EMDR With Children and Adolescents After Single-Incident Trauma

An Intervention Study
Thomas Hensel Kinder Trauma Institut, Offenburg, Germany

This study used a naturalistic design to investigate the effectiveness of eye movement desensitization and reprocessing (EMDR) with children and adolescents who were exposed to single-incident trauma. Participants were 36 children and adolescents ranging in age from 1 year 9 months to 18 years 1 month who were referred consecutively to the authors private practice. Assessments were conducted at intake, post-waitlist/pretreatment, and at follow up. EMDR treatment resulted in signicant improvement (Cohens d = 1.87). Follow-ups after 6 months revealed stable, further slight improvement. It was shown that children younger than 4 years of age can be treated using EMDR and that the group of preschool children had the same benet from the treatment as the school-age children.

Keywords: EMDR; children; adolescents; trauma; treatment outcome

ingle-incident trauma can cause deep and longlasting disruptions of psychological and social development in children and adolescents. The stress reactions make up a wide range of clinical and subclinical symptoms and syndromes, including posttraumatic stress disorder (PTSD), separation anxiety, fear of the dark, sleep disturbances, depression, regressive behavior, social behavioral problems, school and family problems, and more (Yule et al., 2000). In a review of the literature, Adler-Nevo and Manassis (2005) found 10 intervention studies that were conducted with children and adolescents after they had been exposed to a single-incident trauma. All the interventions led to a signicant reduction of posttraumatic symptoms, with trauma-focused cognitivebehavioral therapy and eye movement desensitization and reprocessing (EMDR) emerging as the most effective methods. No preschool children were treated. The present study was designed to examine the potential of short-term treatment using EMDR for children and adolescents with posttraumatic symptoms after single-incident trauma. All the participants had been referred consecutively to the present authors private practice in the years from 2002 to 2007. Of

particular interest was the question of whether it is enough for the practitioner in private practice to learn one single method (EMDR) in order to successfully treat both the entire range of posttraumatic symptoms presented by clients and all age-groups (young children to adolescents). Because of the characteristics of the sample (14 of the children were under the age of 7), it was also possible to examine whether preschool children and very young children benet from this method and whether the results with young children are comparable to the results with older children and adolescents. The EMDR procedure involves having the client concentrate on the worst moment of the trauma memory while following the therapists ngers moving back and forth across the visual eld for perhaps half a minute. Then the client is asked, What came up? or is asked what the client noticed the most. This might be increased or decreased vividness, a thought, another aspect of the memory, an emotion, or a physical sensation. For the next set of eye movements, the client is instructed to use that material as the new focus. This continues until the client reports no remaining distress related to the memory and is able to fully endorse a healthy perspective regarding it.
Journal of EMDR Practice and Research, Volume 3, Number 1, 2009
2009 EMDR International Association DOI: 10.1891/1933-3196.3.1.2

EMDR is now recognized as a standard method of treatment for adults with PTSD (Australian Centre for Posttraumatic Mental Health, 2007; Bisson & Andrew, 2007; Foa, Keane, & Friedman, 2000; National Collaborating Centre for Mental Health, 2005). Six controlled and randomized studies and one controlled study have investigated EMDR treatment of children and adolescents (Hensel, 2006). These studies show extremely high effect sizes and great cost-effectiveness, with an average treatment length of three sessions (see Table 1). Three of these studies also examined the effectiveness of EMDR for children and adolescents with single-incident trauma (Chemtob, Nakashima, & Carlson, 2002: hurricane; De Roos, Greenwald, de Jongh, & Noorthoorn, 2004: explosion of a reworks factory; Puffer, Greenwald, & Elrod, 1998: various single-incident trauma). A meta-analysis of EMDR studies found that treatment delitydoing EMDR properlyleads to better outcomes (Maxeld & Hyer, 2002). For the treatment of children, an age-modied standard protocol is used (Hensel, 2007; Tinker & Wilson, 1999). Following the principle of minimal creativity (Tinker & Wilson, 1999, p. 73), the standard adult protocol is modied only to the extent necessary.

Method
Participants The 36 children and adolescents (22 boys, 14 girls) joined the study consecutively through the years

from 2002 to 2007that is, without selectionas they came to the authors outpatient private practice for treatment of symptoms related to a single-incident trauma They ranged in age from 1 year 9 months to 18 years 1 month (M = 7.93; SD = 3.77). Treatment was discontinued for 4 of the boys (dropouts) because either the parents did not appear for the appointment or the therapy ended after the rst consultation. A total of 32 children received treatment. The average time between the traumatic event (T) and the sign-up for treatment (by telephone) (T1) was 11 months. Three children received treatment within the rst month posttrauma and 11 children within 30 to 90 days after the traumatic event. For 7 children, the traumatic event had occurred 2 to 6 years previously. None of the participating children had received previous psychotherapeutic treatment for the consequences of the single-incident trauma. Table 2 shows the different kinds of single-incident traumatic stressors that the children had been exposed to as well as the childrens symptoms. The symptoms were ascertained by the author in clinical interviews with the parents and, where possible, with the children and adolescents. The most frequent symptoms were separation fears (47%), followed by sleep disturbances (34%) and nightmares (22%). Nineteen percent of the children and adolescents developed specic phobias and intrusions (re-experiencing), 15% developed nonspecic fears, and 12.5% developed jumpiness/exaggerated startle. In the preschool-age children (ages 16), the

TABLE 1. Effect Sizes of (Randomized) Controlled Studies on EMDR With Children and Adolescents PrePost Comparison (Cohens d) n Chemtob et al. (2002) De Roos et al. (2004) Scheck, Schaeffer, and Gilette (1998) Soberman, Greenwald, and Rule (2002) Jaberghaderi, Greenwald, Rubin, Dolotabadi, and Zand (2004) Puffer et al. (1998) Total Mean 32 52 60 29 14 20 207 PTS 1.55 1.33 1.77 .92a 2.3 20 1.57 0.96 1.61 1.33 1.43a 1.39 0.97 .70a 1.04 Dep .54 1.00 1.44 Anx PreFollow-Up Comparison (Cohens d) n PTS 2.04 1.24 Dep .69 1.25 Anx 1.07 1.4 Design EMDR vs. wait list EMDR vs. CBT EMDR vs. active listening EMDR vs. standard care EMDR vs. CBT EMDR vs. wait list

.78 32 2.4 52 1.65 29

.86a

Note. Effect size is Cohens d. PTS = posttraumatic symptoms; Dep = depression; Anx = anxiety; CBT = cognitive-behavioral therapy.
a

Cohens d calculated by the present author. Modied from Hensel (2006).

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TABLE 2. Type of Single-Incident Trauma Experienced and Symptoms Developed by the Participants Age in Years, Months, and Sex 1, 9, girl 2, 5, boy 2, 9, girl 3, 1, girl 4, 11, boy 5, 2, girl 5, 6, girl 5, 9, boy 6, 0, boy 6, 2, girl 6, 4, girl 6, 4, boy 6, 5, girl 6, 6, girl 7, 3, boy 7, 3, boy 7, 10, boy 7, 11, boy 8, 2, boy 8, 7, boy 9, 3, boy 9, 3, girl 9, 5, boy 10, 2, girl 10, 5, boy 11, 6, boy 12, 1, girl 12, 7, boy 12, 9, boy 13, 11, boy 14, 1, girl 18, 1, girl Traumatic Event (T) (no. of months before start of treatment) Attempted strangulation by father (7) Fall, out of shopping cart (3) Witnessing fathers attempted murder of mother (8) Severe pseudocroup attack (life threatening) (2) Dog bite (2) Being locked in cellar (1) Break-in of the family home (1) Life-threatening dog bite on the neck (2) Car accident with family (2) One-time sexual assault by a male juvenile (2) Break-in of the family home (6) Car accident with family (38) Fire alarm at school (2) Dog bite (59) Car accident with family (2) Fire in family home (3) One-time sexual assault by a man (30) Car accident with family (2) Witnessing father severely injured in an accident (6) Car accident with family (3) Car accident with family (5) Car accident with family (11) Lightning strike in immediate proximity (5) First epileptic attack (2) Witnessing domestic violence against mother by father (32) Attack by an adult (1) Mother found unconscious (72) Seeing a motion picture of a persons head being cut off (snuff video) (4) Car accident (33) Victim of an assault by several adolescent boys (6) One-time rape (3) Witnessing death of host-father from asthma attack (24) Symptoms Separation fears, sleep disturbances, phobia of men Separation fears, sleep disorders Separation fears, phobias, jumpiness/startles easily, sleep disturbances Separation fears, sleep disturbances, nightmares, jumpiness/startles easily Phobia of dogs, nightmares Separation fears and fear of the dark, sleep disturbances Separation fears Phobia of dogs, social withdrawal, sleep disturbances, nightmares, headache and stomachache Physiological hyperarousal, fears Separation fears, nightmares Separation fears, sleep disturbances Separation fears, regressive behavior Separation fears and fear of the dark, nightmares Phobia of dogs, fears, social withdrawal Sleep disturbances, regressive behavior Intrusions, separation fears Fear of the dark, refusal to go to school, stomachache Intrusions, fears Separation fears, sleep disturbances Intrusions, fear of riding in the car Separation fears, constant worry about parents PTSD (full blown), sleep disturbances Fears, social withdrawal Separation fears, social withdrawal Aggressive behavior, nightmares Intrusions, sleep disturbances Separation fears, failure at school Intrusions, separation fears, sleep disturbances Nonspecic fears, physiological hyperarousal Psychogenic paralysis of the legs, dissociative symptoms Intrusions, nightmares, thoughts of suicide PTSD (full blown)

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main symptoms were separation fears (71.5%), sleep disturbances (43%), nightmares (35.5%), and specic phobias (355%). School-age children (age 6 and older) frequently showed specic PTSD symptoms, with only two participants meeting full diagnostic criteria. Also common were separation fears (28%) and sleep disturbances (28%). As to gender-specic symptoms, it is noticeable that separation fears were most frequent among girls (71.5%), whereas intrusions were most frequent among boys (28%). Design An extended case series design was used. After signing up for treatment, the children and adolescents were placed on a waiting list until treatment could begin. In this practice setting, ethical considerations forbid any articial lengthening of the waiting period. Once a childs treatment began, the child received as many EMDR treatment sessions as necessary until the presenting symptoms had either disappeared or were so minimal that they no longer disrupted the everyday functioning of the child and the family. This determination was made by the child (age allowing), the childs parents, and the therapist. Alternately, treatment was ended if after three EMDR sessions no improvement of the symptoms could be seen (this was the case with two children). It is the authors experience that in this circumstance further EMDR sessions are not likely to yield improvement. The data from these two children were included in the analyses. Assessment Points At four time points, the severity of the childs stress reactions was assessed by parent questionnaire, using the Parent Report of Post-Traumatic Symptoms (PROPS; Greenwald & Rubin, 1999). The time points were the following: T: Time point of the single-incident trauma (no assessment) (N = 32) T1: Sign-up for treatment (by telephone) (questionnaire, by mail) (N = 29) T2: First EMDR session (questionnaire immediately prior to the session) (N = 32) T3: 1 week after the last EMDR session (questionnaire, by mail) (N = 32) T4: Follow-up 6 months after last assessment (T3) (questionnaire, by mail) (N = 27) EMDR Treatment EMDR treatment was conducted in accordance with the age-modied standard protocol as developed by
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Tinker and Wilson (1999) and Hensel (2007), and the duration of each session was 50 minutes maximum. With preschool-age children, a parent was always present at the session to ensure that the children felt sufciently secure during the trauma confrontation. Occasionally a parent was also burdened by the traumatic eventas indicated by a score of 4 or higher on Wolpes (1990) Subjective Units of Disturbance scale, which is typically used in EMDR (where 0 = no disturbance, 10 = worse disturbance possible). In such cases, the author, as the therapist conducting the treatment, insisted that the parent be treated rst using the EMDR standard protocol. Measures For reasons of economy and in order to have standard measurement across all age-groups, the PROPS (Greenwald & Rubin, 1999) was used. The PROPS measures the parents report across a full spectrum of posttraumatic symptoms in the child; higher total scores reect more posttraumatic symptoms. The measure was translated into German by Wiedemann (2000) and validated in a community setting. Based on ve studies, Greenwald and Rubin (1999) and Greenwald et al. (2002) found good internal consistency of .92, testretest reliability of .80 (after 6 weeks) and .70 (after 6 months), criterion validity, convergent and discriminant validity, sensitivity to change, and a correlation of .85 with the Trauma Symptom Checklist for Children (Briere, 1996). The children in these studies were ages 717 in a variety of countries and settings including community samples, war refugees, and clinical populations (Greenwald, 2004). It must be mentioned that the PROPS has not yet been validated in preschool children and thus that it is not guaranteed that there is sufcient construct validity for this group (Scheeringa, Peebles, Cook, & Zeanah, 2001). However, the present study used the PROPS only to measure change in posttraumatic symptoms and not to establish a diagnosis.

Results
Of the 36 children in the sample, 32 were treated using EMDR (four children dropped out of the study). On average, three treatment sessions were conducted, with 1.5 of these being EMDR sessions. Twenty children and adolescents had one EMDR session, seven children had two EMDR sessions, and ve children had three EMDR sessions. The majority of children (25 of 27) for whom follow-up questionnaires are available beneted from the treatment. The two children who did not show improvement were young
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TABLE 3. Descriptive Statistics of the Sample and Results N Age at start of treatment Total number of sessions Number of EMDR sessions PROPS score: T1 PROPS score: T2 PROPS score: T3 PROPS score: T4 32 32 32 29 32 32 27 Minimum 1.9 1 1 21 13 2 3 Maximum 18.1 7 3 43 44 33 24 Mean 7.93 3.00 1.53 28.33 25.27 11.58 9.69 Standard Deviation 3.772 1.586 .761 6.257 7.948 6.662 6.641

FIGURE 1.

Outcomes based on posttraumatic symptoms score (PROPS).

children (one age 2 years 5 months, the other 4 years 11 months) who showed strong avoidance behavior and would not participate in the EMDR procedure; treatment was discontinued after three sessions. In the case of eight children, a parent was treated successfully using EMDR prior to treatment of the child; this group did not differ from the other children in the results. Table 3 provides a summary of the sample and the results. The average interval between the traumatic event (T) and sign-up for treatment by telephone (T1) was approximately 330 days and between T1 and T2 (waiting period) 34 days. The average time between T2 and T3 was 23 days and between T3 and T4 (follow-up questionnaire) 181 days. Figure 1 shows the results. The effect sizes (Cohens d) were .43 for the wait-list condition (WL: T1T2), 1.87 for the treatment condition (TG: T2T3), and 2.13 for follow-up (F-U: T2T4). Effect sizes (Cohens d) of 0.8 and higher are considered indicative of a large effect size
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that would be clinically signicant. This means that the ndings points to an extremely strong treatment effect. The Wilcoxon matched-pairs signed-rank test (nonparametric) was used to determine the signicance of the differences between the groups because of the small number of participants, sample dependence, and the uncertainty of data normality. It revealed signicant improvement during the waiting period (WL: T1T2), (p = .001). Following treatment (TG: T2T3), there was also a signicant reduction of the symptoms (p < .001), with the improvement being considerably greater than during the waiting period. The followup scores at 6 months showed a maintenance of treatment effects with no signicant differences from the posttreatment scores (F-U: T3T4) (p = .94). Correlations between different variables were calculated using rank-order correlation coefcients (Spearmans rho). The following associations were signicant (see Table 4):
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TABLE 4. Signicant Correlations Between Variables (with two-tailed signicance) Length of Time Change in Between PTS: T2T3 Trauma and T1 Age at T2 Change in PTS: T2T3 PTS at T2 rs = .644 (p < .001) rs = .359 (p = .044) rs = .420 (p = .017) rs = .404 (p = .022)

Note. PTS = posttraumatic symptoms measured on the PROPS.

With increasing age (measured at T2), the children beneted more from the treatment (rs = .40; p = .022), although the older children, or adolescents, had not shown more severe symptoms. Despite this association, there was no signicant difference in treatment success between the group of preschool children (age 6 and younger) (N = 14) and the group of school-age children (older than age 6) (N = 18) (MannWhitney U test). The higher the score for posttraumatic symptoms (PROPS) at the start of treatment (T2), the greater the reduction of symptoms was (rs = .64; p < .001). The longer the time period between the traumatic event and sign-up for treatment (TT1), the more that the children beneted from treatment (rs = .359; p = .044). Posttraumatic symptoms scores (PROPS) at the start of treatment (T2) were higher in children who had been exposed to the traumatic event a longer time ago (TT1) (rs = .42; p = .017).

Discussion
This intervention study examined the effectiveness of trauma-focused treatment under the naturalistic conditions of a private practice setting in Germany. EMDR was provided to children and adolescents who presented with posttraumatic symptoms after having been exposed to a single-incident trauma. There was no selection of the study participants; all 36 children and adolescents who signed up at the practice between 2002 and 2007 for treatment of posttraumatic symptoms took part in the study (four children dropped out prior to beginning treatment). The results showed signicant and large treatment effects, indicating substantial benets from treatment. Only two children were unable to take part in the EMDR procedure and did not show improvement. An effect size of 1.87 (Cohens d) provides evidence of the treatments effectiveness, and the rapidity of the treatment indicates impressive
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efciency as well. The treatment effects were maintained at 6-month follow-up with a slight but not statistically signicant improvement in outcome. During the waiting period before treatment, the trauma symptoms had already improved slightly but signicantly. This agrees with the ndings of other studies (Van der Kolk et al., 2007). As only 3 of the 32 participants signed up for and received treatment within 1 month after the single-incident trauma, the natural remission of symptoms due to trauma in the rst month after the event cannot be a signicant factor in the improvement. The duration of treatment was on average three 50-minute sessions. The present study thus replicates earlier ndings on the use of EMDR with children and adolescents exposed to single-incident trauma. Although the older children and adolescents did not show initial higher posttraumatic symptoms scores (PROPS), they beneted more from the treatment than younger children. It is possible that greater awareness and more stable cooperation on the part of young people contribute to a better result. We know from the research on confrontation therapy for anxiety disorders that a conscious decision and stable motivation for the confrontation is an important factor in the success of the therapy (Berking, Egenolf, & Grawe, 2006). Participants who had been exposed to single-incident trauma longer agothat is, children who had remained without treatment for a longer period of timeshowed more intensive posttraumatic symptoms but also proted more from the treatment. The study showed that age-modied EMDR can be used with preschool-age children (N = 14) successfully and just as effectively as with school-age children. There have been previous case reports of the use of EMDR with preschool-age children (Greenwald, 1994; Robbins, 2000). In the present study, three of four children who were younger than 4 years of age were treated successfully. EMDR thus extends the range of treatment options for traumatized children and adolescents. Based on the authors experiences, young children from age 1 as well as children with mental and physical impairments can benet from EMDR. One of the participants in the study was a boy with autism, for example. It is noteworthy that EMDR was effective in treating posttraumatic symptoms, even though only 2 of the 32 participants presented with full-blown PTSD and a minority of the children showed classical PTSD symptoms. This nding agrees with the results of Ackerman, Newton, McPherson, Jones, and Dykman (1998). There are concerns that the diagnostic criteria
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do not appear to be sufciently age sensitive, especially for preschool-age children (Scheeringa et al., 2001). Research has also shown that children with subclinical PTSD do not differ in trauma-related distress from children with full-blown PTSD (Carrion, Weems, Ray, & Reiss, 2002). Consequently, we can only agree with the American Academy of Child and Adolescent Psychiatry (1998) when it concludes, A reasonable practice parameter in this regard is to offer treatment to children with clinically signicant PTSD symptoms (i.e., severe enough to impair functioning in at least one important domain), whether or not they meet strict DSM-IV PTSD diagnostic criteria (p. S20). Further, the current study shows that following exposure to traumatic events, it makes sense and is promising to focus on the processing of the event rather than to focus in a symptom-oriented way on the fears, sleep disturbances, and so on. The treatment of the traumatic memory with EMDR was sufcient to alleviate these types of symptoms without directly addressing them. The limitations of the study are the small number of participants, the lack of a randomized control group, and the minimal diagnostics. The entire study was conducted by only one person (the author). Treatment delity was likely, given the authors experience as a professional association-approved trainer for EMDR with children and adolescents and as the author of a child EMDR treatment manual (Hensel, 2007). There was no blinded evaluation. Despite these limitations, which are unavoidable in the context of the naturalistic setting of a therapists private practice, this study supports prior ndings showing that EMDR is an effective and efcient method of treatment for children and adolescents with posttraumatic symptoms. The study indicates that EMDR can also be used successfully with very young children. More rigorous research studies are needed to further evaluate these applications.

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Stress Studies, Baltimore. Retrieved March 29, 2008, from http://www.childtrauma.com/postrops.html Hensel, T. (2006). Effektivitt von EMDR bei psychisch traumatisierten Kindern und Jugendlichen [Effectiveness of EMDR for traumatized children and adolescents]. Kindheit und Entwicklung, 15(2), 107117. Hensel, T. (Ed.). (2007). EMDR mit Kindern und Jugendlichen: Ein Handbuch [EMDR for children and adolescents: A manual]. Gttingen: Hogrefe. Jaberghaderi, N., Greenwald, R., Rubin, A., Dolotabadi, S., & Zand, S. O. (2004). A comparison of CBT and EMDR for sexually abused Iranian girls. Clinical Psychology and Psychotherapy, 11, 358368. Maxeld, L., & Hyer, L. (2002). The relationship between efcacy and methodology in studies investigating EMDR treatment of PTSD. Journal of Clinical Psychology, 58(1), 2341. National Collaborating Centre for Mental Health. (2005). Post-traumatic stress disorder: The management of PTSD in adults and children in primary and secondary care. National Clinical Guideline 26. London: Gaskell and the British Psychological Society. Retrieved March 29, 2008, from http://www.nice.org.uk/guidance/index. jsp?action=download&o=29770 Puffer, M. K., Greenwald, R., & Elrod, D. E. (1998). A single-session study of EMDR with children and adolescents distressed by a traumatic memory. Traumatology, 3(2), Article 6. Retrieved March 29, 2008, from http:// www.fsu.edu/~trauma/v3i2art6.html Robbins, J. (2000, December). Brief trauma treatment of a toddler using EMDR. EMDRIA Newsletter: Special Edition, 2527. Scheck, M. M., Schaeffer, J. A., & Gilette, C. (1998). Brief psychological intervention with traumatized young women: The efcacy of eye movement desensitiza-

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