Two Recently Published Studies on Children and Adolescents

EMDR therapy is an effective and safe treatment for many psychiatric disorders, particularly PTSD. Because of ethical and other limitations on psychiatric treatment research, studies involving children generally follow studies involving adults. Accordingly, we can say that the literature on EMDR in children also lags behind the adult literature. The role of EMDR in treating mental disorders in children has not yet been fully established in clinical guidelines. This makes EMDR studies involving children all the more important. In recognition of this importance, we wanted to summarize two recently published studies on EMDR and children, translated by psychologist Derin Kubilay.

 

 

EMDR and Children
 

1.    The Effectiveness of the EMDR Group Protocol for Children in Reducing PTSD Symptoms in Refugee Children

 

Introduction

Since the Syrian Civil War began in 2011, millions of Syrians have crossed the Turkish border in an effort to protect themselves and their families from the effects of war. As a result, 1.9 million Syrian adults and 1.6 million children under the age of 17 have settled in Turkey under the Temporary Protection Regulation. Although their basic needs were met under this protection, many refugees developed mental disorders as a result of the traumatic events they experienced during the war.

In response to this growing need, the Disaster and Emergency Management Authority (AFAD) provided psychosocial support to refugee communities, prioritizing refugee camps. Various intergovernmental organizations, such as UNHCR, established psychosocial rehabilitation centers in these camps. However, the vast majority of Syrian refugees living outside the camps faced numerous difficulties in accessing services in urban areas. This system reached an impasse because of the continuous flow of migrants into metropolitan areas and the difficulty of developing long-term healthcare policies for refugees with temporary status. In addition, local municipalities and public authorities responsible for ensuring urban refugees' access to healthcare services encountered various legal, political, and financial barriers.

In an exceptional case, local public authorities endorsed and supported PTSD treatment for Syrian children in Istanbul. A decision was made to provide group therapy to a large number of potentially traumatized Syrian children. In addition, changes in these children's levels of major depression and well-being were assessed for analysis. This study reports the results of the work conducted by Istanbul's Maltepe district, which led the project.

The Mental Health of Refugee Children Affected by Armed Conflict

Studies investigating war-related PTSD symptoms have shown that the emotional suffering caused by the Syrian Civil War also affects children. Recent studies have observed anxiety symptoms in half of Syrian children, and both depression and anxiety symptoms in one-third of the remaining children. Syrian refugee children also exhibit high levels of PTSD symptoms alongside depression and anxiety. Interestingly, not only Syrian refugee children but also their Turkish peers living near the Syrian border suffer from moderate to severe PTSD symptoms.

In refugees exposed to daily stressors and trauma, untreated mental disorders become chronic. From a broader perspective, Syrian children's well-being is undermined by past traumatic events, such as death threats, torture, hunger, serious injuries, harm to family members, death, or permanent disappearance. It is therefore very important to take a holistic approach to the mental health of Syrian refugee children and examine the determinants of their depression and psychosocial well-being.

EMDR Treatment

According to the Adaptive Information Processing (AIP) model, the human brain generally processes information in an adaptive way. However, traumatic or life-threatening events can disrupt the information processing system, leading to traumatic experiences being stored as unprocessed memories. As a result, these stored memories become associated with certain bodily sensations, negative emotions, and beliefs. EMDR helps people process their traumatic memories and neutralize their negative aspects. When the therapist provides bilateral stimulation through eye movements, the client can access these memories through images, cognitions, emotions, and bodily sensations.

EMDR therapy has also demonstrated effectiveness in children who have experienced trauma. Children understand the world differently at different ages, and trauma can therefore have different effects on traumatized children depending on their age. Psychological interventions must consequently be tailored to children's developmental levels. For this reason, the “Developmental EMDR” protocol is used with children and adolescents.

EMDR Group Protocol with Children (EMDR-GP/C)

Providing individual EMDR therapy may not be practical in disaster settings. When many people are affected by a disaster, group interventions are known to be much more effective and economical. The EMDR Group Protocol with Children was developed after the Marmara Earthquake in 1999. EMDR-GP/C was provided to many traumatized children who could not access individual therapy. Since then, EMDR-GP/C has been modified for use with specific disasters and different populations. EMDR-GP/C differs from EMDR-IGTP (EMDR Integrative Group Treatment Protocol): although both have eight phases, the content of the preparation, desensitization, and installation phases differs. Trauma-specific stories are used to strengthen the emotional, sensory, and verbal aspects of memories, because verbal expression and interpretation are inhibited when a traumatic memory is experienced.

The eight phases of EMDR-GP/C:

1. Introduction: Explaining the nature of trauma, group rules, name tags, and the rationale for completing the scales


2. Preparation: Understanding the children's support systems; explaining EMDR, the safe place, the resource exercise, and installation with BLS (bilateral stimulation)


3. Assessment: Drawing the worst image on a small section of the paper and measuring the SUD level (subjective units of distress, including distressing emotions, bodily sensations, etc.)


4. Desensitization: Drawings are made on four separate sheets of paper with bilateral stimulation (butterfly hug or knee tapping). When necessary, processing can continue with a fifth and sixth drawing.


5. Installation: Installation is carried out using a healing story written according to the Information Processing Model, together with bilateral stimulation.


6. Body scan: A positive bodily state is installed using a relaxation technique.


7. Closure and future template: A strong sense of closure is achieved through artwork.


8. Reevaluation: Conducted if possible.

Through these components, EMDR-GP/C helps clients integrate and reconsolidate their traumatic memories. It also gives adaptive meaning to the traumatic event.

Aim of This Study

Considering the high mobility of refugee communities in urban areas and the difficulty of allocating limited financial resources to mental health services for refugee children, we show that EMDR-GP/C offers a cost-effective and rapid approach to addressing PTSD symptoms in refugee children.

A randomized controlled trial was therefore planned to deliver EMDR-GP/C to 121 refugee children exhibiting moderate to severe PTSD symptoms. More broadly, the effectiveness of EMDR-GP/C in reducing depression levels and improving well-being was investigated. Three hypotheses were proposed in this study:

1. EMDR-GP/C may be an effective treatment for reducing PTSD symptoms in Syrian refugee children.


2. EMDR-GP/C may improve the well-being of Syrian refugee children.


3. EMDR-GP/C may be effective in reducing levels of major depression in Syrian refugee children.

Method

A total of 121 Syrian refugee children aged 6–15 who exhibited PTSD symptoms participated in this study. Only those with war-related trauma and symptoms lasting longer than six months were included. These children were reported to meet the diagnostic criteria for PTSD.

In Syria, there is a cultural stigma that only “crazy” people receive psychosocial support. A PTSD diagnosis therefore brings fears of exclusion from Syrian refugee groups and transfer to a hospital. To overcome this cultural barrier, information sheets were prepared in both Arabic and Turkish and distributed during visits to refugee families and their Turkish neighbors. Informational talks were held at schools to encourage parents of Syrian children to seek mental health support for their children as quickly as possible. A 24/7 hotline was established, and families were told they could call if they wanted more information about the project. Following the withdrawal of some participants, 94 participants ultimately continued in the project.

Measures

The 94 participants were randomly assigned to the EMDR and control groups. Nevertheless, there was a high dropout rate in the control group because no intervention was initially provided to that group. This study used the “Child Posttraumatic Stress Reaction Index (CPTS-RI), α=.86” to measure the severity of traumatic memories, the “World Health Organisation (WHO)-5 Well-Being Index, α=.78” to examine subjective well-being, and the “Major Depression Inventory (MDI), α=.87” to assess depressive symptoms. Validity and reliability were assessed through “data accuracy,” “diagnostic reliability,” and “cognitive validity.”

Intervention

The EMDR-GP/C protocol includes the standard eight phases and focuses on a group therapy model. The SUD scale is administered to track progress across sessions. Clients rate their negative emotions from 1 to 10. A decrease in SUD scores indicates relaxation by the end of the sessions. An average session lasts 90–120 minutes.

Data Analysis

In the between-group design, baseline scores and demographic data were analyzed using t-tests. Pretreatment scores were controlled for, and between-group differences were analyzed using ANCOVA.

Results

The vast majority of these children were boys, and a large proportion had lost a family member in the Syrian Civil War. Pretest scores did not differ significantly between the EMDR and control groups. However, PTSD symptoms decreased in the EMDR-GP/C treatment group relative to the control group. EMDR therapy also had a significant effect on well-being scores and depression levels. The passage of time itself reduced the severity of PTSD symptoms. EMDR therapy was found to produce significant improvement in PTSD symptoms between the pretest and posttest.

Discussion

The aim of this study was to evaluate the effect of EMDR-GP/C on PTSD in Syrian refugee children. The first hypothesis examined the therapeutic effect of EMDR-GP/C on PTSD symptoms. The second and third hypotheses investigated the potential positive effects of the EMDR-GP/C intervention on well-being and depression. To our knowledge, this is the first study to assess the effectiveness of EMDR group therapy delivered to refugee children living in an urban area.

In terms of practical application, this study serves as an example by offering local municipalities and public authorities an EMDR-GP/C group protocol that they can use with refugee children in their areas. There were statistically significant improvements in PTSD symptoms, depressive symptoms, and well-being levels. All research hypotheses were therefore supported, demonstrating the effectiveness of EMDR-GP/C.

Many refugee children are capable of processing their trauma and confronting distressing thoughts by expressing them in drawings. When children repeatedly look at negative pictures they have drawn previously, trauma processing may be impeded. A separate sheet should therefore be used for each drawing to allow trauma processing to continue. Initial drawings generally featured themes such as tanks destroying villages, planes bombing buildings, injured or dead people, and gloomy weather. Toward the final sessions, however, these themes were observed to change to smiling animals, children playing in the street, and sunny weather.

The trauma-specific EMDR-GP/C intervention was therefore found to help children process trauma. Installing resources before moving on to trauma processing was very helpful. Second, incorporating a healing story into EMDR-GP/C was highly useful. This reduced SUD scores and fostered hope for the future and positive emotions. The story incorporates traumatic events, beginning with positive emotions, then moving through negative feelings and sensations, and finally closing with positive emotions and hopeful statements. It also aims to consolidate memories that have not been verbalized. While drawing during the desensitization phase activates implicit memory, the healing story activates verbal memory. Some children had difficulty performing the butterfly hug as a relaxation exercise. Bilateral stimulation was therefore provided through knee tapping, which offered an alternative rhythm compatible with Eastern culture.

Finally, preparing a manual before fieldwork is very important because it facilitates access to information and standardizes the therapy format for all therapists. This manual includes information on trauma, population characteristics, self-protection methods, precautions during intervention, emergency contacts and locations, assessment scales, detailed information on EMDR-GP/C, documentation templates, and resources. Developing a structured intervention plan can therefore make it possible to turn the chaotic atmosphere of a trauma setting into a context for successful treatment.

Conclusion

This study shows that EMDR-GP/C is not only effective in helping refugee children recover from community-level trauma, but also practical, economical, and feasible within a short period. Given the effectiveness of group therapy, it is clear that this approach can be implemented in metropolitan areas where refugees live, through local municipalities and district governorates. For example, refugee policies incorporating EMDR-GP/C would help reach these children and families. Community-based organizations and nongovernmental organizations can improve life satisfaction among refugee children with depressive symptoms by integrating EMDR-GP/C into social support services.

REFERENCE

Banoğlu, K., & Korkmazlar, Ü. (2022). Efficacy of the eye movement desensitization and reprocessing group protocol with children in reducing posttraumatic stress disorder in refugee children. European Journal of Trauma & Dissociation, 6(1), 100241.

 

 

 

 

 

 

1. EMDR in Young Children (Ages 4–8) with Posttraumatic Stress Disorder: A Multiple-Baseline Design

Introduction

Young children exposed to traumatic events are at high risk of developing PTSD as well as many other psychological problems. Compared with other age groups, preschool-aged children have a notably high rate of maltreatment, neglect, and physical and sexual abuse. In addition, young children are more vulnerable to the adverse consequences of traumatic events because they have limited coping skills and depend on their caregivers for protection and emotional support.

Furthermore, exposure to trauma during this critical stage of brain development may have irreversible consequences for the neurophysiological regulatory system. If PTSD is not treated during this period, the disorder may follow a chronic course. In particular, an initial PTSD diagnosis has been found to predict the same diagnosis three years later. Psychological distress in childhood has also been found to be significantly associated with psychological disorders in adulthood, such as mood disorders, anxiety, and substance dependence. Early and effective treatment is essential to reduce the long-term effects of trauma and PTSD.

Unfortunately, the literature contains very few studies on effective treatments for PTSD and traumatic symptoms in early childhood. The two generally recommended psychotherapeutic approaches are trauma-focused cognitive behavioral therapy and EMDR. In EMDR, clients are asked to hold a distressing image related to their traumatic memories in mind while making saccadic eye movements. Given the very limited number of studies using EMDR as an intervention for young children, this study can be said to make a valuable contribution to the literature by demonstrating that EMDR may be an effective approach.

This study targeted children aged 4–8 and used a multiple-baseline experimental design. This allowed an initial evaluation of treatment for a specific group and enabled analysis of both the intervention process and its outcomes. Two PTSD-related symptoms were measured daily for each child using a diary method, providing rich data to help caregivers gain insight into their children. Assessments were thus sent at pretest, posttest and three-month follow-up. A significant decrease in PTSD symptoms was expected, and the aim was for children to show no PTSD symptoms according to DSM-5 criteria after EMDR therapy. Reductions in emotional and behavioral problems were also expected.

Method

Nine participants took part in the study. Participants were assigned to three EMDR therapists. Inclusion criteria were being aged 4–8, meeting DSM-5 criteria for PTSD, and receiving no other treatment during the study.

Study Design

Two different series of assessments were conducted:

1. At three time points (pretest, posttest, and three-month follow-up), PTSD diagnostic status was assessed using semistructured diagnostic interviews, while emotional and behavioral problems were measured using standardized questionnaires.


2. A nonconcurrent multiple-baseline experimental design used daily measurements to assess the child's two PTSD symptoms as reported by the primary caregiver.

The nonconcurrent multiple-baseline experimental design uses the RoBiNT scale, which evaluates the internal and external validity of single-case research designs. Participants' caregivers completed daily measurements during the no-intervention phase (phase A), during the intervention (phase B), and at three-month follow-up (phase FU). Randomized replication of the experiment strengthened the design by separating the effects of time from those of the intervention. Baseline duration ranged from 10 to 24 days across participants. The minimum baseline of 10 days was chosen to observe individual differences before the intervention began.

Intervention

EMDR is a brief, trauma-focused intervention for PTSD and trauma-related symptoms. It follows Shapiro's standard eight-phase protocol, adapted to the relevant age group. These phases comprise client history, treatment planning and preparation, assessment, desensitization, installation of positive cognitions, scanning for distressing bodily sensations, positive closure, and reevaluation.

If a child was exposed to traumatic events before the age of four, a combined EMDR procedure is used. This involves following the standard protocol with the EMDR storytelling method to enhance the treatment effect. Participants receive six weekly treatment sessions lasting one hour each. Parents of children aged 4–6 remain in the treatment room throughout the session as both informants and observers to support their children. Parents of children aged 6–8 are present at the beginning and end of each session to inform the therapist about their child's functioning over the previous week. At the end of each session, the therapist updates the parents on the session's progress.

Measures

The Diagnostic Infant and Preschool Assessment (DIPA) is a semistructured diagnostic interview conducted with caregivers of children aged 2–8. Daily Measures of the Two Main PTSD Symptoms tracks how and when treatment changes PTSD symptoms; the primary caregiver reports daily on the child's two selected PTSD symptoms. The Trauma Symptom Checklist for Young Children (TSCYC) is a questionnaire for caregivers of children aged 3–12 that assesses PTSD symptoms and related emotional and behavioral problems. Finally, the Strengths and Difficulties Questionnaire for Parents (SDQ‑P) is a behavioral screening questionnaire examining the behavior, emotions, and relationships of children aged 4–17.

Procedure

Caregivers of children aged 4–8 who had experienced one or more traumatic events and exhibited PTSD symptoms were informed about the study. Caregivers who agreed to participate and completed the informed consent form were administered the DIPA to assess whether their child met the inclusion criteria. A pretest was then conducted, two PTSD symptoms were identified, and a diary app was installed on the caregiver's phone. The caregiver began daily measurements on the day of the pretest and continued every day until one week after EMDR therapy ended. Posttest assessments (DIPA, TSCYC, SDQ) were conducted one week after the sixth session. Three months after treatment, the caregiver completed the diary for another 10 days, and the DIPA interview and questionnaires were administered again.

Statistical Analysis

Randomization tests were conducted for each client's main symptoms to analyze the diary data. To examine the long-term effects of EMDR, randomization tests comparing baseline with the three-month follow-up were performed.

Findings

At the end of treatment, seven of eight participants no longer exhibited PTSD symptoms, indicating an 85.7% recovery rate. Comparisons between the baseline and treatment phases (N = 9) revealed small (SMD > 0.2), medium (SMD > 0.5), and large effects (SMD > 0.8). In summary, diary data showed overall reductions in the two identified PTSD symptoms, anxiety levels, depression scores, and anger during therapy and at the three-month follow-up. All participants' emotionally charged traumatic memories were processed across the sessions. All caregivers reported satisfaction with EMDR therapy.

Discussion

The aim of this study was to demonstrate that EMDR is an effective treatment for children aged 4–8 who exhibit PTSD symptoms. The results showed an 85.7% improvement in PTSD symptoms with EMDR. Parent-reported PTSD symptoms and associated anxiety, depression, and anger also decreased. Most importantly, treatment gains were maintained at the three-month follow-up. Considering that all children were suffering as a result of multiple or chronic traumatic events, brief, six-session EMDR therapy can successfully reduce symptoms even in children with the most severe traumatic symptoms.

The effects measured through daily assessments were not statistically significant at the individual level. This was due to the low statistical power of single-case studies with an A–B phase design and the considerable differences between individuals. The unexpectedly high variance may be attributable to the types of PTSD symptoms assessed. Many parents identified temper outbursts and sleep disturbances as the main PTSD symptoms. The selection of these two symptoms is particularly understandable given their impact on daily life. However, the fact that both symptoms are common responses to minor stressors in young children and part of their normal emotional development may explain this finding. Variance was therefore to be expected. A diary covering a broader range of PTSD symptoms or a brief PTSD inventory may be more sensitive to young children's emotional states. In addition, emotional and behavioral problems decreased substantially.

One strength of this study was that PTSD symptoms were measured at different phases using multiple methods, including a diagnostic interview, standardized questionnaires, and individualized daily measures. This provided insight into how these symptoms change in everyday life. Second, replicating the multiple-baseline experimental design nine times helped establish whether changes in symptoms were actually attributable to treatment. Finally, treatment was delivered according to a manual, and therapists received supervision to enhance treatment effectiveness. However, limitations such as the absence of an active control condition, the lack of examination of placebo effects, caregivers' inability to act as independent assessors, and the small sample size substantially affected the generalizability of the study. Recommendations included conducting this study with younger children (aged 1.5–4) and with a broader age range (1.5–8). Future studies could assess the benefits of EMDR therapy for children with specific traumatic experiences. In conclusion, this study showed that EMDR is a feasible, effective, and brief treatment for children aged 4–8 who exhibit PTSD symptoms.

Participant	Sex	Age	Trauma type	Frequency (Duration)
1	Male	4,5	Medical trauma	Multiple (2.0-3.6)
2	Male	5,1	Domestic violence	Chronic (prenatal -4.1)
3	Male	5,3	Medical trauma	Multiple (0-4)
4	Female	7,5	Domestic violence	Multiple (0-4)
5	Male	5,4	Medical trauma, Domestic violence	Multiple (prenatal -4.6)
6	Female	6	Domestic violence	Chronic (0.3-5.6)
7	Female	7,9	Traumatic grief following a sibling's death	Multiple (7.6-7.7)
8	Male	5,5	Medical trauma, Domestic violence	Chronic (prenatal - 5.1)
9	Female	5,11	Domestic violence	Multiple (0 - 5.4)

 

 

REFERENCE: Olivier, E., de Roos, C., & Bexkens, A. (2021). Eye Movement Desensitization and Reprocessing in Young Children (Ages 4–8) with Posttraumatic Stress Disorder: A Multiple-Baseline Evaluation. Child Psychiatry & Human Development, 1-14.