University of Amsterdam
Faculty of Social and Behavioral Sciences
Graduate School of Childhood Development and Education
Seizure-related Anxiety and Trauma Symptoms in Pediatric Epilepsy:
Treatment Efficacy
Research Master Educational Sciences Thesis 2
Elmedina Dautovic 0527653
Supervisors: Dr. H. R. Rodenburg & Dr. F.J. Oort Second supervisor: Dr. A.M. Meijer
Contents Preface 2 Thesis II 4 Abstract 5 Introduction 6 Method 10 Results 19 Discussion 25 References 30
Figures and tables 36
Preface
Before you, you see the result of nearly two years of hard work: my second research master thesis, a pilot-study into EMDR treatment of seizure-related anxiety and/or trauma symptoms in children with epilepsy.
The preparations for this study started in March 2009, with an invitation from the Royal Dutch Academy of Arts and Sciences for (master) students to write a research proposal for a study that could be completed in ten months. During brainstorm sessions, in which Roos Rodenburg, Anne Marie Meijer, Frans Oort and I were involved, the idea that children with epilepsy might have
seizure-related anxiety and/or trauma symptoms and that these could possibly be treated with EMDR was given shape. Roos Rodenburg (my supervisor) and Frans Oort (director of the Research Master) guided me in writing this proposal, which was granted in May 2009. Hereafter a very turbulent time followed in which we had to motivate neurologists and pediatric psychologists to cooperate with us in this project, both my supervisor and I were so passionate about, and to write a protocol for the medical ethical committee (MEC) of the Academic Medical Centre in Amsterdam. After the protocol was approved by the MEC, inclusion, screening, diagnosing, and treatment of the children followed (March - December 2010), and finally the writing of this thesis.
This pilot study is being continued and, as we speak, I am collecting follow-up data of the participants. When all data are collected, the results of this thesis will be revised into a manuscript1 and submitted to the Journal of Pediatric Psychology. Furthermore, on the basis of the pilot-studies results a grant proposal will be written, and submitted.
Although we experienced many setbacks and delays during this study, I'm very glad that I got to experience every aspect of doing research: (co)writing the proposal and research protocol, collecting the data in a clinical setting, interacting with children, parents, and professionals, analyzing the data,
1
Dautovic, E,. de Roos, C., van Rood, Y., Oort, F., Sander, l., Rodenburg, H. R., & Dommerholt, A. (2011). Seizure related anxiety in children with epilepsy: treatment efficacy. Manuscript in preparation.
writing this thesis and eventually writing and submitting a manuscript . Looking back I have learned a lot, and this entire process has made me a more mature and secure clinical researcher. Which I tend to stay for a long time.
Abstract
The objective of this study was to investigate the efficacy of eye movement desensitization and reprocessing (EMDR) on seizure-related anxiety and/or trauma symptoms in children with epilepsy. The „indirect‟ effects of the treatment on the child‟s quality of life, subjective happiness, seizure frequency/severity, and parental anxiety about epilepsy were also investigated. In total 31 children with epilepsy and their parents were screened for anxiety disorders, including trauma symptoms. Twelve children reported (sub-)clinical levels of anxiety and/or trauma symptoms and seven were diagnosed with seizure-related anxiety and/or trauma symptoms. From these seven children, N = 5 agreed to be treated with EMDR. Before and after EMDR treatment questionnaires concerning anxiety disorders, trauma symptoms, quality of life, and subjective happiness were completed by the children and one or both of their parents. The Reliable Change Index (RCI) was calculated to assess statistically significant change in anxiety and/or trauma symptoms due to treatment.
In 80% of the children, seizure-related trauma symptoms significantly decreased after treatment. Positive, non-significant effects of the treatment on anxiety, quality of life, and subjective happiness were also found. In addition, seizure frequency/severity did not change due to treatment. For parental anxiety about epilepsy no change was found after treatment. This was due to the participating parents not showing problematic pre-treatment scores, leaving little room for improvement.
Overall, EMDR seems effective for treating seizure-related anxiety and/or trauma symptoms in children with epilepsy. However, further research should provide more insight into the efficacy of EMDR in this special pediatric population and with regard to this subject matter.
Seizure-related Anxiety and Trauma Symptoms in Pediatric Epilepsy: Treatment Efficacy
Epilepsy is the most common central nervous system disorder in children and adolescents, affecting approximately five in every 1000 children. Most epilepsies are diagnosed during childhood and annually five to seven in every 10.000 children up to the age of fifteen are diagnosed with epilepsy (Cowan, 2002). Epilepsy does not only have consequences for the medical status of
children; previous studies have shown that there are negative effects on the psychological well-being of these children as well (Austin, 1989; Oostrom, Smeets-Schouten, Kruitwagen, Peters, &
Jennekens-Schinkel, 2003). Meta-analyses show that children with epilepsy are at increased risk for developing psychopathology and behavior problems, when compared to children from normative and general populations (McDermott, Mani, & Krishnaswami, 1995; Rodenburg, Stams, Meijer,
Aldenkamp, & Deković, 2005). Moreover, research has shown that the risk for internalizing problems (e.g. anxiety/depression, withdrawal, and somatic complaints) is higher than the risk for externalizing problems (e.g. rule breaking behavior and aggression) in children with epilepsy (Dunn, Austin, & Perkins, 2009; Rodenburg, et al. 2005).
Anxiety seems to be the most frequent internalizing problem in the pediatric epilepsy population (Ettinger, Weisbrot, Nolan, Gadow, Vitale, Andriola, et al. 1998; Goldstein & Harden, 2000; Marsh & Rao, 2002; Vasquez & Devinsky, 2003) and a strong body of literature suggests that the
prevalence of anxiety disorders in children with epilepsy ranges from 13.0 to 48.5 percent (Caplan, Siddarth, Gurbani, Hanson, Sankar, & Shields, 2005; Williams, Steel, Sharp, Delos-Reyes, Philips, Bates, et al., 2003; Alwash, Hussein, Matloub, 2000). Although anxiety is one of the most common psychological disorders in children and adolescents in the normative population (Cartwright-Hatton, McNicol, & Doubleday, 2006), the prevalence percentages of anxiety disorders are much higher in pediatric epilepsy than in the normative population (Beyenburg, Mitchell, Schmidt, Elger, & Reuber, 2005; Caplan et al., 2005; Vasquez & Devinsky, 2003; Williams et al., 2003).
Posttraumatic stress disorder (PTSD) is a severe disorder in the anxiety disorders spectrum, that can develop after witnessing, experiencing, or being confronted with an event that involves
threatened or actual death, a serious physical injury, or a threat to one‟s physical or mental integrity (American Psychiatric Association: DSM-IV-TR, 2000). The incidence of PTSD varies due to the nature and severity of the experienced event (Salmon & Bryant, 2002) and research into the incidence of PTSD in the general population of children is rather inconclusive (Rodenburg, Benjamin, de Roos, Meijer, & Stams, 2009). The few researchers that have tried to capture the overall prevalence have found that it ranges from 1.3% to 6.3% (Essau, Conradt, & Petermann, 1999; Giaconia, Reinherz, Silverman, Pakiz, Frost, & Cohen, 1995; Kerig & Wenar, 2005). The prevalence of PTSD-symptoms in the pediatric epilepsy population was recently found to be 38% (Dunn et al., 2009). Although it is not yet established that anxiety and/or trauma symptoms may be related to epileptic seizures, anxiety and/or trauma symptoms related to seizures may considerably account as an explanation for child internalizing problems.
Precipitants and triggers of seizures may provoke stress and/or anxiety in children with epilepsy (Kazak, Kassam-Adams, Schneider, Zelikovsky, Alderfer, & Rourke, 2006). For example, physical sensations occurring before a seizure can become signs of imminent danger and cause feelings of anxiety. Also, specific physical sensations may bring about memories of a previous (traumatically experienced) seizure and this might induce feelings of anxiety too (van Rood, de Jong, & de Roos, 2005). In addition, other stimuli (i.e. specific situations, persons, objects) may remind the child of seizures or frightening seizure-related events and induce anxiety as well. Furthermore, the fear of death (Newsom-Davis, Goldstein, & Fitzpatrick, 1998) and the unpredictability of seizures (Pianta & Lothman, 1994), but also parental anxious reactions, worry, and stress due to the perceived
vulnerability of their child (Chapieski, Brewer, Evankovich, Culhane-Shelburne, Zelman, &
Alexander, 2005; Green & Solnit, 1964; Levin & Banks, 1991) may induce or worsen anxiety and/or trauma symptoms in children with epilepsy. Moreover, the possible loss of control during a seizure
(International League Against Epilepsy, 1981), and perceived stigma (Baker, Brooks, Buck, & Jacoby, 1999) might expose a child to very uncomfortable and frightening situations possibly causing (seizure-related) anxiety and/or trauma symptoms. Scott and Stradling (1994) have found that in order to develop PTSD it is not always necessary to experience one crucial traumatic event, but that an accumulation of stressful events can also cause PTSD. So, several stressful seizure-related experiences, might contribute to seizure-related anxiety and seizure-related trauma symptoms as well.
Anxiety, stress, and strong emotions in general can trigger seizures and increase seizure frequency (Mattson, 1991). In addition, having epilepsy and seizures can be very stressful for
children and may be accompanied by anxiety, worrying, frustration, and anger (Lathers & Schraeder, 2006). Higher levels of anxiety have been associated with more non-compliance to medical treatment (Muller, Koen, & Stein, 2005). Because of non-compliance, seizures are more likely to occur, which in turn may contribute to exacerbation of the anxiety. Furthermore, seizure severity has shown to be an important predictor of anxiety (Smith, Baker, Dewey, Jacoby, & Chadwick, 1991). Anxiety can have a profound influence on the quality of life in individuals with epilepsy (Beyenburg et al., 2005). Psychological trauma complaints have also shown to influence the quality of life in epilepsy patients (Devinsky, 2003). Therefore, anxiety and trauma symptoms related to epilepsy in children are considered a psychological and medical burden impairing psychological wellbeing and functional (medical) status.
Within the pediatric medical and psychology field, some knowledge with regard to posttraumatic stress symptoms in children with chronic conditions is available. For example, Alonzo (2000)
described the relation between chronic illness and PTSD and stated that the cumulative adversity of having a chronic condition might be related to developing PTSD, and in addition maladaptive,
impaired, and extended coping. Kazak et al. (2006) developed a model of pediatric medical traumatic stress (PMTS). They defined PMTS as “psychological and physiological responses of children and
their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences” (Kazak et al., 2006, p. 343). Anticipatory anxiety in epilepsy has frequently been mentioned in epilepsy research (e.g., Engel & Pedley, 2007; Jackson & Turkington, 2005; Goldstein, Seidenberg, & Peterson 1990). Yet, only one case study of seizure phobia in a 26 year old woman, with generalized and complex partial seizures, has been described. This woman experienced “extremely aversive physical experience of her seizures” and believed that people “would be
disgusted by the sight of her having a seizure” (Newsom-Davis et al., 1998, p.104). For these reasons she avoided situations she considered being dangerous and became highly sensitive for seizure precipitants (Newsom-Davis et al., 1998). Thus, to date anxiety and trauma symptoms related to seizures seem understudied in the pediatric epilepsy population.
Cognitive behavior therapy (CBT) is an evidence based treatment for PTSD and anxiety disorders in children (e.g. Barrett, Duffy, Dadds, & Rapee, 2001; Perrin, Smith, & Yule, 2000). A recent meta-analysis into eye movement desensitization and reprocessing (EMDR) has shown positive effects on anxiety and trauma symptoms in children (Rodenburg et al., 2009). However, close to nothing is known about established treatment interventions for children with epilepsy who are anxious for upcoming seizures and/or have seizure-related psychological trauma symptoms. This study intends to address this gap by first screening children with epilepsy for anxiety and trauma symptoms and second by investigating the efficacy of EMDR in treating seizure-related anxiety and trauma symptoms in these children. The main goal of this study is to examine the efficacy of EMDR on clinical seizure-related anxiety and trauma symptoms to non-clinical levels in children with epilepsy.
In this study seizure-related anxiety is defined as anxiety and/or avoidant behavior due to events related to seizures (e.g. loss of bladder and bowel control, stigmatization, and shame). Seizure-related anxiety occurs when a child is confronted with (the memory of) such an event, which may result in more stress and as a consequence, more seizures. Seizure-related trauma symptoms are
defined as trauma symptoms causally related to a frightening experience related to a seizure. To our knowledge, seizure-related anxiety and trauma symptoms have not yet been investigated in children with epilepsy.
The efficacy of EMDR is investigated in a case series design (: a compilation of single subject studies). Single subject studies allow to investigate rare or exceptional conditions with
accompanying smaller sample sizes (Rapoff & Stark, 2008). Drotar (2009) stated that “Because of the heterogeneity of clinical populations in the field of pediatric psychology, it will be impossible to use large-scale intervention research, especially RCT‟s, to document the generalizability of
empirically supported interventions for the broad range of clinical problems that are seen in practice. For this reason, case studies and series that document the clinical effectiveness of empirically
supported interventions with clinical populations have a critical role to play in the future of pediatric psychology” (Drotar, 2009, p. 797).
It is hypothesized that EMDR treatment will result in a reduction of seizure-related anxiety and trauma symptoms from (sub)clinical to non-clinical levels. Furthermore it is hypothesized that EMDR treatment will also improve the quality of life, subjective happiness, and seizure
frequency/severity in children with epilepsy. Additionally, it is hypothesized that treating the child‟s seizure-related anxiety and/or trauma symptoms with EMDR will reduce parental anxiety about epilepsy as well.
Method Procedure
This study is part of a larger pilot-project of the Epilepsy Institute in the Netherlands Foundation (SEIN) and the University of Amsterdam (UvA), into seizure-related anxiety in children with
epilepsy. The project has been approved by the Medical Ethical Committee of the Academic Medical Center of the University of Amsterdam (nr. MEC 10/008 # 10.17.0033as). The larger project consists
of a screening study in which children with epilepsy are screened for seizure-related anxiety and/or trauma symptoms, and a treatment trial in which children who are clinically diagnosed with seizure-related anxiety and/or trauma symptoms are treated with EMDR. In the current study both the screening of children and the treatment trial are described, yet only the treatment-trial data are analyzed.
Participants were included from March 2010 until June 2010. The participants in this study were children with epilepsy and their parents. The first author and SEIN‟s neurologists screened the children for the in- and exclusion criteria. Children were included in the study if they were between 8 and 18 years old, were diagnosed with epilepsy, had an IQ above 75, and were currently treated for epilepsy by a child neurologist. Inclusion criteria for the EMDR treatment trial were clinical or subclinical (above average) levels of anxiety and/or trauma symptoms related to seizures. Children diagnosed with chronic conditions other than epilepsy (besides ADHD, for this is very common in children with epilepsy (Dunn, et al., 2009)), children with psychogenic pseudo epilepsy seizures or a history of pseudo-seizures, and children whose anxiety and/or trauma symptoms were not related to epilepsy seizures, were excluded from the treatment part of this study.
Screening
For twelve weeks the first author was present at three outpatient clinics of SEIN (Heemstede, The Hague, and Utrecht). The families of children who met the inclusion criteria received a letter
containing information about the study. Approximately one week before their visit to the outpatient clinic, the families received another letter reminding them that during their next visit to the outpatient clinic a researcher would be present and that if they wished they could participate in the study. At the outpatient clinics the researcher approached the children and their parents and asked them whether they were willing to participate. If so, parents and children were asked for written informed consent. When children agreed to participate in the study, they and one or both of their parents either
return envelope, was sent to their home address. After returning the completed questionnaires, all children received a small gift to thank them for their cooperation.
If children‟s scores on the questionnaires indicated clinical or subclinical (above average) levels of anxiety and/or trauma symptoms, they were referred to an intake session with a child
psychologist. Before the intake session, the psychologists were provided with information considering the screening of the patient. They received a brief description of the condition of the patient, on the basis of the completed questionnaires. In this description it was specified whether the patient displayed clinical anxiety, trauma symptoms, or both. If the child was diagnosed with anxiety and/or trauma symptoms related to the child's seizures or epilepsy, the child was included into the EMDR treatment trial. Subsequently, the child was referred to specialized EMDR-therapists, trained with the EMDR children‟s protocol, for treatment (Beer & De Roos, 2004).
Treatment trial
The children (and their parents) who were referred to EMDR treatment were again provided with an information letter, explaining that clinical anxiety and/or trauma symptoms related to seizures were established and that if they wished,EMDR would be offered to treat the anxious feelings. Furthermore, they were informed about the purpose of the EMDR treatment trial and asked for written informed consent. Subsequently, children (and parents) who gave consent were treated with EMDR. Before the first EMDR session parents received a seizure-diary in which they could report the number and type of seizures their child experienced during treatment, and whether or not there were differences (particularities) in comparison to previous seizures.
The EMDR procedure consists of 8 stages; after taking the history, explaining EMDR, and the assessment of the traumatic/fearful event (i.e. target selection) the target is desensitized. The therapist asks the patient to hold the disturbing target image and aspects related to it in mind and to simultaneously attend to the bilateral stimulation introduced by the therapist. Bilateral stimulation consists of alternating left-right eye movements, ear tones or hand tapping, at a rate of approximately
two stimuli per second for about 45 seconds. Hereafter the patient is asked to briefly report what comes to mind. The procedure is repeated until the original target is no longer disturbing and dysfunctional cognitions about the trauma have become functional (Shapiro, 2007).
In the current study, one EMDR session lasted for 45 minutes and the number of sessions (1-5) was dependent on the level of distress associated with the disturbing memories related to seizures. EMDR was given until there was no remaining distress associated with the disturbing memories related to seizures, as indicated by a child‟s self-reported distress score of 0. For reliability reasons all EMDR sessions were videotaped. Before and after the EMDR treatment trial children and their parents were asked to complete questionnaires concerning anxiety, trauma symptoms and their epilepsy.
Participants
In total, 82 children and their parents were approached and asked to participate in this study. Of these 82, 38 agreed to participate (46.34%). Of the non-participating children, 34 refused
participation (41.46%) and 10 (12.20 %) were eventually unable and/or unsuitable to participate for diverse reasons. After a few requests, 7 of the participating families, failed to return their
questionnaire-packages. In total, 31 children participated, 9 boys (29.03%) and 22 girls (70.97%). Twelve (38.71%) children were screened with seizure-related anxiety and/or trauma symptoms. This is in accordance with the PTSD prevalence rate in the pediatric epilepsy population (Dunn et al., 2009). Of these 12 children, 4 refused an intake. Seven children were diagnosed with seizure-related anxiety and/or trauma symptoms and referred to the EMDR treatment trial. Five children agreed to participate in the EMDR treatment trial. Most of the participating children were girls (80%). Mean age of the children was 12.8 years. Of the children, one (20%) went to a regular elementary school, two (40%) went to a special needs elementary school and two (40%) engaged in vocational
EMDR sessions to decrease the amount of distress caused by their frightening/traumatic seizure related memories. One child (20%) needed three EMDR sessions.
Five parents agreed to participate in the EMDR treatment trial, two fathers and three mothers. Mean age of the parents was approximately 44.4 years (mothers: 43.0, fathers: 46.5). All parents reported being married. Two parents (40%) reported to have two children and three parents (60%) reported to have three children, including the participating child.
Design
The EMDR treatment trial consisted of two measurements: a pretest one week before treatment (T1) and a posttest one week after closure of EMDR treatment (T2). Data collection was conducted by the first author of this project. A graphic display of the design of the study is given in table 1.
[Insert Table 1 about here]
Measures
Primary outcome measures
Anxiety. The Screen for Child Anxiety Related Emotional disorders (SCARED-R; Muris, Mayer, Bartelds, Tierney, & Bogie, 2001) was selected for this study to assess symptoms of the entire anxiety spectrum, because on the one hand its items are closely connected to the anxiety disorder symptoms described in the DSM-IV and on the other hand it has shown to be sensitive to treatment effects (Muris et al., 2001). This questionnaire consists of 69 items that measure generalized anxiety disorder (e.g. “I worry about others not liking me”, 9 items), separation anxiety including school phobia (e.g. “I worry about sleeping alone”, 12 items), social phobia (e.g. “I am shy”, 7 items), panic disorder (e.g. “When I feel frightened, it is hard to breathe”, 13 items), obsessive-compulsive
disorder (e.g. “I want things to be in a fixed order”, 9 items), traumatic stress disorder (e.g. “I try not to think about a very aversive event I once experienced”, 4 items), and three specific phobias: the
animal type, the blood-injection-injury type, and the situational-environmental type (e.g. “I am afraid of an animal that is not really dangerous”, 3 items; “When I see blood, I get dizzy”, 7 items; “I am afraid of heights”, 5 items). Children were asked to rate on 3-point Likert scale how often an event occurs (0 = „almost never‟; 1 = „sometimes‟; 2 = „often‟). The reported reliability (Cronbach's α) of this scale was .92 and the subscale reliabilities range from .66 to .87.
Posttraumatic stress symptoms. The Dutch version of the Children‟s Responses to Trauma Inventory (CRTI; Alisic, Eland & Kleber, 2006) was based on the Impact of Event Scale (IES; Horo-witz, Wilner, & Alvarez, 1979) and the Impact of Event Scale Revised (IES-R ; Weiss & Marmar, 1997). This questionnaire assesses three characteristics of trauma symptoms: intrusion (e.g., “I dreamt of it”, 7 items), avoidance (e.g., “Trying not to think of it”, 11 items) and arousal (e.g., “Trouble sleeping”, 6 items). Furthermore, the questionnaire addresses other specific trauma reactions (e.g., “Physical complaints”, 10 items).
In accordance with Alisic, the CRTI was slightly adapted, so it could be used to examine whether children display seizure-related trauma symptoms. The adaptation incorporated the addition of one question at the start of the questionnaire, namely: “Have you ever experienced anything
shocking/upsetting/scary related to your epilepsy and/or seizures? If not, you can choose to not complete this questionnaire; If so, please complete this questionnaire”.
After affirmatively answering the first question, the child was asked to remember the seizure-related traumatic event and to rate on a 5-point-Likert scale (0 = not at all; 5 = often) how often (PTSD-)symptoms occurred during the previous week. The items in this questionnaire are connected to the DSM-IV description of PTSD. The reported reliability (Cronbach‟s α) of this scale was .92. The subscale reliabilities range from .71 to .79.
Emotions about epilepsy. Children were asked to rate their emotions (anger, anxiety, sadness, and shame) about having seizures on a visual analogue emotion scale (VAES). The VAES is a 4 item self report continuous scale with emotions ranging from not angry, anxious, sad or ashamed at all (0) to
very angry, anxious, sad or ashamed (10). Since this is the first time the VAES is used in research and no reliability nor reference scores are available, this scale is not taken into account in the calculations, but is merely used as an addition to the anxiety and PTSD measures. Because each emotion was measured with a single item, the reliability of this scale could not be calculated (Van der Zee, 2004).
Secondary outcome measures
Health Related Quality of Life. The KIDSCREEN-27 (KIDSCREEN-27; Ravens-Sieberer, Auquier, Erhart, Gosch, Rajmil, Bruil, et al., 2007) is a parent and child report of health-related quality of life, consisting of 27 items that assess five dimensions of events related to physical well-being (5 items), psychological well-well-being (7 items), parent relations & autonomy (7 items), social support & peers (4 items), and school environment (4 items).Children and parents were asked to rate on 5-point Likert scale if and how often an event occurred (0 = „not at all‟; 5 = „totally‟ or 0 =
„never‟; 5 = „always‟). The reported subscale reliabilities (Cronbach‟s α) of this scale ranged from .61 to .74.
Subjective Happiness.Perceived happiness in children was measured with the Subjective Happiness Scale (SHS; Lyubomirsky & Lepper, 1999). The SHS is a 4-item self-report scale to measure global subjective happiness, to be rated on a 7-point Likert scale (e.g., “In general, I
consider myself (1) not a very happy person - (7) a very happy person”). Children only were asked to fill in this questionnaire. The reported reliability (Cronbach‟s α) of this scale was .81.
Seizure frequency and severity. Seizure frequency and severity during treatment are measured using a seizure-dairy. The parents are asked to, while the treatment lasted, daily report the number and type of seizures their child experienced, and whether or not there were particular differences compared to previous seizures.
Parental anxiety about epilepsy. The Parental Anxiety about Epilepsy scale (PAE, Chapieski, et al., 2005) was used to measure the degree of anxiety parents experience regarding their child‟s
epilepsy. This scale consists of 14 items (e.g., “If my child has a seizure when I am not there, others will not know what to do to keep him or her safe”). There are five answer options varying from (1) „this is not a worry of mine‟ to (5) „I am extremely worried about this‟. The reported reliability (Cronbach‟s α) of this scale was .91.
Analyses
The Statistical Package for the Social Sciences (SPSS) versions 16 and 17 were used to provide descriptive information about the sample.
Normative deviation scores (NDS) were used to calculate the clinical status of an individual(: the severity of their problems) before treatment (Veerman, 2007). The NDS indicates how much an individual score deviates from a normal score. A NDS score below 1.00 indicates that there is no problem, whereas a NDS above 1.29 indicates considerable problems, and a NDS above 1.96 indicates very serious problems compared to the normative population.
The reliable change index (RCI), a method advised by Drotar (2009) was used to calculate individual pre- to posttest change in anxiety and/or trauma symptoms, quality of life and happiness, with regard to each participating child (Jacobson & Truax, 1991; Veerman, 2007). The RCI, which controls for coincidence or error, is used to calculate the individual change in anxiety and/or trauma. An RCI of 0 indicates that no difference is detected between pre-treatment and post-treatment scores, whereas an RCI of 1 indicates that the difference between the pre-treatment and post-treatment scores is equal to the standard error of its difference. The RCI is considered to have a normal distribution with a mean of 0 and a SD of 1. Based on α = 0.05 or based on α = 0.025 (one-tailed significance testing) respectively RCI's of > +1.64 or < -1.64 and > +1.96 or < -1.96 indicate statistical significance, suggesting real change.
After calculating the status and change for each individual child, both were combined into status and change categories. A child's status can either be positive (S+, NDS < 1.29) or negative S-, NDS ≥
1.29), and due to treatment there might be positive change (C+), no change (C0), or negative change (C-) considering the child's problem2.
Finally, frequencies were calculated for the percentage of children that had significant changes in seizure-related anxiety and/or trauma symptoms to sub-clinical and non-clinical levels (positive, significant change), for the percentages of children that showed more anxiety on clinical, elevated levels (negative significant change), and children for whom no change was found, were calculated.
Frequencies were also calculated for the percentage of children being- not to very- sad, angry, ashamed, or anxious on the visual analogue emotion scale.
Primary outcomes
The hypotheses tested are: H0: The pre-EMDR outcome scores do not differ from the post-EMDR outcome scores. H1: The post-EMDR outcome scores are significantly lower (amelioration to non-clinical levels) when compared to pre-EMDR outcome scores (T1-T2). Because the direction of alternative hypothesis is known (significant amelioration) one-tailed significance testing with RCI > 1.96 (based on α= 0.025) and RCI > 1.64 (based on α= 0.050) was used. In addition, it was
hypothesized that post-treatment less children would have negative emotions about their epilepsy and/or seizures.
2
When a higher score, is indicative of more problems, a NDS 1.00 ─ 1.28 indicates moderate problems, a NDS of 1.29 ─ 1.64 indicates considerable problems, a NDS of 1.65 ─ 1.96 indicates severe problems, a NDS > 1.96 indicates very severe problems, a RCI of +1.64 / +1.96 indicates positive change, a RCI between -1.64 ─ +1.64 / -1.96 ─ +1.96 indicates no change, and a RCI < -1.64 / -1.96 indicates negative change.
However when a higher score, is indicative of less problems , a NDS -1.00 ─ -1.28 indicates moderate problems, a NDS of -1.29 ─ -1.64 indicates considerable problems, a NDS of -1.65 ─ -1.96 indicates severe problems, a NDS < -1.96 indicates very severe problems, a RCI of -1.64 / -1.96 indicates positive change, a RCI between +1.64 ─ -1.64 / +1.96 ─ -1.96 indicates no change, and a RCI < +1.64 / +1.96 indicates negative change.
Secondary outcomes
Furthermore, it was investigated whether health related quality of life, as perceived by child and parents, and the child's subjective happiness are significantly higher, whether seizure
frequency/severity decreases and whether parental levels of anxiety about epilepsy are significantly lower at post-EMDR treatment when compared to pre-EMDR treatment (T1 – T2).
Results Anxiety
To assess whether anxiety decreases due to EMDR treatment, NDS's and RCI's3 (see table 2) were calculated for all individual children on one total anxiety scale and eight subscales.
The mean NDS on total anxiety before treatment was .12, indicating that this group of children before treatment did not display problems considering total anxiety. After treatment the mean NDS non-significantly decreased to a score of -.63 [RCI = .85]. In four of the children (80%) total anxiety decreased after treatment, yet this decrease was significant in one child (20%) only [pretest NDS = .05, posttest NDS = -1.89, RCI = 2.22**]. One child (20%) showed a significant increase in total anxiety [pretest NDS = -.50, posttest NDS = 1.10, RCI = -1.83*].
On the subscale level, one child (20%) had severe generalized anxiety complaints before treatment [pretest NDS = 1.78]. After treatment this NDS significantly decreased to a non-clinical level [posttest NDS = -.44, RCI = 1.96**]. Another child (20%), with a non-clinical pre-treatment score on generalized anxiety disorder [pretest NDS = .99], showed a highly significant decrease in generalized anxiety complaints [posttest NDS = .99, RCI = 2.23**].
Before treatment one child (20%) had considerable problems considering social phobia [pretest NDS = 1.40]. After treatment these problems non-significantly decreased to a moderate level [posttest NDS = 1.12, RCI = .28].
Two children (40%) had moderate [pretest NDS = 1.01] and very severe [pretest NDS = 2.99] panic disorder symptoms before treatment. After treatment their scores significantly decreased to respectively no problems [posttest NDS = -.73, RCI = 1.64*] and moderate problems [posttest NDS = 1.01, RCI = 1.87*]. One child (20%) with a non-clinical pre-treatment score [pretest NDS = .63] on panic disorder reported significantly less panic disorder complaints after treatment [posttest NDS = -1.24, RCI = 1.77*]. Another child, with a non-clinical pre-treatment score [pretest NDS = -1.01] on panic disorder, reported significantly more complaints after treatment [posttest NDS = 1.80, RCI = -2.65**].
On posttraumatic and acute stress disorder symptoms, one child (20%) had a pre-treatment score indicative of considerable problems [pretest NDS = 1.30]. After treatment these non-significantly decreased to a non-clinical level [posttest NDS = -.56, RCI = 1.21].
For specific phobia of the blood-injection-injury type one child (20%) had considerable problems before treatment [pretest NDS = 1.31]. After treatment these problems decreased to a non-clinical level [posttest NDS = .60], although significantly [RCI = .74]. Another child showed a non-significant increase in complaints on this same subscale [pretest NDS = .14, posttest NDS = 1.47, RCI = -1.39].
On specific phobia of the situational/environmental type, one child (20%) had a pre-treatment score indicative of severe problems [pretest NDS = 2.40]. After treatment, this score decreased non-significantly, indicating a considerable problem [posttest NDS = 1.49, RCI = .97]. One child showed a non-significant increase [pretest NDS = .55, posttest NDS = 1.39, RCI = -.90]. Another child showed a highly significant decrease in situational/environmental phobic complaints. This child did not have a problematic pre-treatment score though [pretest NDS = .55, posttest NDS = -1.57, RCI = 2.26].
No scores indicating neither problems nor significant changes were found in separation anxiety disorder, obsessive compulsive disorder, or specific phobia of the animal type.
[Insert table 2 about here]
Posttraumatic stress symptoms
NDS's and RCI's were calculated for all individual children for the total trauma symptom scale and the four subscales (: intrusion, avoidance, arousal, and other specific trauma reactions) to
examine whether (seizure/epilepsy) related trauma symptoms decreased due to EMDR treatment (see table 3).
The mean NDS on overall trauma symptoms before treatment was 1.06, indicating that this group of children had moderate trauma symptoms before EMDR treatment. After treatment the mean NDS significantly decreased to -.69, indicating no trauma symptoms [RCI = 3.01**]. In four children (80%) overall trauma symptoms significantly decreased after treatment [pretest NDS = .97, posttest NDS = -1.12, RCI = 3.67**; pretest NDS = 1.08, posttest NDS = -.93, RCI = 3.55**; pretest NDS = 1.08, posttest NDS = -.50, RCI = 2.79**; pretest NDS = 1.63, posttest NDS = -1.06, RCI = 4.76**]. One child (20%) showed a non-significant decrease in overall trauma symptoms [pretest NDS = .52, posttest NDS = .14, RCI = .68].
For the trauma symptom subscales the following results were found. Considering intrusion, none of the children showed clinical treatment scores. In one child (20%) the already non-clinical pre-treatment intrusion complaints decreased significantly, indicating even less complaints [pretest NDS = .38, posttest NDS = -1.23, RCI = 1.71*].
Three children (60%) had considerable and severe avoidance of trauma-related situations/objects before treatment [pretest NDS = 1.47; pretest NDS = 1.60; pretest NDS = 1.72]. In all of them these complaints significantly decreased to a non-clinical level after treatment [posttest NDS = -1.61, RCI = 3.22**; posttest NDS = -.63, RCI = 2.32**; posttest NDS = -1.24, RCI = 3.09**]. One child (20%) showed a highly significant decrease [pretest NDS = .49, posttest NDS = -1.53, RCI = 2.10**] and
another child (20%) showed a non-significant decrease [pretest NDS =.86; posttest NDS = -.01; RCI = .90] in avoidance, but these children did not have problematic pre-treatment scores.
One child (20%) had very severe arousal complaints before treatment [pretest NDS = 1.99]. After treatment complaints significantly decreased to a non-problematic level [posttest NDS = -.80, RCI = 2.59**].
Considering other specific trauma reactions two children (40%) reported moderate [pretest NDS = 1.05] and severe problems [pretest NDS = 1.67] before treatment. After treatment their complaints decreased to a non-problematic level [respectively: posttest NDS = -.25, RCI = 1.42; posttest NDS = .09, RCI = 1.72*], in the second child (20%) this decrease was significant.
[Insert table 3 about here]
Emotions about epilepsy
Before and after treatment children were asked to rate how angry, anxious, sad, and ashamed they were about having epilepsy and seizures (see table 4).
Before treatment three children (60%) reported not being angry about having epilepsy and seizures, one child (20%) reported being angry, and another one (20%) reported being very angry. After treatment three children (60%) still reported not being angry about having epilepsy and seizures and two children (40%) reported being angry.
Reported anxiety about having epilepsy and seizures did not change: before and after treatment, three children (60%) reported not being anxious and two children (40%) reported being anxious.
Before treatment all children reported being either sad (60%) or very sad (40%) about having epilepsy and seizures. After treatment two children (40%) still reported being very sad, but three children (60%) reported not being sad any more.
Two children (40%) reported not being ashamed about having epilepsy and seizures, the rest reported to be ashamed (20%) or very ashamed (40%). After treatment four children (80%) reported not being ashamed anymore. One child (20%) still reported being ashamed.
[Insert table 4 about here]
Health related quality of life
Before treatment none of the children reported a low health related quality of life (problematic NDS) on any of the subscales. After treatment no significant changes were found (see table 5).
[Insert table 5 about here]
In contrast, parents reported more problems considering their child's health related quality of life before treatment (see table 6). More specifically, two of the parents (40%) reported severe [pretest NDS = -1.63] and very severe problems [pretest NDS = -2.07] before treatment on their child's physical wellbeing. After treatment they reported less problems considering their child's physical wellbeing, however these decreases were not significant [posttest NDS = -.61, RCI = -.86; posttest NDS = -1.52, RCI = -.46]. Regarding psychological wellbeing two of the parents (40%) reported moderate [pretest NDS = -1.28] and considerable problems [pretest NDS = -1.32], which non-significantly decreased after treatment [posttest NDS = -.40, RCI = -.73; posttest NDS = -.85, RCI = -.39]. Considering their child's social support and peers, three parents (60%) reported very severe problems before treatment [pretest NDS = -1.68; pretest NDS = -2.21; pretest NDS = -2.64]. After treatment these problems non-significantly decreased according to two parents [posttest NDS = .05, RCI = -1.38; posttest NDS = -2.21, RCI = .00; posttest NDS = -1.77, RCI = -.70].
One parent (20%) reported severe school problems [pretest NDS = -1.68]. After treatment these problems significantly decreased to a non-problematic level [posttest NDS = .00, RCI = -1.65].
[Insert table 6 about here]
Subjective Happiness
Before treatment only one child (20%) reported being unhappy [pretest NDS = -1.79]. After treatment this score significantly increased to a non-clinical (happiness) level [posttest NDS = .89, RCI = -2.49**]. The other children‟s pre-treatment scores displayed that they thought of themselves as being happy. This did not significantly change after treatment (see table 7).
[Insert table 7 about here]
Seizure frequency and severity
During and after the treatment none of the participating children showed a decrease in seizure frequency and severity. Yet, also none of them experienced more (severe) seizures than usual, as reported by their parents in the seizure-diaries.
Parental Anxiety about Epilepsy
None of the participating parents reported problematic ranges of anxiety about their child's epilepsy before treatment (see table 8). After treatment no significant positive or negative changes were found.
Discussion
The aim of this study was to examine the efficacy of EMDR in reducing clinical seizure-related anxiety and trauma symptoms to non-clinical levels in children with epilepsy, using a case series design. It was hypothesized that EMDR treatment would result in a reduction of seizure-related anxiety and/or trauma symptoms from (sub-)clinical to non-clinical levels. Furthermore, it was hypothesized that EMDR treatment would also improve the quality of life, subjective happiness, and seizure frequency/severity in children with epilepsy. Additionally, it was hypothesized that treating the child‟s seizure-related anxiety or trauma symptoms with EMDR would reduce parental anxiety about epilepsy as well.
In line with expectations, NDS and RCI results displayed positive treatment effects, after merely one to three EMDR sessions, on seizure-related anxiety and trauma symptoms. More specifically, all children showed a decrease in (seizure-related) trauma symptoms after treatment. This decrease, from (sub-)clinical to non-clinical levels, was statistically significant in four children (80%). A decrease in total anxiety complaints was also detected in four children (80%), however this decrease was only significant in one child (20%). Furthermore, significant decreases were found on several anxiety subscales (: generalized anxiety disorder (two children, 40%), panic disorder (one child, 20%), and specific phobia of the situational/environmental type (one child, 20%)).
Although most children were diagnosed with both seizure-related anxiety and trauma symptoms by experienced child psychologists, their pretest anxiety scores were at a non-clinical level. The discrepancy between the diagnosis of the child psychologist and the children‟s self-reported anxiety during the pretest, might be due to the fact that during the intake session with the child and its parents, the child psychologist addressed specific related trauma symptoms and seizure-related anxiety complaints, whereas the questionnaire used for measuring anxiety (scales) focused on anxiety in general. An explanation for the non-clinical pretest anxiety scores might be that most of the children were seizure-free at the time of treatment. Seizure severity has shown to be an important
predictor of anxiety (Smith, et al., 1991) and the lack of seizures could explain the lack of clinical anxiety.
A discrepancy in improvement between the trauma and anxiety scales was found. Before treatment, children reported more (clinical) trauma symptoms than anxiety complaints; after treatment, regarding these trauma symptoms, more improvement was reported. This discrepancy might on the one hand be due to the lack of clinical pretreatment anxiety scores, leaving little room for improvement. On the other hand this could possibly be explained by the fact that the
questionnaire used for measuring anxiety (scales) assessed anxiety in general, whereas the
questionnaire used to measure trauma symptoms was adapted to specifically measure seizure-related trauma symptoms. Given that, the treatment focused on seizure-related anxiety and/or trauma
symptoms, and not anxiety in general, this scale might not have been adequate for measuring (improvement in) seizure-related anxiety. Therefore, future research should focus on developing an instrument for measuring seizure-related anxiety.
On the contrary to expectations, a significant post-treatment increase in total anxiety complaints was found for one child (20%). This child also showed significantly increased post-treatment scores on panic disorder complaints and did not show a significant decrease in trauma symptoms. A plausible explanation for this increase in anxiety complaints could be that, while undergoing the EMDR treatment, this child‟s mother became somatically ill and had to undergo several surgeries. Steck, Amsler, Grether, Schwald Dillier, Baldus, Haagen et al. (2007) have found that children of somatically ill mothers show more internalizing behavior problems. Furthermore Adewuya and Ola (2005) found that family stressors, among other risk factors, were significant predictors of anxiety in a group of adolescents with epilepsy. For the EMDR treatment focused merely on treating seizure-related trauma symptoms and anxiety, and not anxiety in general, this child‟s anxiety scores did not decrease due to treatment.
The children's perception of their health related quality of life did not improve significantly after treatment, but they did not report to have a low health related quality of life before treatment, leaving little room for improvement. On the contrary, their parents reported lower pre-treatment health related quality of life, which positively changed after treatment. This difference between child self-report and parent self-report might possibly be due to parents of children with a chronic condition tending to perceive their child as being vulnerable or helpless (Green & Solnit, 1964). Their child being in treatment might be comforting for parents, influencing their perception of the quality of life of their child. In one of the children (20%) a significant increase in subjective happiness was found
Although an improvement in medical status (seizure frequency/severity) could not be found, possibly due to most of the participating children having non-active epilepsy at the time of the treatment, from the seizure diaries it was clear that none of the children experienced more seizures after treatment. One parent did report more fatigue in their child during the treatment, however fatigue is a common side-effect of EMDR that can last up to a couple of days after treatment. Other side-effects of EMDR are a feeling of loss of control over thoughts and feelings (de Jongh & ten Broeke, 2009), but these were not reported. No effects of the treatment on parental anxiety about epilepsy were found, but this can be explained by the fact that parental anxiety about epilepsy was not problematic before treatment.
This study shows positive effects of EMDR treatment on seizure-related anxiety and/or trauma symptoms. We, however, are not able yet to indicate EMDR a well-established treatment for seizure-related anxiety and/or trauma symptoms. To investigate whether a treatment is effective by using single subjects, Chorpita, Yim, Donkervoet, Arensdorf, Amundsen, McGee et al. (2002) have set a number of guidelines. In the current study, although several of the guidelines (: an adequate
experimental design was used, characteristics of the participant sample were clearly specified, and experiments were conducted using treatment manuals) were followed, we were not able to include
over nine participants and were unable to compare this treatment to a well established control treatment (e.g., CBT).
However, the current study did manage to live up to several of Maxfield and Hyers (2002) revised gold standard criteria -RGS; an expansion of the gold standards (Foa & Meadows, 1997; Lohr, Tolin, and Lilienfeld, 1998) including 10 guidelines for assessing EMDR effectiveness- and in that way improved its empirical value. More specifically, in the current study all participants met the target symptom criteria (RGS #1), all measures were reliable, valid, and adequate (RGS #2), a blind, trained, and independent assessor was used (RGS #3 and #4), treatment was given following the EMDR children‟s protocol (RGS #5), assignment to treatment was unbiased (RGS #6), treatment fidelity was adequate (RGS #7) and multimodal measures were used (: self-report, parent report, interview with psychologist; RGS #9). Unfortunately it was impossible to fully live up to all
standards: most children had concurrent psychopharmacology (: Anti Epileptic Drugs; RGS#8) and the number of EMDR sessions varied dependent on the needs of the child (1-3 sessions; RGS #10).
This study has some limitations. The sample was very small, but this is not unusual in clinical single subject research (Rapoff & Stark, 2002) and pilot studies. Yet, with a sample this size we cannot fully generalize the results to the population of children with epilepsy and future research should focus on expanding this sample. In addition, most of the investigated children had non-active epilepsy at the time of treatment making generalizing even more difficult. Another weakness is that most children (80%) were adolescent girls. However, Kashani and Orvaschel (1990) found that overall, girls were more likely to report any type of anxiety disorder than boys. Another weakness is that there are no reliable and valid instruments (yet) for measuring seizure-related anxiety and/or trauma symptoms. Therefore existing anxiety and trauma symptom scales (with very good
psychometric properties) were used. However, it seems that these instruments did not fully capture all aspects of seizure-related anxiety and/or trauma. Furthermore, for this was a pilot study, no control group was included in the design and mostly self-report measures were used.
Despite its limitations, the current study does yield new knowledge. In childhood epilepsy research neither seizure-related anxiety and/or trauma symptoms nor the effect of treating these symptoms with EMDR was investigated before. However, when looking at the described results seizure-related anxiety and/or trauma symptoms are prevalent in 38.71% of the investigated children and seem to be a considerable problem. Furthermore, in four out of five children (80%) treatment with EMDR showed positive results on trauma symptoms and anxiety complaints. However, this sample is too small and too unilateral to generalize these positive effects. Therefore, the investigated concepts should be taken into account in future research. This future research should focus on investigating seizure-related anxiety and/or trauma symptoms in a larger, more representative (more boys; more children with active epilepsy) sample, including a control group and using adapted multimodal measurements.
Some practical implications can be derived from the results of this study. Clinicians working with children with epilepsy should be aware of the existence of seizure-related anxiety and/or trauma symptoms and the possible impact of epilepsy and/or seizures on the child's internalizing behavior problems. Furthermore, professionals should pay attention to possible seizure-related frightening and/or traumatic experiences causing distress in children. In these cases they could consider the use of EMDR treatment.
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Figures and Tables
Table 1. EMDR treatment trial design
Intake T1: Pretest EMDR treatment T2: Posttest
Intake with therapist Questionnaires: 1 week before treatment
1-5 EMDR sessions Questionnaires:
1 week after treatment closure Time
Table 2 NDS´s RCI´s and status-change scores: Anxiety scales (from the Screen for Child Anxiety Related Emotional disorders: SCARED-R)
Total Anxiety
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 0.82 -0.26 1.24 S+ C0 S+
2 F 12 3 0.11 -1.28 1.59 S+ C0 S+
3 F 12 1 -0.50 1.10a -1.83* S+ C- S
-4 F 16 3 0.05 -1.89 2.22** S+ C+ S+
5 F 15 2 0.10 -0.81 1.05 S+ C0 S+
Generalized anxiety disorder
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 -0.09 -0.38 0.25 S+ C0 S+
2 F 12 3 1.78c -0.44 1.96** S- C+ S+
3 F 12 1 -0.16 0.11 -0.26 S+ C0 S+
4 F 16 3 0.99 -1.54 2.23** S+ C0 S+
5 F 15 2 -0.42 -0.42 0 S+ C0 S+
Separation anxiety disorder
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 1.01a 0.03 0.63 S+ C0 S+ 2 F 12 3 0.46 -0.47 0.60 S+ C0 S+ 3 F 12 1 -1.39 -0.24 -0.75 S+ C0 S+ 4 F 16 3 0.02 -1.75 1.14 S+ C0 S+ 5 F 15 2 -1.16 -1.46 0.19 S+ C0 S+ Social phobia
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 0.92 -0.04 0.93 S+ C0 S+ 2 F 12 3 -0.84 -0.14 -0.69 S+ C0 S+ 3 F 12 1 1.40b 1.12a 0.28 S+ C0 S+ 4 F 16 3 -0.41 -1.54 1.12 S+ C0 S+ 5 F 15 2 0.17 -0.69 0.84 S+ C0 S+ Panic disorder
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 0.06 -0.74 0.76 S+ C0 S+
2 F 12 3 0.63 -1.24 1.77* S+ C+ S+
3 F 12 1 -1.01 1.80c -2.65** S+ C- S
-4 F 16 3 1.01a -0.73 1.64* S+ C0 S+
5 F 15 2 2.99d 1.01a 1.87* S- C+ S+
Obsessive compulsive disorder
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 0.50 -1.00 1.25 S+ C0 S+
2 F 12 3 -0.09 -1.69 1.33 S+ C0 S+
3 F 12 1 -1.69 0.23 -1.60 S+ C0 S+
4 F 16 3 -0.33 -2.03 1.42 S+ C0 S+
Posttraumatic and acute stress disorder
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 0.10 -0.78 0.58 S+ C0 S+
2 F 12 3 -0.08 -0.49 0.27 S+ C0 S+
3 F 12 1 -0.08 0.74 -0.54 S+ C0 S+
4 F 16 3 1.30b -0.56 1.21 S+ C0 S+
5 F 15 2 0.370 -0.09 0.30 S+ C0 S+
Specific phobia: Animal type
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 -0.85 -0.85 0 S+ C0 S+
2 F 12 3 -1.05 -1.05 0 S+ C0 S+
3 F 12 1 -0.50 1.15a -1.53 S+ C0 S+
4 F 16 3 -0.94 -0.94 0 S+ C0 S+
5 F 15 2 -0.94 -0.94 0 S+ C0 S+
Specific phobia: Blood-Injection-Injury type
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 1.31b 0.60 0.74 S- C0 S+
2 F 12 3 -1.52 -1.85 0.35 S+ C0 S+
3 F 12 1 0.14 1.47b -1.39 S+ C0 S+
4 F 16 3 -0.98 -1.31 0.35 S+ C0 S+
5 F 15 2 -0.32 -0.32 0 S+ C0 S+
Specific phobia: Situational/Environmental type
Child Sex Age Diagnosisᵜ NDS Pretest NDS Posttest RCI Pretest-Posttest S/C Pretest-Posttest
1 M 9 3 2.40d 1.49b 0.97 S- C0 S -2 F 12 3 0.55 -1.57 2.26** S+ C0 S+ 3 F 12 1 0.55 1.39b -0.90 S+ C0 S+ 4 F 16 3 -1.23 -1.23 0.00 S+ C0 S+ 5 F 15 2 -0.75 -1.23 0.51 S+ C0 S+ *α = .050 **α = .025
ᵜ1 = seizure-related anxiety; 2 = seizure-related trauma; 3 = both
a = modarate problems (NDS 1.00 ─ 1.28), b = considerable problems (NDS 1.29 ─ 1.64), c = severe problems (NDS 1.65 ─ 1.96); d = very severe problems (NDS > 1.96)
