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

Findings and Recommendations

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.

The full CPSTF Finding and Rationale Statement and supporting documents for Mental Health: Multi-Tiered Trauma-Informed School Programs to Improve Mental Health Among Youth are available in The Community Guide Collection on CDC Stacks.

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 for teachers, staff, parents, or community partners, or social, emotional, and behavioral learning for all students.
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).
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.

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).

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.

Summary of Results

The CPSTF finding is based on evidence from 11 studies total.

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.

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 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?
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?

Implementation Considerations and Resources

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. 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.
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.
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.
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.

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