EMDR Treatment Efficacy in Maltreated and Traumatized Children

Project location: Italy, Rome
Project start date: December 2011 - Project end date: October 2013
Project number: 2011-36
Beneficiary: Cospexa

Child maltreatment (CM) is generally thought to encompass four types of violence against children: physical abuse, sexual abuse, physical neglect, and psychological abuse. Estimating the prevalence of CM remains complex and imprecise due to lack of systematic and nationwide prevalence studies on the phenomenon. Reliable data based only on reported cases document a prevalence between 1% (Sedlak, & Broadhurst, 1996) and 3% (Euser, van IJzendoorn, Prinzie, Bakermans-Kranenburg, 2010), while it's generally agreed that most part of the child abuse and neglect phenomenon is largely unreported. In fact, when data are from self-report studies, overall prevalence may dramatically rise like in a recent study (Lamers-Winkelman, Slot, Bijl, Vijlbrief, 2007) where prevalence was 19.5%.
As far as consequences are considered, in addition to physical injuries CM may also lead to serious psychological, emotional, behavioral, cognitive and neurobiological disorders (Azar & Wolfe, 1998; Behen et al., 2009; Berliner & Elliott, 2002; Teicher, 2002) among children.
Specifically, CM has been linked with the development of internalizing disorders (such as depression, anxiety, Post Traumatic Stress Disorder (PTSD), somatic complaints, suicidality), externalizing disorders (in the form of aggression, acting out, anger, impulsiveness, delinquency, and hyperactivity), as well as attachment disorders, sexually inappropriate behaviors, and cognitive impairment or delays (Azar & Wolfe, 1998; Finkelhor & Berliner, 1995; Kaplan, Pelcovitz, & Labruna, 1999; Turner, Finkelhor, Ormrod, 2010).
Among the aforementioned disorders, PTSD is generally reported not only as the most common but also as the one with more enduring symptomatology through the life span when CM occurs. Within a clinical sample of child sexual abuse victims, for instance, nearly 36% of adult survivors have been reported to have PTSD (Rodriguez, Ryan, Van de Kemp, & Foy, 1997).
Because of the widespread incidence of CM, a variety of psychological treatments for its main psychological consequences have been developed and are currently in use. Although, historically, these treatments were rarely evaluated, the last decade has seen a dramatic increase in the number of empirical studies documenting their effectiveness (Skowron, Reinemann, 2005). However, to date it remains uncertain whether these treatments, on the whole, are effective. This is mainly due to two mutually influencing factors. The first is relative to the many existing type of treatments, whose so-called "therapeutic factors" are very difficult to isolate and study. The second has to do with the target of those treatments, in that different treatments will try to tackle: the individual victim or the family system; specific effects of CM (symptoms; intrapsychic representations; behaviors; etcetera); peculiar combinations of these. This will inevitably result in an impossibility to state "what (treatment)" really works for "whom" (the victim/the family) and on "what levels" (target of the intervention).

The principal investigators of this project are members of the Steering Committee of "Spazio Sicuro", the Province of Rome's Centre of Excellence for the psychosocial management, diagnosis and treatment of abused and neglected children and their families. The Centre has managed more than 1.000 child abuse situations in the last 10 years, developing a solid expertise in the field, with special emphasis on assessment and treatment issues.
Especially in times of economic crisis, it becomes of paramount importance to devise evidence-based treatments whose efficacy and short-term perspective can allow both those who are in need to undergo them, and a Centre like ours to provide high numbers of treatment for the targeted clinical population.
Since the massive requests for psychological treatments following childhood traumas cannot be adequately tackled by the clinical resources of our Centre, we are turning to a model of psychotherapeutic intervention mainly focused on the reduction/extinction of the psychological burden of post traumatic symptoms in the abused children.
Though still limited, research on this issue is showing good effectiveness of EMDR treatment of post traumatic conditions as those of frequent occurrence in abused children as well in type II or complex traumas (Ahmad, Larsson, Sundelin-Wahlsten, 2007; Pagani, Di Lorenzo, Verardo, Nicolais, Monaco, Lauretti, Cogolo, Niolu, Ammaniti, Siracusano and Fernadez, in press).
EMDR is an empirically supported treatment for PTSD, guided by the Adaptive Information Processing model (AIP), which was described by Shapiro (2001) as an inherent information processing system geared to process experiences to an adaptive state. According to this model, information related to distressing or traumatic experience is not always completely processed and the memory of the event can remain stored in a dysfunctional way, causing post-traumatic symptoms and suffering. In AIP terms, high levels of disturbance can disrupt the information processing system and cause memories to be stored in state specific form, unable to integrate with other functional information. The goal of EMDR therapy is to access the dysfunctionally stored experiences and stimulate the innate information processing system in order to take the traumatic memory to adaptive resolution. A distinct characteristic of EMDR is the use of alternating bilateral stimulation such as eye movement, tactile or auditive. The patient is asked to focus upon the image of the traumatic memory and the associated negative cognitions, disturbing feelings and sensations while simultaneously attending to an alternate stimulus for brief sets of approximately 30 seconds. Between one set and another the client is instructed to give a feedback of what he notices or comes to his mind. Typically the patient will refer changes in the image, in cognitions, emotions or physical sensations which indicate processing. During an EMDR session the components of the distressing memory are linked with other more adaptive information existing in the neural networks and therefore desensitization and reprocessing of the memory occur, which contribute to symptom reduction and remission. The AIP model argues that the targeted memory emerges from its isolated state to become appropriately integrated with the larger comprehensive memory networks, forging new associations and connections.

Aim of the study, which received a grant from the Nando Peretti Foundation, is to test the efficacy of EMDR treatment with a clinical population of abused children in the reduction/extinction of post traumatic symptomatology, contrasting such a therapeutic methodology to routinely offered standard supportive therapy intervention.
Each year, the "Diagnosis and Treatment" Unit of our Centre serves an outpatient clinical population of approximately 60 abused and neglected children. Referring to our experience so far, nearly half of this clinical population is expected to show clear and diagnosable signs of post traumatic symptoms (PTSD and "PTSD-like" symptomatic constellations). Considering the whole clinical population, the Unit will either perform an initial diagnostic assessment or be asked by Province of Rome's health and social services to provide psychological treatment.
In both cases, children will be screened for actual and concurrent post traumatic symptomatology via the administration of :
- CBCL - Child Behavior Checklist/Caregiver-Teacher Report Form (Achenbach, Rescorla, 2000) if aged 2 to 6
- CRIES - Children's Revised Impact of Event Scale (Perrin, Meiser-Stedman, Smith, 2005), if 6 or above.
Children showing post traumatic symptomatology will then be randomly assigned to two groups:
1) EMDR treatment group (N=12): (see above). The length of the intervention is within an average range of 15 sessions.
2) Supportive therapy group (N=12): a supportive psychotherapeutic intervention aimed at the working-through of the traumatic experience as main therapeutic factor for the reduction/extinction of PTSD symptomatology. The length of the intervention is within an average range of 25 sessions.
Before entering treatment, all children's cortisol levels will be measured as a biological concurrent measure of their post traumatic condition.
The "EMDR treatment group" children will then be given EMDR treatment, while the "Supportive therapy group" children will receive routine supportive therapy mainly aimed at symptoms management and reduction.
At the end of these treatment phase, all children will be screened for a second time for post traumatic symptomatology, using the same psychological and neurobiological testing procedures and methodologies.
A 6-month follow-up will therefore be performed to investigate stability of change.
In order to:
a)reach a significant clinical population of N=50 PTSD children that will be split in the two different treatment modalities, and
b)complete 6-month follow-up for each,
the estimated length of the project is of 2 years.

Anticipated achievements or outcomes of the Project
The expected output is a significantly more evident and stable extinction of post traumatic symptomatology within the "EMDR treatment group" in comparison with the "Supportive therapy group". In such a case, soon after the end of the treatment phase, all the children of the "Supportive Therapy Group" will be offered a 6-month EMDR treatment. If data should support our hypothesis, EMDR treatment would be implemented as the first-choice treatment for traumatized children in our Centre.