One warning sign that a child could have dissociative identity disorder and what increases their risk, according to a psychiatrist

• Dissociative identity disorder is a condition where a person enters various self-states when triggered.
• People are rarely diagnosed in childhood because DID is misunderstood and rare.

Dissociative identity disorder, formerly called "multiple personality disorder," is an extremely misunderstood mental health condition where a person's mind is divided into various self-states, developed in childhood as a protective mechanism. Someone with dissociative identity disorder (DID) may switch or shift among these states under a variety of conditions, including stress, but also to manage daily life tasks.

It affects an estimated 1.5% of people worldwide.

People who have DID are rarely diagnosed in childhood and spend around seven years on average in the mental health system seeking help for their many severe psychiatric symptoms, Dr. Richard Loewenstein, a psychiatrist at University of Maryland Medical Center, told Insider. According to Loewenstein, who saw his first patient with DID in 1981, people with the condition are misdiagnosed an average of four times before receiving a DID diagnosis.

He added that DID individuals have high rates of self-destructive and suicidal behavior, leading to frequent psychiatric hospitalization.

He said mental health professionals can diagnose adults with DID through a series of in-depth interviews that take into account symptoms like amnesia and suicidal ideation. But DID symptoms tend appear differently in children than adults, according to Loewenstein.

Clinicians who specialize in DID haven't agreed upon a specific age someone can be diagnosed, said Loewenstein, but mental health professionals and parents have described DID-like symptoms in very young children, and diagnosis of DID may become possible around six.

Here is what puts a child at risk of DID and the sign the may have it, according to Loewenstein.

It's normal for children to have imaginary friends, but for children with DID these companions can feel controlling

Children with DID tend to have simpler self-states that are less fleshed-out than adults with the condition, according to Loewenstein.

Adults who dissociate tend to have more distinct self-states, where they personify certain traits in a limited and stereotypical way. A person's self-states are often conflicting, Loewenstein said. One self-state could be gay and the other homophobic, or one is a man and the other is a woman, regardless of the person's core personhood.

But in children who are still learning who they are and could be, those states aren't as fleshed out. Instead, they may say they have imaginary friends.

Though imaginary friends are a normal phenomenon for many children through school age, children who could have DID, may have more "autonomous imaginary companions" that "make the child feel like he/she is controlled from inside," Loewenstein said.

He added that these imaginary friends may manifest as inner voices often in conflict. They could persist long after the usual developmental window for having imaginary friends in childhood, and even be experienced in adults with DID, he said.

They come from an abusive home or went through repeatedly abusive experiences

Not everyone who experiences childhood trauma like abuse or abandonment will develop DID, since there may be a genetic component to the condition, said Loewenstein.

But if a child repeatedly feels alone, out of control, and unsafe, it could make them more likely to dissociate to protect themselves, and carry that behavior into adulthood.

Abuse and abandonment can happen outside of the home and away from parents, Loewenstein noted. In these cases, the child is often unable to get comfort and soothing from parents that ignore or reject the child's distress related to trauma, he said.

He said there are instances of children who had multiple surgeries while young and are left in the hospital to recover without their parents at their sides.

If a child is repeatedly sexually abused by someone other than their parents, it can have the same impact.

"Then the only thing to do is to go away in their head," which can lead to DID, said Loewenstein.

Their parents have dissociative identity disorder

One 1987 study on mothers with DID found about one-third were "competent or exceptional mothers," 16% were grossly abusive, and the rest were "compromised or impaired as parents." There isn't any research on fathers with DID.

Based on Loewenstein's experience, parents with DID may unintentionally "shape their children's states to be very similar to their own states."

If a parent is triggered while their child is around, they may see their child as a dangerous person rather than a child, said Loewenstein. If he notices this pattern comes with violence, the first step is to intervene by alerting child protection services and potentially law enforcement. The child must be referred to a clinician with experience with trauma-related dissociation, and the whole family must be assessed for abuse, dissociative disorders, and other post-traumatic disorders like PTSD, he said.

The separation can stop a parent with DID from entangling their children in their self-states, Loewenstein said.

In treatment, he's seen mothers come in with grade school-aged children. If the child does something that angers the mother, he's watched the mother switch to an "angry violent state," which causes her child to enter "a terrified tiny state," where they become quiet and physically withdraw to block being attacked.

"Then you must intervene urgently to stop the assault. I've seen the parent and child both switch back and deny recall of what has just happened," due to apparent amnesia, Loewenstein said.

This behavior may indicated that a child has DID, Loewenstein said.

October 14, 2022: This story was updated to include more information about children with DID, including regarding imaginary friends.