E
YE MOVEMENT desensitisation and
reprocessing (EMDR) is a recently
developed treatment that facilitates the
resolution and integration of traumatic
memories and has proved effective for the
treatment of post-traumatic stress disorder
(PTSD). The approach is used to access,
process and facilitate the integration of trau-
matic memories leading to their adaptive
resolution. This is a complex methodology
that is structured in eight phases and
requires the subject to focus on the trau-
matic memory (target), while being exposed
to a bilateral sensory stimulation, thus help-
ing and accelerating adaptive processing.
This therapeutic methodology has
already been used in different kinds of
trauma in the field of PTSD (American Psy-
chiatric Association, 2004; Chambless et al.,
1998; Foa et al., 2000), and its effectiveness
with PTSD has been explored in emergency
situations (Bleich et al., 2002) and with child
victims of trauma (Chemtob et al., 2002; Fer-
nandez et al., 2004; Jaberghaderi et al., in
press; Jarero et al., 1999). This field study
explores the effectiveness of EMDR on the
level of reported post-traumatic reactions
and symptoms in the context of a specific
emergency: the Molise earthquake of 2002.
The primary purpose of this study was to
assess the anticipated remission or reduction
of PTSD symptoms in the primary school
children who survived the earthquake.
The project has been an excellent exam-
ple of the collaboration between mental
health public agencies (ASL) and the EMDR
Association in Italy, whose members went to
the earthquake site three times on a volun-
teer basis. EMDR was a specialised part of an
extensive and comprehensive emergency psy-
chology programme at the earthquake site.
Since the event met all the DSM IV crite-
ria for PTSD (American Psychiatric Associa-
tion, 1994, 2000), and since EMDR has
proved to be very effective for this kind of
disorder, it became the treatment of choice
with the school population. No one in Italy
will forget this traumatic earthquake for
many years. The only building that collapsed
in the earthquake was the primary school,
and 27 out of 59 children were killed. As cli-
nicians we know that, without treatment, the
people who experienced the event, like the
surviving children or the rescuers, could be
forced by their brain not only to remember,
but also continuously to relive it. Consider-
Educational & Child Psychology Vol 24 No 1 65
© The British Psychological Society 2007
EMDR as treatment of post-traumatic
reactions: A field study on child victims
of an earthquake
Isabel Fernandez
Abstract
This field study explores the effectiveness of EMDR (eye movement desensitisation and reprocessing) for the
post-traumatic reactions of child victims in the post-emergency context of an earthquake that occurred in
2002 in Molise, a region of Central Italy. EMDR was chosen as the treatment for the children of the San
Giuliano Primary School in Molise. Twenty-two of the children who experienced the traumatic event, being
suddenly buried under the debris of their collapsed school and in contact with the bodies of their dead class-
mates for hours, received three cycles of EMDR treatment over one year, with a total average of 6.5 sessions
of EMDR each. The results show that EMDR contributed to the reduction or remission of PTSD symptoms
and facilitated the processing of the traumatic experience.

ing the developmental age of the children,
without a focused and effective treatment
their personality could develop around the
traumatic event and adapt to it, increasing
the risk of developing psychological disor-
ders later in life. Single or chronic trauma
can have a serious impact on psychological
functioning even years after the event. Mor-
gan et al.(2003) noted that in one disaster
where many children were killed in their
school (Aberfan) it was estimated that, 33
years later, some 29 per cent of the survivors
still suffered from PTSD.
For this reason it was essential to inter-
vene in the aftermath of this disaster, provid-
ing psychological support and appropriate
treatment. Among the methodologies used
with the entire population were educational
groups, active listening, defusing, debriefing
and EMDR.
Method
Participants
As noted, the event met all the criteria for
PTSD. The children were exposed to a direct
and extreme situation which caused the
death of their friends and classmates and
where their own lives were threatened (the
survivors were convinced that they would not
be rescued from the rubble). The post-trau-
matic reactions were not only linked to the
stress of having almost died, but also to grief
for the death of their classmates, cousins and
siblings and to the exposure to their dead
bodies under the rubble (from 1 to 10
hours). Furthermore, it is important to con-
sider that many of these small victims also
lost their homes, their daily life routine and,
above all, their friends. All of these factors
accumulated and increased the probability
of developing PTSD. As indicated in the
NICE guidelines (National Institute for Clin-
ical Excellence, 2005), individuals at high
risk of developing PTSD after a major disas-
ter should be screened for PTSD one month
after the disaster. During the earthquake the
school was destroyed and all the six-year-old
children died. Altogether, 32 children sur-
vived and 27 died. Of the children who sur-
vived 29 were treated with EMDR. Of these,
three dropped out and four did not partici-
pate in the full treatment programme. For
this reason the data analysis and the conclu-
sions of this study refer to the remaining 22
children who participated in the full pro-
gramme. The age range of the children
treated was between 7 and 11 years.
Procedure
EMDR was agreed upon and supported by
the Italian National Health Service, the
authorities and the school personnel, as well
as by the parents of the children treated. The
school faculty was cooperative and support-
ive during treatment. These people were also
provided with psychological support
through active listening, group debriefings,
group meetings about children’s reactions to
stress, information sessions on how to man-
age the classes on a day-to-day basis and
information on EMDR treatment.
Educational meetings with parents were
an essential part of the intervention pro-
gramme, addressing stress reactions and
advising on how to manage their traumatised
children in order to provide a more effective
support aimed at reducing and normalising
their reactions. The support and informa-
tion given to the parents were useful tools to
help and to reassure their children. A ques-
tionnaire on symptoms was administered
and full information about the intervention
with children and about EMDR was given in
order to obtain informed consent. Question-
naires focusing on post-traumatic stress reac-
tions of the children were administered to
help them identify the children’s conditions
and enhance cooperation during the whole
process.
Parents were allowed to attend their
children’s EMDR sessions in order to
support and help them understand the pro-
cessing experience. This facilitated post-
treatment support, shared and discussed by
the clinicians after each treatment cycle. Par-
ents’ involvement and cooperation were so
strong that it led them to ask for support for
their other children and for themselves.
66 Educational & Child Psychology Vol 24 No 1
Isabel Fernandez

The three cycles of treatment took place
one month, three months and a year after
the event, with a total average of 6.5 EMDR
sessions per child. The earthquake occurred
on 31 October 2002, and the first EMDR
treatment cycle was administered in the first
week of December, the second in February
and the third and last one in November
2003.
The EMDR treatment was conducted
according to the standard protocol pre-
sented by Shapiro (2001) and Greenwald
(1998). Targets for EMDR treatment were
the most disturbing part of the event, the
present triggers provoking anxiety and the
future situations generating anticipatory
anxiety. All eight phases of the EMDR treat-
ment protocol were carefully followed: his-
tory-taking, preparation (relaxation with a
‘safe place’ exercise, explanation and
description of the method, target identifica-
tion) and assessment preceded EMDR pro-
cessing sessions, which were followed by
desensitisation, installation, body scan, clo-
sure and re-evaluation (see Grandison in this
issue for a brief account of these phases).
Children’s individual sessions lasted from 30
to 90 minutes, depending on the develop-
mental level and response of each child. The
questionnaire was administered a week
before and a week after each EMDR treat-
ment cycle. From these findings five meas-
ures were obtained:
●l1 December 2002 (pre-treatment
assessment);
●28 January 2003 (post treatment and pre-
treatment assessment of February cycle);
●10 February 2003 (post-treatment
assessment);
●20 November 2003 (pre-treatment
assessment);
●1 December 2003 (post-treatment
assessment).
Some common memories addressed with
many children and used as the first target
memory for EMDR processing, were the fol-
lowing:
●when I was found under the rubble with
my veins open, risking bleeding to death;
●the image of four dead children around
me;
●darkness, and my mother’s anger at my
being late;
●in the afternoons I am alone, because all
my friends are dead;
●the moment when the walls fell and the
floor moved;
●when my parents told me that my friend
was dead;
●a bleeding hand hanging over my face.
Assessment tools
The assessment tools were administered to
the children five times by independent asses-
sors, that is, the psychologists of the local
public health unit. Clinicians belonged to the
national EMDR Association and went to the
earthquake site from other cities (Milan and
Rome). Diagnosis and assessment were there-
fore conducted by independent assessors and
not by those conducting the clinical inter-
vention. The effectiveness of the three treat-
ment cycles and the trend of PTSD symptoms
following EMDR were assessed using the
results of a directly administered question-
naire prepared by the National Institute of
Health to study the symptoms of the three
clusters of PTSD in children. The question-
naire consisted of a list of typical PTSD symp-
toms. It included items on intrusiveness,
avoidance and hyper-arousal in order to iden-
tify the number of symptoms for each cluster
and make a DSM-IV TR PTSD diagnosis. This
was supported by the use of the SCID-1, Clin-
ical Version (First et al., 1997).
The NICE guidelines state that effective
treatment of PTSD can only take place if the
disorder is recognised, and that identifica-
tion of PTSD in children causes specific
problems, but improves if children are asked
directly about their experiences. Our experi-
ence was that children were able to describe
their experience and present reactions
clearly and in a matter-of-fact way to their
therapists. Also, when asked about the most
disturbing part of the event, they were able
to identify the targets for EMDR treatment as
shown above in the procedure section.
Educational & Child Psychology Vol 24 No 1 67
EMDR as treatment of post-traumatic reactions

Results
The data recorded for the five measures
were analysed using the Wilcoxon matched
pairs signed ranks test. Table 1 shows the
results for each of the three clusters of PTSD
symptomatology as well as a combined result
for all three clusters together, based on a
comparison of the first measure (December
2002) and the last measure (December
2003). Figures 1–3 show the measurements
across each of the five time points.
These results point to a significant
decrease over the treatment period in over-
all PTSD symptomatology. When the three
clusters are taken together the difference is
significant beyond the 0.01 level. In addi-
tion, each of the three clusters analysed sep-
arately, while falling marginally short of this
level, is significant beyond the 0.05 level.
The meaning of these results in practical
terms can be illustrated by considering the
proportion of the sample that met DSM-IV
criteria for PTSD before and after EMDR
treatment (Figure 4). While the numbers
remained at a similar level during the acute
period following the trauma, with no reduc-
tion apparent in the early stages at January
2003, the numbers thereafter reduced
steadily, from an initial figure of 61 per cent
to a final figure of 9 per cent.
Discussion
This study presents the outcomes for 22
children in relation to PTSD one year after a
major trauma, following treatment using
EMDR. The percentage of subjects who
developed PTSD a month after the event was
very high. However, the trauma of which
these children had been victims was extreme
in its severity, and in disasters at this level
comparably high rates of PTSD have been
reported in the literature (see Galea et al.,
2005, for a review). The remaining children
who did not develop PTSD within three
months of the event did not develop it at all.
Three months after the event, as indi-
cated in the January 2003 report, there had
been no decrease in the number of children
identified as having PTSD. This is an indica-
tion of the fact that the reactions to stress did
not decrease naturally. According to DSM-IV
it is expected that within three months of the
traumatic event 50 per cent of the popula-
tion should present a spontaneous remission
of the symptoms of PTSD. In contrast with
this projection, the expected improvements
did not take place within this timescale.
Other factors could be important here – for
example, the death of another child two
months after the earthquake, the decrease in
volunteers and media attention and the
return to daily life for the first time in the
month of January. This is consistent with the
PTSD literature, which points to the possibil-
ity of symptoms fluctuating, with a worsening
following new stressful life events or memo-
ries of the original trauma (Rubin, 2003).
Over the course of treatment there was a
significant decrease in all measures of PTSD
symptomatology, and by the end of one year
only three of the treated children still met
PTSD diagnostic criteria. These results point
to the effectiveness of EMDR as a therapeu-
tic intervention for these primary school
children following a major critical incident.
The interpretation of the data must take
account of a number of limitations in this
field study. The most important of these are
the lack of a control group and the small
sample size. These were factors that it would
68 Educational & Child Psychology Vol 24 No 1
Isabel Fernandez
ClusterStatistical significance
(Wilcoxon test)
Avoidance= 0.015
Intrusive- ness = 0.011
Arousal= 0.015
Sum of clusters= 0.003
Table 1: Clusters of symptomatology of PTSD.
Comparison December 2002–December 2003

have been impossible to change as the sam-
ple was determined by the circumstances of
an emergency situation, and all of the
affected children required treatment on an
equitable basis. However, this limitation that
prevented the research from meeting exper-
imental parameters points at the same time
to one of the strong points of the study, since
it arises from a real-life crisis requiring an
immediate and practical solution.
At the same time the lack of a control
group raises the question of whether the
measurable improvements reported might
have been the result of spontaneous remis-
sion. That is, after a trauma of such severity,
followed by a number of ongoing stressful
events, recovery from PTSD might have
shown a delay during the first few months,
but with spontaneous recovery becoming
apparent after that period, from February
2003 onwards. While the literature on the
natural course of PTSD following disasters is
limited, it nevertheless contains a number of
pointers to support the view that in this study
the reduction in PTSD demonstrated the
results of treatment. It has been noted above
that in the 33-year follow-up by Morgan and
her colleagues (2003) of the survivors of the
Aberfan disaster in Wales the level of PTSD
was still very high. Aberfan had a number of
similarities to the disaster reported here. In
October 1966 thousands of tons of colliery
waste slid down a mountainside and buried a
primary school, killing 116 children, half of
the school population. In the study by Chem-
tob et al.(2002), a randomised control trial
of EMDR with children traumatised follow-
ing exposure to a hurricane, symptoms were
still present three and a half years after the
disaster.
Perkonigg et al.(2005) conducted a lon-
gitudinal study of the natural course of
PTSD in 125 adolescents and young adults
and noted that, on follow up 34–50 months
later, 48 per cent of the sample had shown
no significant remission of symptoms. They
Educational & Child Psychology Vol 24 No 1 69
EMDR as treatment of post-traumatic reactions
AVOIDANCE
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
D ec 02 J an 03 F eb 03 Nov 03 D ec 03
p = 0.015
Figure 1: Trend of avoidance symptomatology December 2002–December 2003

concluded that PTSD is often a persistent
and chronic disorder. After the Armenian
earthquake of 1988, 95 per cent of children
from a severely exposed city and 26 per cent
of children from a mildly exposed city had
severe levels of PTSD 1.5 years after the inci-
dent (Goenjian et al., 1995). In a random
sample of adults studied after the 1989 earth-
quake in Newcastle, Australia, the preva-
lence of PTSD had only decreased by about
50 per cent in the first two years after the
event (Carr et al., 1997). It is therefore rea-
sonable to propose in the present study that
a reduction from over 60 per cent of
children meeting PTSD criteria to less than
10 per cent pointed to treatment effects
rather than spontaneous remission.
It is important to remember that
children and parents as well as the commu-
nity involved in this disaster shared all post-
traumatic reactions, mourning processes,
loss of homes, sense of guilt and conflicts
arising in the community. It is well known
that the anxieties of adults are perceived and
absorbed by children and can become an
obstacle in the resolution of psychological
disorders. Many children said they were
affected most of all by their parents’ behav-
iour and display of emotions. Not only did
EMDR treatment enable the resolution of
the experience in an adaptive manner, but it
also allowed the children to talk about their
individual experiences, the most disturbing
ones and the situations that became prob-
lematic after and because of the earthquake.
After such a dramatic experience it is essen-
tial to be able to talk in a safe environment
(provided by the therapist’s presence) and
express irrational ideas, images, physical sen-
sations and emotions with words. The EMDR
treatment focused also on helping the
children experience the mourning processes
70 Educational & Child Psychology Vol 24 No 1
Isabel Fernandez
INTRUSIVENESS
0
0.5
1
1.5
2
2.5
3
D ec 02 J an 03 F eb 03 Nov 03 D ec 03
p = 0.011
F igure 2:T rend of intrusiveness symptomatology December 2002 December 2003
Figure 2: Trend of intrusiveness symptomatology December 2002–December 2003

in a natural way, strengthening their
resources, reducing stress reactions and nor-
malising their behaviours.
Conclusions
This study has clear implications for the work
of educational psychologists. As profession-
als who have constant contact with children
and with schools they occupy a key position
for providing support in these settings after
critical incidents. There have been very
many accounts throughout the world of nat-
ural and other disasters affecting children,
leading to significant levels of post-traumatic
stress disorder. EMDR provides educational
psychologists with an evidence-based therapy
that can be used effectively in reducing these
symptoms following critical incidents.
Educational & Child Psychology Vol 24 No 1 71
EMDR as treatment of post-traumatic reactions
AROUSAL
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
D ec 02 J an 03 F eb 03 Nov 03 D ec 03
p = 0.015
61%
64%
46%
29%
9%
0%
10%
20%
30%
40%
50%
60%
70%
D ec 02 J an 03 F eb 03 Nov 03 D ec 03
Figure 3: Trend of arousal symptomatology December 2002–December 2003
Figure 4: Proportion of sample meeting PTSD criteria

Acknowledgements
The EMDR treatment was agreed upon and
coordinated by ASL 4 Basso Molise, within
the POSPE project (programmes of support
and psychological treatment of the people
affected by the earthquake of 31 October
2002 in Molise).
Address for correspondence:
Isabel Fernandez, Associazione per l’EMDR
in Italia, Via Paganini, 50, 20030 Bovisio,
Masciago (MI), Italy.
E-mail: [email protected]
72 Educational & Child Psychology Vol 24 No 1
Isabel Fernandez
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