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Phobic Reactions In Children And EMDR
Nur Dinçer, Şeniz Pamuk, Olcay Güner /
Specific phobia has been defined as marked and persistent fear of clearly discernible, circumscribed objects or situations. Phobia is considered specific to the particular person and usually is not shared by the larger population. EMDR has been used with 15 children ages between 6-17, who had a direct, unpleasant experience with the source of the specific phobia. The duration of the sessions was between 1-4. The results show that the children were able to formulate resources, think about the “bad picture”, define their emotions and body sensations. All the children were capable of going through the EMDR procedure. The results and the follow-up studies demonstrate that the children were able to overcome their fears and maintain their newly acquired skills.
DSM-IV defines specific phobias as the irrational, marked and persistent fears that are observed in the individual, in relation to a specific situation or thing. The anticipation of confronting the feared stimulus, usually creates a sudden feeling of anxiety.
For children to get this diagnosis, it is not necessary that they have developed awareness that their fear is irrational or meaningless. This awareness shows an increase with age. Children may express their anxiety through behaviors like crying, temper tantrums, numbness, and clinging. Children rarely notice the distress they experience and its causes.
The similarities between phobic reactions and traumatic experiences and the proven effectiveness of EMDR in trauma, oriented us to use EMDR with children who had different forms of phobia.
The routine use and the observed benefits of EMDR with phobic children in our clinical setting, have inspired us to analyze the relevant recorded data. The children were grouped according to the origins of phobia, namely children with phobias of known origin and unknown origin. The effect of EMDR on phobias with an unknown origin is the topic of another study. The aim of this study is to see the effectiveness of EMDR in cases of phobia with a known origin. Since research on this topic is very limited it is also hoped that the results will shed some light on this area.
Sample and Procedure
15 children who were brought to the Institute for Behavioral Sciences between years 1999-2006 were included in the study; 8 of whom were girls and 7 were boys. The children were between ages 6-17, the mean being 10.67.
Since this study was not designed for a specific type of phobia, all the children having some type of phobia were included. Here, a maximum of three fears are examined for each child. The work with these children was not designed for research, but conducted clinically. These children and their parents stated that the fears experienced by these children restricted their functioning at home and also in other environments.
In 9 of the cases phobia was the main reason for referral and in 6 cases, phobia was secondary to other problems. In 11 of the cases EMDR was the only method of intervention and in four cases EMDR was used in conjunction with other methods, namely art therapy and cognitive-behavioral therapy. The number of EMDR sessions needed differed between 1-4.
EMDR: EMDR, is a technique which necessitates the focusing of the individual on a distressing event with the help of a specific protocol and the use of various forms of bilateral stimulation of the brain.
Art therapy: Art therapy is defined as the expression of inner feelings through art. In this method, all forms of art, like drawings, dance, music, drama can be installed, besides using concrete materials, like paints, ribbons, beads, various forms of paper, etc.
Art therapy helps people, by making them aware of many thoughts and feelings that they keep in their subconscious and processing them. The main issue in art therapy is not the formation product; the focus is on the process of creating. The creative capacity of the person is used as a healing power.
Cognitive-Behavioral Therapy: In cognitive-behavioral therapy, the main focus is on the unfunctional cognitions and beliefs of the person; the aim is to replace the unfunctional cognitions with functional ones. When working with phobia, relaxation and desensitization are commonly used techniques.
The children who had some type of a phobia were included in the study. The types of phobia covered a wide range. The types of phobia handled in this study are listed below:
List of phobias experienced by children:
- Fear of animals (dogs,sharks, insecte, bees, jellyfish, etc.)
- Fear of darkness
- Fear of staying home alone
- Fear of failing a test, getting excited
- Fear of abandonment
- Fear of talking to boy friends
- Fear of lightening
- Fear of getting ill
- Fear of not being able to sleep at night
- Fear of a disaster
- Fear of airplanes
Examples of negative and positive cognitions
|Negative cognitions||Positive cognitions|
|“I am a coward”||“I am brave”|
|“I am not safe”||“I am safe”|
|“I am stupid”||“I am successful”|
|“I am not successful”||“I can overcome this”|
|“I am not worth talking to”||“I can do alone”|
The Wilcoxon Test, and the Kruskal-Wallis Test were the main instruments of analyses in this study.
In the following section the abbreviations stand for the following:
SUDS1=SUDS score taken at the beginning of the treatment
SUDS2=SUDS score taken at the end of therapy
SUDS3=SUDS score taken from child during follow-up
SUDS4=SUDS score taken from mother during follow-up
Fear1=The most important fear of child according to mother
Fear2=The second most important fear according to mother
Fear3=The third most important fear according to mother
At the beginning of therapy 1.71 fears were identified by mothers and children and 1.42 fears were dealt with until the termination of the therapy. In other words, it was necessary to deal with all the fears one-by-one to relieve the child (Table 1).
The means of SUDS scores during the therapy and in the follow-up period show that, there is a very clear reduction in SUDS scores at the end of the treatment. (Table 2).
These results show that there was a statistically significant drop in the SUDS scores of the first two fears measured before and right after the treatment, the drop in the third fear was not significantly obvious, although a reduction is seen. (Table 3)
These findings point out that the reduction in SUDS points, in other words, the lessening of discomfort was steady over time. The moderate positive effects of fear3 were also held.
The comparison of SUDS scores given by mothers and children in the follow-up period are in accordance with each other and provide evidence that the positive outcomes are both maintained and are observable, that the lessening of the anxiety also reveals itself in the behaviors of children.
The mothers were also interviewed about the behavior components of the phobias. Many of the mothers declared that the behavior problems related to phobia had significantly diminished. Most children were, for example, able to go near dogs, they could get on the plane easily, they could stand lightening, and so on. Some examples of the observations of mothers are given below.The mothers were also asked to rate the effectiveness of the study. All of the mothers stated that they thought that the treatment was very effective both in reducing distress caused by the phobia and in reducing the behavior problems. All the children shared the view of their parents about the effectiveness of the study.
Examples of behavior changes observed by mothers:
|“My child fears that I will abandon him”||“My child can wait for me after school, even when I am late”|
|“My child is afraid of the dark”||“My child can go upstairs by himself in the night”|
|“My child is afraid of bees and closes all the windows when it is summer”||“My child can open the windows and stay outside, in the summer”|
These ratings by mothers and children in the follow-up period may be seen as a moderate support for the view that EMDR is more effective in cases of real fears than in cases imaginary fears (http://www.emdr.com/q&a.htm#q.6).
Here, the ratings of mothers show no relation to the reduction of SUDS points, which is in contrast to the findings for imaginary fears. The same trend is observed also for fear2 and fear3.
The use of EMDR as the only method of intervention or its use in conjunction with other methods, did not have any significant effect on the amount of reduction in SUDS scores, similar to the finding in the study for imaginary fears.
Whether phobia was the main reason for coming or, was secondary to another problem, also did not have any effect on the amount of reduction in SUDS points. This finding is also in line with that of imaginary fears.
The length of time between the end of therapy and the follow-up also did not create in difference; the benefits were maintained both in the short-term and in the long-term period after treatment.
As a result of these findings it could be stated that, EMDR is a very effective method in the alleviation of distress and behavior problems brought about by phobias in children.
The literature on the effects of EMDR in phobic children is quite limited. In this study, the effectiveness of EMDR on phobic reactions displayed by children was examined.
There are two major drawbacks to this study, which direct us to interpret the results cautiously. One is the very limited sample size, and the other is the non-experimental design of the study. Moreover, the administration of standardized anxiety, phobia and/or behavior scales could have strengthened the findings.
The comparison of the SUDS scores at the beginning and end of the treatment, delineate very clearly, that EMDR as a technique is very powerful in reducing the uncomfort experienced by children. The benefits are maintained over time. Moreover, the reduction in behavior problems which accompanied the fear have also diminished.
As a result, it can easily be said that EMDR should be treatment of choice when dealing with fears in children. It was a common observation that the children were amazed by the results of the study. Even though they had difficulties in concentrating at the start, they soon became very concentrated and, made the flow of thoughts into a film, where they mostly came up with spontaneous solutions. An example would be “Please do not end the set yet, I am about to conquer the dog, I feel so powerful now”. They would usually come to the next session telling how brave they were. “Ask me what I have done when I saw a dog on the street, I just walked by.”
Davison, G.C. & Neale, J.M. (2004). Anormal Psikolojisi. Türk Psikologlar Derneği Yayınları, Ankara.
DSM-IV (1998). Mental Bozuklukların Tanısal ve Sayımsal El Kitabı. Amerikan Psikiyatri Birliği ile Hekimler Birliği Yayınları, Ankara.
Table 1. The mean SUDS scores at the beginning and end of treatment and in the follow-up period
|SUDS1(beginning)||SUDS2(termination)||SUDS3(follow-up child)||SUDS4(follow-up mother)|
|Fear1 (most important)||9.27||1.63||.93||.87|
|Fear2 (second important)||9.00||2.80||1.00||1.00|
Table 2. The differences between the beginning and final SUDS points of the first mentioned fear.
|Difference between SUDS1-SUDS2 for fear1||15||-3.436||.001**|
|Difference between SUDS1-SUDS2 for fear2||15||-2.032||.042*|
|Difference between SUDS1-SUDS2 for fear3||15||-1.342||.180|
* p<0.05, **p<0.01, ***p<0.001
Table 3. The comparison of the SUDS points taken from the child at the end of the study and the time of follow-up
|Difference between SUDS1-SUDS3 for fear1||15||-3.450||.001**|
|Difference between SUDS1-SUDS3 for fear2||15||-2.041||.041*|
|Difference between SUDS1-SUDS3 for fear3||15||-1.414||.157|
* p<0.05, **p<0.01, ***p<0.001
Table 4. The comparison of SUDS points taken from the child at the end of treatment and from mother in the follow-up period
|Difference between SUDS1-SUDS4 for fear1||15||-3.455||.001**|
|Difference between SUDS1-SUDS4 for fear2||15||-2.214||.027*|
|Diference between SUDS1-SUDS4 for fear3||15||-1.414||.157|
* p<0.05, **p<0.01, ***p<0.001
Table 5. The ratings of mothers about the present effect of fear1 and the differences in SUDS scores.
|Mother:”Fear1 does not effect the behavior of my child any more”||Difference between SUDS1-SUDS2||Difference between SUDS1-SUDS3||Difference between SUDS2-SUDS3||Difference between SUDS1-SUDS4||Difference between SUDS2-SUDS4|
* p<0.05, **p<0.01, ***p<0.001