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


The University of California, San Francisco’s Healthy Environments and Response to Trauma in Schools (HEARTS) Program promotes school success for trauma-impacted students through a whole-school approach utilizing the response to intervention multi-tiered framework. Tier 1 involves school-wide universal supports to change school cultures into learning environments that are more safe, supportive and trauma-informed. Tier 2 involves capacity building with school staff to facilitate the incorporation of a trauma-informed lens into the development of supports for at-risk students, school-wide concerns and disciplinary procedures. Tier 3 involves intensive interventions for students suffering from the impact of trauma. Program evaluation questions were: (1) Was there an increase in school personnel’s knowledge about addressing trauma and in their use of trauma-sensitive practices? (2) Was there an improvement in students’ school engagement? (3) Was there a decrease in behavioral problems associated with loss of students’ instructional time due to disciplinary measures taken? (4) Was there a decrease in trauma-related symptoms in students who received HEARTS therapy? Results indicate preliminary support for the effectiveness of the HEARTS program for each of the evaluation questions examined, suggesting that a whole-school, multi-tiered approach providing support at the student, school personnel and system levels can help mitigate the effects of trauma and chronic stress. Key areas for further studies include (a) an examination of data across more HEARTS schools that includes comparison control schools and (b) disaggregating disciplinary data by race and ethnicity to determine whether disproportionality in the meting out of disciplinary actions is reduced.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2


  1. Anderson, R. L., Lyons, J. S., Giles, D. M., Price, J. A., & Estes, G. (2002). Reliability of the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH) scale. Journal of Child and Family Studies, 12, 279–289.

    Article  Google Scholar 

  2. Blaustein, M., & Kinniburgh, K. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. New York: The Guilford Press.

    Google Scholar 

  3. Bloom, S. (1995). Creating sanctuary in the school. Journal for a Just and Caring Education, 1(4), 403–433.

    Google Scholar 

  4. Bowen, D. J., Kreuter, M., Spring, B., Cofta-Woerpel, L., Linnan, L., Weiner, D., & Fernandez, M. (2009). How we design feasibility studies. American Journal of Preventive Medicine, 36(5), 452–457.

    PubMed Central  Article  PubMed  Google Scholar 

  5. Bucher, K. T., & Manning, M. L. (2005). Creating safe schools. The Clearing House, 79, 55–60.

    Article  Google Scholar 

  6. Buka, S. L., Stichick, T. L., Birdthistle, I., & Earls, F. J. (2001). Youth exposure to violence: prevalence, risks, and consequences. American Journal of Orthopsychiatry, 71(3), 298–310.

    Article  PubMed  Google Scholar 

  7. Center for Labor Market Studies. (2009). Left behind in America: The nation’s dropout crisis. Boston: Northeastern University and Chicago: The Alternative Schools Network.

  8. Cole, S. F., Eisner, A., Gregory, M., & Ristuccia, J. (2013). Helping traumatized children learn: Creating and advocating for trauma-sensitive schools. Boston: Massachusetts Advocates for Children.

    Google Scholar 

  9. Cole, S. F., O’Brien, J. G., Gadd, M. G., Ristuccia, J., Wallace, D. L., & Gregory, M. (2005). Helping traumatized children learn: Supportive school environments for children traumatized by family violence. Boston: Massachusetts Advocates for Children.

    Google Scholar 

  10. Collaborative for Academic, Social, and Emotional Learning (CASEL). (2012). 2013 CASEL guide: Effective social and emotional learning programs (Preschool and elementary school edition). Chicago, IL: CASEL.

    Google Scholar 

  11. Dilley, J., Weiner, D., Lyons, J., & Martinovich, Z. (2003). The validity of the child and adolescent needs and strengths assessment. Toronto: Poster presented at the American Psychological Association Annual Convention.

    Google Scholar 

  12. Epstein, K, Speziale, K., Gerber, E., & Loomis, B. (2014). Trauma informed systems initiative: 2014 year in review. Unpublished manuscript, San Francisco Department of Public Health, San Francisco, CA.

  13. Ford, J. D. (2009). Neurobiological and developmental research: Clinical implications. In C. Courtois & J. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide. New York: The Guilford Press.

    Google Scholar 

  14. Hodgdon, H. B., Kinniburgh, K., Gabowitz, D., Blaustein, M. E., & Spinazzola, J. (2013). Development and implementation of trauma-informed programming in youth residential treatment centers using the ARC framework. Journal of Family Violence, 28, 679–692.

    Article  Google Scholar 

  15. Hopson, L. M., Schiller, K. S., & Lawson, H. A. (2014). Exploring linkages between school climate, behavioral norms, social supports, and academic success. Social Work Research, 38, 197–209.

    Article  Google Scholar 

  16. Howard, G. S. (1980). Response-shift bias: A problem in evaluating programs with pre/post self-reports. Evaluation Review, 4, 93–106.

    Article  Google Scholar 

  17. Howard, G. S., Millham, J., Slaten, S., & O’Donnell, L. (1981). Influence of subject response-style effects on retrospective measures. Applied Psychological Measurement, 5, 144–150.

    Article  Google Scholar 

  18. Howard, G. S., Ralph, K. M., Gulanick, N. A., Maxwell, S. E., Nance, D. W., & Gerber, S. K. (1979). Internal validity in pretest-posttest self-report evaluations and a re-evaluation of retrospective pretests. Applied Psychological Measurement, 3, 1–23.

    Article  Google Scholar 

  19. Johnston, K., & Brinamen, C. (2006). Mental health consultation in child care: Transforming relationships among directors, staff, and families. Washington, DC: ZERO TO THREE.

    Google Scholar 

  20. Kiser, L. J., & Black, M. (2005). Family processes in the midst of urban poverty. Aggression and Violent Behavior, 10, 715–750.

    Article  Google Scholar 

  21. Klatt, J. & Taylor-Powell, E. (2005). Synthesis of literature relative to retrospective pretest design. Presentation to the 2005 Joint CES/AEA Conference, Toronto.

  22. Mabie, G. E. (2003). Making schools safe for the 21st century: An interview with Ronald D. Stephens. Educational Forum, 67, 156–162.

    Article  Google Scholar 

  23. Losen, D. J., Martinez, T., & Gillespie, J. (2012). Suspended education in California. The Center for Civil Rights Remedies at the Civil Rights Project at UCLA.

  24. Mirsky, L. (2011). Restorative practices: Giving everyone a voice to create safe saner school communities. The Prevention Researcher, 18, 3–6.

    Google Scholar 

  25. Nisbett, R. E., & Wilson, T. D. (1977). Telling more than we can know: Verbal reports on mental processes. Psychological Review, 84(3), 231–259.

    Article  Google Scholar 

  26. Porche, M. V., Fortuna, L. R., Lin, J., & Alegria, M. (2011). Childhood trauma and psychiatric disorders as correlates of school dropout in a national sample of young adults. Child Development, 82(3), 982–998.

    PubMed Central  Article  PubMed  Google Scholar 

  27. Praed Foundation. (1999). CANS manual.

  28. Public Counsel. (2015). Fix school discipline: How we can fix school discipline: Toolkit for educators. Retrieved from

  29. San Francisco School Board. (2014). Safe and supportive schools policy. San Francisco: San Francisco Unified School District.

    Google Scholar 

  30. San Francisco Unified School District (SFUSD). (2008). Beyond the talk: Taking action to educate every child now. SFUSD 2008–2012 Strategic Plan. San Francisco: San Francisco Unified School District.

  31. Soto-Vigil Koon, D. (2013). Exclusionary school discipline: An issue brief and review of the literature. The Chief Justice Earl Warren Institute on Law and Social Policy, Berkeley School of Law, University of California.

  32. Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.

  33. Van der Kolk, B. (2014). The body keeps the score. New York: Viking Press.

    Google Scholar 

  34. Wisconsin Department of Health Services. (2013). Retrieved from

  35. Wolpow, R., Johnson, M. M., Hertel, R., & Kincaid, S. O. (2009). The heart of learning and teaching: Compassion, resiliency, and academic success. Olympia, WA: Washington State Office of Superintendent of Public Instruction Compassionate Schools.

    Google Scholar 

Download references


This study was funded by The Metta Fund, John and Lisa Pritzker Family Fund, The Tipping Point Foundation, Lieff, Cabraser, Heimann & Bernstein, LLP, SFUSD School Improvement Grant, MEDA Mission Promise Neighborhoods, SFUSD (Department of Children Youth and Their Families Mayor’s Wellness Program funds), SF Community Behavioral Health Services, The Denver Foundation, The Giving Trust, Kaiser/Colorado Education Initiative and The California Endowment. Our sincere thanks to the dedicated clinicians, researchers and staff from our UCSF and AMHC programs, especially Quyen Le, Olivia Park, Megha Tailor and Martha Shumway for their help with our program evaluation, Lynn Dolce and Martha Merchant for their contributions to the HEARTS curriculum and Nancy Milliken and the UCSF Center of Excellence in Women’s Health for their support. We are deeply grateful to our school district partners, SFUSD and APS.

Author information



Corresponding author

Correspondence to Joyce S. Dorado.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Dorado, J.S., Martinez, M., McArthur, L.E. 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 8, 163–176 (2016).

Download citation


  • Trauma
  • Complex trauma
  • School-based mental health
  • School to prison pipeline
  • Trauma-informed schools
  • Prevention