“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”
― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook
Dissociative identity disorder is the result of repeated or long-term childhood trauma. It cannot form after 6 to 9 years of age. Therefore, there must be children who can be diagnosed with DID. Because children are diagnosed with DID more rarely than adults are, some assume that DID is not valid or that it does not truly form as a response to childhood trauma. What this position fails to take into account is that that although DID must form while an individual is still a child, it can fully manifest or become apparent at any age. Even many adults with DID are often not immediately diagnosable to such, and clinicians who have no training regarding dissociation might never realize if one or more of their patients have DID. DID in adults is often at first mistaken for a variety of other conditions, and DID is even harder to recognize in children.
In children, the presentation of DID is often more covert and less complete than it is in adults. Dissociation may be visible primarily through problems with memory, concentration and attachment and through play with traumatic themes. Full switches between alters are rare when compared to passive interference and identity disruption, and switches are easily mistaken for normal signs of adolescence or for other, more common disorders such as major depressive disorder, bipolar disorder, or attention deficit disorder.
Despite all of this, DID is sometimes diagnosed in children, even young children, who show especially noticeable symptoms of the disorder or who blatantly switch. Occasionally, children with documented trauma histories will show extreme variations in behavior and temperament that are associated with identifying themselves by a different name. Episodes of fear, anger, or aggression may not be recalled by the child after they occur. These children might enter frequently zone out, daydream, or enter trance-like states. They might have unprovoked and extreme changes in mood or consistently switch through different sets of preferences, opinions, and skills. This is all discussed in the case of Leigh, a young girl who was eventually diagnosed with the disorder (Muller, 2013)1.
The International Society for the Study of Trauma and Dissociation (ISST-D), a leading organization for research and education regarding trauma and dissociation, has both a FAQ page that is meant to educate caregivers about dissociation in children and adolescents and treatment guidelines for professionals who work with dissociative children and adolescents. The FAQ addresses how children may experience non-pathological dissociation, depersonalization and derealization, amnesia, dissociated parts, and full blown dissociative identity disorder. It lists additional indicators of dissociation in children such as the child repeatedly regressing to a younger state, referring to themself by a different name or as "we," repeatedly cycling through gaining and losing the same sets of skills, seeming unable to feel emotions or being unaware of their emotional state, showing confusion over what situations are or are not safe, being unable to recall important but non-traumatic events and situations, admitting to hearing voices in their head, reporting having people inside who boss them around, displaying signs and symptoms of posttraumatic stress disorder, being unable to feel pain or not reacting to pain, or having frequent but unexplained health problems (ISST-D, n.d.).2
Because dissociative states develop more the more that they are used and exposed to new situations, dissociative states in children are often not as fully developed or obvious as can be alters in adults. In children, there might be less dramatic changes that accompany a switch between parts, and children might be less likely to realize that having such distinct parts is unusual or might be unwilling or frightened to admit to their presence or talk about them. As well, children with dissociative disorders are less likely to engage in aggressive, sexual, or harmful behaviors, and dissociative episodes in children are more easily written off as inattentiveness. Finally, the adults around and in charge of the dissociative child might deny that they child could have been hurt enough for them to have a dissociative disorder, especially a severe dissociative disorder like DID (ISST-D, n.d.).2
There are specific diagnostic measures that can indicate that a child might be struggling with a dissociative disorder. These include the Children’s Dissociative Experiences Scale and Posttraumatic Symptom Inventory [CDES/PTSI], Adolescent Dissociative Experiences Scale, version 2 [A-DES, II], Adolescent Multi-Dimensional Inventory of Dissociation [A-MID], and Child Dissociative Checklist[CDC-III]. It is important that dissociative children be recognized as such so that they can get proper treatment before their disorder can worsen and to prevent further suffering (ISST-D, n.d.).2
Like the ISST-D, the Sidran Institute also has specific guidelines for parents whose children are dissociative. It addresses ways to avoid triggering or upsetting children who are victims of abuse as well as how to handle children's alters. It discusses acting out and destructive behavior, amnesia between alters and how this relates to system responsibility and accountability, and how to allow the child to express their emotions in safe and healthy ways (Waters, 1996).3 In contrast, the ISSTD's guidelines for professionals addresses a wide variety of dissociative symptoms that can arise in disordered and traumatized children. It discusses: who is qualified to treat dissociation in children; how dissociation can present in children; how to assess for dissociative disorders, trauma, and dissociative symptoms in children; the length and course of treatment, the role of the therapist in treatment, cautions regarding treating dissociation, the goals of treatment, and possible adjunctive treatments. Care is taken to inform clinicians how to recognize switches between alters during diagnostic interviews and how to react by encouraging internal cohesion and awareness instead of switching or dissociative behaviors. Instructions are given as to how the clinician can encourage the child's family to react in similar ways by acknowledging the child as a whole and not placing emphasis on the child's internal separation (ISSD, 2004).4
Not only is DID possible in children, it is something that is not created or encouraged by clinicians but in fact is something that clinicians stress must not be worsened by acknowledging alters as literal realities instead of dissociative parts that should be helped to integrate into one whole. Entire books address how to promote integration in children. Books related to recognizing and treating dissociation in children include The Dissociative Child: Diagnosis, Treatment and Management edited by Joyanna Silberg (a chapter of which can be found online here), Dissociative Children: Bridging the Inner and Outer Worlds by Lynda Shirar, The Child Survivor: Healing Developmental Trauma and Dissociation by Joyanna L. Silberg, and Dissociation in Traumatized Children and Adolescents: Theory and Clinical Interventions edited by Sandra Wieland (which can be found online here).
Finally, there was an entire article about how psychiatric nurses can recognize and treat dissociation and dissociative disorders in children. It has since been redacted due to references that could not be verified, but it itself is still referenced in many other similar case studies and studies and can confirm the way in which clinicians were meant to react to dissociation and alters in children and adolescents. It can be found here (Weber, 2009).5
1 Muller, R. T. (2013, December 27). Understanding dissociative identity disorder in children. Retrieved from https://www.psychologytoday.com/blog/talking-about-trauma/201312/understanding-dissociative-identity-disorder-in-children
2 ISST-D. (n.d.). Child/adolescent FAQ's. Retrieved April 19, 2015, from http://www.isst-d.org/default.asp?contentID=100
3 Waters, F. S. (1996). Parents as partners. Retrieved from http://www.sidran.org/resources/for-survivors-and-loved-ones/parents-as-partners/
4 ISSD Task Force on Child and Adolescents. (2004). Guidelines for the evaluation and treatment of dissociative symptoms in children and adolescents. Journal of Trauma & Dissociation, 5(3), 119-150. doi:10.1300/J229v05n03_09
5 Weber, S. (2009). THIS ARTICLE HAS BEEN RETRACTED Treatment of trauma- and abuse-related dissociative symptom disorders in children and adolescents. Journal of Child and Adolescent Psychiatric Nursing, 22(1), 2-6. doi:10.1111/j.1744-6171.2008.00163.x