"Okay, let's just calm down for a minute and I will try to answer your questions," Susannah spoke soothingly. "This is an alter who hasn't been out before?" Sam asked for clarification. "Yes, I'm sure this is an alter who has never been out before. He may have already been in the system or Todd may have split off a new alter or fragment and no, I don't think he is deaf. I think this alter is male and approximately three to five years old." Susannah explained and then went on. "I'm reasonably sure that this one has no language skills. I am also reasonably sure that this alter is autistic." Most of the staff had already figured that out, but Viki, Sam, Kevin and Téa looked at each other with fear. Susannah could feel their anxiety increase. She was afraid that, of them all, this alter's behaviors would be the hardest ones for them to cope with. Getting into his world and even more, getting him into theirs would not be easy.
*****
Susannah asked everyone to come to her office for the debriefing. Frank returned from his break and joined them. Susannah waited until Todd's family and her staff were settled and began to speak. "First I want to know if any of you have any questions or comments about the restraint? Anyone feel there could have been a better or different way to handle the situation?" "I don't think he would have calmed without sedation. He would not have held still on is own for us to administer it," Eileen spoke up. The others nodded in agreement. "You do all realize that this alter is probably very young and most likely autistic?" They nodded again. "Do any of you have more of an issue using physical restraints on such a young child?" Susannah asked and looked around. "I do," Janet spoke up. "I know it was necessary, yet it still disturbs me. He had no idea why we were doing that to him and he was terrified." Looking at Todd's family, Janet continued. "I hate to make this analogy, but it feels like when I take my cat to the vet. He has no idea why I'm holding him and letting this person hurt him. I don't think I will ever get used to having to do restraints on kids." "Would you prefer not to be involved in any future restraints?" Susannah asked. Janet thought for a minute "No, I understand it is sometimes necessary and at least he's being handled by people who care for him. That isn't always the case in some facilities."
Susannah understood how difficult doing whatever treatment was necessary for the very young alters could be. "I want you all to understand that it is all right if any of you have a problem with any particular aspect of Todd's treatment. I want you to always feel free to discuss it," Susannah made this clear to them. Viki spoke up. "I really want to thank all of you for the care you give my brother. I am happy to see that you do not take things like having to restrain him lightly. We are all very grateful for the level of care Todd is receiving." Some of the staff said thank you and some of them, not trusting their voice, nodded and smiled sadly.
"You were certainly right about seeing him cry out for his mother and beg her forgiveness. Man! That was a killer," Angelo stated, shaking his head at the memory. "It's normal for a child to think that they are the cause of everything that happens around them," Eileen commented. "Yes it is. Especially in a case like this, when the remaining parent tells them it's their fault," Terry added. "A child needs to have a reason for what is happening to them. The only reason Todd had was that he did something to cause his mother to leave him. If he had been a better or braver boy she would not have gone. Then finding her, only to have her send him back to his tormentor, did the most damage," Susannah added.
"Mom said something about another new alter coming out?" Kevin asked. "Yes, his name is Storm and he's nine. I believe he's been dormant in the system for a while." Addressing Todd's family, Susannah stated, "If you can, I would like all of you to hear the tape of the session I had with Storm and Todd. Then I will answer your questions about Storm and the things he and Todd disclosed before you came into the room. I'm sure once you hear the tape you will have many more questions." They all nodded in agreement.
"Susannah," Viki began nervously. "You couldn't get Todd back or reach any of the other alters. Can Todd stay inside this time? Can he be lost to us forever?" Susannah heard the fear in Viki's voice. "I don't think that will happen. I believe Todd and his whole system just need some time to stabilize." Susannah could see her words didn't reassure them. "You're still not saying it is impossible for him to stay inside forever," Sam wanted more reassurance and Susannah could not honestly give it to him. "No, I'm sorry. I wish I could tell you that it's impossible, however, there is always that possibility. I can tell you that it is unlikely and I don't believe that's what happened, but there is always that possibility," Susannah sadly admitted. Viki could see how frightened Tea looked. She turned to her. "Tea, I am afraid for Todd, but I know how Todd has fought to survive all these years. I also know how much my brother loves us and especially loves you. He'll be back. Todd doesn't abandon those he loves. He'll be back." Viki realized that she really believed every word she just said. She believed with every fiber of her being that Todd would come back. She began to relax a little. Sam still remained fearful. He kept it to himself.
Susannah turned to Frank. "Are you okay?" "Yeah, it just got to me a little. I'm gonna have to go ten rounds with the punching bag when my shift ends. Then Frank asked Susannah, "Do you think he'll digest the disclosure?" "I'm not sure. I hope so. Just his remembering is a huge step, unfortunately he was completely overwhelmed. The whole system may have been overwhelmed." "Do you think he just split off this autistic alter?" Terry asked. "There is a very good chance. This has been the most traumatic memory Todd has had. This alter could have been dormant in the system for a while, but I have a feeling that today's memories cased the split to just happen" Sam turned to Susannah. "We knew there was a danger of that happening. So what happens in the future! Todd has so many traumatic things to remember. Does he just keep splitting until there are hundreds of them!" They could all hear the fear and frustration in Sam's voice.
"As Todd begins to trust that we can keep him safe when the memories happen and begins to have confidence in his ability to handle them, meaning that he sees the world will not end if he remembers. He will start to feel stronger. Each time he makes it through, even with the help of another alter, it will help him. Right now not only doesn't Todd want to remember, there may be alters in the system who don't want him to remember, thinking something terrible with happen. The more it is proven to them that something terrible did not happen the less afraid they will be." "Did he react as strongly as he did because I was in the room and heard?" Tea asked. "Tea, I know Todd was upset when he realized that you were still there and heard what his father did to him, but I really believe he needed you to hear. Todd didn't just remember. He allowed himself to remember," Susannah explained and assured.
Kevin stood up and walked toward the window. He banged his fist against the wall. "How's he going to do it? How the Hell is he going to be able to remember all the things that were done to him and not go inside forever? I have to tell you, if it were me I could never do it." Viki walked to where Kevin stood. "Kevin, thank God you will never have to, but if you did you would get through it and so will Todd. If there is one good thing my father seems to have given us all it's the strength to survive no matter what is done to us. Sweetheart, don't sell yourself short. There have been a lot of very awful things in your life that you have survived, your dad dying, having Lee Ann take your son away, my illness, the fire. Please, don't be so hard on yourself." Kevin was surprised. He had not expected him mom to say that to him. Tears formed in his eyes. "My God! I need her praise and acceptance almost as much as Todd does," Kevin thought to himself, embarrassed by the revelation. Kevin hugged Viki and they both went back and took their seats.
"Susannah, are you sure this alter is autistic?" Sam asked. "No, not completely, but he has already displayed many symptoms of it and it is quiet common for there to be autistic and handicapped alters. They usually come out in a situation like this, when the host and the system are completely overwhelmed. It is very similar to the Baby coming out. No one else wants to come out, so this alter was either sent out or created." "Do you think he has any language skills at all?" Angelo asked. "No, I don't, although I can't really be sure yet. I don't know how much of what we say he understands either. I want to discuss his biting Steve. This alter probably has no concept of someone else's pain. He is not at all strong, physically, as those of you who participated in the restraint must realize, but assault precautions need to be in place. He has aggressive tendencies and will most likely continue to bite and lash out in various ways when feeling threatened and possibly when any demands are placed on him. We will try to reduce or hopefully eliminate those behaviors as quickly as possible. In the meantime, if possible, you have to manipulate yourselves environmentally so that you are not in a position to be bitten. I think handling him from behind is safest, for now. We will probably be doing a lot of hands on therapy with this child. If you need to lead him, lead him by his shoulders whenever possible. Try to place your arms or other body parts in a place that he can't reach with his mouth." Susannah turned to Tea, Sam, Viki and Kevin.
"How much do any of you know about autism?" They looked at each other and all admitted that they knew next to nothing. "If this child is autistic he seems to be in the moderate to severe range. Children with autism can be as different from each other as any typical child, but there are some characteristics that many of them have in common. The behaviors you saw this alter present with are some of them. There are different tools we use to diagnose autism. We use the DSM IV. With this, there are six criteria out of three lists that we look for. One of the other more common screening tools we us is CARS, Childhood Autism Rating Scale. Using a 7-point scale, we look for the degree to which the child's behavior deviates from that of a typical child of the same age. I will need to observe and assess this child the next few times he comes out, if he does. I have a feeling he may stay out for a while because of what Todd's memory may have done to the system. Just the fact that this alter was sent out tells me that Todd's system is most likely in total chaos and completely overwhelmed," Susannah surmised.
"He seemed to be in his own world," Sam remarked. "Quite often children with autism live in their own world. It is not by choice. They are isolated in their world. As for Todd, all the feelings he felt during the trauma he remembered today came back to him, the terror and fear, the extreme helplessness and humiliation. He couldn't handle them. If this child is autistic, he was probably created just for the purpose of keeping the world out. We are going to have to get into his world and try to reduce the stereotypic behaviors and increase behaviors like paying attention, using language, even if it's nonverbal like pointing, play skills and eventually eye contact. Most likely this little boy does not know how to play with toys appropriately," Susannah explained.
"Isn't autism neurological disorder?" Viki asked. "Yes, it interferes with normal development of the brain in areas that control verbal and nonverbal communication, social interaction, sensory and motor development. It is also four times more common in boys than girls. That is one of the reasons I believe that this child is probably male." "Do you think Todd has developed some kind of neurological disorder, in addition to the epilepsy or is this caused by the epilepsy?" Tea asked Susannah, clearly confused. "No, epilepsy doesn't cause autism. However, about thirty-five percent of all children with autism develop epilepsy, especially as they get older. There may be some neurological deficits in the brain when this alter takes over the body that causes this or it may be the need for an alter who is in a world of his own. Like the Baby, it is possible that this alter has never experienced abuse. That is why I feel that he may have just been split off."
"Is this a form of psychosis?" Sam asked. "No, autism is considered a Pervasive Developmental Disorder. The symptoms and characteristic behaviors present themselves in a wide variety of combinations and in any degree of severity. This alter may not present with all the behaviors, but as I said, he has already displayed some of them." "Was the odd way he looked at the window shade and at the candy one of the symptoms?" Viki asked. "Yes, some children with autism use their peripheral vision almost exclusively. I'm sure you also noticed his lack of eye contact." "He stared at the ceiling when Susannah spoke to him," Viki informed Kevin, who had not been in Susannah's office with them. "Was hitting himself and poking himself in the eye some of those behaviors?" Sam asked Susannah. "Yes, self-injurious behaviors and self-mutilation are a big problem with some children with autism. They sometimes use them out of frustration or fear. He may use them to avoid demands or to reduce stress. Some children self-injure or mutilate if they are in pain or uncomfortable in some way or sometimes just to gain attention. Very often in autism the senses are over or under stimulated and everyday things in the environment become extremely uncomfortable or even painful to the child."
Tea started to remember some of his other odd behaviors. "Was that why he sniffed and licked the objects on your desk and the toys and even your sleeve?" "Yes, he was looking for sensory input. He may also suffer from an over stimulation of some senses and find normal odors, tastes, sounds and images very disturbing," Susannah replied. "Was his playing with the window shade in your office a symptom too?" Sam asked, sounding curious and discouraged at the same time. "Yes, it was a repetitive, possibly a ritualistic behavior. Also, his inability to change direction and stop playing with it and the tanturming that followed are also stereotypic behaviors. He was completely resistant to any intrusion in his play.
Kevin's mind was racing and at the same time he was numb. He felt sick whenever he thought of what Todd had to remember. He could not fathom what it must feel like to remember that your own father forced sexual abuse on you. Kevin desperately wanted to learn how to help this little alter who had come out when Todd could not face his memories.
"Susannah, if there is a neurological component to this, isn't there some treatment or medication you can give this little boy?" "Kevin's right, there must be some kind of medication for autism?" Tea added to what Kevin had to say. "There is no specific cure for autism, and no one drug. Scientists are looking for abnormalities in the brain structures that make up the limbic system. Inside the limbic system an area called the amygdala is known to help regulate aspects of social and emotional behavior. One study of high-functioning children with autism found that the amygdala was indeed impaired but that another area of the brain, the hippocampus, was not. In another study, scientists followed the development of monkeys whose amygdala was disrupted at birth. Like children with autism, as the monkeys grew, they became increasingly withdrawn and avoided social contact. Differences in neurotransmitters, the chemical messengers of the nervous system, are also being explored. For example, high levels of the neurotransmitter serotonin have been found in a number of people with autism. Since neurotransmitters are responsible for passing nerve impulses in the brain and nervous system, it is possible that they are involved in the distortion of sensations that accompanies autism. One of the drugs that they have been trying with children with autism is Zoloft and some of the other SSRIs. As it can with Brina's ritualistic behaviors, Zoloft may also help the ritualistic behaviors of this child. They are basically obsessive compulsive behaviors like Brina's, if the child has them" "You're planing to start Todd on that anyway, so that's good. I mean that may help this child too," Viki commented, hopefully.
Susannah did not want to sound discouraging, nevertheless, she knew that there hasn't been that much success with this. "I hope so, but to date there has been no conclusive study done with this. What I would like to try with this child, if he is autistic, is called Applied Behavior Analysis. ABA is the only method with a study complete with a control group. It has been met with a lot of success. It is based primarily on B.F. Skinner's principles of operant conditioning and on behavior modification. Doctor Ivar Lovaas did the pioneering research with ABA." "What do you mean by behavior modification, like Pavlov and his dogs?" Sam asked, not liking the sound of this. "No, I know it sounds like that but there are many differences. I would like to explain the program I have in mind for this alter in detail. For right now, the basic idea is to reduce the undesirable behaviors and reinforce the desirable ones, to discriminate between different stimuli and to give him functional communication." Susannah knew this was going to be difficult for them to accept.
"There are some things you need to understand. If this child is autistic, there is a chance he is also mentally retarded to some degree. His IQ may only be in the mid-forty to mid-fifty range and there is a good chance it is under seventy." "No way Susannah!" Kevin spoke up, harshly. "Todd is a genius. I don't believe that any of them can be . . ." Kevin couldn't even say the words. Kevin was still in denial over the chance that Timmy may be suffering from a deficit in his intellect. He hated what was happening to all of them.
"Kevin, I'm sorry, I know it is difficult to understand. I'm not saying this definitely the case. This alter may not have a low IQ at all. I just want to prepare you for the possibility." Kevin shook his head, but kept quiet. He knew Susannah had to be wrong about that. He was more determined than ever to help this child.
"I don't understand, if this alter needs to be in his own world why not just let him be?" Tea wondered out loud. "Because it will be impossible to do treatment with him this way. Like the others he will eventually have to become a part of Todd. Just the way we have to help the others work through their particular issues and in a sense to grow up, we have to do the same for this child. Even the Baby will eventually have to be helped to mature, but we are looking far into the future. For now we need to help this child for himself. It is what is best for him. The behaviors you saw may be just the tip of the iceberg. If he has the full spectrum of stereotypic behaviors we will certainly have our work cut out for us."
"Susannah, I want to help. I want to work with this little boy in whatever way I can," Kevin volunteered. "I'm glad you feel that way. He will need all of us working with him. I think it may also be necessary to bring in a therapist who works with children with autism. I did some work with children with autism when I was in Switzerland. A colleague of mine had a child with autism and ran a program at the hospital where I worked. The work is intensive and he may need more than this treatment team to work with him. For starters, he needs to be assessed for some things, like what skills and abilities he already has, his developmental level, the severity of his autistic symptoms and his tolerance for intervention. Then, the first thing he needs to learn is how to learn. Many children with autism do not learn things the way typical children do. Most are visual learners. Some are auditory learners and some learn tactilely. We are going to have to find out which way this alter learns best. In essence we will have to retrain his brain. We also need to find out what precedes his behaviors, especially what precedes tantruming. As a first step I would like to do what's called a reinforcer assessment and a functional analysis. Usually the parents would draw up a list of what stereotypic behaviors they want decreased and what behaviors they would like to see increased. They would also have a pretty good idea of what is reinforcing to the child. What foods, toy's, games, video's, activities, things like that, the child likes to engage in. In this case, that is not possible because you are not familiar with this child. Functional analysis is used to determine the function of particular inappropriate behaviors. Then behavioral strategies are devised to reduce maladaptive behavior by using differential reinforcement of appropriate behavior and aversives to try to decrease inappropriate behaviors . . ."
"Susannah, what do you mean by aversives? You're not planning on having him punished in some way?" Viki was horrified by the thought. "No, not physically, ever! Aversives would be something like requiring him to do a boring task, or giving him a time-out, or withholding a favorite toy, or turning off the TV, perhaps a firm word. Even if he doesn't understand the words, he will begin to associate the tone with the inappropriate behavior, although, many of these children do understand even if they have no language skills to use. Screaming and crying may be one of the ways he communicates, especially if these behaviors increase around others. Once we have an idea of what function a particular inappropriate behavior serves and what reinforcers work best with this child the real work begins. We use differential reinforcement to reward the child's appropriate behavior and responses."
Tea needed some clarity on this. "What do you mean by 'differential reinforcements?'" She asked. "Every single time you see this child engaging in the correct behavior, in or out of a therapy session, you reinforce that behavior with verbal or social praise and at the beginning, a tangible or edible reinforcer or a preferred action like playing a game. We have to discover what motivates this little boy. We also reward by the quality of the child's response. If the child does something really big, something that was especially difficult or really puts extra work into something we would make a really big deal over it with our praise and we would probably double or triple the reinforcer or use a more powerful one. We also use DRO, Differential Reinforcement of Other Behavior. That would be to reinforce a substitute appropriate behavior for an inappropriate one. We will give him substitutes for some of his stereotypic behavior, which is what we call the autistic behaviors. For instance, if his licking of things persist, we may use Oral Motor Therapy. It will give him something appropriate to satisfy his need for oral input, something like a lollipop or even things like a sports bottle with a thick straw, or aquarium tubing to chew on. Sometimes this can also help if he has any tendency to bite himself, although it is not always helpful with that."
"Do some of these children do that?" Tea asked nervously. "Yes, self-injurious biting is common. There is also DRI, Differential Reinforcement of Incompatible Behavior," Susannah replied and continued. We try to engage him in something that makes engaging in a stereotypic behavior difficult. We need to do a reinforcer assessment to tell us what will work with him. A reinforcer is something that increases the probability of a behavior. The usefulness of a reinforcer is how the child responds to it. How much it motivates him to do the work. If he's not interested in it then it is not a reinforcer to this child. We already know he likes chocolate."
"At least this one likes to eat," Kevin commented in a joking tone. "You think this is funny!" Sam spat out. "No . . . I . . . Sam, I'm sorry, I was just trying to lighten the mood," Kevin was worried about Sam. He seemed to be jumping down everyone's throats these days. Viki took Kevin's hand and squeezed it. She looked at Sam. She could see he was already sorry for his outburst. "I'm sorry, Kev. I know you meant it that way." Sam apologized, hating the way he was feeling lately. Sam and Viki were both still having problems with the therapy Susannah was describing for this child.
