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Practice Profile

Eye Movement Desensitization and Reprocessing (EMDR) for Children with PTSD

Evidence Ratings for Outcomes:

Promising - More than one Meta-Analysis Mental Health & Behavioral Health - Trauma/PTSD
No Effects - One Meta-Analysis Mental Health & Behavioral Health - Internalizing behavior
No Effects - One Meta-Analysis Mental Health & Behavioral Health - Anxiety Disorders

Practice Description

Practice Goals/Target Population
Eye Movement Desensitization and Reprocessing (EMDR) is a treatment intended to reduce symptoms of posttraumatic stress in children (ages 4 to 18) who have been diagnosed with posttraumatic stress disorder (PTSD).
 
Practice Components
EMDR involves using a standardized protocol consisting of a structured 8 phased sequence. During (1) history taking and (2) preparation, the therapist takes the child’s history, plans treatment, and explains EMDR. The therapist then asks the child to focus on the traumatic memory by means of direct questioning; asks the child for a negative, dysfunctional cognition (thought) related to the traumatic memory; and to also create a positive, functional thought. Attention is given to the emotion connected to the memory and dysfunctional thought.
 
During (3) assessment, the child is asked to find places on his or her body where the physical phenomena are felt. During (4) desensitization, the child is asked to focus on the traumatic memory and its associated dysfunctional cognition, emotion, and the physical sensations while the therapist tries to stimulate eye movement by, for example, moving a hand slowly back and forth in front of the child’s face. Alternatively, for younger children, the therapist might tap on the child’s hand. Each new connected association with the traumatic memory is followed by a new series of stimuli. The level of disturbance is repeatedly measured on a 10-point Likert scale, the Subjective Units of Disturbance (SUD), until the level decreases to zero.
 
During (5) installation, the therapist seeks to connect the child’s traumatic memory with his or her earlier formulated positive, functional cognition while conducting new sets of stimuli; this is measured on a 7-point Likert scale, the Validity of Cognition (VOC). The therapist repeats this procedure until the child assigns a 7 to the positive cognition.

During (6) body scan, the therapist checks whether physical sensations are still present, and then engages in (7) positive closure and (8) re-evaluation. The number of sessions required varies according to the type of traumatic event and severity of the client’s symptoms (Rodenburg 2009).
 
Practice Theory
EMDR is based on the adaptive information processing (AIP) model. The model posits that health is supported by positive and successful experiences and that the brain is equipped to process adversity. However, when a traumatic or negative event occurs, information processing may be disrupted. This prevents forging connections with adaptive information that is held in memory networks. The memory is then dysfunctionally stored without appropriate associative connections and with many elements still unprocessed (EMDR Institute, Inc. 2017). EMDR treatment induces a physiological condition in which unprocessed memories of traumatic experiences become linked with already established networks such as healthy processed memories. 

Meta-Analysis Outcomes

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Promising - More than one Meta-Analysis Mental Health & Behavioral Health - Trauma/PTSD
Aggregating the results from seven studies, Rodenburg and colleagues (2009) found that Eye Movement Desensitization and Reprocessing (EMDR) treatment had a statistically significant effect on children’s trauma status at posttest, compared with a control group who did not receive EMDR. The overall mean effect size was 0.56, suggesting that the treatment had a positive, medium effect on children who have experienced trauma. Conversely, The Washington State Institute for Public Policy (2016), using four studies in their analysis, found an overall mean effect of -0.78 for posttraumatic stress. This finding however was not statistically significant at posttest, compared with the control group.
No Effects - One Meta-Analysis Mental Health & Behavioral Health - Internalizing behavior
The Washington State Institute for Public Policy (2016), using three studies in their analysis, found that EMDR treatment did not have a statistically significant effect on measures of children’s major depressive disorders at posttest, compared with a control group who did not receive EMDR.
No Effects - One Meta-Analysis Mental Health & Behavioral Health - Anxiety Disorders
The Washington State Institute for Public Policy (2016), using two studies in their analysis, found that EMDR treatment did not have a statistically significant effect on measures of children’s anxiety disorders at posttest, compared with a control group who did not receive EMDR.
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Meta-Analysis Methodology

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Meta-Analysis Snapshot
 Literature Coverage DatesNumber of StudiesNumber of Study Participants
Meta-Analysis 12001 - 20087209
Meta-Analysis 22001 - 20105306

Meta-Analysis 1
Rodenburg and colleagues (2009) reviewed studies that examined the effect of Eye Movement Desensitization and Reprocessing (EMDR) on posttraumatic stress disorder (PTSD) symptoms in children. They performed a keyword search of electronic databases after which they applied the ancestry method in locating studies referenced in the articles from the initial search. Authors, investigators, and clinicians were contacted as needed to clarify statistical and design questions. Study eligibility included 1) presence of a comparison group, 2) child participants who had been treated for posttraumatic stress reactions, 3) random assignment of children to the treatment group and comparison group, 4) participants who were 18 years or younger, and 5) the availability of posttreatment trauma scores.

Seven studies were included in the review. All seven studies were published between 2001 and 2008. In total, the studies reported on 109 children treated with EMDR and 100 children in the comparison group, with an age range of 4 to18 years. All studies measured posttraumatic stress reactions in some way.
 
The scales that were most frequently used to measure PTSD symptoms were the Children’s Reaction Inventory (CRI), Child Report of Post-Traumatic Symptoms (CROPS), Impact of Events Scale (IES), and the Parent Report of Posttraumatic Symptoms (PROPS). One study (Rubin et al. 2001) used the Child Behavior Checklist (CBCL) to measure child-internalizing problems (depression and anxiety, withdrawal, and somatic complaints). While this measure was not specifically developed to measure traumatic stress reactions, it was included in the analysis. Excluded for trauma measurement were scores on the Subjective Unit of Disturbance (SUD) and on the Validity of Cognition (VOC) Scale, because those measurements are highly vulnerable to demand characteristics (Acierno et al.1994).

The effect size metric was calculated using Cohen’s d, and the overall mean effect size was calculated using a fixed effects model. Across the seven studies, children in the control groups were 1) on the wait list for treatment, 2) received treatment as usual, or 3) received cognitive–behavioral treatment. 

Meta-Analysis 2
The Washington State Institute for Public Policy (2016) performed a multivariate meta-regression analysis of studies that evaluated cognitive–behavioral therapy for depression and anxiety. The authors used four primary search procedures to locate studies including 1) an examination of bibliographies of systematic and narrative reviews; 2) a review of citations in the individual studies; 3) independent literature searches of research databases using search engines such as Google, ProQuest, EBSCO, ERIC, PubMed, and SAGE; and 4) contacting authors of primary research to learn about ongoing or unpublished evaluation work. The most important criteria for inclusion was the presence of a control or comparison group or use of advanced statistical methods to control for unobserved variables or reverse causality. 

Five studies were included in the meta-analyses. All studies were published between 2001 and 2010. A total of 306 children were included in the analysis across all studies, with ages ranging from 6 to 15 years old, with an average age of 10 years.  The studies took place in Australia, the United Kingdom, and the United States. The studies measured at least 1 of the following three outcomes: post-traumatic stress, major depressive disorder, or anxiety disorder.  No information is reported about the specific scales used.
An effect size was calculated for each program effect. For continuously measured outcomes, effect size is calculated with a Cohen’s d effect size and a Base variable, which is measured as a standard deviation of the outcome measurement. For dichotomously measured outcomes, effect size is calculated with a D-cox effect size and a Base variable, which is measured as a percentage. Once effect sizes are calculated, the individual measures were summed to produce a weighted average effect size. The inverse variance weight was calculated for each program effect, and these weights were used to compute the average.
 
Some studies included in the analysis had small sample sizes, which have been shown to upwardly bias effect sizes, especially when samples are less than 20. The Hedges correction factor was used to adjust all mean-difference effect sizes, (where N is the total sample size of the combined treatment and comparison groups). 
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Cost

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As of 2009, the treatment cost $886 annually in the state of Washington. This amount was calculated from the weighted average cost from the studies used in the analysis, and based on the average number of hours of therapy reported in the studies multiplied by the average regional support networks’ costs for individual therapy for children with posttraumatic stress disorder (Washington State Institute for Public Policy 2016).
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Evidence-Base (Meta-Analyses Reviewed)

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These sources were used in the development of the practice profile:

Meta-Analysis 1
Rodenburg, Roos, Anja Benjamin, Carlijn de Roos, Ann Marie Meijer, and Geert Jan Stams. 2009. “Efficacy of EMDR in Children: A Meta-Analysis.” Clinical Psychology Review 29:599–606.  


Meta-Analysis 2
Washington State Institute for Public Policy. 2016. Eye Movement Desensitization and Reprocessing (EMDR) for Child Trauma. Olympia, Wash.: Washington State Institute for Public Policy. 
http://www.wsipp.wa.gov/ReportFile/1468
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Additional References

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These sources were used in the development of the practice profile:

Acierno, Ron, Michel Hersen, Vincent B. Van Hasselt, Geoffrey Tremont, and K. Meuser, K. 1994. “Review of the Validation and Dissemination of Eye-Movement Desensitization and Reprocessing: A Scientific and Ethical Dilemma.” Clinical Psychology Review 14(4):287−99.


EMDR Institute, Inc. “Theory.”  Accessed November, 1, 2017.

http://www.emdr.com/theory/

Rubin, Allen, Sharon Bischofshausen, Kelly Conroy-Moore, Beth Dennis, Mike Hastie, Linda Melnick, Donna Reeves, and Teresa Smith. 2001. “The Effectiveness of EMDR in a Child Guidance Center.” Research on Social Work Practice 11(4):435−57.


Shapiro, Francine. 2007. EMDR and Case Conceptualization from an Adaptive Information Processing Perspective. Handbook of EMDR and Family Therapy Processes. Hoboken, N.J.: John Wiley & Sons Inc.
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Practice Snapshot

Age: 4 - 18

Gender: Both

Targeted Population: Children Exposed to Violence

Settings: Other Community Setting

Practice Type: Children Exposed to Violence, Cognitive Behavioral Treatment, Individual Therapy, Victim Programs

Unit of Analysis: Persons