Highlight: HEARTS, San Francisco
University of California San Francisco, Child and Adolescent Services, Dept. of Psychiatry, HEARTS (Healthy Environments and Response to Trauma in Schools) Project
UCSF HEARTS is a multi-level school-based prevention and intervention programs for children who have experienced trauma that aims to promote school success for traumatized children and youth by creating school environments that are more trauma-sensitive and supportive of the needs of these students. This project draws its model in part from the flexible framework for trauma-sensitive schools described in the section above, published by Massachusetts Advocates for Children in the book entitled, “Helping Traumatized Children Learn: A Report and Policy Agenda.”
HEARTS has implemented its multi-level program in four San Francisco Unified School District (SFUSD) schools in the southeast sector of San Francisco: El Dorado Elementary, Bret Hart Elementary, Paul Revere School, and George Washington Carver Elementary. These schools serve some of the most under-resourced and chronically traumatized neighborhoods in San Francisco. HEARTS provides services within the three-tiered framework for prevention and intervention that is similar to the framework employed by PBIS:
- primary prevention or “fostering the emotional well-being of all students through school-wide safe and supportive environments”, e.g., classroom presentations on coping with stress;
- secondary prevention or “supports and services that are preventive and enable schools to intervene early to minimize escalation of identified behavioral health symptoms and other barriers to school success”, e.g., skills building groups for at-risk youth; and
- tertiary interventions or “intensive services and schools’ participation in coordinated care for the small number of students demonstrating significant needs”, e.g., trauma-informed therapeutic interventions around post-trauma difficulties.
A key ingredient of the HEARTS program is that it addresses the effects of trauma not only at the student level, but also at the adult caregiver level (i.e., parent/guardian and school staff), and at the system level (i.e., school climate, procedures, and policies). The HEARTS team provides critical support and training to parents/guardians through support groups and workshops, and to school personnel through professional development training, mental health consultation, and wellness support that addresses burnout and vicarious traumatization. Such training and support to school staff helps to build capacity in school staff and provide them with trauma-sensitive strategies to address classroom behavioral difficulties, training that educators typically do not receive in teacher education coursework.
In partnership with SFUSD, the HEARTS mental health practitioners have delivered more than 1800 hours of training and consultation to SFUSD and trained 700 SFUSD staff and affiliates. In the target schools, HEARTS provides on-site psychotherapy and mental health consultation three days per week. In surveys, school staff in these schools report a 57% increase in their knowledge about trauma and its effects on children, and a 64% increase in their use of trauma-sensitive classroom school practices. At El Dorado Elementary School, where HEARTS has been in operation for 4 years and where the school consistently tracked office discipline referral data, staff reported a 32% decrease in such referrals and a 42% decrease in violent student incidents after the first year of HEARTS implementation (2009-10 academic year).
School staff at target sites stated that the training and support has changed their perspective from “these are problem children” to “these are scared and hurt children.” A principal at one of the HEARTS’ schools told the HEARTS staff that:
[This] has shifted the way we discipline students at the school. . . . We are a lot more empathetic… we take more time to allow kids to cool off…to have those meltdowns and then come back without being suspended or sent home…So….getting at that Cradle to Prison pipeline ….we’re not reproducing the same model of ‘oh, you’re out of here,’ ostracizing kids and sending them home for things that they may feel are out of their control.
In an effort to more deeply embed a trauma-sensitive approach into the culture of SFUSD, HEARTS has also provided support and training to over 80 SFUSD Student and Family and Community Support Department medical and mental health personnel, through a multiple-session “Training of Trainers.” The goal of the HEARTS Training of Trainers is to build capacity with these personnel to bring the HEARTS curriculum on complex trauma and trauma-sensitive strategies to their school sites.
HEARTS staff have found that one of the greatest barriers to implementation occurs when school and/or district leadership do not recognize that behavioral health well-being is a prerequisite to success in the classroom and treat behavioral health as an off-shoot or something that can be placed in a silo to be addressed only in a crisis. When a school does not proactively establish a vision for integration of social and emotional learning with academic learning, and obtain buy in from staff and the community, success is elusive and mental health staff tend to be used only in crisis situations or after a student’s behavior has escalated out of control. Consequently, school leaders and educators operate in crisis-oriented mode, often resorting to knee-jerk school removals and punishments to address trauma-related behavior, which only serves to further alienate traumatized students and push them out of school.
The key to success, according to HEARTS leaders, is to implement a whole-school model of behavioral health that incorporates an understanding of the effects of trauma on students, staff, and systems, and that provides prevention and intervention at each of these levels. It is crucial to use a collaborative approach that involves key members of the school community (including families, teachers, administrators, mental health staff, and other school staff)to develop the specifics of these supports so that they are tailored to the needs and culture of the school. It is also essential that time is taken to develop buy-in at every level around the fact that learning and behavioral health are intricately intertwined and both must be addressed for student success.
As Associate Director Lynn Dolce explained, “Working on a school-wide behavioral health plan leads to safety for every student, not just those children struggling with the impacts of trauma.”
Currently, HEARTS is funded by several outside private grant sources, but it has not received a commitment of ongoing financial support from San Francisco Unified School District or any other institution, thereby putting the long-term sustainability of the work at risk.
Interview with: Joyce Dorado, Ph.D., Project Director, USCSF HEARTS, and Lynn Dolce, Associate Director, Child & Adolescent Services
How did you go about creating a partnership with the San Francisco Unified School District and its individual schools to bring in the HEARTS project?
Joyce: For many years, our former director, Miriam Martinez, worked on developing a relationship with the school district by attending meetings and reaching out to various district leaders. When a strong relationship was established with the district Superintendent as well as the Associate Superintendent of Student Support Services, we were able to work together to apply for the necessary funding to start the project.
What criteria did you use to determine which schools should be part of the pilot?
Joyce: We looked for high need schools, based on whether there was a high percentage of free and reduced lunch students, whether the neighborhood served was impacted by trauma, and if there was a significant achievement gap between African-American and Latino students on the one hand and Caucasian and Asian students on the other. It was also critical that the school have an infrastructure to support the change, namely: (a) a principal who believed that a whole school trauma-sensitive model was needed to address the effects of trauma,(b) buy in from at least some staff at the school, and (c) a location in the school that was private where we could provide individual and group therapy. We were not looking to replicate the traditional model: therapists who come in from the outside, do therapy for individual students for a limited amount of time and leave. We were looking to help foster culture change in the school towards being more safe, supportive, and trauma-sensitive.
In addition we were looking for a school with a well-functioning “Care Team.” Within SFUSD’s model, this is a team that meets weekly and typically includes the principal, mental health staff, special education staff, the attendance/discipline advisor, the school psychologist (who often has multiple sites) and a parent liaison (hired from the community). The team comes together to discuss school-wide issues (such as school climate, school safety, and the Positive Behavioral Interventions and Supports plan), as well as students of concern with behavioral or academic difficulties. To create whole school change, we knew that we needed to be an active part of this team.
How did the criteria selected result in your involvement at El Dorado Elementary School?
Joyce: El Dorado had a strong principal who understood that social emotional learning was a foundation of student achievement. The lead school social worker also understood the whole school approach. The Principal had also put together a strong staff who understood that they needed to attend to the social and emotional needs of the children, not solely the academic needs. In addition, El Dorado School largely serves children from Visitation Valley, as well as Sunnydale, one of the most under-resourced and chronically stressed communities in San Francisco.
How was this project funded?
Lynn: We received a very generous grant in December 2008 from the Metta Fund (a private foundation) for more than a million dollars, $300,000 for the planning year and another $400,000 for each of three implementation years. The grant not only funded our services, training, and time at the three schools for 3 years, it funding a 9 month planning period, stipends for school staff to attend training after hours, and our ongoing work with the District on developing broader policies to support trauma-sensitive practices throughout the district. We also were able to obtain other funding from the John and Lisa Pritzker Family Fund; the San Francisco Department of Children, Youth, and Their Families; Lieff, Cabraser, Heimann& Bernstein, LLP; the Mount Zion Health Fund; and SFUSD School Improvement Grant (SIG) funds. Also, Metta funded us this fiscal year for another year of the Training of Trainers. These funders have been really excited about the work that we have been doing, and its through their generosity that we have been able to continue to deepen and broaden the work with our schools.
How did you roll out the HEARTS project in the district and at the school?
Lynn: Before we even applied for the grant, we spent a lot of time working with District leadership. We went to a number of meetings to engage with them around the 5-year strategic plan they were developing related to addressing the achievement gap. To SFUSD’s credit, this plan included a clear understanding of the societal and social-emotional underpinnings of this achievement gap. The plan is called Beyond the Talk and is on SFUSD’s website. Through this engagement, we were able to make educated and collaborative decisions about how best to roll this out inside an individual school and how to begin to get traction with providing consultation with school leaders who work with multiple schools where we would not have an onsite presence. We can’t underscore how important it was to create the relationships with administrators at the top levels through this face to face relationship building. We understood the goals of the District and the language that the educators were using to engage around key issues; this helped us to integrate the work and support the overall system goals.
At the school level, we used the 9 month planning period to get to know the school staff, as well as the specific culture and inner workings of the school. This helped us to create a tailored plan with the school leadership for how we would engage with them and provide support, and to ensure we had a place on the professional developmental calendar. We presented a professional development training for all staff on Trauma and Learning before the school year started.
Then, from the start, we were an integral part of the Care Team, and this helped us to really see what was needed and help make micro and macro changes.
On a day to day basis, what does the HEARTS project do at the school to help support the culture and climate change?
Joyce: We have a postdoctoral fellow who has school experience and trauma training at the school three full days a week providing psychotherapy for kids with a history of trauma. This therapy is trauma-informed and intensive. It also involves engaging the caregivers in the therapy, as well as student-focused consultation with the child’s teachers. The fellow is also able to be there to help deescalate the child on the playground or in the classroom, and to provide training and ongoing support for teacher and other staff members to learn how to do the same. The fellow is able to quickly reinforce the skills the child is learning related to self-regulation and provide the same tools to staff, so that instead of kicking the student out they can help the student cope with their own anger or frustration and return to class.
Lynn: Joyce was also at the school for at least one day a week and attended the CARE team meetings weekly. From the outset, we established that our role was to collaborate with the staff and teachers. The fact that we were there on the ground with them so much helped them know that we understood what they were up against and that we were there to provide them with skills and support.
Joyce: In the first year, we helped to lay the ground work to create a discipline policy at the school that was about building skills as opposed to being punitive. The fellow met with each and every teacher around developing a “Collaborative Problem Solving” plan with a couple of their students who needed the most support. The active ingredient in these meetings was less the model itself, but more the value of having teachers reflect on how to build relationships with students and build skills in student around problem solving and self-regulation (helping the student to identify, express, and modulate their feelings).
Over the course of a couple of years, the school adopted a new discipline policy (link to document), which is still a work in progress, but includes a trauma-informed tiered intervention framework. The focus is on helping students build skills instead of just giving out consequences. We also worked on a stronger safety plan, which was focused on clear and consistent responses to safety issues (e.g., potential Child Protective Services issues, students who made suicidal statements, and dangerous or traumatic events in the neighborhood). A plan can incorporate strategies for preventing students from witnessing crime, such as moving the kindergartener play area away from the street where most of the crime was occurring.
In the CARE team meetings, we debriefed the most recent incidents and discussed the systemic actions needed to make the school more safe and supportive for students and staff.
We have provided a great deal of professional development at El Dorado to go deeper into trauma sensitive strategies and to provide training to staff on stress, burnout, and vicarious trauma. The Principal prioritized this training, which meant that we were on their Professional Development calendar several times throughout each year.
Were there other practices already in place that helped change the culture and lower disciplinary referrals and violence so quickly at the school?
Joyce: Data-based decision-making is key to any real reform and to measuring the impact of these reforms. At El Dorado, unlike some of the other schools, we had a very strong elementary advisor who took on the time-consuming job of keeping track of all office referrals. He not only tracked who was getting referred from class and why, but he kept different categories – fighting/violence incidents versus non-fighting incidents. He did this with a simple excel sheet. We know that the District is working on developing and rolling out an Office Discipline Referral tracking system for every school. The key will be not just having the data system but making sure there is adequate staffing to ensure that the data is accurately entered, tracked, and then, of course, analyzed by the CARE teams. It should be noted that a potential barrier to this accurate data collection could be that in schools where students are being regularly removed from class, the data can be somewhat daunting, and so some administrators may be worried about what the data might say about their school. But at El Dorado they understood the need to understand the problem to address it.
Another thing that was very helpful: the principal did a needs assessment or “gap survey” before we came on board. The staff identified that it was important to address the needs of the children who had trauma in their lives. They had already identified that time and energy needed to be devoted to looking at the issues facing the children at the school through a lens of stress, poverty, and trauma. So there was buy-in about HEARTS from the moment we hit the ground there.
What were some of the challenges that you faced at El Dorado with implementation?
Joyce: The outside forces that impact under-resourced schools. When we started the project, the series of education budget cuts in California had just begun. The District was laying off teachers and social workers and handing out pink slips in large quantities at our schools. The teachers at the schools were already overwhelmed with their responsibilities and this added to their worry and really affected morale. Even though many of the pink slips were rescinded, some of the teachers had already started looking for other work, and so the school experienced a fair bit of turnover. We ended up trying to advocate for the teachers at El Dorado to be able to stay at the school because of the specialized training they had received through HEARTS, and we provided information to the District about how this type of significant instability is most harmful to the children at high-needs, hard-to-staff schools like El Dorado. As I mentioned before, El Dorado serves the some of the most vulnerable children in the city who are most susceptible to be re-traumatized by instability and staff turnover.
The crisis factor was another challenging element. During our first year at El Dorado, the Care Team meeting, which was held in the principal’s office, was interrupted nearly every time because of one child or another coming into the office with a crisis. The meeting would stop and everyone would get involved with de-escalating the student. The conversation and the strategies could not move upstream to prevention and changing structures because we were constantly putting out fires. As part of the team, we helped the other team members reflect on how to protect the Care Team meeting time so that they could set more long-term goals. The next year, the office was closed for that hour and a specific staff member assigned to address the crises. This helped the Care Team to be a lot more efficient and effective.
We also realized that teacher stress and burnout meant could lead to high teacher turnover, and that when teachers are so stressed out, this could affect their ability to take care for the needs of the children. So, we provided teacher wellness support through a number of different avenues. When we consulted with teachers about how to address the challenges faced by a particular student, we would also talk with the teacher about how they were doing and what might be affecting their health and well-being. In year two, we helped start a teacher wellness group. At El Dorado, this ended up essentially being a structured time each week where the teachers went on a short walk with the postdoctoral fellow to build community and provide a time get some exercise and fresh air to lower their stress levels. Wellness of the staff is key to wellness of the students. It seems like not a lot of other programs focus on this. And we wanted to make sure that it wasn’t just about going to the bar on Friday to burn off steam; we wanted to help create structures for healthy coping.
Given that in our lowest income schools the factors of teacher and administrator turnover and burnout are very real, how do you ensure that these practices become part of the institution? In other words, how do you permanently change the structure?
Joyce: We have started to do intensive training and consultation with the staff in the Student Family Community Support Department in the District:a Training of Trainers with the high school wellness center coordinators, the school social workers, and some school nurses, so they can bring the HEARTS curriculum and trauma-informed consultation to their school sites. We also are encouraging them to look at the effects of trauma from a systems perspective. It has also been key that we have relationships with many staff at the school and district levels, so that when there is turnover, we do not lose our connection and momentum in that system. Also, we have realized that the more that we can convince the academic leadership at the district level that trauma-sensitive practices are integral to learning and academic achievement, the less likely these practices will be pushed to the margins.
In addition, a critical component is that rather than just “fixing” the problems that come up in our schools, we are continually building the capacity of the school staff so that they have the tools to help the students themselves. We want to empower the school staff to make the changes.
Lynn: Of course, ultimately, we need the District to invest district resources in the ongoing training of staff around these issues and to hire staff who are trained to continue to do the work. At this time, the District is incredibly under-resourced, and maybe because of this has not invested funds in the Trauma-Sensitive framework in a way that would allow it to transform from a pilot to a whole district reform effort.
Are there examples that you can point to where you see the practices have become a part of the structure and will outlast your involvement at the schools sites or in the District?
Joyce: It’s music to my ears to be at a school or district meeting and hear SFUSD folks use some of the trauma-sensitive language and approaches that we have been using in our trainings and conversations with the District. Also, in the past year, we have become more involved with the Restorative Practices Initiative at SFUSD (see http://healthiersf.org/Programs/PS/Restorative%20Justice/index.php). HEARTS values, goals, and methods dovetail perfectively with those of Restorative Practices, and they are incorporating trauma concepts and trauma-sensitive strategies into their district-wide trainings now.
At El Dorado, during the Care Team, team members routinely talk about building teacher-student relationships and figuring out ways to help kids learn self-regulation skills (both central tenets of a trauma-sensitive schools approach) when they discuss how to help kids who are behaving disruptively in the classrooms. And these days we see trauma-sensitive strategies regularly built into the behavior plans for kids of concern—these are plans that El Dorado school staff have put together without our direct consultation on these specific plans. In addition, many of the teachers have internalized trauma-sensitive practices, for example, by building “Peace Corners” into their classrooms. The Peace Corner is a specifically designated space in the room with self-regulation tools like stress balls, bubbles, a bean bag chair that can safely enfold and “hug” the student, and headphones so the student can listen to soothing music. If a child is feeling dysregulated or agitated, or is spacing out and dissociating, the teacher can recognize this and say “go ahead and use the Peace Corner for a few minutes,” and the child can get calmer and then come back to their classwork. This has become part of the language and the fabric of the school.
Some teachers have “Peace Corners,” and others have more mobile “Cool Down Kits,” boxes that contain self-regulation tools for kids (and school staff) to use when they need it. At the end of last school year, the SFUSD Student Family and Community Support Department had some money that they needed to spend by June, and they picked up the phone and called us to tell us that they wanted to buy “Cool Down Kits” for each and every social worker in the District, to help replicate this practice in schools throughout the District. So we helped them pick out tools to put in these kits. It was wonderful and inspiring that they decided to do this with their remaining funds for the year.
Is there anything else you want to tell other leaders who are hoping to create a Trauma Sensitive School or system?
Joyce: If you want to make meaningful change for children and youth who have experienced complex trauma, it’s simply not enough to try to get these kids into therapy. Trauma is a public health issue that requires systems level thinking, as well as long-term planning that keeps in mind a multicultural and developmental lens. Similar to SAMHSA’s efforts to infuse Trauma-Informed Care into public mental health systems (see www.samhsa.gov/co-occurring/news-and-features/shifting-perspective.aspx), we believe that it is important for all people that work with children and youth to have a shift in perspective, so that when a student is having difficulties, instead of asking the question, “What is wrong with you?” we ask “What happened to you that led you to this point?” This shift will help us all to respond more emphatically and effectively to these young people, so that we can give them the support, structure, and skill-building that they need to heal, develop, learn, and thrive.
Helping Traumatized Children Learn, A Report and Policy Agenda, Massachusetts Advocates for Children: Trauma and Learning Policy Initiative In collaboration with Harvard Law School and the Task Force on Children Affected by Domestic Violence (2005).
 The Behavioral Health and Public Schools Framework, Introduction to the Framework, visit http://BPHS321.org, p. 1.