EMDR in Children and Adolescents [Free Article]
EMDR stands for “Eye Movement Desensitization and Reprocessing.” Created by psychologist Francine
Shapiro in 1989, EMDR was first used for posttraumatic stress symptoms associated with military combat and sexual assault, and the treatment has a strong base of support. For instance, it was recommended with “moderate clinical confidence” by the American Psychiatric Association’s 2004 Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder, and it was “strongly recommended” for the treatment of trauma by the Department of Veterans Affairs / Department of Defense’s 2004 Clinical Practice Guideline for the Management of Post-traumatic Stress. Data show that the treatment eases the emotional sequelae of interpersonal violence, accidents, witnessed violence and natural disasters.
EMDR can best be described as a type of cognitive behavioral therapy with an emphasis on exposure techniques. However, it has atypical features that are not shared with other well-known treatments, features that can be off-putting to the uninitiated. The typical treatment course for adults includes eight sessions
and the following components:
- The treatment is introduced, a therapy target (typically a trauma memory) is chosen and maladaptive beliefs associated with the target are stated.
- The client selects a “safe place,” a past experience or image associated with comfort and well-being, that is called upon when needed.
- A negative thought is identified that is associated with the memory along with a positive thought—an empowering self-statement that the individual wishes to believe in.
- The client is asked to focus on the traumatic memory, the negative thought, and any associated sensations or emotions while engaging in side-to-side eye movements. The client reports a distress level, and the procedure continues until the distress level fades.
- Any new emotions, sensations, or images that arise during the treatment above or between sessions are subjected to the procedure described in step 4. 6.
- The identified positive thought is assessed and strengthened.
- Sessions close with relaxation exercises as needed to help clients return to a state of equilibrium.
Whether EMDR works as well in children as it does in adults is unclear. The 2010 AACAP Practice Parameters for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder say the evidence is insufficient. In practice, most therapists treat children slightly differently, using bilateral hand tapping rather than eye movements (due to developmental difficulties with eye coordination in young children), children’s drawings rather than images as representations of traumatic memory, sets of examples of negative and positive thoughts for children to choose from, and visual analogue scales for distress ratings.
Case reports have described the benefits of EMDR for children after hurricanes, car accidents, bullying, and sexual assault. Larger but uncontrolled studies have examined EMDR for refugee children with associated traumas in Sweden, children temporarily buried after an earthquake in Italy, children who had persistent PTSD symptoms following a major hurricane in Hawaii, and children in a general clinic population. While compelling, these reports are limited based on their design (for a recent review, see Adler-Tapia R and Settle C, J EMDR Pract & Res 2009;3(4):232–247).
A few more sophisticated studies have compared EMDR to waitlist controls, to CBT, or to other active treatments. When compared to waitlist controls in one study, EMDR was shown to improve child-rated PTSD symptoms after motor vehicle accidents at three and 12 months follow-up. However, no improvements were seen on measures of anxiety, depression or global function (Kemp M et al, B.Clin Child Psychol Psychiatry 2010;15(1):5–25).
A comparison of EMDR with CBT for children who experienced a fireworks factory explosion in Amsterdam found similar benefit for both treatments (de Roos C et al, Eur J Psychotraumatol
2011;2). Another CBT vs EMDR study compared 12 sessions of each treatment for sexually abused Iranian girls. Again, both treatments were associated with significant clinical improvements, with large effect sizes on trauma measures and smaller effect sizes for more general mood and behavioral measures (Jaberghaderi N et al, Clin Psychol & Psychoth 2004;11:358–368).
These studies suggest that EMDR is most helpful for PTSD-specific symptoms. Supporting this conclusion, the one available negative study compared children with a wide range of diagnoses who received EMDR in addition to standard therapy (play therapy, family work, group therapy) with a group who received the standard therapy alone. No differences were found between groups on the Achenbach Child Behavior Checklist, a global behavioral measure not specific to PTSD (Rubin A et al, Res Soc Wrk Pract 2001;11:435–457).
Readers should know that EMDR is a treatment that stirs controversy. Many call the most unique feature of EMDR, the eye movements, a smokescreen covering what is essentially a simple, exposurebased treatment. Others have developed detailed neurobiological theories related to memory processing to explain the eye movements and other bilateral stimulation techniques in EMDR. While one case study reported increased suicidality and panic attacks after EMDR treatment (Kaplan R and Manicavasagar C, Aust & N Zeal J Psych 1998;32:731–732), EMDR seems to be a safe form of treatment, overall, with a strong following among clinicians and a growing body of supporting empirical evidence, particularly for PTSD symptoms related to discrete trauma episodes.
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