Dissociation in Children and Adolescents -- What it is, How it presents, and
How we can understand it (p. 1-27)
1. Which is NOT true about dissociation in children?
a. Extreme dissociation occurs when, in order to feel safe, the child
needs to separate the emotions, physical sensation, or experiences so
completely from his awareness that the child, outside of conscious
awareness, "creates" separate parts of himself to hold these emotions,
sensations, or experiences.
b. While in a dissociative state, the child may be unaware of all the other
learning and experiences the child has had in life. He may experience fear,
anger, loss, and loneliness without remembering that he is now in a safe
c. The child always remembers what he does when he is in a dissociative
d. In the most extreme form of dissociation, the dissociated parts take over
the child's functioning, switching between parts suddenly and often without
the child or other people around the child being able to recognize what
triggered the switch. The child does not have awareness that other states or
parts exist. Without this awareness, the child has little or no control over
which part is present at any particular moment.
2. What is the KEY reason why ongoing dissociation occurs in a child?
a. Because that child experienced trauma of some kind.
b. Because that child had parents who were significantly irresponsible.
c. Because that child was sexually abused.
d. Because that child had no safety, support, or soothing that could help
the child through a trauma.
3. Regarding the various theories of dissociation, what are therapists
encouraged to do with their young dissociative clients?
a. Neurobiological research on dissociation encourages therapists
to help the child and family to decrease stress, increasing a sense of
safety. The child should be helped to become aware of the many different
emotional and body responses that have been cut off through dissociation.
Therapists should also encourage parents to repeat nurturing experiences
over and over again.
b. The Discrete Behavioral State Model encourages therapists to do
two things: 1) to provide calming when the child is overactive and to
provide activation when the child is under-aroused. 2) to provide bridging
through play, art, or words between the child's traumatized states and other
states. These other states may hold the physical sensations or emotional
responses that were split off from the trauma experience or they may hold
information on the child's present world that is now safe or at least safer
that at the time of trauma.
c. The Disorganized Attachment Model teaches therapists the
importance of identifying the child's particular attachment pattern
(rescuer, victim, persecutor) and helping parents (natural, foster,
adoptive) provide secure attachment experiences, paying particular attention
to the attachment relationship between the parent and the child.
d. The Ego State Model teaches therapists to help the child promote
communication between his ego states through the use of a pie diagram, or
drawing the varying parts of self, or imagining different aspects of the
self. The child is encouraged to have the parts that experienced the new
safer experiences tell the younger parts that are still caught in the old
unsafe world about the "now" world.
e. The Structural Model of Dissociation recommends to therapists a
three-stage treatment: 1) stabilization and symptom reduction, 2) treatment
of traumatic memories, and 3) personality integration and rehabilitation.
The first stage works with the ANP (apparently normal part of the child's
personality) by establishing safety, simplifying daily life, setting limits
on demanding relationships, and developing skills. In stage two, the ANPs
are encouraged to share traumatic memories with the EPs (emotional part of
the child's personality). Stage three includes coping skills and the
information that may have been missed during the times of dissociating.
f. All of the above.
Chapter 2: Dalma (4 to 7 Years Old) -- "I've Got All My Sisters with Me"
4. What did therapist Sandra Baita say to Dalma that prompted her to
use dolls to depict the sexual abuse done by her father?
a. She asked Dalma what her favorite toy was.
b. She asked Dalma if she could draw a picture of her family.
c. She asked Dalma what her house was like.
d. She asked Dalma (her birth name) if Debora (the name her father gave her)
might have any information about the things that happened with Daddy.
5. During the first year of Dalma's treatment, she lived in foster care and
had no contact with her parents. Her behavior stabilized. The first time
that therapist Sandra Baita saw Dalma display the sexual and primitive
behaviors of a little girl moaning and rubbing her body on the sofa, how did
Sandra immediately respond?
a. Sandra asked Dalma very skillful questions, to help Dalma become
aware of her own behavior and feelings.
b. Sandra asked Dalma to draw a picture of her behavior.
c. Sandra said nothing and just observed Dalma quietly, having a calming
effect on her.
d. In a soft voice, Sandra kept telling Dalma that she was OK now and she
was in a safe place now. Sandra wanted Dalma to know that the source of
danger was no longer part of her life.
6. What technique does Sandra recommend therapists use in order to keep
the vulnerable parts of the child safe, and to keep the hostile parts (like
those identified with the abuser) aside while the other parts of the child
are talking about the abuse?
a. verbal repetition using a calm, soft tone of voice.
b. a containment technique, like drawing a box.
c. guided imagery.
d. stabilization and organization.
7. One of the therapist's job with dissociative clients is to make
them aware of their various parts, helping them to know which part emerges
when. This enhances internal connections between the parts. During the third
phase of treatment, what technique did therapist Sandra Baita use to help
Dalma talk about her traumatic experiences and the way she felt inside?
a. The Containment Technique
b. The Pie Chart Technique
c. The Inside-Outside Technique
d. The Russian Doll Technique
Chapter 3: Emma (6 to 9 Years Old) -- From Kid Actress to Healthy Child
8. After therapist Els Grimminck taught Emma's family how to recognize
Emma's various dissociated states, she told the parents to hold Emma
responsible for everything she did so Emma could not claim that she was not
at fault for something one of her dissociated states had done.
What did Emma's teacher do when Emma did not behave properly in class?
a. She made Emma stand out in the hallway.
b. She put Emma at a special table until she calmed down.
c. She sent Emma to the principal's office.
d. She stopped teaching the class until Emma behaved properly.
9. What did the therapist do that stopped Emma's nightmares and
a. She used hypnotherapy to convince Emma that the dangers were over.
b. She used role play of good and bad characters so Emma could put the bad
characters far away from her.
c. She used picture drawings so Emma could have power over those who had
d. She helped Emma create a Big Book of Secrets in which Emma put pictures
and stories about memories that she could deal with when she was ready to do
10. Why did Emma's mother not get along with the therapist?
a. She was angry at the therapist for reprimanding her for allowing the
b. She disagreed with the therapist's advice to not relate to her child as a
peer, but rather as a child.
c. She was jealous that the therapist had developed an attachment to her
d. She thought that the therapist charged too much money.
Chapter 4: Jason (7 Years Old) -- Expressing Past Neglect and Abuse (p.
11. On Day 1, therapist Renee Potgieter Marks asked 7-year old Jason "Mmmmm,
I wonder who is the Jason who needs to save other people?" Jason answered,
"It is Lee."
This meant that
a. Jason had not understood the therapist's question.
b. Jason was angry.
c. Jason was not listening because he was distracted.
d. Lee was a dissociative part of Jason.
12. Children will not disclose their dissociative parts until they feel
safe, and are
d. asked a direct question.
13. Which of the following did the therapist Renee Potgieter Marks NOT
a. The therapist believed that Jason's dissociative parts would be less
likely to retaliate or be defiant if they knew that the parent loved and
accepted them. So the therapist had Jason's adoptive mother write a letter
to one of Jason's dissociative parts, expressing her love to this part and
thanking him for looking after Jason. (107)
b. The therapist believed that by using a simple visual technique (of a frog
and a prince) that Jason could see that his adoptive mother was better able
to care for him than one of Jason's dissociative parts. So the therapist
measured all of Jason's parts both in age and size. Then she measured
Jason's adoptive mother. After this Jason chose his adoptive mother to care
for him and meet his emotional needs.
c. For children who suffered emotional trauma early in life, the therapist
believed that these children could now learn attachment from visiting a
therapist once a week and attaching to the therapist.
d. The therapist believed that a child needs to learn to trust a parent
before that child can accept the parent's love. So the therapist designed
trust games where the child has to totally rely upon the parent to keep him
safe, games such as the child jumping into the arms of a parent, balancing
on a gym ball with the help of a parent, and being blindfolded and led
around obstacles by a parent.
14. When children finally do disclose accounts of sexual abuse, it is
a. in the first-person: "This is what was done to me."
b. in the second-person: "This is what was done to you."
c. in the third-person: "This is what was done to (a third person object,
like a doll)."
d. through one of his dissociative parts.
15. As treatment progressed and Jason identified each of his parts, the
therapist did certain things to help Jason respect those parts that
dissociated when life was overwhelming. This helped Jason to integrate all
these parts into a whole picture of himself. What did the therapist NOT do
with each part?
a. She had Jason draw each part, identify their current name, and
identify their current job.
b. She had Jason give each part a new name.
c. She had Jason give each part a new job.
d. She had Jason tell each part to go away.
"Integration of all the dissociative child's split-off parts is crucial
to assisting the child to learn in school, to engage in appropriate
behaviors, to develop his/her capabilities, and to form meaningful and
lasting relationships. As long as fragmentation exists, the dissociative
child patient relies more on his or her dissociative defenses" -- p. 134
Chapter 5: Ryan (8 to 10 Years Old) -- Connecting with the Body (p.
16. ____ in young children is one of the most significant indicators of an
occurrence of sexual abuse or of having witnessed such behavior.
a. Sexualized behavior
b. Violent outbursts
c. Extreme lethargy
d. Suppression of affect
"Dissociation can be viewed as a defense mechanism to help a child avoid
overwhelming feelings and a sense of annihilation when a traumatic event
occurs. It is an automatic mechanism that preserves the self so that
they child may be able to survive and function. The child can 'check
out' and not feel or be aware on a conscious level across all sensory
domains when a traumatic event is occurring. In the extreme form of
dissociation, a child can form dissociative states -- separate states of
awareness -- in which the child separates from himself or herself and
develops states or 'parts' that contain unwanted, traumatic material,
such as thoughts, feelings, and behavior. It is important to note that
it is still one child but 'separate states of consciousness. In extreme
form, dissociative identity disorder (DID), these states with separate
levels of consciousness have impermeable barriers between the states
with only one or some states holding some aspect of the trauma. The
impermeable barriers prevent the flow of information among the states
and with the external world, causing partial or complete amnesia for
behavior and for events in the world. These states can contain different
feelings, thoughts, behaviors, and bodily sensations. When they take
control over the child's body, they can exhibit frequent, extreme, and
confusing changes in mood, behavior, thought, and bodily senses." -- p.
17. What did therapist Frances Waters say at the end of the 6th session
that would help to decrease Ryan's child management problems?
a. Responding to Ryan's misbehavior with consistent and fair
b. Getting all dissociative parts of Ryan to accept and attach to his
c. Teaching Ryan relaxation techniques.
d. Rewarding Ryan for successfully going to the bathroom.
18. During the 12th through 14th sessions, what did therapist Frances
Waters have Ryan do to move him toward integrating his dissociative parts?r.
a. She had him play with clay dolls.
b. She had him give new names to all his dissociative parts.
c. She had him describe the sexual abuse that he experienced at age three.
d. She had him draw a picture of a hockey rink with three of his parts