Dealing With the Aftermath of Mass Disasters: A Field Study on the Application of EMDR Integrative Group Treatment Protocol With Child Survivors of the 2016 Italy Earthquakes

'School-based screen-and-treat': An effective blueprint for expediating access to care in children experiencing PTSD following disasters

OBJECTIVES

While 5%-10% of children exposed to natural disasters develop PTSD, few children access support. This paper reports on the proactive 'screen-and-treat' approach deployed following devastating floods in Queensland, Australia, in 2011 and presents results for children in the Lockyer Valley (the most impacted community).

DESIGN

Open treatment study (2011-2012) within a government-funded post-disaster service response.

METHODS

One hundred and fifty children (7-12 years) completed pencil-and-paper screening (PTSD, anxiety and depression) at school. Eighty children endorsing either clinical levels of PTSD, or moderate levels of PTSD and clinical levels of either anxiety or depression, and their parents, completed a structured diagnostic interview. Forty-eight children were offered a free trauma-focused CBT intervention. The parents of 19 children accepted this offer. Most clinicians were clinical psychology trainees from local universities. All measures were repeated at post-treatment, 6- and 12-month follow-up. Note: The term 'parents' is used to refer to the wide variety of people serving as a child's primary caregiver.

RESULTS

Pre-treatment, all children met diagnostic criteria for full (N = 17) or sub-clinical PTSD. By post-treatment, 10.5% met criteria for PTSD, with 0% meeting criteria at the 12-month follow-up. The incidence of anxiety and depressive disorders also reduced significantly. There were no differences in outcomes for children seen by trainees compared to experienced clinicians.

CONCLUSIONS

A school-based screen-and-treat approach offers potential as a means of identifying and treating children following natural disaster exposure. However, engagement of families at the outset, and when offering intervention was challenging. Postgraduate trainees represent an effective potential workforce in a post-disaster environment.

A Scoping Review of Trauma-Informed Pediatric Interventions in Response to Natural and Biologic Disasters

A scoping review was performed of trauma-informed psychological interventions to treat anxiety, depression, and posttraumatic stress symptoms in youth in response to natural/biologic disasters. The specific aims were to identify psychosocial interventions used in response to natural/biologic disasters, report the interventions' effectiveness, describe limitations, and provide treatment recommendations and future directions. Of the 45 studies extracted, 28 were on natural disasters and 17 on biologic disasters with the majority related to the COVID-19 pandemic. The most commonly implemented interventions were Cognitive Behavioral Therapy (CBT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and eye movement desensitization and reprocessing (EMDR). The UCLA Posttraumatic Stress Disorder Reaction Index (UCLA PTSD-RI) and the Strengths and Difficulties Questionnaire (SDQ) were the most frequently used measures. Methodological rigor was varied, with 60% randomized, controlled trials. Overall, there was a significant decrease in posttraumatic stress symptoms, distress, anxiety, and depression regardless of whether the participant received CBT, TF-CBT, or EMDR. Generally, there was not a significant decrease in anxiety and depression with yoga, cognitive fear-reduction, emotion-based drawing, and community health education. Recommendations for future directions include larger-scale studies with group and on-line interventions that include younger children with moderation analyses by gender and race/ethnicity.

Feasibility and effect of emotional freedom therapy on sleep quality in patients with end-stage renal disease receiving maintenance hemodialysis: A pilot study

OBJECTIVE

To explore the feasibility and efficacy of emotional freedom therapy (EFT) in improving sleep quality and managing negative emotions in end-stage renal disease patients on maintenance hemodialysis.

METHODS

Between May 2021 and February 2022, 66 maintenance hemodialysis patients with sleep problems were recruited and randomized into an intervention and control group. The intervention group underwent a 12-week intervention of EFT. Two groups' hospital anxiety depression scale (HADS) scores, Pittsburgh sleep quality index (PSQI), and interdialysis weight gain (IDWG) before and one week after the formal intervention were collected and compared. Feasibility analysis was performed using a feasibility questionnaire and in-depth interviews with patients.

RESULTS

Before the intervention, there was no statistical difference in the anxiety, depression, PSQI scores and IDWG between the two groups. After balancing the effects of gender and pre-intervention scores, two-way ANCOVA results showed that there were statistically significant differences between the two groups after the intervention in terms of anxiety, depression, sleep quality, sleep duration, daytime dysfunction and PSQI total score. However, interactions effect for IDWG was statistically significant. Simple effects analysis revealed a difference in post-intervention IDWG between the intervention and control groups for patients over 65 (p < 0.05). Most patients agreed or strongly agreed that the EFT was easy to schedule and they did not experience difficulties during learning the EFT process (respectively 75% and 71.88%). And 75% of the participants were willing to continue practicing EFT. Qualitative content analysis identified five prominent categories related to feasibility and acceptability: affirmation, benefits, communication, support and trust.

CONCLUSION

EFT can relieve anxiety and depression, enhance sleep quality, and improve the physical condition of patients with end-stage renal disease receiving maintenance hemodialysis. As well, the EFT intervention is practicable, acceptable, and perceived as being beneficial to the patient.

Parental Support during the COVID-19 Pandemic: Friend or Foe? A Moderation Analysis of the Association between Maternal Anxiety and Children's Stress in Italian Dyads

There is evidence that parental psychological disorders in stressful situations increase the risk of disturbance in child development. This has been investigated in disasters but not in pandemics, which are sensibly different from other types of traumatic events. We investigated the relationship between mothers' anxiety and their children's (self-reported) stress and the boundary conditions of this association during the first full COVID-19 lockdown in Italy. During the COVID-19 pandemic, mothers might have increased their protective attitudes to secure and support their children; we tested whether the relationship between mothers' anxiety and children's stress was weaker (buffer effect) or stronger (over-protection effect) when perceived parental support was high. We measured mothers' anxiety, children's perceived parental support, and children's stress in a sample of 414 8- to 11-year-old primary school children (229 females, Mage = 9.44) and 395 mothers (Mage = 42.84). Results supported the over-protection scenario and provided the first evidence for the "helicopter-parent effect" during the COVID-19 pandemic: mothers' anxiety was positively associated with children's stress only when perceived support was high. Our finding highlights the importance of educating parents (for example, via emotional training) to prevent the worst consequences of adverse events in children and promote their mental health.

The effect of the online eye movement desensitization and reprocessing early intervention protocol (EMDR R-TEP) for the risk groups with post-traumatic stress symptoms during the COVID-19 pandemic

The aim of the research is to investigate the effect of eye movement desensitization and reprocessing (EMDR) therapy on post-traumatic stress disorder (PTSD) levels of individuals who can be defined as high-risk groups during the pandemic. Therefore, the online EMDR R-TEP Protocol was applied to a total of 154 individuals working with coronavirus patients, frontline professionals (Doctors, Nurses, Paramedics, Polices, Red Crescent), relatives of coronavirus patients, coronavirus patients, and relatives of someone who died from coronavirus and the PTSD symptom level before, after, and 1 month after therapy was measured and examined. A personal information form and impact of events scale were used to collect data. Analyses showed that EMDR therapy was effective in reducing the PTSD level in all groups. The PTSD levels of frontline professionals continued to decrease until the follow-up test but remained the same in the other groups.

What Do We Know About EMDR Therapy Research? A Bibliometric Analysis

Bibliometric analysis is a quantitative method designed to analyze large volumes of scientific output data and to map the intellectual landscape of a specific area of knowledge by describing its scientometric indicators (e.g., number of publications and citations, etc.) and structural relationships (e.g., co-authorship patterns, keyword clustering, etc.) between its different components. In this article, methods of bibliometric analysis are applied to the corpus of publications on eye movement desensitization and reprocessing (EMDR) therapy research. A total of 1,150 papers found in the Web of Science database and published between 1994 and early 2021 were included in the analysis. Retrieved bibliometric data was analyzed and visualized using VOSViewer software. Temporal distribution of publications (number of publications per year); spatial distribution of publications (author affiliations); top journals; impact of EMDR research as assessed by highly cited publications; author co-citation as a measure of collaboration; literature co-citation as a measure of internal structure; and key terms were analyzed. The results of the study provide the readers with a broad, “one-stop overview” of the current state of research on EMDR therapy, with a focus on the quantitative characteristics of its output and on the key represented topics.

Child and Adolescent Psychosocial Support Programs Following Natural Disasters-a Scoping Review of Emerging Evidence

PURPOSE OF REVIEW

This review aimed to identify and describe evidence published in the past 3 years from trials of psychosocial support programs for children and adolescents affected by natural disasters.

RECENT FINDINGS

Previous reviews have indicated these programs are beneficial overall. Positive impacts were documented in school-based programs conducted by trained teachers and paraprofessionals with stronger effects achieved by more qualified professionals. The review found supporting evidence for positive impacts of post-disaster psychosocial programs. However, the strength of evidence is limited due to heterogeneity in interventions and evaluations. The stepped care model was found to be useful in differentiating between programs and level of available evidence. Hobfoll's five essential elements of mass trauma intervention provide an additional means of guiding program content and assessments, particularly for universal programs. Identified gaps in evidence included groups likely to be at most risk: preschool children, ethnically diverse groups, those with disability, and social disadvantage. There were promising indications of program benefits for groups with repeated exposure to natural disasters.

Group eye movement desensitization and reprocessing interventions in adults and children: A systematic review of randomized and nonrandomized trials

This review systematically synthesized existing literature on group protocols of eye movement desensitization and reprocessing (EMDR) therapy for treating a range of mental health difficulties in adults and children. We conducted database searches on PsychINFO, EMBASE, MEDLINE, Web of Science, The Cochrane Library and Francine Shapiro Library up to May 2020, using PRISMA guidelines. Studies were included if they used at least one standardized outcome measure, if they present a quantitative data on the effect of group EMDR protocols on mental health difficulties and if they were published in English. Twenty-two studies with 1739 participants were included. Thirteen studies examined EMDR Integrative Group Treatment Protocol (IGTP), four studies examined EMDR Group Traumatic Episode Protocol (G-TEP), four studies EMDR Integrative Group Treatment Protocol for Ongoing Traumatic Stress and one study considered EMDR Group Protocol with Children. Of the 22 studies included, 12 were one-arm trials and 10 were two-arm trials. We assessed risk of bias using a revised Tool to Assess Risk of Bias in Randomized Trials (ROB 2) and Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I). Overall, the results suggested that Group EMDR protocols might be an effective tool in improving a wide range of mental health-related outcomes including posttraumatic stress disorder (PTSD), depression and anxiety. However, the included studies are limited to methodological challenges. The limitations and future directions are discussed.

Child-Focused Mental Health Interventions for Disasters Recovery: A Rapid Review of Experiences to Inform Return-to-School Strategies After COVID-19

There is a worldwide need for mental health interventions to address the mental health needs of children under 12 who are returning to school in the post-COVID-19 environment. The basic characteristics of child-focused, post-crisis interventions are currently unknown, but they are essential for developing high-quality, expedient RTC programs. We conducted a rapid systematic review, via established PICO methodology, to appraise the characteristics of such interventions. We queried databases (PubMed, PsycInfo, ERIC) for English and Spanish publications describing mental health interventions to reduce mental health symptoms and sequelae among children exposed to disasters and other community crises. We described the following characteristics: type of intervention, length, number of sessions, number of staff delivering the intervention, and other characteristics. A total of 18 original articles met the inclusion criteria: 11 correspond to a controlled trial type of study and 15 addressed PTSD after disaster or crisis situations. Cognitive-behavioral therapy (CBT) was the most common intervention type, school-based/related interventions were the most common method, and five articles described an important role of teachers as mediators of therapy.

Psychological Impact of the COVID-19 Pandemic on Adults and Their Children in Italy

Aim: The coronavirus disease 2019 (COVID-19) pandemic has abruptly changed the life of millions as travel and social contacts have been severely restricted. We assessed the psychological impact of COVID-19 on adults and children, with special attention to health care workers (HCWs). Methods: A self-rated online survey, including the Impact of Event Scale-Revised (IES-R) for adults and the Children Revised Impact of Event Scale-Revised-13 items (CRIES-13) for their 8-18-year-old offspring, was conducted in Italy on March 20-26, 2020. Linear mixed-effects models were applied to the data, accounting for age, sex, education, and other demographic characteristics. Results: Data were available from 2,419 adults (78.4% females, mean age 38.1 ± SD 13.1 years; 15.7% HCW) and 786 children (50.1% male, mean age 12.3 ± 3.2 years). Median (IQR) IES-R score was 30.0 (21.0-40.0), corresponding to mild psychological impact, with 33.2% reporting severe psychological impact. IES-R was lower in HCWs (29.0) than non-HCWs (31.0), but HCWs directly involved in COVID-19 care had higher scores [33.0 (26.0-43.2)] than uninvolved HCWs [28.0 (19.0-36.0)]. Median CRIES-13 score was [21.0 (11.0-32.0)], with 30.9% of the children at high risk for post-traumatic stress disorder. Parent and child scores were correlated. Conclusions: Up to 30% of adult and children in the pandemic area are at high risk for post-traumatic stress disturbances. The risk is greater for HCWs directly involved in COVID-19 care and for their children.

The Current Status of EMDR Therapy, Specific Target Areas, and Goals for the Future

While eye movement desensitization and reprocessing (EMDR) is considered an evidence-based treatment for posttraumatic stress disorder (PTSD) in adults, there are differences as to how various international treatment guidelines judge the strength of this evidence base. Furthermore, in areas other than adult PTSD, major guidelines differ even more as to the strength of the evidence base and when to use EMDR. In 2019, the Council of Scholars: The Future of EMDR Therapy Project was initiated. Several working groups were established, with one assigned to the focus area of research. This article is a product of that working group. Firstly the group concluded that there were five areas where there was some base that EMDR was effective, but more data were needed to increase the likelihood that it would be considered in future international treatment guidelines. These areas were PTSD in children and adolescents, early EMDR interventions, combat PTSD, unipolar depression, and chronic pain. In addition, research into cost-effectiveness of EMDR therapy was identified as one of the priorities. A hierarchical system was used for classifying and rating evidence in the focus areas. After assessing the 120 outcome studies pertaining to the focus areas, we conclude that for two of the areas (i.e., PTSD in children and adolescents and EMDR early interventions research) the strength of the evidence is rated at the highest level, whereas the other areas obtain the second highest level. Some general recommendations for improving the quality of future research on the effectiveness of EMDR therapy are formulated.

Efficacy of the 'Children in Disaster: Evaluation and Recovery (CIDER)' Protocol for Traumatized Adolescents in Korea

BACKGROUND

We aimed to evaluate the feasibility of trauma-focused group therapy in adolescents exposed to traumatic events in Korea.

METHODS

We recruited 22 adolescents (mean age, 16 years; standard deviation, 1.43; range, 13-18 years). Children in Disaster: Evaluation and Recovery (CIDER) V1.0 is a trauma-focused group therapy comprising eight 50-minute-long sessions. The effectiveness of the intervention was evaluated using the Korean version of the Children's Response to Traumatic Events Scale-Revised (K-CRTES-R), the Beck Depression Inventory (BDI), the State Anxiety Inventory for Children (SAIC), and the Pediatric Quality of Life Inventory (PedsQL). The data were analyzed by the Wilcoxon signed-rank test.

RESULTS

A significant improvement was revealed in trauma-related symptom scores (Z = -2.85, P < 0.01), depressive symptom scores (Z = -2.35, P < 0.05) and quality of life scores (Z = -3.08, P < 0.01). Additionally, a marginally significant improvement was found in anxiety symptom scores (Z = -1.90, P = 0.058).

CONCLUSION

CIDER is a potentially effective intervention for adolescents exposed to traumatic events. Larger controlled trials are needed.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0004681.

EMDR Group Protocol With Children: A Field Study

The Eye Movement Desensitization and Reprocessing Group Protocol with Children (EMDR-GP/C) was first developed by Korkmazlar following the Marmara earthquake in Turkey in 1999 and can be adapted for different populations. This study focused on EMDR-GP with children who lost their fathers in the mine explosion that occurred in 2014 in Soma, Turkey. The EMDR-GP/C was used with 41 children (7–12 years old) in the early intervention, 3 weeks after the disaster, and used with 25 other children (6–13 years old) in the late intervention, 18 months after the disaster, when posttraumatic stress disorder symptoms had developed. The differences between the early and late implementations of EMDR-GP/C are presented in this article. In the early intervention, children processed the trauma by focusing on the “events” as they saw or heard them; however, 18 months after the disaster, children processed their “emotions” about the event in the desensitization phase. Results show a significant decrease in scores of subjective units of disturbance (SUDs) for both intervention periods. An analysis was also conducted, comparing decreases in SUD scores for younger and older children, with no differences found in their response to treatment. Pre and follow-up data were collected for the late intervention condition, using the Child Report of Posttraumatic Symptoms (CROPS), and showed a significant decrease at 18-month follow-up. Further studies are suggested to determine effectiveness of EMDR-GP/C with other populations.

The EMDR Recent Birth Trauma Protocol: a pilot randomised clinical trial after traumatic childbirth

Objective: This pilot study investigated the effectiveness of brief EMDR intervention as compared to treatment-as-usual (TAU) in women with post-partum PTSD symptoms.Design: A pilot randomised controlled trial was conducted to evaluate possible differences between one EMDR session (n = 19) and one TAU session (n = 18) delivered in a maternity ward in the aftermath of childbirth.Main Outcome Measures: The primary outcome measure was the rate of remission of post-partum post-traumatic stress symptoms (i.e. IES-R score <23) in both groups at 6-weeks (T1) and 12-weeks' post-partum (T2). Secondary outcome measures were mother-to-infant bonding, post-partum depressive symptoms, the presence of flashbacks and level of distress.Results: Most of the women improved their post-partum post-traumatic stress symptoms after only one treatment session. EMDR resulted more effective than TAU in reducing the proportion of women with post-partum post-traumatic stress symptoms at 6-weeks' post-partum (78.9% EMDR vs. 39.9% TAU; p = .020). Moreover, women treated with EMDR experienced less flashbacks and distress as compared to TAU. No significant difference was found between treatments on mother-to-infant bonding and post-partum depressive symptoms.Conclusions: These findings, although preliminary, suggest that a brief EMDR intervention could be a viable and promising tool in the early treatment of post-traumatic stress related to traumatic childbirth.

The Efficacy of EMDR Early Interventions

This brief narrative review begins with an overview of posttraumatic response and explains the value of early treatment in reducing/eliminating symptoms of distress and possibly preventing the development of posttraumatic stress disorder (PTSD) or other disorders. The article then summarizes the efficacy of eye movement desensitization and reprocessing (EMDR) therapy as an early intervention treatment. It outlines the historical context of EMDR early interventions and describes the three protocols which have research support from randomized controlled trials (RCTs), elaborating on their supportive evidence in seven RCTs conducted within 3 months of the traumatic event. These studies showed that EMDR early interventions significantly reduced symptoms of traumatic stress and prevented any exacerbation of symptoms. EMDR was superior to wait-list and to control conditions of critical incident stress debriefing, reassurance therapy, and supportive counseling. The article also examines the disparate evaluations of EMDR early interventions in the PTSD treatment guidelines, from the International Society for Traumatic Stress Studies, the World Health Organization, and the National Institute for Health and Clinical Excellence. Despite promising clinical experience and initial controlled studies, there are still substantive gaps in the evidence base for EMDR early interventions. The article concludes with recommendations for future research, emphasizing that future trials adhere to the highest standards for clinical research and that they investigate whether EMDR early intervention prevents the development of PTSD or increases resilience.

EMDR Therapy With Children and Adolescents

This special issue aims to highlight the importance of exploring the empirical base for eye movement desensitization and reprocessing (EMDR) therapy with children and adolescents. Such an endeavor is set within a context where the American Psychological Association recommends trauma-focused cognitive behavioral therapy (TF-CBT) as the treatment of choice and the National Institute of Health and Care Excellence (NICE) recommends EMDR for children when TF-CBT fails to be effective. Studies in this special issue suggest otherwise and represent EMDR’s global reach over seven different countries. The studies address a range of conceptual gaps and evaluate differing EMDR protocols for individual and group delivery. Participants from preschool to adolescence experienced single event, cumulative violence, and trajectories of trauma and present with a range of trauma symptoms. Although studies with differing methodologies highlight the efficacy of EMDR with differing populations, recommendations are made for rigorous research designs in order to influence professional guidance organizations.