A 2023 meta-analysis led by Hoppen and colleagues examined whether children and adolescents with post-traumatic stress disorder (PTSD) benefit equally from psychological interventions, regardless of whether they have experienced a single traumatic event or multiple traumas (Hoppen et al., 2023). Analyzing 57 randomized controlled trials (RCTs) and over 4,000 young people, the study found that psychological therapies—including trauma-focused cognitive behavioural therapy (TF-CBT) and other evidence-based interventions—are effective in reducing PTSD symptoms for both groups. The frequency of trauma exposure did not significantly influence how well these interventions worked. These findings support the use of psychological therapies for all young people with PTSD and highlight the importance of offering effective care, even for those who have faced complex or repeated adversities.
Psychological therapies can support recovery for children and adolescents with PTSD, regardless of trauma history.
Understanding Trauma and PTSD in Youth
PTSD is a common mental health condition among children and adolescents worldwide, often developing after traumatic experiences such as violence, abuse, accidents, or disasters (Lewis et al., 2019; Alisic et al., 2014). Previous research shows that youth exposed to multiple traumatic events are at higher risk for developing PTSD and may face more severe symptoms than those who experience a single trauma (McLaughlin et al., 2013; Copeland et al., 2007). Multiple exposures can also mean greater lifetime adversity, less family support, and increased vulnerability to social and community stressors (Finkelhor et al., 2007).
There has been uncertainty whether psychological treatments for PTSD are as effective for young people who have experienced multiple traumas compared to those with a single event. This question is highly relevant, since many youth referred for care have histories of repeated adversity (Danese & McLaughlin, 2023).
Current treatment guidelines for children and young people with post-traumatic stress disorder (PTSD), including those with multiple trauma exposures, generally recommend trauma-focused psychological interventions as the first line of treatment. The UK’s National Institute for Health and Care Excellence (NICE) guidelines advise trauma-focused cognitive behavioural therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) for all CYP with PTSD, regardless of whether the trauma was single-incident or repeated (NICE, 2018). Similarly, international guidelines, such as those from the International Society for Traumatic Stress Studies (ISTSS), recommend evidence-based trauma-focused therapies for youth with both single and multiple trauma exposures, while noting that those with complex or chronic trauma histories may require a longer course of therapy or additional components addressing affect regulation and interpersonal difficulties (ISTSS, 2018). Despite the high prevalence of complex trauma, there are currently no widely endorsed guidelines that recommend fundamentally different interventions for multiple-traumatized youth compared to those with single-event trauma, though clinical practice may be tailored to individual needs and comorbidities.
Many young people with PTSD have experienced more than one trauma, raising important questions for treatment.
How Was the Study Conducted?
The authors systematically searched four major research databases up to April 2022, identifying 57 randomized controlled trials that focused on psychological interventions for children and adolescents with PTSD as the primary treatment target (Hoppen et al., 2023). All included studies used random group allocation and enrolled participants who met full or partial criteria for PTSD. Only trials with at least 20 participants were included to ensure reliable results.
The authors compared trials where participants had experienced a single traumatic event to those who were expose to two or more traumatic events. Interventions included trauma-focused cognitive behavioural therapy (TF-CBT), eye movement desensitization and reprocessing (EMDR), other psychological therapies, and multidisciplinary approaches (Morina et al., 2016; Brown et al., 2017). Control conditions ranged from waiting lists or no treatment (passive) to supportive counseling or treatment as usual (active). The authors evaluated the short-term and longer-term effectiveness of interventions for reductions in PTSD symptoms, comparing active treatments to control groups.
Rigorous analysis helps clarify which interventions work best for young people with PTSD.
What Did the Study Find?
Psychological interventions were highly effective in reducing PTSD symptoms compared to passive control conditions for both single-trauma and multiple-trauma samples (Hoppen et al., 2023). For trauma-focused CBT (TF-CBT), strong effects were observed regardless of trauma history (Gutermann et al., 2016).
When psychological interventions were compared with active control conditions (such as supportive counseling), results still favored the evidence-based therapies, particularly for youth with multiple traumas. Data for active control comparisons in single-event PTSD was limited, but available evidence was consistent with the overall findings.
Additional analyses, including those that treated trauma exposure as a continuous variable (number of events), confirmed that the frequency of trauma did not reduce the benefits of psychological therapy.
Long-term outcome data was more limited, especially for youth with single-event PTSD, but the available evidence suggests that positive effects of psychological interventions persisted for several months after treatment (Morina et al., 2016; Hoppen et al., 2023). In the meta-analysis, the median follow-up period among the included studies was six months, with some studies providing data up to twelve months post-treatment. This indicates that the improvements observed were short-term but tended to be maintained for at least half a year after the end of therapy, even among young people with histories of multiple traumas.
Evidence-based psychological therapies can help young people heal from trauma, regardless of how many traumas they have faced.
Implications for Practice and Research
The findings support evidence showing that psychological therapies, including trauma-focused interventions like TF-CBT, can help children and adolescents recover from PTSD, whether their trauma history involves one event or many (Hoppen et al., 2023; Gutermann et al., 2016). This is particularly important given the high rates of multiple trauma exposure in real-world clinical settings.
Results reinforce the importance of providing evidence-based interventions and highlight the need for training and supervision to support their effective use, even in complex cases (Danese & McLaughlin, 2023; Brown et al., 2017).
The findings also have implications for research: there is a need for more high-quality studies, particularly for single-event trauma PTSD, that use active control conditions and longer follow-up periods (Hoppen et al., 2023). Improved reporting of trauma histories and participant characteristics will strengthen future meta-analyses and help tailor interventions further (Morina et al., 2016). Furthermore, ensuring that studies are inclusive and reflect the diversity of young people’s experiences will be key (Alisic et al., 2014).
Effective, evidence-based therapy should be available to all young people with PTSD, regardless of trauma history.
Strengths and Limitations
This meta-analysis directly compares outcomes for youth with single versus multiple trauma exposures, using rigorous, pre-registered methods and comprehensive study selection (Hoppen et al., 2023). The authors carefully evaluated study quality and considered potential biases. However, several limitations are noted. Reporting of trauma history was incomplete in some studies, and definitions of “multiple trauma” varied. Long-term outcomes were less frequently assessed, and more research is needed on recovery over time (Lewis et al., 2019). Some studies were small or had methodological limitations, though overall quality was moderate to good.
Continued research and improved study quality will help ensure all youth receive effective care.
Children and adolescents with PTSD, regardless of whether they have survived a single traumatic event or multiple traumas, can benefit from psychological therapies, particularly trauma-focused interventions such as TF-CBT (Hoppen et al., 2023; Gutermann et al., 2016). The frequency of trauma exposure does not diminish the effectiveness of these treatments. Ensuring access to evidence-based care for all young people with PTSD remains a vital priority for clinicians, researchers, and policymakers alike.
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.
Learning objectives
- To review the core components of trauma-focused CBT, where the most PTSD and Complex PTSD symptom change can occur, and barriers to delivering evidence-based treatment
- To consider whether “stabilisation” is necessary as part of trauma-focused CBT
- To be introduced to the STARTT model and practise using it – considering and planning for working with psychological, developmental, physical, social, risk, culture and diversity issues that can affect trauma therapy
- To gain confidence in deciding when to start trauma memory work with children and young people with PTSD or Complex PTSD
NB This blog has been peer reviewed
References
Alisic, E., Zalta, A. K., van Wesel, F., et al. (2014). Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis. The British Journal of Psychiatry, 204(5), 335–340. https://doi.org/10.1192/bjp.bp.113.131227
Brown, R. C., Witt, A., Fegert, J. M., Keller, F., Rassenhofer, M., & Plener, P. L. (2017). Psychosocial interventions for children and adolescents after man-made and natural disasters: A meta-analysis and systematic review. Psychological Medicine, 47(11), 1893–1905. https://doi.org/10.1017/S0033291717000496
Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64(5), 577–584. https://doi.org/10.1001/archpsyc.64.5.577
Danese, A., & McLaughlin, K. A. (2023). Child and adolescent trauma and PTSD: Toward a precision mental health approach. Journal of Child Psychology and Psychiatry, 64(2), 163–179. https://doi.org/10.1111/jcpp.13665
Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31(1), 7–26. https://doi.org/10.1016/j.chiabu.2006.06.008
Gutermann, J., Schreiber, F., Matulis, S., Schwartzkopff, L., Deppe, J., & Steil, R. (2016). Psychological treatments for symptoms of posttraumatic stress disorder in children, adolescents, and young adults: A meta-analysis. Clinical Child and Family Psychology Review, 19(2), 77–93. https://doi.org/10.1007/s10567-016-0202-5
Hoppen, T. H., Meiser-Stedman, R., Jensen, T. K., Birkeland, M. S., & Morina, N. (2023). Efficacy of psychological interventions for post-traumatic stress disorder in children and adolescents exposed to single versus multiple traumas: meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 222(4), 196–203. https://doi.org/10.1192/bjp.2023.24
Lewis, S. J., Arseneault, L., Caspi, A., et al. (2019). The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. The Lancet Psychiatry, 6(3), 247–256. https://doi.org/10.1016/S2215-0366(19)30031-8
McLaughlin, K. A., Koenen, K. C., Hill, E. D., et al. (2013). Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 52(8), 815–830.e14. https://doi.org/10.1016/j.jaac.2013.05.011
Morina, N., Koerssen, R., & Pollet, T. V. (2016). Interventions for children and adolescents with posttraumatic stress disorder: A meta-analysis of comparative outcome studies. Clinical Psychology Review, 47, 41–54. https://doi.org/10.1016/j.cpr.2016.05.006
