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Abstract

Dissociation is a common and often overlooked symptom in traumatised children. Although there is a lack of a scientific consensus as to the nature of dissociation and very limited research about dissociative identity disorder (DID) in children, the authors have seen children given this diagnosis recently referred to their clinic and are concerned about this practice and the parenting approaches that have ensued. The diagnosis of DID in children may be rare or of doubtful validity, but repeated traumatic experiences of an interpersonal nature can have a profound effect on a child's identity, memory and self-organisation. Furthermore, abuse and neglect can increase the risk of dissociative symptoms. This brief article considers dissociation in post-traumatic stress disorder, then outlines developmental factors hypothesised to be associated with dissociation in childhood and early adulthood. It warns that clinicians should keep an open mind about how dissociation may manifest transdiagnostically, and concludes with recommendations for further research.
Dissociative identity disorder:
a developmental perspective
Simon Wilkinson & Margaret DeJong
SUMMARY
Dissociation is a common and often overlooked
symptom in traumatised children. Although there
is a lack of a scientific consensus as to the nature
of dissociation and very limited research about dis-
sociative identity disorder (DID) in children, the
authors have seen children given this diagnosis
recently referred to their clinic and are concerned
about this practice and the parenting approaches
that have ensued. The diagnosis of DID in children
may be rare or of doubtful validity, but repeated
traumatic experiences of an interpersonal nature
can have a profound effect on a childs identity,
memory and self-organisation. Furthermore,
abuse and neglect can increase the risk of dis-
sociative symptoms. This brief article considers
dissociation in post-traumatic stress disorder,
then outlines developmental factors hypothesised
to be associated with dissociation in childhood
and early adulthood. It warns that clinicians should
keep an open mind about how dissociation may
manifest transdiagnostically, and concludes with
recommendations for further research.
KEYWORDS
Dissociative disorders; post-traumatic stress dis-
order; trauma.
We write as consultant psychiatrists at a national
specialist clinic in the UK, which since the 1980s
has taken referrals for children who have experi-
enced abuse and neglect. In the course of this work
we have learned that dissociation is a common and
often overlooked symptom in traumatised children.
In the past year, however, we have seen two children
referred to the clinic already diagnosed with dis-
sociative identity disorder (DID) and have been con-
cerned about the diagnoses and advice parents have
been given.
There is very limited research about DID in chil-
dren, and there are developmental questions to be
asked about making such a diagnosis at an age
when identities are still forming. At the same time,
repeated traumatic experiences of an interpersonal
nature can have a profound effect on a childs iden-
tity, memories and self-organisation. It is common
for children who have been removed from home to
have a limited or confused understanding of why
this has happened, and to have negative thoughts
about themselves from which they may take refuge
in fantasy. They may have had formative experi-
ences, such as of sexual abuse, which have not
been acknowledged by the adults in their lives.
Such circumstances must necessarily be a breeding
ground for identity confusion. Although the diagno-
sis of DID may be rare or even of doubtful validity in
children, we are keen that this should not obscure an
improved understanding of how abuse and neglect
increase the risk of dissociative symptoms.
Defining dissociation
A review of dissociation is complicated by the lack of
a clear scientic consensus as to its nature. It may, of
course, be non-pathological. Some of the symptoms
in the Dissociative Experiences Scale (DES)
(Dubester 1995), such as driving and not remember-
ing part of the journey, are a part of everyday life.
The same applies to the fantasy, role-play and
imaginary friends of childhood. Meta-analytic data
have indeed shown gradual decreases in dissociation
with age (van Ijzendoorn 1996). Meanwhile, there is
debate about what psychiatric symptoms may be
treated as dissociative. Consider for example the cri-
teria for post-traumatic stress disorder (PTSD). The
DSM-5 (American Psychiatric Association 2013)
has adopted a dissociative subtype of PTSD,
featuring symptoms of depersonalisation and
derealisation, but many authors argue that
ashbacks are also dissociative (Dorahy 2015). As
vivid, sensory, fragmentary experiences, they
certainly are not integrated in the way of typical
autobiographical memories. Auditory hallucina-
tions have also been treated as dissociative in
nature (Moskowitz 2009), and this may be recognis-
able to clinicians who notice how voices often reect
traumatic themes in a patients life.
The DSM-5 criteria for DID refer to recurrent
gaps in the recall of everyday events, important per-
sonal information and/or traumatic events that are
inconsistent with ordinary forgetting. Amnesia for
traumatic events, whether complete or partial, is,
however, recognised as a common feature of PTSD
in both the ICD-10 and DSM-5 classications
(World Health Organization 1993; American
Psychiatric Association 2013). Historically, such
CLINICAL
REFLECTION
Simon Wilkinson, BA(Oxon),
MBBS, MRCPsych, is a consultant
child and adolescent psychiatrist at
Great Ormond Street Hospital,
London, UK. He is head of the
Parenting and Child Team at the
hospital, which carries out expert
witness work for the family courts
and assessments and treatment of
children who have experienced abuse
and neglect. He has published in the
area of complex post-traumatic stress
disorder. Margaret DeJong, BA,
MDCM, FRCPsych(Can), FRCPsych
(UK), is an honorary consultant child
and adolescent psychiatrist at Great
Ormond Street Hospital, London. She
was head of the Parenting and Child
Team at the hospital for 12 years and
was involved for many years in
multidisciplinary expert witness work
in complex child protection cases.
She developed specialist expertise in
the field of maltreatment and pub-
lished in this area.
Correspondence: Dr Simon
Wilkinson.
Email: simon.wilkinson@gosh.nhs.uk
First received 20 Mar 2020
Final revision 2 Apr 2020
Accepted 14 May 2020
Copyright and usage
© The Authors 2020
BJPsych Advances (2020), page 1 of 3 doi: 10.1192/bja.2020.35
1
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amnesia has been seen as a defence mechanism, but
more recent work on PTSD has looked at memory
dysfunction, one observation being that affected
people simultaneously experience excessive involun-
tary remembering (such as ashbacks) and impaired
intentional recollection (Brewin 2007). This picture
will, of course, be further complicated when trau-
matic events occur at a preverbal stage or an age
when autobiographical memories are not yet as reli-
ably encoded and stored.
Evidence showing a high level of comorbidity
between borderline personality disorder and DID
(Dorahy 2014) should therefore be thought about
in the light of which symptoms in the former (feel-
ings of emptiness, disturbances in self-image) may
consist of dissociative elements. The DSM-5 recog-
nises this in its reference to severe dissociative symp-
toms as a possible feature. In what can become a
polarised debate about the presence or absence of
a disorder, we are keen therefore to keep an open
mind about how dissociation may manifest trans-
diagnostically and with a spectrum of severity.
The association between early-life trauma
and dissociation
The research which informed the adoption of a
dissociative subtype of PTSD in DSM-5 showed
that dissociation predicted higher PTSD severity
and levels of comorbid psychiatric disorders (van
Huijstee 2018). Those with the dissociative
subtype were more likely to have a history of
early-life trauma; why might this be the case? This
question has attracted a number of hypotheses.
First, given that dissociation is more common in
childhood, could traumatised children be more
vulnerable to a deviation in developmental
trajectory that leads to more persistent dissociative
experiences? Second, does attachment play a role
in a stress diathesis model (discussed further
below)? Third, is it simply due to the fact that
early-life trauma is highly correlated with
increased chronicity and severity (Dorahy 2015).
We are also prompted to reect that children are
usually helpless in the face of maltreatment,
meaning that dissociation may offer some relief
from experiences that are otherwise inescapable.
The evidence has tended to suggest that, although
trauma exposure increases risk, there are other
factors at play, and some people will experience dis-
sociation without such exposure (Briere 2006).
Several longitudinal studies have shown family
environmental factors contributing to the develop-
ment of dissociative symptoms independently of,
and more signicantly than, trauma exposure;
these include parental dissociative symptoms and
maternal unavailability (Ogawa 1997) and lack of
involvement and contradictory, role-reversed or dis-
oriented parental responses (Dutra 2005).
The potential role of attachment style
A replicated nding in these studies and others
(Carlson 1998) is that disorganised attachment
styles in infancy predicted dissociative symptoms
in adolescence and young adulthood. Children with
a disorganised attachment will show contradictory
behaviours (both proximity-seeking and avoidant)
towards caregivers presumed to be experienced
as either frightening or frightened (Main 1990) and
producing a paralysing motivational conict for
the child. Disorganised attachment behaviour is
often marked by moments of freezing, dazing or
trance-like states that bear a phenotypic resem-
blance to dissociation. This inability to develop
strategies for comfort and protection, with a failure
to integrate conicting and discrete emotional
states may, it is hypothesised, increase vulnerability
to dissociation as a response to future stressors
(Liotti 2004).
Diagnosis of DID in children: the evidence
and potential effect on parenting advice
When it comes to DID in children, however, the evi-
dence base is very small. Boysen (2011) summarises
this and nds a total of 255 children described in the
literature, with four research groups in the USA
accounting for 65% of the cases, and 93% of the
cases emerging from descriptions of children in
treatment. With an evidence base of this nature,
there can be no condent claims about the validity
of the diagnosis, let alone its prevalence or what
effective treatment might look like.
In spite of this, we have had several children
referred to our clinic with diagnoses of DID. This
has led to advice to parents to acknowledge and
respond to their childrensaltersand attribute feel-
ings and behaviours to them. We are very concerned
about this practice: children with traumatic back-
grounds are especially in need of emotionally sensitive
parenting to become more secure in their attachment
relationships. They also need help gradually to
develop a more integrated sense of self as individuals
who are valued for stable traits and preferences and
who feel responsible for their actions, all of which is
likely to be impeded by attention paid to alters.
A call for further research
While wishing to advocate a high degree of caution
about the diagnosis of DID in childhood we are
keen to understand more about how parenting,
other aspects of the family environment and trau-
matic experiences may, in additive ways, increase
vulnerability to dissociation. There is a need for
Wilkinson & DeJong
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more research, which should include increased use
of measures of dissociation in population and clin-
ical samples and further longitudinal studies collect-
ing data on risk inuences such as attachment status
over time. It is conceivable that DID is more
common from adolescence, a time when psycho-
logical reworking of early trauma takes place, and
identity formation is a key developmental task.
Given the strength of recent evidence demonstrating
an association between emotional abuse and neglect
and a range of mental illnesses, increased risk of dis-
sociation should also be researched (Humphreys
2020). Evidence in some analyses that parental dis-
sociation is a risk factor for dissociative symptoms in
children (Ogawa 1997) should prompt more genetic-
ally informed research. Furthermore, are there inter-
ventions that may reduce the future incidence of
dissociation in those who are vulnerable? In the
meantime, clinicians should be vigilant to the possi-
bility of dissociation in traumatised children as well
as to the wider impact their experiences have on
identity, memory and self-organisation, and thera-
peutic work should be directed accordingly.
Author contributions
Both authors made contributions to the conception
of this article and analysis of the research literature.
S.W. wrote the rst draft and both authors subse-
quently revised it, gave approval for its nal form
and take responsibility for the content.
Declaration of interest
None.
ICMJE forms are in the supplementary material,
available online at https://doi.org/10.1192/bja.
2020.35.
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Dissociative identity disorder
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The test-retest reliability of the Dissociative Experiences Scale (DES; Bernstein EM, Putnam FW [1986] Development, reliability, and validity of a dissociation scale. The Journal of Nervous and Mental Disease 174:727-735) in a clinical sample was found to be .93 for the total DES score and .95, .89, and .82 for the three subscale scores of amnesia, depersonalization-derealization, and absorption (dissociative identity disorder [DID], DSM-IV), respectively. Test-retest reliabilities within diagnostic groups of multiple personality disorder, dissociative disorder not otherwise specified, and a general other category of psychiatric diagnoses were obtained for total and subscale scores on the DES. These ranged from .78 to .96. Tests of mean scores across the two test sessions showed the total and subscale scores to be temporally stable. The DES was also found to be highly internally consistent: Cronbach's alphas of .96 and .97 were observed for the total DES scores taken at times 1 and 2, respectively. Construct validity of the DES was demonstrated by differentiation among the subscale scores in a repeated-measures analysis of variance (F[2,154] = 32.03, p < or = .001). Normality and general distribution issues were also addressed and provided a rationale for using the DES with parametric statistics. Reasons why the DES (as it was originally designed) is not appropriate as a dependent measure in outcome research are discussed, along with needed future research. Implications of the findings for the clinical usefulness of the DES as a diagnostic instrument are noted.