Introduction

Numerous studies show that a large percentage of children have experienced a traumatic event at least once before adolescence. Post-traumatic stress disorder (PTSD) develops in 3% of traumatized children, while 13.4% of children later develop severe post-traumatic stress symptoms (PTSS) (Alisic, E. et al., 2008) . If we take into account the sudden increase in traumatic events in the last ten years, we can assume that this percentage is much higher. We will list some of such extreme traumatic events.

Exposure to the Covid^[1], pandemic during the period 2020 to 2023 has left severe consequences. The death of about 7 million people in the world, states of emergency, fears, loss of family members and loved ones, etc. they left serious consequences not only on the health, but also on the psychological state of children.

Increasingly frequent natural disasters, the consequences of climate change in the world are also major traumatic events that favor the development of PSTD in children. The great floods in Serbia in 2014 threatened 1.6 million people and claimed 57 lives (Maksimović, May 6, 2023). The loss of homes, family members, relatives and friends left catastrophic consequences on the psychological life of these children^[2]

Terrorist attacks, in addition to the large number of innocent victims, also leave deep traces on the psychological life of children and adults. Several terrorist attacks have occurred in Russia and claimed a large number of lives (Tarabrina & Bykhovets, 2016; Speckhard, Tarabrina, & Mufel, 2005). The last one happened on March 22, 2024 in Krasnogorsk, in the Crocus concert hall, where at least 137 people died and more than 154 were injured. In Beslan, a city in the North Caucasus, in 2004, terrorists took over the school on the first day of school, September 1, in an attack that became known as the "Russian 9/11". More than 1,000 students, parents and staff were held hostage for more than two days. At least 334 people were killed, most of whom were children.

In Serbia, on May 3, 2023, at the Belgrade school^[3], a thirteen-year-old boy shot his fellow students with a firearm, killing 10 and wounding 6. Just a few days later, according to the copy cat principle (Werther's effect), a similar massacre took place in the vicinity of Mladenovac, when the twenty-one-year-old attacker killed 8 people and wounded 14 with automatic weapon.

Violence happens every day in many families. Physical and sexual abuse of children leaves unfathomable, permanent psychological consequences.

in all wars, all over the world, in all areas, the victims are usually civilians, especially children. War traumas have been particularly studied (see: Milicevič, Milenović, & Marković, 2016), and the consequences of PSTD are difficult to eliminate.

All of the above points to the necessity of taking preventive measures as well as measures to eliminate the consequences of various extreme traumas in children.

The need for prevention and adequate treatment of the consequences of PTSD in children is becoming more and more necessary.

Analyzes of the effectiveness of the application of different types of psychotherapies. technique and method in PTSD children based on different criteria showed high efficiency of EMDR therapy.

EMDR therapy - Eye Movement Desensitization and Reprocessing, which was first discovered and applied by Dr. Francine Shapiro in 1987, is being used more and more today.

One of the goals of this paper was to provide a brief review of the literature and analysis of the experiences so far in the application of EMDR in working with children who are victims of violence in war and peace. This literature review is only an illustration of the effectiveness of EMDR treatment of children with PTSD. The analysis was performed on the basis of several characteristics and criteria, and the effectiveness compared to some other therapeutic methods was compared.

EMDR terapy (Eye Movement Desensitization and Reprocessing)

Dr Francine Shapiro (1948-2019) began work on designing this psychotherapeutic technique in 1987. In the following years, she confirmed the effectiveness of EMDR in the treatment of the trauma of Vietnam War veterans, but also in PTSD victims of sexual violence (Shapiro, & Forrest, 2001).

EMDR (eye movement desensitization and reprocessing) is a psychotherapy technique that is suitable for the treatment of psychological and emotional disorders caused by traumatic experiences. We have already mentioned some of those traumatic experiences. These can be natural disasters, violence, aggressive attacks, war experiences, losses in the family, disturbing events from childhood, as well as stressful events in adulthood.

EMDR therapy is based on physiological mechanisms, stimulating the part of the brain responsible for the adaptive elaboration of information. This allows the person to experience the traumatic memory in a new, more adaptive and less distressing way. The effectiveness of this therapy lies in the direct effect of bilateral stimulation (BS) on brain neurophysiological mechanisms highlighting the physiological components of emotional disorders. It works with the negative cognitive aspect (negative cognition), the positive cognitive aspect (positive cognition), but also with emotions, bodily sensations and other symptoms that accompany the traumatic event and memories of it.

EMDR shows high efficiency in working with children who have experienced traumatic experiences such as family and peer violence, war stress, etc. Children and adults show different symptoms after such events. These are post-traumatic and acute stress responses such as: reliving, intuitive thoughts, flashbacks, nightmares, fears and avoidance, feelings of alienation and increased arousal, insomnia, then difficulties in concentration and hypervigilance of attention. As for acute stress complaints, dissociative behavior, withdrawal, aggressiveness, psychosomatic reactions and other symptoms can occur (Speckhard, Tarabrina, Krasnov & N. Mufel, 2005; Milićević, 2016, 2024).

In working with children, EMDR uses materials such as drawings with feelings, cognitive messages about them, instruments for measuring the ranking of anxiety and feelings, as well as various toys. The application of these materials enables the child to process and overcome his traumatic experiences in a positive and efficient way. Shapiro notes that EMDR produces faster results with children than with adults.

EMDR therapy can take place in three directions: (1) work on traumatic experiences from the past; (2) work on the current stressful situation and (3) anticipation of solving problems in the future. The advantage of the EMDR method lies in the fact that it can be used in combination with all other conventional forms of psychotherapy.

In EMDR, the therapist works together with the client to identify a specific problem that will be worked on during the psychotherapy process. Using a clearly structured therapeutic protocol, the therapist guides the client through eight stages:

(1) History taking and therapy planning.

(2) Preparation for EMDR and explanation.

(3) Evaluation and preparation of target memory. The client is asked to focus on the worst moment of the memory including the image, thought, emotion and physical sensation.

(4) Desensitization of memory. The therapist asks the patient to keep the target image in mind while concentrating on the bilateral stimulation stimulus for about 30 seconds. The client briefly reports on what is coming up and the therapist guides him to refocus on it during further exposure to the bilateral stimulation. This continues until the client reports no disturbing experiences associated with the traumatic memory.

(5) Installation. Guiding the client to accept a relevant positive belief about the event.

(6) Body scanning refers to the identification and processing of any residual disturbing bodily sensations.

(7) Closing the session.

(8) Re-evaluation, i.e. re-evaluation of the addressed goals as a basis for planning and directing further interventions.

During EMDR therapy, a child can experience and express very intense and dramatic emotions with traumatic detailed memories. However, at the end of the therapeutic work, there is usually a reduction of symptoms and unpleasant feelings related to the traumatic experience. This leads, as Shapiro (2001) points out, to the reduction of symptomatology, to the change of negative beliefs in the direction of positive ones, and thus enables optimal functioning of the client, i.e., the child.

Results and evaluation of previous EMDR trauma treatments in children

In order to demonstrate the effectiveness of EMDR trauma treatment in children, we will list only some of the most famous analyzes and studies.

Some studies show that EMDR (Shapiro, 2007) is effective in the treatment of PTSD in children and adolescents (De Roos et al., 2017) to a greater degree than CBT (trauma-focused cognitive behavioral therapy). It is also more successful than some other therapeutic techniques. Both EMDR and TF-CBT appear to be equally effective in treating PTSD symptoms, but the same results are achieved more quickly with EMDR therapy. This means that the same positive results using EMDR are achieved faster and the results are more permanent and permanent.

Hoogsteder et al. (2021) tested the effectiveness in the treatment of adolescent trauma with a multistage meta-analysis on a sample of 566 respondents, the average age of the respondents was 13 years (SD = 1.59). The results confirm that both TF CBT and EMDR treatments had a significant overall effect (d = 0.909) on the reduction of trauma symptoms and behavioral problems. Treatment was more effective in older adolescents.

Jaberghaderi et al. (Jaberghaderi, Greenwald, Rubin, Zand, & Dolatabadi, 2004) examined the effect of twelve CBT and EMDR treatments on fourteen randomly selected Iranian girls aged 12 to 13 years who had been sexually abused. Posttraumatic stress symptoms and problematic behavior were assessed before and two weeks after treatment. Both treatments showed significant effects on posttraumatic symptom outcomes and behavioral outcomes. Research gives some advantage to EMDR over CBT. These findings suggest that both CBT and EMDR can help girls recover from the effects of sexual abuse, and that structured trauma treatments can be applied to children in Iran.

In one study, a group of authors (Wadaa, et al., 2010) examined the prevalence of PTSD among Iraqi children and the success of EMDR treatment in Iraqi children with an average age of 10.17 years. The sample consisted of 29 boys and 31 girls who immigrated to Malaysia during the Iraq War. These children were assessed for PTSD. After the assessment, the children were divided into two groups (experimental and control) The results showed that EMDR is effective in reducing PTSD symptoms

One of the advantages of using EMDR in working with children lies in its flexibility (Civilotti, et al., 2021). The therapist has the ability and freedom to adapt the therapy to the client's age and culture. Another advantage lies in the possibility of its group application after mass traumas when time and resources do not allow an individual approach. Group protocols increasingly being used  (Jarero et al., 2006) in treatments of massive traumas.

These are just some of the numerous studies on the effects of applying CBT and EMDR in working with children and adolescents who have been victims of various forms of violence. Although the results of these studies differ somewhat in terms of the benefits of using a particular type of therapy for PTSD, they are all united in stating that both CBT and EMDR provide significant improvements and a visible reduction of symptoms in traumatized children.

There are EMDR centers in Russia ans Serbia that have highly qualified specialists who have been trained according to the standards of the EMDR Association. They are always up to date with news and current knowledge, and undergo regular supervision. They follow professional standards and code of ethics. We are an association of practicing EMDR therapists (EMDR - Eye Movement Desensitization and Reprocessing). They have been conducting EMDR therapy and training EMDR specialists in certified training programs since 2008^[4].

Application of EMDR in work with child victims of violence in Serbia

Therapists, members of the EMDR Association of Serbia and EMDR therapists in the territories of the former Yugoslavia (e.g. Bosnia and Croatia) had extensive experience in individual work with victims of various types of violence and successfully applied this method in practice.

After the mass shootings in May 2023 in the territory of Belgrade and the surroundings of Mladencovac (BBC in Serbian, May 6, 2023, Maksimović, S.), the need for organized teamwork with victims of violence emerged. Of course, there was an even greater need for organizing preventive activities. The Crisis Team of the EMDR Association of Serbia was formed and the Support Project for users who were most exposed to these traumatic events was initiated. It is about helping victims of all six levels, starting from victims who directly experienced the crisis event, family members or relatives of the deceased, operators in the crisis (first responders), through the community where the crisis happened, etc.

The reasons for the involvement of EMDR therapists are the earlier recommendations for the use of EMDR in trauma work by: (1) the World Health Organization (WHO); (2) American Psychological Association (APA) (1998-2002); (3) International Society for Traumatic Stress Studies (2000); (4) British Department of Health (2001); (5) Department of Defense and Department of Health (Veterans Health Affairs) U.S.A. (2004); (6) Italian Ministry of Health (ministero della Salute) (2003); (7) UK Department of Health - NHS; (7) National Institute for Clinical Excellence (NICE) with the recommendation that all patients suffering from PTSD disorders should be treated with trauma-focused psychotherapy (trauma-focused CBT or EMDR) (Clinical Guideline 26-March 2005; according to EMDR Croatia, 2024)

Nevertheless, one of the main reasons for the formation of the Crisis Team of the EMDR Association of Serbia was the initiative launched by traumatized users of all levels. In cooperation with EMDR experts from abroad (EMDR Italy, EMDR UK and EMDR Bosnia and Herzegovina), a series of additional trainings, consultations and expert meetings were held for selected EMDR therapists from Serbia. In addition to supporting those directly and indirectly affected, the team is also available for work with trauma and the organization of psychological support in the community, in crisis situations.

"This team is currently working on a direct support project for users, and will remain available for quick response in all future crisis situations when trauma-oriented support is needed (natural disasters or those caused by human action)" (EMDR Association of Serbia, 2024).

The project "Psychosocial support aimed at the prevention of PTSD" was initiated in 2023 by the Association of EMDR Serbia, and at the initiative of the users themselves, i.e. trauma victims. Over twenty EMDR therapists who work with directly affected users in Belgrade, Mali Orašje and Dubona are involved in the project. The project and team activities are led by Vesna Bogdanović, president of EMDR Serbia and Jelena Zulević. The project is supported by the Government of Serbia and the organization Reconstruction Women's Fund. Specially trained EMDR therapists are assigned to three sectors: (1) adult team, (2) child and adolescent team, and (3) field team. The way of working is adapted to the specific needs of clients and includes work with individuals and groups.

"In our approach, there is a special emphasis on confidentiality, trauma-informed practice and flexibility in the organization of support, adapted to the needs of clients and communities." All clients have the option of choosing the therapist they work with" (Association of EMDR Serbia, 2024).

          The mission of the Crisis Team is to provide psychological help and support, enable quality emotional health, recovery and resilience of directly and indirectly affected persons, by creating a safe and supportive environment.

The goals of the Crisis Team are as follows:

(1) Providing immediate, timely support and intervention during crisis events to reduce negative emotional consequences and prevent PTSD and complicated grief.

(2) Staff and community education: Provide training and education to school staff and the community about the importance of mental health, recognizing the signs of trauma, and providing support.

(3) Conduct continuous research and evaluation: The goal is to evaluate the effectiveness of the support program in order to determine results and identify areas for improvement.

(4) Establishing cooperation with other relevant organizations and institutions: In this way, a comprehensive and trauma-informed approach to support and reduction of trauma-related stigma would be ensured.

(5) Continuous monitoring and improvement of the work of the crisis team and the support program based on feedback and knowledge from practice.

The services provided by the Crisis Team are:

(1) Emergency intervention: is reflected in the provision of support to individuals, on the ground, groups or communities that have recently experienced a traumatic event.

(2) Assessment and evaluation: The team conducts an assessment of the current situation in order to identify priority areas/groups/persons for intervention and plan further steps.

(3) EMDR therapy: with the aim of processing traumatic experiences, reducing symptoms and restoring emotional well-being.

(4) Education and training/consultative work: Organization of workshops, seminars and training with the aim of informing the wider community and other professionals about trauma, EMDR therapy and strategies for dealing with stress. It can contribute to expanding awareness and knowledge about trauma and provide tools for support in crisis situations.

(5) Coordination and cooperation with other organizations such as: health institutions, government agencies, non-governmental organizations and local communities. This will allow resources to be coordinated, information to be shared and work together to provide support to affected people.

(6) Counseling and support to members of the association involved in intervention in crisis situations. This includes providing guidance, supervision, post-intervention debriefings and providing emotional support to team members.

Conclusion

By analyzing the literature and works on the effectiveness of CBT and EMDR treatment of children and adolescents who have experienced various forms of violence in peace and war, it cannot be determined with certainty which is more effective. The mentioned researches and evaluations contain shortcomings in terms of sample size, length of continuous monitoring of the effect of applied therapies, insufficient number of therapists, time constraints, etc. However, an important conclusion can safely be drawn regarding the undeniable effectiveness of trauma-focused treatments such as CBT and EMDR. This has been confirmed by the World Health Organization, as well as many other important institutions, based on numerous successful results in the application of these therapies. EMDR seems to have certain advantages in terms of speed of obtaining positive results, their durability and stability, as well as in terms of flexibility. The application of group protocols enables timely and efficient response in mass crisis situations (Milićević, 2024).

The need for CBT and EMDR therapy in the world, as in our country, is obvious and is constantly increasing. Exposure to constant stressogenic and traumatic factors requires the professional approach of professional therapists in the prevention of various forms of violence in children and adolescents and their rehabilitation.

Experiences with mass murders and the increase in peer violence in Serbia, as well as in neighboring countries and the whole world, impose an urgent need to hire professional therapists, especially those who are trained in the therapeutic treatment of children who are victims of violence.

The experiences of the therapists and the formed crisis team of the EMDR Serbia Association within the project "Psychosocial support aimed at the prevention of PTSD" are significant and applicable. We are still waiting for a detailed analysis of those experiences and their application in the future.