Children Who Hear Voices

Lynne Malcolm: Hi, it's All in the Mind on RN, I'm Lynne Malcolm. Today:

Reading: Did you hear that? Help for children who hear voices.

Lynne Malcolm: Most parents would be familiar with their child talking to imaginary friends or their favourite cuddly toy in play. It's seen as a natural and important part of the development of children's imaginations. But, what happens when a child's world of make-believe seems to become a reality?

Reading: Turning nine years old two days ago was going to change my life. Things are going to be different, including my science grade…well, at least I hope so. I was sitting at my desk at school when my teacher, Mr Jones, handed me my science test sheet. I turned it over and barely finished reading the first question when that thing happened again. I couldn't believe it, that dreadful thing happened again! I thought to myself, I'm so weird. I was so scared to tell my counsellor that I heard a voice. It was so hard to talk about. The voice I heard belonged to a man, a one-legged pirate actually. He harassed me and I wanted him to stop. A lot of the time I felt like I was going to lose my mind.

Reading: Meet Carlos. For quite some time Carlos heard and saw two voices. One was a fire-blowing dragon that made hissing noises, and the other was a terrible which who had a menacing laugh.

Reading: Lala heard a voice too. Soon after her mother's passing, Lala started seeing her mum's figure and hearing her voice, especially at bedtime. From time to time Lala even talked back to the voice.

Reading: Chang heard a voice too, Mr Charley Charles. Mr Charley showed up whenever, wherever and however he wanted. Chang felt scared each time the noises and voice showed up. He felt like he was being harassed and bullied by Mr Charley.

Lynne Malcolm: Excerpts from the children's book Did You Hear That? by child psychologist from Singapore, Dr Seetha Subbiah.

Seetha Subbiah: The book is actually a very child friendly book, it's got lots and lots of illustrations. Although it covers a very heavy topic, it's simplified and it reads like a storybook. It's an interactive, dynamic book, where the main character is Susie, and she shares with her readers her experience and her frustrating experience with voices and how her parents and teacher helped her to realise that it's not bad, it's not wrong, it's not weird, it's not odd if you are hearing voices.

And they don't realise that she is hearing voices at first, but they do realise that she is struggling with something, and because they couldn't figure out what it was they encouraged her to see a counsellor and that there's no taboo to it and it's okay to go see one. And they finally take her there, and after some time the therapist is able to help her verbalise what's going on and normalise the fact that she may be hearing voices and helps her understand why the voices came about, when they came about and what was sustaining it, and helped her decide what she wanted to do with the voices and to set goals and help her achieve her own goals.

And then Susie goes on to introduce four other kids from different cultures and different countries, different backgrounds, but they all share something in common and it's the voices.

Lynne Malcolm: Dr Seetha Subbiah has 22 years of international experience in clinical psychology, treating children who've had trauma in their lives. In the course of her work she has found that some children hear voices that aren't there as a type of coping mechanism. One particular little girl inspired Seetha Subbiah to write a book for children who hear voices.

Seetha Subbiah: Having worked with kids that heard voices, I couldn't find anything in the market to use to help these kids normalise the experience, there were no clinical tools out there. But in 2003 I came across one child, the first child for whom I had to fight very hard to help her in the way that I thought she could be helped and needed to be helped, only because she had already been in treatment for six years and she had been passed on from one therapist to the next and one psychiatrist to the next. And by the time that I met her I was told that she is a lifer on medication because she was taking a concoction of medications. And they said it won't take too much of your time, just spend 10 minutes and just make sure she is taking her medication once a month and just send her out, there is nothing that can be done.

So I took on the case, and after I met her for the first time I said, no, there's something really going on with this child, I can't possibly just spent 10 minutes and shoo her out of my office, because right from the waiting area she wouldn't acknowledge me. She was there with her foster mother, there was no emotional reaction, no physical reaction, she just stared straight at the wall and sat military style with her arms right angled to her body and was very stiff. But she walked into the treatment room with me and she just had a very glazed look. No response for the whole hour, nothing, not a twitch of the eyebrow, I didn't even see her blink. She must have blinked but I didn't see her blink. And I said, no, something is not right, I've got to try and figure out…yes, I have a thick file with all sorts of notes in there and no one really knows what's going on with her, so they've tried different kinds of medication, but I'm going to pretend like there's nothing there and I'm going to start from scratch. So I worked with her for 2 ½ months before I got a reaction, and it was just a split second look, glance at me, and that was it.

Lynne Malcolm: When you say you worked with her, what did you do?

Seetha Subbiah: For the first 2 ½ months?

Lynne Malcolm: Yes.

Seetha Subbiah: I tried to rule out everything. Could she see? Vision? I walk right in front of her, she would not even track me with her eyes. Could she hear me? Can she understand my language? Can she understand my accent? Then I gave her options to leave the room if she didn't want to be there. But she didn't leave, she just sat there, and I said, okay, maybe she doesn't want to walk out right in front of me, so I'll go out for 10 minutes, I'll come back in 10 minutes and you can leave during that time. If not, when I come back then I'll just gather that you want to be here because I'm setting aside this whole hour, it's your hour, you get to choose and decide what you want to do and I will be here, and any time you're ready you just let me know.

So initially I would just sit there and try and engage her and I would just look at her, and I figured maybe that was just too overwhelming. So I said, well, I'm not going to be looking straight at you because that may be making you uncomfortable. What I'm going to do is I'm going to bring my work in, I'll bring my work in and I'll just sit here, I'll be looking at my books, and whenever you're ready you just give me a sign, show me a hand signal. I tried all of it, your eyes, blinking your eyes twice means this and once means this, hand signal, move something on the desk. And it took me 2 ½ months, and the first thing she did was give me a glance.

So then after that I said, okay, maybe it's because she is on so many different medications she is just very sedated and had a very blunted affect. So I tried to convince the psychiatrist that she was working with to see if she could titrate the medications, so lower the medication, because I needed something to work with, I needed some emotion, I needed anger, sadness, happiness, something to work with. There was just nothing, blank.

So I managed to convince them and they said, well, go knock yourself out, nothing is going to happen, I give you two weeks, I'll titrate it down just a little bit. If you don't see anything, then that's it, we will go back on. But thankfully she gave me some reactions within two weeks and she started engaging, not verbally but nonverbally, through drawing exercises, just showing that she wanted to connect. I would make a mark on the paper and she will make another mark on the paper. And so we went back and forth like this, and then she started manipulating toys in the room.

And so as treatment went on, it took about two years to complete treatment, and during that time we slowly titrated the medication back all the point where it was just almost nothing there. And I started to realise that she was hearing voices, had been hearing voices, and the reason why she was sitting military style right from the start was that she was trying with all her might, every single hair on her body, to try and control the voices so that she could engage with me and engage with school, engage with home, engage with other kids. She was like a zombie going to school, and everyone just accepted that that how she was and was going to be. She was failing her subjects, she didn't have any friends at school, didn't communicate with her foster family or her siblings. She was basically like a walking vegetable for those number of years.

And by the time she was done with treatment, teachers were saying that they didn't recognise this child, this is some other child, because she was getting As and Bs in school and she was laughing, playing, had friends and had sleepovers with friends, and friends would stay over the whole night, they didn't find her boring. And she was engaging with her foster family, and she seemed like a regular kid.

Lynne Malcolm: So what do you think had happened to the voices that made her non-communicative to start with? What happened in the process of the treatment with you?

Seetha Subbiah: It took quite a bit of work for her to figure out when the voices started. And before she entered the foster system in the US she had been subjected to quite a bit of abuse in her biological family, and that's why she was taken away from the family and placed in a foster family. So it was as a result of that abuse and the reaction to that abuse that she started hearing the voices. At first it was entertaining and enjoyable, they kept her company, she missed her family. And then it started becoming very intrusive and problematic and frustrating and overwhelming because she no longer had control over the voices. They decided when they showed up, how they showed up, why and how long they stuck around before they left.

Lynne Malcolm: And so how did you will help her manage those intrusive voices?

Seetha Subbiah: So she had to decide what she wanted to do with the voices, what role she wanted the voices to have in her life. And based on that we went forward. She wanted to get rid of them completely, so we proceeded along those lines and tried to figure out a whole bunch of different things that she could try to see what worked for her and what didn't. So she called them a bag of tricks and experimented with various things, like writing down what the various voices said and tore them up and threw them out, got babysitters in to keep an eye on the voices while she needed to do things. And talking to the voices and explaining to them that she will attend to them at a later time when she was available, et cetera.

Lynne Malcolm: So she took control of the voices, in a way.

Seetha Subbiah: Yes, she did.

Reading: After several weeks of talking to a counsellor, I realised that the voice I heard had something to do with a really bad experience I had when I was younger. I told my counsellor I still wanted the one-legged pirate to disappear completely. We brainstormed to see how I could deal with him. Some ideas we came up with didn't work and others did. I like to call the things that worked for me my tricks. Can you believe it? After four weeks I didn't feel so afraid and terrified. He finally stopped pestering me, I no longer felt so angry. I felt like I was in charge.

Reading: Carlos knew he was not crazy. He understood that his voices were trying to protect him from feeling uncomfortable and sometimes scary emotions like anger, sadness and fear. When Carlos felt that the dragon and the witch were too much to handle, he used several tricks. After some time, the witch and the dragon didn't bother him so much.

Reading: Lala is four years old. Six months ago her mother died quite suddenly. Soon after her mother's passing, Lala started hearing her voice, especially at bedtime. Her father became really worried after the third time he heard Lala talking to no one. Finally he took Lala to see a counsellor for help. After some time, Lala started explaining to her counsellor that mummy had to go because she was sick and the doctors could not do anything more to help her. Now I get to spend more time with my daddy. Just like my mummy, daddy loves me a lot.

Lynne Malcolm: You're with All in the Mind on RN. I'm Lynne Malcolm, and you've been hearing excerpts from the children's book Did You Hear That? Help for Children Who Hear Voices, by child psychologist, Seetha Subbiah.

She explains what's known about why children begin to hear voices.

Seetha Subbiah: There are lots of different reasons. Although hearing voices and seeing things that are not there, which are auditory and visual hallucinations, which are hallmark features of schizophrenia…schizophrenia is something that cannot be diagnosed until an older age…there are many other reasons why children may be hearing voices and seeing things that are not there. Trauma is usually a very large group of people. So trauma can come in the form of sexual abuse, physical abuse, emotional, psychological abuse, or it can just be a very jarring experience, not necessarily a tsunami or a reaction to an earthquake, but it can be just standing at the street corner and you see a car accident that was very alarming to a child. So that's one large group. Then another group of would be grieving children. Then sometimes as a result of depression or bipolar disorder you might hear voices. Substance abuse is another one, as a result of illicit drugs or sometimes even drugs that are given, like morphine in the hospital, you might end up seeing things are hearing things that are not there.

Lynne Malcolm: So your particular area of expertise is helping children who have been impacted by child abuse. What role does voice hearing play in that trauma?

Seetha Subbiah: There are no two children that I have seen that have presented the voice hearing exactly the same way or as a result of their early experiences will experience voices in the same way.

For some kids, the voice may take on the persona of the abuser. Sometimes it can be of the victim, so themselves. Sometimes it may have nothing to do with any character they might have come into contact with. And sometimes it is just a feeling that is so overwhelming and challenging for them to hold themselves and take responsibility for that, that is kind of packaged and parcelled out and projected out. And either immediately or at some point in the future it takes on a persona, it takes on a voice, a character. And for some kids it could be one voice or one noise, and for some others it may be three or four, and others it can be 10, 50 or 60. So when I say noises, it could be static noises, it could be phone ringing noises, it could be someone just calling out your name.

And it's so far off that only people who have experienced trauma will know what it feels like. All of us have that experience. Sometimes you think the phone rang and it didn't, or someone called you from the other office, you will go over and no one called for you. So like everything else, like depression, sadness et cetera, there is a continuum. And for voice hearing also there is a continuum. So many of us have had that kind of experience once in a while, or at least minimum once in a lifetime, but if you multiply that by 100 or 200 then you can kind of imagine what people who hear voices on a regular basis feel. So not only that they hear voices, but they are intrusive and challenging, overwhelming voices.

Lynne Malcolm: So what's your impression of how many children do experience voice hearing?

Seetha Subbiah: That's a great question. I don't know the exact numbers, and that's because this area has been a very neglected area for a long time, so there hasn't been much research done in the area. One of the numbers that I've come across is the Hearing Voices Network which is a large international organisation now, estimates that there are 280 million voice hearers throughout the world, and that includes adults as well.

My first version of the book was completed in 2006 and at that time my peers in the US asked to use this book, and it is Microsoft Word format with no pictures in them. And so first they started using it in a very targeted manner, introducing the book to only kids who heard voices. Then they decided to just leave this book lying around in the treatment room. And when that happens they noticed lots more kids who were gravitating toward the book, despite the fact it had no illustrations, and they started drawing pictures in there and started talking about voices that they had been hearing. Although the presenting symptoms, so the reasons why they came to the clinic in the first place had nothing to do with voices, there were other reasons, and they had been working with these kids for a year and never knew about the voices until they came across this book.

So then they started giving me feedback, that there are far more kids that hear voices than we ever thought. And we need to reach out to more of these kids because for some reason they think it's either not relevant or it's not appropriate to talk about the voices, and maybe culture has something to do with it, maybe what they are introduced to when they are really young, for example Mickey Mouse, Donald Duck, they will talk about someone being coocoo if they are hearing voices or talking to themselves, and so very early on they think it's something that is not socially acceptable and it's weird if you are hearing voices, and they hold back that information. And if that's what is going on then we really need to reach out to the kids and help normalise it. And so then after that is when I started getting more pressure to formalise the book and actually publish it.

So to answer your short question, I don't know exactly how many kids there are, and also culture plays a part in it and whether the community and society within which a child hears voices either celebrates the voice hearing or thinks it's problematic, and to what extent it's problematic.

Lynne Malcolm: So tell me a little bit more about the range of cultural responses to voices. I know your background, you're from Singapore. How, for example, is voice hearing seen and responded to in your background?

Seetha Subbiah: We are a multiracial and multireligious, multicultural community, so there are lots of perspectives and there are lots of subcultures within our communities. And so it depends on which community the child may come from. For example, Taoism which originated in China, there are Taoism mediums, they call them mediums. So a god or a goddess will come through that person and communicate to the people through that medium. And that is considered acceptable, and people actually will celebrate it and go and visit people who are mediums.

Then there are various religions, like Hinduism, that it's common for people to go into religious trances. It may be momentary but they are trances, and no one thinks anything of it. And if it's a Catholic family and if a child is hearing voices, then they get very concerned and they will consult with the priest, and typically an exorcism is what would be in order. So depending on which culture the child is from and how the family reacts to it, we may see them in the clinic or we may not see them in the clinic. And it's not actually the voice hearing that is the problem per se, it is the reaction to the voice and how one responds to the voice that becomes a problem.

What we've discovered is that there are lots more people out there who hear voices than actually we see in the clinic. So how do these people who hear voices and don't show up in the clinic survive and manage to go through their life, and then others find it challenging to get through daily life and doing what they need to be doing every day.

Lynne Malcolm: How would you like this book to impact the way people approach children who may be disturbed in some way, and perhaps the way they are treated?

Seetha Subbiah: I think the most important thing is to help find out why a child is hearing voices, and what may have been at the genesis of it, because that will help you understand as a clinician what the approach should be and the direction. And for families and just society in general to not mock the experience, not to label them very quickly as childhood schizophrenics, because thus far the first line of treatment for schizophrenia has been medication, and medication has side-effects. So I believe that we should try everything else first before we go to that. And by giving medication, not only could they suffer the effects of the medication, side-effects, but they may never end up getting the real treatment that they need, which is to try and understand where this came from. Because usually they are not born with it most of the time, so it shows up at some point. Why did it show up, when did it show up. And allow the child to gain control of it and decide what they want to do with it, as opposed to us deciding.

Lynne Malcolm: And one of the other things that you've included in the book are…you call it interactive because you've included little questions to the reader at the bottom of the page saying have you ever experienced this, do you think this is weird, questions like that to try and engage the child reader in thinking about it. Is that a particular strategy that you decided was going to be helpful?

Seetha Subbiah: Yes. Because there were no tools like this out there, I wanted to make sure that I made it really simple and engaging, that even a clinician who hasn't had training in knowing how to treat this sort of condition, the book will kind of guide you through it. And having worked with children in treatment, they can be very, very persistent. They so desperately want to be understood by adults that they will keep repeating and repeating and repeating until you get it. So even if the clinician were to miss it and not know which direction to go in, if it's right in front of the child, these questions are being asked, it's my belief that they will keep repeating it until the clinician will get it.

So I wanted the book to be as far reaching as possible, so hopefully any child that picks it up will find someone or something in there that they could relate to. The questions is one of them. Others may respond to the illustrations. So each child is completely different. Each family background that the child is from is completely different. There are kids with disability, there are kids who are chubby, there are kids who are skinny, there are kids who look like Barbie dolls. The stereotype is that if you look a certain way then you are protected from everything, but that is not necessarily true. So this is one of those things that I think will be good for kids to understand and accept that people are different and that we shouldn't marginalise them and we should normalise and accept them.

Lynne Malcolm: So what response have you had to the book so far?

Seetha Subbiah: Completely surprising. I had intended it as a clinical treatment tool, but I recognise and realise that kids who don't hear voices are finding it very interesting and they find that they can relate to it as well because there are so many emotions that are being talked about and challenging experiences, and every child has a challenging experience, not necessarily voice hearing, but they may feel marginalised or not accepted for something else, whether they are short or tall or curly hair or straight hair et cetera. And so lots more people are talking about it. An interesting request was for movie rights, which I had never thought this book would lend itself to, but there it is.

My hope and wish is that this book will reach every child that may be suffering in silence or alone somewhere in the corner and help them and help their families, and especially kids who are not able to verbalise what may be going on with them and they are struggling with it, that they can come out and get help for it, and it's not a bad thing, it's not a weird thing, it just is, and it's trying to tell you something. The voices are trying to tell you something. So don't ignore them, and just attend to them, and life can be good and happy with voices.

Reading: You know what? I'm not the only one. There are many other kids who hear voices. Would you like to understand and manage your voices like Carlos, Chang, Lala and me? If talking to someone and using tricks don't help with managing the voices immediately, don't give up, there are other things that can help you. Don't forget, it takes a lot of courage to talk about voices. It took each of us some time to learn about the role voices played in our lives and then how to cope with them. It was hard for all of us. You're not alone, just keep at it. We did it and so can you. Wishing you all the best in your journey.

Lynne Malcolm: Thanks to Mika Nielsen, Ada Saydam and Aparna Hari for the readings from the book Did You Hear That? Help for Children Who Hear Voices, by Dr Seetha Subbiah.

You'll find further details on the All in the Mind website.

Production today by Diane Dean and sound engineer Simon Branthwaite. I'm Lynne Malcolm. Thanks for your company, until next time, bye for now.

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