Complex Trauma in Children and Adolescents Essay

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Complex trauma may be best thought of as an imprecise label that refers to children in clinical settings who present with a history that includes severe or prolonged exposure to multiple traumas and/or other adverse events and a clinical presentation of serious emotional and behavioral problems and/or conditions that extend across functioning domains. From a clinical perspective it is less important how these children are labeled than it is to help them with their problems and needs. In selecting treatment approaches, the focus should be on matching interventions that are supported by theory or empirical evidence for improving outcomes to the problems or conditions that bring the children and their families into the clinical setting.

Exposure To Trauma

It is now well established that children and adolescents are exposed to potentially traumatic events (PTEs) at significant rates, that most children have some distress following exposure to a PTE, that a nontrivial percentage of exposed children develop significant emotional and behavioral problems related to PTEs, and that exposure increases risk for a variety of subsequent problems.

Prevalence rates of exposure vary between studies due to a number of factors, including the type of PTE exposure assessed, the specificity of the screening questions, whether children are asked the questions directly, whether the design is retrospective, and the nature of the sample. For example, studies using multiple, behaviorally descriptive questions typically yield higher rates for sexual and physical abuse than those using a single, general gate question. Studies employing samples of children residing in inner-city areas report much higher rates of exposure to serious community violence than do other groups. Until quite recently, studies tended to focus on one or a few types of potentially traumatic events, making it difficult to ascertain the cumulative burden of exposure. More recent studies that have screened for multiple traumas find that it is common for children who are exposed to one type of trauma to be exposed to others, with a substantial percentage having been exposed to four or more traumas.

In terms of impact, studies also vary for similar reasons, including what outcomes are assessed; how outcomes are measured; whether the design is prospective or cross-sectional; and whether self-report, parent report, official report, or a combination of sources for outcomes is used. The degree and nature of impact tends to differ based on the source of the information. In general children report higher levels of posttraumatic stress, anxiety, and depression than caregivers. Overall, the results converge in finding that a significant percentage of exposed youth develop a posttraumatic stress response such as posttraumatic stress disorder (PTSD) and have higher rates of emotional and behavioral problems than nonexposed children. Predictors for negative outcomes include severity (e.g., sexual penetration, injury), perception of life threat, and duration. Prior exposure to trauma increases the likelihood of negative impact for a particular event, and a history of more traumas is associated with worse outcomes.


There is currently no consensus definition of the term complex trauma. In part this is due to the use of the term trauma to describe both PTEs and their impact. In terms of defining the events, an unresolved question is what events are included. PTE was originally defined, as described in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM–III), as an event outside ordinary human experience that was associated with a threat to life and limb. Now that it is known that even conservatively defined traumas are relatively common, rareness is no longer a relevant criterion. The objective threat criterion was abandoned as it became widely accepted that such often nonviolent experiences as child sexual abuse were subjectively experienced as threatening. Direct exposure is no longer considered necessary, as individuals who know someone who died violently or offspring of trauma exposed individuals can develop PTSD.

More recently, however, the definition of trauma has expanded further. For example, children with serious illnesses such as cancer have been studied for post trauma reactions. Some commentators have characterized insecure attachment and neglect as forms of trauma. Others have argued that historical experiences of oppression or subjugation of a group constitute a form of trauma history for all current members of the group (e.g., Native Americans or African Americans). This departure from defining trauma as an event or series of events experienced directly or indirectly by the individual to including a whole range of adverse conditions that might negatively affect children or groups makes it difficult to arrive at a definition of trauma or complex trauma.

Broadening the definition of trauma raises questions about what constitutes trauma as distinguished from other types of adversities that negatively affect children’s growth and development. Many children exposed to trauma, however it is defined, have also been exposed to other adverse life events (e.g., poverty, homelessness, parental divorce, parental substance abuse, mental illness, and/or imprisonment) and have complicating circumstances (e.g., being an undocumented immigrant, a non-English-speaker, and/or developmentally disabled). Co-occurrence of trauma and adversity is common and cumulative burden is associated with more severe outcomes.

This suggests that complex trauma might best be defined by the presence of severe and pervasive psychological distress and impairment in a child who has a history of trauma. In almost all cases where children exposed to trauma have significant persisting psychological and functional problems there will be a constellation of historical and contemporaneous variables that include multiple trauma exposures and other adversities.


In terms of treatment effectiveness, the evidence for children exposed to trauma is highly consistent with research on child psychotherapy in general. What is most relevant to treatment planning is the nature and severity of the problems, not the source. Key principles are matching interventions with theoretical and empirical support to identified problem areas, systematically applying the interventions, and focusing on skill acquisition.

Trauma-focused cognitive-behavioral therapy is the best researched trauma-specific intervention, with multiple randomized clinical trials. It has been shown to reduce PTSD symptoms, anxiety, and depression and moderate trauma-related behavioral reactions in sexually abused children, community violence–exposed youth, and children exposed to multiple traumas.

A variety of other interventions that target other outcomes have been applied to children with trauma histories and shown to have empirical support. Parent–child psychotherapy, a dynamically informed, attachment-based intervention for mothers who have been exposed to domestic violence and their young children, has produced very promising results in a randomized trial. An efficacious version of parent behavior management, parent–child interaction therapy, has been shown to be effective for children exposed to physical abuse, neglect, and domestic violence in reducing behavior problems, in improving the parent– child relationship, and in cases of physical abuse, in reducing referrals to Child Protective Services. Abuse-focused cognitive-behavioral therapy for physically abusive families similarly reduces child behavior problems and violent family behavior. There is emerging evidence on the application to adolescents of an intervention called dialectical behavior therapy that was originally designed for self-harming adults, most of whom had trauma histories. Although clinical trials of youth given other proven treatments have not always collected data on trauma exposure, it is likely that many of the youth have significant trauma histories and benefit by the treatment that the intervention targets (e.g., multisystemic therapy, functional family therapy for delinquents).


  1. Turner, H. A., Finkelhor, D., & Ormrod, R. (2006). The effect of lifetime victimization on the mental health of children and adolescents. Social Science and Medicine, 62, 13–27.

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