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A comparison of CBT and EMDR for sexually‐abused Iranian girls


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Fourteen randomly assigned Iranian girls ages 12–13 years who had been sexually abused received up to 12 sessions of CBT or EMDR treatment. Assessment of post-traumatic stress symptoms and problem behaviours was completed at pre-treatment and 2 weeks post-treatment. Both treatments showed large effect sizes on the post-traumatic symptom outcomes, and a medium effect size on the behaviour outcome, all statistically significant. A non-significant trend on self-reported post-traumatic stress symptoms favoured EMDR over CBT. Treatment efficiency was calculated by dividing change scores by number of sessions; EMDR was significantly more efficient, with large effect sizes on each outcome. Limitations include small N, single therapist for each treatment condition, no independent verification of treatment fidelity, and no long-term follow-up. These findings suggest that both CBT and EMDR can help girls to recover from the effects of sexual abuse, and that structured trauma treatments can be applied to children in Iran. Copyright © 2004 John Wiley & Sons, Ltd
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Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 11, 358–368 (2004)
Copyright © 2004 John Wiley & Sons, Ltd.
Published online in Wiley InterScience ( DOI: 10.1002/cpp.395
A Comparison of CBT
and EMDR for
Iranian Girls
Nasrin Jaberghaderi,1Ricky Greenwald,*,2
Allen Rubin,3Shahin Oliaee Zand1 and
Shiva Dolatabadi1
1Allame Tabatabaee University, Tehran, Iran
2Child Trauma Institute, Greenfield, MA, USA
3University of Texas at Austin, USA
Fourteen randomly assigned Iranian girls ages 12–13 years who had
been sexually abused received up to 12 sessions of CBT or EMDR
treatment. Assessment of post-traumatic stress symptoms and
problem behaviours was completed at pre-treatment and 2 weeks
post-treatment. Both treatments showed large effect sizes on the post-
traumatic symptom outcomes, and a medium effect size on the behav-
iour outcome, all statistically significant. A non-significant trend on
self-reported post-traumatic stress symptoms favoured EMDR over
CBT. Treatment efficiency was calculated by dividing change scores
by number of sessions; EMDR was significantly more efficient, with
large effect sizes on each outcome. Limitations include small N, single
therapist for each treatment condition, no independent verification of
treatment fidelity, and no long-term follow-up. These findings
suggest that both CBT and EMDR can help girls to recover from the
effects of sexual abuse, and that structured trauma treatments can be
applied to children in Iran. Copyright © 2004 John Wiley & Sons, Ltd.
*Correspondence to: Ricky Greenwald PsyD, P.O. Box 544,
Child Trauma Institute, Greenfield, MA, 01302, USA.
Sexual abuse victimization can lead to a range of
consequences in children, potentially including
post-traumatic stress disorder (PTSD), develop-
mental delays, increased anxiety and depressive
symptoms, and disruptive, sexually inappropriate,
and regressive behaviours (Kendall-Tackett,
Williams & Finkelhor, 1993). There are relatively
few controlled studies of the efficacy of treatments
for the sequelae of sexual abuse (Saywitz,
Mannarino, Berliner, & Cohen, 2000) and other
childhood trauma (Cohen, Berliner, & March,
2000). There is currently greatest support for the
efficacy of various forms of cognitive-behavioural
therapy (CBT), typically including some combina-
tion of psycho-education, coping skills training
and exposure. Intervention with parents has also
been shown to be helpful, but is beyond the scope
of this review.
For example, Deblinger, Lippman and Steer
(1996) compared a 12-week programme of abuse-
focused CBT provided to children only, to parents
only, or to both children and parents, with
CBT versus EMDR 359
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 358–368 (2004)
standard community care for a total of 100 sexu-
ally-abused children ages 7 to 13 years. Results
indicated that all groups improved on PTSD symp-
toms; however, CBT provided directly to the chil-
dren resulted in significantly greater improvement.
In another study of 49 children ages 7 to 14
years, those who were provided with abuse-
focused CBT experienced significantly greater
improvement in depression and social competence
than those receiving nondirective supportive
therapy (Cohen & Mannarino, 1998). However,
the groups did not differ in PTSD symptoms,
possibly because the trauma was a focus in the con-
trol condition as well.
A newer treatment, eye movement desensitiza-
tion and reprocessing (EMDR), has been shown to
be efficacious in a number of adult trauma studies,
and preliminary findings with traumatized
children are also promising. EMDR is a treatment
for traumatic memories and their sequelae that
requires the client to perform bilateral eye move-
ments while concentrating on the trauma memory.
The procedure consists of a structured sequence of
treatment components (Shapiro, 1995) that have
been identified as being effective across trauma
treatment modalities (Hyer & Brandsma, 1997;
Sweet, 1995), including psycho-education, cop-
ing skills training, and exposure (including
emotional processing and cognitive restructuring
A recent review of randomized treatment
studies, published as part of the International
Society for Traumatic Stress Studies’ Treatment
Guidelines, found EMDR to be an empirically sup-
ported efficacious trauma treatment (Chemtob,
Tolin, van der Kolk, & Pitman, 2000), with the
reservation that EMDR had not yet been directly
compared to other validated focused PTSD treat-
ments such as prolonged exposure. Since the pub-
lication of that review, several studies meeting
most of Foa and Meadows’ (1997) gold standard
criteria have directly compared EMDR to validated
CBT treatments (including an exposure compo-
nent) for PTSD. Findings across studies indicate
that both treatments were, in general, comparably
efficacious (Ironson, Freund, Strauss, & Williams,
2002; Lee, Gavriel, Drummond, Richards, &
Greewald, 2002; Power, McGoldrick, & Brown,
2002; Taylor et al., 2003; A. McFarlane, presentation
at the Annual Meeting of the International Society
of Traumatic Stress Studies, San Antonio, Novem-
ber 2000; B. O. Rothbaum, presentation at the
Annual Meeting of the Association for the
Advancement of Behavior Therapy, Philadelphia,
November 2001). Three studies (Ironson et al.,
2002; Power et al., 2002; A. McFarlane, presentation
at the Annual Meeting of the International Society
of Traumatic Stress Studies, San Antonio, Novem-
ber 2000) suggested that the therapeutic effect may
have occurred more quickly for EDMR than for
CBT. One study (Ironson et al., 2002) found that the
level of distress both during and between sessions
was lower for EMDR; this study also a found lower
drop-out rate in the EMDR group.
These findings suggest that EMDR may be at
least equal to other CBT approaches in efficacy and
acceptability while being more efficient, in that
with EMDR much less homework is required, and
the treatment effect may be achieved in fewer ses-
sions. However, it would be premature to draw
this conclusion. There are many CBT approaches,
not all of which were compared; furthermore, such
findings need to be replicated and elaborated. Also,
one study found that EMDR fared much worse
than CBT in terms of drop-out rates as well as out-
comes for treatment completers (Devilly & Spence,
1999). Unfortunately, significant methodological
problems make this study difficult to interpret (see
Chemtob et al., 2000; Lee et al., 2002).
There is no published controlled research on
EMDR for sexually-abused children. EMDR has
been used successfully with women who were sex-
ually abused as children (Edmond, Rubin, &
Wambach, 1999). There are also several wait-list
studies that suggest EMDR’s efficacy with trauma-
tized children and adolescents (variety of types of
trauma events; Puffer, Greenwald, & Elrod, 1998;
Soberman, Greenwald, & Rule, 2002). One wait-list
study following a disastrous hurricane only treated
children with EMDR who had failed to respond to
a generally effective prior cognitive-behavioural
group treatment (Chemtob, Nakashima, Hamada,
& Carlson, 2002). The only direct treatment com-
parison studies of EMDR for children or adoles-
cents did yield results favourable for EMDR. One
study compared EMDR to Active Listening for
adolescent and young adult females (Scheck,
Schaeffer, & Gillette, 1998) and another compared
EMDR to Systematic Desensitization for Iranian
college students (Dolatabadi, 2000). EMDR has not
yet been tested with children or adolescents
against a credible alternative trauma treatment.
Our primary goal in the present study was to
directly compare the efficacy of CBT and EMDR in
the treatment of sexually-abused girls. We were
also interested in the relative acceptability and
efficiency of these treatments. Finally, we wanted
to see how these treatments would perform with
360 N. Jaberghaderi et al.
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 358–368 (2004)
Iranian children as compared with the mostly first
world English-speaking samples reported in the
Iranian girls ages 12–13 years with a reported
history of sexual abuse victimization were
randomized to two active trauma treatment
conditions, CBT and EMDR. Assessment of
post-traumatic symptoms and problem behaviours
were completed pre- and post-treatment. Because
of the wide range of symptoms experienced by
sexually-abused children (Kendall-Tackett et al.,
1993), the focus was not PTSD but a wider range
of symptoms and behaviours.
Child Report of Post-traumatic Symptoms
The CROPS is a 26-item self-report questionnaire
covering the broad spectrum of post-traumatic
symptoms actually found in traumatized children
(Fletcher, 1993) including but not limited to those
symptoms of child/adolescent PTSD listed in the
DSM-IV (American Psychiatric Association, 1994).
The respondent is asked to endorse current
symptoms on a 0–2 scale of intensity (none, some,
or lots), total possible range of 0–52, with a score
of 19 or over indicating clinical concern. The CROPS
has shown good validity and reliability in several
settings and languages (Greenwald & Rubin,
1999; Greenwald, Rubin, Jurkovic et al., 2002;
Wiedemann & Greenwald, 2000) as well as sensitiv-
ity to change in post-traumatic status (R. Greenwald
et al., poster presented at the Annual Meeting of the
International Society for Traumatic Stress Studies,
Baltimore, November, 2002). The CROPS was trans-
lated into Persian, independently back-translated
to English, then reviewed by the original author
(RG) with item revisions as needed until the origi-
nal author was satisfied with the translation.
Parent Report of Post-traumatic Symptoms
The PROPS is a 32-item companion measure to
the CROPS, also broad-spectrum and with similar
validity and reliability (Greenwald & Rubin, 1999;
R. Greenwald et al., poster presented at the Annual
Meeting of the International Society for Traumatic
Stress Studies, Baltimore, November, 2002; J.
Wiedemann & R. Greenwald poster presented at
the Annual Meeting of the International Society for
Traumatic Stress Studies, San Antonio, November,
2000). It must be filled out by an adult who is famil-
iar with the child’s behaviour; in this case, by the
child’s parent. The respondent is asked to endorse
current symptoms on a 0–2 scale of intensity, total
possible range of 0–64, with a score of 16 or over
indicating clinical concern. The PROPS was also
translated according to the procedures described
above. There is some item overlap with the CROPS
but substantial differences as well. The em-
phasis with the CROPS is thoughts and feelings,
whereas the emphasis with the PROPS is
observable behaviours.
Rutter Teacher Scale
The Rutter Teacher Scale was developed to assess
whether a child has a potential mental disturbance
(Kresanov, Tuominen, Piha, & Almqvist, 1998;
Rutter, 1967). It contains 26 statements in which
teachers rate the extent of problematic behaviours
exhibited by the child in school, such as
hyperkinetic behaviours, antisocial externalizing
behaviours, internalizing difficulties, relationship
problems, and dysfunctional habits. Scores can
range from 0 to 52, with 9 and above considered
the clinical range. The Rutter Teacher scale has
been found to have good reliability and validity in
a variety of studies across a variety of cultures,
including countries in Europe and Asia (Almqvist
et al., 1999; Kresanov et al., 1998; Kumpulainen,
Rasanen, & Henttonen, 1998; Morita, Suzuki, &
Kamoshita, 1990; Rutter, 1967). This Persian lan-
guage version omits two of the original items,
includes six additional items, has good psycho-
metric properties, and has a clinical range of 13
and above (Yousefi, 1998).
Subjective Units of Distress Scale (SUDS)
The SUDS (adapted from Wolpe as described in
Shapiro, 1995) measures intensity of subjective dis-
tress in response to a particular stimulus, such as a
traumatic memory. It is a widely used measure
which has been shown to correlate with several
physiological measures of stress (Thyer, Papsdorf,
Davis, & Vallecorsa, 1984; Wilson, Silver, Covi, &
Foster, 1996). Non-reactivity to a traumatic
memory is considered a primary indicator of
recovery (Horowitz, 1986). This 11-point scale uses
10 as the highest level of distress and 0 as the
CBT versus EMDR 361
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 358–368 (2004)
lowest level, or absence of distress. In this
study the SUDS was used as one of the termination
criteria, but not as an outcome measure.
A recruitment letter signed by the Principal Inves-
tigator (the PI; NJ) and the school principal was
sent to the homes of 125 sixth grade girls (ages
12–13 years) in an urban school in Iran. Volunteers
were asked, with their parents’ consent, to com-
plete the CROPS. Of the 123 who did, 62 received
a score of 19 or higher, indicating a clinically sig-
nificant level of post-traumatic symptoms. Then in
an office at the school, these 62 girls completed the
Lifetime Incidence of Traumatic Events (LITE;
Greenwald, 2000; R. Greenwald, A. Rubin, A. M.
Russell, & M. B. O’Connor, poster presented at the
Annual Meeting of the International Society for
Traumatic Stress Studies, Baltimore, November,
2002; also translated as above), a checklist allowing
the respondent to endorse exposure to a variety of
adverse events. Of these, 24 endorsed having been
sexually abused. These girls then participated in a
structured interview in school, conducted by the
PI, to determine the quantity and severity of the
sexual abuse. Of these, 19 girls were determined to
have experienced a qualifying abuse experience,
defined as unwanted oral, anal, genital, or breast
contact with another person, occurring 6 months
or more prior to the study. Consent/assent pro-
cedures were repeated for those eligible for
participation in the treatment study, and all
All participants were in the same socio-economic
status, a de facto condition of attendance at the
school where the study took place. All participants
lived with their biological parents.
Participants were randomly assigned to treat-
ment condition, with some adjustments to promote
equivalence between groups. Four participants
had experienced penetration, and they were
blocked and then randomized, to ensure that two
went to each treatment condition. Three partici-
pants had only experienced a single abuse event;
they were also blocked; two went to the EMDR
group and one to CBT. Five of the girls’ sexual
abuse was due to incest. One of these was dis-
qualified because her brother was continuing to
molest her (despite the researcher’s efforts; chil-
dren’s protection is not mandated in Iran). The
other four were blocked to ensure that two went
to each treatment condition. The randomization
procedure for each subgroup of participants was
to pick their names out of the hat while alternat-
ing group assignments.
Ethical Considerations
It is not yet customary in Iran for universities
to have Institutional Review Boards or Ethics
Committees, so in lieu of such a structure, the
investigators discussed the design with respected
colleagues for feedback regarding scientific and
ethical concerns. The study was designed with the
usual precautions including the emphasis, at each
phase of recruitment, on the informed and volun-
tary nature of participation. The initial forms
included a way to contact the investigator to
discuss any distress engendered by participation;
and subsequent interviews were followed by
debriefing to ensure that participants were not left
in a state of distress. Consistent with other trauma
studies in which participants primarily reported
neutral or positive response (Brabin & Berah, 1995;
Martin, Perrott, Morris, & Romans, 1999; Newman,
Walker, & Gefland, 1999; Ruzek & Zatzick, 2000),
these participants indicated no special study-
related distress that required follow-up or referral,
except as already noted elsewhere in this paper.
Perhaps the most challenging ethical issue we
faced was how to balance the value of informed
consent with the sometimes conflicting value of
protection of participants. In Iran there is enor-
mous stigma associated with being a victim of
sexual abuse, and we were concerned that by
making the focus of the study explicit, we would
risk subjecting participants to ostracism by their
teachers and even by their own parents. On the
other hand, we wanted to provide as much infor-
mation as possible, so that participants and their
parents could make informed choices. Therefore
the study was presented as a trauma treatment
study, but with the nature of the trauma unspeci-
fied. Those parents judged by the PI to be suffi-
ciently open-minded and supportive were further
informed that the trauma being treated was sexual
abuse. Only five parents were so informed, three in
the EMDR group and two in the CBT group. Need-
less to say, this approach caused controversy
among the cross-cultural research team! However,
we ultimately recognized that the core value was
participant protection, and that specific procedures
designed to protect participants have to be
culturally sensitive and take local conditions into
In general, we felt that we were successful in our
efforts to protect participants. Despite the discon-
certingly high response rate to the first wave of the
362 N. Jaberghaderi et al.
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 358–368 (2004)
study (123 out of a possible 125) – perhaps a reflec-
tion of the authoritarian nature of Iranian culture –
potential participants did seem comfortable in
declining participation as the study progressed
towards the treatment phase. Those children who
were eligible for treatment but did not participate
did agree to a follow-up evaluation which in fact
indicated no further concerns; these children were
already doing well in school and socially.
The parents of those children who dropped out of
treatment were provided an additional psycho-
educational intervention and referral options. The
parents of the child who was ineligible due to
ongoing abuse were also provided with psycho-
education and referral options. This did lead, even-
tually, to the girl moving to live with relatives,
where she was not subject to further molestation.
The PI introduced the study and procedures to the
teachers in a group. Following the structured inter-
view in the screening procedures described above,
the pre-treatment assessment was conducted by
two psychologists who did not know the children
and were blind to assignment. For each participant,
the parent completed the PROPS, the girl com-
pleted the CROPS, and the participant’s several
teachers completed the Rutter as a group. The mea-
sures are all paper-and-pencil, and respondents
generally completed the forms with no assistance.
When assistance was needed, the psychologists
had been trained to help the respondent(s) to
understand the meaning of the item while avoid-
ing helping the respondent(s) to select their
response. Treatment was conducted after school
hours, at the nearby University clinic. Two weeks
after each participant’s final session, the post-
treatment assessment was conducted in the
same manner as described above, with the same
respondents for a given participant. Participants
requiring further treatment (those who failed to
meet termination criteria but had used up all their
sessions) were referred following the post-
treatment assessment.
Treatment Conditions
Each treatment was manualized, with reference to
published texts for more detail. In this study the
CBT procedure was based on Deblinger and Heflin
(1996), with additional activities from Camino
(2000). Although the activities were standardized,
they were tailored to the individual participants.
The CBT therapist was the fourth author (SOZ), a
professor and clinical psychologist who had been
trained in CBT by M. R. Mohamadi of Roozbeh
Hospital. The EMDR procedure was based on
Shapiro (1995), with age-appropriate modifications
suggested by Greenwald (1999). The EMDR thera-
pist was the fifth author (SD), a professor and
clinical psychologist who had been trained in
EMDR (levels 1 and 2) by G. Puk of the EMDR
Institute. Both had prior clinical experience with
children. The PI was present for all sessions, CBT
and EMDR, to observe and take notes.
Our challenge was to make the treatment condi-
tions as equivalent as possible, while also allowing
each of the treatments to be conducted (within
limits) according to its own standards. Implement-
ing a treatment approach on its own terms – the
way a practicing clinician would do it – supports
ecological validity. The trade-off is that the condi-
tions were not exactly equivalent across treat-
ments. The design reflects an attempt to balance
the interest in both internal and external validity.
In the CBT condition, the focus was on skill
development (e.g. symptom management) and on
exposure to the identified sex abuse memory. In the
EMDR condition, the skill development focus
was much more limited, and the focus on the iden-
tified trauma memory was not as strict. For
example, a minor upsetting memory was targeted
with EMDR as preparation for EMDR with the
identified sex abuse memory. The EMDR therapist
was allowed to treat other trauma memories with
EMDR if they arose spontaneously while working
with the index trauma, but was not allowed to sys-
tematically work through all trauma memories (as
would normally be done in clinical practice).
Duration of sessions was limited to 45min. In the
CBT condition, all sessions took 45min. In the
EMDR condition, most sessions were closer to
30min with some taking the full 45 min. Differ-
ences in number of minutes per session was not
systematically tracked.
In the CBT condition there was homework for
every session, such as checklists, drawings, and
listening to tapes of the exposure narrative. We
estimate that participants in the CBT group com-
pleted about 10–15h of homework in total, but
homework time was not systematically tracked.
Homework in the EMDR condition was minimal,
limited to drawing a ‘safe place’ on one occasion
between sessions early in the treatment.
Termination criteria was treatment specific, but
with a maximum of 12 sessions. CBT treatment
CBT versus EMDR 363
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 358–368 (2004)
also had a 10-session minimum in order to com-
plete certain activities; EMDR treatment had no
designated minimum. CBT treatment was termi-
nated prior to 12 sessions if the SUDS was 0–2 and
the primary abuse-related anxiety symptoms were
at a severity rating of 25 per cent or lower. EMDR
treatment was terminated prior to 12 sessions if the
SUDS was 0–2 and positive self-statements related
to the abuse were whole-heartedly endorsed, as
indicated by a 6 or 7 rating on a 7-point scale.
Parents also attended a single psycho-
educational session, the same for both groups, pro-
vided by the child’s therapist, within the first 2
weeks of treatment.
Pre-treatment Comparison of Groups
The groups did not differ significantly at pre-treat-
ment on age, socio-economic status, type, severity,
amount of sexual abuse, or extent of other
trauma/loss history. They also did not differ
significantly at pre-treatment on scores on any of
the outcome measures. In fact, the groups were
very similar on these pre-treatment variables.
Retention of Participants
One participant was disqualified prior to random-
ization because of ongoing abuse. Two other par-
ticipants, one from each condition, did not ever
start treatment. Both of these girls said that they
were not interested in treatment, and indeed both
of them were functioning well in school and other
areas of their lives. Two additional participants,
one from each treatment condition, dropped out
after starting treatment, because their parents
stopped bringing them, reasons unknown. The
drop-outs were not re-assessed. The other 14 par-
ticipants, seven in each condition, completed the
treatment as well as the post-treatment assessment.
Treatment Duration
In the CBT group, one participant terminated after
10 sessions, one after 11 sessions, and the rest after
the maximum of 12 sessions. In the EMDR group,
two participants terminated after four sessions,
one after five sessions, one after six sessions, and
three after eight sessions.
Post-treatment Referral
Those participants who did not meet termination
criteria at the post-treatment assessment were
determined to be in need of further treatment, and
were referred accordingly. Three participants in the
CBT group were referred for further treatment;
none in the EMDR group were referred.
Treatment Outcome
Table 1 displays the mean pretest and posttest
scores for each group. On the CROPS, compared to
pre-treatment, the EMDR group improved signifi-
cantly (p<0.05), but the CBT group did not (p=
0.116). However, the difference in improvement
between groups was not significant. On both the
PROPS and the Rutter, both groups improved sig-
nificantly (p<0.05), but the difference in improve-
ment between groups was not significant. Analyses
of covariance were used to test the significance of
between group differences, with pretest scores
serving as the covariate. Paired samples t-tests
were used to test the significance of within group
pretest to posttest differences.
Clinically Significant Change
One step in considering the clinical significance
of the pretest to posttest changes is to examine
Cohen’s d, an effect size statistic that is calculated
by dividing the pretest to posttest change by the
pretest standard deviation. When dis at about 0.8
or above, the effect size is considered large. When
it is at about 0.5, it is considered medium (Cohen,
1988). As shown in Table 2, large pretest to posttest
effect sizes were found for both groups on the
Table 1. Mean pretest and posttest scores on three
outcome measures, by group
Test Group Between
EMDR CBT groups p
Mean SD Mean SD
CROPS pretest 34.86 5.8 30.00 6.4
CROPS posttest 18.86* 7.9 22.71 6.9 0.15
PROPS pretest 21.00 6.2 22.43 10.3
PROPS posttest 10.14* 5.4 11.29* 6.6 0.96
Rutter pretest 13.71 12.2 8.86 7.7
Rutter posttest 5.00* 5.3 3.00* 2.9 0.42
* Pretest to posttest within group change statistically significant
364 N. Jaberghaderi et al.
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 358–368 (2004)
CROPS and PROPS, and medium effect sizes were
found for both groups on the Rutter.
Another way to consider clinical significance is
to see how many participants in each group moved
from clinical to normal ranges on each of the
outcomes. On the Persian version of the Rutter
Teacher Scale, a total score of 13 or more is consid-
ered in the clinical range (Yousefi, 1998). As
shown in Table 2, both of the CBT participants, and
one of the two EMDR participants, who started
in the clinical range at pretest moved to
the normal range at posttest. Although the other
EMDR participant did not reach the normal range
at posttest, she showed more pre- to posttest
improvement than all but one other participant
(also in the EMDR group) in the study. She had the
highest (worst) score at pretest, and improved from
33 at pretest to 15 at posttest. On the CROPS a total
score of 19 or more is considered in the clinical
range (Greenwald & Rubin, 1999). At pretest, all
participants in both groups were in the clinical
range on the CROPS. At posttest, three of the
EMDR participants and two of the CBT partici-
pants had moved to the normal range. On the
PROPS a total score of 16 or more is considered in
the clinical range (Greenwald & Rubin, 1999). At
pretest, five of the seven participants in each group
were in the clinical range. In the EMDR group, four
of those five moved to the normal range at posttest.
In the CBT group, three of the five moved from
the clinical to the normal range.
An additional way to consider clinical signifi-
cance is to calculate the reliable change (RC)
index (Jacobson, Follette, & Revenstorf, 1984), by
dividing each participant’s pre- to post-treatment
change score by the standard error of measure-
ment. If RC exceeds 1.96, the change is considered
unlikely to be due to imprecise measurement. As
shown in Table 2, on the Rutter Teacher Scale, four
of the seven participants in each group had RCs in
excess of 1.96. On the CROPS, all seven of the
EMDR participants, as compared to four of the
seven CBT participants, had RCs in excess of 1.96.
On the PROPS, five of the seven EMDR partici-
pants and six of the seven CBT participants had
RCs in excess of 1.96.
Acceptability and Efficiency of Treatments
In a ‘horse race’ study in which no efficacy differ-
ence is detected between the two treatments, other
considerations become more prominent. One is
treatment acceptability. If the participant will not
mount the horse, or cannot stay on it, she will not
finish the race. Therefore, the drop-out rate is a
Table 2. Indicators of clinical significance on three outcome measures, by group
Measure Group EMDR CBT Group
EMDR CBT Normal Clinical Normal Clinical EMDR (n=7) CBT (n=7)
Cohen’s dindicator of effect size (mean pretest to posttest change divided by pretest standard deviation)
CROPS 2.8 1.1
PROPS 1.8 1.1
Rutter 0.71 0.72
Number of participants in clinical and normal range
Pretest 0707
Posttest 3425
Pretest 2525
Posttest 6152
Pretest 5252
Posttest 6170
Number of participants whose reliable change index (RC) scores were significant (RC >1.96)
Rutter 44
CBT versus EMDR 365
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critical consideration when comparing treatments.
One participant was excluded from the study prior
to randomization, as noted above, due to ongoing
victimization. Following randomization, there
were four drop-outs, two from each condition. In
each condition, one drop-out occurred prior to
treatment onset, and one subsequent to treatment
onset. Thus, in this study there was no evidence
of differential acceptability of one treatment over
Another concern relates to the efficiency of a
treatment, the amount of time and effort it takes to
achieve the desired effect. Other things being
equal, a more efficient treatment can relieve
suffering more quickly, and can make limited
treatment resources more widely available. To
determine efficiency, we first compared the mean
number of sessions it took each group to complete
treatment. (As we noted earlier, treatment lasted
up to 12 sessions, and was terminated sooner if the
SUDS associated with the abuse memory reached
0–2, along with other treatment-specific criteria.)
As shown in Figure 1, the mean number of sessions
per group was 6.1 for the EMDR group and 11.6 for
the CBT group. Using an independent samples
t-test, this difference was statistically significant
(t=7.1; df =12, p<0.000) and large (ES =4.2).
Here we abandon the horse metaphor in favour
of the more modern custom of measuring fuel effi-
ciency in miles per gallon. We then divided each
participant’s change score by the number of
sessions each had. This indicated the mean amount
of change per session on each outcome measure, as
shown in Figure 2. The mean per session change
on the Rutter Teacher scale was 1.4 for the EMDR
group and 0.50 for the CBT group (p=0.04). On the
CROPS, the mean per session change was 3.0 for
the EMDR group and 0.67 for the CBT group (p=
0.04). Thus, the difference between the two groups
was statistically significant on both the Rutter and
CROPS measures. The EMDR group also had a
higher mean per session change on the PROPS;
however, the difference was not significant (p=
0.18), with a mean of 2.4 for the EMDR group and
0.96 for the CBT group. The effect sizes for all three
comparisons were large: 2.0 on the Rutter; 2.3 on
the CROPS; and 2.0 on the PROPS.
Several features of this study limit confidence in
interpretation of findings. The limited power
inherent in such a small sample size makes it dif-
ficult to detect possible actual differences between
the treatments. The small sample size also limits
the study’s external validity. The use of one thera-
pist for one treatment condition and another ther-
apist for the other condition makes it impossible
to distinguish therapist effects from the specific
effects of the treatments. Also, although the PI,
who was knowledgeable regarding both treat-
ments, observed all sessions, there were no formal
procedures to monitor or evaluate treatment
adherence. These limitations were unavoidable
given the limited resources (including scarcity of
therapists in Tehran trained in structured trauma
treatment methods) available to the investigators.
Figure 1. Mean number of sessions for each group Figure 2. Mean amount of change per session on each
outcome measure
366 N. Jaberghaderi et al.
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 358–368 (2004)
An additional limitation is the absence of a no-
treatment condition. The inclusion criteria mitigate
this problem, in that a clinically significant level of
post-traumatic symptoms more than 6 months
after the trauma indicates a degree of chronicity.
Thus, although having a no-treatment control con-
dition would have been preferred, it is unlikely
that the apparent treatment effects found in this
study would have occurred within that 3-month
period in lieu of treatment.
EMDR was clearly far more efficient in terms of
number of sessions to termination criteria, as well
as amount of change achieved per session, at least
on two of the three outcome measures. An addi-
tional efficiency issue, from the participants’ point
of view, is the amount of homework required for
each treatment—much more for CBT. This adds to
the trend of similar findings favouring EMDR re
efficiency, across controlled comparison studies.
Despite the apparently superior efficiency of
EMDR, questions remain on this issue. First of all,
participants in the CBT condition had a required
minimum of 10 sessions whereas there was no
minimum in the EMDR condition. This discrep-
ancy carries the risk of differential expectancy
effects as well as extension of CBT treatment
beyond what would have otherwise been needed.
However, since only one participant in the CBT
condition finished after 10 sessions, this minimum
number of sessions did not artificially extend the
duration of treatment for at least six of the seven
participants in the CBT condition. Even so, the ter-
mination criteria may have biased the findings
regarding the efficiency of EMDR. EMDR is struc-
tured to reduce the SUDS as quickly as possible,
whereas the CBT approach includes skills training
that may be less likely to lead to rapid symptom
reduction. Although quicker relief does seem
preferable, we do not know what the longer term
follow-up results would be. Although participants’
gains have maintained in most of the other com-
parison studies (for both treatments), we cannot be
sure how the participants in this study would
compare over time. Would the EMDR group con-
tinue to do well as a result of participants’ lower
level of post-traumatic symptoms post-treatment?
Or would the CBT group continue to improve over
time, as participants recovered from the exposure
and gained more experience in using the skills they
had learned?
On the other hand, study eligibility criteria, treat-
ment procedures, and termination criteria may
have biased the findings to favour CBT’s efficacy.
Participants were eligible for inclusion if they met
sexual abuse victimization criteria, whether or not
they had experienced additional trauma as well.
In fact, all participants in each group did report
additional trauma history, and furthermore all par-
ticipants in each group endorsed at least one
additional event as continuing to be highly dis-
tressing. Although in the EMDR condition treat-
ment could be terminated once the participant was
no longer distressed by the memory of the index
trauma, participants may have been suffering from
additional trauma that would remain untreated
and possibly continue to drive post-traumatic
symptoms and problem behaviours. On the other
hand, CBT focuses in part on coping skills that can
be broadly applied; and termination criteria
included reduction of anxiety symptoms that were
not specifically referenced to the index trauma
memory. Considering that the outcome measures
also did not target memory-referenced post-
traumatic stress, but global symptom measures, it
might have been more fair to EMDR to continue
with treatment until all trauma had been resolved
(up to the 12 session limit), not just the index
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helping these sexually-abused Iranian girls to
reduce their post-traumatic stress symptoms, and
in helping the girls to improve their behaviour.
EMDR was considerably more efficient in achiev-
ing these results. These findings suggest that both
CBT and EMDR can help girls to recover from the
effects of sexual abuse, and that structured trauma
treatments can be applied to children in Iran.
However, replication with better power and
controls is warranted.
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... Completion of six sessions or fewer if units of distress reduced to zero Deblinger et al, 2011 Three or more sessions of a possible 8 or 16 Diehle et al, 2015 Eight sessions but treatment could be concluded earlier if cured Ertl et al, 2011 Completion of all eight sessions Foa et al., 2013 Eight or more sessions of a possible 14 Ford et al, 2012 Five or more sessions of a possible 12 Goldbeck et al, 2016 Eight or more sessions Jaberghaderi et al, 2004 Ten or more sessions of TFCBT No minimum for EMDR Jaberghaderi et al, 2019 ...
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Background Despite the established evidence base of psychological interventions in treating PTSD in children and young people, concern that these trauma-focused treatments may ‘retraumatise’ patients or exacerbate symptoms and cause dropout has been identified as a barrier to their implementation. Dropout from treatment is indicative of its relative acceptability in this population. Objective Estimate the prevalence of dropout in children and young people receiving a psychological therapy for PTSD as part of a randomized controlled trial (RCT). Methods A systematic search of the literature was conducted to identify RCTs of evidence-based treatment of PTSD in children and young people. Proportion meta-analyses estimated the prevalence of dropout. Odds ratios compared the relative likelihood of dropout between different treatments and controls. Subgroup analysis assessed the impact of potential moderating variables. Results Forty RCTs were identified. Dropout from all treatment or active control arms was estimated to be 11.7%, 95% CI [9.0, 14.6]. Dropout from evidence-based treatment (TFCBTs and EMDR) was 11.2%, 95% CI [8.2, 14.6]. Dropout from non-trauma focused treatments or controls was 12.8%, 95% CI [7.6, 19.1]. There was no significant difference in the odds of dropout when comparing different modalities. Group rather than individual delivery, and lay versus professional delivery, were associated with less dropout. Conclusions Evidence-based treatments for children and young people with PTSD do not result in higher prevalence of dropout than non-trauma focused treatment or waiting list conditions. Trauma-focused therapies appear to be well tolerated in children and young people.
... The eight phases and three-pronged protocol facilitate a comprehensive evaluation of the clinical picture, client preparation, and processing of the following: a) past events that set the foundation for pathology, b) current disturbing situations, and c) future challenges (Shapiro, 2012;. Another study indicated that EMDR therapy can be more successful than CBT for the treatment of sexually abused girls (aged 12 to 13 years) (Jaberghaderi, Greenwald, Rubin, Zand and Dolatabadi, 2004). EMDR has been successfully used for the rapid desensitization of traumatic memories and cognitive restructuring that leads to a significant reduction in the symptoms of emotional stress, distracting thoughts, anxiety, repeated memories of the event, and nightmares. ...
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A number of effective treatments are available for children and young people who have developed various forms of psychological difficulties as a consequence of traumatic experiences. The aim of this paper is to review the therapeutic approaches employed when working with children who have been exposed to various forms of abuse and neglect during their childhood. This paper provides relevant information to psychotherapists and counsellors on new trends in therapy, as well as techniques and possibilities in interventions in this field, not only with respect to traumatised children, but also family members and other caregivers involved in the child’s life. Furthermore, this paper reviews the therapeutic interventions used to treat emotionally, sexually, and physically abused children, neglected children, children who have witnessed domestic violence, and children who have been exposed to multiple forms of abuse.
... Of all therapies, TF-CBT has received the strongest empirical support to date. Until now, five randomized controlled trials (RCTs) have compared trauma-focused CBT to EMDR therapy for paediatric PTSD, with no differences observed for diagnostic remission or symptom reduction (Jaberghaderi, Greenwald, Rubin, Zand, & Dolatabadi, 2004;Jaberghaderi, Rezaei, Kolivand, & Shokoohi, 2019;De Roos et al., 2011. With few RCTs having compared active treatments for paediatric PTSD, little is known about whether or which baseline (i.e. ...
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Background: With few RCTs having compared active treatments for paediatric PTSD, little is known about whether or which baseline (i.e. pre-randomization) variables predict or moderate outcomes in the evaluated treatments. Objective: To identify predictors and moderators of paediatric PTSD outcomes for Eye Movement Desensitization and Reprocessing Therapy (EMDR) and Cognitive Behavioural Writing Therapy (CBWT). Method: Data were obtained as part of a multi-centre, randomized controlled trial of up to six sessions (up to 45 minutes each) of either EMDR therapy, CBWT, or wait-list, involving 101 youth (aged 8-18 years) with a PTSD diagnosis (full/subthreshold) tied to a single event. The predictive and moderating effects of the child's baseline sociodemographic and clinical characteristics, and parent's psychopathology were evaluated using linear mixed models (LMM) from pre- to post-treatment and from pre- to 3- and 12-month follow-ups. Results: At post-treatment and 3-month follow-up, youth with an index trauma of sexual abuse, severe symptoms of PTSD, anxiety, depression, more comorbid disorders, negative posttraumatic beliefs, and with a parent with more severe psychopathology fared worse in both treatments. For children with more severe self-reported PTSD symptoms at baseline, the (exploratory) moderator analysis showed that the EMDR group improved more than the CBWT group, with the opposite being true for children and parents with a less severe clinical profile. Conclusions: The most consistent finding from the predictor analyses was that parental symptomatology predicted poorer outcomes, suggesting that parents should be assessed, supported and referred for their own treatment where indicated. The effect of the significant moderator variables was time-limited, and given the large response rate (>90%) and brevity (<4 hours) of both treatments, the present findings suggest a focus on implementation and dissemination, rather than tailoring, of evidence-based trauma-focused treatments for paediatric PTSD tied to a single event.
... About one in 10 children would be sexually abused before their 18th birthday (Daigneault, Esposito, Bourgeois, Hébert, Delaye, & Frappier, 2017). About one in seven girls and one in 25 boys would be sexually abused before they turn 18 (Jaberghaderi, Greenwald, Rubin, Zand, & Dolatabadi, 2004;DeVoe & Faller, 1999). It was estimated that 2013, about 400,000 babies born in the U.S. would become victims of child sexual abuse unless something is done to stop it (Harker, Jütte, Murphy, Bentley, Miller, & Fitch, 2013). ...
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Introduction: One in 10 children would be sexually abused before their 18th birthday; about one in seven girls and one in 25 boys would be sexually abused before they turn 18. The statistics continues to increase even as low and middle-income nations of the world are gradually coming out to report cases of child sexual abuse. Aim: This study aimed to assess the knowledge and perceived effect of sexual abuse among adolescents attending selected secondary schools in Mushin Local Government. Methods: 414 respondents from selected secondary schools in Mushin Local Government participated in the study using the multistage random sampling technique. A self-designed questionnaire was used to collect data. Data were analyzed using Statistical Package for the Social Sciences version 26 and bivariate analysis was conducted using Chi-square test. Results: More than half of the adolescents fall within the age range of 15–17 years and majority were females. In addition to this, just a little above half of the participants were Christians and just below half of the students were in SSS 2. Also, more than half of the participants were Yorubas and well above half were from a nuclear family. Just about half of the adolescents have good knowledge about sexual abuse. In the measures of association, the relationship between the level of knowledge of sexual abuse and the perceived effect of sexual abuse was statistically significant. The relationship between adolescents’ perception of the effect of sexual abuse and their concept of the common forms of sexual abuse was also statistically significant. Conclusion: This study revealed that the adolescents under study had knowledge about sexual abuse and this knowledge determined their perception of the effect of sexual abuse, and this in turn determines what they consider as child sexual abuse. It is therefore necessary to intensify efforts on educating and re-educating children and adolescents on sexual abuse, how to identify it and how to prevent it through campaigns and health promotional activities.
Similar to adults, children and adolescents may experience a wide range of potentially traumatic events and develop trauma-related psychological disorders which negatively impact on their functioning and development. This chapter presents basic background on epidemiology of childhood trauma and provides information on diagnostic assessment of traumatised children and adolescents. Age-specific self- and proxy-report measures are introduced. Furthermore, current evidence on secondary prevention of trauma-related disorders and on treatment of child and adolescent PTSD is described. Trauma-focused cognitive-behavioural therapy, Eye Movement Desensitisation and Reprocessing (EMDR), psychodynamic therapy, school-based interventions, and pharmacological treatments are presented in detail. Also, current evidence on treatment of young children below the age of 6 years is described.
Sexual abuse is a serious social issue with adverse psychosocial consequences in the person who is victimized. High prevalence rate of abuse in both children and adults, no matter female or male, indicate that anyone can be a victim of this hazard. The manifestation of mental-health outcomes is diverse in nature and different across individuals and is determined by complex array of factors. This calls for the application of intervention techniques that are well-established by empirical research to be effective among victims of sexual abuse. This chapter is an attempt to discuss treatment methods established as effective and also other methods that are in use, though with limited research literature on its effectiveness or efficacy, for Posttraumatic Stress Disorder (PTSD) and other prominent and debilitating psychological and interpersonal effects of sexual abuse. Further, special issues concerning research and practice as well as future directions are outlined.
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Aim: Interpersonal trauma exposures are associated with anxiety, depression and substance use in youth populations (12-25 years). This meta-analysis reports on the effectiveness of psychological interventions on these symptom domains in addition to posttraumatic stress. Method: Following PRISMA guidelines, a search of electronic databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO and PILOTS) was performed for interventions provided to young people following interpersonal trauma exposure. Two raters evaluated studies and extracted relevant data, and meta-analysis were conducted. Results: Of the 4,832 records screened, 78 studies were reviewed and 10 randomised controlled studies, including 679 participants with a mean age of 15.5 analysed. Results indicated that psychological interventions are effective in reducing symptoms of posttraumatic stress (7 RCT’s, g = 1.43, p = .002), and anxiety (4 RCT’s, g = .30, p = .003), but not depression (9 RCT’s, g = 0.27, p = .052). Only two studies were identified for the treatment of substance use (g = .70, p < .001). Conclusion: While effective for posttraumatic stress and anxiety, current interventions fail to address comorbid depression adequately. Intervention development is needed to adequately address the complex therapeutic needs of young people with a history of interpersonal trauma.
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The chapter highlights two psychodynamic therapies, Cognitive Hypnotherapy and EMDR. Both therapies focus on implicit or unconscious processes for the rapid relief of cognitive anxiety. The objective is to give credence to the therapies both in the scientific and medical domains. The philosophy is concerned with changing negative cognitions and dysfunctional feelings through a process of desensitisation and reprocessing, utilising positive imagery. The chapter gives quantitative scientific evidence for the beneficial effects of both therapies (after only two sessions) as well as qualitative documentation through a case study.
There is a well-established relation between exposure to child maltreatment and the onset and course of multiple, comorbid psychiatric disorders. Given the heterogeneous clinical presentations at the time services are initiated, interventions for children exposed to maltreatment need to be highly effective to curtail the lifelong burden and public health costs attributable to psychiatric disorders. The current review describes the most effective, well-researched, and widely-used behavioral and pharmacological interventions for preventing and treating a range of psychiatric disorders common in children exposed to maltreatment. Detailed descriptions of each intervention, including their target population, indicated age range, hypothesized mechanisms of action, and effectiveness demonstrated through randomized controlled trials research, are presented. Current limitations of these interventions are noted to guide specific directions for future research aiming to optimize both treatment effectiveness and efficiency with children and families exposed to maltreatment. Strategic and programmatic future research can continue the substantial progress that has been made in the prevention and treatment of psychiatric disorders for children exposed to maltreatment.
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This systematic review aimed to assess the efficacy of cognitive-behavioural approaches (CBT) in addressing the immediate and longer-term sequelae of sexual abuse on children and young people up to 18 years of age. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2011 Issue 4); MEDLINE (1950 to November Week 3 2011); EMBASE (1980 to Week 47 2011); CINAHL (1937 to 2 December 2011); PsycINFO (1887 to November Week 5 2011); LILACS (1982 to 2 December 2011) and OpenGrey, previously OpenSIGLE (1980 to 2 December 2011). For this update we also searched and the International Clinical Trials Registry Platform (ICTRP). We included 10 trials, involving 847 participants. The conclusions of this updated review remain the same as those when it was first published. The review confirms the potential of CBT to address the adverse consequences of child sexual abuse, but highlights the limitations of the evidence base and the need for more carefully conducted and better reported trials. Abstract BACKGROUND Despite differences in how it is defined, there is a general consensus amongst clinicians and researchers that the sexual abuse of children and adolescents (‘child sexual abuse‘) is a substantial social problem worldwide. The effects of sexual abuse manifest in a wide range of symptoms, including fear, anxiety, post-traumatic stress disorder and various externalising and internalising behaviour problems, such as inappropriate sexual behaviours. Child sexual abuse is associated with increased risk of psychological problems in adulthood. Cognitive-behavioural approaches are used to help children and their non-offending or ‘safe’ parent to manage the sequelae of childhood sexual abuse. This review updates the first Cochrane review of cognitive-behavioural approaches interventions for children who have been sexually abused, which was first published in 2006. OBJECTIVES To assess the efficacy of cognitive-behavioural approaches (CBT) in addressing the immediate and longer-term sequelae of sexual abuse on children and young people up to 18 years of age. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2011 Issue 4); MEDLINE (1950 to November Week 3 2011); EMBASE (1980 to Week 47 2011); CINAHL (1937 to 2 December 2011); PsycINFO (1887 to November Week 5 2011); LILACS (1982 to 2 December 2011) and OpenGrey, previously OpenSIGLE (1980 to 2 December 2011). For this update we also searched and the International Clinical Trials Registry Platform (ICTRP). SELECTION CRITERIA We included randomised or quasi-randomised controlled trials of CBT used with children and adolescents up to age 18 years who had experienced being sexually abused, compared with treatment as usual, with or without placebo control. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed the eligibility of titles and abstracts identified in the search. Two review authors independently extracted data from included studies and entered these into Review Manager 5 software. We synthesised and presented data in both written and graphical form (forest plots). RESULTS We included 10 trials, involving 847 participants. All studies examined CBT programmes provided to children or children and a non-offending parent. Control groups included wait list controls (n = 1) or treatment as usual (n = 9). Treatment as usual was, for the most part, supportive, unstructured psychotherapy. Generally the reporting of studies was poor. Only four studies were judged ‘low risk of bias’ with regards to sequence generation and only one study was judged ‘low risk of bias’ in relation to allocation concealment. All studies were judged ‘high risk of bias’ in relation to the blinding of outcome assessors or personnel; most studies did not report on these, or other issues of bias. Most studies reported results for study completers rather than for those recruited. Depression, post-traumatic stress disorder (PTSD), anxiety and child behaviour problems were the primary outcomes. Data suggest that CBT may have a positive impact on the sequelae of child sexual abuse, but most results were not statistically significant. Strongest evidence for positive effects of CBT appears to be in reducing PTSD and anxiety symptoms, but even in these areas effects tend to be ‘moderate’ at best. Meta-analysis of data from five studies suggested an average decrease of 1.9 points on the Child Depression Inventory immediately after intervention (95% confidence interval (CI) decrease of 4.0 to increase of 0.4; I2 = 53%; P value for heterogeneity = 0.08), representing a small to moderate effect size. Data from six studies yielded an average decrease of 0.44 standard deviations on a variety of child post-traumatic stress disorder scales (95% CI 0.16 to 0.73; I2 = 46%; P value for heterogeneity = 0.10). Combined data from five studies yielded an average decrease of 0.23 standard deviations on various child anxiety scales (95% CI 0.3 to 0.4; I2 = 0%; P value for heterogeneity = 0.84). No study reported adverse effects. AUTHORS' CONCLUSIONS The conclusions of this updated review remain the same as those when it was first published. The review confirms the potential of CBT to address the adverse consequences of child sexual abuse, but highlights the limitations of the evidence base and the need for more carefully conducted and better reported trials. Plain language summary The sexual abuse of children is a substantial social problem that affects large numbers of children and young people worldwide. For many children, though not all, it can result in a range of psychological and behavioural problems, some of which can continue into adulthood. Knowing what is most likely to benefit children already traumatised by these events is important. This review aimed to find out if cognitive-behavioural approaches (CBT) help reduce the negative impact of sexual abuse on children. Ten studies, in which a total of 847 children participated, met the inclusion criteria for the review. The reporting of studies was poor, and there appear to be significant weaknesses in study quality. The evidence suggests that CBT may have a positive impact on the effects of child sexual abuse, including depression, post-traumatic stress and anxiety, but the results were generally modest. Implications for practice and further research are noted.
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A randomized experimental evaluation found support for the effectiveness of eye movement desensitization and reprocessing (EMDR) in reducing trauma symptoms among adult female survivors of childhood sexual abuse. Fifty-nine women were assigned randomly to one of three groups: (1) individual EMDR treatment (six sessions); (2) routine individual treatment (six sessions); or (3) delayed treatment control group. A MANOVA was statistically significant at both posttest and follow-up. In univariate ANOVAs for each of four standardized outcome measures EMDR group members scored significantly better than controls at posttest. In a three-month follow-up, EMDR participants scored significantly better than routine individual treatment participants on two of the four measures, with large effect sizes suggestive of clinical significance.
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Describing traumatic experiences is a routine feature of mental health assessment and treatment it is accepted that in the clinical context this will be distressing to some patients. Research on the experience and sequelae of trauma is also a situation where people may be asked for detailed accounts of traumatic experiences. A common concem voiced by ethics committees is whether the process of reviving memories of past traumas may adversely affect the research participant. The study to be described here attempts to shed some light on this issue.At the conclusion of intensive interviews with 257 mothers and 160 fathers who had a stillborn baby some years earlier, parents were asked about the extent to which they found the interview distressing and the extent to which they found it helpful or unhelpful. We found that of the small proportion of parents who found the interview distressing, nearly all reported that it had also been helpful to them. These data suggest that in evaluating research which involves the evocation of painful memories, ethics committees should not focus on whether participants will become distressed by the research, but rather on whether the study is designed in such a way that the final outcome will be a positive one for participants.
Twenty children and adolescents were treated for a single traumatic memory with a single session of eye movement desensitization and reprocessing (EMDR). Treatment was delayed 1 m for half the group. Over half of the 20 participants moved from Clinical to Normal levels on the Impact of Events Scale, and all but 3 showed at least partial symptom relief on several measures at 1-3 m following a single EMDR session. Results should be interpreted with caution, but were positive, and essentially consistent with analogous findings of EMDR with adults.
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We suggest that trauma contributes to the development and persistence of conduct problems, and should be addressed. Eye movement desensitization and reprocessing (EMDR) was selected as a promising trauma treatment. Twenty-nine boys with conduct problems in residential or day treatment were randomized into standard care or standard care plus 3 trauma-focused EMDR sessions. The EMDR group showed large and significant reduction of memory-related distress, as well as trends towards reduction of post-traumatic symptoms. The EMDR group also showed large and significant reduction ofproblem behaviors by 2-month follow-up, whereas the control group showed only slight improvement. These findings provide support for EMDR's use as a trauma treatment for boys ages 10-16, as well as support for the hypothesis that effective trauma treatment can lead to reduced conduct problems in this population.
This study evaluated treatment outcome for 49 recently sexually abused children aged 7-14, who were randomly assigned to receive either sexual abuse-specific cognitive behavioral therapy (SAS-CBT) or nondirective supportive therapy (NST). Respondents and their nonoffending parent were provided with 12 individual treatment sessions, which were closely monitored for adherence to the assigned treatment modality. Participants and parents completed several standardized assessment instruments pre- and posttreatment. Results indicated that there was a significant group-by-time interaction on the Children's Depression Inventory and the Child Behavior Checklist Social Competence Scale, with the SAS-CBT group improving more than the NST group on both of these instruments. Clinical findings also suggested that SAS-CBT was more effective than NST in treating sexually inappropriate behaviors. Implications for clinical practice and future research are discussed.
The authors report on the development and initial validation of two brief measures of children’s posttraumatic symptoms: a child self-report and a parent report. Intended applications include postdisaster screening, tracking children’s recovery in research and clinical settings, and screening for posttraumatic stress among children with various presenting problems. A sample of 206 urban and rural schoolchildren, Grades 3 through 8, and their parents, completed these measures as well as a checklist of the child’s trauma-loss history. Findings provide preliminary support for the internal consistency, test-retest reliability, content validity, and criterion validity of each measure. We recommend cautious use of the measures, and suggest additional avenues of study.
This study examined the differential effects of child or non-offending mother participation in a cognitive behavioral intervention designed to treat posttraumatic stress disorder (PTSD) and other behavioral and emotional difficulties in school-aged sexually abused children. The 100 participating families were randomly assigned to one of three experimental treatment conditions—child only, mother only, or mother and child—or to a community control condition. Pre- and post-treatment evaluation included standardized measurement of children's behavior problems, anxiety, depression, and PTSD symptoms as well as of parenting practices. Two-by-two least-squares analyses of covariance were used to compare outcome measures. Results indicated that mothers assigned to the experimental treatment condition described significant decreases in their children's externalizing behaviors and increases in effective parenting skills; their children reported significant reductions in depression. Children who were assigned to the experimental intervention exhibited greater reductions in PTSD symptoms than children who were not. Implications for treatment planning and further clinical research are discussed.