Saturday, September 04, 2004

Dissociation in school children: an epidemic of failing in disguise

The International Society for the Study of Dissociation NEWS
VoIume22. Number 4 July/August 2004  

Critical Issues:
Dissociation in school children: an epidemic of failing in disguise
By Na'ama Yehuda, MSC, SLP, TSHH
(Reprinted by Permission)

As a part-time speech-language pathologist in inner-city public schools, I treat academically failing children who are mandated for speech services due to speech-language disorders and delays. All too often, masked by or masqueraded as problems with memory, auditory processing, word-retrieval, social language, restricted vocabularies, learning disorders, ADHD, and PDD; children exhibit alarming symptoms of dissociation. However, even though dissociation can impact cognition, language, socialization, and learning, it is almost always left unidentified. Speech-language pathologist and other education professionals don't know how to recognize dissociation and aren't trained to tend to it even if they do somehow name it. It is a terrible oversight.

Dissociative children in mainstream education aren't rare, at least not in the low-income, high-violence areas I work in. In the 2002-2003 school-year alone, out of 24 children on my caseload, six received scores higher than 12 on the CDC, and five more had scores over eight. Given that most checklists were filled by teachers (and not parents or guardians), and had limited information about home and nighttime behavior, CDC scores in some students could have been even higher. My colleague had several dissociative children on her caseload, as did the other two speech teachers" employed by the school. Together, we serviced over 100 kids-a forth of the school's roster. It was a chaotic school, filled with disillusioned teachers and shuffling, spark-less children who were just as disillusioned (so many were in foster care that forms avoided the word parent, using only "guardian"). 

Paramedics and police were called to the elementary school almost daily for violence against peers and teachers, and "psychotic breakdowns" such as a table-tossing six-grader, a five-year-old running down hallways with glass shards in his mouth, and a non-responsive fifth-grader. Granted, that particular school was not an average elementary school and has earned the dubious prestige of one of "most failing schools" in all of New York City... It was located in the heart of Harlem, with drug related shootings on corner bodegas, and crumbling public housing projects that were home to many of the students. It would have been hard to find a child who did NOT experience violence and trauma. One would expect that with such harsh a reality, the school would be highly tuned to the impact of trauma on its students. .Yet it was not so. If anything, staff showed desensitization that was itself disturbingly dissociative...

As a consultant, I'm usually assigned to a different school every year, often such that couldn't attract enough staff to cover the kids needing services. There were dissociative children on every caseload in every school I've worked in, including a special-education school for children with Autism. If one keeps in mind the statistics of child maltreatment and the research on post-traumatic stress symptoms in maltreated children and children who witnessed trauma, this prevalence shouldn't be surprising. In fact, it is probably likely that there are dissociative children in every school around the country, maybe around the world! Close to one million child-maltreatment cases are substantiated annually in the US alone, and even this figure is suspected to be vastly under-reported. Upward of 75% of substantiated maltreatment comes from the hands of close family, often resulting in foster placements and/or destabilization of family units which further stresses already overwhelmed children.

Dissociation research is yet to conduct large scale prevalence studies in the general and/or traumatized young population. However, with post traumatic stress strongly associated with child maltreatment and subsequent dissociation, statistics from PTSD research can maybe hint at the possible prevalence of dissociative symptoms in school-age children. The percentage of PTSD in maltreated children ranges from 20% to over 63%, depending on definition and evaluation criteria. In medically ill children (including car-accidents and burns), PTSD prevalence was found to be 12% to 53%, and in children exposed to disasters (earthquakes, hurricanes) and war, from 14% to 95%, Even indirect exposure to violence places children at risk for post-traumatic symptoms, and in today's society is a frequent stressor: up to 80% of inner-city adolescents report witnessing an assault, 40% a shooting or stabbing, and almost 25% a homicide. PTSD prevalence in a sample of these teens ranged from 23% (in high-school students exposed to community violence) to 65% (in a sample of adolescent female offenders ages 13-22, many of whom have been abused) (Silva 2004). In general, severity of post-traumatic symptoms is directly related to the severity and proximity of the traumatic event. Children exposed to severe, chronic, and/or multiple-source trauma, often present with dissociative symptoms which further impact their ability to do learn and socialize (Silberg 1998, Putnam 1997, Attias & Goodwin, 1999). Young children who have little parental support due to parents who are absent, overwhelmed by their own post-traumatic stress, and dealing with psychiatric conditions, are more vulnerable to post-traumatic stress and dissociation, let alone if the caregiver is the cause of trauma (Silva 2004). In the schools I've worked in, parental support was often significantly compromised or unavailable. With family-units smaller, single parenting on the rise, and divorce affecting almost one out of two households, parental supports can be compromised well beyond society's borders of under-privileged, high-violence-exposed population.

The significance of the statistics above is that even due to maltreatment alone, an estimated up to 600,000 children are added annually to those already burdened by post-traumatic symptoms. Our education system is filled with millions of maltreated and otherwise traumatized children who still have to go to school. There they are expected to learn, communicate, and socialize; regardless of whether and why they might be unavailable for learning due to persistent states of arousal, anxiety and dissociation (Attias & Goodwin, 1999; Putnam, 1997; Silva, 2004).

My students' turbulent life and confirmed or likely trauma was common knowledge and most teachers weren't without compassion to the children's plight. However, other than immediately following a serious trauma, school staff did not make the connection between a child's behavior in class and his or her history and present stresses. Once a child was placed in foster care or some time passed since the trauma, the child was supposed "to be over it", even grateful. Frequent family "re-arrangements", separation from parents and siblings, and multiple foster placements were rarely considered a good enough explanation for a child's acting out or spacing out. Like a hologram, children's dissociation ended up mirrored in the dissociation and compartmentalization of the adults around them: school is school, home is home, and history is history. Teachers' blindness to children's pain wasn't malicious. School professionals simply aren't educated about traumatic aftermath or dissociation. Children are left to bear the blame for coping skills that-if identified and treated-can make enormous academic and personal difference (Attias & Goodwin, 1999; Putnam, 1997; Siiberg 1998, Silva, 2004).

Though quite burnt-out by overcrowded classrooms and ever-changing teaching programs, school staff can benefit from understanding and recognizing dissociation. Teachers I've worked with were interested in having skills that would then help them better manage and motivate their most difficult students; even if only because ultimately students' achievements reflects heavily on a teacher's perceived skill. Once they understood what dissociation is, why it happens, and why a child might apply it in the classroom, teachers were generally open to reduce confrontation and encourage grounding. Simple things, such as filling in an aggressive yet denying child as to what just took place, rather than immediately interrogating for 'why did you do that?" helped tremendously. As did looking at a child's "spacing out" through the lens of overwhelm rather than laziness, or considering the fact that an upset-at home or in class- might be at the root of a shift in behavior and skills. Simultaneously speech-language work focused on filling up what seems like dissociation-specific holes in communication: learning cause and effect, understanding sequence and consequence, identifying and naming feelings and body-states, predicting outcome, turn taking, and telling stories. With this help, and even though they sorely needed adequate counseling which they didn't get, students were at least better able to tolerate daily interactions as well as to take tiny yet heartening risks to attach to adults who were in turn more compassionate and less flustered.

Educating tens of thousands of teachers is a tall order. Related service providers such as school psychologists and speech-language pathologists are a good place to start: the children we see are already failing and therefore more likely to have issues needing attention. Dissociation and hyperactivity (in sexually abused girls) were the best indicators for learning problems, avoidant behavior, and overall poor academic performance (Putnam 1997). With the numbers of maltreated children and the price of dissociation so astronomical, anything that can be done to help identify dissociation in children who are already failing academically and socially is crucial.

Future research will hopefully elucidate whether certain communication disorders symptoms are more indicative of post-traumatic and dissociative behavior than others. The ISSD current commitment to move dissociation into the mainstream, will no doubt (I'm an eternal optimist...) help de-stigmatize dissociation and evolve to a place where every mental-health professional will be wellversed in evaluation and treatment of dissociation. The recent publication of the ISSD guidelines for the evaluation and treatment of dissociative symptoms in children and adolescents is already paving the way for that. In the meanwhile, there is enough already known about trauma and development to support screening for dissociation among children sent for related services. Especially in cases where trauma is known or likely and the child already exhibits unusual behaviors and symptoms.

From the time they are four-years-old to when they reach eighteen, children spend most of their waking hours in school. For eight hours a day five days a week, they are in a potentially safe and can be seen and their struggle be heard. For the hundreds of thousands of traumatized children in our school system, and the many of them who are dissociative, trauma-educated staff can make the difference between healing and failing. While teachers and speech-language pathologists are not expected to treat children's dissociation, they can-with relatively little training-function as frontline screeners of dissociation that heeds further assessment, cooperate with therapeutic teams, and assist with carry over of grounding and integrative skills.

1. Attias, R., Goodwin, 1. (1999). Splintered Reflections: Images of the Body in Trauma. Basic Books.
2. Child Maltreatment (1997): Reports from the States to the National Child Abuse and Neglect Data System
3. Putnam, F W (1997). Dissociation in Children and Adolescents: A Developmental Perspective, The Gulliford Press.
4. Putnam, EW (1997) Child Dissociative Checklist (CDC) Version 3, Dissociation in Children and Adolescents: A Developmental Perspective, The Gulliford Press, Appendix Two, pp 354-356.
5. Silberg,J. (1998). The Dissociative Child:Diagnosis, Treatment, and Management, Sidran Press.
6. Silva, R.R (2004) Post Traumatic Stress Disorders in Children and Adolescent Handbook. Norton Press,
pp.8-9, 14

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