Journal of Trauma & Dissociation
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Dissociation and psychopathology in residential
youth: a brief report
Iro Fragkaki MSc, Esther Louise Weijman MSc & Maaike Cima
To cite this article: Iro Fragkaki MSc, Esther Louise Weijman MSc & Maaike Cima (2019)
Dissociation and psychopathology in residential youth: a brief report, Journal of Trauma &
Dissociation, 20:5, 594-602, DOI: 10.1080/15299732.2019.1597816
To link to this article:  https://doi.org/10.1080/15299732.2019.1597816
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JOURNAL OF TRAUMA & DISSOCIATION
2019, VOL. 20, NO. 5, 594–602
https://doi.org/10.1080/15299732.2019.1597816
Dissociation and psychopathology in residential youth:
a brief report
Iro Fragkaki MSc , Esther Louise Weijman MSc, and Maaike Cima, PhD
Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
ABSTRACT ARTICLE HISTORY
Although dissociative symptoms are observed in several psy- Received 18 September 2018
chiatric disorders and linked to antisocial behavior and offend- Accepted 19 January 2019
ing, the relation between dissociation and psychopathology or KEYWORDS
comorbidity has not been consistently investigated in residen- Dissociation;
tial youth yet. This brief report documented prevalence and psychopathology;
comorbidity rates of several psychiatric disorders and exam- adolescents
ined their relation to dissociation in residential youth. The
study included 100 male adolescents (Mage = 16.51) admitted
to residential youth care facilities. Psychopathology was
assessed with the Mini International Neuropsychiatric
Interview for children and adolescents (MINI-KID) and dissocia-
tion was measured with the Adolescent Dissociative
Experiences Scale (A-DES). Externalizing problems (conduct
disorder, oppositional defiant disorder, attention deficit hyper-
activity disorder) were the most prevalent (81%) followed by
substance abuse/dependence (71%), manic/hypomanic symp-
toms (40%), anxiety (35%), and depression (33%). High comor-
bidity was also observed in externalizing problems with
alcohol/substance abuse/dependence (67%), manic/hypoma-
nic symptoms (35%), depression (31%), and anxiety (30%).
Logistic regression analyses revealed a significant link between
dissociation and externalizing problems, depression, and
manic/hypomanic symptoms, as well as comorbid externaliz-
ing problems and depression or manic/hypomanic symptoms.
The findings highlight the need to assess dissociation in order
to better understand the multifaceted individual profile of
residential youth and incorporate it in the treatment plan.
Antisocial and delinquent behavior is a common reason for referral to mental
health services in adolescence and numerous adolescents enter the residential
care system. Although there are different approaches across countries in youth
care (e.g., duration of care, range of age) and distinct policies for placement in
juvenile correctional institutions or residential care institutions, youth with
severe behavioral problems and minor offenses are most commonly admitted
to residential care institutions in European countries and the United States.
Epidemiological studies have examined the prevalence of antisocial behavior as
well as the wide range of psychopathology in incarcerated and residential care
CONTACT Iro Fragkaki i.fragkaki@pwo.ru.nl Behavioural Science Institute, Radboud University,
Montessorilaan 3, Nijmegen 6525 HR, The Netherlands
© 2019 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives
License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction
in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
JOURNAL OF TRAUMA & DISSOCIATION 595
populations. High prevalence of conduct disorder (CD) and oppositional defiant
disorder (ODD) (~50%) has been documented in detained youth, as well as high
prevalence of attention deficit hyperactivity disorder (ADHD), depression,
anxiety, and substance use disorders that varies among age, sex, and ethnic
groups (Fazel, Doli, & Langstrom, 2008; Garland et al., 2001; Teplin, Abram,
McClelland, Dulcan, & Mericle, 2002). In addition, high rates of trauma expo-
sure are prevalent in residential and detained youth and childhood trauma is
predictive of persistent antisocial behavior and offending (Dierkhising et al.,
2013; Fox, Perez, Cass, Baglivio, & Epps, 2015).
Extensive scientific evidence has also consistently linked trauma exposure
to dissociation (Vonderlin et al., 2018). Dissociation is defined in DSM-5 as
“a disruption of and/or discontinuity in the normal integration of conscious-
ness, memory, identity, emotion, perception, body representation, motor
control, and behavior” (American Psychiatric Association [APA], 2013,
p. 291). Dissociation includes a wide range of experiences ranging from
mild normative experiences (being very absorbed by a book) to pathological
dissociation, such as depersonalization (detachment from one’s own mind,
self, or body), derealization (detachment from surroundings), or amnesia
during a particular event or period of time (APA, 2013). Dissociation can be
a coping mechanism in response to trauma. The individual withdraws from
the outside world to an inner self and experiences changes in consciousness
in order to minimize or escape the emotional distress caused by the ongoing
traumatic experience (Putnam, 1997). Adolescence is a very critical period
for dissociation, as dissociative-like experiences, such as identity confusion
and absorption to oneself, are common and a part of the development of self
and identity. However, chronic dissociation of affect and behavior is deter-
rent for the adolescent’s ability to construct a sense of self and integrate a set
of different needs (Armstrong et al. 1997).
A recent meta-analysis demonstrated high levels of dissociation in a broad
range of psychiatric disorders, namely dissociative disorders, post-traumatic
stress disorder, borderline personality disorder, conversion disorder, substance-
related and addictive disorders, eating disorders, schizophrenia, anxiety, and
affective disorders (Lyssenko et al., 2018). However, although comorbidity is
frequently observed in psychiatric patients, the aforementioned meta-analysis
did not investigate the link between dissociation and comorbid disorders.
Additionally, this meta-analysis did not examine the relation between antisocial
personality disorder or disruptive disorders and dissociation. Dissociative symp-
toms are often observed in offenders and dissociative states have been associated
with violent behavior (Moskowitz, 2004). In specific, a review demonstrated that
one quarter of offenders reported pathological levels of dissociation and these
offenders committed more violent crimes (Moskowitz, 2004). Relatedly, higher
levels of dissociation have also been linked to antisocial behavior and offending
in youth (Kerig & Modrowski, 2018; Leibowitz, Laser, & Burton, 2010). The
596 I. FRAGKAKI ET AL.
study by Kerig andModrowski (2018) demonstrated a path from polyvictimiza-
tion to dissociation and borderline symptoms that further led to offending and
another study found that dissociative symptoms predicted sexual offenses in
a juvenile sample (Leibowitz et al., 2010). Most importantly, scientific evidence
has revealed that pathological dissociation can interfere with treatment and lead
to poorer treatment outcomes in several psychiatric disorders (Bae, Kim, & Park,
2016; Spitzer, Barnow, Freyberger, & Grabe, 2007). Surprisingly, despite the high
prevalence of dissociation in a plethora of psychiatric disorders and its clinical
relevance, there is a substantial lack of its assessment both in research and in
clinical practice. A more thorough examination of dissociative symptoms can be
very informative not only on themultifaceted forms of psychopathology but also
on potentially different treatment responses.
This study aimed to report the prevalence rates of several psychiatric disorders
and examine whether and which disorders were associated with dissociative
symptoms in male adolescents living in residential youth care facilities in the
Netherlands, who exhibited primarily externalizing problems. In the
Netherlands, juveniles aged 12 to 18 who exhibit severe behavioral problems or
have committedminor offenses (e.g., drug-related offenses, property offenses, and
violence) are admitted to residential youth care facilities similar to other youth care
institutions in Europe and residential treatment centers in theUnited States. Given
the high prevalence of comorbidity in youth with externalizing problems
(American Psychiatric Association, 2013), we also documented comorbid disor-
ders and investigated their relation to dissociation. History of trauma and callous-
unemotional (CU) traits that are frequently observed in this population were also
included in the analyses to untangle the independent effect of dissociative symp-
toms on psychopathology.
Method
Participants
The study included 100 male adolescents (Mage = 16.51 SDage = 0.96) recruited
from residential youth care facilities in the Netherlands. The participants were
admitted to residential care for severe behavioral problems, mainly externalizing
problems and delinquent behavior, and/or adverse family environment. The
majority of the participants were of Dutch origin (n = 83). Almost all the partici-
pants followed a low level track in school (n = 96).
Materials
Dissociation
The Adolescent Dissociative Experiences Scale (A-DES; Armstrong et al., 1997)
was administered to assess dissociative symptoms. A-DES is suitable for
JOURNAL OF TRAUMA & DISSOCIATION 597
adolescents aged 11–18 and it consists of four subscales: dissociative amnesia,
absorption/imaginative involvement, passive influence, and depersonalization/
derealization. It includes 30 items rated on an 11-point Likert scale (0 = never,
10 = always) and the total score is the mean score of all the items. A-DES has
been used extensively in healthy and clinical adolescents samples and it has very
good psychometric properties with excellent internal consistency and good
construct validity (Armstrong et al., 1997; Farrington, Waller, Smerden, &
Faupel, 2001). The Cronbach’s α in this study was .94.
Childhood trauma
Childhood traumatic experiences were assessed with the Childhood Trauma
Questionnaire – Short Form (CTQ; Bernstein et al., 2003). It consists of 25
items about childhood trauma and has five subscales: physical, sexual, and
emotional abuse, and physical and emotional neglect. The items are rated on
a 5-point Likert scale indicating the frequency of the traumatic experiences
(1 = never true, 5 = very often true). CTQ is a valid screening instrument for
childhood trauma. A sum score of all the items was calculated and higher
scores indicate higher frequency of childhood trauma. CTQ has very good
psychometric properties in community, psychiatric, and forensic populations
(Cima, Smeets, & Jelicic, 2008; Thombs, Bernstein, Lobbestael, & Arntz,
2009). The Cronbach’s α in this study was .93.
Callous-unemotional traits
Callous-unemotional (CU) traits were assessed with the Inventory of
Callous-Unemotional traits – Youth version (ICU; Frick, 2003). It consists
of 24 items rated on 4-point Likert scale (0 = not at all true, 3 = definitely
true) and it has three subscales: callousness, uncaring, and unemotional.
A total sum score is computed and higher scores indicate higher CU traits.
The ICU is widely used in healthy and clinical samples and has very good
psychometric properties (Feilhauer, Cima, & Arntz, 2012; Kimonis et al.,
2008). The Cronbach’s α in this study was .82.
Psychopathology
The Mini International Neuropsychiatric Interview for Children and
Adolescents (MINI-KID; Sheehan et al., 1998) was administered to assess
the presence of current DSM-IV and ICD-10 psychiatric disorders. The
MINI-KID is a fully structured and widely used screening interview for
children and adolescents (age 6–17) with a binary (yes/no) format. It has
very good psychometric properties with substantial sensitivity and specificity,
interrater and test-retest reliability, and concordant validity with other rele-
vant instruments (Sheehan et al., 2010).
598 I. FRAGKAKI ET AL.
Procedure
The study was conducted at residential youth care facilities as part of a larger
project that was granted Medical Ethical approval by the Central Committee
on Research Involving Human Subjects and the Dutch Ministry of Health.
Participants completed the A-DES, ICU, and CTQ and then trained graduate
students administered the MINI-KID interview. Participation was completely
voluntary and the participants were allowed to terminate their participation
at any time. Written informed consent was obtained from all participants.
Parental written informed consent was obtained for participants below
16 years of age according to the Dutch law. Participants received financial
compensation for their participation.
Results
Table 1 presents the prevalence of CD, ODD, ADHD, depression, any
anxiety disorder, alcohol/substance abuse/dependence, and manic/hypoma-
nic symptoms as well as the mean of ADES in each group. From the total
sample, 90% presented pathological symptoms of the aforementioned dis-
orders, 81% exhibited two or more comorbid disorders, and 51% exhibited
three or more comorbid disorders. The descriptive statistics and correlations
among the dissociation, CU traits, and trauma are presented in Table 2.
Logistic regressions were conducted to examine whether dissociation was
related to psychopathology controlling for trauma, CU traits, and age. To
Table 1. Dissociative symptoms and prevalence rates of psychopathology and
comorbidity.
N (%) ADES (M, SD)
CD 66 2.14 (1.79)
ODD 45 2.22 (1.69)
ADHD 30 2.29 (1.43)
CD+ODD 34 2.19 (1.87)
CD+ADHD 20 2.74 (1.52)
ODD+ADHD 16 2.58 (1.45)
ADHD/CD/ODD 81 2.08 (1.67)
CD only 22 1.88 (1.84)
ODD only 6 2.74 (1.18)
ADHD only 2 1.50 (0.14)
Depression 33 2.75 (2.10)
Anxiety 35 2.46 (1.82)
Alcohol/Substance abuse/dependence 71 1.94 (1.63)
Manic/hypomanic symptoms 40 2.46 (1.77)
ADHD/CD/ODD + Depression 31 2.85 (2.13)
ADHD/CD/ODD + Anxiety 30 2.60 (1.92)
ADHD/CD/ODD + Alcohol/Substance abuse/dependence 67 1.94 (1.67)
ADHD/CD/ODD + Manic/hypomanic symptoms 35 2.66 (1.80)
No disorder 10 0.76 (0.83)
ADES = Adolescent Dissociative Experiences Scale; CD = Conduct Disorder; ODD = Oppositional
Defiant Disorder; ADHD = Attention Deficit Hyperactivity Disorder.
JOURNAL OF TRAUMA & DISSOCIATION 599
Table 2. Descriptive statistics and correlations.
M SD Range 1 2 3 4 5 6 7
1.A-DES 1.89 1.59 0–7.57 –
2.ICU 29.44 10.05 8–60 .277** -
3.CTQ total 45.65 18.30 25–106 .355** .020 -
4.Physical abuse 8.30 5.25 5–25 .232* −.074 .821** -
5.Sexual abuse 6.19 2.88 5–21 .273** .011 .546** .332** -
6.Emotional abuse 9.64 5.31 5–25 .386** −.006 .861** .723** .459** -
7.Physical neglect 8.92 4.05 5–20 .228* .020 .779** .500** .331** .505** -
8.Emotional neglect 12.6 5.67 5–25 .267** .118 .826** .521** .281** .580** .697**
A-DES = Adolescent Dissociative Experiences Scale; ICU = Inventory of Callous-Unemotional Traits;
CTQ = Childhood Trauma Questionnaire
* p < .05, ** p < .01, *** p < .001.
minimize the number of tests, we combined CD, ODD, and ADHD as
indicators of externalizing problems. Dissociation predicted externalizing
problems, b = 0.59, z = 2.10, p = .036, OR = 1.80, CI[1.10, 3.29], depression,
b = 0.60, z = 2.89, p = .004, OR = 1.83, CI[1.25, 2.85], and manic/hypomanic
symptoms, b = 0.44, z = 2.58, p = .01, OR = 1.56, CI[1.13, 2.23]. Additionally,
neither trauma, b = 0, z = 0.24, p = .809, nor CU traits, b = 0.04, z = 1.19,
p = .233, were related to externalizing problems. Dissociation was not related
to anxiety, b = 0.25, z = 1.51, p = .130, or alcohol/substance abuse/depen-
dence, b = 0.01, z = 0.03, p = .979. Moreover, dissociation was significantly
associated with comorbid externalizing problems and depression, b = 0.56,
z = 2.81, p = .005, OR = 1.75, CI[1.22, 2.69], as well as comorbid externalizing
problems and manic/hypomanic symptoms, b = 0.53, z = 2.91, p = .004,
OR = 1.69, CI[1.21, 2.49], compared to only one of the two disorders. It was
also marginally related to comorbid externalizing problems and anxiety,
b = 0.30, z = 1.82, p = .068, but not with comorbid externalizing problems
and alcohol/substance abuse/dependence, b = −0.16, z = −0.92, p = .357.
Model diagnostics were conducted for multicollinearity, linearity, and scaled
residuals, indicating a good fit of the models. Due to the large number of
tests, False Discovery Rate (FDR) correction for multiple testing was applied
(Benjamini & Hochberg, 1995). The results were marginally significant for
externalizing problems (adjusted p = .064), and significant for depression
(adjusted p = .015), manic/hypomanic symptoms (adjusted p = .023), as well
for comorbid externalizing problems and depression (adjusted p = .015), and
manic/hypomanic symptoms (adjusted p = .015).
Discussion
The aim of the study was to report prevalence rates of psychopathology and
examine the relation between dissociation and psychopathology in residential
youth. The findings showed high prevalence rates of CD, ODD, ADHD,
depression, anxiety, alcohol/substance abuse or dependence, and manic/
600 I. FRAGKAKI ET AL.
hypomanic symptoms in a sample of male adolescents living in residential
care. In addition, high rates of comorbidity were observed between externa-
lizing problems (CD, ODD, ADHD) and depression, anxiety, alcohol/sub-
stance abuse or dependence, and manic/hypomanic symptoms. Importantly,
high levels of dissociation were associated with externalizing problems,
depression, manic/hypomanic symptoms, as well as comorbid externalizing
problems with depression or manic/hypomanic symptoms.
These findings are in accordance with the results by Lyssenko et al. (2018) that
highlighted the presence of dissociation in a wide range of psychiatric disorders
in adults. In addition, externalizing problems that were highly prevalent in our
sample were also related to higher dissociation, in line with previous evidence in
comparable samples (Kerig, 2018; Leibowitz, 2010; Walker, 2002). Crucially,
comorbidity was also associated with higher levels dissociation compared to only
one diagnosis. Given the complex psychopathological profiles and the high
comorbidity rates in residential youth, this finding is especially informative
and relevant for clinical practice. Comorbid disorders require more multifaceted
interventions and there is an increased interest in identifying factors that might
impede treatment response and providing personalized care to each patient
based on their individual profile. Considering that dissociation can interfere
with treatment and lead to poor treatment response (Bae et al., 2016; Spitzer
et al., 2007), it is crucial to, first, assess dissociative symptoms and identify
patients with high levels of dissociation and, second, take it into account and
incorporate it in the treatment plan.
Several limitations should be acknowledged. First, our sample included only
males and thus did not provide information on dissociation levels in females or
potential sex differences. Second, the participants were in residential care mostly
due to externalizing problems. Comorbid disorders were highly prevalent in our
sample and we could not compare patients with only one diagnosis. Therefore,
our findings can be informative only for comparable samples of residential
youth. However, given the complexity and the wide range of psychopathology
in this specific population, it is more ecologically valid to take into account the
presence of comorbidity. Third, we used ADES to assess dissociation, which is
a screening questionnaire and not a thorough interview.We propose that ADES
is an easy and quick instrument to assess dissociative symptoms in clinical
practice that can give the therapist the opportunity to determine whether
a more thorough interview is warranted.
Overall, this brief report documented the prevalence rates of several
psychiatric disorders and comorbidity in male adolescents in residential
care and elucidated the link between dissociation and externalizing problems,
depression, and manic/hypomanic symptoms. These findings highlight the
need to assess dissociation in residential youth in order to better understand
its role in psychopathology and incorporate it in intervention plans.
JOURNAL OF TRAUMA & DISSOCIATION 601
Acknowledgments
We would like to thank the Stichting Koningsheide for funding this project.
ORCID
Iro Fragkaki http://orcid.org/0000-0003-3976-0878
Maaike Cima http://orcid.org/0000-0002-3458-5276
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