CMS Complex Trauma Definition and Guidance for States

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Guidance on Complex Trauma as an Eligible 2703 Chronic Condition

Under the State Option to Provide Health Homes for Enrollees with Chronic Conditions, some States are proposing "Complex Trauma" as a new qualifying chronic condition.

This guidance on complex trauma draws upon the domains within the definition of serious emotional disturbance (SED)1. While there may be similarities in the condition(s) and symptoms that arise in either complex trauma or SED, the therapeutic approaches associated with the same diagnoses may vary significantly when the symptoms arising from traumatic experiences are identified as such. Trauma experts indicate that with complex trauma, the clinical diagnoses may be more severe and typically present as comorbidities or multiple diagnoses.

  1. Definition of Complex Trauma2
    1. The term complex trauma incorporates at least:
      1. Infants/children/or adolescents´ exposure to multiple traumatic events, often of an invasive, interpersonal nature,3 and
      2. the wide-ranging, long-term impact of this exposure.
    2. Nature of the traumatic events:
      1. often is severe and pervasive, such as abuse or profound neglect;
      2. usually begins early in life;
      3. can be disruptive of the child´s development and the formation of a healthy sense of self (with self-regulatory, executive functioning, self-perceptions, etc.);
      4. often occur in the context of the child´s relationship with a caregiver; and
      5. can interfere with the child´s ability to form a secure attachment bond, which is considered a prerequisite for healthy social-emotional functioning.
    3. Many aspects of a child´s healthy physical and mental development rely on this secure attachment, a primary source of safety and stability.
    4. Wide-ranging, long-term adverse effects can include impairments in:
      1. physiological responses and related neurodevelopment,
      2. emotional responses,
      3. cognitive processes including the ability to think, learn, and concentrate,
      4. impulse control and other self-regulating behavior,
      5. self-image,
      6. relationships with others, and
      7. dissociation
  2. Essential Parameters Associated with Complex Trauma:
    1. Exposure to trauma leads to adverse prolonged effects
    2. Nature of trauma exposure is interpersonal; occurs in multiplicity and/or recurring traumatic events
    3. Multiple developmental impairments/diagnoses
    4. Multiple functional impairments (behavioral indicators of severity)
  3. Diagnoses Most Common Among Those with Complex Trauma
    1. Recent findings have delineated two general patterns among children exposed to complex trauma: 1) a cluster of diagnoses related to conduct / behavior problems (e.g., ODD, CD) as well as substance abuse, and 2) a cluster characterized by PTSD, anxiety disorders, and depression.
    2. Data from the National Child Traumatic Stress Network (NCTSN) Core Data Set show that those with complex trauma have significantly higher rates of all problems/disorders except ADHD, OCD, and phobic disorder.
  4. Disability and Functional Impairment
    Impairments in multiple domains of functioning: including sustaining relationships, regulating affect and emotions, school performance and cognitive behavior.
  5. Interventions Recommended for Treatment of Complex Trauma
    1. Intervention adapted for use with complex trauma populations: Trauma-focused Cognitive Behavioral Therapy (TF-CBT)
    2. Interventions developed specifically for the treatment of complex trauma and demonstrating evidence of utility in treating this population:
      1. Attachment, Self-Regulation and Competency (ARC)
      2. Trauma Affect Regulation: Guidelines for Education and Therapy (TARGET)
      3. Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)
      4. Real Life Heroes
      5. Trauma Systems Therapy
      6. Integrated Treatment of Complex Trauma
    3. Interventions that are evidence-informed and widely-used for the treatment of complex trauma4:
      1. Dissociation Focused Therapy (Silberg & Sandra Wieland)
      2. Dialectical Behavior Therapy (Rathus & DeRosa)
      3. Neurosequential Model of Therapeutics (Perry & Dobson)
      4. Eye Movement Desensitization and Reprocessing (Shapiro & Wesselman)
      5. The Sanctuary Model (Bloom)
      6. Child Parent Psychotherapy (Lieberman & Van Horn)
      7. Parent-Child Interaction Therapy (Urquiza & Timmer)
  6. Screening and Assessment
    The assessment of complex trauma involves both assessing the child´s exposure to multiple or recurring traumatic events, as well as the wide-ranging and severe impact of this trauma exposure across domains of development. It is important that mental health providers, family members, and other caregivers become aware of specific questions to ask when seeking the most effective services for these children.

    The NCTSN´s website features a section on complex trauma. Refer to, "How to Conduct a Comprehensive Assessment of Complex Trauma" page on the website. The NCTSN also maintains a table of Standardized Measures to Assess Complex Trauma on the website.


1. 1
2. Developed in partnership with SAMHSA and the National Child Traumatic Stress Network (NCTSN), 2
3. [V]ictimization can be defined as harm that comes to individuals because other human actors have behaved in ways that violate social norms. Even though we sometimes refer to people as "victims of hurricanes", "cancer victims", or "accident victims", the more common reference for the term victimization is interpersonal victimization. In interpersonal victimization, the elements of malevolence, betrayal, injustice, and immorality are more likely to be factors than in accidents, diseases, and natural disasters. (Finkelhor, 2008, p. 23) 3
4. Julian Ford published a book in 2013 (Treating Complex Traumatic Stress Disorders in Children and Adolescents: An Evidence-based Guide, eds. Julian Ford & Christine Courtois, Guilford Press), that includes sections on Individual Psychotherapy Models and Systemic Approaches to Treatment 4

File: Chronic Conditions 10.20.15