State Efforts to Address ACEs and Trauma and Build Resilience

States are working to prevent and mitigate ACEs and trauma, and have an opportunity to advance trauma-informed care with the implementation of the 988 hotline.

By Anna Heard

Adverse childhood experiences (ACEs) are potentially traumatic events that can affect a person’s health, well-being and success into adulthood. The COVID-19 pandemic has exacerbated these dynamics by disrupting the lives of families. Over 140,000 children have lost a primary or secondary caregiver and, as a result of school disruptions, many children have become more socially isolated. These factors can negatively impact mental health, especially given many children across the nation were already experiencing poor mental health outcomes before the pandemic began. In February 2022, the Centers for Disease Control and Prevention (CDC) released a report that describes children’s mental health trends from 2013 to 2019 based on federal analysis. About one in five (20.9 percent) children and adolescents aged 12-17 years had experienced a major depressive episode, and 36.7 percent of high school students in 2019 reported persistently feeling sad or hopeless in the past year. The report also mentions the lack of a comprehensive way to evaluate children’s mental health and notes that there is limited data on positive indicators like resilience, meaning the ability of youth to overcome the challenges they have faced. Addressing these issues is critical since long-term effects of ACEs linger throughout the lifespan and can lead to mental health and substance use disorders into adulthood.

ACEs Learning Collaborative and Trauma-Informed States

States have a vital role to play in preventing and addressing ACEs and supporting efforts to address crisis, mental health and the long-term effects of trauma. The National Governors Association (NGA) has supported states in their efforts on ACEs, trauma and resiliency through multiple projects over the years. In 2020 and 2021, NGA and the National Academy for State Health Policy (NASHP) convened five states (Delaware, Maryland, Pennsylvania, Virginia and Wyoming) as part of a technical assistance project focused on statewide approaches to address ACEs. This work culminated in the publication State Actions to Prevent and Mitigate Adverse Childhood Experiences.

Several Governors have issued executive orders to declare their state trauma-informed and direct state agencies to prioritize addressing ACEs. Pennsylvania, for instance, is developing a Universal Healing Strategy after taking the stance that every child who experienced the pandemic has at least one ACE. Others have created an office tasked with coordinating cross-agency efforts related to trauma and resilience. Delaware created a Statewide Trauma-Informed Care Coordinator role to lead implementation of Governor John Carney’s Executive Order 24 to make Delaware a trauma-informed state and to integrate trauma-informed best practices into state agencies. Virginia launched its Office of Trauma and Resilience Policy this year to coordinate efforts on trauma following the success of the Virginia HEALS program, which is an initiative to prevent and mitigate childhood trauma and victimization through a trauma-informed model of service delivery. As the U.S. Surgeon General reports, states can take several tactics to support children’s mental health, including addressing the economic and social barriers that contribute to poor mental health, integrating screening and treatment into primary care, and coordinating efforts across levels of government. By promoting resilience, states can prepare young people to better adapt to difficult circumstances and support their own wellbeing throughout their lives.

The State Trauma and Resilience Network

After the success of the ACEs Learning Collaborative, the mid-Atlantic states involved in that project formed the State Trauma and Resilience Network. This group is comprised of Governors’ advisors and senior state leaders focused on addressing ACEs, trauma and resilience in their states. In 2022, the Network expanded to include several more mid-Atlantic states (Connecticut, New Jersey, New York and North Carolina), and participating states recently decided to expand nationwide with the addition of Wyoming and Wisconsin, aiming to add additional states as they become interested. The group has been meeting monthly since fall 2021 as a space to share experiences, ideas and best practices peer-to-peer. Thanks to the generous support from the Robert Wood Johnson Foundation, the Network was able to come together at their first in-person gathering in Washington, D.C. on June 30, 2022. During the day, state participants had a chance to hear from federal partners from the CDC and the Office of the U.S. Surgeon General about opportunities for state-federal collaboration to address ACEs and trauma, along with strategies to integrate trauma-informed care into court systems. The group also explored innovative approaches on reducing trauma through intentional design of public spaces, such as incorporating educational content in public bus stops. The state participants also engaged in peer-to-peer sessions to discuss the importance of including cross- and inter-agency approaches as part of state trauma and resilience initiatives and linking to potentially related issues including substance use disorder and mental health, crisis response and 988 implementation, public health and education.

What 988 Means for Trauma-Informed Care

The implementation of the 988 hotline is a timely example of this coordinated approach. On July 16, 2020, 988 was designated as the new three-digit dialing code to route callers to the National Suicide Prevention Hotline, now known as the 988 Suicide & Crisis Lifeline. Congress passed legislation in 2020 designating 988 as the three-digit number people can call when experiencing suicidal ideation or a mental health crisis. This has been a nationally coordinated effort led by the Substance Abuse and Mental Health Services Administration (SAMHSA), the Department of Health and Human Services and the Department of Veterans Affairs. States play an essential role in the hotline’s implementation.

The 988 number can be reached 24/7 by call, text and chat and is answered by an individual at one of 200 call centers located across the country. Veterans can press 1 after dialing 988 to reach the Veterans Crisis Line, where a responder will help them through the crisis and connect the caller with their local VA medical center or another community resource. Other callers will reach and speak to trained counselors, and most crises are resolved during the call. If more assistance is needed, the centers can dispatch a mobile crisis team or connect callers to community programs for crisis stabilization. These steps are all part of the crisis response continuum of care and represent a more trauma-informed approach than using 911 and law enforcement to handle these situations.

There are an estimated 21 million people in the U.S. with a current or past exposure to trauma. The CDC has documented the linkages between ACEs and suicide, with having any ACE associated with a higher risk for suicide. Suicide is a leading cause of death in the U.S., with one death by suicide occurring every 11 minutes in 2020. Researchers have determined that there are an estimated 39 million people in the U.S. who need this crisis response service, though only 12 million use it now. The transition to 988 is expected to increase the number of individuals who can benefit from this support.

The 988 hotline is addressing an important gap toward achieving a coordinated, accessible way for people to access crisis and trauma response that will have lasting effects. The hotline is also an avenue to provide trauma-informed care through a trained counselor and connect people in crisis to available resources in their community. States have an opportunity to connect people in crisis with the help they need to address their trauma and support their path to resilience.

Ongoing NGA Support of Trauma and Resilience Efforts

The upcoming NGA Health and Human Services Institute in September will feature a session focused on trauma and resilience and how federal-state partnerships can strengthen these efforts. NGA will continue to support states in this important work through the State Trauma and Resilience Network and as a partner of the nationwide Pathways to Resilience project. The Pathways project raises awareness about the impact of adversity and trauma on individuals, families, and communities and advances cross-sector strategies for promoting equity, lifelong health and well-being by convening state and community leaders to break down silos, build connections, and identify and implement practical solutions.

States are at a moment of inflection and change in many aspects, especially as it relates to the post-pandemic recovery and in their understanding of and efforts to address trauma. NGA is working with states to facilitate linkages among trauma-related programs nationwide and will continue working with states on trauma-informed and trauma-anticipatory efforts that focus on awareness of the paths toward recovery and resilience. These efforts will also focus on those paths that include supports and education on the implications of living with trauma and linking these efforts to those underway across sectors.


The following resources may be helpful as states continue to implement and enhance the 988 hotline.