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Journal of Trauma & Dissociation

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Dissociation in Sexually Abused Puerto

Rican Children: A Replication Utilizing
Social Workers as Informers
a

Joel Manzano-Mojica PhD , Alfonso Martnez-Taboas PhD , Sean

b

K. Sayers-Montalvo PhD , Jos J. Cabiya PhD & Larry E. AliceaRodrguez JDMSW

Support of Sexual Abuse Victims and their Families Program, Carlos

Albizu University, San Juan, Puerto Rico
b

Clinical Psychology Program, Carlos Albizu University, San Juan,

Puerto Rico
c

Carlos Albizu University, Office of the Chancellor, San Juan, Puerto

Rico
Available online: 17 Jan 2012

To cite this article: Joel Manzano-Mojica PhD, Alfonso Martnez-Taboas PhD, Sean K. Sayers-Montalvo
PhD, Jos J. Cabiya PhD & Larry E. Alicea-Rodrguez JDMSW (2012): Dissociation in Sexually Abused
Puerto Rican Children: A Replication Utilizing Social Workers as Informers, Journal of Trauma &
Dissociation, 13:3, 330-344
To link to this article: http://dx.doi.org/10.1080/15299732.2011.641205

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Journal of Trauma & Dissociation, 13:330344, 2012

Copyright Taylor & Francis Group, LLC
ISSN: 1529-9732 print/1529-9740 online
DOI: 10.1080/15299732.2011.641205

Dissociation in Sexually Abused Puerto Rican

Children: A Replication Utilizing Social
Workers as Informers
JOEL MANZANO-MOJICA, PhD
Support of Sexual Abuse Victims and their Families Program, Carlos Albizu University,
San Juan, Puerto Rico

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ALFONSO MARTNEZ-TABOAS, PhD

Clinical Psychology Program, Carlos Albizu University, San Juan, Puerto Rico

SEAN K. SAYERS-MONTALVO, PhD

Clinical Psychology Program, Carlos Albizu University, San Juan, Puerto Rico

JOS J. CABIYA, PhD

Carlos Albizu University, Office of the Chancellor, San Juan, Puerto Rico

LARRY E. ALICEA-RODRGUEZ, JD, MSW

Support of Sexual Abuse Victims and their Families Program, Carlos Albizu University,
San Juan, Puerto Rico

This study explores dissociative symptoms in 3 different groups

of Puerto Rican children. Data were collected on 40 children
with documented sexual abuse history, 39 children with psychiatric disorders but without a history of sexual abuse, and
40 community control children. Dissociative symptoms were
assessed with the child using the Trauma Symptom Checklist for
Children (TSCC); a social worker answered the Child Dissociative
Checklist (CDC). Results indicated that children with sexual abuse
obtained significantly different scores on both the TSCC and the
CDC. Further analysis indicated that child and social worker
reports of dissociative symptoms were highly correlated (r = .73).
Furthermore, 30% of the children in the sexual abuse group scored

Received 10 August 2010; accepted 24 May 2011.

Address correspondence to Alfonso Martnez-Taboas, PhD, Clinical Psychology Program,
Carlos Albizu University, San Juan Campus, P.O. Box 9023711, San Juan, PR 00902-3711.
E-mail: amartinez@sju.albizu.edu
330

Journal of Trauma & Dissociation, 13:330344, 2012

331

at or above the cutoff point of 12 on the CDC, which is indicative of a dissociative disorder. None of the children in the other
2 groups obtained such a score. The results suggest that children with documented sexual abuse victimization demonstrate a
significant number of dissociative phenomena that not only are
subjectively experienced but also can be observed by a nonfamily
member. Finally, as nearly a third of the abused children obtained
a score of 12 or higher on the CDC, the next step is to prepare
clinicians to conduct a proper and formal diagnosis assessment of
dissociative disorders.

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KEYWORDS sexual abuse, Puerto Rican children, dissociation,

trauma
Growing epidemiological and clinical research documents that dissociative
experiences or symptoms are frequently reported by children, adolescents,
and adults with histories of traumatic abuse (Gershuny & Thayer, 1999;
Lewis, Yeager, Swica, Pincus, & Lewis, 1997; Macfie, Cicchetti, & Toth, 2001;
Martnez-Taboas, Canino, Wang, Garca, & Bravo, 2006). Also, the great
majority of adults and children who present with a dissociative disorder have
a history of a plethora of traumatic experiences (Silberg & Dallam, 2009).
In the case of children and adolescents, most of those traumatic experiences
can be documented with external evidence. For example, Coons (1994) and
Hornstein and Putnam (1992) found that 95% of their series of dissociative
children had experienced corroborated abuse.
Dissociative phenomena present a challenge to many mental health professionals. For example, dissociation has been linked to such diverse chronic
psychopathological conditions as psychogenic seizures (Bowman & Kanner,
2007), posttraumatic stress disorder (PTSD; Simeon, 2007), conversion disorders (Nijenhuis, 2009), and borderline personality disorder (Zanarini &
Jager-Hyman, 2009), among others. Research studies with children, adolescents, and adults point to the conclusion that dissociative experiences and
symptoms, in some instances, hinder the therapeutic response of psychiatric
patients (Breh & Seidler, 2007; van der Hart, van Ochten, van Son, Steele,
& Lensvelt-Mulders, 2008). For example, Kanner, Parra, and Frey (1999),
studying a variety of prognostic factors in psychogenic seizures, found that
those patients who had elevated dissociative symptoms presented a poor
prognosis of their condition. For their part, Gulsun, Doruk, Uzun, Turkbay,
and Ozsahin (2007) found that those patients with high dissociation scores
on the Dissociative Experiences Scale experienced a reduced benefit from a
pharmacological intervention compared with those with a low score. Similar
results have been reported when using cognitive behavior therapy with
panic patients who have high scores on the Dissociative Experiences Scale
(Michelson, June, & Vives, 1998).

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332

J. Manzano-Mojica et al.

Although extensive literature exists on the clinical parameters of

dissociation in adults, the same cannot be said for the presence of
dissociation in children and adolescents. This in unfortunate, because many
theoretical approaches suggest that dissociative disorders usually originate in
traumatic stressors confronted during the formative years. Moreover, children
have less mature coping mechanisms to tolerate stress and have a greater
innate capacity to use trance and fantasy to separate mentally from traumatic
experiences (Pynoos, Steinberg, & Goenjian, 1996; Silberg & Dallam, 2009).
Nevertheless, studies conducted in the United States, Turkey, Sweden,
The Netherlands, and Puerto Rico have shown that dissociative symptoms
and disorders can be reliably and validly detected and studied using a wide
variety of sensitive research instruments (for a review, see Lewis-Fernndez,
Martnez-Taboas, Sar, Patel, & Boatin, 2007). Furthermore, many studies have
found a strong correlation between dissociative symptoms and a variety of
traumatic experiences (Brunner, Parzer, Schuld, & Resch, 2000; Calamari &
Pini, 2003; Carrion & Steiner, 2000; Farrington et al., 2002; Kisiel & Lyons,
2001; Macfie et al., 2001; Prohl, Resch, Parzer, & Brunner, 2001).
In the case of Puerto Rican youths, Martnez-Taboas and colleagues
have empirically documented the extent of the relationship between trauma
and dissociation utilizing two large, independent epidemiological cohorts.
In the first study, Martnez-Taboas et al. (2004) administered the Adolescent
Dissociative Experiences Scale8 (ADES-8) to a representative sample of
459 medically indigent adolescents aged 11 to 17 who received mental
health services in Puerto Rico. Results indicated that the ADES-8 showed
expected patterns of convergent validity with variables that are hypothesized to be intimately related to dissociative disorders, such as psychiatric
impairment and a wide variety of abusive experiences. In a second study,
Martnez-Taboas et al. (2006) administered the ADES-8 to a representative
island-wide household probability sample of youths aged 11 to 17. A logistic regression analysis indicated that all five of the abuse and victimization
variables were significantly associated with the dissociative factor. Also, the
study documented the fact that as the abuse became more frequent and
severe, there was a greater likelihood that the respondents reported severe
dissociative symptoms.
The current study is an extension of the one reported by Reyes-Prez,
Martnez-Taboas, and Ledesma-Amador (2005). In that study, the authors
assessed dissociative experiences in three groups of children utilizing the
Spanish translation of the Child Dissociative Checklist (CDC). Three groups
of children were recruited: a control group of 33 children, an attentiondeficit/hyperactivity disorder (ADHD) group of 30 children, and a group
of 31 children with a documented and validated history of abuse (mainly
sexual abuse). Results indicated that the group with the documented abuse
obtained a significantly different score (p < .05) on the CDC than the other
two groups. Moreover, 55% of the children in the abuse group obtained

Journal of Trauma & Dissociation, 13:330344, 2012

333

a score at or above the suggested cutoff score of 12 for pathological

dissociation, but no child in the control group obtained such a score and
only 17% in the ADHD group did.

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AIMS OF THE STUDY

The aims of this study were to corroborate the finding that a group of
sexually abused children can be differentiated from a normative and a psychiatric control group in terms of their dissociative symptoms. This study
deviates from the Reyes-Prez et al. (2005) investigation in three ways. First,
instead of using an exclusively ADHD control group of children, we utilized
a psychiatric control group with mixed diagnoses. Second, in the present
investigation we additionally examine dissociative symptoms as reported by
the child himself or herself. And third, the social worker assigned to the child
by the Protection Plan of the Department of the Family of the Government
of Puerto Rico was the person selected to score the CDC. As far as we
know, this is the first study to use social workers to score the CDCs of the
children under their care. In using the social worker as the rater of the CDC,
we wanted to answer two questions. First, are dissociative symptoms sufficiently marked and persistent as to be noted by a person who is not a family
member but who has sufficient knowledge of the child? The social workers
in our study had weekly contact with all of the children in their caseloads,
and they had to monitor their progress in therapy. Second, are there any correspondences between what the social worker is seeing and the subjective
symptoms of dissociation as reported by the child? To adequately address
this aim, we conducted a statistical test to see what type of relationship could
be documented between the scores of the social worker on the CDC and
those of the children on the Dissociation subscale of the Trauma Symptom
Checklist for Children (TSCC; a self-report scale). To add rigor to the present
study, we also compared scores on the CDC for three groups of Puerto Rican
children: (a) a sexually abused group, (b) a psychiatric control group, and
(c) a normal community control group. It was hypothesized that the group
of children with documented sexual abuse would obtain significantly higher
scores on the CDC compared with the other two groups of participants.
In the present study we confined our analysis to the presence of
a history of experiences of sexual abuse. Although we know that other
types of abusive experiences have profound psychological sequelae (Lanius,
Vermetten, & Pain, 2010), we decided to limit our analysis to this specific
type of abuse. Also, similar to the study of Reyes-Prez et al. (2005), a psychiatric control group was utilized. The main reason for including such a
comparison group was that we wanted to know whether the psychiatric
impairment and anguish that are inherent in psychiatric youths could impact
scores on the CDC.

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J. Manzano-Mojica et al.

METHOD

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Participants
Participants in this study were 119 children between 7 and 11 years of age,
gathered through a three-group design methodology. The three groups in
which the participants were classified are presented next.
Sexually abused group (SAG). This group included 40 Puerto Rican
children (18 boys, 22 girls) of the Support of Sexual Abuse Victims and
their Families Program. The mean age for this group was 9.92 years (SD =
1.56). These children were selected after their allegations of sexual abuse
were validated. The process of validation was based on the guidelines
of the American Professional Society on the Abuse of Children (American
Professional Society of the Abuse Children, 1990) and carried out by welltrained professionals with a PhD, PsyD, or MSW in a behavioral science
field. Although we know that all children in this group were receiving psychological interventions at the Support of Sexual Abuse Victims and their
Families Program, we could not obtain data on their specific diagnosis or
the duration of the psychological interventions.
Psychiatric control group (PCG). This group was composed of non
sexually abused children receiving psychological treatment. This group
included 39 children (22 boys, 17 girls) of the Community Mental Health
Clinic at Carlos Albizu University. The mean age for this group was 9.88 years
(SD = 1.26). These children participated in the study after announcements
were made available to their caregivers. These children had to meet the
following criteria in order to be included in this group: no history of sexual abuse but receiving active psychological treatment. These children had
to have been active in psychotherapy for less than a month. Children who
participated in this group had the following diagnoses: problems with primary group support (70%), ADHD (25%), adjustment disorders (2.5%), and
generalized anxiety disorder (2.5%).
Community control group (CCG). This group was composed of non
sexually abused children with no history of psychiatric disorder. This group
included 40 children (21 boys, 19 girls). The mean age for this group
was 9.43 years (SD = 1.58). These children were selected upon availability through personal presentation of the study and announcements in the
community. These participants had to meet the following criteria in order
to be included in this group: no history of psychological treatment and/or
sexual abuse.

Instruments
CDC (Putnam, Helmers, & Trickett, 1993). This scale is completed by
observers who are well familiarized with childrens behaviors, such as their
parents. The CDC consists of 20 items related to dissociative symptoms.
A score of 12 or more is defined as a possible indicator of pathological

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Journal of Trauma & Dissociation, 13:330344, 2012

335

dissociation (Putnam, Helmers, & Trickett, 1993). The CDC was translated
into Spanish and adapted for use in Puerto Rico by Reyes-Prez et al. (2005).
The scale has shown an internal reliability index of .88 after a complete
comprehensive process of translation and adaptation guided through the
Brislin (1986) method. In the present investigation we obtained an internal
reliability index of .82.
TSCC (Briere, 1996). This instrument is a self-report scale consisting of
54 items that assess childrens response to a traumatic event through a variety of symptoms. The TSCC has six clinical subscales: Anxiety, Depression,
Anger, PTSD, Dissociation, and Sexual Concerns. The scales were translated
and adapted for the Puerto Rican culture by Navedo (2000). The instrument
has shown an internal reliability index of .92. For this study we used only the
Dissociation and PTSD subscales. In the present investigation we obtained
an internal reliability index of .85 for the TSCCDissociation subscale and
.92 for the TSCCPTSD subscale.

Procedures
Approval for this study was obtained from the internal review board of
Carlos Albizu University. After we obtained the required informed consents
from each child and his or her legal guardian, the CDC was administered
to the social worker in charge of the child and the TSCC was administered
verbally by the principal investigator to the children in an individual session.
The aforementioned scales were then scored and statistical analyses were
performed.

RESULTS
Normative Information
Descriptive analyses were performed for the CDC and the PTSD and
Dissociation subscales of the TSCC for all groups. Kurtosis and skewness
indexes were within normal parameters (1.00) for all groups, even though
the kurtosis index for the CCG was slightly higher (1.11). Results indicated
that a normal distribution of participants scores was present in the CDC.
However, both the PTSD and Dissociation subscales of the TSCC presented
greater kurtosis and skewness indexes for the SAG (Dissociation subscale),
PCG (PTSD subscale), and CCG (PTSD subscale). Table 1 presents the normative information for the CDC and the PTSD and Dissociation subscales of
the TSCC for all groups.

Analysis of Variance (ANOVA)

After normality indexes were determined, a univariate ANOVA was performed to verify whether there were significant differences in the mean

336

J. Manzano-Mojica et al.

TABLE 1 Kurtosis and Skewness Indexes for All Groups on the CDC and on the PTSD and
Dissociation Subscales of the TSCC

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Measure
CDC
SAG
PCG
CCG
Total
TSCCPTSD
SAG
PCG
CCG
Total
TSCCDissociation
SAG
PCG
CCG
Total

Min

Max

Kurtosis

SE of kurtosis

Skewness

SE of skewness

4
0
0
0

18
9
6
18

0.88
0.57
1.11
0.11

0.73
0.74
0.73
0.44

0.50
0.54
0.80
0.85

0.37
0.39
0.37
0.22

0
0
0
0

24
14
1
24

0.50
12.81
1.92
0.58

0.73
0.74
0.73
0.44

0.37
3.11
0.42
1.22

0.80
0.38
0.37
0.22

2
0
0
0

26
6
3
26

2.99
0.29
0.44
4.97

0.73
0.74
0.73
0.44

0.41
0.32
0.29
1.90

0.37
0.38
0.37
0.22

Notes: CDC = Child Dissociative Checklist; PTSD = posttraumatic stress disorder; TSCC = Trauma
Symptom Checklist for Children; SAG = sexually abused group; PCG = psychiatric control group; CCG =
community control group.

scores of each group on the CDC and on the PTSD and Dissociation
subscales of the TSCC. Levenes test of equality of error of variances was
first performed for participants scores on the CDC and TSCC. The analysis
revealed that the variances were not equal among groups on the CDC and
the PTSD and Dissociation subscales of the TSCC: CDC, F(2, 116) = 9.67,
p = .001; PTSD, F(2, 116) = 25.37, p = .001; Dissociation, F(2, 116) = 18.95,
p = .001. These results indicate that each groups score distribution behaved
differently from one another on the CDC and TSCC subscales.
Taking into consideration these results, we compared group scores on
each measure. The ANOVA showed significant statistical differences between
the groups on the CDC and the PTSD and Dissociation subscales of the
TSCC: CDC, F(2, 116) = 148.34, p = .001; PTSD, F(2, 116) = 156.56,
p = .001; Dissociation, F(2, 116) = 73.11, p = .001. Furthermore, large effect
sizes (r > .50) were found on each measure using eta. Table 2 presents the
mean scores, effect sizes, and observed power for each measure for the
compared groups.
In addition, a Tukey post hoc analysis was performed for the groups on
all measures. On the CDC, there were differences in mean scores between
the SAG and PCG (M dif = 7.76, p = .001) and the SAG and CCG (M dif =
8.08, p = .001) but not between the PCG and CCG (M dif = 0.31, p = .83) on
the CDC. Furthermore, differences were also found on the PTSD subscale
of the TSCC between the SAG and PCG (M dif = 9.73, p = .001), the SAG
and CCG (M dif = 12.13, p = .001), and the PCG and CCG (M dif = 2.39,
p = .004). Finally, differences were also found on the Dissociation subscale
of the TSCC between the SAG and PCG (M dif = 5.53, p = .001), the SAG and
CCG (M dif = 8.00, p = .001), and the PCG and CCG (M dif = 2.47, p = .001).

Journal of Trauma & Dissociation, 13:330344, 2012

337

TABLE 2 Mean Scores, Effect Sizes, and Observed Power for Each
Measure for the Compared Groups
Measure

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CDC
SAG
PCG
CCG
TSCCPTSD
SAG
PCG
CCG
TSCCDissociation
SAG
PCG
CCG

SD

10.28
2.51
2.20

3.04
2.46
1.27

12.53
2.79
0.40

5.05
2.38
0.50

9.23
3.69
1.22

4.93
1.51
0.86

Observed power

.85

1.00

.85

1.00

.75

1.00

Notes: CDC = Child Dissociative Checklist; SAG = sexually abused group; PCG =
psychiatric control group; CCG = community control group; TSCC = Trauma
Symptom Checklist for Children; PTSD = posttraumatic stress disorder.

Finally, an ANOVA was performed for gender within groups for the
CDC and for the PTSD and Dissociation subscales of the TSCC. No statistical
differences were found by gender, and effect sizes were small for each group
on each measure (see Table 3).
Because the Levenes test of equality of error of variances demonstrated
that each groups score distribution behaved differently from the others on
the CDC and TSCC subscales, a Kruskal-Wallis test was performed to verify
the ANOVA results. Statistical differences were found among groups mean
TABLE 3 Descriptive Analysis and Results of the ANOVA by Gender for Each Group on Each
Measure
Boys
Measure
CDC
SAG
PCG
CCG
TSCCPTSD
SAG
PCG
CCG
TSCCDissociation
SAG
PCG
CCG

Girls

SD

SD

df

10.56
2.86
2.33

3.05
2.75
0.97

10.05
2.06
2.05

3.08
2.02
1.54

0.27
1.03
0.49

1,38
1,37
1,38

.60
.32
.49

.08
.16
.11

11.67
3.00
0.43

5.12
2.83
0.51

13.23
2.53
0.37

5.00
1.66
0.50

0.94
0.37
0.14

1,38
1,37
1,38

.34
.55
.71

.15
.10
.06

9.22
3.55
1.24

5.56
1.60
1.00

9.23
3.88
1.21

4.49
1.41
0.71

0.00
0.47
0.01

1,38
1,37
1,38

1.00
.50
.92

.00
.11
.00

Notes: ANOVA = analysis of variance; CDC = Child Dissociative Checklist; SAG = sexually abused group;
PCG = psychiatric control group; CCG = community control group; TSCC = Trauma Symptom Checklist
for Children; PTSD = posttraumatic stress disorder.

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J. Manzano-Mojica et al.
TABLE 4 Mean Rank Scores for Each Group on the CDC,
TSCCPTSD Subscale, and TSCCDissociation Subscale
Measure
CDC
SAG
PCG
CCG
TSCCPTSD
SAG
PCG
CCG
TSCC
Dissociation
SAG
PCG
CCG

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75.55

.001

92.73

.001

84.06

.001

Mean rank
98.43
41.12
39.99
96.99
59.50
23.50
94.53
61.23
24.28

Notes: CDC = Child Dissociative Checklist; TSCC = Trauma

Symptom Checklist for Children; PTSD = posttraumatic stress
disorder; SAG = sexually abused group; PCG = psychiatric
control group; CCG = community control group.

ranks for the CDC and TSCC subscales. These nonparametric results were
similar to those found in the ANOVA. Table 4 presents the mean rank scores
for each group on each measure.

Evaluation of the Cutoff Points of the CDC

A frequency analysis was performed to verify how many participants
reported a score equal to or higher than 12 on the CDC based on the
assumption that scores of 12 or more are indicative of the possibility of
pathological dissociation (Putnam et al., 1993). The results indicated that
30% of the participants of the SAG had a score of 12 or higher on the CDC,
whereas none of the participants of the PCG and CCG obtained a score
above 12 on the CDC (see Table 5).
TABLE 5 Percentage of Participants with a Score of 12 or
Higher on the CDC by Group
Score 11

Score 12

Group

SAG
PCG
CCG

28
39
40

70
100
100

12
0
0

30
0
0

Notes: A score of 12 or more is defined as a possible indicator of pathological dissociation (Putnam et al., 1993). CDC = Child Dissociative
Checklist; SAG = sexually abused group; PCG = psychiatric control
group; CCG = community control group.

Journal of Trauma & Dissociation, 13:330344, 2012

339

Other Analysis
We wanted to know whether the dissociation scores given by the social
worker correlated with the subjective dissociative symptoms as noted by
the child. We found a significant and moderatehigh correlation (r = .73,
p = .001) between the CDC and the Dissociation subscale of the TSCC.

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DISCUSSION
As previously stated, the CDC has been extensively investigated utilizing
normative, psychiatric, and trauma/abuse populations. The results from
many studies point out that the CDC is a useful screening instrument for
assessing dissociative profiles in children. Indeed, a wide variety of studies that have utilized child and adolescent samples highlight the fact that
traumatized youths present higher levels of dissociation than nontraumatized samples (Brunner et al., 2000; Calamari & Pini, 2003; Carrion & Steiner,
2000; Farrington et al., 2002; Kisiel & Lyons, 2001; Macfie et al., 2001; Prohl
et al., 2001).
The findings from the present study point to the importance of the
assessment of dissociative symptoms in children with a history of sexual
abuse. In this study, and the one conducted by Reyes-Prez et al. (2005),
children with documented experiences of sexual abuse showed marked
dissociative symptoms. In fact, 55% of the participants in the Reyes-Prez
study showed dissociative symptoms suggesting a dissociative disorder.
In the present study we found that a considerable minority (30%) also performed at or above the cutoff point for a dissociative disorder. The two
investigations also highlight the fact that the dissociative symptoms were
duly noted and documented by family members (Reyes-Prezs study), by
a nonfamily member (social worker), and by the child (present study).
In other words, the dissociative experiences and symptoms appear to be so
notable and marked that even a nonfamily member can observe them.
We understand that this is a significant finding because it suggests that
behavioral manifestations of dissociation in children that are sufficiently disruptive can be noted by persons who do not live day to day with the child.
This finding could be potentially used by clinicians to scrutinize, in a more
vigorous manner, the behavioral markers of dissociative children.
Other findings merit some comments. For example, in our sample, girls
and boys from the SAG demonstrated similar dissociation scores (M = 10).
This is consistent with previous studies in which it has been found that it
is not until late adolescence that a marked difference on dissociation scores
is present, such that females clearly outnumber male adolescents; this finding is similar to findings in adults (Putnam, Hornstein, & Peterson, 1996).
Developmental studies indicate that the ratio of female to male dissociative

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J. Manzano-Mojica et al.

identity disorder cases steadily increases from 1:1 in childhood to 8:1 in adolescents. Possible reasons for this gender disparity that begins in adolescence
are that there may be gender-related differences in the types or duration of
abusive experiences experienced by males and females or that the clinical
phenomenology of dissociative males is somewhat different or more covert
than that of females.
An interesting result is that the children, who were receiving psychological treatment because of a variety of psychiatric dysfunctions, tended to
have very low scores on the CDC. In our study, the mean score was 2.5. This
low score could be related to the clinical profile of the PCG, which consisted
mainly of children with ADHD and problems with primary group support.
We think that a treatment variable is inadequate to explain the low scores on
the CDC because all of the psychiatric group participants had been receiving
treatment less than a month before our study began. The current results are
consistent with our previous investigation, in which children with a diagnosis of ADHD also obtained a low score on the CDC (Reyes-Prez et al.,
2005). They are also similar to those reported by Zoroglu, Tuzun, Ozturk,
and Sar (2002) with psychiatric children in Turkey. These data suggest
that psychiatric control participants do not present behavioral dissociative
manifestations unless they present a plethora of abusive experiences.
That possibility was put to the test in a study by Martnez-Taboas et al.
(2004) in which the ADES-8 was administered to 459 medically indigent
youths who were being attended to at various psychiatric clinics throughout
Puerto Rico. The results showed that nearly 46% had a score of 0 on the
ADES-8; the mode was 0 and the median score was 0.25. Thus, although
the sample was composed of youths with many psychosocial disadvantages
who were attending psychiatric clinics, rarely did these youths self-report
any dissociative symptoms. However, when we analyzed those youths who
reported frequent abusive experiences, the ADES-8 easily discriminated
them from those with no or slight abuse (Martnez-Taboas et al., 2006).
Previous epidemiological studies (Martnez-Taboas et al., 2004,
2006) have indicated that youths who present with a wide variety of
abusive or traumatic experiences tend to experience marked dissociative
phenomena. The present study, although limited to experiences of sexual
abuse, is consistent with the idea that sexual abuse is a highly traumatogenic experience to many people (Jonas et al., 2011; Kendler et al., 2000).
In fact, various theoretical models postulate that dissociative experiences
constitute a psychobiological response to damaging aversive events, such
that the person tries to distance or protect himself or herself from the
physical and psychological fear and desperation that implicate confronting
traumatic events (Putnam, 2006). In so doing, they evidence a failed processing of emotional information, manifested as dysfunctional fluctuations
in consciousness and behavior (Putnam, 2006; Silberg & Dallam, 2009).

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Another notable finding is that the high dissociation score given

by the social workers to the sexually abused children correlated highly
and significantly with the Dissociation subscale of the TSCC (r = .73).
This indicates that the dissociative experiences were not only noted by
the external observer but also were duly noted and reported by the
child. This type of data clearly suggests that dissociative experiences
have a phenomenological/subjective sphere that is also manifested at the
behavioral level (e.g., trances, switching states).
It is important to underscore that the results of the current investigation
are consistent with what is known of dissociative processes in other parts
of the world. For example, our findings are similar to those obtained by
Zoroglu et al. (2002) in Turkey. These researchers also documented that
a cutoff score of 12 discriminated nicely among their abused, control, and
ADHD groups, such that only 6.8% of the second and 18.2% of the third
group of children obtained a score of 12 or above. In addition, in their
control group the mean score on the CDC was only 3.7, compared with
2.8 in our previous investigation (Reyes-Prez et al., 2005) and 2.2 in our
current report.
Also consistent with previous research is that the mean score of our SAG
was 10.3, which is remarkably close to the one obtained by Reyes-Prez et al.
(2005) in Puerto Rico (12.0). According to this result, many sexually abused
children demonstrate a wide plethora of affective and behavioral signs that
are consistent with alterations in identity, consciousness, and memory. Those
dissociative signs appear to be observed cross-culturally, as they have been
documented in various parts of the world (Lewis-Fernndez et al., 2007;
Silberg & Dallam, 2009).
The current investigation has several limitations. First, although all social
workers were presumed to know very well the children in their caseloads,
we did not include a question for which the social worker could specify
how well he or she knew the child. This leaves open the possibility that at
least some social workers may not have had sufficient information or known
sufficiently their children to make a precise score on the CDC.
Second, we limited our abuse variable to sexual victimization. It is
well known that in some investigations, other types of victimization (e.g.,
physical abuse, emotional abuse and neglect) are more intimately related
to dissociative symptoms. For example, in the epidemiological study by
Martnez-Taboas et al. (2006), the variables of physical abuse and frequent
exposure to community violence were more related to the dissociation
score than being sexually abused. Third, we did not conduct a follow-up
assessment with a structured clinical interview to determine the number of
children who not only presented with highly dissociative experiences but
who also presented with dissociative pathologies or diagnoses.
Nevertheless, this study has a number of strengths. Our scales and
instruments were rigorously translated and adapted to our Spanish-speaking

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J. Manzano-Mojica et al.

population. Also, we utilized two control groups, a normative and a clinical

one, to compare the results. In addition, the abuse history of our children
was rigorously validated by external experts before our study. In addition,
this is the first study, as far as we know, in which the CDC was scored by a
nonfamily member. Also, we statistically correlated the dissociation scores
as assessed by the child and the social worker, obtaining a moderately
high correlation. Lastly, this study demonstrates that dissociative phenomena can be clearly documented in a Hispanic population, which contributes
to the growing transcultural literature. It has been found that dissociative
phenomena and pathologies can be clinically assessed and identified in a
wide variety of countries (see the recent review by Lewis-Fernndez et al.,
2007).
In summary, we understand that future studies that provide a more
comprehensive and integrated examination of the traumatogenic profile of
abused children, including demographic, psychiatric, familial, and contextual
factors, are needed. In addition, investigations into the mechanisms underlying the creation of dissociative defenses or experiences are also necessary.
Nevertheless, the present results suggest that clinicians working with victims
of sexual abuse must pay special attention to the specific psychiatric needs
of this population, particularly the extensive dissociative symptoms that a
considerable number of those youths manifest.

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