Game-Based Mental Health Interventions for Children

1. Game-Based Mental Health Interventions for Children Dr. Gavin Doherty, Trinity College Dublin Gavin.Doherty@tcd.ie Dr. David Coyle, University of Bristol

2. A global challenge • 1 million suicides per year (WHO). • Mental illness is leading cause of disability in the developed world (WHO, DALY). • Most people with mental illness do not receive the necessary treatment. • Greatly increase access to mental healthcare services • Increase levels of engagement with services • “Individuals with mental illness receive harsh stigmatization, resulting in decreased life opportunities and a loss of independent functioning over and above the impairments related to mental disorders themselves.” • Annual Review of Clinical Psychology (Hinshaw & Stier, 2008)

3. A global challenge

4. Mental Health and Children "Most mental disorders begin during youth." "Poor mental health is strongly related to other health and developmental concerns." "Most mental health needs in young people are unmet.” Patel et al., The Lancet, 2007.

5. Game-based interventions • Young people do not usually receive treatment through their own choice. • Many young people are interested in computer games • – promising strategy for increased engagement. • Even acting as an icebreaker can be beneficial. • Many approaches to treatment involve a psycho-educational component. • - rich, interactive delivery. • Disclosure effects.

6. Personal Investigator • Use in clinical sessions involving one therapist and one client. • Aims to support therapists in achieving broad therapeutic aims, including: • achieving and maintaining client engagement • relationship building • helping to create a context for more detailed conversations between client and therapist.

7. Personal Investigator Players are solution detectives, interacting with characters in the 3D environment, collecting keys and filling in a detective notebook. Includes videos with peer stories. Structured conversations – Brief Solution Focussed Therapy First clinical pilot (4 adolescents). Rebuild. Second clinical pilot (22 adolescents) D. Coyle, M. Matthews, J. Sharry, A. Nisbet and G. Doherty, Personal Investigator: A Therapeutic 3D Game for Adolescent Psychotherapy, Interactive Technology and Smart Education, 2(2), 2005. (Initial pilot)

8. Second clinical evaluation 8 therapists who used PI with a total of 22 adolescents Age range: 10 – 16 Difficulties including: • low mood/depression • anxiety • low self esteem • suicidal ideation • anger management difficulties • attention difficulties • bullying D.Coyle, G. Doherty, J.Sharry, An evaluation of a solution focussed computer game in adolescent interventions. Clinical Child Psychology and Psychiatry, 14, (3), 2009, (Clinical study).

9. Personal Investigator • Results suggest that P.I. can help in building an effective client–therapist relationship, can assist in structuring sessions, and can assist in improving client engagement in the therapeutic process. D.Coyle, G. Doherty, J.Sharry, An evaluation of a solution focussed computer game in adolescent interventions. Clinical Child Psychology and Psychiatry, 14, (3), 2009, (Clinical study).

10. Personal Investigator “The flexibility to use computer games instead of straight talk is valuable. It emphasises opening communication barriers and joining adolescents at their level. It provides a focus, and is in line with their interest level and adolescent methods of communicating.” “It [PI] helps to create a rapport and a three way dynamic. Therapist is not directly posing the questions. You sit alongside each other facing the problem. The computer screen becomes the third party in the room allowing sessions to be less directive and more relaxed, opening up the lines of communication.” “I feel PI does not have a life of its own. It is part of a team working together: PI - the therapist - the young person. The pace was not dictated by PI but by the whole team. “

11. PlayWrite – adaptable games PlayWrite: an application which allows MHC professionals to create or adapt therapeutic 3D computer games, which can then be used in adolescent interventions.

12. Authoring environment Therapist can easily edit the dialogues to be used in the game Common questionnaire options. Video easy to incorporate.

13. Designing for mental health Games created with PlayWrite .

14. GNAT’s Island – CBT for children • Cognitive Behavioural Therapy is the recommended intervention for a wide variety of mental health problems. • Involves meta-cognitive tasks which do not come naturally to young people. • GNATs Island produced by clinical psychologist. • Built around a series of conversations, which implement core aspects of CBT. • Designed to fully integrate with a 6 week manualised intervention for adolescents experiencing mild to severe difficulties. D. Coyle, G. Doherty, N. McGlade and G. O’Reilly, Exploratory evaluations of a computer game supporting Cognitive Behavioural Therapy for adolescents, ACM CHI 2011.

15. Designing for mental health GNATs Island Study Study 1: a multiple base line clinical study by clinicians independent of the design team ( n = 6). Baseline scores 8 and 4 weeks prior to treatment. Post treatment and 6 week follow up. YSR and CBCL. Session by session CSRS and WAI. Study 2: a member of the design team used the game as part of his own practice (n = 15) Study 3: a non-clinical study of acceptance rates and impressions amongst child and adolescent mental health professionals (n = 216)

16. Designing for mental health GNAT’s Island Clinical Study Case Example 1: 10 yr old boy: CBCL DSM Scales

17. Designing for mental health GNAT’s Island Clinical Study Case Example 2: 11 yr old girl: CBCL Anxiety Scale

18. Designing for mental health GNAT’s Island feedback All 5 clinicians said they would like to continue using the game 4 of 5 would recommend the game to a colleague 3 expressed a preference for using the game in a flexible manner Clinicians All 6 adolescents rated the game as helpful All 6 felt they had changed in some way 5 of 6 would recommend the game to a friend Clients

19. Designing for mental health Second clinical study • Expectation management played an important role in client’s acceptance of the game. • Additional action oriented game play would be beneficial at the end of sessions, but not during sessions. • Open questions generate conversations, multiple choice questions provide checkpoints. • Provide matching technology options at follow up sessions. • Transitions between paper and a computer can have a jarring effect, but paper options should be included. • A parental role needs to be carefully considered.

20. Designing for mental health Professional survey • 13 workshops • Lasting 90 minutes each, and including a full walk through of the game • 216 clinicians – all work with adolescents, 54.7% use CBT on a regular basis.

21. Designing for mental health GNAT’s Island - summary The game: • Had a positive effect on the client-therapist relationship • Reshaping the dynamics of the therapeutic interaction • Helped to create a context in which adolescents could engage more easily with the therapeutic process and with the clinician. • Provides an overall structure and active process. • Uses elements of fun and concrete representations of difficult concepts, to make the CBT process more suited to the developmental needs of adolescents.

22. Designing for mental health Best practice - interaction design • Designing high quality software applications can be difficult at the best of times. • Requirements and work analysis • User centered design • Focus on understanding context of use • Obtain input from real users • Validate and evaluate designs with real users. • Prototype quickly and repeatedly evaluate. • Participatory design

23. Designing for mental health What are the problems? • Can’t use usual development processes: • Loosely defined tasks • Ethical constraints • Difficult to talk to end users • Very slow evaluation cycles • Danger of producing unusable and unengaging technology. • If you get technology development wrong, all evaluations can show is that you got the technology development wrong. • Formative vs. Summative evaluation. D. Coyle, G. Doherty, J. Sharry and M.Matthews, Computers in Talk-based mental health interventions, Interacting with Computers, 19(4), pp.545-562, 2007.

24. Designing better systems • Needs analysis of both clients and therapists • Collaborative design • Roleplay with therapists to explore issues • Workshops to develop ideas • Iterative development/rapid prototyping • Formative and summative evaluation • Usability evaluation – peer evaluations • Significance of first small clinical pilot • Guidelines • Design for outcomes • Make systems adaptable and sustainable • Provide flexibility in development of support G. Doherty, D. Coyle and M. Matthews, Design and Evaluation Guidelines for Mental Health Technologies , Interacting with Computers, 22(4), 2010

25. Collaborative development • Development of technology platform(s) • Development of individual therapeutic programmes. • Different evaluation processes and timescales. D. Coyle and G. Doherty, Clinical Evaluations and Collaborative Design: developing new technologies for mental healthcare interventions, Proceedings of ACM CHI 2009.

26. Adaptable, sustainable, scalable • Tailor content to • Specific disorder • Working methods and context of therapists • Local client group • Individual client • Reduce overhead in • Adapting and updating content • Writing new programmes • Dissemination.

27. Conclusions • Games are promising as an integrated part of in-person delivery for children and adolescents. • Balance between gameplay and therapeutic goals. • Use in a group setting would also be worth exploring. • No one treatment will suit everyone. Huge variety in disorders and client groups. • Need to get development right if we are to learn anything from trials. http://www.scss.tcd.ie/Gavin.Doherty http://www.scss.tcd.ie/misc/TMH