A Scoping Review of School-Based Efforts to Support Students Who Have Experienced Trauma

Implementing a School-Wide Trauma-Informed Education Approach: An Evaluation of Student-Outcomes during the First Year of Implementation

Trauma-informed education is an internationally and widely adopted approach to support traumatized students in their needs in schools. In this two-year longitudinal pre-posttest design study, the outcomes of a school-wide trauma-informed approach during a baseline year and first year of implementation in two regular primary and six special primary and secondary schools were examined with six measurement waves. We examined students' perception of school class climate, more specifically class atmosphere, quality of student relationships, quality of teacher-student alliance and order in the classroom. In addition, we examined posttraumatic stress symptoms, internalizing, externalizing, attention and total behavioral problems, executive functioning, and resilience. Results of the piecewise latent growth curve models showed more positive scores for atmosphere in the classroom and resilience at the end of the first implementation year compared to the end of the baseline year. In addition, there was an increase in youth-reported classroom atmosphere during the implementation year. After the first year of implementing the trauma-informed educational approach initial modest positive outcomes begin to emerge.

Adverse childhood and school experiences: a retrospective cross-sectional study examining their associations with health-related behaviours and mental health

BACKGROUND

Adverse childhood experiences (ACEs) increase individuals' risks of poor health across the life course. For children that suffer household-based ACEs, experiences in other settings such as schools have the potential to exacerbate or mitigate risks of poor health. However, few studies have examined such effects. This study aimed to examine relationships between household-based ACEs, school experiences and adult health outcomes.

METHODS

A national cross-sectional household survey (N = 1,868 aged 18+) was undertaken in Wales using random quota sampling (November 2022 to March 2023). Measures included nine household-based ACEs; two measures of childhood school experience (having been bullied, sense of school belonging); and adult health outcomes (smoking, binge drinking, low mental wellbeing, mental illness, violence). Associations between ACEs, school experience and health outcomes were examined using chi squared tests and binary logistic regression.

RESULTS

The proportion reporting both having been bullied and lower school belonging increased with ACE count (0 ACEs 6%, 4 + ACEs 51%). Higher ACE count was independently associated with increased risk of all adult health outcomes except binge drinking, while poorer school experience (having been bullied, lower school belonging) was associated with increased risk of low mental wellbeing, mental illness and violence victimisation. For example, adjusted odds of current mental illness rose to 3.98 in those reporting 4 + ACEs (vs. 0 ACEs) and 3.37 in those reporting both having been bullied and lower school belonging (vs. not bullied, higher school belonging). In individuals with 4 + ACEs, adjusted prevalence of current mental illness reduced from 44% in those reporting both having been bullied and lower school belonging to 19% in those reporting not having been bullied and higher school belonging.

CONCLUSIONS

For children who grow up in adverse home environments, exposure to further adversity at school may amplify risks of poorer health and life outcomes. However, schools are opportune settings for children who lack safety and support at home to recover from stress, develop resilience and access support. Trauma-informed approaches in schools that recognise the impacts of adversity and support children to overcome it have the potential to improve educational and health outcomes. Further research is needed to identify effective approaches.

Disenfranchised Grief: The Death of a Student With Special Needs and the Coping of the School Staff - A Qualitative Study

The educational staff that meets the children at school struggles to cope with the death of a child, and often avoids talking with them about the death and their sense of loss. This way of coping is complicated in the case of grief among children with special needs, called "disenfranchised grief ". The aim of this qualitative study was to examine the experience and the perceptions of the educational staff in schools for special education and to assess their way of coping, support and care they employ following the death of a student. 15 staff members from different schools in Israel, interviewed. The findings reveal that schools are a significant source of support for students, staff and parents, alike, in the processing of the loss. The special education frameworks generally maintained a special and close connection with students and families. procedures and guidelines are required following death of a student.

A systematic review of non-clinician trauma-based interventions for school-age youth

Exposure to adverse childhood experiences (ACEs) is recognised globally as a risk factor for health problems in later life. Awareness of ACEs and associated trauma is increasing within schools and educational settings, as well as the demand for supportive services to address needs. However, there is a lack of clear evidence for effective interventions which can be delivered by non-clinicians (e.g., the school staff themselves). Thus, we undertook a systematic review to answer the question: What evidence exists for the efficacy of non-clinician delivered trauma-based interventions for improving mental health in school-age youth (4-18 years) who have experienced ACEs? The protocol for the review is registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42023417286). We conducted a search across five electronic databases for studies published between January 2013 and April 2023 that reported on interventions suitable for non-clinician delivery, were published in English in the last 10 years, and involved participants aged 4-18 years (school-age) that had exposure to ACEs. Of the 4097 studies identified through the search, 326 were retrieved for full text screening, and 25 were included in the final review. Data were extracted from included articles for analysis and selected studies were quality assessed using validated assessment tools. Data were analysed through narrative synthesis. There was considerable heterogeneity in study design, outcome measures, and the interventions being studied. Interventions included CBT, mindfulness and art-based programs. A key finding was that there is a lack of high-quality research evidence to inform non-clinician delivered trauma-informed interventions. Many included studies were weak quality due to convenience sampling of participants and potential bias. Cognitive Behavioural Therapy (CBT)-based approaches are tentatively suggested as a suitable target for future rigorous evaluations of interventions addressing ACE-related trauma recovery and mental health improvement in school-age youth.

Characteristics of mental health literacy measurement in youth: a scoping review of school-based surveys

Mental health literacy (MHL) was introduced 25 years ago as knowledge and beliefs about mental disorders which aid in their recognition, management, or prevention. This scoping review mapped the peer-reviewed literature to assess characteristics of secondary school-based surveys in school-attending youth and explore components of school-based programs for fostering MHL in this population. The search was performed following the method for scoping reviews by the Joanna Briggs Institute (JBI). Searches were conducted in four scientific databases with no time limit, although all sources had to be written in English. Primary studies (N = 44) provided insight into MHL surveys and programs for school-attending youth across 6 continents. Studies reported that most youth experience moderate or low MHL prior to program participation. School-based MHL programs are relatively unified in their definition and measures of MHL, using closed-ended scales, vignettes, or a combination of the two to measure youth MHL. However, before developing additional interventions, steps should be taken to address areas of weakness in current programming, such as the lack of a standardized tool for assessing MHL levels. Future research could assess the feasibility of developing and implementing a standard measurement protocol, with educator perspectives on integrating MHL efforts into the classroom. Identifying the base levels of MHL amongst school-attending youth promotes the development of targeted programs and reviewing the alignment with program components would allow researchers to build on what works, alter what does not, and come away with new ways to approach these complex challenges, ultimately advancing knowledge of MHL and improving levels of MHL.

Trauma-sensitive school concepts for students with a refugee background: a review of international studies

Children and adolescents with a refugee background are at high risk for traumatization. Once they arrive in safe countries, schools are the institutions where teachers are responsible for caring for them sensitively and competently. Furthermore, schools are organized in learning groups consisting of multiple peers of the same age, which provides excellent opportunities for social learning and experiences of social support. In this respect, schools are the appropriate places where preventive concepts can be applied to students with a refugee background. This systematic review summarizes studies that examine or evaluate existing international concepts of trauma-sensitive schools for supporting traumatized students with a refugee background. Based on N = 41 selected articles, 17 relevant concepts of trauma-sensitive schools were identified. In 35.3% of the concepts, traumatized students with a refugee background are explicitly included in the target group of the concept, while 47.1% of the concepts refer to groups of students with trauma as a result of various adverse childhood experiences, which also occur more frequently within the population of refugee children and adolescents 17.6% of the concepts contain specific adaptations for pupils with a refugee background. The majority of these concepts were developed in the United States. Additional concepts can be reported for Australia, the United Kingdom, Turkey, and Cambodia. Based on available empirical data, no significant effectiveness regarding the researched concepts' effects on academic and other school-related data can be determined. Although some studies indicate positive effects concerning school-related target variables, most of the studies have only limited significance due to inadequate research designs and methodological deficiencies. Therefore, there is a great need for further development, careful implementation, and evaluation of trauma-sensitive concepts in schools, especially for the growing group of refugee students.

Differences in Well-Being at School Between Young Students With and Without a Refugee Background

Students with a refugee background are a vulnerable group in education. Adverse experiences and unsafe circumstances that they encounter prior, during and after their flight can place a great burden on their mental health and psychological well-being. Little is known about the psychological well-being of young refugee students in kindergarten and early years of primary school. The current study examined the psychological well-being of 4- to 8-year-old students with a refugee background residing in the Netherlands (n = 136), compared to Dutch peers without a refugee background (n = 406). Primary school teachers completed three questionnaires which assessed multiple indicators of their students' psychological well-being: Strengths and Difficulties Questionnaire (SDQ), Social-Emotional Questionnaire (SEV) and Risk and Protective factors Trauma Observation School Situations (RaPTOSS). In line with the hypothesis, results showed overall lower psychological well-being among refugee students compared to non-refugee students. Teachers observed more total difficulties in socio-emotional functioning, anxious and mood disturbing behavior, ADHD symptoms, problematic social behavior and post-traumatic stress symptoms (small effects), and less developed trauma protective factors and prosocial behavior (medium effects) among students with a refugee background compared to their non-refugee peers. However, the findings also demonstrated that half of the refugee students did not have any scores that fall in the clinical range of the psychological and behavioral problems assessed. The results underline the need to promote protective factors such as positive self-image, self-regulation skills, safety and relations in the classroom and prosocial behavior among students with a refugee background.

Implementing trauma-informed care in a special education setting: An initial exploration of a multi-tiered model

Implementing trauma-informed care in a special education environment serving youth from historically marginalized communities with high levels of exposure to potentially traumatic events (PTEs) requires a systematic tiered approach consistent with public health guidelines. Little is known about the implementation of this framework in special education settings where youth have significant emotional and behavioral difficulties. To address this need, a consultant-community partnership was forged between a hospital providing mental health services and a therapeutic day school that serves a special education cooperative. The current case study explores the design and implementation of a three-tiered model of trauma-informed care in a special education setting. This study will address the specific practices implemented at each tier, discuss successes and challenges, and summarize future directions for research, practice, and policy.

Exploring School Professionals' Definitions of Childhood Trauma

PURPOSE

Little is known about school professionals' definitions of trauma outside of the context of trauma-informed school trainings.

METHODS

The present study used thematic analysis to explore school professionals' open-ended definitions of childhood trauma (N = 1271). Follow-up chi-square tests of independence were used to investigate differences in professionals' definitions based on their professional role and education.

RESULTS

Five themes were identified: effects of trauma, events of trauma, solutions to trauma, emotional responses, and no knowledge. Effects of trauma and events of trauma contained ten and five subthemes, respectively. School professionals who identified long-term effects of trauma on students most commonly listed general negative effects (e.g., "An experience or event that can negatively impact that child") instead of effects on specific domains such as behavior or emotions (e.g., "An experience that negatively impacted a child emotionally"). School professionals who identified an event of trauma most commonly provided examples of trauma (e.g., child maltreatment) or a general definition of trauma. School professionals' roles and education were somewhat related to their definitions of childhood trauma. Findings suggest that childcare providers and professionals without a bachelor's degree have gaps in their knowledge of child trauma.

CONCLUSIONS

These results suggest school professionals have some foundational knowledge about trauma, but it is not universal. To best serve school professionals working with this vulnerable population of students, researchers and practitioners should design future trauma-informed professional development opportunities around school professionals' prior knowledge and understanding of trauma as well as their potential misunderstandings of trauma.

Minding the gap: Evidence, implementation and funding gaps in mental health services delivery for school-aged children

State and local educational agencies are grappling with growing mental health needs among school-aged children that intensified during the COVID-19 pandemic. We undertake a case study of the experiences of one state, Tennessee, to examine the landscape of mental health interventions that are being deployed and to illuminate contextual factors that can support their implementation or exacerbate state and local challenges in addressing children's fast-rising mental health needs. We begin with an examination of the knowledge base on interventions and approaches that are commonly employed in K-12 schools to address children's mental health needs, including in Tennessee, with the aim to identify notable gaps in what we understand about their implementation and impacts on student outcomes. We find a lack of rigorous research that can inform efforts to improve the implementation and effectiveness of school-based mental health interventions. We bring this insight to our case-study analysis, which shows that this lack of guidance from research is compounded by inadequate, time-limited and fluctuating public funding that hinders local efforts to establish strong, ongoing programs that provide or connect K-12 students to essential mental health services. We call for more federal funding to support state and local implementation of proven and promising interventions for addressing children's mental health needs and more rigorous evaluations to strengthen the evidence base on their implementation and impacts.

School-Based Interventions for Child and Adolescent Victims of Interpersonal Violence

BACKGROUND

Interpersonal violence against children and adolescents can affect their mental health and functioning in the long term. To reduce mental health problems in children and adolescents, school-based mental health interventions have been shown to be beneficial. A review of school-based interventions designed to mitigate posttraumatic symptoms after interpersonal violence is lacking to date.

METHODS

We searched for original studies published in English or German until November 2019 in 6 electronic databases. Supplementary search strategies to reduce publication bias were implemented. Peer-reviewed original studies assessing school-based interventions for children and adolescents under the age of 21 after interpersonal violence were included. Relevant data was extracted, synthesised and assessed qualitatively. The methodological quality of included studies was assessed.

RESULTS

Of 5,021 unduplicated publications, 15 studies met eligibility criteria. The included studies were almost exclusively conducted in the USA; over half utilised a randomised-controlled design. Studies mainly focussed on Posttraumatic Stress Disorder (PTSD) or depression. In all studies, implemented interventions partially or fully mitigated posttraumatic symptoms. Nine school-based interventions, five of which were based on cognitive behavioural therapy (CBT), were identified. School staff were often involved in intervention implementation besides mental health professionals.

CONCLUSIONS

School-based interventions can be beneficial to reduce mental health problems in children and adolescents after interpersonal violence. Trained school staff aided by mental health professionals can implement trauma-informed practices at school. While school-based interventions may be a feasible way to provide children and adolescents with accessible mental health care, further research on school-based trauma interventions outside the USA is necessary.

A Scoping Review on the Use and Potential of School-Based Drama Therapy to Enhance Socio-emotional Skills in Early Childhood

Drama therapy incorporates play, imaginary engagement, embodiment, and perspective taking to promote interpersonal skills and affective functioning. Existing school-based drama therapy (SBDT) research has demonstrated utility with select populations; however, much of the SBDT literature has featured disparate findings. Absent from the current literature is a thorough synthesis of the benefits of SBDT for socio-emotional development in early childhood, an age cohort that may be well suited for drama therapy due to the method's theoretical and practical focus on action, symbolism, and play. A scoping review was conducted to answer the research question: What is the use and potential of SBDT to enhance socio-emotional skills in early childhood? Following a thorough database and manual search, 406 articles were identified and, after screening, 16 articles met the inclusion criteria. Based on the results, practice recommendations include the use of metaphor, distance, and life-drama connection to enhance socio-emotional skills, using dramatic play as a tool to address adverse experiences, and applying SBDT to support specific clinical populations. Policy recommendations include the use of SBDT within a public health trauma approach and the need for ecological integration of SBDT into schools. Research recommendations include the need for a broad-level articulation of a scaffolded SBDT research agenda in schools focused on socio-emotional skills and recommendations specific to methodological and reporting rigor.

Mental health in refugee children

Almost half of the world's forcibly displaced population are children, most commonly originating from Syria, Iraq, and Afghanistan. Health disparities are well documented, especially for mental health, but not consistent across groups, time or context. Despite high exposure to trauma and stress, refugee children also show remarkable resilience. An ecological model of refugee health including both risk and resilience factors is therefore recommended. The model also includes the dynamic inter-relationship of past traumatic experiences, ongoing daily stressors and the disruptions of basic systems affecting both the individual and families as a whole, offering a framework to better understand the health disparities and appropriate interventions for refugee children.

Australian Educators' Perceptions and Attitudes Towards a Trauma-Responsive School-Wide Approach

Staff perceptions and attitudes regarding the introduction of the Reframing Learning and Teaching Environments (ReLATE) trauma-responsive school-wide approach were investigated in three Catholic primary schools in Victoria, Australia. School leaders, teachers, and support staff were interviewed regarding their experiences of the approach either individually or in focus groups. Educator attitudes towards trauma-responsive education was evaluated using the ARTIC-ED Scale, prior to and after participating in the six-month intervention. Qualitative data were interpreted using ecological analysis of the themes arising guided by the trauma informed principles and frameworks of the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Trauma Learning Policy Initiative (TLPI). Findings indicated significant shifts towards trauma-responsive practice following the introduction of ReLATE. Strong themes emerged relating to the influence of improved trauma knowledge on perceptions of student behavior, consequent reported adaptations to behavior management practices, strengthened sense of trust and respect in the school climate, the centrality of leadership to effect change, and importance of school-fit to program uptake. Strengths and limitations of ReLATE are considered, along with implications for teacher professional learning, the role of leadership in effecting change and significance of perceived school-fit and collaboration.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-021-00394-6.

Generating youth dialogue through the literary arts: A citywide youth health collaboration in the U.S

A process and outcomes evaluation was conducted of a citywide literary-arts initiative designed to reduce stigma, amplify underrepresented narratives, and generate dialogue about violence. Over 4 months, students in 85 middle schools read a novel addressing mental health and violence-related themes. As a collaboration between a public school district and public library system, the program's classroom activities emphasized dialogue, while coordinated library events supported community engagement. Students completed pre/postsurveys (total n = 1487); school program leaders (n = 39) and public librarians (n = 14) completed postsurveys. Half of student respondents reported personal encounters with violence. Most said the novel influenced their thinking; students with personal experiences of violence reported greater influence than those without. Highest rates of dialogue were seen among students who read the novel in full, and over half of postsurvey respondents wanted more dialogue opportunities. Leaders and librarians indicated that the program was smoothly integrated with existing curricula, but also offered recommendations for improved processes. Findings suggest that this intervention was effective at stimulating dialogue while providing assets-based opportunities for youth to share experiences and concerns. Current program processes indicate promise for further engagement and impact, with some modifications. To this end, authors draw upon evaluation findings and youth development literature to offer recommendations for program development and replication in other regions.

Effectiveness of Promotive and Preventive Psychosocial Interventions on Improving the Mental Health of Finnish-Born and Immigrant Adolescents

Background: Schools are considered natural environments in which to enhance students’ social–emotional skills and mental health in general, but they can be especially important for students with refugee and immigrant backgrounds. The current study tested the effectiveness of two school-based interventions in enhancing the mental health and wellbeing of adolescents of native, refugee, and immigrant backgrounds. It further analyzed the role of age, gender, daily stressors, and discrimination in affecting the interventions’ effectiveness. Methods: A three-arm cluster RCT with parallel assignment was applied among the 16 schools. Schools were randomized to three conditions of two active interventions and a waiting-list control condition. Students (n = 1974) filled in an online questionnaire at baseline before the interventions, after the interventions, and at follow-up an average of 9 months after the interventions. The effectiveness criteria were internalizing and externalizing problems, resilience, and prosocial behavior. Results: Interventions were generally not effective in decreasing mental health problems and increasing psychosocial resources. The expected positive intervention effects were dependent on students’ age and gender and exposure to socioeconomic daily stressors. Conclusion: Interventions enhancing teacher awareness and peer relationships at school should be carefully tailored according to the strengths and vulnerabilities of participating students, especially their daily stress exposure, but also age and gender.

Associations Between School Mental Health Team Membership and Impact on Service Provision

Schools are the most common venue in which children and youth receive mental health services. To organize delivery of mental health care to such a large number of children, use of school teams is often recommended. Yet, there is limited empirical literature about the composition of school mental health teams or teams’ relations to service provision. This study investigated team composition, including team multidisciplinarity (number of different types of professionals) and the presence of a community provider, and the relations of these two variables to service provision at Tier 1 (mental health promotion), Tier 2 (early intervention) and Tier 3 (intensive treatment) for 386 schools representing different school sizes, locations, and urbanicity. Results suggested team multidisciplinarity and the presence of a community provider were related to more frequent endorsement of service provision at schools. Practice and research implications are discussed including possible application to hiring decisions and further research with longitudinal data and information on service quality.

Parenting activities and the transition to home-based education during the COVID-19 pandemic

This study reports on parent-child dynamics during initial COVID-19 related school closures, based on cross-sectional analyses of a survey that utilized a convenience sampling approach. Data were collected in April 2020, approximately five weeks after the World Health Organization declared that the Coronavirus was a pandemic. Participants (N = 405) were adults recruited throughout the U.S. This study examines data from parents (69% mothers and 31% fathers) with at least one child 0-12 years of age. The majority were White (71%) and 41% had at least a bachelor's degree. The majority of parents (78%) were educating their child at home due to COVID-19. Most (77.1%) reported use of online tools for at-home education, including educational apps, social media, and school-provided electronic resources. More than one-third (34.7%) of parents said their child's behavior had changed since the pandemic, including being sad, depressed, and lonely. Most parents were spending more time involved in daily caregiving of their children since COVID-19. Two out of every five parents met the PHQ-8 criteria for major depression or severe major depression (40.0%) and the GAD-7 criteria for moderate or severe anxiety (39.9%). Multivariate analyses indicated that, compared to non-depressed parents, parents who met criteria for probable major or severe depression (B = -0.16, 95% CI = [-0.29, -0.02], p = .021) and parenting stress (B = -0.37, 95% CI = [-0.47, -0.27], p < .001) were negatively associated with parents' perceived preparation to educate at home. Compared to parents with minimal or mild anxiety, parents with moderate or severe anxiety reported higher child anxiety scores (B = 0.17, 95% CI = [0.06, 0.28], p = .002). Parenting stress was also positively associated with higher child anxiety scores (B = 0.40, 95% CI = [0.32, 0.48], p < .001). Content analyses of open-ended questions indicated that school closures were a significant disruption, followed by lack of physical activity, and social isolation. Overall, study results suggested that parents' mental health may be an important factor linked to at-home education and child wellbeing during the pandemic.

Moving Policy Toward a Whole School, Whole Community, Whole Child Approach to Support Children Who Have Experienced Trauma

BACKGROUND

As attention to the potential negative outcomes of childhood trauma has grown, so have calls for schools to take an active role in supporting students experiencing trauma. These calls extend beyond efforts initiated by individual schools to include those mandated by state law, which largely focus on teacher training and on screening for adversity.

METHODS

This article explores the evidence base and limitations for current approaches in state law and explores how policies to address other student health, safety, and wellness issues can help either ameliorate or exacerbate students' experiences with trauma.

RESULTS

Few trainings for nonclinical staff have rigorous evidence of effectiveness, and based on evidence of teacher trainings on other topics, cannot work in environments that do not actively reinforce and encourage the application of that knowledge. Trainings also largely do not acknowledge the structures and systems, including systemic racism within schools, that may contribute to disparate rates of adversity for black and American Indian and Alaskan Native children. Screening carries several risks, including confounding adversity with experiencing trauma, missing broader contextual adversity, and potentially retraumatizing children.

CONCLUSIONS

State policymakers need to take a more holistic approach in creating policies to support students experiencing trauma.