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INTRODUCTION Complex trauma-related posttraumatic stress disorder (PTSD) and comorbidities pose a significant mental health burden in children. However, the comparative effectiveness of psychological interventions and shared therapeutic components remains unclear. METHODS We conducted a systematic review, network, and component network meta-analysis of randomized controlled trials of psychological interventions for children and adolescents with complex trauma. PubMed, Embase, Web of Science, PsycINFO, and Cochrane Library were searched up to September 2024. PTSD was the primary outcome; retention and comorbid symptoms (depression, anxiety, dissociation, externalizing problems) were secondary outcomes. RESULTS Forty-eight studies (6,017 participants) were included in this review. Multimodal group interventions (SMD -1.68, 95% confidence interval [CI] -3.04 to -0.32), phase-based trauma-focused cognitive behavioral therapy (TF-CBT) with parental involvement (-1.12, -1.53 to -0.70), TF-CBT (-1.06, -1.59 to -0.52), non-TF-CBT with parental involvement (-0.93, -1.70 to -0.17), eye movement desensitization and reprocessing (-0.85, -1.60 to -0.10), and phase-based TF-CBT (-0.79, -1.20 to -0.39) significantly reduced PTSD. Exposure emerged as the only significantly effective component for PTSD (-0.85, 95% credible interval [CrI] -1.60 to -0.06). Efficient component combinations included affective modulation with a therapeutic foundation of psychoeducation and nonspecific elements for PTSD (-0.97, 95% CrI -1.92 to -0.01) and exposure plus parental involvement with the same foundation for depression (-2.11, 95% CrI -4.06 to -0.20). CONCLUSION Trauma-focused approaches were the most effective treatments for pediatric PTSD and emotional comorbidities related to complex trauma. A more cost-effective intervention approach may prioritize exposure techniques, incorporate affective modulation, and include parental involvement when feasible.
