Child Dissociative Checklist (CDC)

The Child Dissociative Checklist (CDC) is a 20-item observer-report measure designed to assess dissociative symptoms in children (Putnam, Helmers, & Trickett, 1993). Developed as the first validated clinical measure of childhood dissociation, the CDC serves as a screening tool for identifying children who may require further assessment for dissociative disorders. It is completed by a clinician, caregiver or adult who knows the child well, such as a parent, foster parent, or teacher, rating behaviors observed currently or over the past 12 months.

Dissociation is defined as “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (American Psychiatric Association, 2013). In children, dissociation can manifest differently from adults due to developmental differences in cognitive capacity, with symptoms often appearing as behavioral rather than subjective internal experiences. While some level of dissociation is normative in childhood (particularly among preschoolers), pathological dissociation develops when it becomes an automatic response to stress, impairing functioning and increasing susceptibility to serious psychopathology (Hornstein, 1993; Putnam, 1997).

While the CDC does not have subscales, items cover several domains of dissociative behavior in children, including:

• Dissociative amnesia: Memory gaps, forgetting personal information, not remembering traumatic experiences
• Identity confusion/alteration: Referring to self in third person, rapid personality changes, age regression
• Depersonalization/derealization: Trance states, “spacing out,” staring blankly
• Perceptual disturbances: Hearing voices, imaginary companions taking control
• Mood/behavior fluctuations: Rapid mood shifts, aggressive outbursts, self-harming behaviorsCover

The CDC has demonstrated utility in multiple contexts, including child protection services, residential treatment facilities, and outpatient mental health settings. It is particularly valuable for assessment of children who have experienced trauma, especially interpersonal trauma such as physical and sexual abuse (Hulette et al., 2008; Macfie, Cicchetti, & Toth, 2001b). Research consistently demonstrates elevated CDC scores in children with trauma histories, with physical abuse showing a particularly strong relationship to dissociative symptoms in young children (Macfie et al., 2001b).

In clinical practice, the CDC helps identify dissociative symptoms that might otherwise be overlooked or misdiagnosed as attention problems, behavioral issues, or mood disturbances (Endo, Sugiyama, & Someya, 2006). Screening for and accurately identifying dissociation is critical, as these symptoms can interfere with the effectiveness of standard interventions and may require specific trauma-focused approaches. As such, the CDC can be used to inform treatment planning, as where dissociative symptoms are identified, therapy may include a focus on grounding skills and regulation strategies, with careful attention to pacing, safety and consistent attunement. 

The CDC should be considered one component of a comprehensive assessment that may include clinical interviews, other standardized measures, and behavioral observations. While elevated scores warrant further investigation, the CDC is not a diagnostic instrument on its own (Putnam et al., 1993; Wherry et al., 1997).

The CDC total score ranges from 0-40. Higher scores indicate more severe dissociative symptoms. While no formal subscales exist, clinicians may find it helpful to evaluate items in context of the domains described earlier (amnesia, identity confusion, depersonalization/derealization, perceptual disturbances, and mood/behavior fluctuations) to better understand specific symptoms.

Based on research using the CDC, the following interpretive guidelines are recommended:

• Normal to mild: Score 0-11, 1st to 80th percentile: Within normal limits for most children.
• Moderate: Score 12-15, 81st to 95th percentile: Above the typical range for non-dissociative children and may reflect some significant dissociative symptoms. Scores are common in children with histories of abuse or significant stressors.
• High: Score 17-20 = 99th to 99.98th percentile: Strong indication of clinically significant dissociative symptoms and potential traumatic etiology. Most children with dissociative disorders score in this range.
• Severe: Score ≥ 21= ≥ 99.99th percentile: Extreme level of dissociative symptoms, strongly suggestive of Dissociative Identity Disorder or other severe dissociative condition. Scores in this range are commonly seen in children with diagnosed dissociative disorders. 

The total score is also expressed as a percentile rank, based on normative data from Endo et al. (2006) of non-dissocative children. This percentile contextualises the client’s score relative to the general population, indicating the percentage of individuals who scored lower than the client. For example, a score at the 85th percentile means that 85% of people in the community sample scored lower than the client, placing them in the upper range of dissociative experiences.

When the CDC score is at 12 or higher, further assessment for a dissociative disorder may be recommended as this threshold identified 96% of children meeting criteria for dissociative disorders in previous validation studies (Putnam et al., 1993). Scores at or above this threshold warrant additional attention and potential follow-up with structured interviews or other more comprehensive assessment to investigate the nature and extent of dissociative symptoms. 

Significant changes in the total score are indicated by shifts of half a standard deviation or greater (approximately 6 total score points or more) following the guidelines of the Minimally Important Difference (Turner et al., 2010).

On first administration a bar graph showing the CDC total score is displayed. 

In addition to the bar graph, a comparison graph illustrating the client’s scores relative to dissociative and non-dissociative reference groups are displayed. 

When the assessment is administered multiple times, a longitudinal line graph of the total CDC score is generated to track changes over time.

The CDC demonstrates strong psychometric properties across multiple studies with diverse samples of children. These findings support its use as a reliable and valid measure of dissociative symptomatology in children. Internal consistency of the scale is excellent, with Cronbach’s alpha values typically ranging from .85 to .88 (Putnam et al., 1993; Wherry et al., 1997). Test-retest reliability over a one-year period has been established at rho = .69 for the full sample, with ρ = .66 for sexually abused children and ρ = .61 for control children (Putnam et al., 1993). Item-level test-retest reliability ranges from .57 to .92. This indicates good stability of the measure over time, despite the natural variation in children’s dissociative symptoms that might occur with development or changing circumstances.

Convergent validity is supported by correlations between the CDC and other measures of childhood psychopathology. Wherry et al. (1997) found significant positive correlations between the CDC and the Child Behavior Checklist (CBCL) internalizing (r = .52), externalizing (r = .61), and total problem scores (r = .72). Relationships with measures specifically assessing trauma symptoms have also been established, with Milot et al. (2013) reporting moderate to strong correlations between the CDC and both the Trauma Symptom Checklist for Young Children (r = .39) and CBCL-derived PTSD scales (r = .55). 

The 20 CDC items were derived from clinical experience with dissociative children and matching predictor lists independently generated by other researchers, supporting content validity (Putnam et al., 1993). Construct validity has been supported through item analysis, showing item-total correlations ranging from .59 to .79 (Putnam et al., 1993). Putnam et al. (1993) conceptualized the CDC as unidimensional and it is predominantly used as a unidimensional assessment of dissociation (Putnam et al., 1993).

The CDC has been studied in various populations, allowing for comparative normative data. In the original validation study (Putnam et al., 1993), mean scores were: control girls (M = 2.3, SD = 2.7), sexually abused girls (M = 6.0, SD = 6.4), children with Dissociative Disorder NOS (M = 16.8, SD = 4.7), and children with Dissociative Identity Disorder (M = 24.5, SD = 5.2). These distributions demonstrate a clear continuum of dissociative experiences from normative to pathological levels. Other studies have contributed additional normative data, with consistently lower means in non-clinical samples compared to traumatized and clinically referred samples. Further normative data is described in table 1. 

A score of 12 or higher has been established as the clinical cutoff for significant dissociation. This cutoff has shown a good ability to distinguish between children with dissociative disorders and non-clinical samples, with approximately 96% of children with diagnosed dissociative disorders scoring above this threshold (Putnam et al., 1993). 

Category descriptors for the CDC were derived based on percentile distributions from the non-abused sample reported by Wherry et al. (2009), and in consideration of the wider literature. The clinical cutoff of 12 (Putnam et al., 1993) serves as the boundary between normal and mild-to-moderate dissociation. The percentile distribution of the non-dissociative sample shows the 1st-80th percentiles with equivalent scores of 0-11 within the typical range for most, and 81st-95th percentiles corresponding to scores 12-15 indicating elevated dissociation. The equivalent score range for the 99th-99.99th percentiles are scores 17-20, indicating high levels of dissociation, and the 99.99th percentile and greater corresponds to scores 21+, reflecting severe dissociative symptoms typically seen in dissociative disorders. 

• Normal to mild: Score 0-11, 1st to 80th percentile: Within normal limits for most children.
• Moderate: Score 12-15, 81st to 95th percentile: Above the typical range for non-dissociative children and may reflect some significant dissociative symptoms. Scores are common in children with histories of abuse or significant stressors.
• High: Score 17-20 = 99th to 99.98th percentile: Strong indication of clinically significant dissociative symptoms and potential traumatic etiology. Most children with dissociative disorders score in this range.

Severe: Score ≥ 21= ≥ 99.99th percentile: Extreme level of dissociative symptoms, strongly suggestive of Dissociative Identity Disorder or other severe dissociative condition. Scores in this range are commonly seen in children with diagnosed dissociative disorders.

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