THE EFFICACY OF EMDR THERAPY IN CHILDREN AND ADOLESCENTS: A CROSS CULTURAL META ANALYSIS by KRISTIN LOMBARD CRONK B.A., Clark University, 2011 PsyD, University of Colorado Denver , 2018 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Psychology in School Psychology School Psychology Program 2018
i This t hesis for the Doctor of Psychology degree by Kristin Lombard Cronk h as been approved for the School Psychology Program by Bryn Harris, PhD, Chair Franci Crepeau Hobson, PhD, Advisor Colette Hohnbaum, PhD Date: May 12, 2018
ii Cronk, Kristin Lombard (PsyD, School Psychology Program) The Efficacy of EMDR Therapy in Children and Adolescents: A Cross Cultural Meta Analysis Thesis directed by Associate Professor & Program Director Franci Crepeau Hobson ABSTRACT Eye movement desensitization and reprocessing (EMDR) has emerged as an effective treatment of post traumatic stress disorder. The current study examined the effectiveness of EMDR with various cultural groups of children and adolescents using meta a nalytic procedures. The total sample from eight EMDR effectiveness studies of culturally diverse populations consisted of 241 participants, all of whom were in the experimental groups that received EMDR therapeutic interventions. Ou tcomes were categorized based on effect size gathered from pre and posttest mean scores and standard deviations. Measures relating to the outcome of EMDR therapy in relation to the reduction of reported PTSD symptoms had an overall large effect size (mean d = 1.18), suggesting that the effectiveness of EMDR is generally similar across cultural groups . Findings have implications for the use of EMDR with youth from diverse backgrounds . Keywords: EMDR, children, trauma, cross cultural The form and content of this abstract are approved. I recommend its publication. Approved: Franci Crepeau Hobson
iii TABLE OF CONTENTS CHAPTER I. I NTRODUCTION .. .......................... ......................... ........................ ..... ...... ................. 1 Trauma in Children and Adolescents................................................ .. .....................1 The Prevalence and Presentation of Trauma In Children...... . ...... . .............. 1 Overview of the EMDR Therapeutic Approach...... .... ............ ... .. .... .. . ....... ............ 2 Essential Practi ces and Efficacy.............. ............ ... ..... ... ............. ............... 3 Theoretical Foun .. .. ... ... .................... ................ ..... ... .............................. 7 Initial Research F .. . Demonstrated Effica ... .. .... 8 Cultural . .. 0 II. INT RODUCTION TO RESEARCH AND METHODOLOGY .......... .. ... ... ...........12 Vulnerable Populations, Cultural Considera . .... 12 Meta Analysis as a Method of Synthesizing Research ......... ..... ...... ....... ............ . 13 Hypothesis and Objective ........... ... ......................... ........... ........ .................... ...... 14 III. MATERIALS AND METHODS ................. ......... ........ ... ...... ............. ....................... ..15 IV. RESULTS ......................... .................... ........ ........ ..... ................................. .................19 V. DISCUSSION . ............ ... ..... ..................... .... .................. ..............................25 VI. CONCLUSION AND FUTURE DIRECTIONS ............................. ..... .... ...................28 REFERENCES ....... .......................... .................... .................. ... .... .............................. 31
iv LIST OF TABLES TABLES 1. Characteristics of the Studies Included in the Meta A nalysis 21 2. Effect Sizes for Outcome Variables by Study ... 22
1 CHAPTER I LITERATURE REVIEW Trauma in Children and Adolescents P revalence and p resentation . Worldwide, c hildren are exposed to a vast array of adverse experiences and crises. These incidents include those that are due to human action, such as domestic violence, abuse, or neglect, as well as several forms of non interpersonal incidents, including life threatening illness, accidents, and natural disasters (De Bellis & Van Dillen, 2005). Such experiences can result in traumatic reactions, and for some children, diagnosable disorders , including acute stress disorder (ASD), depression, generalized anxiety disorder, childhood traumatic grief, specific phobias, separation anxiety , and Post Traumatic Stress Disorder (PTSD ; Stallard, 2006). PTSD is classified by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM 5) as a trauma and stressor related disorder ( American Psychiatric Association ; APA , 2013). The basis of PTSD is the experience of events involving actual or threatened death or serious injury, or a threat to the person themselves or others while experiencing intense fear, especially when feelings of helplessness or horror are induced at the time of the event ( APA , 2013). T he DSM 5 further clarifies that tr aumatic events are not necessarily an isolated occurrence; children can be the victim of single traumatic experiences (Type I trauma) or suffer from enduring adversities (Type II trauma ; De Bellis & Van Dillen, 2005). T he development of PTSD can vary base d on and in relation to the nature and severity of the events experienced ( Salmon & Bryant , 2002) . Factors such as the individual physical proximity to the trauma, the individual 's individual perception of the event, the resilience of the i ndividual and the insulating or risk factors present ( e.g., supportive family or
2 social structure or lack thereof) play a significant role in the outcome for and outcome of the individual . Additionally, the length of time which has passed since the trauma took place ha s also been shown to have a role in the presentation and severity of symptoms, as well as the likelihood that a n individual may develop PTSD (Salmon & Bryant, 2002). There is some evidence that children experience traumatic events differently than adults do, leading to a noticeable difference in the symptoms and presentations of PTSD in children when compared to adults (Adler Nevo & Manassis, 2005). In addition, t here are differences in the expression of symptoms in children depending on developmental stage, ( e.g. , tantrums, separation anxiety, and repetitive play ; Diehle, Opmeer, Boer, Mannarino, & Lindauer, 2015). PTSD is therefore a condition that is heterogeneous in both its development and its presentation, wherein its initiation and development is highly variable and dependent on a wide array of influencing factors (Rodenburg, Benjamin, de Roos, Meijer & Stams, 2009). This in turn may contribute to the variance and inconclusive nature of the evidence regarding the incidence of PTSD in children , with estimates rang ing from zero percent to extremely high percentages, depending on the nature of the trauma to which the children were exposed (De Bellis & Van Dillen, 2005; Kilpatrick, Ruggier o, Acierno, Saunders, Resnick & Best, 2003; Yule, 2001). For example, children who have experiences which include enduring adversities, direct exposure to traumatic events, and interpersonal violence develop PTSD at higher rates compared to their peers (De Bellis & Van Dillen, 2005; Kilpatrick et al., 2003; Pine, 2003). Overview of the EMDR Therapeutic Approach Essential p ractices of EMDR . There are a number of well established and empirically supported trauma therapies , including Cognitive Behavioral Thera py ( CBT; Chemtob et al., 2002; Stein et al., 2003; Smith et al., 2007), and Narrative Exposure Therapy (Neuner et al.,
3 2008; Wendling, 2009, Ruf et al. 2010) . However, these are not necessarily effective or developmentally appropriate for every child and t heir particular experiences . One promising approach to treating childhood trauma is Eye Movement Desensitization and Reprocessing (EMDR ; Rodenburg et. al, 2009). EMDR was first described as a concept in 1989 and was developed into a theoretical approach in the 1990s by Francine Shapiro as a method to help trauma survivors access and process traumatic memories so they can be brought to an adaptive resolution (Shapiro, 2001). According to Shapiro and Maxfield (2002), disturbing memories are usually processed by thinking, talking, and sometimes dreaming about the experience. This process is elaborated upon in an article by Solomon, Solomon, and Heide (2009): As the brain slowly processes the memory, it is transferred to the left cerebral cortex where it is file with neutral memories, the stored information can be retrieved when needed to understand new experiences. Traumatic experiences are highly charged emotionally and overwhelm the brain integrating traumatic memories, connecting them with similar memories, and storing them. Instead, the episodic memory of the experience may be stored in the limbic system indefinitely. Dysfunctio nally stored traumatic memories can lead to maladaptive coping strategies. (p. 393) I ntegral and fundamental to EMDR treatment is this assumption that th e activation of dysfunctionally stored memories is the underlying cause of the intense anxiety and other symptoms of PTSD (as well as a myriad of other maladaptive emotional, cognitive, and behavioral responses) that is often experienced by those in EMDR th erapy (Shapiro, 2001, 2014a, 2014b).
4 2007, 2014a, 2014b; Solomon & Shapiro, 2008), EMDR treatment starts with taking a detailed history and planning treatment, explanation of and preparation for EMDR. The therapist subsequently asks the client to focus on the traumatic memory by means of directive questioning. The client is asked to reflect on and express a negative, dysfunctional cognition related to the traumatic memory , a nd then supply an alternate positive, functional cognition (Shapiro, 2001). Attention is focused on the emotion that is connected to the memory and dysfunctional cognition and the client is asked to reflect on places in the body where any physical phenomen a are felt. The client is then asked to attend to the traumatic memory and its associated dysfunctional cognitions, emotions and physical sensations, this time in combination with bilateral stimulation (either visual, auditory, or touch; Shapiro, 2001). Ea ch new association linked with the traumatic memory is followed by a new series of stimuli. The level of disturbance is repeatedly measured on a ten point Likert scale (Subjective Units of Disturbance ; SUD) until substantially decreased to zero, which impl ies desensitization to the traumatic memory. Then the traumatic memory is connected with the earlier formulated functional cognition on the Validity of Cognition Scale (VOC), a seven point Likert scale, while conducting new sets of stimuli (Shapiro, 1995). This is repeated until the client assigns a 7 to the functional cognition (installation). Finally, the therapist checks whether physical sensations are still present, and follows up with positive closure and re evaluation. The number of sessions require d varies according to the type of traumatic event (Type I versus Type II) and the severity of the psychopathology (Shapiro, 2001, 2014a, 2014b). Theoretical Foundations and Influences . theorizing that when a traumatic event or extremely negative experience happens, information
5 processing in this system may be incomplete, likely as a result of the interference of strong negative feelings or dissociation interfering with the memory and information processing (S hapiro, 2002). This traumatic memory is then stored dysfunctionally, without the properly associated adaptive connections and with many elements still unprocessed. Consequently, this prevents the necessary and proper storage of this memory and the retrieva l and forging of connections with more adaptive information stored in other memory networks (Siegel, 2002). This results in dissonance and difficulty in resolving the traumatic experience, as the person can objectively possess the information necessary to react adaptively to their trauma but is not reliably able to access and then act upon this knowledge ; thus, it stays separate from the trauma response (MacCulloch & Feldman, 1996). This can be especially challenging in moments when these traumatic memories are triggered by circumstantial sensory input, such as similar physical sensations, noises, or locations, but the individual do es not connect this knowledge with their experience (Siegel, 2002). The Adaptive Information Processing model ( AIP ) proposed an d utilized by Shapiro ( 2007, 2014a, b) in her design and implementation of EMDR as a therapeutic intervention theorizes that the EMDR phases induce a physiological condition in which sufficient information processing is achieved (Shapiro, 2007, 2014a, b). More specifically, this condition occurs through the lessening of the states of physiological arousal which may be triggered by the processing of that trauma (Shap iro, 2007, 2014a, 2014 b). Several hypotheses have been suggested and researched in an attempt to explain the underlying function of bilateral stimulation and the mechanism of the processing itself as posited in the AIP model (Shapiro, 1995, 2001, 2007; Sol omon & Shapiro, 2008). These hypotheses generally posit that EMDR induces a REM
6 sleep state like condition (e.g., Stickgold, 2007), which is associated with other hypothesized effects, such as increased hemispheric communication (e.g., Christman, Propper, & Dion, 2004), the investigatory reflex (e.g., Barrowcliff et al., 2004; Lee & Cuijpers, 2013), working memory (e.g., Gunter & Bodner, 2008; Jeffries & Davis, 2013), and increased relaxation (Shapiro, 2007). By disrupting this reflexive reaction, more flu id and thorough processing of the traumatic event can be achieved, without the physiological arousal that can often occur during flashbacks or when individuals are exposed to a trigger which causes them to re experience, on some level, their trauma (Shapir o, 2007: 2014(a)(b)). There are other models of therapy which utilize a similar model for processing trauma and have also demonstrated some degrees of effectiveness, including the emotional processing model ( Power & Dalgliesh, 2015; Ehlers & Clark, 2000; Foa & Kozak, 1986, 1998) . The EMDR protocol and its procedures facilitate the access to their existing emotional networks and the integration of new, adaptive information into those networks. The AIP model used in EMDR differs from the emotion al processing model in that in EMDR, the connecting of information within and between memories is unprompted and spontaneous, whereas in the emotional processing model it is generally thought to be a function of new corrective information, incompatible wit h the pathology and creating cognitive dissonance, which follows from recurrent prolonged exposure ( Power & Dalgliesh, 2015 ; Shapiro, 2007, 2014a, b). In this way, the AIP model used in the EMDR approach and its associated protocols allow for a level of f ree association and distancing which is not typically present or endorsed within the emotional processing model (Rogers & Silver, 2002; Solomon & Shapiro, 2008). EMDR is applied using a standardized protocol which consists of a structured sequence of treat ment components which have proved effective across various trauma treatment modalities
7 (Shapiro, 2001). The three pronged approach of EMDR incorporates queries concerning the etiology of prior traumatic events, the triggers of PTSD symptoms (present), and the creation of future templates with a focus on developing resources which the patient can use to adequately cope with upsetting events in the future (Shapiro, 2001). For children , an adapted protocol is typically utilized, with the adoption of age approp riate modifications as suggested by Tinker and Wilson (1999), Greenwald (1999) and Adler Tapia and Settle (2008). The Efficacy of EMDR Initial Research Findings and Contention . for adults who had been diagnosed with post traumatic stress disorder. The theory behind EMDR is that a person can be desensitized to their traumatic memories and dampen their maladaptive reactions to it by engaging in short imagined exposure to this memory in conjunction with the utilization of bilateral stimulation. The accepted methods of bilateral stimulation per Shapiro (2001, 2014a, 2014b) involve bilateral visual motion, sounds in alternating ears, or touch which crosses the body. This process is repeated until the accompanying level of disturbance has disappeared and the dysfunctional cognitions about the trauma have become functional (Shapiro, 2007). Three years after EMDR was introduced to clinical practice, Solomon, Gerrity, and Muff (1992) documented a dearth of controlled outcome studies, specifically in relation to the treatment of PTSD. Their review of the research literature discovered only six non pharmacological studies, and they ultimately r eached the conclusion that all of the experiments [was] needed before any of these approaches can be pronounced effective as lasting treatments of Gerrity, and Muff, 1992, p. 637).
8 Demonstrated Efficacy and Acceptance of EMDR . several reasons, most recently with reference to the absence of an empirically validated model which adequately explains the underlying mec hanics of the effects of the EMDR method (Gunter & Bodner, 2008; Perkins & Rouanzoin, 2002). Additional debates have also arisen around the role of bilateral stimulation in the EMDR method (Lohr, Lilienfeld, Tolin, & Herbert,1999). However, i t has been demonstrated that eye movements contribute to memories being reported as less vivid and unpleasant in people with non clinical symptoms (Andrade, Kavanagh, & Baddeley, 1997; Barrowcliff, Gray, MacCulloch, Freeman&MacCulloch et al., 2004; Kavanag h, Freese, Andrade, & May, 2001). Additionally, eye movements have been found to decrease psychophysiological arousal and increase parasympathetic activity in people with PTSD symptoms (Elofsson, von SchÃ¨ele, Theorell, & Sondergaard, 2008; Sack, Lempa, Ste inmetz, Lamprecht, & Hofmann, 2008). The APA Division of Clinical Psychology launched a project in 1995 with the aim of determining the degree of solid empirical evidence support ing different existing therapeutic methods (Chambless et al., 1998). Within t his project, independent reviewers established that EMDR merited placement on a list of empirically supported treatments, specifying that EMDR is , p. 9 ). It is important to note that this pro ject deemed no other therapies meant for use with PTSD populations to be empirically supported by controlled research (Shapiro, 2002). According to Chemtob et al. (2000), after additional published controlled studies were assessed, EMDR was designated as e ffectual for the treatment of PTSD by the International Society for Traumatic Stress Studies (ISTSS). Furthermore, when a meta analysis of all published studies on psychological and pharmacological treatments for PTSD was conducted, the researchers reporte d that the results of
9 Finally, t hirteen randomized controlled efficacy studies supporting EMDR were published i n 2002 leading EMDR to be considered a standard form of treatment (Shapiro, 2002). This substantial body of research that has accumulated over the past 25 years has led EMDR to be declared an effective trauma treatment in many of the clinical guidelines of professional organizations and national mental health services (Rodenburg et al., 2009; Shapiro, 2014(a)(b)). As a result , professionals including psychologists and psychiatrists have since utilized EMDR with clients who have been diagnosed with PTSD. EMD R training and research institutes have opened in at least 52 countries in cluding Europe, North America, Africa, Asia, Australia and Central and South America as of 2009 (Maxfield, 2009). In the last decade, the number of the studies that have evaluated t he efficacy of EMDR in children or adolescents wit h PTSD has increased. In a 2009 meta analysis by Rodenbu rg, Benjamin, et al, EMDR demonstrated a small but signifi cant advantage over CBT . This analysis also found that studi es using a combination of parent and child report showed medium to large effect sizes, whereas studies using child report yielded small effect sizes (Rodenburg et al, 2009) . A further meta analysis conducted by Brown et al. in 2017 focused on trauma resulting from man made and natural disasters compared the efficacy of various interventions, including EMDR, and found comparable positive effects of all interventions (Brown et al., 2017). Another 2017 meta analysis conducted by Morena Alcazar et al. found that childre n treated with EMDR therapy demonstrated a reduction of their trauma associated symptoms as well as their comorbid anxiety symptoms as compared to patients in the respective control conditions (Moreno Alcazar et al. 2017).
10 Cultural Influences on Trauma . In background can influence both the development and expression of trauma. C ulture affects how people make sense of post traumatic distress , the communication of trauma, as well as help seeking (and w hat it looks like or how it is viewed), and expectations of treatment (BÃ¤Ã¤rnhielm & MÃ¶sko, 2015). According to BÃ¤Ã¤rnhielm and MÃ¶sko (2015), cultural aspects of communication related to language, idioms of distress, discourse systems, help seeking, and iden tification of signs of trauma and assessment and treatment are likely to vary greatly between refugee populations. (BÃ¤Ã¤rnhielm & MÃ¶sko, 2015). Historically , most psychological interventions used in treating refugees and other diverse populations have been a mixture of various elements from different psychotherapeutic approaches. The se interventions also do not appear to be based on a consistent theory and there seems to be a concerning lack evidence on their effectiveness (Ba o lu, 2006). Of additional co ncern is the fact that many efficacy studies do not tend to include minorities in their samples and the literature in the field has long debated whether the standard PTSD interventions, such as cognitive behavioral therapy (CBT) or EMDR, are applicable to diverse populations, including refugees (Slobodin & Jong, 2015). Although numerous studies have shown that difficulty in gaining access to healthcare contributes to the further deterioration in general health and mental health among immigrant and refugee populations (Laban et al. 2004, 2005, 2007, 2008; Bhui et al. 2006; Gerritsen et al. 2006), no uniform solution has been found so far. Sadly, these difficulties are not limited to refugee populations and often children and families from diverse backgrounds here in the U.S. face similar challenges of racism, discrimination, and difficulty accessing healthcare and mental health services, despite their status as citizens or recent immigrants rather than refugees
11 (Bustamante et. al, 2012; Viruell Fuentes, Miran da, & Abdulrahim, 2012; Gonzal es, SuÃ¡rez Orozco & Dedios Sanguineti, 2013).
12 CHAPTER II INTRODUCTION TO RESEARCH AND METHODOLOGY Vulnerable Populations, Cultural Considerations, and Research Needs At the time of this study, no meta analysis had been conducted examining the variance in efficacy of EMDR in children from diverse cultural backgrounds. With meta analysis, researchers are enabled to discover the consistencies within a set of apparently in consistent findings. As such, more accurate conclusions can be drawn than those presented in any of the separate studies (Durlak, 2013). Due to increased statistical power, small effects can be taken into account and because systematic bias in the interpre tations of results is reduced, a reliable quantitative estimation of the efficacy of EMDR in multicultural contexts can be accomplished. The first aim of this meta analysis wa s to determine whether there is a significant difference in between culturally diverse treatment groups and secondly, if differences do exists, to determine the significance and magnitude of that difference (i.e. , effect size) in PTSD symptoms present in children based on their sociocultural background. While the professional literature contains a number of guidelines and theoretical approaches for the treatment of refugee populations and asylum seekers, there exists very little empirical evidence and research regarding the efficacy, feasibility, and realistic appl ication of these interventions E ven less research exists about the efficacy of the aforementioned approaches with children and youth within these refugee populations , and s till less research exists which examines the effect of multicultural factors, socio cultural or socio political factors, or linguistic differences on the effectiveness of trauma interventions, especially with refugee populations. EMDR (Eye Movement Desensitization and Reprocessing) has previously shown some effectiveness at treating such trauma, and PTSD in particular. However, much of this research
13 has been centered around a particular immigrant or refugee population, with little research examining the effectiveness of EMDR with the aforementioned populations in comparison to the (typical ly Caucasian) participants in many EMDR efficacy studies. Via a synthesis of existing research , this study aim ed to compar e efficacy rates of EMDR for different populations and to determin e if EMDR effectiveness varies across different cultural and ethnic backgrounds of children. Much of the current research examining EMDR with non white populations has been conducted with refugees and asylum seekers; therefore , much of the discussion related to EMDR has been focused t here. While this is not the specific population on which this study focuse d , it is important to look into the use of EMDR with these populations, as they are often minorities, and therefore relevant to the ultimate interest of this study. Meta analysis of The Effectiveness of EMDR in Reducing PTSD Symptoms A meta analysis is a quantitative synthesis of research to reveal patterns in outcomes across a body of literature (Lipsey & Wilson, 2001). In effect, a meta analysis endeavors either to establish a conse nsus in the literature on a particular topic or to unearth or more precisely define a need for more research in a given area. In relation to the focus of th e present study, Shapiro (2014) established that EMDR is effective in producing a significant reduct ion in intrusive PTSD symptoms in research participants. Specifically, in her 2014 meta analytic study, Shapiro noted that s even of the ten studies reviewed found EMDR therapy to be more rapid and/or more effective in terms of symptom reduction than trauma focused cogni tive behavioral therapy. Additionally, Shapiro (2014) found that twelve randomized studies of the eye movement component of EMDR indicated that participants reported significant decreases in the vividness of disturbing images and/or negative emo tions and an other eight studies found a variety of other memory effects. A number of other evaluations have document ed that EMDR therapy provides
14 relief from a variety of somatic complaints (Shapiro, 2014). However, while a number of meta analytic studies have been completed in the last decade on the broad topic of the effectiveness of EMDR with various populations, to date there have been no studie s which compare this effectiveness within a cultural context (Shapiro 2014). Thus, at the very least an initial meta analysis examining the effect sizes in studies with culturally diverse populations is necessary to ensure that EMDR is not touted as univer sally applicable and effective if it is, in truth, not. Hypothesis and Objective T his research study explore d the efficacy of using EMDR approaches in the treatment of children experiencing the after effects of traumatic events, with particular focus on children from minority backgrounds . Furthermore, this study aim ed to fill the research gap regarding the effectiveness of EMDR across different ethnic and cultural backgrounds. Until now, while there has been research conducted with minority populations, especially refugee populations, no comparison has been done to ascertain whether the effectiveness of EMDR varies across populations and if ethnic and cultural identities. The overarc hing hypothesis of this research is that EMDR is universally effective across culturally diverse populations.
15 CHAPTER III METHOD Literature Search With the aim of conducting a systematic collection of a non biased and representative sample of published and peer reviewed research studies, multiple strategies were used. A literature search was conducted into the effect iveness of EMDR in treating PTSD symptoms in children and then a second search was conducted for studies looking at the effectiven ess of EMDR with children from different cultural and ethnic backgrounds. Relevant studies were identified through searches using computerized databases, including WILEY, PsycINFO, MEDLINE, ERIC, Springer, Google Scholar, and Serial Solutions 360. The data bases were explored using a range of search terms in different combinations: EMDR, desensitization, eye movement, reprocessing, trauma, PTSD, traumatic stress disorder, child, children, multicultural, refugee, therapy . In addition , searches were made for s tudies conducted in specific regions or countries with child populations with high risk of exposure to traumatic events. Additionally, the ancestry method was utilized to find additional studies of childhood trauma in reviews and articles reporting on empi rical studies. Specifically, reference sections of articles were inspected for relevant studies that had not yet been detected via the initial search strategies . Article relevance was determined via a visual inspection to determine its applicability to the current research study. Inclusion C riteria . Criteria for inclusion into the meta analysis were as follows: (1) Studies had to include control groups (children receiving established trauma treatments, children receiving usual care, or children in a waiting list control procedure); (2) C hild participa nts had to be treated for post traumatic stress reactions; (3) S tudies had to randomize children across the
16 experimental and control groups; (4) S tudies had to include children up to 18 years of age; and (5) S tudies had to provide posttreatment trauma scor es, allowing for the calculat ion of effect sizes for the difference between the experimental EMDR group pre and post treatment. A total of eight studies were found that met the inclusion criteria. Exclusion Criteria . Initially, 20 studies that investigat ed trauma in children with EMDR were identified. Studies excluded from review: 1) I ncluded subjects who were adults or not school aged individuals; 2) P rovided only single group pre test and posttest studies; 3) utilized qualitative methods; 4) Did not pro vide participant ethnicity or cultural background data ; 5) L ack ed substantiated posttest data ; 6) U se d a non evidence based outcome measure ; and/ or 6) Did not provide adequate statistical data for the calculation of effect size. An additional three studies were eliminated due to lack of multicultural diversity in the study sample or because the studies themselves were old enough to be considered less relevant than other studies found with similar populations. Coding and Reliability . A coding system was deve loped based on established practices in meta analysis to include relevant information regarding each study and to determine which studies were appropriate for inclusion in the meta analysis (Lipsey & Wilson, 2001). Included in this coding was an integratio n of pertinent information regarding the setting of each study, general data and demographic information about participants, and experimental design. T his established and consolidated descriptive variables, outcome variables, statistical outcomes , and repo rted effect sizes. Each study included in the meta analysis was also coded for client, design, measure used, and publication characteristics. Participant characteristics were comprised of country of origin/nationality (percentage of each country represente d) and mean age of participants . Design characteristics included the percentage of participants who completed the
17 entirety of the study, use of a follow up measurement and the particular measure utilized, the type of control group (e.g., non established / ty pical care or waiting list or established trauma treatment ; e.g. , CBT, etc.), and type of informant (e.g., child, or parent and child). The intervention characteristic was the number of sessions (three or fewer or more than three). Finally, the publication year for each study was coded. Categorical moderator variables w ere types of study control group, follow up measurement, and type of informant. Year of publication, percentage of study completers, gender (percentage of boys and girls), mean child age, the effect size for differences in trauma between the experimental a nd control group at the pretest, and the number of sessions were continuous moderators. Descriptive Variables Information regarding each included study was coded regarding the date of research, type of publication, focus of research (e.g. , meta analysis, study of effectiveness, test of validity), activities conducted (i.e., group or individual EMDR therapy, utilization of CBT or similar therapeutic approaches for comparison), and population studied (e.g., race/ethnicity, country of origin, gender, and age). Outcome Variables The outcomes for each study were coded by categorizing the effect sizes calculated from the means and standard deviations provided for each study. Specifically, the pre and posttest outcomes were statistically analyzed d , and then categorized as small, moderate, or large in accordance with the categories delineated by Cohen in his 1988 publication. Measurement of trauma The majority of studies used a range of assessment tools to measure posttraumatic stres s reactions and child behavior problems, including depression and anxiety. The scales that were
18 most frequently used to measure PTSD symptoms were the Child Post Traumatic Stress Reaction Index (Child PTS RI; Frederick, Pynoos, & Nader, 1992; Pynoos & Na der, 1988), the Child Report of Post traumatic S ymptoms (CRI; Pynoos, Frederick, Nader, Arroyo, 1987) , the Child Report of Post Traumatic Symptoms (CROPS; Greenwald & Rubin, 1999) , Reaction to Traumatic Events Scale Revised (CRTES R; Jones, Fl etcher, & Ribbe, 2002) , the Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979), the Parent Report of Post Traumatic Symptoms (PROPS; Greenwald & Rubin, 1999), the Post traumatic Stress Symptoms Child R eport (PTSS C; Ahmad, Sundelin Wahlsten, Sofi, Qahar, & Von Knorring, 2000) , and the University of California at Los Angeles Post traumatic Stress Disorder Reaction Index (UCLA PTSD RI; Steinberg, Brymer, Decker, & Pynoos, 2004 . For the purpose of this meta analysis, trauma scales were selected that were mostly used to assess posttraumatic stress reactions, and studies which used measures that only assessed anxiety or depression symptoms were not included. Excluded for trauma measurement were scores on the Subjective Unit of Disturbance (SUD) and on the Validity of Cognition scale (VOC), because these measures are highly vulnerable to demand characteristics (Acierno, Hersen, Van Hasselt, Tremont & Meuser, 1994).
19 CHAPTER IV R ESULTS To examine the difference in trauma scores between the different experimental groups, the calculation and analysis of effect sizes (ES) w ere carried out using the web based program, Practical Meta Analysis Effect Size Calculator (Lipsey & Wilson, 2001). ES was calculated using means and standard deviations fro m the pre selected and coded evidence based pre and posttest outcome measures (e.g., when there were multiple post treatment measurements administered, data from the pre coded and selected post treatment measurement were used). Calculations were made util izing the mean scores and standard deviations from the eight studies included in the meta analysis. S everal effect size statistics were calculated based on the nature of the treatment group sizes, differences in standard deviations, and the relative size o f each sample size (Stangroom, 2017). Specifically, when pre and post treatment groups had similar standard deviations and were of similar size, Cohen's d was utilized. In some cases, Glass' delta was most appropriate, because it uses only the standard de viation of the control group and is an acceptable alternative measure if each group has a different standard deviation (Stangroom, 2017). Additionally, Hedges' g was at times a more appropriate measure of effect size, as it provides a measure of effect siz e weighted according to the relative size of each sample and is considered an alternative where there are different sample sizes (Stangroom, 2017). After calculating the effect size for each relevant measure within a given study, combined mean effect sizes were calculated using SPSS, with the aim of comparing these effect sizes for significant differences. The following parameters were used to assess effect size (ES): large ES = .8, moderate ES = .5, low ES = .2 (Cohen, 1988).
20 Descriptive Variables Eight studies were found to meet inclusion criteria for the analysis. Detailed characteristics of the studies included in the meta analysis are listed in Table 1 . All studies used in this meta analysis were in peer reviewed publications . The total sample consis ted of 241 participants, all of whom were in the experimental groups in their respective study (control groups were not included as the focus of this study was groups receiving EMDR treatment). Table 1 CHARACTERISTICS OF T HE STUDIES INCLUDED IN THE META ANALYSIS. STUDY Sample Size Mean Age Gender Country Type of Trauma Year AHMAD & SUNDELIN WAHLSTEN 33 9.6 years 42% Male 58% Female Sweden Variety, all participants met criteria for PTSD 2007 BECKER ET AL. 59 11.2 years 66% Male 34 % Female USA Violence/ Urban Trauma 2011 CHEMTOB ET AL. 32 8.4 years 31% Male 69% Female Hawaii/ Pacific Islands Disaster Exposure 2002 JABERGHADERI 19 12.5 years 100 % Female Iran Sexual Abuse Victimization 2004 KEMP 27 8.93 years 55% Male 45% Female Australia Motor Vehicle Accident 2009 MASLOVARIC ET AL. 45 16.28 years 42% Male 58% Female Italy Disaster Exposure 2017 DE ROOS ET AL. 26 10.2 years 50 % Male 50% Female Netherlands Disaster Exposure 2011 TANG ET AL. 41 14.48 years 46% Male 54% Female Taiwan Disaster exposure 2015 Table 1
21 All of the studies included in this meta analysis utilized evidenced based outcome measures ; however, while some studies overlapped in their use of a measurement tool, no assessment was used by all eight studies, and only two studies ever shared a given measure. All but one of the studies included both genders in their experimental design and all studies used a slightly different age range of participants, although all participants w ere below the age of 20 and above the age of 4 (mean age = 11.42). Outcome Variables The overall mean effect size for the studies included in the meta analysis was 1.18 (median ES=1.27) , suggesting a large effect size for EMDR therapy based on the data gat hered from multiple evidence based assessments. While the assessments utilized by each particular study varied across all eight of the studies, all included studies used a selection of research based evaluation methods, including the Posttraumatic Symptom Scale for Children ( PTSS C ; Ahmad et al., , 2000 ), Child Report of Post Traumatic Symptoms ( CROPS ; Greenwald et al., 2002), Parent Report of Post Traumatic Symptoms PROPS ; Greenwald & Rubin, 1999), Child Post Traumatic Stress Reaction Index Child PTS RI), Impact of Events Scale Revised ( IES R ; Horowitz et al., 1979, Weiss & Marmar, 1997; Wu & Chan, 2003), Multidimensional Anxiety Scale for Children Taiwanese ( MASC ; , March, Parker, Sullivan, Stallings, & Conners, 1997), Mandarin Chinese version of the Center for Epidemiologic Studies Depression Scale ( CES D ; Radloff, 1977), Child Reaction Index ( CRI ; Inventory ( CDI ; ( RCMAS ; Reynolds & Richmond, 1985), a nd total number of DSM PTSD Criteria met (Rodruiguez, Steinberg, & Pynoos, 1998). Additionally , multiple moderate to large effects were found. The overall range of effect sizes fell between 0.27 and 2.8; with the majority of effect sizes falling in between 0.41
22 and 1.80 (see Table 2). Comparison of d , delta, g ) did not reveal an y appreciable difference s in the effect sizes. More explicitly, for the studies included, the differences in sam ple size and standard deviation did not appear to significantly impact the effect sizes across the three different statistical calculations. Table 2 EFFECT SIZES FOR OUT COME VARIABLES BY ST UDY STUDY Measure d g delta AHMAD & SUNDELIN WAHLSTEN Total PTSS C 0.309134 0.309134 0.271552 PTSD related symptoms 0.406666 0.406666 0.346667 Re experiencing 0.848528 0.848528 0.750000 Avoidance 0.407897 0.407897 0.349206 Hyperarousal 0.019514 0.019514 0.017857 PTSD Non related 0.118745 0.118745 0.713934 BECKER ET AL. CROPS 1.317670 1.317670 1.185393 PROPS 1.239046 1.239046 1.091429 IES 1.598989 1.598989 1.425352 CHEMTOB ET AL. CRI RCMAS CDI 1.632341 1.632341 1.734659 RCMAS 0.517769 0.517769 0.632027 CDI 0.625745 0.625745 0.733266 JABERGHADERI CROPS PROPS Rutter 1.867977 1.867977 1.751613 PROPS 2.30880 2.30880 2.758621 Rutter 0.926046 0.926046 0.713934 KEMP ET AL. MASLOVARIC ET AL. Total No. of PTSD Criteria Met Child PTS RI Total IES R 1.412946 1.412946 1.439024 Child PTS RI Total 1.118113 1.118113 1.010638 MASLOVARIC ET AL. IES R 1.222440 1.285464 1.229155 DE ROOS PROPS CROPS MASC 1.208381 1.208381 1.113043 CROPS 1.188421 1.188421 1.141414 MASC 1.265280 1.265280 1.169492 TANG ET AL. C IES R MASC T CES D 0.793393 0.793393 0.788413 MASC T 1.715821 1.715821 2.004606 CES D 0.902870 0.902870 0.897391
23 While there were some variations present in terms of the reported effectiveness of EMDR therapy across these studies, almost all of the reported effect sizes fell within the large effect size range (14 out of 20 or 70% of effect sizes), indicating that EMDR consistently demonstrate d a large effect in terms of decreasing the trauma related symptoms and pres entation of PTSD in children, regardless of country of origin. The lowest effect sizes were found in the Ahmed & Sundelin Wahlsten (2007) study of Swedish children (ES of 0.27) ; however , upon further investigation, it seems that this may be a result of the assessment used to measure effectiveness (PTSS C). Specifically, this measure consists o f several specifically targeted subscales and a d for the overall scale scores pre and posttest, the effect size wa s 0.27. However , was 0.85. Additionally, the other subscales (Hyperarousal symptoms and PTSD non related symptoms) ha d effect sizes considered to be in the sm all range (0.20 and 0.11, respectively) which may have brought down the overall average of the effect size . Thus , it is possible that a smaller effect size was falsely reflect ed due to scores on scales that are not applicable to the measure ment of EMDR eff ectiveness in on reducing symptoms of PTSD. The largest effect sizes occurred in the Iranian study population (ES of 1.8 and 2.8). The U.S., Australian, and Dutch studies all had multiple measures w ith effect sizes in the large range, while the Iranian, T aiwanese, and Hawaii/Pacific Islander studies all had a combination of effect sizes ranging from medium to large. These data suggest that the effectiveness of EMDR is relatively consistent across populations, as the majority of the effect sizes f e ll within the large range, regardless of the country of origin of the stud y s participants. All studies, aside from the 2004 Ahmad & Sundelin Wahlsten study in Sweden, had at least one measure whose effect size
24 fell into the large range, indicating that a large eff symptoms in those who presented with PTSD.
25 CHAPTER V DISCUSSION T he goal of the current study was to examine the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) in children from different cultural and ethnic groups using meta analytic procedures . Eight studies published between 2002 to 2017 were included in the meta analysis . The total sample consisted of 241 participants, all of whom were in the experimental group in their respec tive study (control groups were not included as the focus of this study was on groups receiving EMDR treatment). Participants in all included studies were children and adolescents who had all experienced or witnessed a traumatic event ( e.g., natural disast er, war/terrorism related event, mass accident). Overall, results showed EMDR treatments to be very effective across all sampled cultural backgrounds when comparing impairment before and after therapy, as well as across multiple outcome measures. The curr ent meta analysis resulted in an overall effect size of d = 1.18, which indicates a very strong relative reduction of symptoms of Post Traumatic Stress Disorder (PTSD) . These results are consistent with the findings of other meta analytic reviews conducted on the effectiveness of EMDR therapeutic interventions ( e.g., Newman et al. 2014; Brown et al. 2017 ) . Fourteen large mean effect sizes were identified based on descriptive variables across all studies, in addition to four moderate to large mean effect si zes based on individual studies, and two small to moderate mean effect sizes based on the reported mean differences and standard deviations reported in each study. Overall, these results showed that EMDR is an effective therapeutic intervention for children from a range of cultural backgrounds , with a similar decrease in symptoms noted after the application of EMDR across samples . This in turn indicates
26 that, in general , the effectiveness of EMDR does not appear to be significantly affected by p articipant cultural background and /or country of origin. Limitations This meta analysis included randomized control trial research only , while other types of research studies such as non randomized, observational , or case studies were not considered. This has the potential to decrease statistical power. In addition , the studies included in the meta analysis used different control conditions. Three studies used pure waiting list, three used comparable interventions such as CBT, two simply treated all childre n with no control condition , and another one did not use any active control condition. Additionally, many of the studies experienced attrition with participants drop ping out of the study before completing the full eight sessions required by EMDR protocols . This may have resulted in some variations in the numbers of participants at the beginning and end of some of the trials , as well as potentially impacting the effects of the treatment on symptom severity . Another limitation relates to the small number of studies that met inclusion criteria. This prevented the completion of a multivariate analysis to d etermine if the factors examined in the subgroup analyses may be confounding each other . Therefore, some caution should be used in drawing conclusions regarding the universality of EMDR therapy. Additionally, the outcome measures used varied quite widely, making it challenging to compare outcomes on any measure beyond examining simple effect sizes. Although they are considered acceptable as a statisti cal measures, effect sizes are generally viewed as less reliable than other statistical approaches to analysis and therefore , this study would have benefitted from more standardized sources of outcome data. This was not possible, largely due to a general l ack of EMDR research with samples of children from diverse
27 backgrounds. Although the minimum number of studies to permit a meta analysis is only three studies (Treadwell, Tregear, Reston & Turkelson, 2006) and many published meta analyses contain nine or f ewer studies (Lau, Ioannidis, Terrin, Schmid & Olkin, 2006), the small number of eight studies included in this meta analytic review limits the generalizability of the findings . It also limited the opportunity to examin e and adjust for publication bias by means of more complex analytic methods (Macaskill, Walter & Irwig, 2001). Moreover, all the primary studies that were included into the meta analysis had small sample sizes. Therefore, the results should be interpreted with caution. If study sample sizes a re relatively small, randomization may not result in equivalence of the contrasted groups. Finally, only published studies were included in the present meta analysis and thus , these studies do not form a random sample of all studies conducted on the subj ect. Due to studies with nonsignificant findings being less likely to be published than those which achieved statistical significance (Hall & Rosenthal, 1995) , there is the potential for a publication bias. Due to these limitations, some caution must be ex ercised in drawing strong conclusions regarding the effects of cultural context on the effectiveness of EMDR.
28 CHAPTER VI CONCLUSION AND FUTURE DIRECTIONS Consistent with previous research (e.g., Oras, Cancela , & Ahmad, 2004; Wilson, Tinker, et al., 2000) , the present study provides some evidence of the effectiveness of EMDR in treating PTSD. Study results support the use of EMDR as a primary treatment for children from diverse backgrounds, including those who are immigrants and refugees. This is sig nificant as age, developmental level, and c ulture can all affect the symptoms and presentations of PTSD (Adler et al. , 2005 ; BÃ¤Ã¤rnhielm & MÃ¶sko, 2015 ; Diehle et al 2015 ) . Arguably, it is plausible that the indicated efficacy of EMDR may afford some signif icant evidential support for certain hypothesized working mechanisms of EMDR; specifically, that of bilateral stimulation. There is also the potential for the aforementioned efficacy to be explained by the numerous procedural differences ; for example , the recurrent short exposure inherent in the practice of EMDR and the freedom for temporal distancing from the traumatic memory throughout the EMDR process (Patel & McDowall, 2016) . This is especially important when compar ing EMDR to other therapeutic int erventions with similar structural mechanics, such as cognitive behavioral therapy or other approaches which include exposure techniques, such as narrative exposure therapy (Lee, 2008, Rogers & Silver, 2002; Solomon & Shapiro, 2008). Furthermore, in additi on to these procedural differences, a number of hypotheses have been postulated to explain the mechanics behind the demonstrated efficacy of EMDR, including the working memory account (Gunter & Bodner, 2008) and the theory of an REM sleep state like condit ion dampening the stress response system reaction (Stickgold, 2007). Additionally, EMDR has been theorized to function as a distractor of sorts, and that through this imposed distance , the individual is enabled to more adaptively manage their reaction to t he traumatic memory through
29 recurrent exposure (Rothbaum et al., 2005). The results of this study seem to support the theory that it is the underlying function of bilateral stimulation that primarily contributes to effectiveness, in that such things as language and cultural context did not appear to have any effect on the effectiveness of EMDR. If a function such as bilateral stimulation is the root of the effectiveness of EMDR, then it stands to reason that its effectiveness would not be mitigated b y such factors as language, country, or cultural context, as it occurs outside of these factors. The present meta analysis included samples of youth from a range of cultural and linguist backgrounds, and EMDR consistently demonstrate d a large effect in ter ms of decreasing the trauma related symptoms and presentation of PTSD , regardless of country of origin or background. To date, the results concerning the investigation of these theories and hypotheses underlying EMDR effectiveness are inconsistent. Howeve r, t he field of neurobehavioral research shows considerable potential to more deeply investigate bilateral stimulation as a treatment technique in addition to other core posited working mechanisms of EMDR (Solomon & Heide, 2005; Stickgold, 2002, 2007). Fin ally, the efficacy of EMDR may be expounded upon through careful consideration and utilizations of the appropriate research standards for the evaluation of component analyses ; specifically , elements such as responsiveness to treatment, large samples for ad equate statistical power, and treatment fidelity (Chemtob et al., 2000; Rogers & Silver, 2002; Solomon & Shapiro, 2008). Supplementary studies, especially studies which have been specifically designed to investigate the respective hypotheses and procedural differences, should assist further inquiry appreciably. This study is the first to synthesize EMDR outcome s tudies across cultural background s and countr ies of origin to determine if there are appreciable differences in the effectiveness of
30 EMDR a mong cultures. Findings suggest that EMDR is a promising treatment for PTSD in children from a range of cultural backgrounds who have experienced trauma. As such, the use of EMDR should be considered as a primary treatment for reducing trauma related symptoms in immigrant and refugee populations.
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