by SM Chafouleas · 2016 · Cited by 278 — Toward a blueprint for trauma-informed service delivery in schools. Developments in prevention-focused services for children have spanned the last five.

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TRAUMA – INFORMED AND MULTITIERED 1 Running Head: TRAUMA – INFORMED AND MULTITIERED CITATION: Chafouleas, S. M., Johnson, A. H., Overstreet, S., & Santos, N. M. (2016). Toward a blueprint for trauma – informed service delivery in schools. School Mental Health, 8 , 144 162. DOI 10.1007/s12310 – 015 – 9166 – 8. Toward a Blueprint for Trauma – Informed Service Delivery in Schools Sandra M. Chafouleas 1 , Austin H. Johnson 1 , Stacy Overstreet 2 & Natascha M. Santos 3 University of Connecticut 1 Tulane University 2 New York University Steinhardt School of Culture, Education, and Human Development 3 KEYWORDS: trauma – i nformed, Response to Intervention, chronic stress, multitiered frameworks Author Note: The authors wish to thank Division 16 of the American Psychological Association for supporting the Trauma – Informed Services Workgroup. Preparation of this manuscript was supported in part by funding provided by the Institute for Education Sc iences, U.S. Department of Education (R305A140543). Opinions expressed herein do not necessarily reflect the position of the U.S. Department of Education, and such endorsements should not be inferred. All authors declare no conflict of interest. Correspon dence regarding this article should be addressed to Sandra M. Chafouleas at the University of Connecticut, Department of Educational Psychology, U – 3064, Storrs, CT 06269 – 2064; email: .

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TRAUMA – INFORMED AND MULTITIERED 2 Abstract Recognition of the benefits to tr auma – informed approaches is expanding , along with commensurate interest in extending delivery within school systems. Although information about trauma – informed approaches has quickly burgeoned, systematic attention to integration within multitiered servi ce delivery frameworks has not occurred yet is essential to accura te, durable , and scalab le implementation. In addition, there is a critical need to concurrently build a strong evidence base regarding trauma – informed service delivery in schools . In this paper, the literatures on trauma – informed approaches and multitiered frameworks for school – based service delivery are connected with the goal to provide suggestions toward building blueprint s for trauma – informed service delivery in schools . Drawing from the literature on implementation blueprints for school – wide positive behavior supports, sections are organized around current knowledge about trauma – informed approaches with regard to blueprints for (a) implementation, (b) professional develo pment, and (c) evaluation. C ritical issues, strategy recommendations, and directions for research are discussed .

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TRAUMA – INFORMED AND MULTITIERED 3 Toward a Blueprint for Trauma – Informed Service Delivery in Schools R ecognition of the benefits to trauma – informed approaches is expanding ( see Overstreet & Chafouleas, this issue ) , along with comm ensurate interest in extending delivery within school systems. School s represent an opportune system for prevention and early intervention across domains related to child success . Historically, school – based outcomes have focused heavily on academic domains , yet there has been increasing acceptance and attention to the connection among social, emotional, behavioral, and mental health outcomes as facilitators or impediments to overall success in sc hool ( National Research Council and Institute of Medicine, 2009 ). A cknowledgement of this connection coupled with the push for service delivery framework s using multitiered prevention logic have created a unique space to integrate trauma – informed approach es in to school – based service delivery. Multitiered frameworks of service delivery are built on foundations involving early identification of risk, varied levels of intervention support designed to teach skills and prevent more serious problems, and cont inual data – driven evaluation of response . This logic fits well with the burgeoning and diverse body of recommendations regarding a trauma – informed approach (see Substance Abuse and Mental Health Services Administration [SAMHSA] , 2014) . However, in order for a trauma – informed initiative in school – based service delivery to be successful , comprehensive blueprint s for implementation, professional development, and evaluation is needed . Unlike academic issues in which identification of need and provision of assistance is relatively focused and non – controversial, a host of layered complexities (e.g. , involvement of multiple systems of care, family privacy, school resource capacity) surroun d trauma – informed service delivery in schools. Thus, successful implementation of a trauma – informed approach to school – based service delivery is

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TRAUMA – INFORMED AND MULTITIERED 4 dependent on identification of these complexities and alignment with careful planning and decision making . Th e purpose of this paper is to connect the literatures on trauma – informed approaches and multitiered frameworks for school – based service delivery , particularly School – Wide Positive Behavior Interventions and Supports (SWPBIS:, in order to faci litate an understanding of these connections towards building blueprint s for a trauma – informed approach to school – based service delivery . T he following sections elaborate upon critical issues, strategy recommendations, and directions for research. First, a brief history of multitiered prevention and intervention for emotional and behavioral outcomes is presented, setting the background for adding trauma – informed outcomes within these frameworks. Next, key considerations in building blueprint s for tr auma – informed service delivery in schools are presented. S tructures for organizing content are heavily drawn from SWPBIS, a nationally – used framework for multitiered service delivery for behavior in schools. Although other theoretical and empirical work in the area of scale up of evidence – based preventive interventions (e.g., Communities that Care : ) is acknowledged, we hav e chosen to use SWPBIS to illustrate our suggestions for trauma – informed delivery in schools given both the detailed framing within multitiered models and the wide – spread familiarity among educators. A tremendous volume of SW PBIS resources exist s at natio nal, state, and local levels, with the guiding blueprints offered by the OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports provid ing a template to draw upon . C urrent knowledge about trauma – informed app ro aches is organized around each of the SW PBIS blueprints (implementation, professional development, evaluation). Throughout the sections , focused content addresses why

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TRAUMA – INFORMED AND MULTITIERED 5 it matters, what is known, and what needs to be done. Finally, concluding comments are provi ded to stimulate future discussions for research and practice agendas. Multitiered prevention and intervention for emotional and behavioral outcomes S ervices for students with academic and behavioral challenges have historically been – test – already exhibit challenges are of some type not result in improved outcomes, and if deemed eligible, access to more intensive supports (Gresham, 2007). Contemporary school – based efforts have moved away from these reactive approaches toward s prevention – oriented model s such as Response to Intervention (RTI) and SWPB IS in which data are routinely used to identify problems early and monitor response to increasingly intensive services to address needs. Such models may generally be referred to th six c ore defining features: (a) the use of evidence – based practice when providing support to students , (b) tiered organization of supports with increasing intensity, (c) use of a data – based problem – solving framework for support decisions , (d) decision r ules for evaluating student response to support and subsequent modifications, (e) measuring and maintaining treatment fidelity, and (f) iden tifying students who need support early (Sugai & Horner, 2009). Models for multitiered prevention frameworks commonly share a three – tiered approach, with Tiers 1, 2, and 3 referring to assessment and intervention for students provided at low, moderate, and high intensity respectively , and with data – based de cision – making occurring at each tier. Developments in prevention – focused services for children have spanned the last five decades. Although initially more widely researched and pushed in education settings around

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TRAUMA – INFORMED AND MULTITIERED 6 academic domains and intervention supports , appli cation of prevention – based logic to social, emotional, and behavioral domains was conc urrently advocated (e.g. Walker et al. , 1996). Related , it is likely a relevant reminder that the tenets of multitiered prevention frameworks began with focus on mental health domains (see Caplan, 1964). R ecently , a joint report by the National Research Council and the Institute of Medicine provided a robust summary and extension of prevention – based logic for behavior and schools within an integrated model for the prevention and intervention of mental, emotional, and behavioral disorders (2009). In addition, f rameworks like SWPBIS and the Interconnected System Framework s have described critical roles for school – based systems in the prevention and interventi on of mental, emotional, and behavioral – related challenges (Barrett, Eber, & Weist, 2013). Despite each of these advances , considerations around incorporating school mental health, specifically trauma and traumatic stress, have yet to be fully and systemat ically developed for multitiered prevention systems . As the prevalence and impact of trauma and traumatic stress become increasingly underst ood (e.g., Felitti et al., 1998 ), the push for schools to provide trauma – informed interventions and services has correspondingly increased ( SAMHSA , 2014). This demand is in part driven by burgeoning evidence demonstrating positive outcomes for school – based trauma – specific interventions on reduction of traumatic stress reactions (Rolfsnes & Idsoe, 2011). An additional driver may be the increased accessibility of social, emotional, and behavioral supports offered in schools. In general, referrals for school – based mental health services have been shown to be more successful than referrals to community agencies (Evans & Weist, 2004) , and this trend appears to extend to trauma – specific interventions (Jaycox et al., 2010). Despite their promise, isolated interventions and programs are difficult to sustain, e ven with high – quality, evid ence – based programs (Cole, Eisner, Gregory, & Ristuccia , 2013;

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TRAUMA – INFORMED AND MULTITIERED 8 a trauma – informed approach ( SAMHSA , 2014) . I n addition to establishing defining features and components of a trauma – informed approach, a second yet equally – relevant focus for an implementation blueprint attends to the systems – level components of implementation with accuracy, durability, and scalability ( Technical Assistance Center on Positive Behavioral Interventions and Supports, 2010 ). A s discussed later, and as a pplied to a trauma – informed approach to service delivery in schools, concerted fo cus is needed around implementation considerations given greater complications associated with the multiple systems of care and stakeholders involved . Next, we review work by SAMHSA and integrate with other content knowledge to establish con sensus around key features of trauma and trauma – informed care. Content Knowledge: Establishing Consensus Around Core Features Establishing content knowledge about core features of trauma and trauma – informed care serves as an important initial step , and is often focused on information such as t he prevalence and impact of trauma on student development and school functioning as well as developing an appreciation of th e complexity of trauma exposure. In our review, t rauma is often associated features are consistent. SAMHS trauma is defined as follows: Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that emotional, or spiritual well – being . 7, 2014). Note the defining focus on the individual and consequences for the individual as a result of experiences. The individual serves as the central focus given recognition of the wide range of

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TRAUMA – INFORMED AND MULTITIERED 9 individual response s to potenti ally traumatic events. T he SAMHS A document (2014) goes experience, and effect. First, the event occurs, which may be a single occurrence or be repeated over time and may include actual or ext reme threat of harm. However, it is the experience of the event by the individual that determines whether it is a traumatic event. Experience is defined by the individual, and varies widely . Many possible internal and external influences on the individu predispositions. In addition, characteristics of the event can influence the experience, including predictability, duration, con sequences, and intensity (Brock et a l. experience then influences the effect of the event, over the short to long term. Most typically, effects are described as occurring for the individual and involve self – regulation, or the ability to manage emotions, impulses, a nd behavior (Hamoudi, Murray, Serensen, & Fontaine, 2015). Examples of individual effects include hypervigilance, inability to cope with daily life, and disrupted cognitive functioning. Neurobiological explanations of adverse effects have been documented and further information continues to emerge, supporting theoretical bases for trauma within ecological, developmental, and biological perspectives (Hamoudi et al., 2015). In vironment, the interpretation of the event is subjective based on an array of interacting ecological, developmental, and neurobiological factors, which produce changes in individual behavior and neurobiology that can persist over time. Following understanding about defining features of trauma and the rationale for a trauma – informed approach, content knowledge about the key principles to a trauma – informed approach is needed . See Table 1 for the key principles as defined by SAMHSA (2014). As discussed in

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TRAUMA – INFORMED AND MULTITIERED 10 the sections on implementation features and on building a professional development blueprint, connecting the key principles to specific skill s in identification of trauma and choosing appropriate strategies for supporting all students fra mes a next essential piece to content knowledge about trauma – informed service delivery in schools . To close this section on content knowledge through establishing consensus around core features , we conclude with brief comments regarding connections betwe en the defining features of trauma – informed services and S WPB I S characteristics ( preventive, instructionally oriented, culturally responsive, evidence based, function based, systems – implementation focused ). The comparison provides opportunity to identify similarities across initiatives as well as gaps in knowledge, which informs both practice in relation to common language and understanding of initiatives as well as possibilities for further research. Compari sons of the core features dr aw many similarities, including goals to prevent the problem and engag e cultural awareness , all of which is wrapped in a focus on the positive rather than the negative or reactive. The core features of SWPB I S are most heavily b ased within a behavioral theoretical framework, and thus, individual behavior is explained and modified primarily through external systems or environmental manipulations (e.g. , teaching expected behavior, reinforcing displays of expected behavior , antecede nt manipulations ). In contrast, emphasis of prevention within a trauma – informed approach is more strongly described with an intra individual lens. That is, building self – regulation (resilience, coping) within the individual is emphasized, with external supports focused on creating safe environments and building positive connections and trusting relationships. A noted strength of SWPB I S is spe cific attention directed toward building capacity for systems implementation within schools. In contrast, a trauma – informed approach acknowledges the need for cross – systems collaboration, but core features provide less specificity

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TRAUMA – INFORMED AND MULTITIERED 11 as to how to accomplish implementation. Thus, one possible need related to a trauma – informed initiative is to attend to careful planning around the system implementation. In the next section, we expand on implementation features, particularly as centered within a multitiered f ramework for school – based service delivery. Implementation Features within a Multitiered Framework Effective implementation is described as including four foundations that interact to enable ongoing monitoring, data – based decision making, and self – enhance ment (Technical Assistance on Positive Behavioral Interventions and Supports, 2010). The se four elements include: outcomes, practices, data, and systems. The elements work together to inform decisions within a multitiered framework of service delivery designed to meet the needs of all students. Outcomes . As previously described, f oundations for the defining features of trauma can be found in perspectives offered by Gerald Caplan in advocating for population – oriented preven tion during the post – e very crisis presents both an opportunity for psychological growth and the danger of psychological deterioration (p . 53). Thus, the strategies associated with defining crisis as an oppo rtunity for psychological growth need to span a continuum of prevention through intensive interventi on, and must include a multi – pronged approach in which every person has access to both the internal and external resources necessary to both reduce stressor s and facilitate coping when experiencing stressor s. Given these considerations, the intended outcomes of a trauma – informed approach can be defined as four – fold: ( a ) prevent adverse events and experiences from occurring, ( b ) build self – regulation capacity in individuals, ( c ) assist individuals exhibiting adverse effects in returning to prior functioning, and ( d ) avoid re – traumatizing individuals who have experienced adverse events (SAMHSA, 2014) . These outcomes align with a multitiered framework in that the overall

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