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A Systematic Review on the Impact of Trauma-Informed Education Programs on Academic and Academic-Related Functioning for Students

Who Have Experienced Childhood Adversity

Sally Roseby1 and Michael Gascoigne1, 2

1 School of Psychological Science, Australian College of Applied Psychology 2 School of Psychology, The University of Sydney

The purpose of this study was to conduct a systematic review of the existing literature regarding trauma-informed education programs and their impact on academic and academic-related outcomes. The articles included for review (n � 15) contained data on trauma-informed education programs imple- mented in preschool, primary/elementary, and high school settings. Academic and academic-related outcomes reported included attendance, disciplinary referrals, suspension, and academic achievement, as well as student resilience, school attachment, and emotional presentation. Findings from this systematic review highlight that trauma-informed education programs can improve students’ academic and academic-related outcomes; however, results were not consistent across the studies. Moving forward, recommendations include the need for additional trauma-informed school-based research to be conducted and dissemination of this research to ensure school systems are upskilled and responding appropriately to their traumatized students.

Keywords: systemic intervention, adverse childhood experiences, school systems

Adverse childhood experiences (ACEs) are associated with a range of deleterious individual outcomes, such as compromised neurodevelopment (Bick & Nelson, 2016; Chugani et al., 2001; Perry et al., 1995); social, emotional, and behavioral difficulties (Burke et al., 2011; Davis & Petretic-Jackson, 2000; Hanson et al., 2015; van der Kolk, 2005); and reduced cognitive and academic functioning (Australian Childhood Foundation, 2018; Blodgett & Lanigan, 2018; Downey, 2007; Perfect et al., 2016). The impor- tance of mitigating the impact of ACEs is further underscored by their association with several adverse social outcomes, such as lower rates of educational accomplishment (Blue Knot Founda- tion, 2015), lower levels of employment (Hardcastle et al., 2018; Liu et al., 2013), and reduced income and lifetime productivity (Covey et al., 2013; Currie & Widom, 2010; Zielinski, 2009). Therefore, determining whether a school-based intervention may improve academic functioning for those who have experienced childhood adversity is of clinical and social significance. In par- ticular, understanding the impact trauma-informed intervention can have on increasing education participation and academic func- tioning in students with a history of ACEs is important. Further- more, with no systematic reviews and/or meta-analyses located in the peer reviewed literature addressing the impact of trauma-

informed education programs on academic or academic-related outcomes, this research seeks to address a gap in the empirical literature. Additionally, it will help inform future clinical work, including school-based work.

The Prevalence of Childhood Adversity

ACEs are prolonged or cumulative traumatic events that have both an immediate and lifelong impact (Felitti et al., 1998; van der Kolk, 2005). They can occur at an individual or familial level and include child abuse or neglect (i.e., sexual, physical, or verbal abuse; emotional or physical neglect), family dysfunction, or stress (i.e., incarcerated household member, domestic violence, divorce or separation, death of a parent, household substance abuse, and household member with a mental or physical illness; Felitti et al., 1998). Moreover, the National Child Traumatic Stress Network reports that childhood trauma occurs when children experience a traumatic event (i.e., neglect or abuse), which can be either acute or chronic, that can overwhelm a child’s ability to cope with the trauma they have experienced (Iachini et al., 2016).

The prevalence of childhood trauma has been widely re- searched, with an estimated five million Australian adults im- pacted (Blue Knot Foundation, 2015). Furthermore, Australian child protection statistics highlight that approximately 225,000 children were harmed or suspected of being at risk of harm from abuse and/or neglect during 2015–2016 (Australian Institute of Family Studies, 2017). With childhood adversity identified as a common occurrence and child protection figures reportedly in- creasing (Australian Institute of Family Studies, 2017) our concern then shifts to considering the impact of intervention on individuals with a history of ACEs.

Sally Roseby X https://orcid.org/0000-0002-5960-2407 Michael Gascoigne X https://orcid.org/0000-0002-2786-7355 Correspondence concerning this article should be addressed to Michael

Gascoigne, School of Psychological Science, Australian College of Ap- plied Psychology, Level 11, 255 Elizabeth Street, Sydney, New South Wales 2000, Australia. Email: [email protected]

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Traumatology © 2021 American Psychological Association 1085-9373/21/$12.00 https://doi.org/10.1037/trm0000276

149

2021, Vol. 27, No. 2, 149-167

This article was published Online First January 18, 2021.

Intervention and Its Impact on Outcomes

Our understanding of intervention as a moderator between childhood adversity and various outcomes is still developing (Perfect et al., 2016). To demonstrate, Skowron and Reinemann (2005) and Weiner et al. (2011) both completed meta-analyses on the effectiveness of psychological interventions for child maltreatment. Although both meta-analyses recognized that in- tervention enhanced functioning, intricacies were noted. Sur- prisingly, neither meta-analysis included academic functioning as an outcome variable. Nevertheless, it has been suggested that mental health treatment can have a positive impact on students’ educational outcomes (Baskin et al., 2010; Becker et al., 2014). Moreover, when discussing intervention, it is vital to emphasize the need for unified systems of care and systemic level inter- vention, that is, trauma-informed school settings (Chafouleas et al., 2016).

School-Based Intervention

Education offers a significant intervention opportunity for stu- dents who have experienced childhood adversity (Brunzell et al., 2016), with schools uniquely situated to support their traumatized students (Soleimanpour et al., 2017). Additionally, recovery from trauma is no longer viewed as taking place solely within counsel- ing settings, with educators supporting this and recognizing they too can help traumatized children, by providing a nurturing and safe school environment (Berardi & Morton, 2017). With the positive impact of school-based trauma-specific interventions on students’ traumatic stress symptoms already accepted (Rolfsnes & Idsoe, 2011), the advantages of trauma-informed approaches in schools is also increasing in acceptance (see Overstreet & Cha- fouleas, 2016).

Being trauma informed means understanding the impact of trauma on neurobiology, neurodevelopment, and attachment (Kin- niburgh et al., 2005). This understanding allows educators to integrate this knowledge into the fabric of the school community and provides a perspective to the complex challenges faced daily by their traumatized students (Morton & Berardi, 2018). Substance Abuse and Mental Health Services Administration (SAMHSA) state that,

A program, organization or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist retraumatization. (SAM- HSA, 2014, p. 9)

Therefore, trauma-informed schools respond to the needs of their students by integrating effective practices, programs, and proce- dures into all aspects of the school culture (Overstreet & Chafou- leas, 2016). These practices, programs, and procedures may in- clude trauma-informed school leadership, trauma-informed policies and procedures, professional development for school staff, adequate financing, and a safe school environment (Kataoka et al., 2018).

The Current Study

The aim of this systematic review is to summarize the existing literature regarding the impact of trauma-informed education pro- grams on academic and academic-related functioning for students with a history of ACEs. By updating the literature across academic and academic-related functioning more broadly within a single systematic review, this will allow for a broad range of directions for future research to be provided. Furthermore, this research is of clinical and social importance to understanding the impact of trauma-informed intervention on academic functioning.

Method

Literature Search

This systematic review process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA; Moher et al., 2009). PRISMA contains an evidence- based guide for the identification and categorizing of published articles throughout the literature review process. Consistent with these guidelines, this systematic review was prospectively regis- tered on the National Institute for Health Research PROSPERO International Prospective Register of Systematic Reviews website (registration number: CRD42018117662). The following research databases were systematically searched during February and March, 2019: PubMed, Web of Science, PsycINFO, Education Resources Information Centre (ERIC), as well as 11 journals that contain the word “school” (i.e., Journal of School Psychology, School Psychology Quarterly, School Mental Health, School Psy- chology Review, Psychology in the Schools, School Psychology International, Intervention in School and Clinic, Advances in School Mental Health Promotion, Journal of Applied School Psy- chology, Canadian Journal of School Psychology, Preventing School Failure). The databases and journals selected cover a varied range of education, psychological, medical, and sociologi- cal research topics. To review some of the gray literature, a search of dissertations was included within the search of the PsycINFO database.

The following keywords were used in the search: adverse child- hood experiences; negative life events; trauma; childhood adver- sities; posttraumatic stress. Choosing to use broad terminology as opposed to more narrow definitions (i.e., child sexual abuse, neglect) guarded against the limitation of not capturing all the relevant studies as a result of using too narrow definitions of trauma. Additionally, this allowed for the broader definition as outlined by the National Child Traumatic Stress Network to be adopted, that is, childhood trauma occurs when children experi- ence a traumatic event (e.g., abuse, neglect, or victimization), which can be either short term (i.e., acute) or long term (i.e., chronic), that can overwhelm a child’s ability to cope with a traumatic experience (Iachini et al., 2016). The following key- words were then added: intervention; treatment; therapy; counsel- ing; group; program�; trauma-informed; alternate setting. Finally, we added keywords regarding the following outcomes: educat�; achievement; academic; grades; discipline; attendance. The pres- ence of an asterisk in the keywords indicates that all applicable terms beginning with that root were used. Due to the large number of studies being returned and the focus being on school environ-

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ROSEBY AND GASCOIGNE150

ments, limiters were put in place. See Table 1 for the relevant search strategies and limiters used in each database.

Inclusion Criteria

Studies were included in the systematic review if they met the following inclusion criteria: (a) involved a trauma-informed edu- cation program being implemented at a whole school level (even if results were only reported for one segment of the whole school intervention); (b) targeted participants who have been exposed to childhood adversity whether directly or indirectly; (c) measured an academic, that is, grades, attendance, academic achievement, stan- dardized achievement, discipline (as outlined in Perfect et al., 2016), or academic-related outcome, that is, resilience, behavior, school attachment, or student–teacher relationship (as outlined in Baskin et al., 2010); (d) must be in English. Studies were excluded from the systematic review if they (a) did not report evidence of increasing trauma-informed knowledge in school teachers or other education staff (as outlined in Kataoka et al., 2018) or (b) de- scribed a multitier system of support that was not explicitly re- ported as trauma-informed (see Chafouleas et al., 2016, for more information on trauma-informed multitiered systems of support).

Articles chosen for inclusion or exclusion to this systematic review are documented according to the PRISMA Statement (Moher et al., 2009). Figure 1 illustrates the literature search conducted in the four identified databases, subsequent identi- fied journals and articles, and the application of the inclusion and exclusion criteria.

As shown in Figure 1, five articles were unable to be sourced, despite them appearing in the results of our literature search. These articles could not be located, despite attempting to locate or directly approaching the corresponding authors of these articles.

Data Coding

Studies that met the inclusion criteria for the systematic review were individually coded by Sally Roseby to assist in evaluating the research design and fields of interest contained in each article. Based on the inclusion criteria and rationale of the current review, each study was coded along the following methodological and treatment variables and characteristics: (a) authors; (b) journal; (c) sample size/school size; (d) basic study type/design; (e) study setting (i.e., mainstream or alternate school setting); (f) method/s used to gather data (i.e., self- report, assessment, parent report, teacher report, etc.); (g) length of time trauma-informed education program was imple- mented at setting (if applicable); (h) theoretical underpinning of intervention (i.e., was the trauma-informed education program based on one particular approach); (i) outcome areas examined (i.e., academic or academic-related outcome); and (j) overall findings. We also included specific variables of the participants (where applicable) and their experienced childhood adversities, including (a) sex of participants; (b) age mean or age range; (c) types of trauma experienced (i.e., abuse, neglect, various, acute

Table 1 Search Strategy Used (Including Limiters) for Each Database Search Completed

Database Search string Limiters applied

Pub Med (“adverse childhood experiences” OR “negative life events” OR trauma OR “childhood adversities” OR “post-traumatic stress”) AND (intervention OR treatment OR therapy OR counselling OR counseling OR group OR program OR programme OR “trauma-informed” or “alternate setting”) AND (education OR achievement OR academic OR grades OR discipline OR attendance) AND psychology

And psychology added to search string Limited to child-birth–18 years

Web of Science (“adverse childhood experiences” OR “negative life events” OR trauma OR “childhood adversities” OR “post-traumatic stress”) AND (intervention OR treatment OR therapy OR counselling OR counseling OR group OR program OR programme OR “trauma-informed” or “alternate setting”) AND (educat� OR achievement OR academic OR grades OR discipline OR attendance) AND (infant OR child OR adolesce� OR minors OR pediatric OR pediatric)

PsycINFO (included dissertations search)

(“adverse childhood experiences” OR “negative life events” OR trauma OR “childhood adversities” OR “post-traumatic stress”) AND (intervention OR treatment OR therapy OR counselling OR counseling OR group OR program OR programme OR “trauma-informed” or “alternate setting”) AND (educat� OR achievement OR academic OR grades OR discipline OR attendance)

Narrowed by subject age, including preschool age (2–5 years), school age (6–12 years), adolescence (13– 17 years), and childhood (birth–12 years)

ERIC (“adverse childhood experiences” OR “negative life events” OR trauma OR “childhood adversities” OR “post-traumatic stress”) AND (intervention OR treatment OR therapy OR counselling OR counseling OR group OR program OR programme OR “trauma-informed” or “alternate setting”) AND (educat� OR achievement OR academic OR grades OR discipline OR attendance)

No limiters applied

Note. ERIC � Education Resources Information Centre.

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CHILDHOOD ADVERSITY AND ACADEMIC FUNCTIONING 151

or chronic). Lastly, specific consequences associated with the experienced trauma were also included, that is, depression or traumatic stress symptoms (if applicable).

Results

A total of 15 articles were identified that examined trauma- informed education programs and their impact on academic or academic-related outcomes. These articles were conducted in a variety of educational settings including preschools, primary/ elementary schools, and high schools. They included a diverse range of trauma-informed education programs as well as vari- ous academic or academic-related outcomes. These are dis- cussed below, with the trauma-informed theories and models discussed and the articles organized into intervention settings, that is, preschool, primary/elementary, or high school.

Interventions Used Across the Studies

Among the 15 articles reviewed, there were several trauma- informed theories and models employed to support with up- skilling educators and implementing trauma-informed systems. See Table 2 for a summary of the trauma-informed theories and models employed across the 15 articles reviewed. To highlight the diversity, eight different trauma-informed theories and mod- els were identified in this systematic review; however, there was some overlap, with several studies drawing from the same model of implementation. To illustrate, four studies (Dorado et al., 2016; Holmes et al., 2015; Mitchell, 2016; Pfenninger Saint Giles, 2016) used the attachment, self-regulation and compe- tency model (Blaustein & Kinniburgh, 2010) to inform their trauma-informed approach, with four additional studies (Baroni et al., 2016; Crosby et al., 2017, 2018; Day et al., 2015) using

Figure 1 Flowchart of the Literature Search and Documentation of the Screening, Inclu- sion, and Exclusion Processes

3282 ar�cles iden�fied in the Pub Med database

2648 ar�cles iden�fied in the Web of Science database

2503 ar�cles iden�fied in the PsycINFO database

339 ar�cles iden�fied in the ERIC database

7921 ar�cles, a�er 851 duplicates iden�fied

7921 �tles and abstracts screened

135 full text ar�cles were reviewed

10 papers were selected for the systema�c review

15 papers were selected for the systema�c review

0 addi�onal papers were included a�er searching specific journals with the word ‘school’

4 addi�onal papers were included a�er screening reference lists of iden�fied ar�cles and other relevant ar�cles

120 were excluded on the basis of the inclusion and exclusion criteria, with 5 unable to be located

1 addi�onal paper included due to authors knowledge

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ROSEBY AND GASCOIGNE152

Table 2 Description of Trauma-Informed Theories and Models

Intervention Description of intervention Articles that used intervention

Attachment, self-regulation and competency (ARC) model (Blaustein & Kinniburgh, 2010)

The ARC model is a guideline for working with traumatized children in the community

Dorado et al., 2016; Holmes et al., 2015; Mitchell, 2016; Pfenninger Saint Giles, 2016The ARC model addresses trauma in three main areas: (a)

attachment (e.g., building adult affect management and attunement skills as well as building routines and rituals), (b) self-regulation (e.g., developing appropriate emotion identification, modulation, and expression skills in individuals impacted by trauma), (c) competency (e.g., developing executive functioning skills as well as self- development and identity in individuals impacted by trauma).

Berry St education model (BSEM; Brunzell et al., 2016)

BSEM draws on neuro-scientific findings and outlines domains and themes for teachers to work through sequentially with their students.

Stokes & Turnbull, 2016

The BSEM comprises five domains: body, stamina, engagement and character, all anchored by relationships. Within each of these domains there are themes and specific teaching strategies and recommendations provided, e.g., the domain of body includes themes, specific teaching strategies, and recommendations for “de- escalation,” “present, centered, grounded,” “mindfulness,” and “self-regulation.”

Multitiered system of supports Multitiered systems of support offer three tiers of services to students, staff and the wider system; these include universal strategies, targeted strategies and intensive strategies. These supports are further scaffolded with work-force development trainings.

Dorado et al., 2016; Hatchett et al., 2017; Judge, 2018; Shamblin et al., 2016

Intervention components for trauma-informed multitiered systems of support can include universal consultations with teachers on a weekly basis, universal classroom training for students on coping with stress, targeted resiliency and trauma curriculum (i.e. REACH program), intensive crisis support for trauma-impacted school staff.

Work-force development trainings for trauma-informed multitiered systems of support can include the child trauma academy’s neuro-sequential model of therapeutics (Perry & Hambrick, 2008) and trauma-focused cognitive behavior therapy (Cohen et al., 2006) or more individualized training packages that focus on the neurobiological and physiological impact of complex trauma on students.

PACE Centre for Girls PACE Centre for Girls is a nonprofit organization that serves girls of middle and high school age. They use a “gender-responsive” framework for its academic services. “Gender-responsive” treatment approaches are designed for girls, specifically those involved with or at risk of involvement with the juvenile justice system. PACE’s program model promotes safety and positive relationships and uses strengths-based and trauma-informed approaches. PACE also rolled out in-person staff training on its key pillars as a gender-responsive, strengths-based, and trauma-informed program.

Millenky et al., 2019

Risking connection (Saakvitne et al., 2000)

Risking connection is a staff training curriculum for working specifically with survivors of childhood abuse, with an emphasis on “collaboration” with the client as opposed to “control” of the client’s dangerous behaviors. The main components of the Risking Connection curriculum are (a) an understanding of trauma, (b) importance of the relationship between client and “treater,” (c) safety, including maintaining physical and emotional safety while establishing healthy boundaries, (d) transforming vicarious trauma experienced by the treater.

Gonshak, 2011

(table continues)

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