The 'little men' with a big impact on autism
Ian was only 12 years old and in his first year of high school, but he was in a state of social and emotional crisis.
His teachers described him as insolent, lacking respect for authority, having problems with his peer group and poor temper control. They also reported that his attention in class was poor, as were his concentration and organisational skills.
When Ian was assessed by educational psychologists, he scored highly on anger, anxiety, stress and depression.
He said that he had no "friend-making skills", and therefore no friends, and that he was being bullied, and he seemed incapable of understanding the feelings or perspectives of others.
Psychologists concluded that Ian had Asperger's syndrome and was at risk of suicide.
Tasked with turning things round was Anne Greig, an educational psychologist in Argyll and Bute.
"I could not get him to engage at all - nobody could," she says. "But the little I knew about him was that he loved cartoons."
A favourite of Dr Greig's from her own childhood was the cartoon strip, The Numskulls, featured in The Beano comic book.
The Numskulls - Brainy, Blinky, Radar, Snitch and Cruncher - live inside the head of a boy called Edd and control his actions. But sometimes they arecareless, mischievous or fall asleep, leading to all sorts of problems for Edd.
Dr Greig began to ponder how she might use the cartoon strip in her sessions with Ian.
She decided to combine the principles of cognitive behavioural therapy (CBT) - which encourages a person to think in new ways that can have a positive impact on their feelings and behaviour - with the use of cartoon strips.
When she returned to her office, she asked her colleague Tommy MacKay if he knew whether The Beano was still in print. By chance, he happened to have a copy of the latest issue. The pair began to develop Dr Greig's fledgling idea and in June this year - some 10 years later - The Homunculi Approach to Social and Emotional Well-being was published.
"Homunculi" is Latin for "little men": the approach involves children creating characters who help them to problem-solve, develop social skills and regulate their thoughts, feelings and behaviour.
To tackle his problems, Ian created five main characters dealing with moods, sleep problems, friendships, communication and motor tics - they were called Moody, Couch Potato, Gaffa, Chatterbox and Twitch. Moody helped Ian to stop being aggressive or shouting, going into a bad mood and hurting inside. Couch Potato helped him to get to sleep. Gaffa looked after facial expressions. Chatterbox helped Ian to know when to stop talking, take turns and be interested. And Twitch's job was to stop nervous tics and jumpiness.
Special gadgets were allocated to each character. For example, Gaffa had a friendship repair toolkit. Meanwhile, a "head homunculus" was always on patrol and ready to pick up the signs of when problems were in danger of arising. He also had a "good rule book" that contained advice about problems, written in the form of social story scripts (for example, one was about how to get a good night's sleep).
Therapeutic sessions - which took place once a week for 10 weeks - involved working through a specific problem visually, using relevant characters and an array of gadgets.
All characters and gadgets were detachable and could be moved around to enact the problem storyline. The evolving story was recorded, providing a record of the session that could be used later to create, for instance, a cartoon strip as a homework exercise.
The impact on Ian was impressive. Before the intervention, he had clinically significant scores for anxiety, depression and stress; anger was also a problem. Later, his scores were average for his age.
These improvements in Ian's emotional well-being translated into better behaviour in class, with his teachers expressing far fewer concerns.
Ian, meanwhile, reported that the homunculi worked for him in real situations. He indicated that certain difficulties had subsided to the extent that he no longer needed two of his characters. He also developed the skills to establish a group of friends.
Mental health problems such as stress, anxiety and depression are far more common in young people with autism than in the general population, but there are few appropriate interventions, says Professor MacKay who, as well as working part time as an educational psychologist in Argyll and Bute, is visiting professor of autism studies at the University of Strathclyde.
The Homunculi Approach plugs this gap, he believes.
Professor MacKay, who is also clinical director of the National Diagnostic and Assessment Service at Scottish Autism, argues that the assumption is too often made that mental health issues are part and parcel of autism but that this need not be the case.
"CBT is now an evidence-based therapy for children on the spectrum," he says.
But this form of therapy, needs to be adapted in order for it to be suitable for children with autism - and that is where the homunculi approach comes in, says Professor MacKay.
"You can't just take the way that CBT operates for the general population and transpose that on to the autistic population - it needs to be done differently and modified," he explains.
The homunculi approach is highly visual and creates a script for managing problems - a working method that has already been shown to work well with children on the autism spectrum.
"There is also a lot in it that young people simply find enjoyable, which is important because if you are enjoying a programme, you are more likely to engage with it," Professor MacKay says.
The approach can be delivered by anyone and is suitable for young people aged 8-18.
Professor MacKay adds: "There is a tremendous gap in resources to address the counselling and therapeutic needs of those who are on the autism spectrum or who have related difficulties. This cannot be left to the scarce availability of psychologists and accredited therapists.
"Materials are needed that can help teachers, support workers, professionals in many different specialisms and parents in supporting young people's needs."
CBT is also recommended for the treatment of many childhood problems and is often the first choice in treating children with depression.
One in 10 children and young people has a diagnosable mental health disorder, according to research published in 2005 by the Office for National Statistics, but only a small proportion of them receive any form of specialist help, with estimates ranging from 10 per cent to 21 per cent.
The homunculi approach can also benefit young people in this population, Professor MacKay says.
In 2008, he and Dr Greig published research examining the impact of their approach on a mixed group of more than 30 young people, ranging in age from eight to 18.
Half were on the autistic spectrum, while the other half had a wide variety of problems, including exam stress, friendship problems, low self- esteem and depression.
After taking part in the programme, self-ratings on these target areas showed significant improvement, and again scores on anger, anxiety, depression and stress fell considerably, reaching levels that compared favourably with figures for the general population. The statistical analysis of these results showed that they were highly significant and that a real change had taken place for these young people across all the included areas of difficulty.
Earlier this year, a further trial of the homunculi approach took place at Hermitage Academy in Argyll and Bute, involving a group of 22 S1 pupils with a wide range of needs but who had all struggled with the transition to secondary school.
Dr Greig explains: "The idea was to put something in place that would be preventative, so we weren't picking up these youngsters in a year or two with adjustment and mental health issues."
Initial findings indicate that the young people's self-efficacy - their ability to complete taks and achieve goals - has improved.
Full results comparing their progress with a control group at Oban High will be published before Christmas.
The Homunculi Approach to Social and Emotional Wellbeing was published in June by Jessica Kingsley Publishers
1 in 100 - The prevalence of autism in children and adults based on recent studies.
6,506 - The number of children in Scotland diagnosed with ASD.
1 in 10 - The prevalence of mental health disorders among children and young people.
10 - The number of years it has taken to produce the homunculi approach to social and emotional well-being.
AUTISM IN BRIEF
Autism is a lifelong developmental disorder that affects people in various ways, but all those with the condition will have in common difficulties in three areas of functioning, sometimes known as the triad of impairments. People on the autistic spectrum will have problems with communication, social interaction and restrictive and repetitive routines of behaviour.
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Original headline: Meet the `little men' who have a big impact on autism