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Dissociation in Traumatized Children and Adolescents
edited by Sandra Wieland, Ph.D.
. 2011.
(Routledge: New York, NY
) All rights reserved [384 pages].
[Answer 17 of 25 questions correctly to receive
18 hours of continuing education credit.]

Chapter 1: 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 place.
c. The child always remembers what he does when he is in a dissociative state.
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" (p. 29-73)
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 (p. 75-96)
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 flashbacks?
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 hurt her.
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 so.

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 abuse.
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 daughter.
d. She thought that the therapist charged too much money.

Chapter 4: Jason (7 Years Old) -- Expressing Past Neglect and Abuse (p. 97-140)
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
a. calm.
b. comforted.
c. happy.
d. asked a direct question.

13. Which of the following did the therapist Renee Potgieter Marks NOT believe?
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 usually
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. 141-195)
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. 145

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 consequences.
b. Getting all dissociative parts of Ryan to accept and attach to his parents.
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?
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 playing together.

19. In session 32, what did Ryan do that made his therapist and mother both realize that he was describing the sexual abuse that had occurred when he was three years old.
a. He revealed a new dissociative part.
b. He drew a picture with distinct shapes and feelings.
c. He acted out the behavior with dolls.
d. He gave each dissociative part a new job.

20. Toward the end of these sessions, therapist Frances Waters asked Ryan, who struggled with encopresis, to go inside himself to have a meeting with his parts and come up with some rules about how the parts should function. Which of the following was NOT one of those rules?
a. Only Ryan is to be out. The others will watch and listen from the inside and help Ryan.
b. All parts are to stay connected to the body and use the toilet.
c. Any problems that the parts have will be talked about in therapy so that they can work on staying together.
d. Each part is to have a graduation ceremony where they can then go away.

Chapter 6: Joey (11 to 12 Years Old) -- Moving Out of Dissociative Protection (p. 197-261)
21. Therapist Sandra Wieland believes that a child with dissociative parts is still responsible for his or her behavior, no matter which part is currently in control. What tool did Sandra give Joey's parents to hold him responsible for the behavior of all his parts?
a. She had the parents administer logical consequences for certain behaviors, such as Joey spending 5 minutes in his room when he throws a temper tantrum.
b. She taught Joey's parents how to use shame in order to encourage right behaviors.
c. She had Joey's parents withhold privileges until Joey completed certain tasks (homework, chores, etc.)
d. She gave a picture that Joey drew of his parts to the parents so they could have Joey point to which part was misbehaving at the time.

22. During an excellent 2-week period, Joey did not call anyone names, did not steal, and did not lie. What had therapist Sandra Wieland done with Joey in the session right before this 2-week period?
a. She had him draw out all the possible consequences for his behavior and read them aloud.
b. She asked him to tell all of his dissociative parts about the consequences so one part of him could not get the other part in trouble.
c. She had him name all of his good qualities and say them aloud.
d. She had him write out the kind of behavior he wanted to have at home and in school.

Chapter 7: Angela (14 to 16 Years Old) -- Finding Words for Pain (p. 263-284)
23. What was a "turning point" in Angela's therapy?
a. When Joyanna asked Angela to communicate with the parts of herself through introspection and focused attention.
b. When Joyanna asked Angela to switch into the other parts of herself so Joyanna could speak directly to them.
c. When Angela made a list of words from a thesaurus describing the other Angela's pain and then reading the list of words aloud to her mother so her mother would know how she felt.
d. When Angela successfully sent all of her bad parts away.

Chapter 8: Leroy (7 Years Old) -- "It Is Almost Like He is Two Children" (p.285-341)

24. What strategy did Na'ama Yehuda NOT use when Leroy would become overwhelmed or explosive?
a. Saying to him in a calm voice to take a deep breath.
b. Reminding him that he is safe.
c. Finding something to praise in him.
d. Verbal correction.

25. Teachers can help reduce the number of dissociative episodes in their classrooms by gently approaching an agitated child and letting the child know where the child is and who the child is. This technique is called
a. Grounding
b. Reassuring
c. Checking In
d. Narrating/describing/putting in context
e. Deferring blame/investigation/consequence
f. Providing safety for all