What Is Complex Trauma?

When people think of trauma, they often imagine a specific, distinct experience — a frightening accident, a natural disaster, or an experience of violence. And it’s true that going through any very upsetting or life-threatening experience (or watching a loved one do so) can lead to post-traumatic stress disorder (PTSD) and other mental health challenges.

But trauma experts increasingly recognize that there’s another form of trauma that involves prolonged, repeated experiences and symptoms that often look different from PTSD. This is most commonly known as complex trauma.

Children who have gone through complex trauma often experience profound challenges as a result, and their symptoms are frequently misunderstood. Knowing the signs of complex trauma and understanding how it affects kids can go a long way toward getting them the support they need.

Complex trauma isn’t a diagnosis, but rather a concept that describes how chronic upsetting and dangerous experiences impact people, especially children.

“It’s a more fundamental change,” says Jamie Howard, PhD, a clinical psychologist and the director of the Trauma and Resilience Service at the Child Mind Institute. “A typical trauma might really shake up your schema of how the world works. With complex trauma, it affects how the schema is developed in the first place.”

Complex trauma generally stems from chronic, interpersonal negative experiences such as abuse, neglect, or violence in the child’s home or community. Because parents or caregivers are often the ones harming the child in situations like these, the child doesn’t have the chance to develop a sense of safety and trust in adults. That disruption of the child’s core sense of attachment to caregivers is a key element of complex trauma.

“Any kind of trauma can disrupt trust,” Dr. Howard says. “But with complex trauma, you don’t necessarily develop an ability to trust people in general.”

The evidence base for complex trauma is growing, with research indicating that children who have been through trauma that is ongoing and interpersonal in nature tend to have more intense symptoms and behavioral challenges than those who have experienced other forms of trauma.

The development of the concept of complex trauma began several decades ago, when clinicians working with people who had experienced ongoing traumatic events (such as survivors of child abuse) noticed that these people’s symptoms were often more varied than the symptoms of PTSD. This distinct set of symptoms became known as “complex PTSD” (CPTSD) and later evolved into a proposed diagnosis termed “developmental trauma disorder” (DTD).

The ideas of complex trauma and DTD developed in large part through the work of the clinician and author Bessel van der Kolk, MD. DTD is not included as a distinct disorder in the most recent diagnostic manual that clinicians use, the DSM-5. But some of the updated PTSD symptoms in the DMS-5 were influenced by the research of Dr. van der Kolk and his colleagues.

To some extent, the symptoms of complex trauma overlap with the symptoms of PTSD. For instance, kids who have experienced complex trauma may experience flashbacks, nightmares, and feelings of emotional numbness.

But with complex trauma, the symptoms are more pervasive. Kids’ behavior can look completely unpredictable. “Their lives have been so chaotic that they haven’t found a coherent way to organize the world,” says Dr. Howard. “And so they look physically and emotionally disorganized and dysregulated. They’re not sitting still, they’re moving around, they’re sort of jumpy. They’re a little bit like a live wire.”

Children who have experienced complex trauma frequently meet the criteria for a range of different DSM-5 disorders, but there is currently no one diagnosis that captures their typical symptom profile.

However, experts agree that the following symptoms are generally associated with complex trauma:

• Challenges with attachment and relationships
• Difficulty regulating emotions and behavior
• Challenges related to attention span and other cognitive abilities
• Dissociation from reality
• Low self-esteem
• Overall negative outlook on the world

Dr. Howard notes that being in loud, chaotic environments can quickly get overstimulating for kids who have been through complex trauma. “This is when kids start to look like they have ADHD,” she says. “Or they might look like they have a severe mental health disorder because their ability to regulate their physiological responses and make sense of the environment is so compromised.” Complex trauma is also known to interfere with learning and frequently leads to challenges with behavior and focus at school.

There’s no definitive list of the kinds of experiences that can lead to complex trauma. That said, experts generally agree that the events underlying complex trauma usually meet the following criteria:

• They are severely negative, such as abuse, neglect, or violence.
• They take place over an extended period of time.
• They affect the child’s ability to relate to others and build trusting relationships with caregivers and other authority figures.

“Complex trauma doesn’t have to be physical abuse, but the reason attachment is so affected is because it usually is perpetrated by, or not able to be stopped by, a child’s primary caregiver,” Dr. Howard says. “And that’s what makes it so fundamentally disruptive: the primary caregiver isn’t able to provide consistency and safety to the child.”

Dr. Howard notes that this kind of disruption can also occur when a parent isn’t the one causing the trauma. For instance, kids who are exposed to a lot of community violence might develop complex trauma because their caregivers aren’t able to protect them from those dangers, no matter how much they want to.

There isn’t yet conclusive evidence about whether certain populations of children are more likely to experience complex trauma. But, says Dr. Howard, “usually this happens in the context of low resources and environments that are stressful overall,” which means that children in low-income families may be at greater risk.

Complex trauma can be challenging to treat because, unlike the kind of traumatic event that is typical of PTSD, chronic traumatic experiences may be ongoing even as the child is getting treatment. And most of the research behind evidence-based treatments for trauma symptoms in children is focused on PTSD.

That said, it’s still very important for kids dealing with complex trauma to get treatment. The leading treatment for PTSD in children is called trauma-focused cognitive behavioral therapy (TF-CBT), and there is a growing body of research about adapting it for use with complex trauma.

There is also a treatment model known as the ARC Framework that is designed specifically for children who have experienced complex trauma. ARC stands for attachment, self-regulation, and competency, and it focuses on the following goals:

• Attachment: Fostering strong connections between kids and their caregivers and creating a safe, supportive environment in which the family can recover from trauma.
• Self-regulation: Helping kids learn to identify, express, and manage their emotions.
• Competency: Supporting kids’ self-esteem and sense of competence, as well as key developmental tasks like executive functions and social skills.

Dr. Howard notes that building a child’s secure attachment to trusted adults is at the core of any treatment for complex trauma. “Trauma treatment doesn’t involve the abusive parent, if there is one,” she says. “To develop an attachment, you need someone who’s going to be relatively consistently responsive.” This might be another biological parent, a foster parent, a grandparent, or any other reliable caregiver. “What kids need is to form an ability to trust people in this world, to be able to predict how people will respond to them, and have it be appropriate and healthy.”

Dr. Howard also points out that when kids don’t already have a trustworthy adult in their lives, forming a strong relationship with a trained professional like a therapist or social worker can be another way to rebuild their sense of attachment.

For a child who’s dealing with complex trauma, any reliable support from a caring adult can make a big difference. If you’re an educator, clinician, or other consistent presence in a child’s life, there are ways you can help them even if you’re not involved in their formal treatment.

“The first thing is to always take a benign interpretation,” says Dr. Howard. “Sometimes we infer adult thinking, we apply it to kids. But these kids aren’t trying to push your buttons. They’re having a physiological response.”

It’s helpful to stay as calm as possible and to take steps to avoid retraumatizing the child. “You have to be a little more thoughtful in how you approach them,” Dr. Howard advises. “Don’t get too physically close to them because they’re going to think you’re going to hurt them.”

She also recommends keeping your tone of voice neutral, even if you do need to set a boundary or establish a consequence for the child’s behavior. “If you snap at a child who hasn’t been traumatized, it’s not going to totally rattle them,” she said. “But if you start to raise your voice and look angry at a child who’s been multiply traumatized, they don’t know what’s going to happen. It’s like they might duck and cover.”

Overall, says Dr. Howard, it’s important to try to remember why kids who have been through complex trauma behave in ways that can look confusing and frustrating. “They’re doing this because the world is hard to make sense of, and so they’re reactive. It’s best met with calm, consistent respect to help them to overcome what they’ve been through.”