TIRCIA · Psychotraumatology
Complex trauma in children and adolescents: should we stabilise first?
What a 2026 meta-analysis shows
Reference: Li Y., Feng J., Hu W., Zeng Z., Pan Q., Wang J., Li M., Elbert T., Karl A. & Zang Y. (2026). Dismantling psychological interventions for youth with complex trauma. Psychotherapy and Psychosomatics. https://doi.org/10.1159/pps/aemag009
By Marie-Agnès Thulliez · Author · Publishing Director7-minute read
Faced with a child or adolescent who has lived through repeated violence, war, exile or the loss of a parent, many clinicians hesitate to address traumatic memories directly. The reflex is often to stabilise first, sometimes for a long time.
A large meta-analysis published in October 2026 sheds new light on this question in young people. It does not settle everything, but it invites us to revisit certain habits.
In brief
- In children and adolescents exposed to repeated or interpersonal trauma, trauma-focused therapies markedly reduce post-traumatic stress.
- None of these therapies, EMDR included, proves superior to the others.
- Preceding trauma work with a stabilisation phase brings no additional benefit on average.
- The complexity of a trauma history is therefore, on its own, insufficient reason to postpone care. The decision should remain an individual one.
1. The study
An international team, including Thomas Elbert and Anke Karl, brought together all the randomised trials of psychological therapies in young people exposed to so-called "complex" trauma (Li et al., 2026, Psychotherapy and Psychosomatics).
What it analysed
- 48 randomised trials and 6,017 children and adolescents, with a mean age of 11.7 years.
- Prolonged or repeated trauma (war, armed conflict), physical or sexual violence, or a serious disruption of the family environment (exile, domestic violence, death of a parent).
- A network meta-analysis, which compares all the therapies with one another, and a "component" analysis, which looks for the ingredients that have an effect.
An important point of terminology: here, "complex" refers to the type of traumatic exposure, and not to the ICD-11 diagnosis of complex PTSD. The authors make this clear themselves.
Key points
- A network meta-analysis of 48 randomised trials involving 6,017 children and adolescents, with a mean age of 11.7 years.
- A "component" analysis also looks for which ingredients of the therapies are active.
- Here, "complex" refers to the type of traumatic exposure, and not to the ICD-11 diagnosis of complex PTSD.
2. What it shows
Trauma-focused therapies are effective. Compared with no treatment or a waiting list, several approaches markedly reduce post-traumatic stress:
- trauma-focused CBT, with or without a preliminary phase, with or without parental involvement;
- EMDR;
- multi-component group interventions.
None stands out from the others. For EMDR, the effect is large on average, but the estimate remains imprecise (effect size of −0.85, with a confidence interval ranging from −1.60 to −0.10). The authors find no significant difference between the active therapies.
The key finding
Formats that begin with a stabilisation phase do no better than those that address the trauma directly, either on symptoms or on retention in therapy.
Exposure, a lead to be confirmed. The component analysis identifies exposure to traumatic memories as the only element associated, on its own, with a reduction in PTSD. However, this effect is no longer significant when the lower-quality studies are removed. It should therefore be read as a trend rather than as proof.
Limits on other symptoms. Depression decreases with several approaches. On the other hand, no convincing effect appears on dissociation or on behavioural problems, although these analyses are based on few trials.
Key points
- Several trauma-focused therapies, including EMDR, markedly reduce post-traumatic stress compared with no treatment or a waiting list.
- None stands out from the others; for EMDR, the effect is large on average, but the estimate remains imprecise.
- In these trials, starting with stabilisation does no better than addressing the trauma directly, on symptoms as well as on retention in therapy.
- Exposure is the only ingredient associated on its own with a reduction in PTSD, but the effect disappears without the lower-quality studies: a trend.
3. What it does not show
This study is large and rigorous, but it has limitations that should be borne in mind:
- Uneven quality. Of the 40 trials included in the meta-analyses, 35% have a high risk of bias, and only 13% a low risk.
- Specific populations. 40% of the trials involve young people exposed to war or armed conflict, and 42% were conducted in low- or middle-income countries. The results should be applied with caution to young people seen in private practice or in child and adolescent psychiatry services.
- The most fragile patients are missing. Adolescents who are highly unstable, suicidal or severely dissociative are generally excluded from trials. For them, the question remains open.
- A finding about averages. The study shows that a preliminary phase adds nothing on average. It leaves open whether stabilisation is useful for a particular young person.
These results are in line with those obtained in adults, for example in a Dutch trial with EMDR (van Vliet et al., 2021), presented in our article "Do we really need to “stabilise” before treating trauma?". They partly fill a gap we pointed out there: the lack of data in adolescents.
Key points
- Of the trials, 35% have a high risk of bias, and only 13% a low risk.
- In 40% of the trials, the young people had lived through war or armed conflict: caution is needed before applying the findings to private practice or child and adolescent psychiatry.
- Adolescents who are highly unstable, suicidal or severely dissociative are generally excluded from trials: for them, the question remains open.
- A preliminary stabilisation phase adds nothing on average, which leaves open its usefulness for a given young person.
4. In practice
- Look beyond the history alone. A heavy traumatic past is not, on its own, a reason to postpone work on memories.
- Assess the child as they are today: current safety, suicide risk, dissociation, regulation capacities, family support, and the preferences of the young person and their parents.
- Choose from among the validated approaches, according to the therapist's training and the context: trauma-focused CBT, EMDR, or structured group programmes. None has demonstrated superiority.
- Involve parents whenever possible. Formats that involve them are among the most effective, even though the specific effect of this involvement remains to be confirmed.
- Keep stabilisation as a tool, to be adjusted according to the needs observed, rather than as a compulsory step of fixed duration.
Clinical vignette
A fictional case, composed from common clinical situations.
Inès, 14, grew up in a climate of domestic violence and was then placed with a foster family. She has nightmares, jumps at the slightest noise and avoids anything that reminds her of home. For a year, her therapy has focused on relaxation and emotion management. She is doing a little better at school, but the flashbacks persist.
Her new therapist takes stock with Inès and her foster family. Inès is safe, has no suicidal thoughts or significant dissociation, and her foster family is supportive. After a few sessions of psychoeducation, in which the foster family takes part, the work on memories begins. The flashbacks decrease over the following weeks.
Had Inès shown marked dissociation, self-harm or a still-dangerous situation, the therapist would first have worked on safety and regulation, regularly reassessing her readiness for trauma work.
What is established, and what is not
- Established: in young people exposed to repeated or interpersonal trauma, trauma-focused therapies reduce PTSD compared with no treatment.
- Well supported: a preliminary stabilisation phase brings no additional benefit on average.
- Debated: the specific role of exposure and of parental involvement.
- Not demonstrated: the superiority of one therapy over another, EMDR included; an effect on dissociation and behavioural problems.
- Little studied: the most unstable, suicidal or severely dissociative adolescents.
Frequently asked questions
Should stabilisation be abandoned with children?
No. Preparation keeps its place: explaining the therapy, building the alliance with the young person and their parents, providing a few ways to self-regulate. What is being called into question is lengthy, systematic stabilisation decided solely on the grounds of a complex history.
Is EMDR the best choice for adolescents?
EMDR is one of the effective approaches, on a par with trauma-focused CBT. This study shows no superiority of one over the other. The choice depends on the therapist's training, the young person and the context.
And if the child is still living in a dangerous environment?
Safety comes first. Ongoing violence, suicide risk or immediate danger mean acting on the situation first, with child protection services if necessary. This is a prerequisite for any care, distinct from a stabilisation phase in the technical sense.
In one sentence
In children as in adults, a complex trauma history is not in itself a reason to postpone trauma treatment.
It is the assessment of each young person, rather than the severity of their past, that guides the pace of therapy.
References
- Li, Y., Feng, J., Hu, W., Zeng, Z., Pan, Q., Wang, J., Li, M., Elbert, T., Karl, A., & Zang, Y. (2026). Dismantling psychological interventions for youth with complex trauma: A systematic review and component network meta-analysis. Psychotherapy and Psychosomatics. Published online 10 October 2026. Link
- van Vliet, N. I., Huntjens, R. J. C., van Dijk, M. K., et al. (2021). Phase-based treatment versus immediate trauma-focused treatment for post-traumatic stress disorder due to childhood abuse: Randomised clinical trial. BJPsych Open, 7(6), e211. Link
This article summarises the scientific evidence available at the date of publication. It is no substitute for clinical training, supervision, or the advice of a health professional.
