Marian K. Puffer, Ph.D.
Accredited Psychological Associates,
Twenty children and adolescents were treated for a single traumatic memory with a single session of eye movement desensitization and reprocessing (EMDR). Treatment was delayed 1 m for half the group. Over half of the 20 participants moved from Clinical to Normal levels on the Impact of Events Scale, and all but 3 showed at least partial symptom relief on several measures at 1-3 m following a single EMDR session.
Results should be interpreted with caution, but were positive, and essentially consistent with analogous findings of EMDR with adults.
Eye movement desensitization and reprocessing (EMDR) is a recently developed psychotherapy method with reported dramatic efficacy in the treatment of traumatic memories and their psychological sequelae (Shapiro, 1989, 1991). Briefly, EMDR features focusing intensely on the traumatic memory while moving the eyes rapidly from side to side (by following the therapist's moving fingers). This procedure is repeated, focusing progressively on client-generated aspects of the memory (e.g., anger, body tension, insight) until the client reports no further distress, and can fully endorse an adaptive view of the memory. Shapiro (1995) has described the EMDR method in detail.
EMDR's brief history has been characterized by excitement and controversy, following Shapiro's (1989) astounding claim that she desensitized traumatic memories in a number of cases of post-traumatic stress disorder (PTSD), with concomitant symptom alleviation, in a single 90 minute session. Understanding the varying findings of subsequent reports was complicated by the fact that several versions of the method were in use. However, a number of controlled studies using well-trained practitioners has established that EMDR does indeed have a rather dramatic positive effect in the treatment of problems stemming from a single traumatic memory, and has promise in a number of related applications, including multiple-trauma PTSD as well as anxiety and depression. Fidelity to the EMDR protocol has emerged as a critical factor in terms of quality of treatment as well as consistency of effect. Greenwald (1996) has discussed the history and current status of EMDR in detail.
EMDR's applicability to the treatment of traumatized children and adolescents appears to be promising. Case reports have been positive and consistent with findings on analogous treatment of adults, except that child treatment may be even more rapid (Cocco & Sharpe, 1993; Greenwald, 1993, 1994; Pellicer, 1993; Shapiro, 1991). For example, Greenwald (1994) reported that 5 children traumatized by a hurricane showed recovery to pre-trauma symptom levels following 1-2 EMDR sessions. Here we report on a larger study of EMDR with children and adolescents distressed by a traumatic memory.
Participants from several small Midwestern towns were recruited through newspaper publicity as well as therapist referrals. Criteria for eligibility included being disturbed by a specific past event, not being in concurrent treatment during the period of the study, and absence of specific risk factors. One participant who obtained additional treatment during the study was replaced. Twenty children between the ages of 8 and 17 (M=13.5) were evenly split into treatment and delayed-treatment groups on a convenience basis (they could choose to start before or after a school vacation).
Children's Manifest Anxiety Scale (CMAS)
The CMAS (Castenada, McCandless, & Palermo, 1956) is a widely used broad-spectrum anxiety scale for children. It consists of 50 statements which must be endorsed or denied on a dichotomous scale. Scores over 30 are considered to indicate a clinically significant anxiety problem, with scores in the 20-30 range indicating a possible problem.
Impact of Events Scale (IES)
The IES is a widely used measure of post-traumatic stress symptoms (Horowitz, Wilner, & Alvarez, 1979), which has been used with some success with children (Dyregrov & Yule, 1995). It consists of 15 statements frequently endorsed by people with post-traumatic stress reactions, and is referenced to a specific identified past trauma. It offers four levels of endorsement, with weighted scores for a maximum of 75 and a minimum of O, with 26 or over indicating a clinically significant stress reaction.
Subjective Units of Distress Scale (SUDS)
The SUDS (adapted from Wolpe as described in Shapiro, 1989) measures intensity of subjective distress in response to a particular stimulus, such as a memory. It is widely used, and has been shown to correlate with several physiological measures of stress (Thyer, Papsdorf, Davis, & Vallecorsa, 1984; Wilson, Covi & Foster, 1993). Non-reactivity to a traumatic memory is considered an indicator of recovery (Horowitz, 1986). This 11 point scale uses 10 as the highest level of distress and O as the lowest level, or absence of distress.
Validity of Cognition Scale (VoC)
The VoC is a semantic differential scale measuring the "felt truth" about a self-statement relating to the memory (Shapiro, 1989). Similar scales have been validated (see Emmerson & Neely review, 1988), and the VoC itself has correlated well with other outcome measures (e.g., Shapiro, 1989; Wilson, Becker, & Tinker, 1995). This 7 point scale ranges from 1 being completely false to 7 being completely true. In this study, the VoC was an individually selected positive statement, such as "I did the best I could." Therefore, a higher score represents a more positive perspective.
Treatment consisted of a single 90 min session of EMDR, provided by the first author (MKP). At that time, she was a limited-license psychologist in a doctoral program, and had completed the first half of the training available through the EMDR Institute.
All participants were pretested with the CMAS and the IES. The treatment group was then given the SUDS and VoC at the beginning of treatment; these were also used periodically during treatment as process measures. All four measures were readministered 1 wk post-treatment, and again at 1-3 m posttreatment. The delay group went through the exact same sequence as the control group, except that the delay group had an additional pre-test, again including the CMAS and the IES, 1 m earlier. All data was collected by the first author (MKP).
There was no significant difference between the first and second pretests for the delay group. The IES difference M=3.1, SD=8.2, t=1.2, p=.27. The CMAS difference M=1.5, SD=4.9, t=.97, p=.36. With no evidence for a maturation effect, we combined groups for the other analyses.
All measures showed statistically significant treatment effects in the desired direction. Reported p-values are 2-tailed and reflect the difference between the final pre-treatment assessment and the 1-3 m follow-up. The CMAS decrease M=6.2, SD=8.8, t=3.2, p=.005. The IES decrease M=24.8, SD=17.4, t=6.4, p<.0001. The SUDS decrease M=8.8, SD=1.8, t=21.7, p<.0001. The VoC increase M=5.2, SD=1.3, t=17, p<.0001.
A tally of individual scores shows that, from pre-treatment to follow-up, 7 of the participants dropped one level or more on the CMAS, that is, from Clinical to Possible or from Possible to Normal. The same number dropped 10 or more points (with some overlap), but 17 scores went down at least a little. Two gained points (7 and 3) and one stayed the same. On the IES, of the 17 participants starting at the Clinical level, 11 dropped to Normal, and three more dropped 12 or more points while the other three stayed about the same. Of the three who started out in the Normal level, one dropped 9 points and the others went to O. On the VoC, 17 of the participants were at the maximum score of 7 at the follow-up, while the remainder were at 6, 6, and 5 respectively. On the SUDS, 16 of the participants were at the minimum score of O at follow-up, while the remainder were at 4, 2, 2, and 1 respectively.
As could be expected, the measures which focussed directly on the traumatic memory (IES, SUDS, VoC) showed a stronger response to the EMDR treatment than did the CMAS, a more global measure of anxiety. This is probably because the treated traumatic memory, or trauma generally, was not the only source of the child's anxiety. The more directly targeted measures are probably more informative.
On inspection of individual scores, particularly with the trauma-specific measures, it appears that the treatment effect was frequently rather dramatic, but not consistently so. For example, the IES scores indicated that over half of the children moved from Clinical to Normal levels, and 17 of the 20 either went to O or dropped 9 or more points. These findings clearly indicate clinical, or real, significance as well as statistical. However, although the apparent progress of many participants was impressive, for some it was more modest, while a few showed no gains at all.
These results should be interpreted with caution for several reasons. The use of a single investigator for all treatment and evaluation prevents us from ruling out experimenter bias or demand features. Control was further limited by non-random assignment, the relatively small n, and the relatively brief and variable (1-3m) follow-up period. Furthermore, no formal diagnosis was obtained, and no broad-spectrum trauma-focussed measure was utilized. Given these limitations on both internal and external validity, the findings can only be considered suggestive.
On the other hand, some features of the study may have led to an overly conservative estimate of EMDR's efficacy with this population. Three of the 20 participants had current life stressors directly related to the treated memory - a condition that would tend to preclude recovery. Also, the treatment was provided on the basis of only half of the available training from the EMDR Institute, and without knowledge of the specialized approaches available for using EMDR with children (Greenwald, 1993). Treatment fidelity has been identified as a critical issue in EMDR research (see Greenwald, 1996), and it is not possible to determine the extent to which fidelity was achieved here. Finally, use of a single modality in a single treatment session, regardless of client response, is likely to reflect unfavorably on the treatment as compared to its use in actual clinical practice (e.g., Seligman, 1995).
This study provides further tentative support for EMDR's effectiveness in the treatment of children and adolescents distressed by a traumatic memory. The present findings are consistent with the literature on EMDR treatment of traumatic memories with adults, as well as with previous reports of EMDR treatment of children and adolescents. Hopefully, future studies will address the many unresolved issues raised here. Considering the ubiquity of child trauma, and EMDR's promising beginning, further research is urgent.
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- Correspondence concerning this article should be addressed to:
Marian K. Puffer, Ph.D.
Accredited Psychological Associates
1260 Jefferson, Ste. 103
Muskegon, MI 49437,