Recognizing Dissociation in Preschoolers
Familial trafficking is likely to start in early childhood. Recognizing when a young child is suffering from dissociative traumatic stress disorder is an important step to early intervention. This article, written by Fran S. Waters, was originally published in the International Society for the Study of Dissociation in July of 2005.
As I look out the window of my Northern Michigan home, it’s the beginning of the blooming season, which occurs in late May here. I admire the spring flowers while pondering their indomitable ability to survive in spite of the frigid winds and heavy snow that blow off of Lake Superior. I am always amazed to see the delicate tender shoots of crocuses that emerge when this snowy Northern landscape finally thaws. As a weekend gardener, I realize how delicate yet tenacious the tulips, primroses and daffodils must be to bloom once again. However, upon closer scrutiny, I notice that some of the daffodils’ stalks are green but there are no golden flowers atop. I don’t really know why they didn’t bloom this year, but I am reminded how vulnerable flowers are to a severe environment. To maximize their beauty and strength, just the right amount of water, sun, rich soil and, of course, fertilizer are needed. Absence of one of these environmental elements can leave the plants dwarfed and fragile, or not blooming at all. The development of these early bloomers is susceptible to a myriad of factors, genetic and environmental, the later in particular either nourishing or inhibiting their growth. As I ponder the emerging beauty of the spring and the intricate balance it reflects, I recognize how symbolic it is of the right amount of nourishment, security, and stability required in a child’s environment for healthy growth and a strong identity. The vulnerable young children I have treated over 30 years have experienced turbulence, unpredictability, and repeated traumas leaving them fragile, dissociated, and undeveloped without exuberance like the daffodils without their flowers. In the past, there was scant literature on preschool childhood dissociation (Riley & Mead, 1988; Silberg, 1998; Shirar, 1996; Putnam, 1997; Macfie, et al., 2001a; Macfie, et al, 2001b; Haugaard, 2004) but since the development of the classification of Disorganized (D) Attachment (Main & Hesse, 1990, Main & Solomon, 1990), there has been more attention to this population, as dissociative responses are characteristic of disorganized attachment with infants and toddlers. They display a disorganized, chaotic response to their parents marked by wanting to reach out to them, while switching to freezing, staring off, backing away and/or collapsing when the parent approaches (Solomon & George, 2001). The theoretical conceptualization that D attachment may lead to the development of a fragmented self (Liotti, 1992, 1999a, 1999b) appears to be supported by longitudinal studies showing that children with avoidant or D attachment may develop dissociative characteristics (Ogawa, et al. 1997, Carlson, 1998). The research examines various attachment styles, and the mother-child relationship as a mediator or predictor of the development of dissociative symptoms in the child. Avoidant or disorganized attachment may in turn predispose the child to a dissociative response to trauma (Barach, 1991; Liotti, 1999a, 1999b). Also, research indicates that infants and very young children are more prone to dissociate because they don’t have the coping mechanisms to handle fearful or stressful situations independently (Solomon & George, Eds., 1999, Perry, 2001; Lyons-Ruth, K., 2003; Lyons-Ruth et al, 2004; Ogawa, et al., 1997, Carlson et al, 1989).
“Very young children can neither soothe nor protect themselves, and do not have the mobility to seek out another caregiver”
The attachment system motivates the child to approach the parent whenever distressed. Very young children can neither soothe nor protect themselves, and do not have the mobility to seek out another caregiver. If a parent responds in a frightening or contradictory manner, the child can neither approach the caregiver for comfort not flee the very person on whom his life depends. The child’s limited cognitive and behavioral systems for maintaining attachment may break down, leading to dazing, confusion, and rapid alternation between approach and avoidance. These disorganized responses appear to activate the neurophysiological mechanism which involves dissociative adaptive response, i.e. staring, unresponsivity, hypalgesia, depersonalization, and derealization (Perry, 2001). This calls for clinicians to be particularly heedful of dissociative indicators in infants and young children given their neurobiological capacity to dissociate when in the face of persisting threat. Yet, the significance of their responses often continues to be minimized or misinterpreted (Waters, 2005) because professionals erroneously believe that this population, contrary to current research isn’t affected by frightening or/and unresponsive caretakers. Understanding symptoms of disorganized attachment are crucial to early detection and intervention of dissociative processes with preschool children. The following are some prominent indicators of dissociation (Putnam, et al, 1993) in preschool children followed by an analysis of a case study. • Staring, spacing out or trance-like states, including inattention • Amnesia • Extreme fluctuations in emotions and behaviors, including “regressive behaviors” • Dissociative states or self states, including internal voices, referring to self in third person, and the importance of distinguishing between imaginary playmates and dissociated self states I poignantly recall the first preschool case that I diagnosed in 1988 with Dissociative Identity Disorder, before the development of the Child Dissociative Checklist (Putnam, et al, 1993) and much published literature on the subject (Kluft,, 1984; Kluft,, 1985). Katie1 was a bright and articulate three year old child in foster care whom I had assessed, treated and for whom I subsequently submitted a court report. Over time, she disclosed to me multiple traumatic events, i.e. sexual abuse by mother’s boyfriend at 3 years old, and later disclosed sexual abuse by her biological father (convicted of sexual abuse of an older daughter) when she was a year and a half old. She was also neglected, and physically and emotionally abused by her mother and mother’s boyfriend. Katie would sit for extended periods of time staring into space and non-responsive. She would talk out loud to herself referring to herself in the third person. She displayed extreme shifts in mood and behavior marked by sudden angry outbursts over minor requests, uncharacteristic of her usual pleasant behavior. During these outbursts, she would attack her younger brother and then adamantly deny it, crumbling on the floor and extremely distraught that she was unfairly accused. At other times, she would regress into baby talk, particularly after supervised visits with her biological mother. She had episodes in the morning in which she would frantically try on different clothing, particularly underwear and slacks, crying hysterically stating that “Nothing felt right.” No amount of prior agreed selection of an outfit or any reasoning was able to prevent her from escalating into hour-long episodes of chaotic, disoriented behavior to resolve what to wear. Meal times were occasionally stressful because she would suddenly not like her favorite food, macaroni and cheese, and would want something else to eat. She had severe insomnia and would literally hold open her eye lids to deter herself from going to sleep for fear of reoccurring nightmares. Most of these symptoms were exacerbated after visits with her biological mother. My epiphany occurred (when I realized that Katie had Dissociative Identity Disorder) when she was in one of her ‘regressed states’ crawling on the floor engaging in baby talk and mumbling that she needed “to potty.” She extended her hands for me to carry her to the bathroom, which I proceeded to do. When we entered the lobby where her foster mother of 6 months was waiting, I paused with Katie in my arms to inform her foster mother that we were on our way to the bathroom. Katie looked frightened at the ‘stranger’ and turned away refusing to talk to her stunned foster mother while wrapping her small arms tightly around my neck. Although I had been recognizing and diagnosing older dissociative children for a few years at this time, I misconstrued Katie’s younger dissociative state as ‘regressed behavior.’ When, I reviewed the court report, I found that I had indeed described such behavior, i.e. baby talk, crawling, but had not recognized the significance of what I had seen until I witnessed Katie’s amnesia for her foster mother. It was at that pivotal moment when the true meaning of her behavior crystallized for me in an accurate diagnostic picture. A reconceptualization of Katie’s misunderstood, regressed behavior and other symptoms opens the door to discussing multiple challenging factors involved in accurately assessing preschool children for dissociation. For a variety of reasons, it is frequently difficult to understand the meaning of young children’s dissociative behaviors. It is important to consider whether their regressed behavior is indicative of a younger dissociated state. The evaluator needs to distinguish developmenttally inappropriate behavior that may, for example, be an imitation of a new baby in the home from sporadic or frequent extreme switching of atypical behavior, particularly when accompanied by amnesia. Some young children may not exhibit such behavior on a regular basis but the significance of aberrant behavior must be examined carefully, particularly if the child has a trauma history. Katie was an articulate child with good, expressive language. When she uttered singular words and crawled instead of walking, I was struck with this unusual behavior.
“It is important to consider whether their regressed behavior is indicative of a younger dissociated state.”
For example, Katie’s adamant refusal to eat her favorite food is not in itself unusual for children who display oppositional responses, particularly when tired, sick or simply wanting to assert independence. However, what is often characteristic of dissociative children is the extreme degree of such changes in preferences and the accompanying intense affective response. Dissociative children will often become inconsolable and quickly deteriorate. Katie’s frenzied search to find comfortable and acceptable apparel was another clue to some dissociative switching among self states. She was able to identify these self states, ranging in ages from one year old to adult, the latter representing her abusers. There was an internal struggle with her self states to take control over what to wear. In addition, Katie’s comment, “Nothing feels right,” pertaining to anything binding in her abdominal and genital areas was a traumatic reminder of her sexual abuse. I have observed repeatedly this hypersensitivity to clothing in traumatized children who are triggered by sensory stimuli. Children’s triggers may be disguised by their strong oppositional reactions, but a clinician must not assume that the traumatized child simply wants her way. Also, the child’s staring, inattention and/or frenzied activity may be misdiagnosed as Oppositional Defiant Disorder or Attention Deficit Hyperactivity Disorder. If professionals focus primarily on these disruptive behaviors without understanding the contextual relationship between parent and child, as well as the underlying connotations, they may miss their true significance. Then if they employ a strictly behavioral approach, it is likely to be ineffectual. The occurrence of maltreatment and the resulting dissociative mechanisms may easily be overlooked and at worst persist. Katie’s amnesia for aggression toward her brother reflects a frequent indicator of dissociative children, one often misunderstood. Dissociative children’s amnesia for assaultive behavior or “forgetfulness” can easily be misconstrued by weary, frustrated, and angry caregivers who assume that their children’s denial is an escape from responsibility for their behavior. After dissociative children receive consequences for destructive acts, they will frequently persist in their denial of such behavior even though there isn’t any benefit for them to continue. They may also repeat similar aggressive behaviors and be unresponsive to appropriate child management techniques. When astute clinicians see the entire picture of the pernicious impact of child maltreatment, they can understand that disavowal of behavior that others have clearly witnessed is one of the features of dissociation, rather than assuming that the child is simply defiant. Katie’s amnesia toward her foster mother was a potent and florid indicator of a separate dissociative state, rather than regressed behavior. This leads the discussion to discerning between imaginary playmates, fantasy play and dissociative states in young children. Research indicates that at age three, children can distinguish fantasy from reality (Harris, et al, 1991). The formation of separate self states to manage traumatic events with frightened children may develop from early and continued reliance on imaginary playmates (Putnam, 1985). While it is developmentally common for young children to have imaginary playmates, there are some distinguishing differences between imaginary playmates and formation of self states. Dissociative children’s tenacious assertion that the dissociative states are real is one of the prominent responses I and others (Frost, et al 1996) have observed in young traumatized children who exhibit dissociative states, contrary to children who engage in fantasy play. For example, when I query the latter group in play therapy whether their expressed self-ascribed name is “real,” they will look at me in a perplexed way, and respond, “No, silly. I’m just pretending.” They will resume their fantasy play without any disturbance of affect. However, young children with DID are more likely to argue and persist that their self states are real and are separate from themselves. They become very impatient when attempts are made to explain otherwise and are insistent about their separateness. In addition, they will exhibit other dissociative symptoms described above providing a composite picture meeting the criteria for a dissociative disorder. Another challenge in accurate diagnosis of this age group is that their dissociation can easily be misinterpreted and camouflaged due to linguistic deficits (Chicchetti & Beeghly, 1987; Beeghly & Cicchetti, 1994; Yehuda, 2005), and as yet undeveloped cognition, which may, in turn, have been impaired by maltreatment and a chaotic environment. These children’s troubling presentation can be easily misconstrued and misdiagnosed as a pervasive developmental disorder, missing the significance of their dissociative behaviors and perhaps yet undiscovered trauma. Complicating environmental factors can also hinder a correct diagnosis. It is a taxing process to gather a comprehensive child developmental history from caretakers – biological, foster or adoptive– who may not be attuned to the child, may misinterpret the meaning of their child’s disturbed behaviors, or do not have such history. Worst of all, caretakers may be either directly or covertly involved in their child’s maltreatment. The clinician needs to carefully investigate this possibility while simultaneously evaluating the following: family dynamics, quality of the family relationships (particularly parental attachment history), parents’ relationship with their child, and environmental influences, i.e. domestic violence, mental illness, substance abuse, and caretaker’s overinvestment of the child’s dissociative responses that maintain the child’s dissociation (Peters, et al 1998). Assessing the quality of family relationships is particularly significant because these relationships may contribute to the formation of disorganized attachment with the child, which may predispose the child to dissociate. This evaluation process must also be accomplished under the umbrella of an empathetic approach so as not to malign the child’s caregivers. Not a simple task! However, the use of the Child Dissociative Checklist (Putnam, et al 1993) can be very helpful to the parents and clinician in detecting dissociation with young children and a springboard for more thorough discussion of dissociative indicators. Educating the parents about dissociation is paramount to helping them persevere in a loving and accepting manner with their child (Waters, 1996), while also being empathetic to the challenges of raising such a child. This approach needs to be accompanied with compassion for the child’s struggles. Diagnosing preschool dissociative children is critical to sparing them a lifetime of pain, agony and confusion. Like damaged tender spring shoots that regain their strength and vitality with proper care, so can young dissociative children demonstrate amazing resilience. They can recover from traumatic experiences and regain their spark. With early detection, a safe and nurturing environment, and appropriate intervention, they can go on to bloom and flourish into fulfilling adulthood.
“Children’s triggers may be disguised by their strong oppositional reactions, but a clinician must not assume that the traumatized child simply wants her way”