Mental Health: Multi-Tiered Trauma-Informed School Programs to Improve Mental Health Among Youth

Snapshot What the CPSTF Found Supporting Materials Considerations for Implementation

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) finds insufficient evidence to determine whether multi-tiered trauma-informed school programs reduce symptoms of post-traumatic stress disorder (PTSD) or improve mental health and school-related outcomes including student behaviors, disciplinary actions, and absenteeism. Studies showed reductions in PTSD symptoms but lacked comparison groups, had small sample sizes, and did not evaluate PTSD symptoms for all tiers of the intervention. There were not enough studies to determine intervention effects on other outcomes.

Additional studies are needed to determine the effectiveness of multi-tiered trauma-informed school programs. It is important to address this lack of evidence given the prevalence of childhood trauma and the important role schools play in children’s lives.

Intervention

Multi-tiered trauma-informed school programs aim to minimize students’ exposure to adversity, strengthen their coping skills, and improve their mental health and well-being. These programs offer universal (tier 1), targeted (tier 2), and individualized (tier 3) approaches based on students’ exposure to trauma and trauma-related symptoms.

For inclusion in this systematic review, studies must include interventions implemented at each of the three tiers.

Tier 1 delivers universal interventions designed to create safe environments and support a trauma-informed school community for all students. Interventions must screen students for symptoms to identify those in need of more intense intervention at tiers 2 or 3. They also may offer training and psychoeducation (information on awareness and tools to help students regulate behavior) for teachers, staff, parents, or community partners, or social, emotional, and behavioral learning (self-awareness, self-control, and interpersonal skills) for all students. Interventions may be delivered by appropriate mental health providers or trained school staff.
Tier 2 identifies and provides early intervention for at-risk students exposed to trauma who show mild symptoms (e.g., problems focusing on schoolwork). Interventions must include one or more of the following: psychoeducation for at-risk students, trauma-specific group therapy, or classroom supports (e.g., play therapy, social stories, schedule cards). Interventions are typically delivered by trained mental health providers. Training may be offered to teachers to help them screen students for symptoms and improve classroom management.
Tier 3 provides mental health services for students who have experienced trauma and show severe symptoms (e.g., intense outbursts of anger). Trauma-informed counselors or other trained mental health providers deliver services in school settings or refer students to appropriate mental health services outside of school. Interventions may include trauma-focused cognitive behavioral therapy or wraparound services that integrate support systems around the student, including parents or caregivers, mental health providers, and others to address the student’s needs.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Promotional Materials

Community Guide News

More Studies Needed on Multi-Tiered Trauma-Informed School Programs

One Pager

Multi-Tiered Trauma-Informed School Programs to Improve Mental Health Among Youth

Graphics for Social Media

Please visit our social media messages and graphics page for full sized images and suggested social media messages.

About The Systematic Review

The CPSTF finding is based on evidence from 6 studies identified in a published systematic review (Berger et al. 2019; search period through May 2018) and 5 studies identified in an updated search for evidence (search period January 2018 to August 2022).

The systematic review was conducted on behalf of CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to multi-tiered trauma-informed school programs. The team evaluated the effectiveness of the intervention on improving mental health (i.e., PTSD, student depression, student anxiety) and school-related outcomes (i.e., internalizing and externalizing student behaviors, student-staff relationships, absenteeism, disciplinary actions, quality of life).

Context

Trauma is a response to an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening and can have lasting adverse effects on the individual’s mental, physical, and emotional well-being (SAMHSA Concept of Trauma 2014 [PDF – 789 KB]). Traumatic events in childhood, referred to as adverse childhood experiences, or ACEs, are experienced by more than two-thirds of children by the age of 16 (SAMHSA 2023). Childhood experiences of trauma may lead to learning or behavioral problems or both, such as inability to focus on schoolwork, or intense outbursts of anger (Burke et al 2011). In adolescence and adulthood, ACEs are linked to:

Chronic health problems
Poor mental health (e.g., post-traumatic stress disorder [PTSD], feeling sad or hopeless)
Risk behaviors (e.g., substance use)
Socioeconomic challenges in adulthood (CDC 2022).

Preventing and reducing underlying trauma in childhood could reduce negative outcomes in adulthood and promote safer communities for children (CDC 2022).

Multi-tiered trauma-informed school programs aim to prevent and reduce the impact of trauma among all students while offering additional help to students who need intensive support (National Child Traumatic Stress Network, Schools Committee 2017). Multitiered programs (Fondren et al 2020) aim to implement interventions at:

Universal (tier 1) levels
Targeted (tier 2) levels
Individualized (tier 3) levels.

These programs may connect students, especially those with a higher likelihood of traumatic exposures (e.g., students from households with low socioeconomic status [SES] or racial or sexual minority groups, students living with disability; NCTSN 2023), to mental health services and academic supports (Chafouleas et al 2016), which may promote health equity.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

To assess intervention effectiveness, a team of systematic review methodologists and intervention subject matter experts synthesized outcomes for:

Mental health (i.e., PTSD, student depression, student anxiety)
School-related outcomes (i.e., internalizing and externalizing student behaviors, student-staff relationships, absenteeism, disciplinary actions, quality of life)

Studies reported outcomes for students who received interventions at one or more tiers. The systematic review team used the following criteria to interpret assessments:

Tier 1 Assessment: students received tier 1 interventions and possibly tiers 2 or 3.
Tier 2 Assessment: students received tiers 1 and 2 interventions, and possibly tier 3.
Tier 3 Assessment: students received tiers 1 and 3 interventions, and possibly tier 2.

Evidence from the included studies showed multi-tiered trauma-informed school programs reduced PTSD symptoms by a median of 34%. There were not enough studies reporting results for the other outcomes.

CPSTF considered this reduction in PTSD symptoms to be consistent and meaningful (criteria used to determine sufficient level of evidence) but downgraded the finding to insufficient evidence based on recurring gaps in study designs and methods (see the Community Guide Methods Manual for more information about criteria used to determine strength of evidence).

Summary of Economic Evidence

An economic review of this intervention was not conducted because CPSTF did not have enough information to determine if the intervention works.

Applicability

Applicability of multi-tiered interventions for trauma-informed schools was not assessed because CPSTF did not have enough information to determine if the intervention works.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and determine the effectiveness of multi-tiered trauma-informed school programs.

CPSTF identified the following questions as priorities for research and evaluation:

Using comparative study designs and consistent outcome measures, are multi-tiered trauma-informed school programs effective in:
- Reducing mental health symptoms, including PTSD, depression, and anxiety, among students?
- Improving school-related outcomes, including student behaviors, absenteeism, and academic achievement?
Does the effectiveness of multi-tiered trauma-informed school programs vary for students who may disproportionately experience trauma, such as students who identify as sexual or gender minorities, and students with disabilities?
Does program effectiveness vary with different program and study characteristics, such as the specific interventions implemented within each tier, service deliverers, or intervention duration?
What combinations of interventions across the tiers are most effective?
What is the impact of multi-tiered trauma-informed school programs implemented after a crisis or mass exposure (e.g., school shooting, natural disaster) in the United States?

Study Characteristics

Studies were conducted in the United States (10 studies) and Australia (1 study).
Studies were implemented in predominately urban settings (9 studies) among populations with increased likelihood of traumatic exposure.
Students were from households with low-socioeconomic status (7 studies) or trauma-impacted communities (10 studies).
Just over half of the study population was male (54.5% reported in 7 studies).
Five studies from the United States that collected information about students’ racial or ethnic background reported that a median of 39% of students were black or African American; 15% were Hispanic or Latino; and 3.5% were white.
Studies represented all school levels from pre-k through high school.
The median student age was 12.5 years old.

Analytic Framework

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table – Effectiveness Review [PDF – 382 KB]

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies, or one study may be explained in several publications).

Effectiveness Review

Baez JC, Renshaw KJ, Bachman LE, et al. Understanding the necessity of trauma-informed care in community schools: A mixed-methods program evaluation. Children & Schools 2019;41(2):101-10.

Beehler S, Birman D, Campbell R. The effectiveness of cultural adjustment and trauma services (CATS): Generating practice-based evidence on a comprehensive, school-based mental health intervention for immigrant youth. American Journal of Community Psychology 2012;50:155-68.

Diggins J. Reductions in behavioural and emotional difficulties from a specialist, trauma-informed school. Educational and Developmental Psychologist 2012;38(2):194-205.

Dorado JS, Martinez M, McArthur LE, et al. Healthy Environments and Response to Trauma in Schools (HEARTS): A whole-school, multi-level, prevention and intervention program for creating trauma-informed, safe and supportive schools. School Mental Health 2016;8:163-76.

Ellis BH, Miller AB, Abdi S, et al. Multi-tier mental health program for refugee youth. Journal of Consulting and Clinical Psychology 2013;81(1):129.

Hansel TC, Osofsky HJ, Osofsky JD, et al. Attention to process and clinical outcomes of implementing a rural school‐based trauma treatment program. Journal of Traumatic Stress 2012;23(6):708-15.

Holmes C, Levy M, Smith A, et al. A model for creating a supportive trauma-informed culture for children in preschool settings. Journal of Child and Family Studies 2015;24:1650-9.

Hutchison M, Russell BS, Wink MN. Social‐emotional competence trajectories from a school‐based child trauma symptom intervention in a disadvantaged community. Psychology in the Schools 2020;57(8):1257-72.

Perry DL, Daniels ML. Implementing trauma—informed practices in the school setting: A pilot study. School Mental Health 2016;8:177-88.

Shamblin S, Graham D, Bianco JA. Creating trauma-informed schools for rural Appalachia: The partnerships program for enhancing resiliency, confidence and workforce development in early childhood education. School Mental Health 2016;8:189-200.

Tabone JK, Rishel CW, Hartnett HP, et al. Examining the effectiveness of early intervention to create trauma-informed school environments. Children and Youth Services Review 2020;113:104998.

Additional Materials

Implementation Resource

Promoting Mental Health and Well-Being in Schools | CDC
Schools are prioritizing students’ mental health, and there are many tools and resources to choose from. CDC created this action guide as a place to start. It can help school and district leaders build on what they are already doing to promote students’ mental health and find new strategies to fill in gaps.

Search Strategies

Effectiveness Review

(“positive behavio*” OR pbs OR pbis OR “response to intervention” OR rti OR “trauma informed” OR “trauma-informed” OR “trauma sensitive” OR “trauma-sensitive” OR tier* OR multitier* OR “multi-tier*” OR mtss) AND (“posttraumatic stress disorder” OR “post-traumatic stress disorder” OR “post traumatic stress disorder” OR ptsd OR trauma* OR violence OR abuse OR neglect* OR maltreat* OR adverse OR disaster OR terroris* OR war) AND (school) AND la.exact(“English”)

Limit English

Search database inception through 2018

English only.

Add student and other MESH terms

Search Strategy
Database	Strategy	Run Date	Records
Medline (OVID) 1946-	1 (posttraumatic stress disorder or (post-traumatic adj2 stress adj2 disorder) or post traumatic stress disorder or ptsd or trauma* or violence or abuse or neglect* or maltreat* or adverse or disaster or terroris* or war).ti,ab. 2 Stress Disorders, Post-Traumatic/ or violence/ or adverse childhood experiences/ or Child Abuse/ 3 1 or 2 1340483 4 ((Multi* or tier* or multitier* or multi-tier* or mtss or multilevel or multi-level or (multiple adj2 tier)) adj7 ((positive adj2 behavio) or pbs or pbis or intervention* or (response adj2 intervention) or (trauma adj2 informed) or (trauma adj2 sensitive))).ti,ab. 39992 5 (school* or Nursery or daycare or kindergarten or pre-school or preschool or (elementary adj2 education) or (secondary adj2 education) or K-12 or child* or youth or adoles* or student*).ti,ab,kw,kf. 6 schools/ or schools, nursery/ or exp Child Day Care Centers/ or Child, Preschool/ or exp Child/ or Adolescent/ 3308460 7 5 or 6 4157371 8 3 and 4 and 7 1504 9 exp Animals/ not exp Humans/ 5043578 10 8 not 9 1502 11 limit 10 to (english language and yr=”1946-2018	9/14/22	900
Embase (OVID) 1947-	1 (posttraumatic stress disorder or (post-traumatic adj2 stress adj2 disorder) or post traumatic stress disorder or ptsd or trauma* or violence or abuse or neglect* or maltreat* or adverse or disaster or terroris* or war).ti,ab. 1726276 2 violence/ or adverse childhood experiences/ or Child Abuse/ or child neglect/ or posttraumatic stress disorder/ 146985 3 1 or 2 1764084 4 ((Multi* or tier* or multitier* or multi-tier* or mtss or multilevel or multi-level or (multiple adj2 tier)) adj7 ((positive adj2 behavio) or pbs or pbis or intervention* or (response adj2 intervention) or (trauma adj2 informed) or (trauma adj2 sensitive))).ti,ab. 56794 5 (school* or Nursery or daycare or kindergarten or pre-school or preschool or (elementary adj2 education) or (secondary adj2 education) or K-12 or child* or youth or adoles* or student*).ti,ab. 2483665 6 school/ or nursery school/ or Child Day Care/ or exp Child/ or Adolescent/ or Day Care/ 3315014 7 5 or 6 4183449 8 3 and 4 and 7 1955 9 exp Animals/ not exp Humans/ 4022746 10 8 not 9 1951 11 limit 10 to (english language and yr=”1947-2018″		1183 -743 duplicates = 440 unique items
PsycINFO (OVID) 1806-	(posttraumatic stress disorder or (post-traumatic adj2 stress adj2 disorder) or post traumatic stress disorder or ptsd or trauma* or violence or abuse or neglect* or maltreat* or adverse or disaster or terroris* or war).ti,ab. 432006 2 violence/ or adverse childhood experiences/ or Child Abuse/ or child neglect/ or posttraumatic stress disorder/ 105855 3 1 or 2 441079 4 ((Multi* or tier* or multitier* or multi-tier* or mtss or multilevel or multi-level or (multiple adj2 tier)) adj7 ((positive adj2 behavio) or pbs or pbis or intervention* or (response adj2 intervention) or (trauma adj2 informed) or (trauma adj2 sensitive))).ti,ab. 15970 5 (school* or nursery or daycare or kindergarten or pre-school or preschool or (elementary adj2 education) or (secondary adj2 education) or K-12 or child* or youth or adoles* or student*).ti,ab. 1495676 6 schools/ or exp boarding schools/ or exp charter schools/ or exp elementary schools/ or exp high schools/ or exp junior high schools/ or exp kindergartens/ or exp middle schools/ or exp nursery schools/ or exp school environment/ or adolescent health/ or exp Child Health/ or exp Childhood Development/ 189900 7 5 or 6 1515698 8 3 and 4 and 7 1100 9 limit 8 to (english language and yr=”1806 -2018)		779 -318 duplicates = 461 unique items
ProQuest Dissertations and Theses	((noft((multitier* OR “multi-tier” OR mtss OR multilevel OR multi-tier OR “multiple tier:”)) noft(((“positive behavior” OR “positive behavioral” OR “positive behaviors” OR “positive behaviour” OR “positive behaviours”) OR pbs OR pbis OR “response to intervention” OR rti OR “trauma informed” OR “trauma-informed” OR “trauma sensitive” OR “trauma-sensitive”))) AND noft(“post traumatic stress disorder” OR ptsd OR trauma OR violence OR abuse OR neglect* OR maltreat* OR adverse OR disaster OR terroris* OR war) AND noft((school* OR Nursery OR daycare OR kindergarten OR pre-school OR preschool OR “elementary education” OR “secondary education” OR K-12 OR child* OR youth OR adoles* or student*))) AND yr(1743-2018)		11 -5 duplicates =6 unique items
Cochrane Library	1 (“posttraumatic stress disorder” OR “post-traumatic stress disorder” OR “post traumatic stress disorder” OR ptsd OR trauma* OR violence OR abuse OR neglect* OR maltreat* OR adverse OR disaster OR terroris* OR war ):ti,ab (Word variations have been searched) 242162 #2 (multitier* OR “multi-tier” OR mtss or multilevel or multi-tie) NEAR/7 (“posttraumatic tress disorder” OR “post-traumatic stress disorder” OR “post traumatic stress disorder” OR ptsd OR trauma* OR violence OR abuse OR neglect* OR maltreat* OR adverse OR disaster OR terroris* OR war):ti,ab (Word variations have been searched) 58 #3 (school* or Nursery or daycare or kindergarten or pre-school or preschool or “elementary education” or “secondary education” or K-12 or child* or youth or adoles* OR student*):ti,ab (Word variations have been searched) 205765 #4 #1 AND #2 AND #3 with Cochrane Library publication date from Jan 1800 to Jan 2018, in Cochrane Reviews, Cochrane Protocols, Trials, Clinical Answers, Editorials and Special Collection		1 -0 duplicates = 1 unique items
ERIC (1966-)	noft((multi or tier* or multitier* OR “multi-tier” OR mtss OR multilevel OR multi-tier OR “multiple tier”) N/7 (“positive behavior” OR “positive behavioral” OR “positive behaviors” OR “positive behaviour” OR “positive behaviours” OR pbs OR pbis OR “response to intervention” OR rti OR “trauma informed” OR “trauma-informed” OR “trauma sensitive” OR “trauma-sensitive”) ) AND noft(“post traumatic stress disorder” OR ptsd OR trauma OR violence OR abuse OR neglect* OR maltreat* OR adverse OR disaster OR terroris* OR war) AND noft((school* OR nursery OR daycare OR kindergarten OR pre-school OR preschool OR “elementary education” OR “secondary education” OR K-12 OR child* OR youth OR adoles* or student*)Limits: English Pub Year: 1966-2018		19 -12 duplicates = 7 unique items
Scopus	( TITLE-ABS ( “posttraumatic stress disorder” OR “post-traumatic stress disorder” OR “post traumatic stress disorder” OR ptsd OR trauma* OR violence OR abuse OR neglect* OR maltreat* OR adverse OR disaster OR terroris* OR war ) ) AND ( TITLE-ABS ( tier* OR multitier* OR “multi-tier” OR mtss OR multilevel OR multi-tier OR “multiple tier” ) W/7 ( “positive behavio” OR pbs OR pbis OR “response to intervention” OR rti OR “trauma informed” OR “trauma-informed” OR “trauma sensitive” OR “trauma-sensitive” ) ) AND ( TITLE-ABS ( school OR nursery OR daycare OR kindergarten OR pre-school OR preschool OR “elementary education” OR “secondary education” OR k-12 OR child* OR youth OR adoles* OR student* ) ) AND ( LIMIT-TO ( PUBYEAR , 2018 ) OR LIMIT-TO ( PUBYEAR , 2016 ) OR LIMIT-TO ( PUBYEAR , 2015 ) OR LIMIT-TO ( PUBYEAR , 2014 ) OR LIMIT-TO ( PUBYEAR , 2013 ) )		10 -9 duplicates = 1 unique items

Notes: Duplicates were identified using the Endnote automated “find duplicates” function with preference set to match on title, author and year, and removed from your Endnote library. There will likely be additional duplicates found that Endnote was unable to detect.

Review References

Baez JC, Renshaw KJ, Bachman LE, et al. Understanding the necessity of trauma-informed care in community schools: a mixed-methods program evaluation. Children & Schools 2019;41(2):101–10.

Beehler S, Birman D, Campbell R. The effectiveness of cultural adjustment and trauma services (CATS): generating practice-based evidence on a comprehensive, school-based mental health intervention for immigrant youth. American Journal of Community Psychology 2012;50:155–68.

Berger E. Multi-tiered approaches to trauma-informed care in schools: a systematic review. School Mental Health 2021;11:650–64.

Brooks JE. Strengthening resilience in children and youth: maximizing opportunities through the schools. Children & Schools 2006;28:69–76.

Burke NJ, Hellman JL, Scott BG, et al. The impact of adverse childhood experiences on an urban pediatric population. Child Abuse & Neglect 2011;35(6):408–13.

Centers for Disease Control and Prevention. Health Youth at Risk for ACEs. Atlanta (GA); 2022. Available from URL: www.cdc.gov/violenceprevention/aces/help-youth-at-risk.html. Accessed July 12, 2023.

Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs). Atlanta (GA): CDC, 2021. Available from URL: www.cdc.gov/vitalsigns/aces/index.html. Accessed July 12, 2023.

Chafouleas SM, Johnson AH, Overstreet S, et al. Toward a blueprint for trauma-informed service delivery in schools. School Mental Health 2016;8:144–62.

Dorado JS, Martinez M, McArthur LE, et al. Healthy Environments and Response to Trauma in Schools (HEARTS): a whole-school, multi-level, prevention and intervention program for creating trauma-informed, safe and supportive schools. School Mental Health 2016;8:163–76.

Durlak JA, Weissberg RP, Dymnicki AB, et al. The impact of enhancing students’ social and emotional learning: A meta-analysis of school-based universal interventions. Child Development 2011;82:405–32.

Ellis BH, Miller AB, Abdi S, et al. Multi-tier mental health program for refugee youth. Journal of Consulting and Clinical Psychology 2013;81(1):129-40.

Fondren K, Lawson M, Speidel R, et al. Buffering the effects of childhood trauma within the school setting: A systematic review of trauma-informed and trauma-responsive interventions among trauma-affected youth. Children and Youth Services Review 2020;109:104691.

Frankland M. Meeting students where they are: trauma-informed approaches in rural Schools. Rural Educator 2021;42(2):51–71.

Hales TW, Nochajski TH, Green SA, et al. An association between implementing trauma-informed care and staff satisfaction. Advances in Social Work 2017;18:300–12.

Hiller RM, Meiser‐Stedman R, Fearon P, et al. Research Review: Changes in the prevalence and symptom severity of child post‐traumatic stress disorder in the year following trauma – a meta‐analytic study. Journal of Child Psychology and Psychiatry 2016;57(8):884–98.

National Child Traumatic Stress Network. Populations at risk. Rockville (MD): NCTSN, 2023. Available at URL: https://www.nctsn.org/what-is-child-trauma/populations-at-risk. Accessed August 7, 2023.

Perry DL, Daniels ML. Implementing trauma-informed practices in the school setting: a pilot study. School Mental Health 2016;8:177–88.

Substance Abuse and Mental Health Services Administration. Understanding Child Trauma. Rockville (MD): SAMHSA, 2023. Available from URL: https://www.samhsa.gov/child-trauma/understanding-child-trauma. Accessed August 7, 2023.

Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville (MD): SAMHSA, 2014. Available at URL: https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf.

Considerations for Implementation

Despite the finding of insufficient evidence, the following are considerations for implementation drawn from studies included in the evidence review, the broader literature, and expert opinion.

CPSTF calls for more comprehensive and in-depth evaluations of multi-tiered trauma-informed school programs that address the study design and methodology concerns discussed below.

Evidence from included studies indicates that multi-tiered trauma-informed school programs produced some favorable results (see table 1). This body of evidence was limited, however, by lack of clear intervention descriptions, small sample sizes, lack of comparison groups, and lack of assessment at all tiers of the intervention. It is important that researchers include clear descriptions of all components of the intervention as well as how they were delivered as guidance to implementers. Comparison groups are important when assessing outcomes such as PTSD that may improve over time without intervention (Hiller et al 2016). Evaluating multi-tiered trauma-informed school programs using comparative study designs, such as random controlled trials (RCTs) or observational designs that use comparison groups would be helpful to separate the effect of the intervention from improvements that may happen over time. Too few studies reported student behavior outcomes using comparable measurements, making it difficult to determine the overall effect. Establishing a set of standardized measures for researchers to use could assist intervention evaluation, improve communication between researchers, and increase the possibility of summarizing this body of evidence across studies. Finally, evaluations that assess outcomes from all three tiers may provide useful information about how the tiers work together so that the potential benefits of a multi-tiered approach can be fully assessed.

Interventions implemented at each tier varied between studies and were often not well described, making it difficult to determine which combinations of interventions across the three tiers were most effective. Studies also implemented a mix of evidence-based and practice-based interventions and did not indicate whether they were implemented as intended.

Few studies reported information about funding for their multi-tiered trauma-informed school programs. It is important for researchers and implementers to build in plans that ensure schools will be able to continue providing individual interventions to students once the study ends.

Schools can use the tool below to assess their current mental health programming needs and access resources.

The School Health Assessment and Performance Evaluation (SHAPE) System | Mental Health Technology Transfer Center (MHTTC) Network (mhttcnetwork.org)

Below are several publicly available resources for more information about addressing trauma and building trauma-informed schools using evidence-based interventions

Crosswalks

Healthy People 2030

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.