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dcyphr | Comparison of Eye Movement Desensitization and Reprocessing Therapy, Cognitive Behavioral Writing Therapy, and Wait-List in Pediatric Posttraumatic Stress Disorder Following Single-Incident Trauma: A Multicenter Randomized Clinical Trial

Abstract

Trauma-focused psychotherapies are recommended for treating childhood PTSD. Eye movement desensitization and reprocessing (EMDR) therapy is an evidence-based treatment for PTSD in adults, but few well-designed trials have explored its efficacy in children. The authors used a single-blind randomized controlled trial with 2 groups in which patients received EMDR or cognitive behavioral writing therapy (CBWT) or were placed in a wait-list. After 6 weeks, wait-listed participants were randomly assigned to receive either EMDR or CBWT. Follow-ups were done at 3 and 12 weeks after treatment. 


Hypothesis: EMDR and CBWT would both be better than delayed-treatment in achieving remission from PTSD and reducing reported symptoms of PTSD, depression, anxiety, and behavior problems; and both treatment benefits would be maintained at 3- and 12-month follow-ups. 


Both EMDR and CBWT yielded large and significant remission (temporary recovery) rates for pediatric PTSD. They also resulted in reductions in the severity of PTSD symptoms and co-occurring impairments in children and adolescents (aged 8-18 years) seeking treatment after a single traumatic event. Generalization studies and those investigating EMDR efficacy in children with histories of multiple traumatic events as well as children under 8 years of age are needed. 


Introduction

Approximately 16% of children and adolescents exposed to trauma develop pediatric PTSD. It is associated with profound functional impairments (i.e., at the family level) and co-occurring psychiatric disorders that continue into adulthood if left untreated.


Trauma-focused psychotherapies like trauma-focused cognitive behavioral therapy (TF-CBT) are the most common recommended initial treatments for childhood PTSD. They tend to involve some mix of coping-skills training, exposure therapy, and parent interventions. 


EMDR therapy involves the patient engaging (a part of) a traumatic memory while their eyes rapidly move between two points (i.e., a therapist moving their fingers horizontally). The eye movements function to lessen the power of emotionally overwhelming traumatic memories, thereby allowing the patient to engage it without the risk of re-traumatization. EMDR is recommended to treat adults with PTSD, but few studies have explored its application to children. CBWT is a form of TF-CBT that was used for comparison to EMDR as it has much evidence supporting its efficacy. CBWT involves engaging a traumatic memory and re-structuring beliefs related to the trauma through writing and updating the traumatic memory with the help of a therapist. 


Both EMDR and CBWT function to integrate traumatic memories into everyday life (changing them into regular memories), an essential part of recovering from trauma. They are both brief treatments with sessions in this trial lasting no more than 45 minutes. Previous studies of EMDR application for pediatric PTSD lacked strength with small sample sizes, no use of blind assessors, failing to have a control group receiving no treatment, and minimal use of diagnostic interviews. The present study amended the aforementioned shortcomings. Moreover, very few randomized controlled trials have involved a population of treatment-seeking youth (for PTSD) exposed to a single-incident trauma. 


Methods

Study design and participants

Participants were recruited from new referrals to 7 child and adolescent mental health clinics across the Netherlands. 


Inclusion and exclusion criteria

Participants were aged 8-18 years, knew how to read/write/communicate in Dutch, and met DSM-IV diagnosis for PTSD or subthreshold PTSD tied to a single incident. Those with symptoms in need of urgent care (i.e., suicidal thoughts), started using psychotropic medication or were receiving other kinds of psychological treatment, or had an IQ below 80 were excluded. 


Procedure

The three groups (or arms) of the study were randomly assigned and blocked according to a ratio of 2:2:1 (EMDR, CBWT, Waitlist) to ensure statistical strength while withholding treatment to as few participants as possible. 


Primary outcome measures

PTSD symptoms and its diagnostic status were measured by many diagnostic interviews. 


Secondary outcome measures

Diagnostic measures were used to measure co-occurring impairments such as depression and anxiety, and quality of life.


Interventions

EMDR and CBWT were administered in up to six weekly individual sessions lasting up to 45 minutes each, with no further instructions to engage in treatment-related activities after the sessions (for both children and parents). 


Results

EMDR was significantly briefer than CBWT for the average number of sessions (EMDR: 4.1, CBWT: 5.4) and the number of minutes (EMDR: 140, CBWT: 227) it took for participants to recover enough to no longer meet diagnostic criteria for PTSD.


Primary Outcomes

Compared to WL, EMDR and CBWT participants had significant reductions in child- and parent-reports of PTSD symptoms as well as improvements in PTSD severity. These were maintained at 3- and 12-month follow-ups. Interestingly, the EMDR group reported additional improvements in PTSD symptoms between the 3- and 12-month follow-ups. 


Remission rates in EMDR and CBWT (92%) were significantly higher than the WL group (52%). Remission rates in the EMDR group also improved significantly during the 3- and 12-month follow-up period, reaching an astonishing 100% at 12 months according to child and parent interviews. 


Secondary Outcomes

Compared to WL, EMDR and CBWT participants had significant reductions in negative trauma-related thinking (cognitions), child-reported symptoms of anxiety and depression, and parent-reported emotional/behavioral problems. EMDR participants reported additional improvements in child- and parent-reported quality of life between posttreatment and 3 months, and 3-month and 12-month follow-up. 


Discussion

Results were consistent with the authors’ hypothesis. Participants in both EMDR and CBWT maintained (and improved slightly) on the primary and secondary outcomes from posttreatment to 3-month and, importantly, 1-year follow-ups. 


This study is the first three-arm RCT demonstrating the efficacy of EMDR and a brief form of TF-CBT compared to WL for childhood PTSD following a single-incident trauma. This is also the first RCT with children and adolescents using computer-aided CBWT. 


The shortness of both treatments in producing significant results (they around half the time compared to standard TF-CBT interventions) is an important and novel finding. The seemingly efficient nature of both treatments may reflect the idea that components involved in coping-skills training (i.e., parent-focused interventions) may not be necessary for the initial treatment of pediatric PTSD. 


EMDR and CBWT, involving no training in coping-skills and minimal parental involvement before trauma memory work, are well-tolerated treatments that yielded significant reductions in single-incident childhood PTSD and co-occurring impairments in 5 sessions (lasting 45 minutes per session) or less. These gains were maintained up to one year after treatment. 


Generalization studies and further research into the efficacy of EMDR and CBWT involving multiple-incident trauma and children under 8 years of age are warranted.