Critical Review of Research Evidence Part 3 FD

RUNNING HEAD: TRAUMA AND CHILDREN 1
Children, EMDR, and Foster Care
Robert Cope
Colorado State University
SOWK 601: Methods of Research II
Critical Review of Research Evidence Part 3
Dr. Neomi Vin- Raviv
May 10, 2016

TRAUMA AND CHILDREN 2
Children, EMDR, and Foster Care
Children in foster-care are often impacted by trauma on a different scope than other kids.
This may mean that the trauma is a secondary cause from the foster home, biological home and
possibly from multiple moves in a short life span. One promising treatment, eye movement
desensitization and reprocessing (EMDR) has been recognized as an effective intervention for
trauma and it could be a treatment for youth in foster-care. EMDR is an eight-step process that
requires specific training and certification that other interventions do not require. An alternative
treatment that shows similar outcomes to EMDR is Cognitive Behavioral Therapy (CBT). CBT
is a widely known and well-researched treatment that allows most any therapist to use it as an
effective intervention, without much more training than attending a seminar.
Trauma is an established stressor in life that has an impact especially as children age out
of the foster-care system and engage in life out in the world on their own. Children are the
identified target population, specifically labeled as individuals who are under the age of eighteen
years old and living in the foster care system, and primarily those who have experienced
traumatic events. Wilcox et al., (2016) emphasized, “among children exposed to trauma, the
lifetime burdens in terms of cost rivals that of other high-profile public health problems” (p.62).
There is an expanse of multiple stressors which can cause trauma for the child, who may only
have the innate desire to return home to the biological family. The problem statement for this
project is, how are children in foster care affected by trauma and can EMDR be an effective
intervention technique to aid children in resolving the memories associated with the traumatic
experience.

Background
Scope of problem and its population
Imagine that a child who has experienced a family disturbance now requires that they are
removed from the biological families home and placed in a foster-care situation. These youth are
more likely to experience the initial trauma of removal, additional trauma of repeated moves,
abuse, assault which then results in behavioral problems, mental health illness, and physical
health issues. It is unfortunate that these youth are removed from their families and live in
situations that are unfamiliar to them. More than twenty thousand youth age out of the foster care
system every year, more than sixty five percent have been victims of some form of neglect, and
just under half of that sixty five percent go into foster care with some form of medical or mental
health illness. This causes trauma for the youth in an unfamiliar home environment with little
support to deal with all of the new changes (Lockwood, Friedman, & Christian, 2015).
However you look at the calamity of youth in foster-care, the cards are stacked against
them. Children who are healthy are adopted first, adolescents that are unhealthy, have behavior
problems or have been adjudicated are more likely to age out and start adulthood alone and
unprepared (Lockwood et al., 2015). One large issue is the problem of placement for children
who have behavior problems. Cox, Cherry, & Orme, (2011) examined a study of Iowa foster
families who responded to a survey; of the one thousand foster families involved, under half
would accept children with behavior problems. This leads to a shortage of availability for kids
who behave poorly which could be resultant from the trauma of being removed from their family
and untreated exposure to abuse.
To give a population view of the foster care population, the Child Welfare Bureau reports
in a yearly report, how many children were in foster care, how many entered foster care and how

many exited the system. In the 2013 report, there were 402,378 children in foster care, 254,904
children entered into foster care in 2013 and 238,280 children exited foster care (Child Welfare
Bureau, 2015). The report explains that in 2013, fifty one percent of the child population was
placed back with the biological family, and that only ten percent of the children in foster care
aged out of the system. While this seems low, the report did not specify how they were prepared
for life on their own.
The general length of stay in foster care ranged from as high as five years to as low as
one month. Twenty seven percent of the population were in foster care for a range of twelve to
twenty three months and as low as five percent were in the system for more than five years
(Child welfare Bureau, 2015). While the 2016 report was not available, it is estimated that the
population may have changed over the last three years due to the socio-economic issues from the
recent financial boons that the U.S. has faced.
Wilcox et al., (2016) explains trauma as “child maltreatment, neglect, domestic violence
exposure, caregiver impairments that affect parenting, for example parental substance abuse,
incarceration and mental health disorders” (p.62). It was also conveyed by Wilcox et al., (2016)
that childhood trauma is a leading cause of lifetime health problems, these being both mental and
physical health. Adverse childhood experiences (ACE), which are considered the trauma that
youth suffer and the risky behaviors that result from trauma. These risky behaviors could be
substance abuse, mental health issues, and other negative behaviors that the youth may do since
they are unprepared to deal with past stressors (G. E. Chandler, Roberts, & Chiodo, 2015). Of
people affected by sexual abuse trauma, it was found in one study that blood flow is decreased in
the prefrontal cortex, which is responsible for higher cognitive functioning. People who
experienced PTSD (Post traumatic stress disorder) also experienced similar decreased blood flow

in the medial prefrontal cortex (Blanco et al., 2015). This report exemplifies the detrimental
effects trauma has on the brain resulting in permanent behavior effects.
Why is this a problem and its prevalence?
Children in foster care are more likely to attempt suicide, and have drug dependence than
similar aged youth who are not in foster care. Those children who are in foster care are also more
likely to be diagnosed with disorders such as anxiety, conduct disorders and depression (Deutsch
et al., 2015). These issues lead to a higher prevalence of traumatized youth who are in foster
families than youth who are in homes with their naturalized parents. Szilagyi, (1998) asserted,
“ mental health disorders are rampant in the foster-care population, with prevalence’s of severe
disturbance ranging from thirty five percent up to eighty five percent. Mental health care is the
single overwhelming health care need of most children in care” (p.46). Among the youth who are
in foster – care they have experienced distress that is a leading cause of the ill fated preparedness
for future life successes and related to long-term problems.
One prominent study mentioned by several other research articles specified a term
“polyvictimization” (Finkelhor, Ormrod, & Turner, 2007). This new term was coined and
reflects the different types of trauma that a child may experience resulting in a PTSD diagnoses
factors. Telman et al., (2015) explained polyvictimization as having the repeated exposure to
“interpersonal violence such as sexual abuse, physical abuse, bullying, and family violence.
Other researchers have noted that polyvictimization is an important factor to experience PTSD”
(p.128). Children in foster care may present behavior problems as being coping strategies to
protect themselves from experiencing further familial violence. Behavior problems are depicted
as being larger problems, which may be expressed later to future family members. Social

learning theory is provided as an explanation to why children who experience violence, resulting
in the shaping about acceptance of violence as an adult for dealing with stress (Smith-Marek et
al., 2015). This past exposure to violence and abuse can lead to an adult who associates an
acceptance to violence and abuse then repeating the cycle to a future generation.
Why is it essential that something be done to address the problem?
Readily available are the many ideas for why trauma exists in foster care and how to help
youth afflicted by it. Szilagyi, (1998) recommends “every child over the age of four should have
regular encounters with a mental health therapist to help him or her deal with issues of ongoing
separation and loss as well as feelings of sadness, anger, powerlessness, alienation, and
guilt”(p.47). It was also recommended by Szilagyi, (1998) that counseling care should be
offered to the foster family so they can be prepared to handle the possible issues that may arise
between themselves and the child incoming to the home. By treating both the youth and the
family, attachment to the new family may be rectified as the youth and foster parents learn to
interact with the significant needs of the child.
A further issue to consider is positive attachment to the foster-parents. Shea, (2014)
describes attachment issues “without access to attachment security and the soothing and
regulating capacities offered by a caregiver, an infant is unable to develop the capacities to self-
soothe and self-regulate”(p.63). While Shea (2014) referred to infants, it could be estimated that
foster youth who have experienced the loss of a positive attachment may act out due to this loss.
This supports the idea by Szilagyi, (1998) who felt that youth need access to a therapeutic
environment, and especially with foster youth, this would be important. An idea is that EMDR
may be useful in the reprocessing of the traumatic memory, so the youth can finally have balance
with a positive attachment (Dworkin, 2003).

Detailed explanation of EMDR
A current treatment that was considered, Cognitive-Behavioral therapy (CBT) has
considerable history supporting its effectiveness as well as its intervention counterpart TF-CBT
(trauma-focused cognitive-behavioral therapy). Yet, EMDR has a mystery to it, as only trained
and qualified individuals are allowed to practice it, much like psychoanalysis. A re-worked and
very similar intervention to EMDR that was not chosen as a potential treatment for foster
children was Brainspotting. Dworkin, (2003) explained “EMDR is a complex, eight-phase
methodology that integrates elements of cognitive behavioral, psychodynamic, hypnotic, and
family systems elements within its structures” (p.173).
Inside the expansive range of treatments available, EMDR is relatively young, with it
being created within the last twenty-five years. The creator, Francine Shapiro is responsible for
creating EMDR after finding herself on a walk and thinking of a distressing memory when her
eyes fixed on a stable object, the upsetting thoughts she had disappeared (Dworkin, 2003). It was
a novel idea, Shapiro, (1996) declared “ a central component of the method is directing the
clients attention to an external stimulus while he/she simultaneously concentrates on an
identified source of emotional disturbance”(p.209).
Each of the eight phases of EMDR start with an initial history of the client, the current
problem that brought them into treatment and identifies the clients ability to manage anxiety
causing events (Dworkin, 2003). After the initial stage, in the second stage the client is given a
detailed explanation of EMDR and how it works, and safety is affirmed to proceed into the
future steps. Dworkin, (2003) explicated “ in this phase, the client tries different forms of
bilateral stimulation to determine which one feels most productive”(p.174). On Episode 21,
Season 8 of the hit crime show, Criminal Minds, EMDR is used and it only touches on a few

points of the therapeutic approach, such as lights and the brain stimulation (“Criminal Minds’
Nanny Dearest,” 2013). This provides an idea that most people have only a slight grasp of what
EMDR really involves.
In the third step of the eight phase intervention; an anxiety inducing event is chosen from
the clients memory, its then rated on a one to seven scale, and the clinician requests that the
client explain where the distressing feelings exist in their body. Dworkin, (2003) described the
fourth stage “ the client starts with all elements of the assessment phase (third stage) in his or her
consciousness and sets of at least twenty-four alternating eye movements, tones or taps are
administered” (p.174). The clinician breaks periodically during the process to check in with the
client to observe what he or she is experiencing. Once the memory is desentizied down to a
lower anxiety causation the next phase begins. In the following phase, the lessened anxiety is
held onto and processed. The clinician then asks the client to use the traumatic memory and
associate with a positive emotion that they want to associate with it. Again bilateral stimulation
is used, allowing the new belief to be inscribed in the now reprogrammed non-traumatic memory
(Dworkin, 2003).
In the next stage, Dworkin, (2003) affirmed “ the clinician instructs the client to hold the
target memory (new reprogrammed memory) of the trauma and positive cognition and scan his
or her body for residual tension” (p.174). Following the full body evaluation, the client provides
a detailed explanation of any remaining tension from the memory. Should the client have any
remaining, bilateral stimulation is again repeated and the preceding steps are followed again until
the memory does not cause any residual tension in the whole body system. Within the next
stage, the clinician checks in with the client to assess for safety and effective closure of the
session. Unfortunately no literature was found that detailed the last two stages in explicit detail.

The final stage is actually carried into the next session, where a thorough evaluation is done that
allows the clinician to look at how the client made improvements from the first session or what
work needs to be done in that concurrent session (Dworkin, 2003).
Contemporary use of EMDR
EMDR is used a wide variety of settings, from working with children to utilizing this
intervention with seniors. Once specific treatment is using it in the community mental health
setting. At Community Reach Center in Thornton, Colorado; EMDR is used for helping people
who are seeking psychotherapy to remedy a range of problems from substance abuse to PTSD.
They track their treatments heavily with the ability to provide evidence-based practice, in a
structured environment with a trained clinician. In 1996, when Francine Shapiro first created and
started utilizing EMDR in the therapeutic environment, she completed a study on patients with
PTSD. Henceforth her study had been repeated four times and shows very supportive results
which confirm the effectiveness of the treatment for PTSD (Shapiro, 1996).
When a child is born into an abusive environment or to parents that have severe mental
health problems, they have the potential to be removed from the home. Unfortunately this causes
trauma for the youth who only want to be back at home with the biological family. Children in
foster care are affected by traumatic events and EMDR may be used as an effective intervention
for children in this setting. Shea, (2014) indicated “foster care children’s potential lack of
positive caregiving experiences impedes their ability to develop new relationships with new
caregivers” (p.64). In their assertion Shea, (2014) provided an in-depth idea in how foster
children may visualize attachment to the new family as resultant in future pain and withdraw,
causing problems in the home and acting out in the community as well. Shea also explained how

traumatic experiences such as abuse, causing a lack of social interaction skills and preventing
them from connecting on an emotional interpersonal level with the foster family.
Shapiro, (2012) provided a profound explanation of how EMDR may be helpful in
resolving attachment through the identifying the memory and settling of the homeostatic
environment. Shapiro, (2012) affirmed “EMDR interfaces well with the focus of trauma
memories and thus may have much to contribute here as an approach that specializes in the rapid
treatment of disturbing memories” (p.242). There was also a mention of how the homeostatic
environment within the foster home is affected by the re-experience of the trauma memories,
resulting in a dissipation of the attachment to the foster care family members. If the environment
is settled and the memories dispersed, the child may find clarity and environmental security.
(Shapiro, 2012).
A further assertion that is provided by Jarero & Artigas, (2012) looked specifically at
using EMDR in a group setting. Jarero & Artigas, (2012) detailed “the group administration can
involve segments of an affected community, agency, or organization and reach more people in a
time-efficient manner. The protocol is adaptable to a wide age range: from 7 years to the elderly.
It is cost efficient, as it requires just a place in which to write, as well as paper and crayons or
pencils” (p.221). While their study focused primarily on group work, their studies finding could
prove useful in a large-scale traumatic situation. With the current and unfortunate outbreak of
school assaults, a sizeable treatment approach could help more PTSD victims in a shorter time
span than individual treatment sessions would be efficiently utilized.
Ahmad & Sundelin-Wahlsten, (2007) completed a study of the effectiveness of EMDR
treating PTSD on thirty three children who were between six and sixteen years of age. They
found that younger children struggled to detail how they felt during later phases of the eight-step

process, while older children were able to communicate better. Overall, their results showed that
the children who participated in the study saw changes in reflecting on past memories that had
once traumatic, now did not hold the same anxiety towards them. Diehle recommended that
adverse effects of trauma can cause PTSD (post-traumatic stress disorder) and can have long-
term effects for the youth. The study by Ahmad & Sundelin-Wahlsten, (2007) utilized
participants and who had been treated with the eight step process of EMDR. Their study also
found that of the children who completed just one of the EMDR’s eight sections, showed
promise in identifying negative thoughts and learning positive cognitive alternatives.
Field, (2011) evaluated eight studies that employed EMDR to treat children diagnosed with
PTSD, of those eight studies, seven of them showed promising results. While there were some
limitations in sample size and length of treatment, the results showed some promise in treating
traumatized youth.
Shapiro, (2012) explained EMDR’s proposed benefit for traumatic experience as “ from
the EMDR perspective, articulated in the AIP model (adaptive information processing),
adaptively processed memories are prevented from becoming dysfunction ally stored memories
that underlie many disorders” (p.244). These traumatic memories are left over from the
experience, which is reflected in PTSD symptoms and then result as comorbid behavior
concerns. A treatment of the eight step process of EMDR may help the memories from becoming
permanently cemented in long term memory. A problem of trauma in foster care may be aided if
the foster parents have access to services that allow for lost cost preventative treatments of
EMDR. With this availability, the foster parents may be able to aid the child as they progress
through the treatment.

Evidence-based intervention
In the background section, children in foster care were explained as living a rough life.
From multiple housing placements, behavioral, and mental health problems and possible
judiciary circumstances, all of which can be circumstantial factors that affect their ability to find
stable homes. Unfortunately, these youth also face a varying range of trauma that implicitly and
explicitly impacts them (Lockwood et al., 2015). Francine Shapiro, the creator of EMDR
explains it as a multiple step process directly designed as focusing at treatment of trauma
(Shapiro, 1996).
Perry, (1999) helped to identify how trauma affects youth and in particular, PTSD.
Perry, (1999) explained “in the U.S. more than five million children experience some traumatic
event…more than 40% of these children will develop some form of chronic neuropsychiatric
problem that can significantly impair their emotional, academic, and social functioning”(p.2).
His explanation helped identify how trauma affects a large population of youth and specifically
his opening story about a six year old girl, witnessing the murder of her mother really cemented
the fact that this young girl would enter foster care affected by a significant about of
interpersonal trauma. There was further evidence provided that foster youth are affected by
trauma and it in turn affects how they will experience life. Deutsch et al., (2015) explained how
youth who are afflicted by trauma in youth have behavior problems that directly impact their
foster placement and lead to problems as an adult.
There is a preponderance of research to show that trauma affects adolescents and
different interventions are used. One of the most common is EMDR, but another is Cognitive-
behavioral treatment (CBT), which is also commonly used. Leenarts, Diehle, Doreleijers,
Jansma, & Lindauer, (2013) did a expansive search of articles and research that specifically

focused on treatments to help children, and trauma. They found that CBT studies found similar
treatment results as EMDR and in some cases CBT did a better job, but the EMDR treatment was
shorter and just as effective. Whether it was CBT or EMDR, the treatment had the same goal, to
replace negative memories with cognitive reframing that changed the memories.
Two specific studies that identified how EMDR helped adolescents who experienced
trauma was gathered from the Leenarts et al., (2013). Ahmad & Sundelin-Wahlsten, (2007)
looked at how PTSD (post-traumatic stress disorder) affected youth and if EMDR was an
effective treatment. They used a special testing measurement, PTSS-C (post-traumatic stress
symptom scale for children) to diagnose PTSD according to DSM (diagnostic statistical manual
of mental health disorders) benchmarks. Ahmad & Sundelin-Wahlsten, (2007) found “ the
findings for only one single EMDR session is satisfactory for treatment of PTSD in children (e.g.
8) support for similarity of the mechanism of action of the EMDR with that of cognitive
psychotherapy” (p.131). Outwardly considering how EMDR takes less time than traditional
psychotherapy, it was interesting to see that their study pointed to similar results with either
treatment. It may come down to the fact that EMDR and CBT are both useful treatments and
depending on time limitations, which treatment is implemented. Considering alternatives to CBT
is Trauma-focused CBT(TF-CBT) which was created by Cohen and Mannerino, and it is
designed to be completed in 12 sessions, which is considerably longer than EMDR’s 8 step
program (Diehle et al., 2015, and Cohen & Mannarino, 2008). TF-CBT was created with the
specific goal of treating youth with PTSD.
An additional article by Diehle et al., (2015) found in their study that when they adjusted
the TF-CBT treatment to fit into a similar eight stage sequence to EMDR, the TF-CBT group
showed slightly higher results than the EMDR treatment groups. This may have been due to TF-

CBT group having two less members than the EMDR group or due to the type of trauma the
client experienced. Their research did result in finding that both treatments were equally matched
in treating trauma in children and adolescents.
One treatment that had been referenced by Kocina, (2016) was an alternative to EMDR,
called Brainspotting. It is essentially a re-branded version of EMDR, by a clinician who reports it
as being similar, but yet different. A precursory search of Google Scholar and the CSU-database
failed to turn up any peer-reviewed journals that referenced Brainspotting. This writer attended a
seminar on Brainspotting taught by Kocina (2016), who could not adequately defend or provide
research to support her claims against EMDR and how her treatment was more effective. Several
of the articles researched, referred to Brainspotting as poorly designed. Brainspotting articles that
do appear in a Google search are written by one of two authors, and they appear to be the
designers of the intervention.
Jarero & Artigas, (2012) provided particularly strong evidence about EMDR and its
eight-stage process. As each stage progresses it builds on the previous with the first stage used to
identify the traumatic memory and forming a foundation to build upon. Jarero & Artigas, (2012)
found that EMDR can be used with a wide spectrum of populations and trauma types. EMDR is
also specified as being distinctively useful when applied to youth as stated by the apex of the
studies was Shapiro, (2012) who explained how EMDR was very versatile. Shapiro, (2012)
declared “eye movements are associated with physiological changes during EMDR sessions,
including decreased heart rate/ skin conductance, increased high-frequency heart rate variability
(parasympathetic tone),and increased finger temperature and breathing rate” (Söndergaard &
Elofsson, 2008, as cited by Shapiro, 2012, pg. 244). The identification of the physiological

changes in the body were instrumental in allowing the research to show that EMDR was a
particularly useful intervention for traumatized youth.
Strengths and weaknesses
EMDR is based on the idea that eye movements can have an effect on reprogramming the
mind and altering traumatic memories. This allows for the trauma induced memories which are
laden with anxiety causing physiological manifestations, to become replaced with memories that
are not linked to anxiety. Specifically considering how debilitating trauma and PTSD can be,
foster youth can experience similar symptoms. Söndergaard & Elofsson, (2008) looked at a
preliminary review of the studies looking at how the physiological effects of trauma can be
affected by administering EMDR. Of the five studies that were reviewed they found that in all of
them, heart rate decreased, skin electrical signals, and temperature went down for individuals
who were treated with EMDR.
One specific study and hypothesis looked at how EMDR changes mirrored that of REM
(rapid eye movement) sleep. Söndergaard & Elofsson, (2008) declared “EMDR works through
repeated orienting responses, it is apparent from our data that the REM system can be kick-
started simply through eye movements” (p.285). This is a very supportive strength for EMDR
since it involves eye movements being used to reset traumatic memories. Blanco et al., (2015)
supported the fact that traumatic memories have physical and physiological effect on the brain,
where EMDR specifically may be used. Blanco et al., (2015) described “reduced regional blood
flow may indicate that the function of the hippocampus is altered and perhaps weakened relative
to individuals with normal blood flow” (p.67). This supported in that research has correlated the
hippocampus with memory storing both long term and short term memory, disruptions in blood
flow can cause the negative memories (Breedlove, Watson, & Rosenzweig, 2007).

With the memories being stored in the hippocampus, as we get older, the memories are
harder to change. A further strength of the literature available to support the efficacy of using
EMDR with adolescents. Shapiro, (2012) did an expansive search of literature to support the
efficiency and effectiveness of EMDR in treating traumatized youth. Especially in the early
stages of experiencing the trauma. It was found that across the board that EMDR is seen as
effective as similar interventions but has less time needed for treatment, no work to be done at
home and especially useful in emergency situations that other treatments are not as useful
(Shapiro, 2012).
While the strengths point to a supportive stance, stating that EMDR is useful for youth
and adolescents. One consideration to make that is a relatively large problem with EMDR is the
training and understanding of foster children by the clinician. Zilberstein & Popper, (2016)
proposed “it is unlikely that a single evidence-based treatment can be developed for this
population or even for a significant minority of them”(p.33). Zilberstein & Popper did a study of
effective treatments for use with the foster care population, they covered quite an expansive
field, ranging from family therapy to cognitive behavioral therapy. However impressive their
research was, it skips EMDR and never explicitly mentions it as effective in any way. Yet they
do propose the idea that clinicians need to be prepared to work with special populations with a
wide array of issues.
One of the questions that still needs to be answered that Zilberstein & Popper, (2016)
through their assertion presents; that training affects treatment, considering how the EMDR
stages become adapted to the problems related to foster care children. Would the treatment need
to be tailored or does each stage reflect a consistency in treatment that will work with the uniuqe
population, this becomes a question for clinicians to consider.

Corey, (2009) described EMDR as “designed to assist clients in dealing with
posttraumatic stress disorders, EMDR has been applied to a variety of populations
including children, couples, sexual abuse victims, combat veterans, victims of crime, rape
survivors, accident vicctims, and individuals dealing with anxiety, panic, depression,
grief, addictions, and phobias” (p.242).
In all consideration Zilberstein & Popper make a great argument for their concern given to
specilized training of the clinician. Yet, with the comprehensive range of EMDR’s capabilities, it
appears safe to assume that children in foster care would also benefit from this intervention.
One key point to consider is the purported weakness that some attribute to EMDR which
is the misunderstandings around the clinician who performs EMDR. Dworkin, (2003) reasoned
“the clinician, with knowledge of the client’s history and characteristics, uses this information to
enable the client to shift into a more adult mode, releasing him or her from the dysfunctional way
of experiencing his or her problems”(p.172). Acknwoledging the fact that a clinician tends to
have a suito-intimate relationship with their client, being exposed to their emotional problems,
allows them to navigate the waters and apply EMDR in the best course of action.
EMDR’s effectiveness
In treating foster children, one must consider what the most effective treatment would be.
Zilberstein & Popper had concerns about the clinicians abilities and training may affect how
EMDR is applied to the diverse range of calamities that affect the foster youth population. For
EMDR to be truly effective intervention, starting treatment earlier may present the best overall
results. Wilcox et al., (2016) completed a study with a population of youth betwenn eighteen
years old and first born, who had shown symptoms of having medical problems that were

comorbid to PTSD and noticed by the primary care-giver. They utilized two separate
measurements based on DSM-IV criteria.
Wilcox et al., (2016) discovered “ in the total sample, 21% reported medical
problems/disabilities on entry into child trauma services”…more likely to be male, black, living
outside the parental home, receiving public assistance, younger at their first trauma” (p.68).
With the preponderance of the population as being Afircan American and having an experience
of trauma at an early age, it seems rational that earlier treatment may prevent long-term
comorbid health effects. Of the measurements by Wilcox et al., (2016), it was shown that the
three top types of trauma experienced in sequential order are domestic violence, emotional
abuse, physcial abuse, neglect, and sexual abuse. (p.67). This evidential conclusion is an
example of where parents, care providers and clinicians need to be aware of past history through
intake forms and foster-parent education so they are aware of what needs are observed and what
treatment is availble.
There are essentially two ways that a clinician could look at the effectiveness of a
therapeutic intervention. An indirect way would be to consider how foster parents observe signs
of trauma, seek out treatment and by attending the treatment, the youth is less likely to act out
later and cost the county of residence fianacial headaches (Pomerantz, 2008). Another
consideration looking at the effect of treatment with regards to foster youth is the direct
treatment. Schilling, Fortin, & Forkey, (2015) recommends that children who make an entrance
into foster care need to be taken to a medical or clinical professional within the first thirty days to
be fully appraised for trauma. This direct approach will allow the professional to assess for
cormorbid problems that could become larger issues down the road.

By all references, the intervention EMDR appears to be an ethical and recommended
treatment of youth. It is evidence-based, as attributed by the founder Francine Shapiro, as well as
by Ahmad & Sundelin-Wahlsten, (2007). CBT is also referenced by Diehle et al., (2015) as
equally effective. However, EMDR is an eight session treatment that could reduce financial costs
to the county, and to the foster parents. Also EMDR could be completed in less time than CBT,
which can last for months and may not be as applicable to youth who have difficulty
communicating.
Future research
To consider what intervention is best, some people may consider what the history of the
interventions is. Or, possibly how the intervention is measured for its implementation in the
clinical environment compared to its theoretical design. Prochaska & Norcross, (2013) purported
“in its 20 year history, EMDR has garnered more controlled research than any other method used
to treat trauma” (as referenced by Corey, 2009, pg 243). It was also referenced by Corey, (2009)
that EMDR will continue to grow in popularity, and further research will continue to outline
EMDR’s potency when treating for trauma, and other emotional hardships.
Supplementary research is also likely to look at the role of eye movements that EMDR is
essentially based upon. Perkins & Rouanzoin, (2002) presented several research designs that
questioned how the eye movements may not be as important as Francine Shapiro reports them to
be. Of the research articles referenced, a common theme was present, the studies tended to have
small sample sizes, which may be a contributory factor to consider when looking at the
effectiveness of EMDR as an intervention. Future research may need to adjust for larger sample
sizes or length of the studies, so as to assess what happens in the long term after EMDR

treatment ends and what happens when a large sample size is used. The question this presents, is
how would the results change in a sample size increased, would EMDR be as effective.
Ahmad & Sundelin-Wahlsten, (2007) made an explicit observation which needed to be
considered. Ahmad & Sundelin-Wahlsten, (2007) proclaimed “further evaluations of this child-
adjusted protocol have to be conducted before being able to generalize its applicability to the
largely variable child conditions” (p.131). In their study, they adapted an adult formatted EMDR
procedure to a child population. They found that it to be a sanctioned mechanism to aid children
in relieving traumatic symptoms. Nevertheless, it needs to be taken into account that their
intervention model was based on an adult platform and applied to children. Additional research
may need to look at how child specific EMDR formats present therapeutic results in similar
conditions. EMDR appears to be effective, but the research provided a glimpse into a void
where future research could answer questions that help or discredit the validity as an evidence-
based intervention.
Theory in practical application
Singularly, EMDR presents a short intervention history compared to other therapies such
as CBT or Psychoanalysis. Therefore, it needs to be considered how one would apply EMDR
into therapeutic practice, the main fact to consider is how feedback is actualized. Clinicians need
to be able to accurately assess what the clients problem is and how to fine tune EMDR to the
problems at hand. Chandler, Rycroft-Malone, Hawkes, & Noyes, (2016) explained “key to the
phenomenon of feedback is that it creates a flow of information throughout the system”(p.474).
They explained further that not having enough information to precisely determine which
treatment is essential could have lasting negative effects on the patient.

This may mean that shadowing a more experienced clinician who practices EMDR and
applying it to foster children, would be a necessity when learning the intervention. Observing
how a more experienced professional gathers information from the client and family, then apply
the information in practice may help new clinicians gain tools to use in a clinical setting on their
own. Additionally it would be useful for clinical social workers to understand how external
factors are materialized with regards to the EMDR process. Shapiro, (1996) rationalized
“ a central component of the method is directing the client’s attention to an external stimulus
while he/she simultaneously concentrates on an identified source of emotional disturbance.
External stimuli that have been clinically most useful include eye movements, auditory tones,
and alternating hand taps” (p.209). It would be important for the newly trained social worker to
understand how this stimulus is utilized and why it has particular importance. If they fail to
understand how the stimulus is used and why, the EMDR treatment may not be as effective as it
could be.
Also the new clinician needs to fully understand each of the eight steps that EMDR
progresses through and how each sequential step is based off the previous one. If the clinician
skips a step or does not follow the format, the intervention may not be effective or cause
confusion for the client and may very well cause harm. Of particular importance to
understanding the steps is providing positive empathy and unconditional positive regard. While
these Rogerian concepts are foundational learning to the clinical social worker, they are
extremely important for EMDR therapy. An additional important factor is transference. This can
be explained simply as the client transferring their feelings to the therapist and the therapist
responding in a positive nature.

If the therapist responds negatively, it will cause harm to the client and prevent a positive
healing experience. Dworkin, (2003) interpreted transference and empathy as “when a client
perceives the therapist as empathetically caring, a working alliance and a positive transference
develop. However, when the therapist misses an important element of communication, responds
from a position of defensiveness, or ignorance, or embodies aspects of old, unresolved
memories, a negative transference develops”(p.178). Essentially this comes to mean that the
clinician needs to understand that providing positive empathetic support is crucial to competent
EMDR practice. This is especially important when working with foster children who have
experienced so much trauma, having a safe and positive environment would help them start the
healing process.
With regards to transference, it would be very important for the EMDR clinician to have
worked out their own past issues or be working in supervision so they can prevent the transfer of
their problems back onto the client. Again, this is important for the fact that foster-children do
not need to add the clinician’s personal issues to their own. The client needs to be able to heal
from their owns abuses and not added problems which have not been resolved from the
therapists past. Foster children have dealt with enough and the clinical social worker needs to be
educated on the dangers of transferring their past on the client.
In consideration of how EMDR is used today, the therapeutic environment provides a
solid base for EMDR use to grow. Additionally, practicing EMDR as an intervention with the
specific population of foster-children, the earlier the intervention is used would provide an earlier
time for healing to begin. Deutsch et al., (2015) describe how early childhood will prevent
problems later in life, particularly with regards to brain development, emotional regulation, and
development of the delay of gratification. Deutsch et al., (2015) described one very important

factor “failure to establish solid attachment to a caretaker can have direct implications on
placement stability”(p.293). EMDR would be useful in today’s therapy environment by
promoting positive attachment and replacing past negative memories about poor parental support
with positive reprocessed memories.
Although the research has shown that EMDR and TF-CBT are both useful in treating
trauma in children. It is idealized that EMDR would be a shorter therapeutic intervention with
adolescents, and with foster-youth it may be quite useful. Especially, considering how foster-
youth change homes often, treating them in two sessions, versus a twelve session intervention
that CBT promotes may prove to be more realistic. Foster-children represent a distinct group
with their own traumatic intricacies which need to be tailored to the individual. EMDR would be
able to be personalized in a format that CBT would struggle to adapt to. With foster-children,
twelve sessions may drag out a process of revisiting painful memories and cause them to loose
interest.
It is with strong conviction that EMDR would address psychological and physiological
dilemma’s that traumatized a youth’s experience. The eight step process of EMDR allows the
client to choose where to start, what memory to work with and to dictate how they proceed
through treatment. Dworkin, (2003) provided an in-depth exploration of EMDR’s steps and tools
that really provided excellent descriptions for the researcher to identify how EMDR could be
used in practice. While one may hold EMDR in higher regards to that of TF-CBT, usage may
ultimately come down to the clinician’s choice. Education for the therapist would be important
and knowing what works with one client may not work with a separate client facing the same
traumatic past.

EMDR is a young intervention compared to CBT and TF-CBT, but there is strong
evidence to support its results. Whether one believes that eye movements will reset a traumatic
memory is up to the clinician and the client. As a clinician, it is with utmost confidence to
promote EMDR as an effective treatment, for use with foster children, at-risk youth and adults
alike. While in the end, the clinician can promote a specific intervention, it would come down to
what the client chooses and in all reality; they should be given the opportunity to be educated
and make a smart choice as a consumer.
Conclusion
Without a doubt, trauma impacts children at all ages. The presenting problem of PTSD
can be caused of the experience of trauma, whether this is emotional, physical or caused by
sexual abuse or even exposure to family violence. The resulting traumatic exposure may exhibit
itself in behavior problems, which untreated, can affect the child’s ability to be placed in a
permanent home. Unfortunately the behavior problems can also result in violent behavior as an
adult. EMDR has been ultimately presented as a treatment that has positive outcomes when
children and adolescents are provided with treatment.
The problem statement of how are foster children affected by trauma and how can
different therapeutic interventions, particularly EMDR be used to help with memories caused by
trauma? This is answered as being that EMR can provide therapeutic relief in a shorter time
span than similarly effective treatments such as CBT. When considering which treatment to use,
it may come down to financial supports, foster-parent decisions, and the clinician’s assessment
of best-practice for the client.

References
Ahmad, A., & Sundelin-Wahlsten, V. (2007). Applying EMDR on children with PTSD.
European Child & Adolescent Psychiatry, 17(3), 127–132.
http://doi.org/10.1007/s00787-007-0646-8
Blanco, L., Nydegger, L. A., Camarillo, G., Trinidad, D. R., Schramm, E., & Ames, S. L. (2015).
Neurological changes in brain structure and functions among individuals with a history of
childhood sexual abuse: A review. Neuroscience & Biobehavioral Reviews, 57, 63–69.
http://doi.org/10.1016/j.neubiorev.2015.07.013
Breedlove, S. M., Watson, N. V., & Rosenzweig, M. R. (2007). Biological psychology. Sinauer
Associates, Incorporated Publishers.
Chandler, G. E., Roberts, S. J., & Chiodo, L. (2015). Resilience Intervention for Young Adults
With Adverse Childhood Experiences. Journal of the American Psychiatric Nurses
Association, 21(6), 406–416. http://doi.org/10.1177/1078390315620609
Chandler, J., Rycroft-Malone, J., Hawkes, C., & Noyes, J. (2016). Application of simplified
Complexity Theory concepts for healthcare social systems to explain the implementation
of evidence into practice. Journal of Advanced Nursing, 72(2), 461–480.
http://doi.org/10.1111/jan.12815
Child welfare Bureau. (2015). Foster care Statistics 2013 (p. 12).
Cohen, J. A., & Mannarino, A. P. (2008). Trauma-focused cognitive behavioural therapy for
children and parents. Child and Adolescent Mental Health, 13(4), 158–162.
http://doi.org/10.1111/j.1475-3588.2008.00502.x
Corey, G. (2009). Theory and Practice of counseling and psychotherapy.

Cox, M. E., Cherry, D. J., & Orme, J. G. (2011). Measuring the willingness to foster children
with emotional and behavioral problems. Children and Youth Services Review, 33(1), 59–
65. http://doi.org/10.1016/j.childyouth.2010.08.012
“Criminal Minds” Nanny Dearest: Nobody can make it out here all alone. (2013, May 11).
Retrieved March 21, 2016, from http://www.examiner.com/article/criminal-minds-nanny-
dearest-nobody-can-make-it-out-here-all-alone
Deutsch, S. A., Lynch, A., Zlotnik, S., Matone, M., Kreider, A., & Noonan, K. (2015). Mental
Health, Behavioral and Developmental Issues for Youth in Foster Care. Current
Problems in Pediatric and Adolescent Health Care, 45(10), 292–297.
http://doi.org/10.1016/j.cppeds.2015.08.003
Diehle, J., Opmeer, B. C., Boer, F., Mannarino, A. P., & Lindauer, R. J. L. (2015). Trauma-
focused cognitive behavioral therapy or eye movement desensitization and reprocessing:
what works in children with posttraumatic stress symptoms? A randomized controlled
trial. European Child & Adolescent Psychiatry, 24(2), 227–236.
http://doi.org/10.1007/s00787-014-0572-5
Dworkin, M. (2003). Integrative approaches to EMDR: Empathy, the intersubjective, and the
cognitive interweave. Journal of Psychotherapy Integration, 13(2), 171–187.
http://doi.org/10.1037/1053-0479.13.2.171
Field, A., David. (2011). Eye movement desensitization and reprocessing as a therapeutic
intervention for traumatized children and adolescents: a systematic review of the
evidence for family therapists. Journal of Family Therapy, 33(4), 374–388.
http://doi.org/10.1111/j.1467-6427.2011.00548.x

Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Polyvictimization and trauma in a
national longitudinal cohort. Development and Psychopathology, 19(01), 149–166.
Jarero, I., & Artigas, L. (2012). The EMDR integrative group treatment protocol: EMDR group
treatment for early intervention following critical incidents. Revue Européenne de
Psychologie Appliquée/European Review of Applied Psychology, 62(4), 219–222.
http://doi.org/10.1016/j.erap.2012.04.004
Kocina, S. (2016). How Does Brainspotting (BSP) Compare to EMDR? [Business Blog].
Retrieved March 26, 2016, from http://sharonkocina.com/brainspotting-therapy-trauma-
ptsd/brainspotting-vs-emdr/
Leenarts, L. E. W., Diehle, J., Doreleijers, T. A. H., Jansma, E. P., & Lindauer, R. J. L. (2013).
Evidence-based treatments for children with trauma-related psychopathology as a result
of childhood maltreatment: A systematic review. European Child & Adolescent
Psychiatry, 22(5), 269–283. http://doi.org/10.1007/s00787-012-0367-5
Lockwood, K. K., Friedman, S., & Christian, C. W. (2015). Permanency and the Foster Care
System. Current Problems in Pediatric and Adolescent Health Care, 45(10), 306–315.
http://doi.org/10.1016/j.cppeds.2015.08.005
Perkins, B. R., & Rouanzoin, C. C. (2002). A critical evaluation of current views regarding eye
movement desensitization and reprocessing (EMDR): Clarifying points of confusion.
Journal of Clinical Psychology, 58(1), 77–97. http://doi.org/10.1002/jclp.1130
Perry, B. D. (1999). Stress, trauma and post-traumatic stress disorders in children. Child Trauma
Academy Interdisciplinary Education Series, 2(5). Retrieved from
http://www.forallsyrians.net/uploads/1/6/8/5/16859390/trauma_3.pdf

Pomerantz, A. M. (2008). Clinical psychology: Science, practice, and culture. Sage. Retrieved
from,https://books.google.com/books?hl=en&lr=&id=I6HzWp9XKloC&oi=fnd&pg=PR
21&dq=Clinical+psychology+Andrew+pomerantz&ots=rhpnAHlygG&sig=__wXNxztw-
-x13inB5bNypOPYLg
Prochaska, J. O., & Norcross, J. C. (2013). Systems of Psychotherapy: A Transtheoretical
Analysis. Cengage Learning.
Schilling, S., Fortin, K., & Forkey, H. (2015). Medical Management and Trauma-Informed Care
for Children in Foster Care. Current Problems in Pediatric and Adolescent Health Care,
45(10), 298–305. http://doi.org/10.1016/j.cppeds.2015.08.004
Shapiro, E. (2012). EMDR and early psychological intervention following trauma. Revue
Européenne de Psychologie Appliquée/European Review of Applied Psychology, 62(4),
241–251. http://doi.org/10.1016/j.erap.2012.09.003
Shapiro, F. (1996). Eye movement desensitization and reprocessing (EMDR): Evaluation of
controlled PTSD research. Journal of Behavior Therapy and Experimental Psychiatry,
27(3), 209–218. http://doi.org/10.1016/S0005-7916(96)00029-8
Shea, S. E. (2014). Finding Parallels: The Experiences of Clinical Social Workers Providing
Attachment-Based Treatment to Children in Foster Care. Clinical Social Work Journal,
43(1), 62–76. http://doi.org/10.1007/s10615-014-0488-z
Smith-Marek, E. N., Cafferky, B., Dharnidharka, P., Mallory, A. B., Dominguez, M., High, J., …
Mendez, M. (2015). Effects of Childhood Experiences of Family Violence on Adult
Partner Violence: A Meta-Analytic Review: Childhood Family Violence and IPV.
Journal of Family Theory & Review, 7(4), 498–519. http://doi.org/10.1111/jftr.12113

Söndergaard, H. P., & Elofsson, U. (2008). Psychophysiological Studies of EMDR. Journal of
EMDR Practice and Research, 2(4), 282–288. http://doi.org/10.1891/1933-3196.2.4.282
Szilagyi, M. (1998). The Pediatrician and the Child in Foster Care. Pediatrics in Review, 19(2),
39–50. http://doi.org/10.1542/pir.19-2-39
Telman, M. D., Overbeek, M. M., Schipper, J. C. de, Lamers-Winkelman, F., Finkenauer, C., &
Schuengel, C. (2015). Family Functioning and Children’s Post-Traumatic Stress
Symptoms in a Referred Sample Exposed to Interparental Violence. Journal of Family
Violence, 31(1), 127–136. http://doi.org/10.1007/s10896-015-9769-8
Wilcox, H. C., Rains, M., Belcher, H., Kassam-Adams, N., Kazak, A., Lee, R., … Wissow, L.
(2016). Behavioral Problems and Service Utilization in Children with Chronic Illnesses
Referred for Trauma-Related Mental Health Services: Journal of Developmental &
Behavioral Pediatrics, 37(1), 62–70. http://doi.org/10.1097/DBP.0000000000000236
Zilberstein, K., & Popper, S. (2016). Clinical competencies for the effective treatment of foster
children. Clinical Child Psychology and Psychiatry, 21(1), 32–47.
http://doi.org/10.1177/1359104514547597

Critical Review of Research Evidence Part 3 FD

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Andere mochten auch

Andere mochten auch (8)

Ähnlich wie Critical Review of Research Evidence Part 3 FD

Ähnlich wie Critical Review of Research Evidence Part 3 FD (10)

Critical Review of Research Evidence Part 3 FD