The Diagnostic and Statistical Manual of Mental Disorders (2013), indicates for those aged six and older, a diagnosis with post-traumatic stress disorder (PTSD) symptoms include but are not limited to the following: dissociation (i.e. flashbacks), nightmares, recurring, involuntary and distressing memory recollection. Additionally, the DSM-V (2013) indicates that a PTSD diagnosis is accompanied with negative thinking and mood alterations with regard to the traumatic event. Persistent avoidance of triggers associated with the traumatic situation is also common and one of the necessary requirements to receive a diagnosis of PTSD.
“Many youth (possibly up to 50%) who have experienced sexual and physical abuse may display PTSD” (Kearney et al, p. 410, 2012). Research indicates there is difficulty regarding clinicians’ ability to identify and diagnose PSTD in children (Racco, 2014). Consequently, there is confusion concerning comorbidity of symptomatology, which leads to difficulty in identifying the best intervention. Rubin (2007) indicates it is difficult to estimate the outcome of treatment for PTSD with short-term interventions such as Eye Movement Desensitization and Reprocessing (EMDR) which is due to the number of comorbid symptoms of PTSD (i.e. anxiety, depression, substance abuse, and personality disorders).
The portion of the brain that is deeply affected by PTSD is the prefrontal cortex. The individual diagnosed with PTSD may experience a series of debilitating physiological responses as a result of the prefrontal cortex being affected by a traumatic experience. Physiology of that portion of the brain that is affected includes but is not limited to fight or flight, inhibition, planning and anticipation (Blankenship, 2017). The Bilateral eye movement is one of several methodologies of EMDR. Verbalization and cognitive reframing appear to be the key methodological aspects in EMDR, however, cathartic healing, where painful experiences lose their ability to provoke traumatic memories, resulting in intense emotional responses is EMDR’s primary function in trauma healing (Smith, 2004). This suggests the methodology of EMDR has flexibly as an intervention to meet the needs of those who do not meet the formal criteria of PTSD. The tension in the research thus far indicates EMDR is being tested on both those who have received a diagnosis of PTSD and on those whose trauma is enough to indicate PTSD but not quite specific enough for an actual PTSD diagnosis. This review seeks to answer the question: What is the efficacy of EMDR in treating children and adolescents with PTSD?
EMDR Methodology and Protocol
According to Hensel (2008) EMDR methodology includes using bilateral movement of the therapist’s fingers in the air. The client is asked to watch the fingers move back and forth while also concentrating on the memory of the worse part of their traumatic experience. Then the therapist asks the client what he or she noticed the most. Whatever came about from the first set of eye movements is now the material for the new focus of the second set of eye movements. This routine continues until the client is able to report that the distressing memory no longer has power and is able to report a healthy perspective concerning the memory.
One of the interesting features of EMDR is how quickly it begins to help a person who has had a traumatic experience. Adding to this neurological mystery, EMDR works with little to no talking on behalf of the therapist or the client, which does not necessitate cognitive reframing to occur in order for EMDR to work (Smith, 2004).
EMDR was developed by Francine Shapiro (Greber et al, 2012) and includes the bilateral eye movement methodology for an intentional eight phase approach to treatment. Research indicates that these eight stages are able to be manipulated depending on the age and setting of the client. For example, in a study conducted by Jarero, Artigas, Uribe, & García (2016) the eight phase protocol for EMDR was utilized in group therapy. EMDR has a group therapy adaptation: Integrative Group Therapy Protocol (EMDR-IGTP) which allows the eight phases of individual EMDR to be applied in a group setting. A case study from the group therapy concluded that a cancer patient, Eva, diagnosed with severe PTSD, EMDR-IGTP demonstrated its effectiveness in reducing her symptoms from minimum to none.
It should be noted that the majority of the research literature uses the term “bilateral” to refer to the kind of eye movement stimulation that occurs in EMDR. However, Shapiro (2018) uses the phrase “bilateral dual attention stimulation” (p. 2). For the sake of clarity the author of this article will use the phrase, “bilateral” in reference to the eye movement portion of the EMDR protocol.
A review of the literature indicates a diagnosis of PTSD frequently accompanies comorbid symptoms and diagnoses.
EMDR and Comorbidity of PTSD Symptoms
While in tandem, a child who has PTSD symptoms but does not meet the criteria for a PTSD diagnosis, there remains the option to undergo EMDR therapy for trauma related symptoms. However, according to Fleming (2012), regardless of differences in symptomatology both children and adults may be diagnosed with PTSD (an anxiety disorder) after a traumatic experience. Some researchers utilize two categories of PTSD: Simple and Complex. Simple PTSD would refer to a singular traumatic experience whereas complex PTSD would refer to a repeated traumatic experience (Blankenship, 2017).
Comorbidity, once explored in relation to other mental health disorders, helps clarify the role in which EMDR might play in mental health wellness. The DSM-V (2013) indicates those with a PTSD diagnosis are 80% more likely to have another mental health disorder such as depressive, anxiety, bipolar; in the case of males they are more likely to have conduct disorder and substance use disorder. However, Shapiro (2018) reports that children can exhibit symptoms similar to adults who suffer from complex trauma. These symptoms include but are not limited to lying, stealing, aggressive behavior, and defiance.
In a mixed methods case study, Grey (2011) utilized the Beck Depression Inventory-II (BDI-II) for pre, mid, and post treatment of EMDR for a female participant in her thirties, who was employed, married, and of Euro-American descent. She was diagnosed with major depression disorder and panic disorder with agoraphobia. However, the diagnostic criteria was not met for PTSD. Similarly, children can have trauma related symptoms that do not meet the criteria for a PTSD diagnosis (Fleming, 2012). However, in the study conducted by Grey (2011) after twelve EMDR sessions this study indicates the possible efficacy of EMDR in decreasing emotional symptoms in an expedient way. This case study exemplifies a review of the research that indicates, for persons (children and adults) struggling with comorbid depression and anxiety, EMDR may be helpful.
Though children and adults may experience trauma differently, symptomatology does not appear significantly different between the two populations. Because the research literature for EMDR as an intervention in children is being utilized, the following section will explore trauma and PTSD in children.
EMDR Interventions in Trauma and PTSD in Children
Brief therapy, such as EMDR, is recognized as an empirically supported intervention by the International Society for Traumatic Stress Studies (Rubin, 2007). For children, EMDR protocol can be adjusted, as in a study conducted by Hensel (2009). An age modified EMDR therapy for children was used and the study concluded EMDR was effective in treating PTSD symptoms in children. Shapiro (2018) claims children who have encountered trauma in relation to assault or natural disasters are healed from their symptoms as a result of going through EMDR.
Two particular studies have been included in this review because they are examples of evidence based research demonstrate the efficacy of EMDR in the treatment of PTSD in Children. Regarding trauma, a mixed-methods study was created by Turunen, Haravuori, Pihlajamäki, Marttunen & Punamäki (2014). They conducted a study of survivors of a school shooting where survivors were given the opportunity to participate in therapeutic sessions. Of the original sample (N=389, n=236) responded to surveys aimed at gathering the therapy experiences of participants regarding the perceived efficacy of the treatments they received. More professional therapy was given to students with severe trauma, which included regular psychotherapy meetings. Twenty percent of these regular meetings included EMDR therapy. Feedback from the students, analyzed in this study, demonstrates that the students felt the availability of psychosocial therapy was helpful.
In a mixed methods case study, Aranda, Ronquillo & Calvillo (2015) used EMDR as an intervention for an eighteen year old woman, named Sophia, who was single and of Mexican origin. She had been diagnosed with PTSD due to childhood sexual abuse. Neuropsychological and physiological measures were triangulated against psychological inventories providing data to measure improvement. Using biofeedback, this study indicates that Sophia’s decreased heart rate between the baseline at the start and end of the EMDR treatment yields evidence for the treatment’s effectiveness. EMDR treatment resulted in significant improvement of Sophia’s scores on the Paced Auditory Serial Addition Test (PASAT). The PASAT measures working memory and improvement in attention. Additionally, a one year follow-up conversational session with Sophia revealed she had stabilized and no longer demonstrated PTSD symptoms. It should be noted that researchers were unable to gather third-party confirmation of Sophia’s change of behavior.
Due to the complex nature of PTSD symptomatology and the variety of EMDR approaches to trauma, there is a need to review research methodology in order to ascertain the various approaches to applying evidenced based practices to using EMDR in therapy.
Strengths and Weaknesses of Research Methodologies
A review of the research literature indicates some tension regarding methodical testing as well as the usefulness of particular aspects of EMDR methodology. Yet, withstanding this tension, the efficacy reports of EMDR as an intervention for PTSD in children and adolescents remain positive. However, a weakness in research literature reported in a review by Greyber (2012) demonstrates a lack of evidence from random control trials that indicate EMDR is an effective intervention for children who have experienced trauma. Additionally, the review indicates small sample sizes and the use of control groups, which he states does not allow for the placebo affect. Yet, Blankenship (2017) indicates in his literature review that EMDR is an integrative therapy with over twenty random control trials demonstrating its efficacy in treating trauma. Though there is a five year interval between these reviews, the enigmatic quality of results despite methodical approach provides evidence for EMDR as a treatment for trauma related symptoms.
A strength in the research literature indicates an increase in quantitative studies since 2012 regarding the efficacy of EMDR in the treatment of children. For example, a meta-analysis by Brown, et al., (2017) reviewed thirty-six research studies including 3,541 children and youth participants with regards to efficacious treatments for PTSD. This study concludes that EMDR is one of several interventions that has shown to be effective in treating children after a mass traumatic event. However, it should be noted the quality of these studies was not assessed independently.
Research also indicates that case studies have much to offer regarding the efficacy of EMDR treating PTSD. The strengths of the method in the literature often involves mixed methods models in which the participant is tested and also has a follow-up conversations regarding his or her improvement. In Grey (2011) a mixed methods, single case study approach was conducted with a participant (in her thirties) who took 12 EMDR sessions condensed into one month and then was assessed by the Beck Depressive Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI). Though generating objective data, the single case study design, is weakened by it’s lack of universality of results. However, the profit of the mixed methods single case design is supported by the literature—consistent results for effective treatment of EMDR for PTSD symptomatology. In addition to the quantitative data that has been reported, more mixed methods and single case studies with children and adolescents would help the body of efficacious evidence in support of using EMDR to treat PTSD in youth.
A limitation recognized in the research literature indicates a further need for training in EMDR as wells as a lack of knowledge about its efficacy. A study conducted by Edmond, Lawrence, and Schrag (2016) investigated the perceptions and use of EMDR therapy in rape crises centers. Their study indicated that there remains a great deal of uncertainty among counseling staff at Rape Crises Centers regarding EMDR as a treatment for sexual trauma. Additionally, they discovered in their study many of those using EMDR at rape crises centers are doing so without basic training in EMDR. A pattern has been recognized in the research literature that indicates few studies identify the amount and type of EMDR training received on behalf of those doing research regarding the efficacy or effectiveness of EMDR in treating PTSD in children.
Ethical and Culturally Relevant Issues
When deciding on treatment options for a client with a PTSD diagnosis, a primary concern is using an intervention that is evidence based. By consensus in the counseling community, when treating trauma survivors, a PTSD diagnosis is alleviated when the trauma survivor is to work through the traumatic event. EMDR therapy and trauma-focused cognitive-behavioral therapy (CBT) are both recognized as the primary two effective treatments that have empirical support for treating PTSD (Shapiro, 2018).
Research indicates that EMDR is effective in treating PTSD symptoms in children to such a degree that they either have minimum symptoms or are asymptomatic (Fleming, 2012).
Shapiro (2018) indicates that EMDR is a treatment that is effective throughout the lifespan and has successfully been used as intervention with a child as young as age two. Additionally, nine random control trials indicate positive effects for treating trauma related symptomatology in children with EMDR. However, research also indicates criticism towards aspects of EMDR’s bilateral eye-movement, saying the benefits of EMDR are due to it functioning as a kind of exposure therapy (Rubin, 2003). Yet, Maxfield, Lake, & Hyer, (2004) clarify by reporting that subjective distress experienced by participants at the end of EMDR sessions was much lower than that of an exposure therapy session. Ethically, this is important, as the level of emotional distress that may be experienced by a client in therapy needs to be communicated to the client prior to an EMDR intervention.
Shapiro (2018) indicates after a comprehensive client history is taken (Phase 1), then EMDR may be considered as a possible intervention and the client would be prepared for the targeting of memories that may bring emotional disturbance (Phase 2). Ethically, this process first considers the client’s needs, then informs the client regarding how EMDR may affect the client. As a result, veracity, nonmaleficence, beneficence, and autonomy, values of the ACA Code of Ethics (2014) are being upheld.
Concerning multiculturalism and EMDR, therapeutic interventions, particularly with children, therapists may consult the Cultural Formulation Interview (CFI) in the DSM-V (2013) for reference in reviewing applicable questions for their particular client population. In study conducted by ter Heide, June, Mooren, Knipscheer, & Kleber, (2014) on using EMDR for refugees, the authors state that the efficacy of EMDR has been found in participants from non-Western cultural environments. In particular they note that language barriers may be lessoned because speech is not always necessary in EMDR protocol and that EMDR does not have homework assignments.
A review of the literature indicates an increase in random control trials from 2012 to 2018 for the efficacy of EMDR in treating children with PTSD, however a few gaps in the literature are as follows: (1) Fidelity to EMDR protocol is at times neglected or altered to fit a study’s research design. Further research is needed to identify the value of each phase of the EMDR protocol. Present research indicates using correct EMDR protocols leads to better treatment outcomes (Hensel, 2009). (2) Qualitative research is needed for exploring post-treatment analysis as well as participants’ feelings experiences regarding EMDR as a treatment. Additionally, questions that explore how the client felt at each of the eight phases of the EMDR intervention would provide insight as to where clients might need further clarification and insight from their therapist. (3) There is also a need for more longitudinal studies to measure the efficacy of EMDR on PTSD over greater periods of time. (4) Organizations offer differing criteria for training in EMDR, which results in non-standard approaches and techniques. Research is needed to explore the efficacy of different EMDR training programs in teaching therapists how to efficaciously treat PTSD in their clients. Additionally, there are both online and physical location programs for training. A correlational study would serve to provide greater detail on which of the two educational formats has efficacious results. (5) Further research is needed to explore complex PTSD in children and the efficacy of EMDR in treating prolonged trauma. (6) Some skepticism remains regarding the use of bilateral eye stimulation in EMDR methodology and protocol (Greyber, 2012). Further research is needed to identify why the bilateral eye stimulation is efficacious in EMDR and how it works as an efficacious tool for desensitization of traumatic experiences.
American Counseling Association. (2014). ACA code of ethics. Retrieved from https://www.counseling.org/resources/aca-code-of-ethics.pdf
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, D. C.: American Psychiatric Publishing.
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Turunen, T., Haravuori, H., Pihlajamäki, J.,J., Marttunen, M., & Punamäki, R. (2014). Framework of the outreach after a school shooting and the students perceptions of the provided support. European Journal of Psychotraumatology, 5. http://dx.doi.org/10.3402/ejpt.v5.23079