THE CHILDREN
PERCEPTUAL
ALTERATION SCALE
(CPAS): A MEASURE OF
CHILDREN
DISSOCIATION
Mary Evers-Szostak, Ph.D.
Shirley Sanders, Ph.D.
Mary Evers-Szostak, Ph.D., is a pediatric psychologist at Durham
Pediatrics, 2609 North Duke Street, Suite 801, Durham, North
Carolina 27704.
Shirley Sanders, Ph.D., is Adjunct Professor of Psychiatry at
the University of North Carolina at Chapel Hill.
A version of this paper was presented at the Annual
Convention of the American Psychological Association, San
Francisco, California, August, 1990.
For reprints write Mary Evers-Szostak, Ph.D., Durham
Pediatrics, 2609 North Duke Street, Suite 801, Durham, North
Carolina 27704.
ABSTRACT
The Children's Perceptual Alteration Scale (CPAS)was developed
as a standardized, self-report measure of children's dissociative expe-
riences. Fifty-three children between the ages of eight and twelve com-
pleted the CPAS. This included 21 children (17 boys and 4 girls)
seen for psychological evaluation or treatment and 32 children (20
girls and 12 boys) in the normal group. Parents of the children in
the clinical group completed the Achenbach Child Behavior Checklist
and the Eyberg Child Behavior Inventory. Children in the clinical
group scored higher on the CPAS than did those in the normal group.
Total CPAS score was also found to correlate significantly withEyberg
Intensity, and the Obsessive-Compulsive and Aggressive scales of
the CBC. Split-half reliability of the CPAS was good (r = . 75, p <
.001). The CPAS appears to be a valid measure of children's disso-
ciative experiences and may be useful in the study of normal devel-
opment and childhood psychopathology.
INTRODUCTION
Recent increases in reported cases of child abuse and
dissociative disorders highlight the need for objective screen-
ing measures of dissociation (Kluft, 1985a) . There is a clear
need for a standardized measure for children, particularly
in light of the difficulties with the diagnosis of dissociative
disorders in this group. According to Peterson (1990) , chil-
dren predisposed to Multiple Personality Disorder and
severe dissociation are rarely identified at an early age. In
fact, only three percent are diagnosed prior to age twelve
(Kluft, 1985b). There are many possible reasons for this low
identification rate. First, since relatively little is known about
the specific nature of dissociative behavior in children, con-
fusion with other diagnoses such as Childhood Schizophrenia
is probably a factor. Second, Multiple Personality Disorder
may be atypical in childhood or may present differently in
children than in adults. Third, adults may attribute children
reports of the alteration of perception, behavior, or affect
to fantasy or mood. Finally, some clinicians may not be aware
of crucial behaviors that signal dissociation in children and
may not ask critical questions. As a result, they may fail to
determine whether the child misses significant blocks of time,
experiences the loss of affective control or cognitive control
in a depersonalized or automatic way, or is aware of the trig-
gers of these experiences (Kluft, 1985b).
Previous attempts to address these issues have resulted
in the development of behavior problem checklists utiliz-
ing observer reports (Fagan and McMahon, 1984; Kluft, 1978;
Putnam, 1981). These checklists contain items relating to
trance, behavior fluctuation, lying, mood disorder, sleep dis-
order, abuse, amnesia, and developmental issues. While these
observer checklists have been useful, relatively little has been
written about how children themselves perceive their dis-
sociative experiences. Furthermore, the use of clinical judg-
ment and an excessive amount of inference can decrease
the reliability and validity of findings regarding subjective
experiences like dissociation. Therefore, a self-rating scale
would be useful in gathering additional information about
children s dissociative experiences. Such a scale should also
prove useful in diagnostic and treatment efforts.
Sanders (1986) developed the Perceptual Alteration Scale
(PAS) as a self-report measure of dissociation in adults. This
scale has been used with eating-disordered patients (Sanders,
Boswell Hernandez, 1986), hypnotically susceptible sub-
jects (Perry, 1986), and normal college students (Sanders
and Barrett, 1989). In each study the PAS discriminated
between populations. In a further study of content validity
and reliability within a normal college population, the PAS
obtained a reliability of.91. In addition, independent raters
obtained an inter-rater reliability of.72 (Sanders, 1990) . This
measure appears to have content validity and, in the vari-
ous validation studies, these findings seem to support the
construct of dissociation underlying the test items.
The study presented here involved the development of
a self-report measure of dissociation for children eight to
twelve years of age. This development was based on the already
successful efforts with the PAS and worked from an assump-
tion that dissociation is a multi-dimensional concept rather
than a simple one. Dissociation also appears to reflect a con-
tinuum from normal to pathological behavior (Braun, 1988;
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DtSSOCLATION. Vol. V. Va. 2, lime 1942
CHILDREN PERCEPTUALALTERATION SCALE
Kluft, 1985a; Watkins H., Watkins, J, 1990, October, per-
sonal communication), so it was hypothesized that the CPAS
would correlate with a variety of measures of psychological
and emotional functioning. Furthermore, it was predicted
that a developmental trend would be evident with levels of
dissociation decreasing with age. Finally, it was also predicted
that the differences between clinical populations and nor-
mal subjects would be reflected by average to moderate dis-
sociation scores for the normals, and higher scores for the
clinical sample.
METHOD
Selection of Items
The 35 items derived from a factor analysis of the PAS
were reviewed and rewritten to arrive at the 28 items of the
CPAS. This effort was designed to specifically address chil-
dren unique experiences and development. Therefore, it
was necessary to avoid simply extending adult definitions
downward.
The items of the CPAS include automatic experiences,
imaginary playmates, amnesia, loss of time, heightened mon-
itoring, and loss of control over behaviors and emotions.
Children rate the experiences reflected in each item on a
four-point scale from never happening to them (1) to hap-
pening to them all the time (4). The total score is attained
by summing all the ratings. So that higher ratings indicate
higher levels of dissociation, the ratings for item #21 must
be reversed before calculating the total score.
INITIAL STUDY IN A PEDIATRIC POPULATION
Subjects
The subjects were 53 children between the ages of eight
and twelve years. All of the children were patients in a pri-
vate pediatrics practice that included five pediatricians and
one pediatric psychologist. The normal group included 32
children (20 girls and 12 boys) who were being seen for rou-
tine physical examinations. These children had no known
history of behavior or emotional problems. The clinical sam-
ple included 21 children (17 boys and four girls) who were
being seen for either a psychological evaluation or psy-
chotherapy. This group included children with a variety of
diagnoses and mainly mild to moderate psychopathology.
Diagnoses included: anxiety disorder, attention deficit hyper-
activity disorder, depression, oppositional defiant disorder,
encopresis, and learning disabilities.
Procedure
Nurses asked the parents (mainly mothers) of the chil-
dren in the normal sample for permission and gave them a
brief letter outlining the purposes of the study. The vast
majority of parents agreed to let their children participate,
and most of these children completed their CPAS question-
naires at the office. A few questionnaires were returned by
mail.
Most of the children in the clinical sample completed
their CPAS questionnaires at home as part of an initial psy-
chological evaluation or early in the course of psychother-
apy. Parents of the children in this group also completed
the Achenbach Child Behavior Checklist (CBC) (Achenbach,
1978) and the Eyberg Child Behavior Inventory (Eyberg and
Robinson, 1983).
TABLE 1
CPAS Items
1. When I awake, I feel like I dreaming.
2. I m grouchy, but I don mean to be.
3. I cannot sit still.
4. I am hungry.
5. When I start laughing, I cannot stop.
6. When I tired, I do things without thinking.
7. I forget what I am supposed to do.
8. I don like to be at school.
9. I eat even when I am not hungry.
10. I think I want to write, but my hand
does not want to.
11. I love my friends, but I hate them, too.
12. I play many games all at the same time.
13. I steal things, but I don want to.
14. When someone calls me, I don recognize
my name.
15. My feelings change, but I don want them to.
16. I do not remember what people tell me.
17. I don know how I got to school.
18. I hide my thoughts from others.
19. After I hit someone, I wish I hadn.
20. I have an imaginary friend.
21. I think about everything I do.
22. I cannot stop myself from crying.
23. I open my eyes and see I am in a strange place.
24. I want to play and I want to read and I
cannot decide.
25. I m angry, but I don want to be.
26. I cannot stop my thoughts, but I would like to.
27. My mind cannot stop my body from doing things
I don want it to do.
28. I feel like I somebody else watching me.
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DISSOCIATION. Vol. V, No. 2. unc 1992
EVERS-SZOSTAK/SANDERS
RESULTS
CPAS Items
Children in both groups tended to use the full range of
responses on most items.
In reviewing these results, it was thought that most items
with a mean response greater than 1.5 for at least one group
were useful items. Using this criterion, four of the 28 items
of the CPAS failed to meet the cutoff (Items 13, 14, 17, and
23) .
els of dissociation.
Based on these early findings, it also appears that the
CPAS is a reliable and valid self report measure of dissocia-
tion in children. These results are particularly striking in
light of the narrow, relatively mild range of psychopatholo-
gy presentin the clinical group. It seems likely that a study
including children with a wider range of psychopathology
might yield even more striking results. This might include
finding that the normal range of dissociation actually lies
between a very low level of dissociation and a very high one.
Group Differences
There was a clear pattern of high-
er total CPAS scores in the clinical
group with the clinical boys having
the highest average total scores. A t-
test found a significant difference
between the normal and clinical
groupstotal CPAS scores (t(51) =
3.88, p < .001) with the children in
the clinical group reporting higher
levels of dissociation than did chil-
dren in the normal group.
Validity
A correlation matrix also revealed
some significantcorrelationsbetween
total CPAS score and Eyberg In tensity
(r = .60, p < .01), the Obsessive-
Compulsive scale of the CBC (r = 54,
p < .05), and the Aggressive scale of
the CBC (r = .44, p < .05) . A negative
correlation with age was found, but
was not statistically significant.
Reliability
Split half reliability was calculat-
ed by correlating total scores for odd
and even items. Correlations were sig-
nificant for the total sample (r = .75,
p < .001) , the normal group (r = .64,
p < .001), and the clinical group (r
= .82, p < .001).
DISCUSSION
The results of this preliminary
study are encouraging. The finding
that children in both groups tended
to use the full range of responses on
most items supports the notion that
dissociation occurs normally in chil-
dren to some extent and that it may
be measured on a continuum. In addi-
tion, a pattern of higher total CPAS
scores in the clinical group as com-
pared with the normal group suggests
that the CPAS can discriminate
between normal and pathological 1ev
TABLE 2
CPAS Items: Means and Ranges
Normals (N = 32) Clinical(N = 21)
Item Mean Range Mean Range
1. 1.41 1-2 1.95 1-4
2. 2.25 1-4 2.14 1-4
3. 2.25 1-4 2.55 1-4
4. 2.59 1-4 2.86 1-4
5. 2.41 1-4 2.43 1-4
6. 2.00 1-4 2.67 1-4
7. 2.16 1-4 2.48 1-4
8. 2.03 1-4 2.81 1-4
9. 1.97 1-4 1.90 1-4
10. 1.66 1-3 2.24 1-4
11. 1.78 1-4 1.86 1-4
12. 1.19 1-2 1.86 1-4
13. 1.22 1-4 1.15 1-2
14. 1.22 1-2 1.38 1-3
15. 1.81 1-3 2.19 1-4
16. 2.03 1-3 2.52 1-4
17. 1.03 1-2 1.24 1-4
18. 2.03 1-4 2.43 1-4
19. 2.16 1-4 2.76 1-4
20. 1.25 1-4 1.86 1-4
21. 2.22 1-3 2.33 1-4
22. 1.97 1-4 2.00 1-4
23. 1.22 1-3 1.33 1-4
24. 1.88 1-4 2.14 1-4
25. 2.03 1-3 2.10 1-4
26. 1.91 1-3 2.90 1-4
27. 1.45 1-4 2.38 1-4
28. 1.55 1-4 2.33 1-4
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DISSOCIATION, Vol. C. N. 2, June 1992
CHILDREN PERCEPTUAL ALTERATION SCALE
TABLE 3
Total CPAS Scores
The finding of differences between the normal and clin-
ical groups is consistent with similar findings using the PAS
with adult populations. For example, men were found to
report more dissociation than women (Sanders and Barrett,
1989), and the finding here of highest total scores among
clinical boys appears consistent with this. This finding might
be related to risk-taking in boys as compared to the social
expectation that girls behave more predictably. Perhaps this
finding is related to a lower level of self-awareness and self-
consciousness in the boys. More study is certainly needed to
answer this question.
The correlational data suggest that scores on the CPAS
are somehow related to certain behavior problems, but the
scale also appears to be measuring something in addition to
child behavior problems and psychopathology. Perhaps it is
sensitive to normal development, including cognitive, imag-
inative, and behavioral facets. This is another possibility that
deserves further exploration.
The significant correlations with externalizingbehaviors
on the CBC suggest that total CPAS scores at least partly reflect
automatized behavior that is not consciously controlled. This
finding also raises questions about a possible link between
Attention Deficit Hyperactivity Disorder and dissociation. It
seems possible that a subgroup of children with this disor-
der may, in fact, have attention problems that are due to
excessive levels of certain types of dissociative experiences.
Given the large number of children who are identified as
having Attention Deficit Hyperactivity Disorder, this area
would seem to warrant further examination.
Perhaps most importantly, it appears that children in
this age group can provide information about their own dis-
sociative experiences. While the CPAS will likely be of use to
clinicians working with youngsters thought to have Multiple
Personality Disorder, it should be noted that the CPAS appears
to measure something broader than this one disorder.
Further investigation of the CPAS appears warranted. Such
investigation should target more extensive work with a large
normative sample as well as extensive work with a broader
range of clinical populations including: victims of child abuse,
children in acute and chronic pain, and children thought
to have Multiple Personality Disorder. In
addition, there appears to be a develop-
mental trend with the frequency of disso-
ciation decreasing with age and this should
be examined further.
When the CPAS is compared with the
earlier observer rating scales (Fagan and
McMahon, 1984; Muff, 1978; Putnam, 1981),
some overlap is evident. However, several
important differences can be noted. These
address the weaknesses of the observer
checklists. First, the categories of the earli-
er scales are very general and may be col-
ored by the definitions given for adult psy-
chopathology. As is the case in other areas
of developmental psychopathology, it may
be misleading to extend these adult cate-
gories to children. The CPAS was designed
to address experiences and definitions specifically for chil-
dren. Second, since dissociation has been found to extend
to cognitive, behavioral, affective, and perceptual experiences
(Braun, 1988; Sanders, 1986), it is important to look at chil-
dren behavior with respect to these experiences. The ear-
lier checklists categorize mood, but not affect; fluctuation
in behavior, but not changes in control; and third person
quality, but not changes in self-monitoring.
Many of these weaknesses are typical of observer rating
scales in that behavior can be observed but internal experi-
ences cannot. As a result, it is possible that behaviors may
thought to reflect dissociation when that is notwhat the child
is experiencing. It is also likely very difficult to observe behav-
iors that might result from more mild, normally- occurring
dissociation. If this is the case, observer rating scales would
be poor instruments for measuring normal dissociation in
children. It appears that self-report measures may better cap-
ture a wider range of dissociative experiences in children.
If this is the case, self-report measures like the CPAS, which
contain items relating to subjective experiences, should be
particularly helpful to clinicians working with children with
a variety of diagnoses to clarify the presence or absence of
dissociative behaviors ranging from adaptive to maladaptive.
In summary, the CPAS appears to measure a multidi-
mensional concept of dissociation that can be viewed on a
continuum from pathologically restricted dissociative respons-
es to normal ones to pathologically extensive ones. This self-
report measure should be helpful in the study of normal
development as well as the study of childhood psychopathology.
Of course, these findings must be replicated and addition-
al validation studies carried out on a large number of sub-
jects before extensive and definitive statements can be made
about the CPASutility and value. 
MEAN TOTAL
GROUP SCORE RANGE STD
Normal Males 49.50 33 - 64 8.02
Normal Females 51.05 40 - 66 7.32
Clinical Males 62.35 46 - 100 11.56
Clinical Females 53.25 50 - 57 2.60
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D1SS0CI,k T10N, Vol C. No. 2. m,e 1992
EVERS-SZO STAK/ SANDERS
REFERENCES
Achenbach, T. (1978). The child behavior profile. Journal of
Consulting and Clinical Psychology, 46, .488.
Braun, B.G. (1988). The BASK (behavior, affect, sensation, knowl-
edge) model of dissociation. I (1) , 4-23.
Eyberg, S.M., and Robinson, E.A. (1983). Conduct problem behav-
ior: Standardization of a behavioral rating scale with adolescents.
Journal of Clinical Child Psychology,12,347-354.
Fagan, J., and McMahon, P.P. (1984). Incipient multiple person-
ality in children. 172,26-36.
Kluft, R.P. (1978). Childhood multiple personality disorder.
Unpublished data. In Kluft, RP. (1984). Multiple personality in
childhood.Psychiatric Clinics of North America, 7,
Kluft, R.P. (1985a). The natural history of multiple personality dis-
order. In R.P. Kluft (Ed.), antecedents of multiple personal-
ity (pp. 167-196). Washington, DC: American Psychiatric Press.
Kluft,R.P. (1985b). Childhood multiple personality disorder:
Predictors, clinical findings, and treatment results. In R.P. Kluft
(Ed.), Childhood antecedents (pp. 167-196).
Washington, DC: American Psychiatric Press.
Perry, C. (1986) . Initial study of the perceptual alteration scale and
hypnotic susceptibility. Unpublished raw data.
Peterson, G.A. (1990). Diagnosis of childhood multiple personal-
ity disorder.DISSOCIATION,III, 3-9.
Putnam, F.W. (1981) . Childhood MPD proposal. Unpublished raw
data. In Kluft, R.P. (1984). Multiple personality in childhood.
PsychiatricClinics of North America. 7,121-134.
Sanders, S. (1986). The perceptual alteration scale: A scale mea-
suring dissociation.
Sanders, S. October). The perceptual alteration scale: A test of
inter-rater reliability.
Society for Clinical and Experimental Hypnosis, Leiden, The
Netherlands.
Sanders, S., and Barrett, D. (1989, August).The relationship ofthe
perceptual alteration scale to hypnotic susceptibility: An initial study of nor-
mal college students.
Society of Hypnosis, Leiden, The Netherlands.
Sanders, S., Boswell, J., and Hernandez, J. (1986, October) . A
of dissociation contrasting anorectics and bulimics.
the annual meeting of the Third International Conference on
Multiple Personality and Dissociative States, Chicago, Illinois.
The authors wish to thank the staff of Durham Pediatrics,
2609 North Duke Street, Suite 801, Durham, NC 27704.
CPAS
Please read each sentence and circle the number that best describes how often you feel this way.
1. When I awake, I feel like I dreaming.
never sometimes often almost always
1 2 3 4
2. Im grouchy, but I don mean to be.
never sometimes often almost always
1 2 3 4
3. I cannot sit still.
never sometimes often almost always
1 2 3 4
4. I am hungry.
never sometimes often almost always
1 2 3 4
5. When I start laughing, I cannot stop.
never sometimes often almost always
1 2 3 4
95
l lSSOClAT10\, Vol V. N0.2, June 1992
CHILDREN PERCEPTUAL ALTERATION SCALE
6. When I  m tired, I do things without thinking.
sometimes
2
7. I forget what I am supposed to do.
never sometimes often almost always
1 2 3 4
8. I don like to be at school.
never sometimes often almost always
1 2 3 4
9. I eat even when I am not hungry.
never sometimes often almost always
1 2 3 4
10. I think I want to write, but my hand does not want to.
never sometimes often almost always
1 2 3 4
11. I love my friends, but I hate them, too.
never sometimes often almost always
1 2 3 4
12. I play many games all at the same time.
never sometimes often almost always
1 2 3 4
13. I steal things, but I don want to.
never sometimes often almost always
1 2 3 4
14. When someone calls me, I don recognize my name.
never sometimes often almost always
1 2 3 4
15. My feelings change, but I don want them to.
never sometimes often almost always
1 2 3 4
16. I do not remember what people tell me.
never sometimes often almost always
1 2 3 4
17. I don know how I got to school.
never
1
almost always
4
often
3
never sometimes
1 2
often almost always
3 4
96
DISSOC1:1TlO\, Col. V. V. 2. June 1992
EVERS-SZOSTAK/SANDERS
18. I hide my thoughts from others.
sometimes
2
19. After I hit someone, I wish I hadn.
never sometimes often almost always
1 2 3 4
20. I have an imaginary friend.
never sometimes often almost always
1 2 3 4
21. I think about everything I do.
never sometimes often almost always
1 2 3 4
22. I cannot stop myself from crying.
never sometimes often almost always
I 2 3 4
23. I open my eyes and see I am in a strange place.
never sometimes often almost always
1 2 3 4
24. I want to play and I want to read and I cannot decide.
never sometimes often almost always
1 2 3 4
25. Im angry, but I don want to be.
never sometimes often almost always
1 2 3 4
26. I cannot stop my thoughts, but I would like to.
never sometimes often almost always
1 2 3 4
27. My mind cannot stop my body from doing things I don want it to do.
never sometimes often almost always
1 2 3 4
28. I feel like I m somebody else watching me.
never sometimes often almost always
1 2 3 4
never
1
almost always
4
often
3
97
DISSOCIATION. Vol. V, Nu. 2.une 1992