# Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures - Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures - URL: https://alisanburak.com/en/bebek-ruh-sagliginin-iyilestirilmesi-tibbi-prosedurler-sonrasi-travma-sonrasi-sikinti-yasayan-bebeklerde-goz-hareketleriyle-duyarsizlastirma-ve-yeniden-isleme-emdr-hikaye-anlatiminin-etkinligi-kab - Language: en - Last updated: 2026-08-15 - Page title: Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures - Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures | Assoc. 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[Read the original](https://alisanburak.com/bebek-ruh-sagliginin-iyilestirilmesi-tibbi-prosedurler-sonrasi-travma-sonrasi-sikinti-yasayan-bebeklerde-goz-hareketleriyle-duyarsizlastirma-ve-yeniden-isleme-emdr-hikaye-anlatiminin-etkinligi-kab) [← Back to blog](https://alisanburak.com/en/blog) # Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures - Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures October 28, 2024Recent Articles **Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures**- Improving Infant Mental Health: A Pilot Study on the Effectiveness, Acceptability and Feasibility of Eye Movement Desensitization and Reprocessing (EMDR) Storytelling in Infants With Post-traumatic Distress After Medical Procedures **Authors:** Eva S. Potharst1,2, Petra Holtkamp3,4, Lily Walliser2, Agnes H. Dommerholt5, Maartje E. N. van den Heuvel5, Indra Spierts6,7 and Marija Maric2 **Translated by:** Specialist Psychologist Gizem Pozam Abstract Although the prevalence of post-traumatic stress disorder (PTSD) symptoms in infants and toddlers is similar to that in older age groups, and intervention for PTSD is also important in this age group, research on PTSD treatment in infants is scarce. Eye Movement Desensitization and Reprocessing (EMDR) Storytelling is a trauma-focused treatment already used by clinicians for infants with PTSD symptoms. The aim of this study was to evaluate the feasibility, acceptability, and preliminary indications of effectiveness of EMDR Storytelling in infants aged 3–24 months who showed PTSD symptoms after medical procedures. Six infants were included in the study, and personalized items were administered daily during the baseline, intervention, and follow-up phases to assess PTSD symptoms. We also measured PTSD classification and symptoms at three and four measurement points, respectively. Data were analyzed visually and quantitatively. EMDR Storytelling was shown to be feasible and acceptable for all participating families. Parent and therapist reports indicated a clear reduction over time in PTSD classification, symptoms, and daily measured PTSD symptoms in four of the six infants included in the current study. Results for the other two infants were mixed. Attention should be paid to the cognitive (language) and interactional (infant–parent) mechanisms potentially underlying the benefits of EMDR Storytelling. Keywords infants, post-traumatic stress disorder (PTSD), post-traumatic distress, eye movement desensitization and reprocessing (EMDR), EMDR storytelling, intervention, single-case experimental design Introduction Early-life stress is a risk factor for poorer long-term emotional, behavioral, and cognitive development (Smith & Pollak, 2020; VanTieghem & Tottenham, 2017). Family-related factors in particular, such as domestic violence, have been extensively studied as early-life stressors (Vu et al., 2016). Another situation that can cause high levels of stress in young children is hospitalization (D'Agata et al., 2017). An international systematic review showed that 4.6%–9.0% of all infants require hospitalization after birth (Lebreton et al., 2020). These infants regularly undergo painful and invasive medical procedures such as (repeated) blood tests, endotracheal intubation, and insertion of peripheral lines. In neonatology, there is growing awareness that medical procedures and repeated pain can have adverse consequences for infants' neurocognitive development (Grunau et al., 2006). Much less attention is paid to the possibility that an infant may develop post-traumatic stress symptoms as a result of such procedures and the pain experienced, often accompanied by separation from a parent (Lakatos et al., 2019; Perry and Pollard, 1998). Van der Kolk (1997) defines trauma as “the result of exposure to an inescapably stressful event that overwhelms people's coping mechanisms” (p. 243). In 1995, Scheeringa and colleagues published a study on the diagnosis of PTSD in infants and young children, concluding that the criteria in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) were not sufficiently reliable and valid for this age group. Based on 20 case reports of severely traumatized infants, they developed a more developmentally sensitive checklist of symptom manifestations that improved accurate diagnosis of PTSD in infants and young children. Examples of the new diagnostic criteria included episodes with objective features of flashbacks or dissociation, an exaggerated startle response, night terrors, social withdrawal, and a restricted range of affect. These criteria formed the basis for the Traumatic Stress Disorder criteria in the first edition of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:03, Zero to Three, 1994), a comprehensive, developmentally based diagnostic manual for infants and young children. The availability of DC:03 improved recognition of mental health problems in infants by mental health professionals and made it possible to study them in a more standardized way. However, approximately 15 years after this development, De Young, Kenardy, and Cobham (2011) concluded that, despite increased clinical and academic interest in various mental health problems in infants, trauma in infants and young children remained a largely neglected issue. In a review on this topic, they described a point that had become clear in preceding years: because of their limited coping skills and developmental stage, young children appear particularly vulnerable to experiencing post-traumatic symptoms after adverse events. They also concluded that young children have the developmental capacity to experience psychopathology following trauma, and that untreated trauma symptoms can lead to a risk of chronic and debilitating symptom trajectories and negatively affect development. Since then, a major step forward has been taken with the inclusion of developmentally appropriate PTSD criteria in DSM-5. Research using these criteria has shown that the prevalence of PTSD in infants and young children is similar to that in older age groups (De Young & Landolt, 2018). While most studies of PTSD in young children focus on children aged 12–24 months (e.g., Graf et al., 2011; Meiser-Stedman et al., 2008; Scheeringa and Zeanah, 2008), only a few include infants younger than 12 months (e.g., DeVoe et al., 2006; Graf et al., 2013). Medical trauma in infants in their first year of life has been described in the context of childhood cancer and prematurity. Graf and colleagues (2013) assessed PTSD in 48 children aged 8 to 48 months with childhood cancer. They found that approximately one-fifth of the children met the criteria for full PTSD and approximately two-fifths met the criteria for partial PTSD. A case study by Roy and Russell (2000) described post-traumatic symptoms in a 5-month-old boy who had been diagnosed with cancer at two weeks of age and hospitalized several times, during which he underwent invasive medical procedures. The parents observed changes in their child's behavior that could be related to medical trauma: spontaneous waking during the night, followed by uncontrollable crying for an hour or longer, difficulty being soothed after noninvasive procedures, social withdrawal, and an exaggerated startle response. Maronay (2003) hypothesized that the psychological, emotional, and behavioral problems associated with preterm birth may be partly attributable to chronic stress and trauma experienced during admission to the Neonatal Intensive Care Unit (NICU). In a review, Maronay (2003) noted that chronic stress and trauma may have greater adverse consequences in infancy than later in life because significant brain development occurs during this period. Neurological structures and pathways may develop differently to cope with chronic stress and trauma, making the brain more sensitive to subsequent stress not only during hospitalization but also later in life (Perry et al., 1995). Maronay explains that “theoretically, as a premature infant grows, because of the atypical development of their brain, they may be unable to distinguish, at a subconscious level, between the here and now of a stressful event and past events in the NICU.” Signs of trauma in children, such as impulsivity, attention problems, dysphoria, emotional numbing, avoidance behaviors, fears, sleep problems, aggression, and withdrawal, resemble the problems many preterm children face as they grow older (Maronay, 2003). D'Agata and colleagues (2017) also suggest that not only the early developmental stage at birth but also traumatic NICU experiences may be an additional risk factor for developmental problems in preterm children. D'Agata and colleagues (2017) proposed a new concept to describe the intertwined and cumulative early-life experiences of stress, parental separation, and pain that may lead to changes in short- and long-term neurodevelopmental and physiological responses: Infant Medical Trauma in the Neonatal Intensive Care Unit (IMTN). NICU experiences alone (summarized by D'Agata and colleagues, 2017, as stress, parental separation, and pain) are not the only risk factors for later symptomatology. Parental factors also play a role in the development of PTSD symptoms in infants. In infants and young children with cancer, more severe maternal PTSD increased the risk of full or partial PTSD in the children. In infants and young children with burns, the number of PTSD symptoms in the children was also positively associated with maternal PTSD and negatively associated with higher-quality family relationships (Graf et al., 2011). The same association between child and maternal PTSD symptoms was demonstrated in a study of young children who witnessed intimate partner violence (Bogat et al., 2006). Scheeringa and Zeanah (2001) defined this phenomenon as relational PTSD: “The co-occurrence of post-traumatic symptomatology in an adult caregiver and a young child, in which the symptomatology of one partner, usually the adult, exacerbates the symptomatology of the other.” Winnicot (1964) wrote that “there is no such thing as a baby.” He meant that an infant cannot exist alone; someone is needed to care for the infant both physically and emotionally. An infant depends on caregivers not only for physical care but also for support in maintaining and restoring emotional balance after stress. The latter occurs through co-regulation, the bidirectional coupling of oscillating emotional channels between mother and child, which contributes to emotional and physiological stability for both (Butler & Randall, 2013). In the co-regulatory relationship between infant and parent, the regulatory abilities of both infant and parent are important factors. An infant experiencing post-traumatic stress and resulting regulatory problems will turn to their parents more often for co-regulation. In addition, the infant's post-traumatic stress response will increase the parent's tendency to perceive the child as vulnerable following a serious illness or preterm birth (Allen et al., 2004) and to worry about their child. Conversely, when a parent has difficulties with self-regulation, they will be less emotionally available to support the infant's regulation. Parental psychopathology, such as PTSD, is therefore a risk factor for co-regulatory difficulties between parents and infants. However, infant illness, hospitalization, and medical procedures are risk factors for post-traumatic stress not only in children but also in parents (Balluffi et al., 2004; Schecter et al., 2020). This may mean that, on the one hand, children who have experienced medical trauma have a relatively greater need for support with regulation, while, on the other hand, parents' emotional availability may be adversely affected by their own post-traumatic stress. This can lead to a vicious cycle and the persistence of co-regulatory difficulties and PTSD symptomatology. Because of the infant's dependence on their parents, the intertwined nature of the parents' and child's post-traumatic symptoms, and the co-regulatory difficulties between them, parental involvement in the infant's treatment is essential. D'Agata and colleagues (2017) describe the importance of supporting parents in developing a supportive relationship with their child, as well as the importance of creating a language for parents to describe their experiences during their infant's hospitalization. An infant behavioral assessment and intervention program implemented in the Netherlands to teach parents of very preterm children to be responsive to their infants and support their regulation showed positive developmental outcomes for the children (Verkerk et al., 2012). Other studies have focused on preventing or reducing PTSD symptoms in parents whose infants are admitted to the NICU by teaching parents coping and self-regulation skills (Shaw et al., 2013; Horwitz et al., 2015; Kraljevic and Warnock, 2013). Although there is evidence for the effectiveness of parenting programs that focus on improving the co-regulatory parent–child relationship and on preventing or treating parental trauma, in some cases a more direct treatment for the infant's trauma may be needed. Psychologists in the Netherlands (such as IS and PH) have observed that some infants continue to show severe trauma symptoms even after parental support aimed at improving the co-regulatory relationship with their child and trauma-focused treatment for the parents. The literature on the treatment of infant trauma is scarce. Child–Parent Psychotherapy, a psychodynamic, dyadic psychotherapy for infant mental health, has been described as a potential treatment for parents and infants during their NICU stay (Lakatos et al., 2019). This form of dyadic psychotherapy focuses not only on improving the parent–child relationship but also on enhancing the parent's reflective functioning, which supports the development of a narrative about traumatic events that can be shared between parents and child. Weatherston and Browne (2016) describe a similar infant mental health-informed treatment that can be offered to parents and high-risk infants in an outpatient setting after hospitalization. Interventions for traumatized toddlers are mostly based on cognitive behavioral therapy (CBT), but they are also preferably dyadic therapies and take into account the relational context of post-traumatic symptomatology (Rachamim et al., 2017). Prolonged exposure therapy, including psychoeducation, narration of traumatic events by the child, parent, and therapist, and in vivo exposure, was offered to four young children who had experienced medical trauma and their parents (Rachamim et al., 2015). Toys and play were used at different stages. Post-traumatic stress symptoms decreased in both the young children and their parents. In a pilot study of PTSD treatment in 12 preschool children, the effectiveness of dyadic exposure therapy was compared with dyadic client-centered therapy (Rachamim et al., 2021). Only dyadic exposure therapy was shown to be effective in reducing child and maternal PTSD symptoms. In a randomized controlled trial involving 64 toddlers and preschool children with PTSD, trauma-focused CBT was shown to be more effective than being on a waiting list (Scheeringa et al., 2011). Rachamim and colleagues (2017) emphasized the importance of using a case conceptualization before trauma-focused CBT for toddlers. They recommended using a developmentally appropriate case conceptualization model that incorporates aspects of the parent–child relationship and the way the child's and parent's cognitions, emotions, and behaviors influence one another. In cases of medical trauma, they recommended always paying attention to PTSD (symptoms) in both children and parents, parental coping and functioning, possible parental overprotection, and the potential consequences of the trauma for the quality of child–parent attachment (Rachamim et al., 2017). Using a similar case conceptualization may also be a prerequisite for trauma-focused therapy for infants and their parents. Thus, there is promising initial evidence that post-traumatic stress symptoms in toddlers are treatable. However, research has not yet established whether such effects can also be achieved under the age of 24 months, whether this can be achieved with a brief manualized intervention, and how such an intervention can be delivered given the developmental stage. Surprisingly, none of the above studies involved EMDR with toddlers, although EMDR has been found to be effective in reducing PTSD symptoms in older children, adolescents, and adults (Hoogsteder et al., 2022; Lewey et al., 2018; Wright et al., 2024). Eye Movement Desensitization and Reprocessing (EMDR) has also been shown to be effective compared with CBT for treating trauma in older children (Rodenburg et al., 2009; Moreno-Alcazar et al., 2017; Lewey, 2018). To make EMDR treatment acceptable for treating traumatic distress in very young children and infants, Lovett (1999) modified the standard EMDR protocol, resulting in EMDR Storytelling. EMDR Storytelling consists of two phases: (1) a preparation phase in which parents and a therapist write a story about the traumatic event(s) from the child's perspective, and (2) an actual treatment phase in which the story is read to the child, held by one parent, while the infant's working memory is taxed using EMDR techniques. Since Lovett (1999) made these adaptations to the treatment protocol for infants, clinicians have been using the protocol. EMDR Storytelling was translated into Dutch by De Roos and Beer (2017). Three members of our project group (PH, AD, and IS) have used EMDR Storytelling with young children and infants for more than 10 years, following Lovett's protocol and its Dutch translation. They observed that trauma-related regulatory problems reported by parents decreased or disappeared after one or two sessions. These results are consistent with other anecdotal evidence showing positive effects of EMDR Storytelling in previously hospitalized infants (Lovett, 1999; Went, 2014). To date, there has been no systematic research into the effectiveness of EMDR Storytelling. What is missing from the scientific literature is a clearly defined age range of children for whom EMDR Storytelling is appropriate. The lower age limit is of particular interest because EMDR Storytelling relies partly on the child's language comprehension. Infants begin to understand words at 6–9 months of age, and this ability increases rapidly in the second year of life (Bergelson & Swingley, 2015), but language development begins long before this age (Saletta & Windsor, 2018). Within our project group, there is clinical experience of successful treatment with EMDR Storytelling in infants only a few months old who have not yet acquired the ability to understand words. In infants of this age and in older infants, it is assumed that traumatic memories are triggered not (only) by words and sentences but also by other elements used during treatment. In EMDR Storytelling therapy, trauma-related stimuli are used to activate the trauma memory. For example, medical objects are shown while the story is read, audio files containing intensive care sounds are played, and the parts of the infant's body involved in the traumatic events are touched. It is also assumed that, while one parent reads the story to the infant, the other parent holding the infant is emotionally and physiologically affected by the story, which in turn affects the infant. Research has shown that infants' stress levels can be regulated by being held by a parent (Kommers et al., 2018). Microanalysis of mother–infant communication has shown that subtle parental behaviors, such as facial expressions or vocalizations (Beebe and Steele, 2016) and maternal prosody (Spinelli et al., 2017), affect infant (dys)regulation. During storytelling, when the parent experiences emotions, tension may also arise in the infant's body, and this tension may be reduced by taxing the infant's working memory, another element of the EMDR Storytelling session. EMDR Storytelling may therefore be appropriate for infants who do not yet understand spoken language or understand very little of it. Regarding working memory taxation: a recent scientific article on EMDR identified this as the proposed mechanism of action of EMDR for which the most evidence is available (de Jongh et al., 2024). The idea is that EMDR involves a dual focus of attention or “dual taxation” (Wadji et al., 2022), namely the combination of recalling a traumatic memory and another “task” that places demands on working memory capacity. Because the “additional” task limits working memory capacity, it is assumed that working memory cannot retain all elements of the memory, and the intensity with which the traumatic memory is recalled decreases (de Jongh et al., 2024). Since infants cannot yet follow instructions for a task that taxes working memory, the therapist ensures that activities that tax working memory are presented to the infant. Matching the taxing tasks to the recalled memory (for example, a visuospatial task when treating a visual memory) has been shown to have the greatest effect, although unmatched tasks (such as a verbal task when treating a visual memory) are also effective (Matthijssen et al., 2019). Since the traumatic memories of infants with a history of medical procedures are assumed to include bodily sensations, the task or activity offered to the infant should preferably also involve physical sensations. Tapping parts of the infant's body (for example, the infant's knees) was therefore selected as the “task” that taxes working memory. To our knowledge, there are no other studies on the effectiveness of EMDR Storytelling in infants who have experienced medical trauma. As noted earlier, psychological and psychosocial care for parents is already an integral part of hospital follow-up programs. As the latter contributors have observed in their daily practice, suitable, evidence-based interventions directly targeting the infant's post-traumatic distress are unavailable, yet greatly needed. In infant mental health clinical practice, EMDR Storytelling is already used with families whose infant has PTSD symptoms. The aim of this pilot study was therefore to evaluate the feasibility, acceptability, and preliminary indications of effectiveness of a two-session EMDR Storytelling intervention for infants aged 3 to 24 months. Given the relatively innovative nature of this study and intervention, and the potential heterogeneity of treatment effects across participants (Maric & Kok, 2023), single-case methodology was used to investigate our research questions. Other reasons for choosing a single-case experimental design (SCED) were the limited number of infants we expected to include, which would limit power in a more traditional design such as a randomized controlled trial, and the ethical implications of a randomized design in which some infants would be randomized to a condition in which trauma treatment would not be offered. Infants' trauma symptoms were measured daily using personalized items during the baseline, intervention, and follow-up phases, and also through a parent-report questionnaire and therapist-reported classification at three and four measurement points, respectively. We expected to find a greater reduction in daily measurements of trauma symptoms during the intervention and follow-up phases compared with the baseline phase. We also expected improvements in parent-reported infant PTSD symptoms and therapist-reported infant PTSD classification at posttest and at the three-week follow-up. Methods Design This pilot study used SCED methodology. SCED is widely recognized for its potential to support the investigation of new interventions before they are examined in large-group studies (Maric & van der Werff, 2020). We implemented an ABC SCED with a baseline phase A, followed by an intervention phase B and a follow-up phase C. A within-subject comparison (intervention phase B and baseline phase A for each participant) was included. Personalized items were developed based on the child's symptoms assessed before baseline phase A and were administered daily during phases A, B, and C. Questionnaires were completed by parents before and at the end of each phase (at T0, T1, T2, and T3). In addition, the child's trauma symptoms were classified according to DC:05 at T0, T2, and T3. The baseline, intervention, and follow-up phases were designed to be of similar length (three weeks of daily measurements), so that (i) the phases could be easily compared; (ii) this number of observations appeared sufficient for the planned analyses; and (iii) this design was considered feasible for all parties involved. The baseline phase was intended to provide a basis for comparison, as it included a record of the infant's potentially PTSD-related behaviors, represented by daily items, but no explicit therapy or intervention targeting these behaviors. “Usual care” was not standardized here; it consisted of the family's individual management of the infant. The three-week baseline period was based on the time needed to prepare the intervention (writing the story to be read to the infant) and on ensuring that we could collect a representative, stable sample of the infant's behavior even with missing data points (Smith, 2020). At least five data points were needed for this purpose, but baseline periods with more data points may be more representative and therefore increase validity (Smith, 2020). In practice, the period during which daily items were administered was sometimes shorter because, in some cases, developing the daily items took longer than expected. Nevertheless, a minimum of five data points was achieved for all participants. Infant 1's baseline period was much longer than planned (46 measurements). This was because, despite a negative PTSD screening result for the mother, writing the story revealed that her PTSD symptoms were more severe than expected, and she herself needed PTSD treatment before proceeding to the intervention phase, in which she was to read the story to her infant. For the other infants, the number of daily measurements during the baseline period ranged from 7 to 16. The intervention period was also designed to last three weeks. This consisted of EMDR sessions on day 1 and, ideally, day 8, followed by a two-week period needed for integration and consolidation of the treatment effect. This two-week period was based on the clinical experience of the therapists in the research team. Illness, COVID-19-related quarantine rules, and a family holiday delayed the second session for infant 4, extending the intervention period by 45 days. For the other infants, the number of daily measurements during the intervention period ranged from 14 to 19. The number of measurements during the follow-up period ranged from 13 to 23. Participants and Procedure Infants aged 3–24 months with a history of hospitalization at OLVG hospital in Amsterdam and potentially traumatic experiences related to painful medical procedures [e.g., (repeated) blood tests, endotracheal intubation, insertion of peripheral lines, and surgery] were eligible for this study. Six infants aged 4–23 months and at least one of their parents/caregivers were included. Inclusion criteria were: (i) according to the DC: 0-5 diagnostic interview (2016), a positive score for Post-traumatic Stress Disorder on Axis I (Clinical Disorders) and a negative score for levels 3 and 4 of Axis II, Relational Context (there should be no impaired relationship between parent and infant); (ii) the infant experienced regulatory problems such as crying, sleeping and feeding difficulties, or clinging to parents, as indicated by at least one item on the Infant Trauma-Related Stress Symptoms Questionnaire. DC:05 and the Infant Trauma-Related Stress Symptoms Questionnaire are described in more detail under “Outcome Measures.” Exclusion criteria were: (i) parents themselves had PTSD, and (ii) parents were unable to participate in the research. Enrollment in the study took place as follows. At OLVG hospital in Amsterdam, families admitted to follow-up care were screened and referred to the infant mental health center OuderKindLijn (OKL) for EMDR Storytelling if the infant showed signs of trauma. If at least one parent had PTSD, that parent was first referred for treatment. At OKL, families were invited for an intake appointment during which a case conceptualization was developed, symptoms were classified according to DC: 05, and the study's inclusion and exclusion criteria were checked. If families met these criteria, they were asked to consent to participation in the study. When EMDR Storytelling was not indicated, families were referred to another appropriate intervention at OKL. After providing signed informed consent, parents completed the first set of questionnaires (T0). Personalized daily items were developed by the parents, a psychology student undertaking a research internship (LW in some cases), and one of the researchers on the project (EP), with input from the therapist in some cases (PH in some cases). The items were based on high-scoring items on the questionnaire used to measure trauma symptoms, parents' observations of the infant's behavior, and hypotheses about which behaviors might be related to the traumatic events. Daily baseline measurements then began (phase A). During the baseline phase, parents wrote the story of the traumatic events from the infant's perspective with the therapist's help. In a session with the therapist, parents received instructions for writing the story and then wrote it at home. Subsequent sessions were mostly used to revise the story and prepare for the actual EMDR with the infant. A few days before the first EMDR session with the infant, parents completed T1. Two EMDR Storytelling sessions were then conducted, ideally one week apart. Phase B began on the day of the first EMDR session. This phase continued until two weeks after the second session. After parents completed T2 and the infant's trauma symptoms were reclassified according to DC: 05, the follow-up phase began (phase C). This phase lasted three weeks and concluded with a final set of questionnaires (T3) and the final classification of the child's trauma symptoms according to DC:05. Classification of trauma symptoms according to DC:05 was delayed in some cases relative to questionnaire completion because it could only be performed during an appointment between the therapist and the family. In addition, circumstances mentioned in relation to the EMDR sessions, such as the infant's illness, sometimes also affected these appointments. Intervention EMDR Storytelling (De Roos and Beer, 2017; Lovett, 1999) is already used with young infants by PH, AD, and IS. The aim of this treatment is to help the infant process distressing memories and experiences that may underlie their symptoms. The underlying idea is that infants, too, can be reminded of painful experiences through various everyday triggers. By placing these experiences in a (narrative) context while taxing the infant's working memory using EMDR techniques (e.g., tapping), memories may be stored in a more adaptive and less emotionally charged form. Infant development that has stalled may thus get back on track. By writing the story, parents can first reflect on how the child may have experienced, or may still be experiencing, the stressful event(s), and then, during the procedure, provide the support they were unable to provide at the time of the event. Parents are supported in writing the story during one or two sessions in the baseline phase. The actual EMDR sessions each last 45–60 minutes. At the start of these sessions, infants become accustomed to the therapist and the room, and then to the EMDR techniques. The family is given some information about these techniques and told that they may be experienced as intrusive and that the therapist will seek a suitable way to apply them. The therapist may also use a stuffed toy or other objects the infant may find interesting. When the actual Storytelling begins, the infant sits on one parent's lap. After a soothing moment with the infant, one parent reads the traumatic story to the infant while the therapist taps the infant's feet, hands, or legs. These taps, which tax the infant's working memory, may be applied to the body areas where the traumatic events occurred, but only if the parents and therapist expect and observe that the infant does not experience this as intrusive. Other trauma-related stimuli are also used to activate the trauma memory, such as audio files containing intensive care sounds and medical objects that can be shown while the story is read. Reading the story alternates with parents and infant doing something soothing (e.g., singing together). All EMDR Storytelling treatments took place between July and December 2022 and were delivered by PH and one of her colleagues at OKL. Both were experienced in working with infants and their parents in general and in delivering EMDR Storytelling in particular. Outcome Measures Treatment Feasibility. To assess the feasibility of EMDR Storytelling, we counted the number of participants who completed the full EMDR Storytelling treatment. Treatment Acceptability. To assess the acceptability of EMDR Storytelling, parents completed the eight-item shortened version (Nguyen et al., 1983) of the Client Satisfaction Questionnaire (CSQ-8; Attkisson & Zwick, 1982) at follow-up. CSQ-8 items are scored on a scale from 1 to 4, with higher scores indicating greater satisfaction. An example item is: “How satisfied are you with the amount of help you received?” The CSQ-8 has been shown to have good psychometric properties (De Brey, 1983; De Wilde & Hendriks, 2005). Infant PTSD Diagnosis. The Dutch translation (Zero to Three, 2019) of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 05, Zero to Three, 2016) was used by the therapist to check two of the inclusion criteria at T0, namely the presence of PTSD in the child, the absence of an impaired relationship between parents and child, and the presence of past or current medical disorder(s) or condition(s). PTSD can be scored on Axis I of DC: 05, which includes diagnostic criteria for clinical disorders. Parent–child relationship functioning can be scored on Axis II and ranges from 1 (a well-adapted to good-enough parent–child relationship) to 4 (a disordered to dangerous parent–child relationship). Only children whose relationships with their parents were classified as level 1 or 2 were included in the study. Two meetings between therapist and family were held, preferably two weeks after the second EMDR session and again three weeks later, during which the PTSD criteria were checked for the second and third time, respectively (T2 and T3). Infant PTSD Symptoms. The Infant Trauma-Related Stress Symptoms Questionnaire (ITSSQ; Holtkamp, 2020) is a checklist developed and used by pH in the context of clinical practice with EMDR Storytelling. It contains 27 items and assesses symptoms of trauma-related distress and dysregulation. Items are scored on a Likert scale from 1 to 3 and recoded to a scale from zero to 2. An example item is “My baby's body is tense.” The checklist was administered at T0, T1, T2, and T3. Because of the limited number of participants, interrater reliability was calculated across all measurement occasions and was shown to be good (Cronbach's alpha = .82). The infant's PTSD symptoms were also measured using personalized items administered daily during the baseline, intervention, and follow-up phases. Based on the information obtained and hypotheses about which symptoms were related to the traumatic events, personalized items were developed in collaboration with one parent to measure the intensity of current symptoms across the study phases. A seven-point Likert scale was used for all personalized items. Statistical Analyses The mean and standard deviation of the CSQ-8 and ITSSQ total score(s) were calculated. Visual and quantitative analyses of the personalized items administered daily were performed using the Shiny App for Single-Case Data Analysis (Shiny SCDA V2.8; De et al., 2020). We created graphs showing the scores for each item across all three phases. We examined the mean scores for the baseline, intervention, and follow-up phases, compared mean scores between phases, and examined the slopes of trend lines across phases. In addition, for each personalized item, nonoverlap of all pairs (NAP) scores were calculated for all combinations of phases: baseline and intervention, intervention and follow-up, and baseline and follow-up. NAP measures the extent to which scores in one phase match or differ from scores in another phase (Parker & Vannest, 2009). Each data point in one phase is compared with each data point in another phase (the same, higher, or lower). The NAP score is the proportion of nonoverlapping data points between phases. The NAP score ranges from zero to 1, and a score of >.5 indicates an effect in the expected direction, which in our study means a reduction in symptoms between baseline and intervention and between baseline and follow-up. Results Feasibility and Acceptability A description of the infants' (medical) histories and their responses to treatment is provided in the Supplementary Materials. All families completed EMDR treatment, and all completed the Client Satisfaction Questionnaire at T2. The mean score on the CSQ-8, scored on a four-point Likert scale, was 3.7 (SD = .3). All parents reported being satisfied or very satisfied with the intervention. Other results are shown in Table 1. Trauma-Related Stress Symptoms and PTSD Diagnosis in Infants The ITSSQ total scores for each infant at T0, T1, T2, and T3 are shown in Table 2 and Figure 1. For the figure, missing scores were imputed using last observation carried forward. Visual analysis of the figure shows that four children showed a clear reduction in symptoms at T3, one child showed a clear increase, and one child showed neither an increase nor a decrease in symptoms. The presence of a PTSD diagnosis at T0, T2, and T3 is also shown in Table 2. At T0, all six infants were diagnosed with PTSD. At posttest, only two of the six children (33.3%) no longer had PTSD according to DC:05. At follow-up, DC:05 was used again to classify the infants' symptoms in five of the six children (83.3%). All five children were no longer diagnosed with PTSD. Results for each child are shown in Table 2. Visual Analysis of Personalized Trauma Symptoms Daily measurements of personalized trauma symptoms were available for infants 1, 2, 4, 5, and 6. Infant 1's items concerned crying, excessive arching, appearing fearful, and physical restlessness. Infant 2's items concerned crying, waking during the night, excessive arching, and clinging. Infant 4's items concerned resistance to diaper changes, resistance to sleep, inconsolable crying, and waking during the night. Infant 5's items concerned the need to be held, waking during the night, frequency of requests for feeding, and crying. Infant 6's items concerned waking during the night, fear of sounds, restlessness, and resistance to sleep. Daily measurement data for infant 3 were unsuitable for analysis because of the small number of data points. When formulating infant 3's personalized items, the mother reported that her infant mostly showed signs of fear when encountering medical staff. However, this did not occur frequently enough during the study period. Figure 2 shows graphs of the scores on the daily items completed by parents about their infants' personalized trauma symptoms. The mean scores of the personalized items for all infants and each measurement phase, and differences in mean scores between phases, are shown in Table 3. For most items (all items for infants 1, 2, and 5, and items 1, 2, and 3 for infant 4), mean scores decreased from baseline to intervention and decreased further at follow-up. There were a few exceptions. For infant 4's item 4, there was a decrease of 2.0 between baseline and intervention, but an increase of 0.1 between intervention and follow-up. For infant 6, the direction of the differences was inconsistent. Looking at the differences between baseline and follow-up, two items showed an increase and two showed a decrease. Trend lines for the items for all children can be found in the Supplementary Materials. The direction of the slopes of the trend lines is summarized in Table 4. As expected, the slopes of the trend lines during the intervention phase were negative for 15 of the 20 items (75%), indicating a reduction in symptoms during the intervention phase. For 9 of these 15 items (60%), the slope of the trend line was positive or flat during baseline, meaning that the negative trend during the intervention phase could be attributed to the intervention. However, for 6 of the 15 items with a negative trend line during the intervention phase, the trend line was already negative at baseline, making it unlikely that the decrease during the intervention phase could be attributed to the training. Regarding follow-up: for three of the 20 items (15%), symptoms disappeared completely during this phase. For eight items (40%), the trend lines were positive at follow-up (increasing symptoms), and for seven items (35%), the trend lines were negative (decreasing symptoms). Quantitative Analysis of Personalized Items Trauma Symptoms For each personalized item, NAP scores were calculated for all combinations of phases: baseline and intervention, intervention and follow-up, and baseline and follow-up. NAP scores are presented in Table 5. All effects were in the expected direction except for some for infant 6. For infant 1, effects between baseline and intervention and between intervention and follow-up were small. However, effects between baseline and follow-up were moderate. The same applied to infant 2, with a moderate effect for item 1 between intervention and follow-up and a small effect for item 3 between baseline and intervention. Infant 4 showed moderate effects between baseline and intervention. Effects between intervention and follow-up ranged from none to large. Effects between baseline and follow-up were large for three items and moderate for the fourth. Infant 5 showed moderate effects for three items between baseline and intervention, whereas no effect was found for the fourth item. Effects between intervention and follow-up ranged from none to moderate. Effects between baseline and follow-up ranged from none for one item to large for two items. Infant 6 showed mixed results, with both negative and positive effects, mostly small to moderate. Discussion The aim of this pilot study was to evaluate the feasibility, acceptability, and preliminary indications of effectiveness of a two-session EMDR Storytelling intervention for infants aged zero to 24 months. The six infants included in this study had a history of hospitalization and medical procedures. Some infants were admitted to the NICU immediately after birth, while others were hospitalized after a few days, weeks, or months, and one infant around their first birthday. The infants' conditions ranged from perinatal asphyxia, infections and inflammation, failure to thrive, a chromosomal syndrome, pseudocroup, and choking on vomit to heart conditions. Some infants required surgery, while others underwent medical procedures such as scans and blood tests. All infants whose parents completed the daily measurements had regulatory problems related to crying and sleep. In addition, post-traumatic symptoms such as excessive arching, clinging, fearful reactions, and physical restlessness were reported. We found that EMDR Storytelling was indeed feasible (all families completed the intervention) and acceptable (all parents were satisfied or very satisfied with the intervention). Visual analysis showed that, at the final measurement five weeks after the last EMDR session, four of the six infants had improved in parent-rated trauma symptoms, one showed no change, and one showed deterioration, and five of the six infants were no longer classified as having post-traumatic stress disorder. Parents of five of the six infants completed daily measurements of the personalized symptom items. Parents of all children reported improvement with a moderate or large effect size on at least one item between baseline and follow-up, and for four of the five children this applied to at least three of the four items. However, based on the trend lines for items during the baseline and intervention phases, improvement could be attributed to the intervention for only about half of the items showing improvement. There was no clear consistency in the type of items that improved during the intervention phase but not during baseline. Overall, four of the six infants included in this study showed a clear reduction in PTSD symptoms over time. Results for the other two infants were contradictory. Other problems besides PTSD symptoms appeared to play a role in these children: infant 3 had a syndrome causing regulatory problems, and infant 6's family had unresolved family problems. Infant 3's parents reported the impression that EMDR had a very positive effect on infant 3, particularly on how the infant coped with medical staff. Although EMDR Storytelling has been used by infant mental health professionals and EMDR practitioners in children under two years of age, with beneficial results observed, no studies are available on the benefits of this intervention in this particular age group. This study shows that the intervention is feasible for families with infants showing PTSD symptoms after medical procedures, even in the first six months of life. All parents were able to write a story together with the therapist, although one mother first needed trauma treatment herself before she could write the story and read it to her infant. The EMDR sessions were carried out as planned; reading the story alternated with moments of relaxation, and all parents and infants attended both sessions, although some sessions had to be postponed, for example because of the infant's illness. Four infants responded emotionally to the story in one or both sessions. Two infants showed signs of processing their trauma through play immediately after the sessions, for example by changing the diapers of all the stuffed animals in the room. In conclusion, EMDR Storytelling appears to be a feasible intervention for infants younger than 24 months who show post-traumatic stress symptoms after facing different medical problems and undergoing different medical procedures. This is consistent with the results of a meta-analysis of dropout rates in trauma-focused and non-trauma-focused treatments for children and young people, which found similar dropout rates and led to the conclusion that trauma-focused therapies are well tolerated by children and young people (Simmons et al., 2021). The acceptability of EMDR Storytelling was measured with the CSQ-8. The mean score on the CSQ-8, scored on a Likert scale from 1 to 4, was 3.7. The parents of two infants were satisfied with the intervention (33.3%), and the parents of four infants were very satisfied (66.7%). The quality of EMDR Storytelling was rated as good by the parents of one infant (16.7%) and excellent by the parents of five infants (83.3%), and all parents (100%) recommended EMDR Storytelling to friends. Parents appeared to experience the sessions as intense on the one hand and comforting on the other. Two infants initially showed a worsening of symptoms immediately after the first session, but these symptoms subsided within one or a few days. In summary, acceptability was high as reported by the parents of the infants in the current study. The infants' PTSD classification and symptoms were measured using DC:03 (therapist-reported) and the ITSSQ (parent-reported). Only the latter was measured twice before the actual start of the intervention (baseline and pretest). Overall, when considering the combination of therapist-reported PTSD classification and parent-reported PTSD symptoms at follow-up, four of the six infants (66.7%) appeared to benefit from EMDR Storytelling, whereas one infant showed no improvement (16.7%), and results for one infant were contradictory (16.7%). No studies on EMDR Storytelling in infants or even toddlers are available with which to compare the results of the current study. However, a study of EMDR in children aged 4–8 years with PTSD is available. In that study, EMDR (and EMDR Storytelling for children whose traumatic event occurred before age 4) was effective in achieving diagnostic remission in 85.7% of children (Olivier, de Roos, & Bexkens, 2021). The somewhat higher remission rate in that study may be explained by the higher treatment dose (six sessions). In addition, some trauma symptoms in infants, such as crying, may be less specific to trauma and may be symptomatic of other problems in the infant or even difficult circumstances (family problems, a new illness, etc.), making it harder to demonstrate clear and longer-lasting improvements. The infants' PTSD symptoms were also measured using personalized items rated daily by the parents of five of the six participating infants (four per child, thus 20 items in total). These items were analyzed both visually and quantitatively. For the visual analyses, graphs were prepared showing scores during the baseline, intervention, and follow-up phases. Mean scores for each item were compared between phases. For most items, the greatest differences were observed between baseline and follow-up. This corroborates the findings showing that the time required for reductions in PTSD classification and symptoms extended beyond the intervention phase. In four of the five infants (infants 1, 2, 4, and 5), symptoms decreased between baseline and follow-up for all items. In the remaining infant (infant 6), two items showed a decrease between baseline and follow-up, whereas the other two showed an increase. These results also corroborated the findings on PTSD classification and symptoms, which showed clear improvement in infants 1, 2, 4, and 5 but no improvement in infant 6. The improvements shown in the current study are consistent with anecdotal evidence for the effectiveness of EMDR Storytelling in infants (Lovett, 1999; Went, 2014). We also examined the slopes of the trend lines. We expected a negative trend line during the intervention phase (indicating a reduction in symptoms), which was found for 15 of the 20 items. However, only a negative trend during the intervention phase combined with the absence of a negative trend during baseline suggests that the reduction in symptoms during the intervention phase can be attributed to the intervention. This was the case for 9 of the 15 items that showed a decrease during the intervention phase. These items concerned excessive arching (infant 2), resistance to diaper changes and inconsolable crying (infant 4), the need to be held, waking during the night, frequency of requests for feeding, and crying (infant 5), and waking during the night and restlessness (infant 6). For infant 1, the baseline trend line was already negative. This infant's baseline phase was indeed long because circumstances revealed the need for the mother herself to receive EMDR treatment before starting EMDR Storytelling. The mother's treatment may have had a positive effect on the mother–infant relationship and the infant's symptoms. For infant 2, three of the four baseline trend lines were also already negative. During baseline, writing the story helps parents put both their own and their infant's experiences into words. This may already affect parent–infant interaction and co-regulation between parents and infant, and therefore may also affect the child's symptoms. The trend line results indicate that we should be cautious in interpreting the positive findings concerning differences in mean scores on personalized items between phases and PTSD classification and symptoms at follow-up. Although symptoms decreased over time, this may not be attributable to EMDR Storytelling for all items and all infants. We analyzed the personalized items quantitatively by calculating NAP scores between baseline and intervention, between intervention and follow-up, and between baseline and follow-up. These scores indicate the direction and magnitude of an effect. The direction of effects was as expected for all items for all infants except infant 6, whose results were mixed. The only other study evaluating EMDR Storytelling in children that also calculated NAP scores was a study of children aged 4–12 years who had experienced child abuse and neglect (VanTieghem et al., 2017 2012). In that study, only 2 of 8 children showed improvement in trauma symptoms. The nature of the traumatic events may have made trauma symptoms more difficult to treat in this group of children. This is the first experimental study to evaluate EMDR Storytelling in infants aged zero to 24 months. The youngest infant included in the study was only four months old at enrollment. Even this very young infant showed a clear reduction in symptoms after treatment. Previous empirical studies on the effectiveness of trauma-focused treatment in young children included children aged 2–3 years and older (Rachamim et al., 2015, 2021; Scheeringa et al., 2011). One strength of this study is that a range of measures was used in combination, including an acceptability questionnaire, therapist-reported classification of PTSD symptoms, parent-reported PTSD symptoms, and personalized items completed daily by parents. The current study also has limitations. The first is that the lengths of the baseline, intervention, and follow-up phases were not randomized. Instead, the aim was to standardize the length of all phases, but in practice, length was often determined by circumstances such as illness of the infant or therapist, or the need to provide EMDR treatment to parents before starting the child's EMDR treatment. These circumstances may have affected not only phase length but also treatment trajectories and outcomes. In addition, the T2 and T3 questionnaires were completed later than planned for two children. This was a methodological limitation of the study. We administered questionnaires on sensory problems and parental sensitivity/parent–infant co-regulation, but could not include the data in the current article because of the very high percentage of missing questionnaires. Future studies could also include these constructs. Because DC: 0-5 PTSD classification was performed only at T0 (the start of baseline), T2 (the end of the intervention period), and T3 (the end of follow-up), but not at T1 (the end of baseline), we do not know whether any infants would no longer have been classified as having PTSD at the end of baseline. This question applies to the two children who changed from “PTSD” to “no PTSD” between T0 and T2. Another important limitation was that neither the therapist nor the parents were blinded to treatment condition, and both were involved in and highly invested in the treatment process. Since parents and therapists were the only informants in this study, this may have biased the results. For example, hope for improvement and cognitive dissonance may have played a role in potential bias. Involving parents in writing and reading the story may also have had another unintended consequence. We cannot rule out the possibility that this may be a form of exposure therapy for parents and that improvement in any parental trauma symptoms may be one of the mechanisms underlying improvement in the infants' trauma symptoms. We did not measure PTSD symptoms in parents and therefore could not examine this factor as a potential mechanism of action. However, the key question is whether this potential mechanism would have a sufficiently large effect on reducing infants' PTSD symptoms. If writing the story were beneficial for the children, positive effects might have been observed during baseline. Only about half of the personalized items showed a decreasing slope during baseline, whereas the other half showed an increase in symptoms during baseline. During the intervention phase, we found a decreasing trend line for three-quarters of the items. In addition, NAP scores also showed that symptoms were lower during the intervention phase than during baseline for 18 of the 20 items. Together with the examples provided in the case and therapy descriptions, this leads us to question whether an intervention involving only parents would be effective for most infants. Furthermore, the design of the current study does not allow us to draw any conclusions about the effectiveness of taxing the infant's working memory, because we did not include a phase in which the infant was told the story of the traumatic events without tapping the infant's feet, arms, or legs. Simply telling the story to the infant while the infant sits on the parent's lap might produce similar results. Future studies could use more advanced methodological approaches by randomizing phases or choosing a randomized controlled trial as the research design. Future studies could also use experimental designs with microtrials aimed at determining which element or combination of elements of EMDR Storytelling is effective (Leijten et al., 2015). Examples of elements that could be examined in such a study include (1) the parent writing the story only, (2) reading the story to the parent rather than the infant, (3) reading the story while the infant is not being held by a parent, (4) reading the story to the infant without taxing working memory, and (5) reading a neutral story to the infant while taxing the infant's working memory. Future studies could also include measures of PTSD symptoms in parents so that reductions in parental PTSD symptoms can be examined as a potential mechanism of action. Conclusion This is the first experimental study to evaluate EMDR Storytelling in infants showing post-traumatic stress symptoms after undergoing medical procedures. The study shows that EMDR Storytelling is feasible and acceptable for infants as young as four months and their parents. Four of the six infants included in the current study showed a clear reduction in PTSD symptoms over time. Results for the other two infants were contradictory. The design of the current study, and the fact that some infants already showed some improvement on the daily personalized items during baseline, limit definitive conclusions about the beneficial effects of EMDR Storytelling. Nevertheless, the preliminary results are encouraging. The current study provides initial evidence for the effectiveness of EMDR Storytelling for infants suffering from PTSD symptoms. Acknowledgments We are grateful to all the families who participated in this study. We also thank Ineke Reekers of OKL for serving as the EMDR therapist for some of the families and supporting our study, and Myrthe van den Bogaard of OKL for supporting us with data collection. Finally, we thank Iggy Kewilaa and Anjo Neervoort, interns at UvA Minds, for their contributions to the data collection process. Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: We declared that author IS is an author for an EMDR organization. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. ORCID iD Eva S. Potharst https://orcid.org/0000-0002-6401-1521 Supplementary Material Supplementary material for this article is available online. 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