, and how trauma‐informed approaches are being defined and evaluated (Berliner & Kolko, 2016). Adopting a trauma‐informed approach in a complex system such as a school building or district is a time consuming and potentially costly endeavor, and there is potential for harm; therefore, it is important to assess the effects of this approach to inform policy and practice. Objectives The purpose of this review was to identify, describe and synthesize the evidence of effects of trauma‐informed approaches in schools to provide guidance for policymakers and educators and to identify important gaps in the evidence base. Search methods We conducted a search for published and unpublished studies using a comprehensive search that included nine electronic databases and searches of various research registers, gray literature sources, reference lists of prior reviews and relevant studies, and contacts with authors and researchers in the field of trauma and school‐based intervention research. Selection criteria Criteria for inclusion in the review included: 1.Must have used a randomized or quasi‐experimental study design in which participants who received an intervention were compared with a wait‐list, no treatment, treatment‐as‐usual or an alternative treatment comparison group. 2.Studies must have been conducted in a school setting serving PreK‐12 (or equivalent) students. 3.Studies must have assessed effects of a trauma‐informed approach, defined as a program, organization, or system that realizes the impact of trauma, recognizes the symptoms of trauma, responds by integrating knowledge about trauma policies and practices, and seeks to reduce retraumatization. At last two of the three key elements of a trauma‐informed approach must have been present: Workforce development, trauma‐focused services, and organizational environment and practices (Hanson & Lang, 2016). This approach is distinguished from trauma‐specific interventions, which are specific interventions designed to treat or otherwise address the impact/symptoms of trauma and facilitate healing. 4.Studies must have measured a student‐level outcome related to trauma symptoms/mental health, academic performance, behavior, or socioemotional functioning. 5.We did not limit studies based on publication status, geographical location or language. We searched for studies that had been published in the last 10 years, as this is a relatively recent movement Data collection and analysis One reviewer searched all sources and uploaded all potentially relevant citations to Covidence, a systematic review software, for further screening by two reviewers. Two reviewers then independently screened each of the full‐text reports for eligibility using a screening instrument. Disagreements related to eligibility were discussed and resolved between the two reviewers. Data extraction and analysis was not possible due to no studies having met criteria for inclusion in the review. Results A total of 9,102 references from all searches were imported to Covidence for screening. After removal of 1,929 duplicates, 7,173 titles/abstracts were screened, and 7,106 studies were excluded. The remaining 67 studies were assessed for full‐text eligibility by two independent reviewers. All 67 studies were excluded: 49 were neither an randomized controlled trial (RCT) nor quasi‐experimental design (QED); 12 did not examine effects of a trauma‐informed approach; 5 examined only one aspect of a trauma‐informed approach (only workforce OR organizational OR practice changes); one was not a school‐based intervention. Some studies may have been excluded for multiple reasons; however, only the first (primary) reason for exclusion was recorded. See Figure 1 for flowchart of the search and selection process. A full list of excluded studies can be found in References to Excluded Studies. No studies met criteria for inclusion in this review. Authors' conclusions Trauma‐informed approaches are being promoted and used across child‐serving systems, and the number of states and school districts adopting trauma‐informed approaches in schools is growing rapidly (Overstreet & Chafouleas, 2016). While the premise of a trauma‐informed schools approach is a noble one, it is unclear as to whether the promise of this framework is actually delivering the types of systemic and programmatic changes intended, and if those changes are resulting in the outcomes the proponents of a trauma‐informed approach in schools hoped for. The purpose of this systematic review was to find, describe, evaluate, and synthesize effects of trauma‐informed approaches in schools to inform policy and practice. While there are a number of publications that describe trauma‐informed approaches, advocate for the need for trauma‐informed approaches, and discuss the potential benefits of adopting such an approach in schools, we found no rigorous evaluations through our extensive search process. From this review, it seems like the most prudent action for school leaders, policymakers, and school mental health professionals to do would be to proceed with caution in their embrace of a trauma‐informed approach as an overarching framework and begin evaluating these programs. We simply do not have the evidence (yet) to know if this approach works, and indeed, we also do not know if implementing trauma‐informed approaches in schools could have unintended negative consequences for traumatized youth and school communities. We also do not have evidence of other potential costs in implementing this approach in schools, whether they be financial, academic, or other opportunity costs, and whether benefits outweigh the costs of implementing and maintaining this approach in schools. That said, calling for caution in adopting a trauma‐informed approach in schools does not preclude schools from continuing to implement evidence‐informed programs that target trauma symptoms in youth, or that they should simply wait for the research to provide unequivocal answers. We do encourage healthy skepticism and evaluation by the schools who are adopting a trauma‐informed approach and clear descriptions of what schools are doing. Currently, despite several theoretical and guidance documents, it is not clear exactly what schools are doing when they say they are using a trauma‐informed approach. Not only do we need more research on the effects, but descriptive and qualitative research on what is actually being implemented would be a welcome addition to the empirical literature in this area. We suspect that schools may be calling what they are doing a trauma‐informed approach, but what is actually being done from school to school or district to district may vary quite widely in the practice and implementation of this approach. Clearly, rigorous research is needed in assessing the effects of using a trauma‐informed approach in schools and we encourage rigorously designed studies in this area. Evaluating complex interventions such as this is not easy and requires resources. Drawing from research on multi‐tiered approaches in schools could help inform research approaches to assess the effects (and costs) of trauma‐informed approaches in schools.