Assessment and Treatment of Traumatized Children and
Adolescents with Dissociative Symptoms and Disorders

Joyanna Silberg, PhD, Frances Waters, LMSW, DCSW, LMFT

Intended Participants: Licensed mental health professionals (psychiatrists, psychologists, clinical social workers, mental health counselors) who are personally treating a child or adolescent with Complex PTSD, a significant trauma history, or dissociation. Other professionals are encouraged to apply who are supervisors of child or adolescent treatment centers, foster care or adoption center directors or supervisors, university faculty who prepare students to work in the field of child maltreatment, and licensed mental health professionals interested in learning more about treating maltreated children & adolescents. Instructors, Dr. Waters, or Dr. Silberg will determine if their background might fit the seminar content.

Meeting Frequency: Once monthly for 9 months, or once monthly (6 hours) for four months.

Course Format: This course is designed for 2.5 hour sessions of combined literature discussion/lecture and case discussion presented by students. Actual session format is at the discretion of ISSTD faculty.

This course syllabus and bibliography are the property of the International Society for the Study of Dissociation (ISSTD). Please do not copy or distribute without permission from the ISSTD. The ISSTD may be contacted at info@isst-d.org

Educational Objectives

Overall Objective: At the end of this experience, participants will have sufficient knowledge to be able to diagnose dissociative symptoms and disorders in traumatized children and adolescents and will have essential knowledge and skills needed to conduct individual psychotherapy to treat complex trauma in children and adolescents, to work with their caregivers, and to interface with other pertinent professionals in the child's life.

General Description: This course begins with an introduction to theories of dissociation, and looks at trauma and dissociation in children and adolescents from a historical perspective. The course then covers methods of assessment, assessment tools, and differential diagnosis across the spectrum of dissociative pathology.  The psychotherapy section presents a model that integrates child developmental theory, attachment theory and family systems theory with an understanding of how trauma affects the developing brain. The therapy enriches purely cognitive behavioral perspectives with an emphasis on processing emotions related to traumatic events through creative expression and sensitivity to attachment dilemmas in traumatized children. The course addresses techniques for looking at difficult symptoms such as self-injury, trance states, rage reactions and sexual acting out. The course ends with a review of techniques for intervening within the systems that affect the child and adolescent such as family dynamics, social services, schools, and the legal arena. The effect of this work on the therapist through counter-transference will be discussed. 
Clinicians finishing this course will have a comprehensive understanding of how to intervene with the traumatized child with dissociative symptoms to promote healthy development.  

Session-Specific Objectives

Each sections goals are preceded by a section description. Goals can be read as: "Participants will: ..."

Session 1: History of Dissociation in Children and Adolescents and Current Theories of Dissociation (This will be divided into two parts for the 9 session course.)

This session looks at historical descriptions of dissociative children and provides a framework for some of the diagnostic, treatment, and contextual issues that will be explored in later sessions.  Individual instructors will supplement this session’s reading with case material that presents a dissociative child in context.  Presentation of the case will highlight that child dissociative states are less rigid than adult states, and observations of these phenomena have been consistent across the years. The new proposed diagnoses of complex post-traumatic stress disorder and developmental trauma disorder will be presented.  Theories of dissociation and some of the implications of these theories for working with dissociative children will be presented. We begin with explaining Putnam’s discrete behavioral states model. Special attention is focused on the relationship between attachment and dissociation (with special attention to Liotti’s model) with a look at varying theoretical models and some preliminary research on disorganized attachment that supports some of these models.  Neurobiological findings that support some of these alternate theories will be reviewed.   Case material will be presented.

Session 1 Goals:

1. Clarify  three ways that child and adolescent cases may differ from adult cases.
2.  Understand how dissociative symptoms may appear across a continuum of
     severity.
3.  Be able to contrast two theories of dissociation and how they could explain
     dissociative symptomatology.
4.  Recognize three neurobiological impairments caused by trauma

Session 2:  Differential Diagnosis of Dissociative Symptoms and Disorders in Children and Adolescents & Stabilization Techniques (This will be divided into two parts for the 9 session course.)

This session will review diagnostic assessment of children with dissociative symptoms and disorders across a wide spectrum of pathology. Theoretical emphasis is placed on a contextual look at the child with sensitivity to traumatogenic factors and some of the pitfalls of a purely diagnostic approach.  Instructors will demonstrate how to interview children in sensitive ways that allow for expression of hidden affects and states. Overlap between Dissociative disorders and other common problems of childhood will be discussed.  Participants will be able to understand how dissociative symtomatology may manifest as attentional problems, obsessive-compulsive problems, even selective mutism, and other co-morbid symptoms. Participants will learn some of the assessment tools commonly used with children and adolescents and become familiar with the research supporting these. The DSMIVR Dissociative disorders will be reviewed with emphasis on the fact that most children with significant dissociation fall into the DDNOS diagnostic grouping.

An overview of the therapeutic goals of ISSTD’s Guidelines for Evaluation & Treatment of Dissociation in Children and Adolescents will be provided with primary focus on early stabilization techniques for children with dissociative symptoms.  Whether children are living in the families where the original trauma happened or in new adoptive or foster families, situations arise that trigger traumatic responding. This session focuses on how to work with families to minimize these triggers and to establish more secure attachment patterns.  Parenting techniques for managing the dissociative child are addressed. The complex ways in which parental pathology mirrors or reinforces children’s pathology is explained in detail.  The attachment dilemmas of dissociative children are explained in more depth.  Techniques are offered that reinforce parents’ acceptance of the whole child across all dissociative states to increase the security of attachment.  Helping parents establish calmness and safety in the early intervention of treatment and engaging them in utilizing stabilization techniques at home is described.  Illustrative case material is provided.  

Session 2 Goals:

1.  Describe dissociative symptoms in children covering the spectrum from   
     dissociative processes to a disorder and identify differences from other childhood      diagnoses. (e.g., ADHD, OCD,ODD, Bipolar Disorder).
2. Develop specialized interviewing techniques and learn about helpful assessment
     tools that aid in diagnosing childhood dissociation.
3.  Learn psychoeducational techniques for explaining dissociation and trauma
     with children and parents
4.  Support parents’ role at home to provide a calm and safe environment and 
     strengthen secure attachment between the parents and child.
5.  Learn specialized stabilization techniques to empower the child to gain self
     control and stability
6.  Help parents recognize identify and modify triggers

Session 3:  Processing traumatic memories and identifying and working with special problems occurring with dissociative children and adolescents  (This will be divided into two parts for the 9 session course.)

This session will further illustrate grounding and empowerment techniques through the use of imagery, art therapy, cue words and visual prompts for assisting the children to create safe places, manage traumatic triggers, develop cooperation and awareness among dissociative selves, decrease dissociation and improve functioning.   Examples are provided that amplify how to engage the expression of hidden affect states with positive reframing and hypnotic suggestions for healing and recovery that assist in early stabilization of the child.  This session will also discuss working with children and adolescents who have hidden self-states that hold traumatic memories. Participants will be presented with drawing and art techniques, sensori-motor techniques, and play psycho-drama techniques that allow for the expression of hidden affect states and resolution of traumatic memories. Abundant case material, video clips and illustrative drawings are provided.  Presenters will share case material and the group will help to consult on each other’s cases.

Session 3 Goals:

1.  Learn further techniques for teaching children and adolescents’ emotional
     self-regulation, internal awareness and ability to identify and manage triggers.
2.  Increase skills for addressing amnesia and sleep and somatic problems.
3.  Learn how to use effective techniques, including  puppet play, writing, art, imaging,
     EMDR, for expressing feelings of alternate self-states and processing memories.

Session 4:  Integration work with the children and adolescents, collaborative work with the allied systems, and therapeutic self awareness.  (This will be divided into three parts for the 9 session course.)

This session will discuss some of the special management problems encountered
when working with dissociative children and adolescents (e.g., self-injury, sexually acting out, obsessive compulsive behaviors). The final stages of work with dissociative child to achieve fusion and final integration are explained.  Alternate pathways by which this can be accomplished using a variety of creative modalities and imagery are described. Some issues which occur when interacting with systems such as the court, social services, schools, and health care are discussed. The importance of collaboration among professionals is emphasized. The importance of recognizing counter-transference and self-care will be highlighted. 
Extensive discussion of ongoing cases will occur.

Session 4 Goals:

1.  Further identify and address special behavioral problems often occurring with
     dissociation.
2.  Learn specific techniques for achieving spontaneous integration and techniques
     designed for planned integration.
3.  Understand the ongoing developmental challenges faced by the traumatized child
     after integration.
4.  Identify ways to work with common barriers in mental health, school and
     legal systems that present obstacles to assessment and treatment.
5.  Further identify our own counter-transference and learn to use it constructively
     in the therapeutic setting

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