DID in Children

Image: "child abuse" by Peter Bulthuis

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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, attachment, and play with traumatic themes. Full switches between alters are rare when compared to passive interference that presents as overlap or disruption between mental states and discontinuities in experience. When switches do occur, they're easily mistaken for normal signs of adolescence or for other, better known disorders such as major depressive disorder, bipolar disorder, or attention deficit disorder (APA, 2013).¹ 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. Additionally, children might be less likely to realize that having such distinct parts is unusual, and when they do have this knowledge, they might be unwilling or frightened to admit to having parts or to talk about their parts. Finally, even if the dissociative child attempts to seek help, the adults around and in charge of the child might deny that the 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

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 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 (Muller, 2013).³ Additional indicators of dissociation in children include 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

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 

When a child has unrecognized problems with dissociation, they are likely to be subjected to many difficult struggles. Often, they cannot hide their dissociation well, and they might be accused of being careless, inattentive, or liars. Particularly if the child does not understand the reason behind their lapses in attention or memory, they can become confused, self critical, and depressed. Harsh or judgmental reactions from others in response to the children's seemingly inconsistent interests, preferences, and abilities can also confuse and upset dissociative children. Some children seem to be genetically predisposed to dissociate, but maladaptive dissociation is generally associated with maltreatment or other stressful experiences. When children repeatedly rely on dissociation in order to avoid being overwhelmed by difficult situations, they can become sensitized to it and inappropriately dissociate in educational or social settings, which can interfere with their learning and development. This can lead to additional criticism and maltreatment from adults and peers, further upsetting the child and reinforcing their reliance on dissociation. Problems such as social withdrawal or aggressive acting out are also possible (Hauggard, 2004).⁴

In contrast, when dissociation is recognized and diagnosed in children, the prognosis is very positive. In one study, four out of five children with DID were successfully fully integrated, and when two of the children were followed up with 22 and 69 months later respectively, the integration was still stable for both. In the latter case, integration of all five alters was achieved within only twelve therapy sessions. Prior to integration, most of the children's alters had expressed a desire to be "normal." They did not strongly express or differentiate themselves, and most were trauma-oriented (Kluft, 1985).⁵ In general, important aspects of successfully treating dissociative children include ensuring that the child's environment is safe, empathizing with the child about their desire to dissociate in frightening situations, expressing concern about the child's use of dissociation in situations in which they need to be mentally present, learning to recognize signs that the child is dissociating and helping them learn to ground themselves, and educating the child's caregivers and helping them to support the child (Hauggard, 2004).⁴

Both the International Society for the Study of Trauma and Dissociation (ISST-D) and the Sidran Institute have guidelines for caregivers of dissociative children or for professionals who work with dissociative children and adolescents. For parents, advice is given such as how to avoid triggering or upsetting children who are victims of abuse as well as how to handle children's alters. The Sidran guidelines discuss acting out and destructive behaviors, 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).⁶ 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 trauma and dissociation in children, the length and course of treatment, the role of the therapist in treatment, 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 as opposed to 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).⁷

Not only is DID possible in children, it is something that is not created or encouraged by clinicians. In contrast, clinicians stress that childhood DID must not be worsened by treating alters as separate individuals instead of dissociative parts that should be helped to integrate into one whole. Several 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 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 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 articles 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).⁸

¹ American Psychiatric Association. (2013). Dissociative Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). http://dx.doi.org/10.1176/appi.books.9780890425596.dsm08

² ISST-D. (n.d.). Child/adolescent FAQ's. Retrieved from

https://www.isst-d.org/resources/child-adolescent-faqs/

³ 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

⁴ Haugaard, J. J. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and adolesce who have been severely maltreated: Dissociative disorders. Child Maltreatment, 9(46), 146-153.

⁵ Kluft, R. P. (1985). Hypnotherapy of Childhood Multiple Personality Disorder. American Journal of Clinical

Hypnosis, 27(4).

⁶ Waters, F. S. (1996). Parents as partners. Retrieved from http://www.sidran.org/resources/for-survivors-and-loved-ones/parents-as-partners/

⁷ 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

⁸ 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

Additional Resources

Additional research exists on the existence and presentation of dissociative identity disorder in children. Much of it is behind paywalls, but abstracts for some relevant studies can be found here, here, and here. If one can read Turkish, 36 case studies are presented here.