Policymakers increasingly recognize the impact of trauma and adverse childhood experiences (ACEs) on lifelong physical, emotional, and social health and are beginning to support efforts for incorporating trauma-informed care (TIC) into the health and social service sectors. Proposed state and federal legislative, regulatory, and contracting policies aimed at reducing trauma and toxic stress and promoting resiliency and trauma-informed practices are burgeoning. By building on this momentum, federal and state policymakers can further opportunities for encouraging multi-sector implementation of trauma-informed models.

Surge in State Legislation Promoting Trauma-Informed Practices

A March 2017 scan by the National Conference of State Legislatures (NCSL) found almost 40 bills in 18 states that specifically include language on ACEs, representing a dramatic increase from a scan completed just a year ago. In addition, the 2017 NCSL scan identified 20 approved statutes in 15 states that referenced ACEs and trauma-informed policies and practices.

These bills and statutes — from states across the country — promote a variety of trauma-informed practices, such as: screening for ACEs; training staff and providers; and creating safe and supportive environments. They also address implementing trauma-informed processes within a number of health and social service systems, including: health care; behavioral health; child welfare; juvenile/criminal justice; education; and early childhood. Examples of state-level support for trauma-informed practices include:

• California: Legislation introduced this year proposes to include trauma screening under the Medi-Cal (Medicaid) Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT);

• Illinois: A law passed in January 2017 requires social and emotional screenings as part of school entry examinations;

• New York: A bill requires that home health care professionals use the ACEs questionnaire to assess a patient’s health and health risks, and ties Medicaid reimbursement of primary care providers to use of the questionnaire;

• Texas: Legislation passed in June 2017 requires the state juvenile justice department to provide trauma-informed training for juvenile probation and supervision officers;

• Vermont: Legislation signed into law in May 2017 bolsters the state’s response to early childhood toxic stress through a series of steps, including encouraging state colleges and universities to include ACEs and the impact of trauma in their curricula; and

• Wisconsin: The state’s recently passed Brighter Futures initiative will award more than $3 million to public agencies and nonprofits in select counties to reduce and prevent the incidence of ACEs.

Progress on the Federal Level: New Resolutions Recognizing Trauma-Informed Care

The number of federal legislative proposals explicitly referencing trauma-informed practices has grown significantly in the last eight years since the first such bill, the Domestic Minor Sex Trafficking Deterrence and Victims Support Act of 2010, was introduced in 2009. As reported by J. Purtle and M. Lewis in 2017, 49 bills were introduced that specifically use trauma-informed language — of which 28 bills were introduced in 2015 alone — and two bills were passed into law. More recently, newly introduced resolutions encourage efforts to build awareness, support implementation, and promote payment of trauma-informed care:

• The Trauma-Informed Care for Children and Families Act of 2017 (S774/HR1757) was introduced in Congress in December 2016 and, after stalling in committee, was reintroduced in both houses in 2017. The proposed legislation aims to increase understanding and awareness of trauma and identify best practices for prevention and treatment. The bill proposes to: (a) support workforce development, test new trauma-informed strategies, improve data collection on ACEs, and promote trauma-informed service delivery; (b) pilot a Medicaid demonstration program to incentivize coverage of trauma-informed screening and treatment; and (c) increase funding for evaluation of new strategies and foster coordination of cross-sector efforts. The bill has received significant support from a number of national, state, and local organizations, indicating growing awareness of the impact of trauma on health and behavior and the need for it to be addressed. In particular, a proposed Medicaid demonstration program offers a key opportunity to adopt payment and delivery system reform strategies that promote the adoption of trauma-informed care.

• In July 2017, Recognizing the Importance and Effectiveness of Trauma-informed Care (H.Res.443) was introduced by Mike Gallagher (R-WI) and co-sponsored by Danny Davis (D-IL) to increase awareness and encourage the use of trauma-informed approaches among existing programs and agencies at the federal level and to designate a national trauma-focused awareness month and day. The resolution is championed by First Lady of Wisconsin, Tonette Walker, and is among the first bipartisan trauma-specific resolutions. It cites work being done to promote TIC within 12 initiatives in nine states, including efforts in Wisconsin, Florida, and Washington State.

Build on the Momentum: Creating More Opportunities for Trauma-Informed Policy

Policy changes acknowledging the profound effects of trauma, toxic stress, and early adversity provide critical opportunities for upstream prevention, better treatment, and sustained support for individuals and families with histories of trauma. Federal and state policymakers can further this momentum by supporting efforts to:

1. Identify opportunities for collaboration to increase adoption across sectors and within systems. People with histories of trauma are often served by multiple sectors, making cross-sector collaboration a key piece of a trauma-informed approach. Collaboration provides opportunities for efficient service delivery and overall system savings. Policymakers can facilitate cross-sector efforts and support the data-sharing necessary for effective collaboration.
2. Measure the impact and return on investment for TIC to increase adoption within care settings and health systems, and across sectors. Research illustrating the advantages of a trauma-informed approach and enumerating return on investment (ROI) is necessary to support policies addressing ACEs and trauma. Policymakers could support evaluation of TIC models as well as research regarding the relationship between trauma across the lifespan and negative social and health outcomes.
3. Advance delivery system and payment reform models to promote trauma-informed screening, treatment, and referral services. Creating financial incentives and regulatory structures that encourage integrated care, prevention and early intervention, and cross-sector collaboration could increase support for implementing TIC.
4. Engage families and communities with lived experience of trauma to support the adoption of trauma-informed policies across the country. It is important to engage patients in designing effective approaches to address trauma and ensure that individuals with lived experience have a strong voice in the policy development process.
5. Invest in upstream prevention to reduce early adversity, identify problems sooner, and connect at-risk infants, young children, and families with needed services.

Across the country, innovative health and social services organizations are seeking new ways to promote and implement trauma-informed approaches to care. For example, Advancing Trauma-Informed Care, a CHCS-led national initiative made possible by the Robert Wood Johnson Foundation (RWJF), is seeking to identify how trauma-informed approaches can be practically implemented across the health care sector. Mobilizing Action for Resilient Communities and the Campaign for Trauma Informed Policy and Practice are examples of national efforts designed to create resilient, trauma-informed communities. Communities have also formed online, including Resilience USA, a group formed through the ACEs Connection website. An expert panel was recently convened by RWJF to determine how to build the evidence base for trauma-informed care and spread the approach widely across sectors. A forthcoming paper authored by Dr. Jonathan Purtle, Drexel University professor and member of the expert panel, will catalog the existing evidence base for trauma-informed care. A subsequent paper will be released by the panel focused on key opportunities for advancement of a trauma-informed approach. These efforts are essential to informing and catalyzing broad system-wide adoption of efforts to address trauma and capitalizing on the recent surge in state and federal support for TIC.