Childhood Dissociative Symptoms Measured as Risk Factors for Eating Disorder
Development
Larisa Hanger
Richmont Graduate University
CED 7713: Methods of Research
Dr. Mary Plisco
November 15, 2021
Abstract
Dissociation has been found to be a mediating factor between childhood trauma and eating disorder (ED) development (Thornley, 2015; Moulton et al., 2015; Pugh et al., 2018). Lev-ari et al. (2021) found that traumatized children developed dissociative survival mechanisms that were protective during the trauma but were often unnoticed and left untreated. Once the numbing achieved through dissociation began to take the form of life-threatening ED behaviors such as purging for many of these children later on, positive outcomes of ED treatment were significantly lowered (Olofsson et al., 2020). Otherwise put, dissociation often led to disembodiment which in turn catalyzed the development of full-blown EDs. In examining early indicators of traumatized children that developed EDs, studies were used that explored the relationship between observed trauma symptoms and the children who got care. Some students received early intervention after more easily recognizable signs of trauma were observed. However, many traumatized students who may have had more indistinct dissociative symptoms were not identified until they were hospitalized due to EDs (Bruce, 2019; Putnam, 1997). The present study aimed to detect schoolchildren who had experienced trauma but had not received early intervention by identifying dissociative symptoms using a quantitative comparative research design with both an educator and a clinician as observers. It was hypothesized that the research-based tool would allow both educators and experienced clinicians to accurately identify children who could benefit from early intervention with high validity and reliability by assessing the quantity of detectable dissociative symptoms.
Keywords: children, trauma, abuse, neglect, dissociation, eating disorder (ED)
Childhood Dissociative Symptoms Measured as Risk Factors for Eating Disorder Development
Childhood trauma can prompt a long-lasting cycle of dysfunctional coping without early intervention (Herman, 2015). There is a wide body of research that has demonstrated a positive correlation between childhood traumatic experiences and the development of an eating disorder (ED) as a survival mechanism (Brewerton, 2007). As early as 1994, it was also suggested that a direct correlation between a possible precursor to ED development, dissociation, exists (Rosen & Petty, 1994). More recent studies have continued to confirm the relationship by examining dissociation as the mediating factor between childhood trauma exposure and ED development (Thornley, 2015; Moulton et al., 2015; Pugh et al., 2018). A large theme overlooked in these studies was how the researchers’ acquired data could be integral to life-saving, preventative action for those at high risk of developing an ED. By identifying statistically significant dissociative symptoms in schoolchildren, the need for early intervention could be accurately assessed to prevent the later development of EDs.
Importance of The Issue
One of the first researchers to measure disordered eating in children and older adolescents was Collins (1991), whose study reported 42% of first through third-graders wanted to be thinner. In 1992, Gustafson-Larson & Terry discovered 46% of 9 to 11-year-olds were “sometimes” or “very often” on diets. Researchers a few years later found 81% of 10-year-old children were afraid of being fat (Mcnutt et al., 1997). Additionally, in the early 2000s, 35-57% of adolescent girls reported engaging in crash dieting, fasting, self-induced vomiting, diet pills, or laxatives (Boutelle et al., 2002). These statistics are not as current as would be preferred, but many researchers have still cited them in recent studies because of difficulties in obtaining
reliable, self-reported data from this population with the sensitive topics of food and weight. In the handful of more recent studies, researchers have continued to find similar prevalence rates. This indicates that inferencing the data to the wider population is likely acceptable (Boutelle et al., 2002).
Examining Childhood Trauma
Early life experiences have been shown to have a tremendous effect on mental and physical health outcomes, and researchers have found the damage of childhood trauma is often seen perpetuated for years afterward “by the biological embedding of adversities during sensitive developmental periods” (Norman et al., 2012). A child’s brain development can be severely and permanently damaged by the stress associated with child maltreatment and abuse (Norman et al., 2012). Pignatelli et al. (2016) were able to connect these stressful and neglectful experiences in childhood to the development of various mental health issues such as depression, anxiety, EDs, behavioral problems, suicide attempts, self-harm, and illicit drug use. The traumatic experiences also led to a “lack [of] self-regulation abilities, self-esteem, the ability to tolerate stimulation, and connection” (Pignatelli et al., 2016).
Gruhn & Compas (2020) provided more evidence in regard to the positive correlation between childhood trauma and emotion dysregulation, and they specifically noted patterns of avoidance, suppression, and emotional coping as being effective survival tactics during the trauma. Though conducive to survival when necessary, these tactics were ultimately unhealthy coping mechanisms and connected to “the diathesis for future psychopathology” (Lev-ari et al., 2021).
Mikulincer & Shaver (2008) added that secure attachment at a young age may be crucial in the process of learning adaptive emotion regulation. Moulton (2015) and Pugh, Waller, &
Esposito (2018) also found there was typically a multiple-year lag time before traumatic experiences manifested in diseases and mental disorders. This opened the door to discussions on early intervention which will be explored in greater detail.
The Development of Dissociation and Dissociative Symptoms
The clear connection between childhood trauma and ED development has been wellresearched, but Lev-ari et al. (2021) found that the mechanisms directing the relationship are significantly less known and studied. Though, dissociation was suggested to be one of the mechanisms as early as 1994 by Rosen and Petty.
Dissociation, as defined in the DSM-5, is “a disruption, interruption, and/or discontinuity of the normal, subjective integration of behavior, memory, identity, consciousness, emotion, perception, body representation, and motor control” (American Psychiatric Association, 2013). It was also described as “a state of consciousness during which events and experiences usually integrated in consciousness are divided off and separated from one other” (Lev-ari et al., 2021).
Schwarzberg and Somer (2004) studied the separation and found opposite effects of dissociative defenses: they acted as inner protection and allowed a traumatized individual to move away from the prior experience, but they also were an extreme disruption to healthy processing and recovery. A compounding variable was that if the child’s experience of the trauma was shameful and secretive, their ability to process was severely affected as well. Carretero-García et al. (2012) added to those findings that the need to induce dissociation was even more intense in circumstances of repeated trauma as opposed to a single event.
Both somatoform and psychoform dissociation were found to have positive, wellresearched relations to early and often hidden trauma(s). Somatoform dissociation was defined by Nijenhuis (2000) and Nijenhuis et al. (2005) as an experience related to the body, separate
from the mind, that cannot be explained by a medical condition such as anesthesia, analgesia, pain, or mobility loss. Psychoform dissociation included experiences of the mind such as amnesia, depersonalization, derealization and identity alteration, and confusion. Each of these can be a response to traumatic events and was found to often involve physical or sexual abuse (Rabito-Alcón et al., 2020). Sexual abuse was further correlated with the development of somatoform dissociation and included a “lack of integration of sensorimotor experiences and the mental functions and reactions of the individual” (Nijenhuis, 2000). Though researchers found evidence that early trauma was directly correlated with both psychoform and somatoform dissociation (Palmisano et al., 2017; Nijenhuis et al., 2005; González-Vázquez et al., 2017), certain studies indicated a stronger relationship between somatoform dissociation and EDs (Fuller-Tyszkiewicz & Mussap, 2011) including purging (Fuller-Tyszkiewicz & Mussap, 2008).
Emotional dysregulation was a significant variable in much of the research as it seemed to be the secondary mediator between childhood trauma exposure and the development of EDs. Studies such as those completed by Ricciutello et al. (2012) and Van der Kolk & Fisler (1994) found a link between childhood neglect and later ED development which was the inability to regulate impulses and intensity of emotions. Attachment has been another topic widely thought to be an important variable. For instance, Moulton et al. (2015) found emotion dysregulation with insecure attachment created a significant likelihood of disordered eating.
Many studies have continued to find and emphasize dissociation as the mediator. Lev-ari et al. (2021) noted their finding that dissociation can serve to numb the results of traumatic experiences such as grief, distress, bodily harm, and any number of other unprocessed damages.
They came to the conclusion that “a dissociative inner organization may be life-saving but also enables a pseudo-existence, a zone of half-life” (Lev-ari et al., 2021). In a numbed or
dissociative state, individuals are unable to live fully in the world around them. Dissociation has been shown to create an imaginary realm for children especially; it is a retreat from their lives, or even bodies, that the trauma occurred within (Olofsson et al., 2020).
Thornley (2014) found dissociation to mediate the relationship between childhood trauma history and ED symptoms alongside re-experiencing, avoidance, and emotional dysregulation in both men and women. However, although dissociation was a consistent mediator, Thornley (2014) also concluded those with EDs are more likely to dissociate than the other way around. In other words, though dissociation was a consistent mediator in the trauma and ED relationship, it did not seem directional (Thornley, 2014). This was the only article found that stated this relationship as more significant.
Shifting From Dissociation to Disembodiment
Research has identified that trauma lives on in the body. Even after a childhood traumatic event or repeated events come to an end, the mind and body hold onto those experiences in various, often intangible ways (Herman, 2015). To begin to describe this concept in more detail, Herman (2015) explained: “Traumatic events violate the autonomy of the person at the level of basic bodily integrity. The body is invaded, injured, defiled. Control over bodily functions is often lost… the traumatic event thus destroys the belief that one can be oneself in relation to others” (Herman, 2015). In Herman’s book, Trauma and Recovery, the idea of disembodiment as a result of violation and destruction of self was also introduced. A limitation of that discussion was the research primarily covered psychological trauma associated with rape survivors and combat veterans without a focus on ED psychopathology. But, Herman did have salient findings regarding the dialectic of trauma in both inner life and relationships. The trauma was connected to a loss of connection and control often seen with disembodiment (Herman, 2015).
Scheffers et al. (2017) linked trauma to a severely distorted relationship with the body including body attitude, body satisfaction, and body awareness in their study on the relationship between childhood trauma and dissociation. In turn, the researchers who conducted the RabitoAlcón et al. (2020) study used findings from Scheffers et al. (2017), Van der kolk (2006), and Petzold (1996) and deduced:
Traumatized people can find it difficult to detect internal sensations and perceptions, and sometimes even deny any somatic awareness. Furthermore, memories of traumatic events, which are often related to the body, can lead to the rejection and loss of contact with the body.
In a different study, research showed it was often difficult for ED patients to differentiate between outer and inner experiences and physical and emotional reactions (Nilsson et al., 2019).
A woman who was interviewed in the Olofsson et al. (2020) study discussed her ongoing experiences of dissociation and disembodiment in ED recovery:
Before I was admitted and during the first phase of treatment… I felt like I was unconscious, and then, when I started eating, it felt like I was waking up, and it was not a nice experience. I’d thought that once I started eating again, everything would be fine.
But I felt far more fragile, and my issues became more protruding. I suddenly had to deal with all of it, since my brain woke up, and that was kind of difficult. (Olofsson et al., 2020)
Lev-ari et al. (2021) further explored the progression of dissociation and included in their study that somatic dissociation could be a defense mechanism against the emotional overloading that comes with beginning to attempt embodiment. The interviewee in the Olofsson et al. (2020) study later described in more detail how she had to come in contact with her body and emotions
and how difficult that was after years of separating herself from them. Dismantling the learned survival mechanisms by moving away from disembodiment required explicitly addressing the original childhood traumas. More lag time between the trauma and the attempt to heal it was found to make recovery significantly more difficult, though the researchers found some success by focusing on reducing feelings of shame and helping the patient build agency in therapeutic interactions (Olofsson et al., 2020). Because of the significant number and length of patient interviews completed by researchers, the Olofsson et al. (2020) study presents a unique strength in the overall body of research.
Eating Disorders as Coping Mechanisms
EDs affect at least 9% of the population worldwide (Arcelus et al., 2011), and 9% of the United States population specifically, or 28.8 million Americans, will develop an ED in their lifetime (Report: Economic Costs of Eating Disorders, 2020). Brustenghi (2019) also identified that children who have been victims of any type of abuse are three times more likely to have an ED at some point in their lives in addition to significant behavioral issues. ED symptoms were additionally found to often emerge years after dissociative symptoms began. Purging, for instance, was denoted as a manifestation of original dissociative symptoms and functioned as a way to survive the aftereffects of trauma (Armour, 2016). Dissociative and ED-related coping mechanisms have often been termed maladaptive, but, in fact, they can be incredibly adaptive at the time of their development. “Maladaptive” coping mechanisms are often the mind’s most feasible way to deal with the impact of trauma living on within the body. Nevertheless, what was integral to survival in certain periods can become incredibly damaging over time.
As early as 1995, Everill et al. proposed dissociation could be a mediating factor specifically between trauma and the development of bulimic symptoms. Grave et al. (1997)
corroborated the findings of that study. Research completed by Rabito-Alcón et al., (2020) strengthened the validity of this and brought in binging behaviors as well. It deduced, “some [patients] might have ‘learnt’ to dissociate and to resort to behavior such as purging or compulsive eating to avoid or escape trauma-related feelings, sensations, memories, and cognition” (Rabito-Alcón et al., 2020). Brustenghi et al. (2019) agreed and found binge eating disorder and bulimia had a stronger association with childhood trauma than other EDs whereas anorexia, restricting subtype was found to not be heavily associated with dissociative symptoms (Nilsson et al., 2019). In much of the body of research that was studied, similar themes emerged. The behaviors associated with bulimia and binge eating disorder seemed inarguably linked to earlier-developed dissociative symptoms originating from childhood trauma. Engelberg et al., (2007) also suggested dissociation as a trigger for bulimic behaviors. Though, behaviors associated with a wide variety of EDs such as food restriction, binge eating, compensatory actions, etcetera have all been suggested as coping mechanisms attempting to fight the cognitions and emotional consequences of early trauma (Brustenghi et al., 2019; Rabito-Alcón et al., 2020).
Emphasizing Trauma as the Origin
In research conducted by Brewerton (2007) which synthesized data from other studies, “any experience that can produce PTSD, partial PTSD, or any clinically significant anxiety may also increase the likelihood of an ED” (Brewerton, 2007). Trauma exposures were found to potentially affect individuals by “increasing the risk for many health conditions as drug abuse, diabetes, cancer, heart, and respiratory diseases and obesity among others as well as the individual’s relationship with their own body” (Rabito-Alcón et al., 2020).
The predisposing factors for EDs have been found to be genetic, psychological, and environmental, and at the core of each of these factors was oftentimes trauma. Mazzeo & Bulik
(2009) conducted comprehensive research on this topic and listed three types of geneenvironment (G-E) correlations: passive, evocative, and active. A basic yet essential theme from their G-E correlations findings was, “children receive genes from the same individuals who create their family environment (unless they are adopted)” (Mazzeo & Bulik, 2009). A gene could be passed down as well as played out in a parent as that parent models, for instance, disordered eating behaviors and attitudes. Generational trauma, psychological trauma, and the causes and effects of a traumatic home environment were also pertinent to their findings (Mazzeo & Bulik, 2009).
Attachment issues in childhood were directly correlated with predisposing genetic, psychological, and environmental factors. Pignatelli et al. (2016) found the compensatory behaviors displayed by the neglected children they studied may have been efforts to feel in control while trapped in traumatic familial situations within which they had no control. Specifically, the study mentioned the children lacked the essential experience of being soothed, contained, and cared for. This led to many dissociative coping mechanisms which resulted in low self-esteem and a turbulent emotional state. Efforts to bring about affective modulation of cognitive control were often futile (Pignatelli et al., 2016).
Certain forms of early trauma disclosed by ED patients were more common. The study conducted by Olofsson et al. (2020) found, “The most common trauma was emotional abuse (90%), followed by emotional neglect (80%), physical neglect (70%), physical abuse (55%), and sexual abuse (36%). Nine (80%) had experienced a minimum of three forms of trauma” (Olofsson et al., 2020). These results are limited in validity due to the study only researching 11 white, cisgender, adult female ED patients in a Norwegian tertiary care psychiatric hospital. But, there was a significant pattern in the body of research related to abuse:
childhood sexual abuse and emotional abuse were most positively correlated with the etiology of eating psychopathology or a chronic ED course. Similar to other research, an emphasis on bulimia and binge eating disorder were continuously cited as well (Moulton et al., 2015; Brustenghi et al., 2019; Vrabel et al., 2010; Olofsson et al., 2020; Burns et al., 2012; Caslini et al., 2016; Rabito-Alcón et al., 2020).
There were various findings in the research regarding the types of trauma most directly correlated with future ED development. Longo et al. (2020) found childhood abuse as a nonspecific risk factor for EDs. Burns et al. (2012) and Moulton et al. (2015) discovered childhood emotional abuse as a particularly relevant risk factor. Brustenghi et al. (2019) and Vrabel et al. (2010) cited childhood sexual abuse as a strong predictor of ED development. Similarly, Brustenghi et al. (2019) stated childhood sexual abuse was highly indicative of the development of bulimia or binge eating disorder.
The Difficulties of Treating Eating Disorders
Unfortunately, there was no clinical standard found in the body of research regarding integrating PTSD treatment with ED treatment (Olofsson et al., 2020). A lack of integration was found especially consequential when most ED patients studied by Rabito-Alcón et al. (2020) who were the victims of childhood trauma could not put a stop to their dissociative and ED symptoms.
Bardone-Cone et al. (2008) and Carretero-García et al. (2012) discovered the outcome of patients who had been exposed to trauma in childhood presented with more complex psychopathology and had worse outcomes than patients who reported themselves as not traumatized. Pignatelli et al. (2016) supported that finding and added childhood trauma and dissociative symptoms should always be considered in the care of ED patients for more
successful outcomes. The critical need to also incorporate and target dissociative symptoms was noted by Nilsson et al. (2019) as well because of the extreme disembodiment that has been displayed by ED patients. Olofsson et al. (2020) confirmed that without addressing trauma and its compounding effects, long-term, positive outcomes were significantly hindered. One researcher went so far as to say EDs can be a form of slow suicide (Schurrer, 2018). An informant in the Olofsson et al. (2020) study told researchers:
I feel that the main reason for my eating disorder is trauma, because the eating disorder is only really a symptom. And if I had started working with trauma, and come a bit more into contact with that, worked through it, I think it would’ve been easier to work with the eating disorder, and not the other way around, the way they did it at the ward.
Olofsson et al. (2020) found the positive long-term outcome group processed sensory and emotional exposure related to their trauma whereas the poor long-term outcome group either completely avoided processing trauma in the body or did not properly address it. Other researchers on this subject were in agreement that engaging in grief and reconstruction work was necessary to effectively resolve trauma. Failure to do so perpetuated the trauma and caused entrapment and stasis in the treatment process (Herman, 2015, p. 74). In summary, “ED sufferers with psychiatric sequelae of childhood trauma are known as difficult-to-treat patients with poor prognoses and high drop-out rates” (Olofsson et al., 2020).
The Need for Prevention and Other Notable Findings
The topic of prevention arose for many researchers when they saw such discouraging outcomes for many ED patients. Longo et al. (2020), for example, found dissociative and PTSD symptoms from early abuse and neglect could be treated near the onset to prevent EDs and other severe symptoms from emerging later on. In addition, the lag time between the trauma and
concerning symptoms noted previously by Moulton (2015) and Pugh, Waller, & Esposito (2018) represented an ideal time for intervention. Physical childhood trauma indicators such as bruises and dirtiness needed to be detected alongside the more common, yet often discreet symptoms of dissociation including diminished interest in activities; emotional dysregulation; rapid, profound age regression; difficulty concentrating; disconnection from classmates; a dazed, “spaced out,” or trance-like state; and an exaggerated startle response (Putnam, 1997; Choi et al., 2017; Seijo, 2015). The scarcity of early intervention has been attributed, in part, to these subtle, hard-tonotice dissociative symptoms suggesting trauma exposure. Without recognizing them alongside more visible trauma indicators, the opportunity for intervention is missed (Bruce, 2019; Putnam, 1997).
Without the suggested focus on prevention, the cycle of trauma, dissociation, and ED development is perpetuated. 15% of mothers with a history of bulimia in one study had “attempted to ‘slim down’ their normal weight infants” (Lacey & Smith, 1987). Additionally, researchers in another study discovered 20% of mothers with EDs had tried to change the appearance of their children (Waugh & Bulik, 1999).
The economic cost of EDs has been noted as an important reason for prevention-focused intervention as well. The yearly economic cost of EDs in the United States was calculated to be $64.7 billion last year, and the additional losses of well-being amounted to $326.5 billion (Report: Economic Costs of Eating Disorders, 2020).
Notable, Overarching Inconsistencies
The direct correlation between trauma, dissociation, and EDs was supported at various levels by multiple resources in the body of research. However, there were notable inconsistencies that have not been fully reconciled and should be noted. Norman et al. (2012) found inconsistent
definitions of “childhood” across studies. Another inconsistency was the variable differentiation of neglect versus abuse or lack thereof. Brustenghi et al. (2019), for instance, noted five traumatic domains: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. Norman et al. (2012) explained some studies used the Barnett-Cicchetti Maltreatment Classification System to classify physical abuse as a nonaccidental injury while other studies defined abuse as having been hit, kicked, or punched resulting in medical attention or bruising. Norman et al. (2012) researchers found studies that referred to physical punishment and corporal punishment that may have excluded physical assault or more severe physical abuse. Definitions of emotional abuse, which often included humiliation and verbal abuse by a caregiver, also had significant variation. And, child abuse was found to be complex and difficult to measure and define. Studies on neglect either used the encompassing term, “neglect,” or separated neglect into categories such as physical and emotional neglect (Norman et al., 2012).
Pignatelli et al. (2016) further emphasized the need for emotional, physical, educational, medical, and supervisory neglect and other types of traumatic conditions to be identified. Their study included that there has been extensive research on the topic of abuse and its connection to EDs whereas there is still an absence of studies “specifically investigate[ing] the impact of past neglectful experiences on ED[s]” (Pignatelli et al., 2016).
Another methodological limitation was mentioned in the Longo et al. (2020) study in that the presence of trauma in childhood was different from an actual diagnosis of PTSD. Also, patients may not have described their own experiences as traumatic if they had not been given a diagnosis. It was noted, “underreport and underestimation are major problems for this type of traumatic experience, both because people are usually more able to describe incidents of being abused (i.e. sexually or emotionally) than neglected” (Glaser, 2011). Similarly, “the use of
retrospective self-reports gives rise to the problem of reliability and validity of long-term recall” (Maughan & Rutter, 1997) especially given that dissociation can cause lost blocks of memory. This struggle to ensure reliability and validity since certain variables were hard to define complicated the research, for example, of Longo et al. (2020). There was so much variation to what exactly was measured and the verbiage around it that diminished the reliability of data across studies. Nonetheless, as previously mentioned, Brewerton (2007) did find, “any experience that can produce PTSD, partial PTSD, or any clinically significant anxiety may also increase the likelihood of an ED” (Brewerton, 2007). Longo et al. (2020) also inferred the patients in these studies had to come to some extent of recognition of their own trauma experience to share with researchers. But, what further complicated measures was the researchers had to acknowledge or deny the experience as trauma and decide whether to include it in their study or not (Longo et al., 2020). These limitations highlight the need for a non-self-report measurement of dissociative symptoms that are indicative of trauma.
Summarization of the Gaps in the Research to Date
Although much of the literature from the past 25 years suggests dissociation mediates the relationship between childhood trauma and EDs, research has been limited by underreporting in part by those who may not disclose a traumatic event resulting in false negatives. Patients may report traumatic events that didn’t happen as well. Additionally, though abuse and neglect are similar, there are differences between the two that have often been ignored in research regarding dissociation and EDs. The same applies to trauma versus diagnosable PTSD. Dissociation
Questionaries have grown in their accuracy, but their self-reporting nature may decrease overall accuracy.
Purpose Statement and Hypothesis (Hypothetical Study)
The current body of literature was found to contain empirical and theoretical evidence predominantly confirming the mediating relationship of dissociation between childhood trauma and ED development. Yet, the research lacked methods of detecting more specific ED risk factors connected to dissociation and relied heavily on self-report. The purpose of this study was to develop a sensitive screening tool that could more accurately detect school-aged children who may be displaying dissociative symptoms and could benefit from early intervention. As a result, more children could be kept from developing EDs later on in life. Because of the numerous manifestations of dissociation, the study focused on symptoms correlated with future ED development; though, the methods of this research could be applied in the study of other mental disorders. It was hypothesized that the research-based tool would allow both educators and experienced clinicians to accurately identify children who could benefit from early intervention with high validity and reliability by assessing the quantity of detectable dissociative symptoms.
Method
Participants
The sample included 300 schoolchildren in grades three through five of varying ethnicities and genders enrolled in Georgia’s public school system. The researchers, who were clinicians specializing in childhood trauma, found and recruited participants by getting recruitment assistance from schools, clinics, and community centers that worked with schoolchildren and were interested in learning more about mental health. These organizations allowed the researchers to recruit participants through their email lists as well as with posted flyers. The parents and guardians who showed interest in the study were generally informed about dissociation and what the study would entail in addition to how studying it could help researchers know when early intervention could be beneficial. They were also asked to sign an informed consent form allowing researchers to visit the child’s school, collaborate with the homeroom teacher (who also had to sign an informed consent form), and be in close proximity but not directly in contact with the child for the observation period. Additionally, the children of these parents and guardians were read a more simple description of the study and asked to provide assent. Early intervention recommendations were provided after the study in a follow-up email to the guardians and parents of children identified as having significant risk factors.
Measures
Participants were analyzed using a sensitive screening tool in the form of a questionnaire that was specifically created for a short period of observation in a classroom environment. This was part of the quantitive comparison research design used to assess the number of significant dissociative symptoms exhibited, and it was completed separately by the child’s homeroom
teacher and an on-site clinician over a period of three hours: the hour before lunch, the length of lunch, and the remaining time afterward. Only one student was observed at once.
Procedure and Analysis
After attaining informed consent from the interested guardians and parents in addition to assent from the children, researchers developed a standard, replicable study procedure and scheduled research times with the educators and children over the course of a year with as many factors controlled in the different classroom and lunchroom environments as possible. The same procedure was followed each time the sensitive screening tool was completed. For this quantitative comparative design, both the educator and clinician were given the printed questionnaire and asked to observe a single child over the stated period of time. One limitation of this study was the homeroom teachers had known the children much longer than the clinician. This may have caused them to unintentionally take into account prior observations. Inversely, a strength of this study was clinicians entered the classroom environment with no prior knowledge or assumptions. So, they were able to observe the children without preconceived notions. The completed questionnaires were scanned and added to the virtual library of data the researchers had been collecting after each observation period. After all data was gathered, the researchers used a psychometric assessment to determine the reliability and validity of the sensitive screening tool as this was a quantitative comparative research design with both the educator and clinician as observers. Dissociative symptoms as possible ED predictors in the screening included items that could easily be noticed within a short period of time in the classroom setting such as difficulty recalling information or perplexing forgetfulness; disorganized or agitated behavior; diminished interest in activities; emotional dysregulation including angry outbursts; intense and prolonged periods of reading (primarily fiction novels);
vivid imaginary companionship seen in drawings and discussions with the teacher or other children and through re-enactment; profound age regression; complaints of medical ailments; difficulty concentrating; self-injurious behaviors; disconnection from classmates; frequently daydreaming such as appearing in a dazed, “spaced out,” or trance-like state; exaggerated startle response i.e. seems to confusedly “wake up” after loud noises; and hypervigilant behaviors (Putnam, 1997; Choi et al., 2017; Seijo, 2015). These symptoms are positively correlated with ED symptomology when they appear in clusters and continue to compound over time.
The purpose of this study was to develop a sensitive screening tool to more accurately detect school-aged children displaying significant dissociative symptoms indicative of a greater risk for the development of an ED and who could benefit from early intervention. The hypothesis, which the data confirmed, was that the research-based tool would allow both educators and experienced clinicians to accurately identify the children who could benefit from early intervention with high validity and reliability.
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