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Single event paediatric trauma: Sample representation and the efficacy of response-focused exposure and EMDR

Kemp, Michael (2014) Single event paediatric trauma: Sample representation and the efficacy of response-focused exposure and EMDR. PhD thesis, Murdoch University.

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This thesis focused on paediatric populations who had been exposed to single event trauma such as motor vehicle accidents, burns, falls, animal bites, anaphylaxis and near drowning. The planning for the thesis commenced 16 years ago and the related PhD candidature commenced a few years later1. Since then, the volume of research investigating child trauma and, more specifically, treatments for child trauma has increased markedly.

The aims of the thesis were to determine: i) the efficacy of EMDR compared to a waitlist control condition in children aged 6 to 12 years following a motor vehicle accident, ii) if those who participated in a trauma study were representative of the population compared to those who did not participate in a trauma study; iii) if an assessment involving additional exposure to response focused trauma memories (based on Lang’s 1977, 1979, 1983 bio-informational theory) facilitated recovery, and if so iv) compare the efficacy of a treatment based on response-focused exposure to an established treatment condition such as EMDR. These aims were met by the following four studies.

Study one compared four EMDR sessions to a six week wait-list control condition amongst 27 children (aged 6 to 12 years) suffering from persistent PTSD symptoms after a motor vehicle accident. The efficacy of EMDR was confirmed. In comparison to the wait list condition, EMDR was superior on primary outcome measures including the Child Post Traumatic Stress – Reaction Index and clinician rated diagnostic criteria for PTSD. EDMR was also superior on process measures including Subjective Units of Disturbance and Validity of Cognition scales. Notably, 100% of participants in both groups met two or more PTSD criteria at pre-treatment. At post treatment, this remained unchanged in the wait-list group, but decreased to 25% in the EMDR group. These therapeutic gains were maintained at three and 12 month follow-up.

Study two compared 211 participants with 2333 non-participants in a trauma study on several measures of trauma and injury severity such as duration of hospital visit, heart rate in the emergency department, emergency transport to hospital, admission to hospital, injury severity score, and triage code. Participants were exposed to more severe trauma or injury than non-participants and within the non-participant group, those who had requested further information about the study (N = 573) were exposed to more severe trauma or injury than other non-participants (N = 1760). These findings were contrary to the view that non-participants could be more severely traumatised than participants, and the discovery of a gradient effect within non-participants suggests that participation or greater interest in participation may be associated with greater trauma and injury severity.

In study three, 52 of the children and adolescents from study two with at least moderate PTSD symptoms completed a standard assessment one month after their trauma. A random sample of 22 of these completed an additional response focused assessment task based on Lang’s (1977, 1979, 1983) bio-informational theory which involved the detailed recall of five components of their trauma memory. The stimulus component consisted of visual and auditory memories, whereas the response information consisted of four domains: verbal (words, sounds, thoughts and feelings), somato-motor (head and body position, gross body actions), visceral or autonomic (changes in heart rate, sweating or hot flushes), and processor (mental processes such as dream-like perceptions, racing or muddled thoughts). The response focused assessment resulted in an accelerated rate of recovery in avoidance symptoms from one week to two months later. There was also a reduction in the proportion of participants meeting the PTSD (DSM-IV) criterion for avoidance and a decrease in parent ratings of their child’s somatic complaints.

Study four compared Eye Movement Desensitisation and Reprocessing (EMDR) to a Response Focused Exposure Therapy condition based on the assessment utilised in study three. A total of 28 children and adolescents (aged six to 16 years) who continued to experience persistent PTSD symptoms three months after their trauma were recruited from study two. The EMDR protocol was consistent with the protocol used in study one and the detailed protocol described by Tinker and Wilson (1999). The Response Focused Exposure Therapy condition henceforth referred to as “exposure therapy” involved the repeated and detailed exposure to information from the five components of the trauma memory (as per study three), including one stimulus component (e.g., visual and auditory memories) and four response components (verbal, somato-motor, visceral or autonomic and processor). Both treatment conditions resulted in robust improvements in child, parent and clinician rated PTSD measures and child and parent rated non-PTSD measures. Whilst there was no difference in the duration of treatment sessions between the EMDR and exposure group, the exposure condition involved fewer exposure periods than the EMDR condition [4.8 (+2.1) versus 17.8 (+6.4), p<.001] but longer periods of exposure [157.7 (+58.3) versus 23.5 (+4.7) seconds, p<.001] and a greater total duration of exposure in each session [12.3 (+8.0) versus 7.0 (+3.2) minutes, p<.05]. This result provides support for the efficiency of EMDR, although more research is necessary. The efficacy of both treatments is best explained by the use of vivid and repeated exposure to the trauma memory in a safe environment along with other non-specific elements common to both treatments.

Publication Type: Thesis (PhD)
Murdoch Affiliation: School of Psychology and Exercise Science
Supervisor: Drummond, Peter, McDermott, Brett and Forbes, David
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