|Chapter 1: Dissociation in Children and Adolescents --
What it is, How it presents, and How we can understand it
1. Which is NOT true about dissociation in
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
b. Because that child had parents who were significantly
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
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
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
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
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
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
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
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
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
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
14. When children finally
do disclose accounts of sexual abuse, it is usually
a. in the first-person: "This is what was done
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" --
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
a. She had him play with clay dolls.
b. She had him give new names to all his dissociative
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
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
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
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.
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
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
a. When Joyanna asked Angela to communicate with the
parts of herself through introspection and focused
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
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
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
c. Checking In
d. Narrating/describing/putting in context
e. Deferring blame/investigation/consequence
f. Providing safety for all