Assessment

of
Dissociative
Children and
Adolescents
Presented by Dr Renée Potgieter Marks
Integrate
Email: renee@bictd.org
19 May 2022

Copyright R Potgieter Marks, 2022

 Training objectives

• Why is dissociation in children underdiagnosed?

• Differential diagnosis
• Basic principles in assessing dissociative children
• Introduction to assessing dissociative children
• Managing complicated presentations

Copyright R Potgieter Marks, 2022

Why is dissociation
in children and
adolescents
underdiagnosed?

Copyright R Potgieter Marks, 2022

Child High level of scepticism about
dissociation dissociative disorders in professionals,
underdiagnosed involved with children and adolescents
and under (Putnam, 1991)
recognised.

Smaller number of clinicians in the

field of child dissociation (Ross, 1996)

Child’s fear of ridicule and disbelief by

others about the internal experiences
(McElroy, 1992).

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Child dissociation underdiagnosed and
under recognised.

Clinicians’ disbelief that the child would

assume a defensive posture against
trauma.(Goodwin, 1995)

Clinicians need to rescue the child from a

controversial diagnosis such a DID (McElroy
& McElroy, 1991).
Copyright R Potgieter Marks, 2022
Child
dissociation Kluft (1984) also argues that dissociation
underdiagnosed in children are often not recognised due
and under to a lack of familiarity with dissociative
recognised. symptoms in children, differences in the
presentation in dissociative adults and
dissociative children

The availability of more familiar

diagnoses and the normative nature of
fluctuating behaviours in children.

Copyright R Potgieter Marks, 2022

Child
dissociation The normative dissociative
underdiagnosed experiences of children can make it
hard to differentiate between a
and under
pathological process and
recognised. imagination involved in play
(Haugaard, 2004).

Silberg et al, (2004) also conclude

that children and adolescents might
not report dissociative symptoms as
they may consider it as normal.

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Child dissociation underdiagnosed
and under recognised.

• Silberg & Dallam (2004) refer to (Zoroglu

et al, 1996) who stated that many children
are misdiagnosed because of comorbid
symptomatology for instance, ADHD,
conversion and somatoform disorders,
conduct and oppositional defiant
disorders, schizophrenia and various
forms of epilepsy and affective disorders.
Copyright R Potgieter Marks, 2022
Child dissociation underdiagnosed
and under recognised.

”It is still very difficult for professionals to

accept that in children and adolescents “The
self may no longer be “whole,” and the
dissociated memories and sensations may be
perceived as not being under the control of
the conscious and executive self”. (Silberg &
Wieland, 2013).

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 Differential Diagnoses (Waters 2016)
• ADHD
• Obsessive Compulsive Disorder
• Reactive Attachment Disorder (RAD)
• Bipolar Disorder
• Psychosis (Hallucinations)
• Eating Disorders
• Substance Abuse
• PTSD
• Depression
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Complex Trauma leads to
Dissociation

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 What is dissociation
in children and
adolescents?

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(Wieland 2015), states, ‘Infants and children
who suffer traumatic events – including
abuse and neglect, are particularly likely to
use dissociation (i.e. psychologically ‘moving
away’ from danger) as a survival strategy’.

Copyright R Potgieter Marks, 2022

“When a child feels very afraid and helpless and
cannot physically escape from the situation, he can
find a way to ‘escape’ by blocking off (dissociating)
the terrifying event/s from his memory; by blocking
off (dissociating) feelings of pain, hurt, rage; and by
blocking off (dissociating) bad thoughts about
himself and those hurting him. He may go into a
trance state or ‘space out’ (mild dissociation). He
may become unaware of his surroundings (moderate
dissociation). He may even separate completely from
himself to totally escape from the frightening event/s
(severe dissociation)” (Wieland 2015)
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If the child completely separates
from the self ……..

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 Personality

ANP EP
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 Personality

ANP EP
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BUT …………….

• Some children’s trauma started so early

that they were not able to develop and
ANP!

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 Basic Principles of
Assessing
Dissociation in
Children

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 • “………we should not base our theories of
dissociation in children on the clinical
presentations of adults, but instead on the
clinical manifestation of children and
adolescents.”
• (Silberg, 2013:16)

Copyright R Potgieter Marks, 2022

 Children are NOT adults!
Children do remember
The brain of the child
traumatic experiences,
functions totally different
but their memory works
from that of the adult.
different from adults.

• In assessing
The younger the child
The child often has dissociative children,
powerful sensory and
was when the abuse
occurred the more
somatic memories, which we first need to
are either internalized or
profound the impact on
the child.
externalized through change out
complex behaviours.
assumptions!
Abused children often
display trauma-based
behaviours, which are
often described as
behavioural problems.

Copyright R Potgieter Marks, 2022

 Basic Principles of the
Assessment
Allow Allow a calm, safe space for the child to let you know about her internal world.

Do not interpret Do not interpret unusual information, rather clarify it with the child

Remember that the child is the only person who is really aware or know something
Remember about her internal experiences.

Remember that you, as therapist needs help from the child in order to gain the best
Remember possible understanding of the child’s internal world with regards to the dissociation.

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You might even fail to
identify any
dissociation in a highly
dissociative child!

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 Assessment
of
Dissociation

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 1. What do I see during the assessment?

• General psychological assessment and I

observe …………..

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 2. What do I hear during the assessment?

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3. What happens during the assessment?

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 4. Direct Questions

•Only when asked directly children will:

•Report internal voices
•Imaginary friends
•Hallucinations

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Direct Questions

• 1. Do you have any friends/people inside you that other people does
not know about?
• 2. Do you hear any voices in your head?
• 3. (If yes), ”Can you tell me about these voices”
• “What are they saying?”
• 4. If child reports that they are hearing or seeing something externally,
explore it immediately.

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 5.
Switching

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 “Sometimes the
splitting, although
persistent , is purely
trauma related, the self
creating a fragment to
contain the trauma that
will exist alongside the
everyday
consciousness”

Cairns, 2002
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6. Emotions
during
assessment

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7. Sand Tray
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 8.Amnesia

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9. Drawings

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 Fragmentation of body parts

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 Multiple dots of self

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 Multiple Body Parts

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Draw your
brain and
what is
inside your
brain.

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 Draw
the Outside
of your
Head (Baita,
2015)

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 10. What do parents report?
• Does not listen when spoken to
• Lying about everything!
• Says she cannot remember, which is a blatant
lie
• Lazy and does not want to do anything at all
• Has no friends – always wants to boss friends
around
• Regular enuresis/encoprecis/smearing
Copyright R Potgieter Marks, 2022
 What do parents report?
• Aches and pains
• Cannot feel pain or feeling too much pain when
hurt
• Changes very quickly from friendly to extreme
anger
• Very controlling – wants everyone to do what
she wants to do

Copyright R Potgieter Marks, 2022

 What do parents report?
• Eating problems
• Sleeping problems
• Only wants to be hugged on her own terms
• Demanding
• Hurt others
• Hurt self
• Obsessed with electronic games
Copyright R Potgieter Marks, 2022
 11. What does school report?
• Daydreaming
• Does not complete work
• Disruptive and Defiant
• Quiet and Compliant
• Does not have friends
• Inconsistent performance
• Bully friends/or being bullied
Copyright R Potgieter Marks, 2022
 12. Questionnaires

• Parent – CDC, CBCL & TSCYC

• Child –C-Des, TSCC, Dissociation
Experiences
• Adolescent A-Des, C-Des & YSR
• School observation – CDC & TRF

Copyright R Potgieter Marks, 2022

 Successful assessment of dissociation
in children and adolescents………

• Has more to do with the knowledge of the therapist

about dissociation than scores on forms.

• Has more to do with being curious about the internal

landscape of the child, than interpreting what the child
is doing or saying.

Copyright R Potgieter Marks, 2022

 Successful assessment of dissociation
in children and adolescents………

• Has more to do with being dependent on the child’s

help than relying on your own brilliance.

• Has more to do with your capacity to allow the child to

externalize his/her internal world in creative ways than
expecting answers to questions.

Copyright R Potgieter Marks, 2022

Please DO NOT Dissociate
the Dissociation!

Copyright R Potgieter Marks, 2022

 Resources
1. Guidelines and Training
• ESTD Guidelines for the assessment and treatment of children and
adolescents with dissociative symptoms and dissociative
disorders.
https://www.estd.org/sites/default/files/files/estd_guidelines_chil
d_and_adolescents_first_update_july_2.pdf

• Training in Dissociation in Children and Adolescents: Assessment

and Treatment. https://bictd.org/dissociation.html

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 Resources
2. Books
• Sinason, V. & Potgieter Marks, R. (2021) Treating Children with
Dissociative Disorders: Attachment, Trauma, Theory and Practice.
London: Routledge.
• Silberg, J. (2013). The Child Survivor: Healing Developmental Trauma
and Dissociation. New York: Routledge
• Waters, F.S. (2016) Healing the Fractured Child: Diagnoses and
Treatment of Youth with Dissociation. New York: Springer Publishing
Company.
• Wieland, S. (2015). Dissociation in Children and Adolescents Theory
and Clinical Interventions (2nd Ed.). London: Routledge.

Copyright R Potgieter Marks, 2022