1. EMDR in children Effectiveness and Clinical Implications
DR. DEEPAK GUPTA
MD (Psychiatry), DNB (Psychiatry)
Diploma Child & Adolescent Psychiatry (London, UK)
Consultant Child & Adolescent Psychiatrist
Sir Ganga Ram Hospital
Founder, Centre for Child and Adolescent Wellbeing (CCAW)
New Delhi
ANCIPS 2011, New Delhi

2. EMDR……..
“I turned my feelings into a Ping-Pong ball and smashed them out the window…”

3. EMDR as a Therapeutic Modality
It doesn’t matter how long the memories have been stored and for how long they have been exerting a negative effect on the child.
Children reprocess their traumas more quickly in EMDR than in other therapies and becomes desensitized to the painful memories and images.
The EMDR procedures results in:
Decreasing the vividness of disturbing memory, images and related affect.
Facilitating access to more adaptive information.
Forging new associations within and between memory networks.

4. Efficacy in children Researcher and Year Aim Result
Jaberghaderi et al 2004
Randomized controlled study with 14 Iranian girls
Comparison between CBT and EMDR when used with sexually abused year-old children
Both Cognitive Behavior Therapy (CBT) and EMDR to be quite effective. EMDR proved to be more efficient, as it required fewer sessions and improvement in related behavioral problems.
Ahmad et al 2007
RCT
Effectiveness of EMDR Vs WLC in 6-16-year-old children with a DSM-IV diagnosis of PTSD
EMDR was found to be an effective treatment in children with PTSD from various sources
Frank & Wagner
2006 
CBT Vs EMDR
Meta Analysis
Trauma-focused CBT and EMDR tend to be equally efficacious

5. EMDR is effective in children with:
Crime victims (Solomon 1995, 1998; McNally & Solomon, 1999 )
Child with excessive grief due to the loss of loved ones (Solomon , 1995, 1998)
Trauma due to assault or natural disaster (Lovett 1999; Wilson & Tinker 2000)
Sexual assault victims (Edmond, Rubin, & Wambach, 1999)
Accident, surgery and burn victims who were once emotionally or physically debilitated (Solomon & Kaufman, 1994; Blore, 1997)
Complex PTSD (Manfield, 1998)

6. Phases of EMDR treatment
EMDR involves 8 phases:
Phase 1: History and treatment planning
Phase 2: Preparation
Phase 3: Assessment
Phase 4: Desensitization
Phase 5: Installation
Phase 6: Body Scan
Phase 7: Closure
Phase 8: Reevaluation

7. Phase 1: History and treatment planning
Sufficient information including dysfunctional behavior and symptoms can be obtained from parents, counselors/foster care/case workers
Ask the Child: “what’s the worst thing?” and other details….
The treatment plan is made keeping in mind the targeting sequence and the needed skills and education…..use judgment…..one which is disturbing him currently
Consent from parents

8. Phase 2: Preparation Developmental appropriate explanation of process
Relaxation techniques along with guided visualization are used to deal with the distress if caused
Eye movements
Tactile/Tones
Safe place: real or imagined - to make him/her feel comfortable and secure- draw a safe place

9. Phase 3: Assessment
Memory identified, an image representative of it - can be made as drawings on paper….puppets and toys can be used.
Negative cognition (NC) associated with it…….“I am bad” and a Positive cognition (PC) ….“ I am happy”….that would be later used to replace the negative thought – should be developmentally appropriate (drawings on flash cards)
VoC Measurement/VAS……..1 to 7…can use hand
Emotions….may have to teach about emotions
A 10 point Subject Units of Disturbance (SUD) scale or blocks is used to measure the level of disturbance caused to the client ….number blocks/hands
If any physical sensations present, location also identified.

10. Phase 4: Desensitization
Reprocessing using bilateral stimulation:
This stage is the toughest but should be continued, irrespective of the increasing or decreasing internal distress caused.
Verbatim/Storytelling/drawings to report
Emotional response – usually not much during session but more between sessions
Parents in sessions

11. Phase 5/6: Installation & Body Scan
Positive cognitions only once on the SUD scale the child’s reaches a 0 value…..Developmentally appropriate….
Bilateral stimulation the positive thoughts replace the negative cognitions.
Body scan
When the positive cognitions have been successfully placed, the child is checked for any residual tension that he/she might be still experiencing in any part of his/her body…..children are somatic…..

12. Phase 7/8: Closure & Reevaluation
At the end of each session, it is important that the child attains emotional equilibrium…..playing with them…drawings….
Child is encouraged and appreciated for his efforts.
Closure statement….
Talk to parents.
Re-evaluation
At the beginning of every new session, it is important to re- evaluate in order to be able to determine if the treatment effects have been maintained or not. These can be noted by changes in behavior or thoughts – cross checked by parents.

13. Skills with children More active Creative Innovative
Tactile works well with smaller children
Don’t probe too much especially with smaller children
Involve parents

14. Working with EMDR
Over the last one year, at our centre, we have worked with children (7-18 yrs) with a spectrum of trauma related psychological problems; and varied Phobias including school phobias with whom EMDR was found beneficial.
In most of the cases, the average number of sessions required was 2-4, and they continue to show improvement, even after EMDR was stopped.

15. Case Example….TRAUMA
A 8 yr old male came to us in April 2009, with features suggestive of anxiety disorder.
In November 2008, he developed fever and had his first emotional breakdown. These symptoms developed when his father went out of station on 11th Nov. He would start to cry and complain that why do people who love me always go away.
The child’s paternal grandfather passed away in 2006.
After which his paternal grandmother expired in Jan 2007, and then a month later his maternal grandfather also passed away and in August 2008 his close friend expired in road accident.
According to the parents since the episode in Nov 2008, the child has been restless, clinging, crying, complaining of headaches and pains, nightmares, missing school.

16. Case Example
We decided to help the child using EMDR after the informed consent from parents.
We started individual sessions with the child from 28th March 2009.
The child responded well to the sessions.
He was able to identify his negative and positive cognitions, and rate them on the SUD and VOC scales.
The intervention technique mainly used with the child was drawings.
We did three sessions of EMDR with the child, after which he was better in all domains.

17. Case Example…Phobia
A 9 year old intelligent young boy, extended family, parents doctors, presented with: - fear of thunderstorm and rains from few months -- - increased from last few weeks during rainy season - associated with school reluctance, clinging behaviour and separation anxiety - no academic decline or other psychopathology 3 sessions of weekly EMDR in July-August 2010…..total resolution of fears….doing well……

18. Working with EMDR in group setting
We have worked with children living in foster care (7-18 yrs of age) with history of varied trauma with whom EMDR was found beneficial as reported by children subjectively.

19. Advantages of Using EMDR with Children (Tinker et al., 1999):
Children respond very well to EMDR
Reprocessing often more rapid with children
Since the changes occur automatically, and in a non volitional manner, it makes it comparatively easier to use with children.
Children have less complex memory networks.

20. Advantages of Using EMDR with Children (Tinker et al., 1999):
Standard EMDR protocol may be used with developmentally appropriate modifications.
Even parent(s) can participate in the sessions, as it is generally of a non threatening nature to the parent(s), as well as, the child.
At times when the child is not able to handle the intense emotions that can come up during the sessions, soothing and self soothing approaches, and other therapeutic techniques can be used.

21. Challenges: Co-morbidites especially dissociation Selecting a case
Lack of parental support
Psychosocial adversities – Chronic stressor

22. Conclusion
The maintenance of treatment effects, even after 15 months of administering EMDR have been recorded.
A note of caution is that it is important that professionals be trained to use it before they put it to practice.
EMDR has a huge potential, but along with it comes the clinician’s responsibility to use it wisely as one of the promising psychotherapeutic tools with children with trauma related and other psychological disorders.

23. Finally….. Trauma… a drop in water but ripples over years……. & EMDR….
….I’m in my safe place………….

24. THANK YOU