Children and young people who have experienced trauma often present with a range of emotional, behavioural, and relational difficulties. Those with complex presentations are sometimes considered ‘not ready’ for trauma-focused therapy, delaying access to adequate treatment.
Introduction
Trauma is unfortunately common in childhood. Many children and adolescents experience traumatic events, including abuse, neglect, violence, severe loss, or unstable caregiving environments. While some recover with support, others develop post-traumatic stress disorder (PTSD) or complex PTSD, where difficulties may include emotional dysregulation, problems forming trusting relationships, and negative beliefs about oneself (Cloitre et al., 2018).
There is robust evidence that trauma-focused psychological therapies are effective for PTSD in children and adolescents (Lewis et al., 2020). Nonetheless, clinicians sometimes hesitate to offer these approaches to young people whose circumstances are complicated—for example, those with ongoing instability, high levels of distress, suicide risk, or multiple comorbidities. Some are told they are ‘not ready’, or that therapy should wait until other difficulties are managed. However, current evidence suggests that complexities are not, in themselves, a reason to delay treatment (NICE, 2018).
Why Complexity Should Not Delay Treatment
One concern among practitioners is that trauma memory work might be overwhelming for young people with high levels of distress or instability. However, research indicates that avoiding trauma-focused work can contribute to ongoing symptoms and prolonged difficulties (De Haan et al., 2023). Many of the challenges that lead to concerns about readiness—such as emotional dysregulation, avoidance, or intense distress—are themselves symptoms of PTSD or complex PTSD. In these cases, waiting for symptoms to reduce before starting trauma-focused intervention may inadvertently reinforce avoidance and distress. There is also growing evidence that structured, phased approaches that integrate safety planning, emotional regulation skills, and trauma memory processing can help young people manage distress while engaging in therapy (Cloitre et al., 2012).
Working with Trauma in the Context of Complex Lives
Children affected by trauma may live in environments where stressors remain present, such as ongoing legal processes or family conflict. These realities can lead clinicians to feel unsure about when to proceed. Yet, delaying trauma therapy until overall stability is achieved may contribute to many young people waiting for prolonged periods of time for support. Research suggests that trauma therapy can be adapted to individual needs, with careful planning, pacing, and supervision (Karatzias et al., 2019). Skilled supervision plays a key role in helping practitioners explore fears, monitor progress, and plan how to support young people when therapy feels stuck.
Looking Ahead
Recent work in the field has focused on developing structured supervision approaches to support clinicians to make informed decisions about when and how to begin trauma memory work. These approaches emphasise collaborative planning, proactive discussion of barriers, and shared decision-making between practitioner, supervisor, and young person.
Conclusion
Trauma-focused therapy remains a highly effective treatment for PTSD and complex trauma symptoms in children and young people. Complexity alone should not be seen as a barrier to accessing care. Thoughtful planning, skilled supervision, and a collaborative approach can support young people to engage in trauma therapy safely and meaningfully. Supporting practitioners in feeling confident to offer trauma-focused work is essential in ensuring that young people receive timely and effective care.
Where next?
To Start or Not To Start: Navigating between stabilisation and memory work in cognitive therapy for PTSD is an ACAMH live stream workshop run by clinicians from the tier 4 multi-disciplinary, National and Specialist CAMHS Trauma, Anxiety and Depression Clinic within South London and Maudsley NHS Foundation Trust – Professor Andrea Danese, Dr. Jessica Richardson, Dr. Sarah Miles, Dr. Aysha Baloch.
References
Cloitre, M., Garvert, D. W., Brewin, C. R., Bryant, R. A., & Maercker, A. (2018). Evidence for proposed ICD-11 PTSD and complex PTSD: A latent profile analysis. European Journal of Psychotraumatology, 9(1).
De Haan, A., Lee, C., & Stoddard, J. (2023). Addressing avoidance in trauma-focused therapy. Journal of Child Psychology and Psychiatry, 64(5), 672–684.
Karatzias, T., Shevlin, M., Fyvie, C., & Hyland, P. (2019). Understanding the overlapping nature of complex PTSD and borderline personality disorder. European Journal of Trauma & Dissociation, 3(1), 123–131.
Lewis, S. J., Koenen, K. C., & Neufeld, S. (2020). Psychological therapies for PTSD in children and adolescents: A systematic review. Lancet Psychiatry, 7(9), 734–745.
National Institute for Health and Care Excellence (NICE). (2018). Post-traumatic stress disorder: NICE guideline (NG116).
