Journal Article Review: Treating Dissociation in Children and Adolescents

WCF Clinical Team

What is the definition of Dissociation?

Dissociation means to bring apart, split off or disconnect elements that have something in common, Dissociation is the opposite of association (Diseth, 2005).

The DSM5 categorizes dissociative disorders as: A disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour.

DSM5 describe dissociative symptoms as:

• Unbidden intrusions into awareness and behaviour, with accompanying losses of continuity in subjective experience (i.e., “positive” dissociative symptoms such as fragmentation of identity, depersonalization, and derealization).

• Inability to access information or to control mental functions that normally are readily amenable to access or control (i.e., “negative” dissociative symptoms such as amnesia)

• The disturbance is not a normal part of a broadly accepted cultural or religious practice (i.e., children having imaginary friends).

• The symptoms are no attributable to the physiological effects of a substance (i.e., alcohol intoxication) or another medical condition (i.e., seizures). (American Psychiatric Association, 2013)

Symptoms of Dissociation can include?

• Detachment from self: hyperemotionality, (e.g., I know I have feelings, but I don’t feel them), detachment from thoughts (e.g., My thoughts don’t feel like my own), detachment from whole body or body parts, or detachment from sensations.

• Episodes of depersonalization can be described as having an ‘out-of-body experience.’

• Episodes of derealization can be described as ‘feeling in a fog, dream, or bubble, as if there were a veil or a glass wall between the individual and the world around.’

• Dissociation can take on the form of childhood amnesia, where early memories show up through felt senses in the body, rather than as fully formed recollections. (Marich, 2023)

• Other common are subjectively altered sense of time, rumination, or obsessional preoccupation, or physiological hyperreactivity to emotional stimuli. (American Psychiatric Association, 2013).

Dissociation and the Brain

If we think of trauma as a brain injury, dissociation can be understood as one of the impairments caused by this injury. When somebody experiences a traumatic event, this event can become “split off" from conscious awareness.

The brain is a storage system, and when dissociation happens, the physical, emotional, and cognitive associations related to a traumatic memory can be stored in different areas of the brain, rather than together.

Trauma survivors can become stuck between being forced to remember having been abandoned and betrayed (or the reexperiencing and increased arousal symptoms) while simultaneously trying to forget (which shows up as avoidance, numbing and dissociative symptoms). The tension created by these two opposing forces creates a static vacuum in which speaking, and representation may feel impossible. (Buk, 2009)

This is why sometimes people with trauma have a hard time remembering traumatic things that have happened to them. (Diseth, 2005)

Dissociation and the Body

Dissociation is the body in survival mode. Often people will dissociate at the time of a traumatic event, and this coping mechanism helps them survive in the face of trauma. But because trauma is stored in the body, the nervous system can continue to be triggered and cause the individual to dissociate even when there is no immediate danger. This is because they have not properly processed their traumatic experience. (Diseth, 2005)  

Dissociation is the brain's attempt to protect the body, it does this by:

• Making actions automatic – the person’s behaviour becomes routine and out of their conscious control.

• Separating painful memories and emotions – upsetting memories and feelings are kept in separate mental "compartments" so they aren't as overwhelming.

• Disconnecting from their body – experiencing a sense of being detached or "not themselves," which creates a safer distance between the person and the danger they may feel as a result of their trauma. (Dorahy, 2023)

Dissociation and Mental Disorders

Dissociation is a core symptom of a number of mental disorders including post-traumatic stress disorder (PTSD), borderline personality disorder (BPD), dissociative identity disorder (DID) – previously known as multiple personality disorder (MPD), dissociative amnesia and depersonalization / derealization disorder. However, a person can also experience dissociation without having a diagnosis of any mental health conditions. (American Psychiatric Association, 2013; University of Wollongong. (n.d).

These mental disorders are rarely diagnosed in children. Although, identifying when a child dissociates is important because early intervention may lessen the likelihood of developing personality or dissociative disorder later in life.

It is important to note that dissociative disorder is one of the very few disorders in the classification systems where evidence for psychological causation is included as a criterion for a definitive diagnosis.

This means it is often tough to clinically diagnose dissociative disorders in children when evidence of traumatic experiences is not disclosed.

It is relevant to note that the International Classification of Diseases (10th ed.) classifies Somatoform dissociation symptoms such as sensory losses, loss of motor control, general paralysis and alteration of vision, hearing, taste, and smell as relating to mental dissociation.

Whereas the DSM-5 categorizes these symptoms separately under somatoform disorders, along with somatization, conversion, or pain disorders. These are essentially physical symptoms that cannot be fully explained by medical conditions, medications, or other diagnoses. (Diseth, T.H., 2005)

The Continuum of Dissociation

Everybody dissociates about 10% of the day when we daydream or compartmentalize our thoughts to help us get our work done. Experiences of dissociation can be better understood on a continuum from ‘helpful’ everyday dissociation, such as ‘zoning out’, to ‘less helpful’ dissociation, which may take on the form of mental disorders and negatively impact a person’s everyday life. (Diseth, T.H., 2005)

Understanding dissociation on a continuum also allows for a better understanding of a person’s individual experience. Where the experiences that one individual might find to be a helpful form of dissociation, another individual may find less helpful. (Dorahy, 2023)

Dissociation and Children

Interestingly, there has not been much research completed on treating dissociation in children, despite most academics recognising that dissociative tendencies often develop during childhood in response to adverse life experiences.

Children do not have as many resources available to assist in processing, as the cognitive structures in the brain are not yet fully formed. Therefore, dissociation keeps these traumatic events unprocessed, and these memories can only be remembered when the person has the capacity to and feels safe enough to do so.

For neurodivergent children, dissociation is a natural thing to do during experiences of overstimulation or boredom, and even more so when experiencing abuse. Neurodivergent people already have processing sensitivities and, therefore, may be more likely to demonstrate dissociative tendencies. (Marich, 2023).

What Contributes to Dissociation?

In 2004, a study measured dissociation in children aged 5 to 8 by their schoolteachers completing an Achenbach’s Teacher Report Form (2004), which screens for behaviours such as withdrawal, thought and attention problems. This research identified that children who experienced the following caregiving disturbances were more likely to present with dissociative symptoms. (Dorahy, 2023)

• Early occurring and chronic maltreatment: Ongoing abuse or mistreatment that starts early in a child's life. 

• Insensitive or contradictory care: Care from parents or caregivers that is confusing, inconsistent, or not responsive to the child's needs.

• Neglectful parenting: When parents don't give their children enough attention or love to meet their basic needs.

• Low parental warmth and support: Parents who are not emotionally warm, loving, or supportive toward their child.

• Poor parent-child relationship quality: A relationship between parent and child that is troubled, distant, or unhealthy.

• Infant attachment disorganisation: When babies show confusion or fear when connecting with their caregiver, they do not develop the ability to trust or feel safe with the caregiver.

• Psychological unavailability: When a parent or caregiver is emotionally distant or not able to provide the mental or emotional support to the child.

Of all results, disorganised attachment and psychological unavailability of the caregiver before age two were the strongest independent predictors of elevated dissociation in late adolescence.

What does research tell us?

While the literature reviewed revealed minimal findings on treatment interventions for dissociation in children, the following preliminary studies highlight several potential causes for dissociative symptoms in children. A brief timeline of research over the previous 15 years shows that

2011: (Hulette, A.C. 2011)

• A randomised clinical trial of 118 children, 57 girls (median age 9), and their caregivers found that;

• Children who experience early abuse or are in foster care are more likely to develop dissociative symptoms (like feeling disconnected from reality) when they reach school age than children not in foster care. Girls seem to be more affected by this than boys.

2016: (Herbert, M., 2016)

• 158 children and their non-offending parents were consulted after the disclosure of sexual abuse. Children, parents and teachers completed the self-report victimization scale measure, and trauma-related symptoms (PTSD and dissociation) were used as outcome variables.

• Children who have been sexually abused and also face bullying from their peers are three times more likely to develop dissociative symptoms than children who are not bullied.

2020: (Lewis, J, 2020)

• This study sampled 68 month-child dyads at two time points, when children were 3-4 and then 5-6, and shows that;

• When mothers experience difficulties with emotions and dissociation, it is often connected to similar struggles in their children.

2023: (Dorahy, MJ., 2023)

• A study of 250 parent-child dyads drawn from the community found that;

• The relationship between a caregiver and a baby can impact whether the child develops dissociative symptoms. It's not just about how the caregiver acts, but also how they feel and think about the child and their role as a parent. 

2024: (Woolard, A., et al., 2024)

• Systematic Review of 3064 papers evidenced that;

• There isn't yet a clear, agreed-upon method for treating dissociation in children and teenagers.

Treating Dissociation

It is hard to know what therapies can help treat dissociation when minimal research shows what is effective.

Current research considers therapies such as Dialectical Behaviour Therapy (DBT), Mindfulness-Based Stress Reduction, Eye Movement Desensitization and Reprocessing (EMDR), and psychoeducation for the treatment of dissociation. However, often, the individuals studied in this research were engaged in multiple therapies at once, so it is hard to tell which therapy was helpful. (Woolard, 2024)

Current research also bases possible treatment approaches for children off treatment methods used for adults, so more research must be done to find out what works specifically for children and adolescents.

What we do know so far is that a secure attachments and positive relationships with primary caregivers are the most helpful thing to prevent children from developing dissociative tendencies. (Dorahy, M.J., 2023)

Art Therapy and Dissociation

Research shows that Art Therapy is a helpful therapeutic treatment for people who experience dissociation because the act of artmaking helps to target both the brain and the body at the same time, making it easier to 'bypass’ the dissociation. (Lev-Wiesel, 2022).

Research shows that people who dissociate often picture their emotions and traumatic experiences as images instead of expressing them with words. Visualising these traumatic memories can help them feel safer when beginning to process their feelings.

Art therapy can help people who experience dissociation by 'splitting off’ from their traumatic experience in a healthy way through creating a third place, outside of the brain and the body, where the traumatic experience can exist in an artwork.

A lot of research shows that art therapy is helpful for children because it focuses on communicating through pictures rather than words.

As we know, trauma is stored in the body, and research shows that overstimulation of the vagus nerve and amygdala, and a reduction in the function of the corpus callosum and hippocampus contribute to dissociative symptoms.

Art therapy targets these parts of the nervous system through somatic engagement with materials, so that, from a neuroscientific perspective, the targeting of these systems contributes to a person’s healing in a way that is beyond their awareness. (Buk, 2009; Gerge, 2017)

What does this mean for Carers?

Seeking Support: Caregiving for traumatised children can be overwhelming and often lead to burnout. It is essential that carers connect with their larger support networks so that they can maintain capacity for attentiveness, patience, and understanding when caring for their children and young people.

Engaging with Play: Play is the language of children. Children can create better personal stories when caregivers engage in meaningful, playful interactions with them. This helps them combine their emotions, thoughts, and sensory experiences, reducing the confusion and disconnection often associated with dissociation (Dorahy, 2023; Wooland, 2025).

Identifying Dissociation: Adequate information and support should be provided to caregivers, so they are well equipped to recognise when a child or young person is dissociating. This can often occur during times when they display significant and complex behaviours.

What does this mean for Clinicians?

Appropriate therapeutic support: Traditional cognitive behavioural therapies that rely on verbal expression may not be the most effective interventions for children who display dissociative symptoms, as their experiences often lie outside their conscious awareness and control and cannot be accessed using words alone (Gerge, 2017). If a child or young person dissociates, they should be referred to a professional therapist with experience in dissociation.

Carer Support: It’s essential for our carers to receive appropriate psychoeducation on identifying and managing dissociation and adequate support to prevent burnout. This will ensure they have the capacity to remain attentive, patient, and understanding while caring for children and young people from traumatic backgrounds.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.).

Buk, A. (2009). The mirror neuron system and embodied simulation: Clinical implications for art therapists working with trauma survivors. The Arts in Psychotherapy, 36(2), 61–74. https://doi.org/10.1016/j.aip.2009.01.008

Diseth, T. H. (2005). Dissociation in children and adolescents as reaction to trauma - an overview of conceptual issues and neurobiological factors. Nordic Journal of Psychiatry, 59(2), 79–91. https://doi.org/10.1080/08039480510022963

Dorahy, M. J., Gold, S. N., & O’Neil, J. A. (Eds.). (2023). Dissociation and the dissociative disorders: past, present, future (Second edition.). Routledge. https://doi-org.ezproxy.lib.uts.edu.au/10.4324/9781003057314

Gerge, A., & Pedersen, I. N. (2017). Analyzing pictorial artifacts from psychotherapy and art therapy when overcoming stress and trauma. The Arts in Psychotherapy, 54(NA), 56–68. https://doi.org/10.1016/j.aip.2017.02.001

Hébert, M., Langevin, R., & Daigneault, I. (2016). The association between peer victimization, PTSD, and dissociation in child victims of sexual abuse. Journal of Affective Disorders, 193, 227–232. https://doi.org/10.1016/j.jad.2015.12.080

Hulette, A. C., Freyd, J. J., & Fisher, P. A. (2011). Dissociation in middle childhood among foster children with early maltreatment experiences. Child Abuse & Neglect, 35(2), 123–126. https://doi.org/10.1016/j.chiabu.2010.10.002

Lev-Wiesel, R., Goldner, L., & Daphna-Tekoah, S. (2022). Introduction to the Special Issue The Use of Creative Art Therapies in the Prevention, Screening, and Treatment of Child Sexual Abuse. Journal of Child Sexual Abuse, 31(1), 3–8. https://doi.org/10.1080/10538712.2022.2032895

Lewis, J., Binion, G., Rogers, M., & Zalewski, M. (2020). The Associations Of Maternal Emotion Dysregulation And Early Child Dissociative Behaviors. Journal of Trauma & Dissociation, 21(2), 203–216. https://doi.org/10.1080/15299732.2019.1678211 

Low, G., Jones, D., MaCleod, A., Power, M., & Duggan, C. (2000). Childhood trauma, dissociation and self-harming behaviour: A pilot study. British Journal of Medical Psychology, 73(2), 269–278. https://doi.org/10.1348/00071120016036

Marich, J. (2023) Dissociation Made Simple: A Stigma-Free Guide to Embracing Your Dissociative Mind and Navigating Daily Life. North Atlantic. 

Thomas, P. M. (2003). Protection, Dissociation, and Internal Roles: Modeling and Treating the Effects of Child Abuse. Review of General Psychology, 7(4), 364–380. https://doi.org/10.1037/1089-2680.7.4.364

University of Wollongong. (n.d.). E-learning. Project Air. University of Wollongong. https://www.uow.edu.au/project-air/adults/e-learning/

Valentino, K., Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2008). True and false recall and dissociation among maltreated children: The role of self-schema. Development and Psychopathology, 20(1), 213–232. https://doi.org/10.1017/S0954579408000102

Wherry, J. N., Jolly, J. B., Feldman, J., Adam, B., & Manjanatha, S. (1994). The Child Dissociative Checklist: Preliminary Findings of a Screening Measure. Journal of Child Sexual Abuse, 3(3), 51–66. https://doi.org/10.1300/J070v03n03_04

Wieland, S. (2015). Dissociation in Traumatized Children and Adolescents: Theory and Clinical Interventions (Second edition.). Routledge. https://doi.org/10.4324/9781315740430

Woolard, A., Boutrus, M., Bullman, I., Wickens, N., Gouveia Belinelo, P. de, Solomon, T., Milroy, H., Kendall-Tackett, K., & Kendall-Tackett, K. A. (2024). Treatment for Childhood and Adolescent Dissociation: A Systematic Review. Psychological Trauma, 16(S3), S483–S491. https://doi.org/10.1037/tra0001615