C o m p l e x Tra u m a

Matthew Kliethermes, PhD*, Megan Schacht, PhD,

Kate Drewry, MSW, LCSW

KEYWORDS
 Complex trauma  Children and adolescents  Interpersonal trauma
 Childhood victimization

KEY POINTS
 Complex trauma exposure involves chronic/multiple traumas during developmentally
vulnerable time periods.
 Exposure to complex trauma is a common occurrence for children and adolescents.
 Complex trauma exposure disrupts early attachment relationships and brain
development.
 Complex trauma outcomes involve significant difficulties with emotional, behavioral,
somatic, and cognitive dysregulation.

Acronyms

ADHD Attention deficit/hyperactivity disorder

BTT Betrayal trauma theory
DTD Developmental trauma disorder
HPA Hypothalamic-pituitary-adrenal
PTSD Post-traumatic stress disorder

INTRODUCTION

The construct of complex trauma has evolved significantly in the past 25 years. Part of
the challenge with the development of this concept is that the term complex trauma
has been used to refer to both the traumatic event and the unique sequelae of symp-
toms associated with this type of trauma. One of the earliest attempts to delineate the
concept of complex trauma was attempted by Terr1 who differentiated type I and type
II traumas. According to this model, type I traumas tend to be single events resulting in
symptoms more closely aligned with posttraumatic stress disorder (PTSD), whereas

Disclosure: The authors have no industry disclosures to report.

Children’s Advocacy Services of Greater St Louis, Department of Psychology, University of
Missouri–St Louis, Weinman Building, 1 University Boulevard, St Louis, MO 63121, USA
* Corresponding author.
E-mail address: [email protected]

Child Adolesc Psychiatric Clin N Am 23 (2014) 339–361

http://dx.doi.org/10.1016/j.chc.2013.12.009 childpsych.theclinics.com
1056-4993/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
340 Kliethermes et al

type II traumas tend to be repeated, long-standing events that may present with a
range of symptoms including denial, dissociation, rage, self-destructive behavior,
and unremitting sadness.
The definition of complex traumatic experiences has evolved into one that refers to
severe events that tend to be chronic and undermine a child’s personality develop-
ment and fundamental trust in relationships.2 Building from this characterization,
a complex traumatic event has been further defined as a traumatic event that is repet-
itive and occurs over an extended period of time, undermines primary caregiving re-
lationships, and occurs at sensitive times with regard to brain development.
Complex trauma events vary widely and include physical abuse, sexual abuse,
emotional abuse, neglect, witnessing domestic violence, exposure to community
violence, and medical trauma. The lack of consensus on a definition of complex
trauma has posed challenges for researchers because definitions can have varying
emphasis placed on the number of traumatic events, the types of traumatic events,
the developmental periods in which they occur, or the resulting symptom profile.3
The term complex trauma is also used to refer to the unique pattern of symptoms
associated with this type of experience. Research has struggled to identify the
sequelae of complex trauma; however, it has consistently identified that the impact
of complex trauma is distinctive compared with more acute traumas.2,4–6 Domains
of impairment associated with complex trauma exposure may include deficits in rela-
tionships and attachment, emotional and behavioral dysregulation, cognitive/atten-
tional deficits, and biological changes that may affect physical health. Further,
symptoms such as dissociation, changes to self-perception, and overall shifts in be-
liefs about the world are frequently seen among youth who have experienced complex
trauma.7
Delineating the construct of complex trauma both from the perspective of defining
the traumatic event as well as its resulting sequelae is important to further research
efforts and to avoid unnecessary pathologizing of traumatized children. Even more
importantly, fully understanding the impact of complex trauma on children will best
facilitate clinicians’ ability to enhance protective factors and develop treatment inter-
ventions to help children recover.

Complex Trauma Prevalence

Given the dual definitions of complex trauma, the prevalence of complex trauma can
be thought of in 2 ways. First, it can refer to the frequency of exposure to complex trau-
matic experiences. Second, it can refer to the frequency of complex trauma outcomes
in response to such exposure.

Prevalence of complex traumatic events

Exposure to repetitive or multiple forms of victimization is common in childhood.
Finkelhor and colleagues4 found that 22% of a nationally representative sample of
2030 children aged 2 to 17 years had experienced 4 or more different forms of victim-
ization in the past year. Victimization was broadly defined to include exposure to vio-
lent and property crime (eg, assault, theft), child welfare violations (eg, child abuse),
warfare/civil disturbances, and bullying. The same researchers8 conducted a
screening of lifetime exposure to victimization in a nationally representative sample
of 4053 youth aged 2 to 17 years. Almost 66% of the sample had been exposed to
more than 1 form of victimization, 30% had been exposed to 5 or more types of victim-
ization, and 10% had experienced 11 or more.
Polyvictimization can also start at a young age. For example, in the Turner and col-
leagues8 study, 40% of polyvictims were younger than 13 years of age. A study of
 Complex Trauma 341

213 children aged 2 to 4 years found that 64.3% had a history of trauma exposure, and
that 34.7% of those exposed to trauma had experienced 2 or more traumas.9 A
portion of this sample included children referred to sites providing mental health or
developmental delay services, whereas the remainder were nonreferred children
recruited from the same communities. As discussed later, prevalence of complex
trauma exposure is even higher among at-risk populations such as youth in foster
care10 and those who are justice involved.11

Prevalence of complex trauma outcomes

Given the ongoing debate regarding the validity of complex trauma as a separate diag-
nostic entity in adults12 and children13 it is challenging to specify the prevalence of
complex trauma outcomes. However, research does support a dose-response rela-
tionship with exposure to more trauma types resulting in increased symptom breadth
and complexity for children14–16 and adults.14,17,18
Furthermore, evidence is beginning to emerge regarding the prevalence of develop-
mental trauma disorder (DTD),6 a proposed syndrome designed to describe out-
comes associated with complex trauma exposure. Stolbach and colleagues19
found that, among youth who met criteria for complex trauma exposure, 31% met
the proposed criteria for DTD. This finding suggests that a sizable percentage of youth
presenting for trauma-focused services are showing clinically significant complex
trauma outcomes. Further, a study of 330 former Ugandan child soldiers with severe
histories of chronic trauma exposure found that slightly more than 78% met the pro-
posed criteria for DTD.20 Overall, these findings suggest that outcomes conceptual-
ized as complex trauma are common following exposure to chronic, interpersonal
trauma.

Causes of Complex Trauma Exposure

The causes of complex trauma can also be considered in the context of exposure
and outcomes. With regard to exposure, multiple individual and environmental char-
acteristics have been identified as precipitants for repeated victimization. For
example, Finkelhor and colleagues21 identified 4 primary precipitants for polyvictim-
ization: (1) living in a dangerous community; (2) living in a dangerous family environ-
ment; (3) living in a nondangerous but chaotic family environment; and (4) having
emotional problems that result in increased risky behavior, interpersonal antago-
nism, and risk of victimization. Further, being a polyvictim seems to be a risk factor
for future polyvictimization.22

Causes of Complex Trauma Outcomes

Complex trauma outcomes (discussed later) could be conceptualized as a develop-
mental disorder triggered by exposure to complex trauma. It is theorized that complex
trauma outcomes are influenced by the developmental period during which trauma
exposure occurs, but that they also disrupt subsequent development.7 Therefore,
complex trauma outcomes consist of common traumatic stress reactions (eg,
PTSD, depression, insecure attachment, dissociation) and developmental disruptions
caused by contextual factors related to complex trauma exposure (eg, impaired care-
giving, multiple placements) and traumatic stress reactions (eg, chronic hyperarousal
disrupting development of emotion regulation). Further, impairment seems to be more
chronic and severe when trauma exposure has an earlier onset,23,24 increased dura-
tion,23,25 consists of multiple types of trauma,26 and is interpersonal in nature,27 which
are all part of the definition of complex trauma exposure. So, how does complex
342 Kliethermes et al

trauma exposure result in these outcomes? Possible causal factors include disrupted
brain development and disorganized attachment.

Complex trauma and disrupted brain development

First, considerable research indicates that trauma exposure can result in structural
and functional changes in brain development.28 The areas of the brain most affected
by trauma exposure are the structures that make up the stress response system. For
example, neurobiological findings following trauma exposure include neuroendocrine
dysregulation; reduction in hippocampal, amygdala, and prefrontal cortex volume;
and decrease in corpus callosum size.29,30 These structural changes are thought to
be the causal underpinnings of common posttraumatic symptoms such as hyper-
arousal, reexperiencing, emotional and behavioral dysregulation, dissociation, numb-
ing, attention difficulties, and executive function deficits.31,32
These changes have been conceptualized as an alternate developmental pathway
designed to be an adaptation to a high-stress environment.31 Biologic systems shift
from a focus on learning to a focus on survival.33 Brain organization and activation
become focused on structures that promote rapid, autonomic responses to avoid
harm and regulate arousal (eg, brainstem, midbrain, amygdala) rather than structures
involved in complex learning and long-term adaptation (eg, medial and dorsolateral
prefrontal cortex). This survival-focused brain can defend against immediate harm,
but does so at the expense of systems that prevent exhaustion, injury, and illness
and promote self-regulation and learning.34 These alterations in brain structure and
function result in a combination of affective, somatic, behavioral, and interpersonal im-
pairments perhaps best conceptualized as a dysregulation syndrome.35 The alter-
ations also likely explain the variety of developmental deficits identified in children
exposed to trauma, including speech-language disorders,36 executive functioning
deficits,37 working memory,38 and overall cognitive ability.39
It remains difficult to distinguish how the brain changes related to complex trauma
differ from those seen in research specific to PTSD. For example, changes in brain
function and structure have been detected less than a month after trauma expo-
sure,40,41 suggesting that extended activation of the human stress response may
not be a causal necessity. In contrast, research has suggested that earlier onset
and longer duration of trauma exposure are associated with more significant structural
changes in the brain.23,25 It also seems possible that the structural changes are more
closely related to the presence and severity of PTSD rather than characteristics of
trauma exposure.30,42 However, this relationship is also unclear because other re-
searchers have shown changes in the brain structure of trauma-exposed individuals
regardless of diagnostic status.30,43 In addition, there seems to be some validity to
the idea that trauma exposure affects brain development differentially depending on
what region of the brain is developing most actively when the trauma occurs. Ander-
sen and colleagues44 showed that adult hippocampal volume was most related to
sexual abuse occurring between 3 and 5 years of age and between 11 and 13 years
of age, corpus callosum area was most related to sexual abuse between ages
9 and 10 years, and frontal cortex volume was most related to sexual abuse during
ages 14 to 16 years. Based on these findings, it seems reasonable to suspect that
the changes in brain structure seen after trauma exposure occur on a continuum influ-
enced by a variety of factors (eg, genetic predisposition; onset, severity, and duration
of trauma exposure; severity and duration of traumatic stress reactions; disrupted
attachment; and developmental status), many of which are defining aspects of com-
plex trauma. However, further research is needed to clarify the relationship between
complex trauma and changes in brain function and structure.
 Complex Trauma 343

Complex trauma and disrupted attachment

A second critical causal factor related to complex trauma outcomes is caregiver-child
attachment. By definition, complex trauma is thought to occur in caregiving or rela-
tional contexts,2 and attachment has been implicated in the expression of complex
trauma outcomes. The first year of life largely revolves around development of a
secure attachment relationship between infant and caregiver allowing for emotional
communication and coregulation.45 Schore46 states that secure attachment promotes
brain development, development of social bonds, and development of brain struc-
tures critical for the regulation of stress (ie, hypothalamic-pituitary-adrenal axis).
This contention seems to be supported because researchers have shown increased
cortisol reactivity in insecurely attached children47,48 and differences in gray matter
volume in the right temporal pole and left lateral orbitofrontal cortex in adults who
showed attachment-related anxiety.49
Disorganized attachment is associated with a variety of negative outcomes
including externalizing disorders, aggression, and oppositional defiant disorder.50 It
is thought that youth with a disorganized attachment style lack an organized strategy
for coping with stress and instead show behavioral disorganization or disorientation
when confronted by stress.51 Further, disorganized youth are typically unable to use
the attachment relationship to modulate distress. This inability seems to continue
throughout childhood because these youth are more likely to have social skill deficits,
including inconsistent or overly rigid interpersonal behavior.52
In the context of complex trauma the attachment relationship is commonly dis-
rupted and disorganized. The caregiver overstimulates the child through traumatic
behavior and/or understimulates the child through neglect. Further, the caregiver
does not repair this misattunement, fails to protect the child from stressors, and fails
to help the child regulate arousal.46 Brain structures associated with self-regulation
subsequently remain underdeveloped resulting in a chronic state of dysregulation
characterized by both hyperarousal and hypoarousal.53 This combination of attach-
ment disruption and maltreatment is thought to lead to more chronic and severe
symptoms, beyond the effects of maltreatment alone.54–56 In this context, complex
trauma outcome causes could be construed as the interaction between traumatic
stress responses and disorganized attachment. Pearlman and Courtois57 note
that research from trauma/dissociation and attachment/development supports the
idea that most chronically abused individuals show an insecure disorganized and
dissociative attachment style. Thus the distress and dysregulation associated with
trauma exposure occurs in the context of inability to regulate oneself through
attachment. Further, given that trauma exposure likely occurred in the context of
an attachment relationship, interpersonal interactions may further trigger trauma-
related distress. This distress could contribute to the chronic dysregulation
associated with complex trauma. Some research supports this possibility because
unresolved attachment in adults has been associated with several symptoms remi-
niscent of complex trauma, including dissociation, inconsistent sense of self, and
relationship problems.58

PHENOMENOLOGY

Numerous studies have attempted to describe the sequelae of complex trauma and,
although there is some convergence among this literature, there is not yet a clear
symptom profile.7,13,14,59 As mentioned previously, youth with multiple traumatic ex-
posures typically fare worse than those with a single traumatic exposure and the high-
est level of symptom distress is associated with exposure to multiple interpersonal
344 Kliethermes et al

traumas.60 Further, an increase in the number of different types of traumas experi-

enced is associated with an increase in symptom complexity.14
Several attempts have been made to identify symptom clusters that can accurately
capture the sequelae of complex trauma exposure. What these attempts have identi-
fied is that the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth
Edition, Text Revision (DSM-IV-TR) criteria for PTSD do not seem to accurately and
comprehensively capture the sequelae of complex trauma.14,22 Additional symptom
clusters associated with complex trauma exposure include affect regulation, con-
sciousness, self-perception, perception of the perpetrator, relations with others, sys-
tems of meaning, alterations in attention and consciousness, somatization, and
disturbances in self-regulatory capacities.12,14,61 Given the recent evolution of the
PTSD diagnosis with the DSM-5 it will be interesting to see how research evolves in
this area. It seems that the DSM-5 PTSD criteria may be able to more comprehensively
include youth with complex trauma within the diagnosis. Nonetheless, given that
extensive literature has shown that the experience of complex trauma results in a
significantly different symptom profile than acute trauma, it will continue to be impor-
tant to understand the sequelae of complex trauma in order to develop useful case
conceptualizations.

Dysregulation of Affect and Behavior

Perhaps the most readily apparent symptom clusters of complex trauma are those
associated with affective and behavioral dysregulation. In general, anxiety, depres-
sion, and anger/aggression are frequently comorbid with posttraumatic stress and
the experience of complex trauma.62 Severe, ongoing trauma has the potential to
affect children by overloading their ability to cope with emotions, altering their ability
to access and identify emotions, impairing their ability to tolerate emotional expres-
sion; and impairing their ability to regulate their impulses.7,13,63 These youth subse-
quently tend to present with rapidly vacillating moods with extreme responses
seemingly triggered by minor stressors or by nothing.
Dysregulation of behavior may present as either undercontrolled or overcontrolled
behavioral patterns. The function of overcontrolled behavior is to manage over-
whelming affect and feelings of helplessness by attempting to rigidly regulate what
behavior patterns and routines children may have under their control. In contrast,
undercontrolled behavior is often a reflection of deficits in impulse control, planning,
and executive functioning.7 These adaptations to the overwhelming stress of complex
trauma are children’s best attempts to cope with their experiences, but ultimately tend
to put them more at risk for further traumatization. Their deficits in both emotional and
behavioral regulation leave them without the skills necessary to navigate social situa-
tions and also result in behavioral reactions that may put them at further risk (eg,
aggression, self-injurious behaviors).64

Disturbances of Attention/Consciousness, Cognition, and Information Processing

Disturbances of attention and consciousness may present in a variety of ways: disso-
ciation, inattention, a lack of sustained curiosity, difficulty planning and anticipating,
and so forth.7,13 One way to conceptualize these reactions is as overdevelopment
of avoidance responses.65 Avoidance is a common trauma response and often gener-
alized beyond the initial trauma stimulus (eg, anxiety related to bathrooms or night-
time). However, with complex trauma the avoidance becomes even more extreme
and generalizes to symptoms such as dissociation, memory loss, and impaired exec-
utive functioning.
 Complex Trauma 345

Difficulties with attention and arousal have created much debate over the comorbid-
ity of attention deficit/hyperactivity disorder (ADHD) in children who have experienced
complex trauma. Although ADHD and complex trauma seem to be distinct syn-
dromes, their overlapping symptoms make them difficult to differentiate in children
exposed to complex trauma. Although complex trauma has not been found to be a
risk factor for ADHD,66 additional research is needed to determine how to distinguish
between ADHD and cognitive regulatory deficits related to complex trauma/
dissociation.
In addition to inattention, dissociative symptoms may present as memory loss,
depersonalization, derealization, disengagement, and numbing. It is unclear to what
extent dissociation helps differentiate complex trauma symptoms, but research sug-
gests that dissociation plays a unique role in overall sequelae of complex trauma.67
For example, one study identified that dissociation uniquely contributes to relationship
difficulties, likely because of the impaired interpersonal skills that evolve when disso-
ciative symptoms become more prevalent.68

Interpersonal Difficulties
Complex trauma has the potential to cause a variety of interpersonal difficulties, in
large part through its influence on a child’s attachment and internal representation
of themselves in relation to others.55 This condition may manifest as difficulties with
trust, low interpersonal effectiveness, revictimization, victimizing others, and poor
boundaries.69,70 Because most complex trauma experiences threaten the primary
attachment relationship (eg, domestic violence, sexual abuse, neglect), it is logical
that a resulting symptom cluster would be disruptions to a child’s ability to develop
high-quality, adaptive interpersonal skills. Children with complex trauma histories
often do not experience safety within their relationships and are not able to use their
primary caregiving relationships as a secure base on which to develop internal work-
ing models of themselves and others. In addition, secondary traumatic stressors that
these children often continue to confront (eg, disruptions in foster placements, transi-
tions in family composition) may further impede their ability to develop interpersonal
skills and quality attachment relationships and also present additional risk factors to
overcome. A study of 347 children in long-term foster and kinship care consistently
identified significant social and interpersonal difficulties.71

Distortions in Attributions
Disruptions in attachment and the ability to regulate emotions and impulses is often
linked to the evolution of distortions related to sense of self and expectations of others
and the world.72 Complex trauma often occurs within the context of formative care-
giving relationships that shape children’s beliefs about themselves and the world
around them. The abuse can involve the creation of distorted attributions (eg, being
told that they are damaged), but the children may also develop distorted attributions
as a way of coping with the trauma, their environment, and resulting symptoms (eg,
believing they deserve the abuse and do not deserve anything better). Overall,
these distortions facilitate the development of self-blame, low self-esteem, and poor
self-efficacy.73 These maladaptive beliefs may build a foundation for impaired social
interactions and further mental health deficits.13

Biology
Complex trauma can interfere with many neurologic and physiologic developmental
processes causing biological compromise.7 The neurobiological impact of
trauma can impede the maturation of specific brain structures; neuroendocrine
346 Kliethermes et al

responses; and the coordination of cognition, emotion regulation, and behavior.74

The biological impact of trauma can decrease children’s overall awareness of their
bodies. Further, trauma may manifest as somatic symptoms, increased electrical
irritability in limbic structures,75 or may lead to serious long-term health risk be-
haviors and diseases.76

PREDICTING CLINICAL OUTCOMES FOR COMPLEX TRAUMA EXPOSURE

Trying to appreciate how clinical outcomes associated with complex trauma exposure
vary across development is like trying to pick the winning number on a roulette wheel.
Because of the ever-changing developmental landscape, the frequency of victimiza-
tion, and the ongoing presence of secondary adversities, there are many possible
outcomes.
Exposure to interpersonal violence has been found to place children at greater over-
all risk for psychosocial impairment and PTSD than exposure to noninterpersonal
violence and/or community violence.77 Therefore, the presence of interpersonal
victimization could be a helpful predictor. However, victimization rates have been
found to be generally high across the developmental span of childhood. Further,
research has shown that some of the commonly held beliefs about exposure to
trauma, such as young children being more frequently exposed to domestic violence,
are not necessarily as robust as was once thought.78 In general, boys experience more
peer assaults as they proceed through adolescence, sibling assaults peak in middle
childhood and decline with age, and sexual victimization of girls increases in later
adolescence.78 These findings suggest that trying to predict clinical outcomes by
exposure to interpersonal victimization at a given developmental period may be
impractical.
Family system factors may offer more insight into understanding clinical outcomes
across the developmental spectrum. Risk factors that influence the development of
PTSD in children include externalizing characteristics, family mental health difficulties,
family adversity, low intelligence quotient, and chronic environmental stressors.79
These findings suggest that trying to anticipate clinical outcomes by evaluating the
risk and protective factors (both intrinsic and extrinsic) to a child may be a more valid
and reliable approach.
Overall, research has indicated that a multifaceted approach is required to under-
stand the link between complex trauma experiences and outcomes.55,80 This
approach includes considering traumatic stressors and their related events as
well as the intrinsic/extrinsic factors of the child and their ongoing adjustment. The
resulting picture may be intricate and difficult to predict, but also accurately reflects
the complexity of both the traumas experienced and the children who live through
them.

Family Issues
Offending caregiver dynamics
For many children and adolescents exposed to complex trauma, parents or other pri-
mary caregivers are the source of their trauma. Children who experience trauma
caused by those responsible for protecting and nurturing them are likely to develop
insecure attachment patterns, including disorganized attachment. As many as
90% of maltreated children show an insecure attachment style,81 with disorganized
attachment style being present in half to three-quarters.82 Similar to complex trauma
outcomes, disorganized attachment is associated with emotion regulation difficulties,
externalizing problems, and impaired social functioning.83
 Complex Trauma 347

Betrayal trauma theory offers another framework for understanding the impact of
caregiver-perpetrated or family-perpetrated trauma on children and adolescents. Ac-
cording to this theory, the violation of trust that occurs when children are victimized by
caregivers or others in positions of trust constitutes a threat to their survival.82
Because a child’s awareness of caregiver-inflicted trauma might cause withdrawal
from that caregiver, thereby disrupting the attachment relationship that affords safety
and protection to the child, it may be psychologically necessary for the child to remain
unaware of the betrayal. This so-called betrayal blindness, although enabling the child
to preserve a sense of security, may be associated with significant difficulties related
to dissociation (the mechanism by which betrayal blindness occurs), cognition, mental
health symptoms, and interpersonal functioning.82 For example, research indicates
that experiencing childhood betrayal trauma is associated with later difficulty in recog-
nizing interpersonal betrayals and detecting trustworthiness in people.
Trauma that originates in the family is likely to generate significant secondary
adversities for children and adolescents.81 Caregiver-perpetrated trauma may
necessitate placement in foster care or residential facilities, requiring adjustment
to new caregivers, homes, neighborhoods, communities, and schools. Separation
from family and peers, uncertainty about the future, loss of familiar routines, and
the stress of system involvement can exacerbate trauma-related symptoms or
create additional psychological distress in children placed outside the home. Other
secondary adversities often resulting from intrafamilial trauma include economic
problems caused by parental incarceration or estrangement, significant rifts in im-
mediate or extended family relationships, residential instability, and legal system
involvement.

Resilience/Coping
The family is a child’s first and generally most significant social environment, and as
such plays an important role in determining how children and adolescents adapt to
complex trauma exposure. The role of the family environment in influencing the out-
comes of traumatized children is especially significant given that family variables
(eg, caregiver support, parenting practices) are potential targets of intervention,
whereas variables specific to the trauma exposure (eg, type and duration of exposure)
are often immutable.84,85 Certain family characteristics and relationship qualities are
associated with resilience and adaptive functioning among children who are mal-
treated or exposed to chronic stress. Other types of family conditions and behaviors
seem to contribute to, or exacerbate, trauma symptoms.86
Parenting practices can mediate the impact of trauma on children and adolescents.
Research suggests that there is great variability in parenting practices among families
experiencing child maltreatment and family violence, and aspects of parenting predict
differential outcomes for traumatized children.87,88 Valentino and colleagues89 found
that hostile/coercive parenting was associated with greater PTSD and internalizing
symptoms in children exposed to trauma; in the same study, engaged and supportive
parenting strongly predicted child-reported adjustment. Graham-Bermann and col-
leagues90 found that parenting warmth and effectiveness differentiated children who
seemed to be coping adequately following exposure to domestic violence from those
with problems in adjustment.
Caregiver support is a primary protective factor in children exposed to trauma, pre-
dicting the degree to which children experience and resolve trauma reactions.
Research findings consistently show that children who have a supportive caregiver
show fewer behavioral and emotional symptoms following trauma.84,87,91 As noted
by Cook and colleagues,7 supportive caregiving responses following trauma can be
348 Kliethermes et al

conceptualized as involving 3 factors: (1) believing and validating the child’s experi-
ence, (2) tolerating the child’s affect, and (3) the caregivers’ regulation of their own
emotional response. In contrast, when caregivers deny children’s experiences, the
children’s recovery is impeded because they cannot integrate the traumatic experi-
ences or develop positive coping strategies.7
Research on trauma and attachment provides additional support to the salience of
the parent-child relationship in the aftermath of trauma. Attachment theory posits that
children are biologically driven to seek proximity to a caregiver, especially in situations
perceived as frightening or dangerous.92 Through a secure attachment with the care-
giver, children learn to regulate their emotions and make sense of what is happening in
the environment. Secure attachment can mitigate the impact of overwhelming
stressors and support recovery and healing following exposure to trauma.93

Systemic Issues
Implications for children in care
Children and adolescents in the child welfare system have high rates of trauma expo-
sure, including complex trauma exposure. A recent study of foster children referred
for treatment found that 70.4% of the sample reported at least 2 forms of recurrent
interpersonal trauma perpetuated by caregivers (ie, sexual abuse, physical abuse,
emotional abuse, neglect, or domestic violence); 11.7% reported having experi-
enced all 5 trauma types.10 Among children involved with the child welfare system,
children with complex trauma histories experience more mental health symptoms,
including symptoms of traumatic stress, compared with children with other types
of trauma.10,94
Findings related to the prevalence of complex trauma exposure among children in
the child welfare system and the adverse mental health outcomes associated with
such exposure have important practice implications. First, child welfare professionals
need increased awareness of the nature of complex trauma exposure and its relation-
ship to adverse mental health outcomes. When workers better understand how
children are affected by complex trauma experiences, they will be better able to deter-
mine treatment priorities and address service gaps.10 In addition, frontline workers
should be trained to complete trauma screening on all children who enter the child wel-
fare system, ideally using a standardized assessment tool that has been empirically
validated.10 Identifying children with trauma histories, including complex trauma his-
tories, helps ensure that they are linked with appropriate treatment providers. In addi-
tion, foster parents, residential care workers, and other frontline providers should
receive specialized training related to meeting the needs of children with complex
trauma histories. For example, foster parents should learn how to identify trauma trig-
gers and support children’s development of self-regulation capacities. The National
Child Traumatic Stress Network has developed the Resource Parent Curriculum for
this purpose; see the Network’s Web site (www.nctsn.org) for more information.

Juvenile justice
The correlation between trauma exposure and involvement in the juvenile justice sys-
tem has been well documented. Approximately 90% of youth in juvenile justice facilities
report having experienced at least one potentially traumatic event.64,95 Because of defi-
nitional issues, estimates of complex trauma among justice-involved youth are more
difficult to determine. However, Ford and colleagues96 report that a hierarchical cluster
analysis of a large representative sample of youth in detention settings yielded an esti-
mated prevalence of 35% with complex trauma histories. Another study11 found that
more than half (62.14%) of their justice-involved sample had experienced trauma in
 Complex Trauma 349

the first 5 years of life and 90% experienced multiple trauma types over their lifetimes. In
addition, arrest and juvenile justice confinement experiences can be traumatic for some
youth, compounding their already complex trauma histories, increasing their risk for
additional trauma, and/or triggering memories of prior traumatic experiences.97
The disruption of self-regulation capacities that stems from complex trauma poses
challenges in milieu management and treatment in juvenile justice settings.96 Many
youth with complex trauma histories are unlikely to have the self-regulation skills
necessary to participate in the educational and recreational milieu activities or
respond positively to motivational or crisis prevention interventions offered in these
settings.96 A complex trauma perspective favors milieu interventions that build skills
in self-regulation rather than assuming that youth already possess them.96
The Sanctuary Model is an example of an intervention that can be used to address
the needs of youth with complex trauma histories in the juvenile justice system. Devel-
oped by Dr Sandra Bloom98 and her colleagues in the 1980s, the Sanctuary Model
recognizes the treatment environment as a core modality for healing the wounds of
psychological trauma, and intervenes at the level of organizational culture to create
new, developmentally grounded, trauma-informed routines for the children being
served, their families, staff members, and the organization as a whole.98 This model
is currently being implemented as a systematic organizational change process for
more than 250 human service delivery systems including juvenile programs98 and
has been associated with significant decreases in negative interactions between youth
and staff in juvenile detention centers.99

Clinical Assessment of Complex Trauma

Effective assessment of complex trauma exposure and outcomes in children and ad-
olescents requires the integration of knowledge from a variety of areas, including
trauma, child development, neurodevelopment, attachment, family systems, and child
welfare. Furthermore, this knowledge must be exercised while developing a therapeu-
tic alliance with a youth (and often caregivers) who presents with self-regulation and
interpersonal deficits, and frequent safety concerns. This process is clinically and
personally challenging.
Complex trauma assessment should be embedded in the typical assessment pro-
cess at the initiation of services. It is critical to establish a genuine working alliance
with the youth and caregiver(s). This alliance relies on a careful balance between iden-
tifying vulnerabilities (the standard goal of most assessments) while accommodating
those vulnerabilities (eg, titrating the assessment process to avoid the youth decom-
pensating) and validating youths’ strengths and accomplishments.63 However, as long
as sensitive issues (eg, trauma history) are discussed in a noncoercive, collaborative
fashion, screening does not seem to cause increased deterioration or crises.64 The
building of a working alliance is likely to be tested by the presence of safety risks or
unreported abuse. It is important to respond immediately and calmly to such disclo-
sures to enhance the youth’s actual or perceived safety and control.63 This enhance-
ment can often be accomplished through transparency, providing a clear rationale for
the clinician’s actions and trying to make events as predictable and controllable as
possible for the youth (eg, clearly explaining the investigatory process to a youth
when having to make a hotline report).
Developing a detailed trauma history is a crucial aspect of assessing youth exposed
to complex trauma.63,100 Formal screening instruments may be helpful in this process.
Such instruments include the Traumatic Experiences Screening Instrument101 and the
UCLA Posttraumatic Stress Disorder Reaction Index.102 However, even when directly
evaluated, it is common for traumatic experiences to go undisclosed during initial
350 Kliethermes et al

assessment. Additional disclosures may occur more organically over time as the youth
develops increased trust with the service provider.100 Thus assessment of complex
trauma is often an ongoing process that occurs throughout the course of treatment.
Although developing a detailed trauma history is important, focusing only on past
events is not sufficient.63 It is equally important to identify current or potential events
that may be retraumatizing (eg, facing a perpetrator while testifying at court) or result in
the youth reenacting prior traumatic experiences (eg, a sexually abused youth
engaging in sexualized behavior). These triggers and reenactments can profoundly
affect the youth’s daily functioning and often present as observable behavior patterns
(eg, youths becoming belligerent every time their employers give feedback regarding
their work performance).
The assessment of complex trauma involves more than identifying past traumas and
future triggers. It is also necessary to assess relevant areas of current functioning.
As mentioned previously, youth exposed to complex trauma typically present with
dysregulation associated with affect, behavior, attention/consciousness, cognition,
interpersonal functioning, attributions toward self and others, and biological func-
tioning. Related to these deficits, Ford and colleagues63 recommend that assessment
should identify problems and strengths affecting a youth’s ability to:
1. Identify/prepare for triggers/reenactments and develop coping skills to prevent
harm to self or others
2. Develop or restore emotion regulation (ie, ability to access emotions [especially
trauma-related emotions such as shame and betrayal], capacity to tolerate
emotional expression)
3. Acquire or regain the capacity to accurately monitor bodily sensations and arousal
4. Develop or restore cognitive and behavioral self-regulation to reduce the occur-
rence/severity of maladaptive behaviors (eg, substance abuse, self-harm, sexual-
ized behaviors)
5. Experience safety and attunement in family, peer, and therapeutic relationships
and subsequently develop secure inner models of relationships
6. Develop a personal identity of resiliency and self-determination
These areas can be assessed many ways, but because of complex biographic his-
tories and symptom presentations, it is unlikely that the assessment process can be
accomplished through any single measure or technique.65 Instead it is recommended
to use a variety of approaches with multiple informants.103 For example, the assess-
ment process for youth exposed to complex trauma could include the following:
1. Biopsychosocial interviews conducted with the youth, caregiver(s), and other
relevant familial (eg, grandparent) or professional (eg, caseworker, teacher) entities
2. Semistructured interview for child and adolescent psychiatric disorders (eg, Kiddie
Schedule for Affective Disorders and Schizophrenia104)
3. Behavioral observations of youth in multiple settings (eg, home, school,
community)
4. Wide range of youth-report measures (eg, Youth Self Report,105 Multiphasic
Personality Inventory-A106)
5. Wide range of adult-report measures (eg, Behavior Assessment System for
Children,107 Child Behavior Checklist,105 Teacher Report Form105)
6. Trauma-specific youth-report assessment measures (eg, Trauma Symptom
Checklist for Children108)
7. Trauma-specific adult-report assessment measures (eg, Trauma Symptom Check-
list for Young Children,109 Child Sexual Behavior Inventory110)
 Complex Trauma 351

The Challenge of Diagnosing Youth Exposed to Complex Trauma

As discussed earlier, evaluating youth exposed to complex trauma is challenging.
However, this is intensified by the lack of a psychiatric diagnosis that fully accounts
for the symptom presentation of youth exposed to complex trauma.13 Using
DSM-IV-TR criteria, PTSD has not been the most common diagnosis for traumatized
youth, and comorbid diagnoses are common.111
Therefore it has been argued that PTSD criteria, particularly before DSM-5, do not
fully describe the symptom presentation of many traumatized youth. A wide variety of
diagnoses (eg, ADHD, oppositional defiant disorder, and bipolar disorder) tends to be
used to capture the range of presented difficulties. This variety of diagnoses results in
a confusing diagnostic picture that obscures causal factors and may result in effective
trauma-focused treatments being underused and under-reimbursed for this
population.13
One attempt to address this situation has been the revision of PTSD criteria for
DSM-5.112 The DSM-5 PTSD criteria included a new symptom domain based on nega-
tive alterations in cognitions or mood (eg, persistent negative beliefs about oneself,
others, or the world; persistent negative emotional states), expanded the hyperarousal
domain to include reckless or destructive behavior (eg, reckless driving, excessive
substance use), and added a PTSD subtype characterized by dissociation. DSM-5
PTSD criteria seem to capture outcomes of complex trauma more fully than previous
iterations. The new criteria seem to better describe the impaired self-regulation across
multiple domains (ie, affect, physiology, cognition, behavior, motivation, relationships,
and self-identity).113
Another effort to better capture the sequelae of complex trauma has been the
formulation of DTD. DTD is an attempt to organize the self-regulation deficits derived
from clinical observation and research focused on complex trauma and distinguish it
as a separate diagnosis that includes symptoms of PTSD but also extends beyond
PTSD criteria.63 DTD symptom clusters include PTSD symptoms as well as affec-
tive/physiologic dysregulation, attentional/behavioral dysregulation, and self/rela-
tional dysregulation.63 Although DTD was not included in DSM-5, it is undergoing
validation in an international field trial,63 which may result in its inclusion in future iter-
ations of the DSM.
Debate regarding the validity and usefulness of DTD will likely be a hallmark of the
field for the near future. For example, Schmid and colleagues114 summarize argu-
ments for and against formalized DTD criteria. Arguments in support of DTD suggest
that DTD will (1) allow more specific diagnosis, (2) sensitize professionals and the pub-
lic to the impact of chronic trauma, (3) highlight the developmental course of mental
disorders, (4) stimulate research on complex trauma, (5) help explain the high rate
of comorbidity among traumatized youth, (6) promote development and refinement
of effective treatments, and (7) decrease social and legal stigmatization of traumatized
youth. Arguments against the formalization of DTD criteria include (1) the presence of
overlap with other diagnoses (eg, borderline personality disorder); (2) lack of clarity
regarding the cause of DTD; (3) not all severely traumatized children develop any dis-
order, much less DTD; (4) the possibility that emotional dysregulation may precede
complex trauma rather than be caused by it; (5) lack of age/developmentally sensitive
criteria; (6) DTD may result in true comorbid diagnoses going untreated; and (7) in-
creased pressure to identify past trauma experiences resulting in disrupted therapeu-
tic relationships or false trauma memories.
In conclusion, the diagnosis of complex trauma outcomes is a contentious topic and
will likely remain so for the foreseeable future. The heart of this debate is whether or
352 Kliethermes et al

not complex trauma outcomes represent a distinct disorder from PTSD or are better
conceptualized as simply a more severe form of PTSD. However, the current knowl-
edge base regarding this question is insufficient to make that distinction,12,114 high-
lighting the need for further investigation.

Treatment of Youth Exposed to Complex Trauma

Treating youth exposed to complex trauma can be a complicated, overwhelming pro-
cess. The needs of these youth are typically intense, varied, and rapidly changing,
particularly early in treatment. It can be argued that no gold standard treatment exists
for this population; however, substantial progress has been made in identifying effec-
tive treatment approaches.
The general consensus among experts is that a phase-based approach is most
effective.5,115,116 In this approach, treatment occurs sequentially, with later phases
building on previous phases. For example, early in treatment, youth may be taught skills
to alleviate current emotional dysregulation but also to provide the tools needed for
subsequent trauma processing. Although treatment is generally sequential, phases
may not always proceed in a linear fashion, and previous phases may be revisited as
needed, allowing the therapist to sensitively respond to the chaos and changing needs
of the population.117
Several models of phase-based treatment of complex trauma have been developed.
Ford and colleagues115 describe one approach, consisting of 3 phases: (1) engagement,
safety, and stabilization; (2) recalling traumatic memories; and (3) enhancing daily living.
In phase 1, the therapist works to form a therapeutic alliance and increase the youth’s
sense of safety. This phase is often a significant and lengthy portion of treatment in light
of characteristic difficulties with dysregulation, attachment, and environmental insta-
bility. When these difficulties have become manageable, the second phase of treatment
begins. This phase focuses on trauma-related content and processing traumatic mem-
ories. This phase occurs at a safe, manageable pace through graduated exposure and
ongoing use of the self-regulation skills learned in phase 1. When symptoms of posttrau-
matic stress (eg, intrusive memories, arousal to trauma cues, maladaptive trauma-
related beliefs) have been addressed, the therapist and client move to phase 3, focusing
on developing a healthy lifestyle that is not ruled by trauma triggers or reenactments.
Multiple evidence-based treatment models have been adapted or created to adhere
to a phase-based approach and have shown effectiveness. Effective treatment
models tend to have similar characteristics that include (1) prioritization of safety
and stability, (2) heavy emphasis on relationships, (3) interventions that balance imme-
diate needs and long-term goals, (4) focus on strengths and resiliency, (5) consistent
development of self-regulation skill in multiple domains (eg, emotion, information pro-
cessing, awareness, somatic, relational), (6) mastery of traumatic memories, and
(7) prevention of and preparation for losses and crises.118
The following list (in alphabetical order) provides some examples of evidence-based
treatment models that have been developed or adapted for youth exposed to complex
trauma. This list should not be considered exhaustive and, because of length con-
straints, does not provide a detailed description of each model.

Attachment, self-regulation, and competency

Components-based intervention framework for youth exposed to complex trauma
and their surrounding systems of care.119,120

Child-parent psychotherapy
Psychodynamic, caregiver-child dyadic model for preschoolers.121
 Complex Trauma 353

Dialectical behavior therapy

Flexible, principle-driven, manualized treatment model that integrates cognitive-
behavioral principles with mindfulness practice to enhance self-regulation.122,123
Eye movement desensitization and reprocessing
Trauma-focused treatment model that emphasizes information processing systems
and the resolution of physiologically stored memories.124,125
Integrative treatment of complex trauma
Multicomponent therapy for children and adolescents that integrates complex trauma,
attachment theory, the self-trauma model, and aspects of trauma-focused cognitive
behavior therapy.126
Parent-child interaction therapy
Manualized parent-training program based on social learning and attachment theories
for children aged 2 to 7 years with externalizing behavior problems.127
Real-life heroes
Integrated trauma and resiliency–centered treatment model for latency-aged youth
with history of exposure to complex trauma.128
Seeking safety
Structured psychoeducational model for co-occurring PTSD and substance abuse.129
Structured psychotherapy for adolescents responding to chronic stress
Group intervention for adolescents integrating aspects of trauma-focused treatment
and dialectical behavior therapy.130
Trauma affect regulation: guide for education and therapy
Brief group or individual program for youth with complex trauma histories and their
families.131
Trauma-focused cognitive behavior therapy
Phase-oriented individual treatment model for traumatized youth and nonoffending
caregivers.103,132
Trauma systems therapy
Systemic-based intervention focused equally on dysregulation in youth exposed to
complex trauma and factors in the social environment that trigger and maintain
dysregulation.133

SUMMARY

It is difficult to overstate the current and future importance of complex trauma to child
and adolescent mental health and to society. As described in this article, large
numbers of children and adolescents are exposed to chronic trauma and polyvictim-
ization during highly vulnerable developmental periods. This exposure disrupts early
attachment relationships and takes a severe toll on the developing brain, resulting in
complex and severe symptom presentations resulting from impaired self-regulation.
The subsequent needs of these youth place high demands on the resources of sys-
tems with which they interact, including biologic and adoptive families, education,
child welfare, medical, and juvenile justice. Because of the diversity and severity of
complex trauma outcomes, the provision of mental health services to this population
is replete with challenges. However, gifted researchers and clinicians are increasingly
devoting resources to address the needs of this population. The fruits of this labor can
354 Kliethermes et al

be seen in the development of a comprehensive conceptual framework and multiple,

promising evidence-based treatment models. Challenges remain for youth exposed to
complex trauma and the professionals who work with them, but the knowledge and
tools that have developed over the last 25 years give cause for optimism.

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