Multi-Tiered Approaches to Trauma-Informed Care in Schools PDF

School Mental Health (2019) 11:650–664 https://doi.org/10.1007/s12310-019-09326-0 REVIEW PAPER Multi‑tiered Approaches to Trauma‑Informed Care in Schools: A Systematic Review Emily Berger1 Published online: 10 May 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract...

School Mental Health (2019) 11:650–664 https://doi.org/10.1007/s12310-019-09326-0 REVIEW PAPER Multi‑tiered Approaches to Trauma‑Informed Care in Schools: A Systematic Review Emily Berger1 Published online: 10 May 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Childhood trauma can adversely impact academic performance, classroom behaviour, and student relationships. Research has gradually explored integrated approaches to care for traumatised students in schools. Increasingly, research has pointed to implementation of multi-tiered programs to trauma-informed care for traumatised students in schools. However, evaluations of these programs are limited and no systematic review of the existing evidence has been conducted. The aim of this research was to be the first systematic review to explore evidence on multi-tiered, trauma-informed approaches to address trauma in schools. Results of this systematic review yielded 13 published and unpublished studies. Findings indicated that further research, guided by empirical evidence of the effectiveness of multi-tiered and trauma-sensitive approaches in schools, is required. Recommendations for research in the area of trauma-sensitive, multi-tiered care in schools are provided. Keywords Trauma · Post-traumatic stress disorder · Multi-tiered · Trauma-informed · School Introduction The relationship between trauma exposure and impaired school-related functioning, including behavioural issues, social and emotional concerns, and academic impairment, is well established. Trauma exposure in childhood is associated with lower academic achievement and test scores, lower IQ scores and impaired working memory, and delayed language and vocabulary (Perfect, Turley, Carlson, Yohanna, & Saint Giles, 2016). Traumatised students exhibit poorer attention, disruptive behaviours, aggression, hyperactivity and impulsivity, defiance, and school suspensions, absences and grade retention, as well as depression, anxiety, withdrawal, and low self-esteem (Perfect et al., 2016). Research has also found traumatised children with post-traumatic stress disorder (PTSD) show greater school-related impairment compared to trauma-exposed children without PTSD (Weems et al., 2013). However, while research continues to demonstrate a link between school-related outcomes and trauma, the limited literature has explored the experiences of school staff and teachers in relation to traumatised children. Several * Emily Berger [email protected] 1 Faculty of Education, Monash University, 19 Ancora Imparo Way, Clayton, VIC 3800, Australia 13 Vol:.(1234567890) studies have concluded that trauma-informed practices be implemented in schools to increase support for school staff, improve responses to traumatised children, and reduce behavioural and academic problems of students (e.g. Alisic, 2012; Alisic, Bus, Dulack, Pennings, & Splinter, 2012; Mendelson, Tandon, O’Brennan, Leaf, & Ialongo, 2015). Studies with school teachers and students have found teachers’ experience uncertainty, lack competence, and have limited training and policy knowledge in relation to childhood trauma (Alisic, 2012; Alisic et al., 2012; Dyregrov, 2009; Dyregrov, Bie Wikander, & Vigerust, 1999; Kenny, 2001, 2004; Papadatou, Metallinou, Hatzichristou, & Pavlidi, 2002). Trauma-related confidence has been shown to relate to greater teaching experience, exposure to traumafocused training, and involvement with traumatised children (Alisic et al., 2012). Other studies have documented secondary PTSD symptoms among school staff exposed to student trauma (Berger, Abu-Raiya, & Benatov, 2016; Bride, 2007; Smith Hatcher, Bride, Oh, Moultrie King, & Catrett, 2011). Following the 2011 Canterbury earthquake in New Zealand, Berger and Abu-Raiya et al. (2016) reported positive implications of a universal, school-based, resilience program in reducing teacher PTSD and secondary trauma, increasing self-efficacy and optimism, and improving coping of teachers. A universal, school-based, trauma-informed program for disadvantaged students was also found to improve School Mental Health (2019) 11:650–664 students’ emotion regulation, social competence, academic performance, classroom behaviour, and authority acceptance (Mendelson et al., 2015). An increasing number of studies have shown positive effects of school-based interventions for students with PTSD. The Cognitive Behavioural Intervention for Trauma in Schools (CBITS) and ERASE-Stress program have been reported to lower symptoms of PTSD and depression among students (Berger & Gelkopf, 2009; Jaycox et al., 2009). Teacher-mediated interventions have also had positive impacts on trauma-exposed children, including the Students Exposed to Trauma (SSET) program, adapted from the CBITS program (Jaycox et al., 2009), and programs developed in response to childhood exposure to war and disaster (Powell & Bui, 2016; Wolmer, Hamiel, Barchas, Slone, & Laor, 2011; Wolmer, Hamiel, & Laor, 2011). However, while a growing number of studies have shown the positive effects of school-based interventions related to trauma, little is known about integrated, multi-tiered systems of support to manage trauma in schools. Integration of trauma-sensitive programs within existing evidence-based frameworks is likely to increase the sustainability of school programs in response to student trauma (Chafouleas, Johnson, Overstreet, & Santos, 2016; Nadeem & Ringle, 2016). Several multi-tiered ‘triangle’ or ‘pyramid’ prevention frameworks have been proposed for school mental health promotion. The School-wide Positive Behaviour Support (SWPBS; also known as school-wide PBS, positive behavioural interventions and supports [PBIS], and multi-tiered systems of support [MTSS]) framework is an evidence-based, three-tiered model of intervention, including Tier 1 for universal support of all students regardless of emotional or behavioural concerns (e.g. community-wide disaster exposure); Tier 2 for intensive secondary support with groups of students at risk or showing early signs of emotional or behavioural issues (e.g. directly witnessing or experiencing trauma); and Tier 3 for tertiary, intensive, and individualised intervention for students with significant emotional or behavioural problems (e.g. PTSD as a result of trauma exposure; Sugai & Horner, 2006; Weist et al., 2018). This three-tiered approach is also represented in other frameworks, including the response to intervention (RTI) model (IDEA, 2004), the Public Health Model for Mental Illness and Risk Behaviours (Mrazek & Haggerty, 1994), and, more recently, trauma-informed approaches for rural and disadvantaged students (Hansel et al., 2010; Stokes & Turnbull, 2016). However, better alignment of trauma-informed models within existing multi-levelled, school-based support systems has been suggested to increase delivery and fidelity of trauma-sensitive policies and practices in schools (Chafouleas et al., 2016; Phifer & Hull, 2016; Plumb, Bush, & Kersevich, 2016; McDermott & Cobham, 2014; Reinbergs & Fefer, 2018; Weist et al., 2018). 651 The aim of this systematic review was to evaluate the evidence and address the strengths and limitations of research regarding multi-tiered, trauma-informed interventions in schools. In particular, this review aims to highlight the growing literature concerning the practice of trauma-sensitive, multi-tiered treatment of students in schools, evaluate the design and methods used in evaluating these models, and provide recommendations for improved trauma-based research and program implementation in schools. Although case studies, literature and systematic reviews have been conducted (e.g. Fu & Underwood, 2015; Phifer & Hull, 2016; Price et al., 2012; Rolfsnes & Idsoe, 2011; Weist et al., 2018), this review will focus on evaluating the evidence on alignment of these approaches in schools. This review is timely based on recent suggestions for better clarification around methods for integrating trauma and positive behaviour approaches in schools (Zakszeski, Ventresco, & Jaffe, 2017). Greater understanding of alignment between traumainformed approaches and tiered school-based intervention and support programs is anticipated to increase research for greater adoption of these approaches in schools. This will likely improve staff knowledge and confidence regarding trauma, increase the overall efficiency of schools in accommodating traumatised students, enhance students’ school engagement and academic achievement, and improve posttraumatic growth and recovery of trauma-impacted students. Method Search Strategy The PRISMA protocol, Cochrane handbook and JBI scoping reviewers manual were used to inform this review. Six electronic databases (i.e. PsycINFO, Ovid MEDLINE, ERIC, A+ Education, Web of Science conference proceedings citation index—Science, and ProQuest Dissertations and Theses Global) were used to search for the published and unpublished literature (i.e. conference proceedings and theses), written in English only, and using search terms such as trauma, disaster, violence, post-traumatic stress disorder, PTSD, multi-tiered, trauma-informed, positive behaviour support, PBS, response to intervention, RTI, and school. The inclusion of the published and unpublished literature, including theses and conference proceedings, was decided because this is a relatively new area of research. Because of this, no exclusions were also placed on the year of publication for perspective articles, and other published and unpublished materials. Inclusion of studies was those which referred to and provided evidence of a multi-levelled approach to trauma-sensitive care in schools, including intervention across teachers, parents and/or students. Therefore, articles referring to intervention within one tier of a multi-tiered 13 652 School Mental Health (2019) 11:650–664 model, such as evaluation of an indicated intervention for children identified with PTSD, were excluded from this review (e.g. Cohen et al., 2009; Jaycox et al., 2009). These programs have been reviewed extensively in the past (see, for example, Chafouleas, Koriakin, Roundfield, & Overstreet, 2019; Rolfsnes & Idsoe, 2011). Articles using qualitative and quantitative approaches, or a mixed methodology, were included to capture all the available literature in the area, as well as the literature across all levels of schooling from preschool to secondary school. Research conducted across specialist school settings (e.g. residential treatment centres) were excluded due to the Tier 3 treatment needs of these populations (e.g. one-on-one lessons and support; Day et al., 2015). The search was conducted from March 2018 through May 2018. The search strategy procedure and outcomes are Fig. 1  Search strategy and outcomes presented in Fig. 1. The initial search yielded 1018 results. Of the 1018 results, 265 were excluded as duplicates. All remaining 753 results underwent screening by title, with 408 excluded and 345 retained for screening by abstract. Excluded articles related to school violence and disruptive behaviour prevention, and other articles with no association to trauma. Screening by abstract revealed a further 171 records to be removed and 174 to be retained for screening by full text. Full-text records were then reviewed to reveal 10 results to be retained. The final excluded articles only evaluated one tier of school trauma interventions, or referenced other externalising and internalising disorders with no association made to trauma. These results were then subject to cited reference screening which yielded no records, and a Google Scholar search was conducted to identify an additional three records. Total arcles idenfied (n=1018) PsycINFO (n=298) Ovid MEDLINE (n=61) ERIC (n=199) A+ Educaon (n=11) Web of Science conference proceedings citaon index – Science (n=237) ProQuest Dissertaons & Theses Global (n=212) Screening for duplicates (n=1018) Removed (n=265) Remaining (n=753) Screening by tle (n=753) Removed (n=408) Remaining (n=345) Screening by abstract (n=345) Removed (n=171) Remaining (n=174) Screening by full text (n=174) Removed (n=164) Remaining (n=10) Cited reference screening Idenfied (n= 0) Google Scholar screening Idenfied (n=3) Total arcles/citaons idenfied (n=13) 13 School Mental Health (2019) 11:650–664 Studies excluded were those that dealt exclusively with school violence intervention, behaviour management practices, and other internalising and externalising problems (e.g. community violence and school bullying; Runge, Knoster, Moerer, Breinich, & Palmiero, 2017), as well as articles that described programs and their implementation, but did not evaluate the outcomes of these programs (e.g. McDermott & Cobham, 2014; Saltzman, Layne, Steinberg, Arslanagic, & Pynoos, 2003). Data Extraction and Coding Records were extracted by the author and coded according to the PICOS categories and additional variables, including (a) country where the study was conducted; (b) participant numbers and demographics; (c) type of trauma experienced (e.g. disaster, war, violence); (d) study design and measures; (e) type of intervention implemented; (f) tier levels included; (g) outcomes of the research; and (h) study limitations. Details of the identified studies are included in Table 1. Results Three‑Tier Programs Ten studies were identified as including three levels of intervention for trauma in schools (Cicchetti, 2017; Dorado, Martinez, McArthur, & Leibovitz, 2016; Garfin et al., 2014; Hansel et al., 2010; Hurley, Saini, Warren, & Carberry, 2013; Layne et al., 2008; McConnico, Boynton-Jarrett, Bailey, & Nandi, 2016; Perry & Daniels, 2016; Shamblin, Graham, & Bianco, 2016; Stokes & Turnbull, 2016). These programs varied in their application and evaluation of the tiers (e.g. Layne et al., 2008 evaluating only two of the three tiers) and included training and/or consultation for school staff and parents, social-emotional curriculum with all students and group-based intervention with at-risk students. Layne et al. (2008) conducted the only randomised control trial (RCT), while seven studies involved pre- and post-evaluation design, one a qualitative evaluation (Hurley et al., 2013), and one presented a post-program investigation (Cicchetti, 2017). There was clear variation in the use of validated and descriptive assessment tools, including school attendance and performance data (e.g. Dorado et al., 2016; Stokes & Turnbull, 2016), and staff and student attitudes and knowledge questionnaires (e.g. Student Attitude to School Survey; Teacher Opinion Scale). The University of California Los Angeles Post-Traumatic Stress Disorder Reaction Index for the Diagnostic and Statistical Manual of Mental Disorders IV (UCLA PTSD Index) was used to assess student PTSD in four of the identified studies. Two of the three-tiered models focused on processes underlying 653 a trauma-informed approach rather than traditional wholeschool behaviour management tiers, including relationship building and attachment, emotional and behavioural regulation, and post-trauma resilience and growth (Hansel et al., 2010; Stokes & Turnbull, 2016). Four‑Tier Programs Three studies were identified as including intervention across four tiers of a trauma-sensitive model (Ellis et al., 2013; Holmes, Levy, Smith, Pinne, & Neese, 2015; Saint Gilles, 2016). These models included community and parent engagement, emotional/behavioural intervention for students, identification of students, and referral of students to mental health services. Two of these programs (Holmes et al., 2015; Saint Gilles, 2016) also involved weekly monitoring of the model with school staff for greater fidelity; however, this was not identified as a form of intervention (e.g. follow-up with school staff). Similar to the three-tiered programs, evaluation of aspects of the four-tiered models was limited (e.g. Saint Gilles, 2016). Some variation but also similarities was observed in the design and measures used to evaluate the programs, such as use of war-related measures and the UCLA PTSD Index by Ellis et al. (2013), and measures of children’s internalising and externalising symptoms (e.g. Behaviour Assessment Scale for Children Second Edition [BASC-2] and the Achenbach System of Empirically Based Assessment [ASEBA]) used by Holmes et al. (2015) and Saint Gilles (2016). Discussion This systematic review evaluated the literature on multi-levelled, trauma-sensitive interventions in schools. The review identified 13 studies implementing three or more tiers of school-based support and training for childhood trauma. Many assessed components but not complete tiered systems in response to trauma, including qualitative and teacherreport data of student outcomes, and pilot evaluations. Many additional studies were excluded from this review because of the lack of specific evaluation of screening processes with students (e.g. Cohen et al., 2009) and training programs with staff. Studies involving screening may be viewed as multitiered, with universal screening constituting Tier 1 and targeted intervention with at-risk students constituting Tier 2. Unfortunately, school resources to screen and the limitations of measures to identify at-risk students require further consideration (see Gonzalez, Monzon, Solis, Jaycox, & Langley, 2015; Woodbridge et al., 2015). Studies reported positive improvements in student academic achievement and behaviour (Holmes et al., 2015; McConnico et al., 2016; Saint Gilles, 2016; Stokes & 13 Country USA USA Citation Cicchetti (2017) Dorado et al. (2016) Design Intervention Tier levels Results Strengths Limitations Students, school staff and hospital staff Post-evaluation design CBITS and bounce back Emphasis on internal Clinical perspecSchools with Three tiers: (1) tive with limited school mental behavioural health training and information to health collaborateams identified supervision for assess program and tion and teams and treated more staff, development outcome measures students in Tier of multidiscipli2, and students nary teams, and engaged more implementation of with in-school and trauma-informed community-based practices; (2) services CBITS and Bounce Back with students; and (3) connecting schools with behavioural health team with mental health providers Use of retrospective Complete multiThree tiers: (1) train- Increased staff UCSF Healthy Retrospective pre– 1243 students in pre- and post-evaltiered model of knowledge about ing for staff, parEnvironments post-evaluation; the first year from uation. Little infortraining and suptrauma, trauma ents and students; and Response to HEARTS program four elemenmation on different port presented for impacts and (2) small group Trauma in Schools evaluation survey; tary schools; levels of school students, teachers use of traumawellness and train(HEARTS) based pre and post 47% female and staff (e.g. teachers and parents across sensitive pracon the Attachment, ing intervention discipline referrals 53% male; 38% compared to school three tiers tices. Increased for staff and at-risk Self-regulation and suspensions; African-American, counsellors) student learning, students; and (3) and Competency CANS scale pre, 34% Hispanic or on-task behaviour crisis support for (ARC) framework during and followLatino, and 28% and attendance, trauma-impacted ing intervention other; 175 teachand decreased teachers, families ers, administrators discipline referrals and students and school welfare and suspensions. staff Improvements in CANS subscales of adjustment, regulation, intrusion, attachment and dissociation Participants Table 1  Studies obtained from the systematic search on multi-tiered, trauma-focused interventions in schools 654 School Mental Health (2019) 11:650–664 13 Country USA Chile Citation Ellis et al. (2013) Garfin et al. (2014) Table 1  (continued) Intervention Skills for life (SFL) Supporting the Pilot follow-up Health of Immistudy; WTSS; grant Families PWA—Somali and Adolescents version; UCLA (SHIFA) PTSD Index; DSRS; EDD; sense of belonging; acculturative hassles; Tier 3 program fidelity monitored through weekly clinician meetings Design Pre- and post119 randomly evaluation study; selected second TOCA-RR; PSCgrade students CL; UCLA PTSD from nine schools Index; measures impacted by earthof caregiver–child quake. conflict, caregiver availability and ongoing earthquake worry 30 middle school refugee youth in English language learner class; 19 male and 11 female; 18 Somali and 12 Somali Bantu ethnicity Participants Results Strengths Limitations Pre- and post- evalu- Limited evaluation Four tiers: (1) com- Improved menon Tier 1 of the ation of student tal health and munity engageprogram. Focus on resources across all outcomes across ment and parent a small sample of multiple tiers levels. Stabilisaoutreach; (2) emorefugee students. No tion of resources. tional management evaluation of staff Improved sympand resilience and parent outcomes toms of depresbuilding intervension and PTSD tion for students; for Tier 2, 3 and and (3) and (4) 4 participants. identification Greater PTSD of students and symptom improveintensive services ment for Tier 3 or and mental health higher participants. treatment (using Tier 2 reported TST) lower depression than other tiers. Decrease in resource hardship across all tiers Limited distinction Complete multiThree tiers: (1) skills Lower PTSD and between Tier 2 and tiered model of ongoing earthbuilding training Tier 3. No evaluatraining and supquake worry for for children, teachtion of teacher and port presented for ers and parents; (2) children in indiparent outcomes students, teachers cated compared to group intervention for at-risk students, Tier 1 intervention. and parents across two tiers At-risk children at and their teachers universal and indiand parents; and cated Tiers did not (3) referral of chilreported greater dren with severe PTSD symptoms risk to external than children not services at-risk. Children in indicated programs reported less earthquake-related worry after controlling for other factors Tier levels School Mental Health (2019) 11:650–664 655 13 13 USA Hansel et al. (2010) Holmes et al. (2015) USA Country Citation Table 1  (continued) Design Pre- and post-pro81 preschool chilgram evaluation; dren referred for CTES, ASEBA; HSTS services; CLASS 64% male; 39% African-American, 15% non-Latino white, and 46% other or not specified Tier levels Results Three tiers: (1) rela- Reduced student trauma symptoms, tionship building; including lowered (2) trauma educaoverall PTSD, tion and consultation for school staff intrusion, avoidance/numbing and the comand arousal, and munity; and (3) lowered anxiety, trauma therapeutic depression and services for youth post-traumatic (TF-CBT) stress Head Start Trauma Four tiers: (1) train- Improvements in ing for school staff; teacher-reported Smart (HSTS) student concentra(2) individualised based on the ARC tion, classroom trauma-focused model, TF-CBT, behaviour and intervention; (3) and early childexternalising classroom conhood mental symptoms, and health consultation sultation between parent-reported mental health proimprovements in viders and teachstudent externalisers; and (4) staff ing and internalispeer mentoring ing symptoms. Reported parent and teacher program satisfaction Intervention Rural school-based 115 students receiv- Pre- and posttrauma treatment intervention study; ing therapeutic program impleUCLA PTSD intervention; mented by the Index; TSCC 52.2% males and Louisiana Rural 47.8% females; Trauma Services students exposed Centre to traumatic events Participants Limitations Complete multitiered model of training and support presented for students, teachers and parents across multiple tier Limited specific evaluation of Tier 1, 3 and 4 outcomes, including outcomes for parents and teachers Limited or no evaluEvaluation of ation of teacher and classroom strateparent outcomes gies to care for trauma-impacted students consistent with Stokes and Turnbull (2016) Strengths 656 School Mental Health (2019) 11:650–664 Country USA Bosnia Citation Hurley et al. (2013) Layne et al. (2008) Table 1  (continued) Evaluation of the Qualitative themes: Based on the Three tiers: (1) model only from response to (1) preschool bonds and supthe perspective intervention multichildren’s experiport provided to of educators. The tiered model for ence of violence, all children; (2) model does not student intervencommunication social and emoinclude training and tion and support challenges and tional strategies support of staff and cultural misunderimplemented for parents. Qualitative standing leading to children in need of only design challenging school additional support; behaviour; (2) culand (3) intentural issues, barrisive behavioural ers and approaches intervention for (including children with significant and per- relationships and structure) related sistent behavioural to implementdifficulties ing elements of the model; and (3) responding to the needs and strengths of all students RCT of student No evaluation of Reduced PTSD Three tiers: (1) outcomes teacher and parent and depression classroom educaoutcomes. Evalusymptoms in tion and coping ation of two of the both treatment skills intervention; three tiers and comparison and (2) traumagroups, reduced and grief-focused depression and group treatment maladaptive grief (e.g. TGCT). reactions for treatIntervention also ment condition included school only, and improved staff training and PTSD and depressupervision in sive symptoms at program imple4-month follow-up mentation for treatment and comparison group Limitations Response to intervention (RTI) pyramid model Strengths Qualitative study using semi-structured interviews Results Tier levels Intervention Design RCT using pre- and Evaluation of the 127 war-exposed, post-treatment, and TGCT intervenbereaved and tion 4-month followpost-war impacted up; UCLA PTSD adolescents attendIndex; DSRS; ing 10 schools in UCLA Grief Bosnia; primarily Inventory Muslim students (63% female) 25 early childhood educators, early childhood special educators, and Head Start teachers and administrators living in refugee resettlement communities Participants School Mental Health (2019) 11:650–664 657 13 Country USA Citation McConnico et al. (2016) Table 1  (continued) Design Pre- and post12 early childhood education teachers; pilot evaluation; CLASS; teacher 81% female; 68% self- perceived aged 25–34 years; knowledge and 250 kindergarten, confidence; first and second teacher views of grade students the program and student views of the strategies Participants Outcomes based Increased staff Three tiers: (1) on qualitative self-perceived training program self-report from knowledge of for early childhood students and staff, the impacts and educators; (2) curand pre- and postriculum to promote effects of trauma in childhood. Little evaluation with self-esteem and staff increase in selfefficacy among perceived knowlchildren; and (3) edge of availongoing consultaable resources. tion and coaching Increased selffor staff efficacy and confidence among staff. Endorsement of the importance of trauma-informed education for staff and the curriculum. Qualitative reports from staff that the program assisting student emotion regulation, prompted continued classroom engagement, reduced behavioural disruptions and promoted a positive classroom climate Strengths Supportive trauma interventions for educators (STRIVE) Results Tier levels Intervention Qualitative evaluation of student outcomes and no evaluation with parents Limitations 658 School Mental Health (2019) 11:650–664 13 Country USA USA Citation Perry and Daniels (2016) Saint Gilles (2016) Table 1  (continued) Design Intervention Head Start preschool Experimental design, pre- and setting including post-intervention agency-level parevaluation; ticipants (n = 5), DCEAP2; BASCteachers (n = 10) 2; STSES and children (n = 106) Head start trauma smart (HSTS) program Clifford beers Pilot study using School servicing clinic (CBC) pre- and post410 students from professional measures; PD pre-kindergarten satisfaction survey; development, care through 8th grade; coordination and student-focused 82% Africansatisfaction survey; clinical service American, 13% components Hispanic or Latino, UCLA PTSD Index and 5% white; 32 teachers and/ or administrators; 77 clinical service students from 5th- and 6th-grade classrooms Participants Results Strengths Limitations Pilot study conducted Staff reported train- Evaluation of and Three tiers: (1) in one school. Limimprovement in ing satisfaction, education for staff ited use of standincreased self-care, teacher, stuand students; (2) ardised measures of dent and parent recognition of and (3) identificaprogram outcomes outcomes and trauma, changed tion and individual collaboration attitudes regardreferral, or CBITS ing trauma, and intervention for knowledge of small groups of classroom stress students, as well as reduction stratecontinued teacher gies. Improved consultation staff–family communication and parent advocacy for the program. Student reported increased recognition of stress and knowledge of help sources. Some reduction in PTSD symptoms in CBITS group Included tiers focus- Low reported program Four tiers: (1) train- No changes in fidelity. Limited ing on teachers, ing for school staff; teacher-reported distinction between students and other confidence to (2) individualised Tier 1 and Tier 3 school personnel manage secondary trauma-focused and Tier 4 results PTSD. Reduced intervention; (3) internalising difficlassroom conculties for children sultation between in the intervention mental health procompared to the viders and teachcomparison group ers; and (4) staff peer mentoring Tier levels School Mental Health (2019) 11:650–664 659 13 Intervention Tier levels Results Strengths Limitations 13 ASEBA Achenbach System of Empirically Based Assessment Second Edition, BASC-2 Behaviour Assessment Scale for Children, CANS Child and Adolescent Needs and Strengths, CBITS Cognitive Behavioural Intervention for Trauma in Schools, CLASS Classroom Assessment Scoring System, CTES Childhood Trust Events Survey, DECA Devereux Early Child Assessment, DECAP2 Devereux Early Childhood Assessment Preschool Program, DSRS Depression Self-Rating Scale, EDD Everyday Discrimination Scale, PMHCS Preschool Mental Health Climate Scale, PSC-CL Paediatric Symptom Checklist for Chile, PWA Post-War Adversities Scale, SASS Student Attitude to School Survey, STSES Secondary Trauma Self-Efficacy Scale, TF-CBT Trauma-focused Cognitive Behavioural Therapy, TGCT​ Trauma and Grief Component Therapy, TOCA-RR Teacher Observation of Classroom Behaviour Revised for Chile, TOS Teacher Opinion Scale, TSCC Trauma Symptoms Checklist for Children, TST Trauma Systems Therapy, UCLA PTSD Index University of California Los Angeles Post-Traumatic Stress Disorder Reaction Index for the Diagnostic and Statistical Manual of Mental Disorders IV, WTSS War Trauma Screening Scale Stokes and Turnbull (2016) USA Limited evaluation Complete multiImproved teacher Partnership Program Three tiers: (1) Pre- and Post11 preschool of Tier 3 interventiered model of self-perceived Training for staff for Early Childintervention study; classrooms across tion and distinction training and supconfidence and and social-emohood Mental TOS; PMHCS; five elementary between Tier 1 and port presented for hopefulness to tional curriculum Health and Project DECA; ECMHC schools; 11 teachTier 2 staff training students, teachers manage challengwith students; (2) LAUNCH based satisfaction survey ers teaching 217 and parents across ing behaviours, individual parent– on the Early students; 550 Head three tiers teacher and teacher decrease in use of Childhood Mental Start children in negative behavconsultation; and Health Consulta28 classrooms; 28 iour management (3) assessment tion (ECMHC) teachers and home strategies and and TF-CBT, visitors classroom stress, and parent–child decreased negative interactive therapy attributes of the intervention learning setting, and increased teacher ratings of child resilience No inclusion of parEvaluation of Improvements in Three tiers: (1) Pilot pre- and post- Berry Street Australia 52 grade 5 to 8 ents in the model. classroom strateself-perceived repairing students Education Model intervention study students from one Level of teacher gies to care for preparation of regulatory abili(BSEM). using focus groups primary school, training and consultrauma-impacted teachers, increased ties; (2) repairing with staff and and one combined tation is unclear student self-regula- students consistent students disrupted students; SASS; primary and with Hansel et al. tion during transiattachments; and academic and secondary school; (2010) tion, perceived (3) increasing school suspension 28 teachers and peer and student– students psychodata school leaders teacher relationlogical coping to ship improvepromote postments, improved traumatic growth. student academic Teacher and staff achievement and training implicit in concentration, the model changed classroom discipline and management practices Design Shamblin et al. (2016) Participants Country Citation Table 1  (continued) 660 School Mental Health (2019) 11:650–664 School Mental Health (2019) 11:650–664 Turnbull, 2016) using qualitative methods and behaviour rating scales (e.g. ASEBA and BASC-2). Studies also indicated reduced depression and PTSD symptoms (Ellis et al., 2013; Hansel et al., 2010; Layne et al., 2008; using the Depression Self-Rating Scale [DSRS] and UCLA PTSD Index), and increased self-perceived knowledge and confidence of staff (Dorado et al., 2016; McConnico et al., 2016; Perry & Daniels, 2016; Shamblin et al., 2016), using mostly nonvalidated measures and qualitative methods. Research with greater use of validated and standardised assessment tools to measure staff and student outcomes is required. However, in addition to screening processes, many studies did not assess teacher and parent outcomes (e.g. Holmes et al., 2015; Layne et al., 2008), and all excluding Cicchetti (2017) failed to examine community and external service collaborations. Studies also neglected to integrate findings within existing school-wide PBS and MTSS frameworks, as recommended in the literature (Chafouleas et al., 2016; Phifer & Hull, 2016; Plumb et al., 2016; McDermott & Cobham, 2014; Reinbergs & Fefer, 2018; Weist et al., 2018). This is likely because several of the identified studies evaluated teacher training and student outcomes within already atrisk populations, including children in out of home care, and children from refugee and war-affected backgrounds. These teachers and students are likely to operate within Tier 2 and Tier 3 intervention, rather than within traditional ‘triangle’ models. Further evaluation of Tier 1 universal ‘preventative’ intervention is warranted. However, the strength of these studies is that they provide guidance for integration of multi-tiered trauma approaches into existing school multi-tiered frameworks. Staff training and/or consultation was mentioned by eleven studies, along with community engagement and awareness mention by four studies, training and support for parents by six articles, and student support and classroom curricula mentioned by all studies. Individual parent and student treatment, and groupbased student support using the CBITS and Trauma-focused Cognitive Behavioural Therapy (TF-CBT) programs were also implemented and evaluated (Hansel et al., 2010; Perry & Daniels, 2016; Shamblin et al., 2016). Other programs such as Trauma and Grief Component Therapy (TGCT) also showed promise in terms of improved trauma outcomes (Layne et al., 2008). There were several discrepancies across the programs regarding what constituted Tier 1 compared to Tier 2 and Tier 3 intervention. Alignment of the tiers within existing evidence-based approaches may help to improve the focus and outcomes of research. For example, for some of the programs, there is difficulty determining which aspects of the intervention constituted different tiers or levels of the models (e.g. Holmes et al., 2015; Perry & Daniels, 2016) and how school culture changed to adopt the trauma-informed approach. 661 In terms of other weaknesses, while several of the articles reported positive impacts for students and staff, only one study was a RCT (Layne et al., 2008), with most providing pre- and post-follow-up data. The nature of these interventions, often in response to adverse events, means that RCTs may not be the most appropriate research design approach for ethical and practical reasons. Longitudinal quasi-experimental evaluations in which different tiers of the intervention are provided to staff and students should be considered. Many studies also failed to evaluate outcomes of teacher training and/or consultation, and further consideration of a multi-stakeholder perspective in implementation and evaluation of multi-tiered, trauma-sensitive approaches in schools is required. This is particularly in the light of research demonstrating teachers’ experiences of helplessness and secondary trauma in relation to childhood trauma, popularity of teacher-mediated mental health programs in schools, and the impact of training on staff responses to trauma-impacted students (Alisic, 2012; Alisic et al., 2012; Berger, Carroll, Maybery, & Harrison, 2018; Dyregrov, 2009; Dyregrov et al., 1999). It is likely that several studies were excluded from the current review because the impacts of teacher training and consultation were not evaluated. Implications As indicated previously, one of the main limitations of research on multi-tiered models of trauma care in schools is the lack of inclusion and evaluation of school staff training within these frameworks. A meta-review found that six of the eleven post-natural disaster and conflict interventions were implemented by teachers, and therefore involved training and supervision of teachers (Fu & Underwood, 2015). Based on school-wide ‘triangle’ models and research in other areas (Simonsen et al., 2014), the following theoretical model (Fig. 2) is proposed to help guide evaluations with teachers and align teacher training within existing three-tiered models in schools. This model is also based on research regarding the training and consultation needs of staff (Dorado et al., 2016), and the differing expertise of teachers and school mental health staff (e.g. school counsellors) identified within this review (Holmes et al., 2015; McConnico et al., 2016; Perry & Daniels, 2016; Saint Gilles, 2016). As shown in Fig. 2, three tiers are proposed for teacher intervention and evaluation, including Tier 1: universal training for all school staff regarding childhood trauma; Tier 2: consultation between teachers and school mental health staff; and Tier 3: consultation between school mental health staff and external professionals (e.g. psychologists, mental health clinicians). Tier 2 and Tier 3 acknowledge the consultative role of school mental health staff with teachers, and importance of external 13 662 School Mental Health (2019) 11:650–664 Tier 1: Universal training for all school staff regarding trauma Tier 2: Consultation between teachers and school mental helath staff Tier 3: Consultation between school mental health staff and external professionals Conclusion Overall, research on multi-tiered frameworks in response to trauma is limited but growing. Greater consistency in research methods and interventions (potentially though alignment with school-wide PBS) could improve the evidence and potentially the uptake of trauma-informed approaches in schools. The studies presented in this review provide guidance and structure for selecting, implementing, and evaluating multi-tiered, school-based trauma programs in future. Compliance with Ethical Standards Conflict of interest The author declares that she has no conflict of interest. Ethical Approval This article does not contain any studies with human participants or animals performed by the author. Fig. 2  Three-tiered trauma model for staff training and support in schools community and clinician engagement identified within this review (Cicchetti, 2017; Ellis et al., 2013; Hansel et al., 2010). While the benefits of teacher training have been demonstrated briefly, evaluation of the effectiveness of tiered systems of staff training on staff and student outcomes and teaching practices is required. Limitations Although this study aimed to only include studies that used and evaluated multiple tiers of education and support for staff, students, and/or parents regarding trauma, it became apparent during the conduct of this review that several studies included but did not evaluate some tiers of training and support. Studies of teacher training and support in particular, as well as implementation of Tier 1 positive behaviour support practices, are required. There also needs to be greater consideration of the role of parents, other school personnel (e.g. school counsellors, school leadership teams), and external professionals (e.g. psychologists and community services) in delivery and evaluation of trauma-informed approaches. The model presented in Fig. 2 informs greater inclusion of school and external mental health providers. As research continues in this area, greater use of quasi-experimental designs with an un-randomised comparison group would be appropriate, as well as evaluation of program sustainability and fidelity using longitudinal processes. 13 References References marked with an asterisks indicate studies included in the systematic review Alisic, E. (2012). Teachers’ perspectives on providing support to children after trauma: A qualitative study. School Psychology Quarterly, 27(1), 51–59. https​://doi.org/10.1037/a0028​590. Alisic, E., Bus, M., Dulack, W., Pennings, L., & Splinter, J. (2012). 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