Child/Adolescent Treatment Guidelines
Guidelines for the Evaluation and Treatment of Dissociative
Symptoms
in Children and Adolescents-2003-ISSD Task Force on Children
and Adolescents
These Guidelines were developed by the ISSD Task Force on
Child and Adolescents and
finalized in February 2003. Chairperson: Joyanna Silberg, PhD.
Members: Frances Waters, Elaine
Nemzer, Jeanie McIntee, Sandra Wieland, Els Grimminck, Linda
Nordquist, Elizabeth Emsond.
The committee thanks Peter Barach, James Chu, John Curtis,
Beverly James, John O’Neil, Gary
Peterson and Margo Rivera for critical comments and suggestions.
Copyright 2003, by the International Society for the Study
of Dissociation, 60 Revere
Drive, Suite 500, Northbrook, IL 60062. These Guidelines may
be reproduced without the
written permission of the International Society for the Study
of Dissociation (ISSD) as long as
this copyright notice is included and the address of the ISSD
is included with the copy.
Violations are subject to prosecution under federal copyright
laws.
The ISSD Task Force on Children and Adolescents is pleased
to present the Guidelines for the
Assessment and Treatment of Dissociative Symptoms in Children
and Adolescents. In utilizing
these Guidelines, you might keep the following principle in
mind. According to the Criteria for
Evaluating Treatment Guidelines of the American Psychological
Association (2000), “Guidelines
should avoid encouraging an overly mechanistic approach that
could undermine the treatment
relationship” (p. 2). We hope these Guidelines prove
to be useful rather than prescriptive, and
improve the care of children and adolescents with dissociative
symptoms and disorders.
Joyanna Silberg, PhD, Task Force Chairperson
These Guidelines are dedicated to the memory of Elaine Davidson
Nemzer, 1952-2000.
I. RELATIONSHIP TO ISSD ADULT GUIDELINES
The International Society for the Study of Dissociation (ISSD)
Standards of Practice
Committee issued Guidelines for Treating Dissociative Identity
Disorder (Multiple Personality
Disorder) in Adults in 1994 and updated them in 1997 (ISSD,
1997). As these made no reference
to children and adolescents, the ISSD Executive Council requested
the Child and Adolescent Task
Force to draft guidelines summarizing current clinical knowledge
in the field applying directly to
children and adolescents.
II. SCOPE OF DIAGNOSES ADDRESSED
Although the ISSD Adult Guidelines are specifically directed
to the treatment of
Dissociative Identity Disorder (DID), dissociation in children
may be seen as a malleable
developmental phenomenon that may accompany a wide variety
of childhood presentations.
Symptoms of dissociation are seen in populations of children
and adolescents with other
disorders such as Post-Traumatic Stress Disorder (PTSD; Putnam,
Hornstein, & Peterson, 1996),
Obsessive-Compulsive Disorder (OCD; Stien & Waters, 1999)
and reactive attachment disorder,
as well as in general populations of traumatized and hospitalized
adolescents (Sanders & Giolas,
1991; Atlas, Weissman, & Liebowitz, 1997) and delinquent
adolescents (Carrion & Steiner,
2000). These treatment principles, therefore, are intended
for children and adolescents with
diagnosed dissociative disorders, as well as for those with
a wide variety of presentations
accompanied by dissociative features. In other words, the Guidelines
identify general principles
applicable to dissociative processes regardless of the child’s*
presenting diagnosis.
Diagnosis itself seldom communicates much about the nature
of the child and his or her
world. These Guidelines are not intended to be a basis for
differential diagnosis. While a
dissociative diagnosis specifically geared to children has
been proposed (Peterson, 1991), this has
not been included in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition,
Text Revision (DSM-IV-TR; American Psychiatric Association,
2000). Although even very
young children appearing to meet the criteria for DID have
been described (Putnam, 1997; Riley & Mead,
1988), the prevalence of DID in childhood is currently unknown.
The diagnosis of Dissociative Disorder Not Otherwise Specified
(DDNOS) is the most common in populations of
dissociative children and adolescents (Putnam et al., 1996),
even though no diagnostic criteria
have been set for this diagnosis. While individual case studies
of children with puzzling and
atypical dissociative presentations described variously as
Depersonalization Disorder (Allers,
White, & Mullis, 1997), Dissociative Amnesia or Dissociative
Fugue (Coons, 1996; Keller &
Shaywitz, 1986), and DID (Jacobsen, 1995) continue to be published
in peer-reviewed journals,
there is still no real consensus about the typical case and
thus no consensus about diagnostic
criteria. For this reason, in these Guidelines the perspective
on assessment and treatment is
symptom-based.
* The word child is generally used in
these guidelines to mean both children and adolescents through
high school age.
III. INTRODUCTION
These Guidelines are derived from the published literature,
material from conferences, and
the clinical experience of members of the ISSD Child and Adolescent
Task Force. As this field is
in an early developmental stage, these Guidelines are to be
viewed as preliminary. As the field
develops, they will be modified to incorporate new research
into diagnosis and treatment. In fact,
the literature reviewed here, spanning over 16 years of reporting
on dissociative phenomena in
children, already shows shifts in emphasis and recommendations
over time (Silberg, 2000).
Despite the changing and provisional nature of our knowledge
in this area, it is still important to
have some guidelines in approaching dissociative symptomatology
for the following reasons:
1. Treatment strategies aimed at increasing integration and
reducing dissociation can be
highly effective in treating some of the most seriously impaired
child victims of
maltreatment who are engaged in disruptive and self-destructive
behavior.
2. Information on the treatment of dissociation was not available
when most clinicians did
their training, and it is important to organize clinical information
to help familiarize
clinicians with current treatment approaches.
3. Without careful consideration of developmental issues, the
simplistic application of
treatment approaches for adult dissociation to children may
be potentially dangerous to
children.
For these reasons, these Guidelines are presented for the benefit
of the ISSD membership and the
clinical community at large. It is our hope that research will
continue to amend and refine these
Guidelines, and that their presentation will stimulate discussion,
debate and further analysis that
will enrich the field as a whole. These guidelines must be
used in conjunction with all ethical
codes, health codes, laws or professional regulations that
govern the individual’s discipline or
place of practice.
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