This blog post is a summary of our CSCW 2018 paper “I just let him cry…: Designing Socio-Technical Interventions in Families to Prevent Mental Health Disorders” by Petr Slovák, Nikki Theofanopoulou, Alessia Cecchet, Peter Cottrell, Ferran Altarriba Bertran, Ella Dagan, Julian Childs, Katherine Isbister.
You can also see the follow-up JMIR Mental Health paper here.
Whether you are a child or an adult, the ability to keep calm under stress and cope with strong emotions is really important. In fact, research shows that self-regulation skills are associated with crucial life outcomes — such as how wealthy and healthy you are, or whether you end up incarcerated — with similar correlation sizes as those shown for IQ or your socio-economic status. Moreover, children who are good at these skills early on have a much smaller likelihood of developing mental health conditions later in life, including depression, anxiety, or conduct disorders.
Our research, described in the CSCW 2018 Best Paper, is one of the first to examine how technology could help children and their families develop these crucial skills as part of ‘universal prevention interventions’. These programs are deployed to large populations (e.g., as whole school approaches) to promote and reinforce personal strengths, rather than being targeted to children already manifesting problems. While such programs are already widely deployed (e.g., used in more than 25.000 US schools) and proven to ‘work’ in large-scale RCTs, they are still very resource intensive and lack scaleable techniques to get beyond classroom-based learning and support children in the moments that matter.
What did we aim to do?
We wanted to understand how we might design technology-enabled interventions that could address two assumptions that underpin these challenges of cost and out-of-class facilitation: First is the expectation that learning needs to rely on didactic in-person workshops, with the implication that children have to then ‘apply’ the skills when needed without further support. Second is the assumption that such programs need to be ‘adult-led’, with the children being taught by a trained adult (whether that is a parent or a teacher in school).
Our work suggests that neither of these two needs to be true: through a fundamentally user-centred design process, we developed a proof-of-concept intervention that is inherently child centred (i.e., the intervention empowers the child directly rather than through an adult) and situated (i.e., the learning and support happens during the moments when the skills are needed).
How did we do this?
We started by interviewing parents and children in a particular low income community to understand how they currently deal with emotional moments. What are the strategies that seems to be helpful and what seems not to work? What are their beliefs about emotions and what support do they offer each other if a strong emotion arises?
We then contrasted the findings — showing avoidance & distraction as the key strategies—with literature across Prevention Science and Developmental Psychology. We wanted to understand how common such strategies might be in other populations (very common, unfortunately); and what the longer term impacts might be (highly maladaptive and a strong risk factor for mental health illness).
Drawing on this understanding of what parents/children do (and what psychologists would like them to do) we started exploring the possible design space. In particular, we observed that the most common approach was to expect that children will ‘wait out’ the effects of strong emotions by themselves, often in their personal ‘calming down space’. We decided to orient around design around this everyday experience.
What did we build?
Over a number design iterations, we converged to a notion of a worried pet — a ‘lost’ creature, who is often anxious and can be soothed by calm, stroking movements. This particular choice of narrative was aimed at creating a sense of relationship between the child and the toy, drawing on the interactivity and interdependence of the creature: we hypothesised that framing the creature in need of assistance would draw on the psychological effects of calming down by soothing someone else; and the in-the-moment soothing effects of doing so might result in a shift in the children’s beliefs around emotion regulation over time (i.e., they will realise they are able to control emotions, at least to some extent).
The resulting prototype takes the form of a hand-crafted plush toy, which was designed to travel home with the child from school. The interaction relied on a number of sensors embedded in the ‘creature’ that registered haptic interactions with the toy. In addition, a small vibration motor was used to indicate the creature’s state by mimicking a frantic ‘heartbeat’. If the creature was calming down in response to the child’s touching of the sensors, the heartbeat slowed down and eventually turned into happy purring.
The figure below outlines both the sensor/actuator functionality, but also hints at the theory of change, i.e., how and why we expected the intervention to work. The full paper outlines this in much more detail, including the theoretical grounding.
So … does it work?
We first deployed these prototypes with 14 families for 3 to 4 days (together with a photo diary), interviewing the children afterwards. Our findings indicate that even in the limited amount of time children had the toy at their homes, all children appeared to form a strong emotional connection which in turn drove consistent daily engagement. Moreover, the children’s interview responses as well as the photo data suggested that playing with the `creature’ not only had a soothing effect, but that the children also explicitly engaged with it to calm down.
“I also discovered this new thing. Whenever you leave him alone and you’re very far away from him, he actually gets really anxious. [. . . ] But I would actually never, ever, ever, ever, ever leave him in his nest alone.”
“He made me calm down by just lying on top of me. He just makes me calm down, I don’t know how. He just does.” [C3]
- “Normally when I have a row with my sister I just go back to bed and watch TV, but [the toy] — cos you’ve got to hug her and stroke her, take breaths in and out — it helped a lot.” [C4]
We’ve since further replicated this finding with week-long deployments with another 13 families, including pre-/post- interviews with parents, with similarly strong engagement and soothing effects manifesting for children and parents.
Mother of a 7-year old boy:
“Honestly, a lot calmer. An awful lot calmer. Especially considering he just got back to school, so his anxiety is heightened anyway. He hasn’t had any belly aches or accidents in the past week. And the baby talk has really gone down as well… So he’s really… Having creature at home.. he’s almost completely calm. Honestly, it has been brilliant, really.
I think it’s the control. Because he can’t control his own feelings, but he can control creature’s. So when creature’s upset, he can make him calm down and it makes him feel better… I think that’s why he loves it so much.”
What we find particularly interesting is that such strong engagement, soothing effects, and intricate narratives about the (projected) emotional life of the creature are all generated by an exceedingly simple internal model:
a 6-state machine representing the `emotional state’ from anxious to calm, with a single counter linearly progressing across these.
While we are already really excited about the results so far, there is still plenty of work to do to develop this proof-of-concept into a full intervention: This goes beyond the possible usefulness of our little `lost alien’; more importantly, we see this data as providing a preliminary validation for the situated interventions model more broadly.
This is important within the wider landscape of mental health interventions, where the emphasis on preventative approaches is currently surging both across academia (cf. image on the left) and policy domains. For example, a recent Mental Health Policy Commission report in the UK argues that “without a concerted focus on prevention and early response, meeting demand for young people’s mental health services by scaling-up existing provision would require an extra 23,800 staff at a cost of £1.77 billion — which is clearly unrealistic in terms of funding and recruitment.” Similarly, just within the last 3 years, OECD and WHO published reports highlighting the importance of self-regulation and other socio-emotional protective factors on people’s wellbeing and mental health; and a number of US states mandated social-emotional learning into their curriculum.
The situated interventions envisioned by this paper could potentially lead to an entirely new mode of prevention intervention platforms that are fully embedded in people’s lives and provide contextualised support. This might not only make preventative interventions more effective, less expensive, and more empowering for those who are using them— it could also become as a gold-mine for the fundamental social science research by providing previously inaccessible data to formalise our understanding of the basic developmental processes leading to (mal-)adaptive coping strategies, decomposing existing programs into `intervention kernels’ and testing their efficacy, and rigorously examining the impacts of social interaction on psychological development.
We hope to inspire others across HCI and mental health communities to explore the this exciting research space with us: we’ve already successfully applied these techniques in the context of teaching conflict resolution in Minecraft (with Katie Salen at UC Irvine); and are in process of examining how situated interventions can reposition stress coping interventions for university students.
So if you think that the notion of situated interventions could be potentially useful in a topic area you are working on, please do get in touch — we would love to help as much as we can!
Petr Slovak (@ozzulak, p.slovak [at] ucl.ac.uk)
Katherine Isbister (@kcisbister)