Professor Lina Gega, Professor of Mental Health at Hull York Medical School and the Director of the Institute of Mental Health Research at the University of York, and Dr. Hiran Thabrew of the Te Ara Hāro, Centre for Infant, Child and Adolescent Mental Health at the University of Auckland, New Zealand, talk about the CAMH Special Issue in this Papers Podcast.
Lina and Hiran are two of the editors of the CAMH Special Issue ‘Technology and Mental Health for Children and Adolescents: Pros and Cons’ and they have written the Editorial ‘Control alt delete – technology and children’s mental health’ doi.org/10.1111/camh.12631. There is an overview of the CAMH Special Issue, and their editorial, and the implications for practice.
Discussion points include;
- Evidence into technology’s ability to act as a force of good and also a source of harm for young people’s mental health
- Why minimisation of technology related harm is as important as maximisation of technology related gains
- Need to move beyond dichotomous narratives about technology and how we might achieve a more nuanced stance
- What understandings emerge in terms of gender, diversity, and socio-economic status in relation to techn and mental health
- How collective responsibility can make a difference in the way technology is used to protect and improve mental health
- Whether academics should collaborate with digital companies to improve young people’s mental health
- Advice for CAMH professionals and policy makers.
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Lina is Professor of Mental Health at the University of York, in a joint appointment with Hull York Medical School and the Department of Health Sciences. She holds an honorary clinical appointment as Nurse Consultant in Psychological Therapies at Tees, Esk & Wear Valleys NHS Trust.
As a senior member of the Mental Health and Addiction Research Group, she leads two research themes: Digital Mental Health and Child and Adolescent Mental Health. In her role as Chair of the Postgraduate Programmes Board at Hull York Medical School, she oversees the progression of masters and doctorate students and the quality of taught and research programmes across the two host Universities. Her expertise is in the clinical utility of digital media as means to specialist interventions in mental health. Her recent work focuses on improving practice and outcomes for children and young people affected by mental health problems. Previously, Lina was Programme Director for Cognitive Behaviour Therapy and Branch Lead for Mental Health Nursing at King’s College London, where she received a College Teaching Excellence Award, a College Teaching Fellowship and a Vice Chancellor’s nomination for a National Teaching Award. She served as Clinical Lead for the commissioning (Norfolk) and provision (Northumberland) of psychological therapy services in primary care and the community. Currently, she is Joint Editor for Child and Adolescent Mental Health (CAMH), having previously served as Guest Editor for Frontiers in Psychiatry and Associate Editor for Cogent Psychology. (Bio from Health Sciences, University of York)
I am a Child Psychiatrist and Paediatrician at Starship Children’s Hospital, Senior Lecturer and Postgraduate Course Coordinator within the Department of Psychological Medicine, and Director of Te Ara Hāro, Centre for Infant, Child and Adolescent Mental Health. My research interests include psychological problems experienced by children and young people with long-term physical conditions (chronic illness), eating disorders, autism spectrum disorders, COVID-19 related childhood mental health and the use of technology to improve the mental health of children and young people. (Bio from the University of Auckland)
Jo Carlowe: Hello, welcome to the Papers Podcast series for the Association of Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.
Today I’m interviewing Lina Gega, Professor of Mental Health at Hull York Medical School and the Director of the Institute of Mental Health Research at the University of York, and Dr. Hiran Thabrew of the Te Ara Hāro Center for Infant, Child, and Adolescent Mental Health at the University of Auckland in New Zealand. Lina and Hiran are two of the editors of our recent CAMH special issue, “Technology and Mental Health for Children and Adolescents, Pros and Cons” and they have written the editorial, “Control Alt Delete – Technology and Children’s Mental Health.”
If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did with a rating or review, and do share with friends and colleagues. Lina and Hiran, welcome. Thanks for joining me. Can you each start by introducing yourselves?
Professor Lina Gega: Hi, Jo. Thank you very much for inviting us to speak with you. I am Lina Gega. I am a nurse and a psychological therapist by background, and I lead the Institute of Mental Health Research at York, which brings together over 30 departments, and schools, and offices of the university whose work relates to mental health.
Dr. Hiran Thabrew: And I’m Hiran Thabrew. I’m a child psychiatrist and paediatrician. I completed my medical training in the UK and moved to New Zealand 20 years ago, and I’ve been a researcher for the past 10 years and interested in finding new ways to improve children’s mental health, especially using digital technologies.
Jo Carlowe: Lina, can you start by telling us about the CAMH special issue? What are some of the highlights?
Professor Lina Gega: This special issue, really, is a collection of over 20 articles on the topic of technology and mental health for children and adolescents. So the articles are original research studies, and evidence synthesis, and some opinion pieces that capture both the bright and the dark side of the digital world in the context of child mental health. But the collection of articles sort of try to give a balanced perspective between the protective or therapeutic functions of technology and its added value.
But also, they consider some of the risks and potential or actual harms. And the second part of your question, in terms of the highlight, I think the thing that struck me more in this special issue is that it capture the international community. We had contributions from countries like Denmark, Peru, Italy, Turkey, Estonia, Russia, Canada, in addition to sort of US, and Australian, and UK that feature quite often in scientific papers.
And this is quite apt given that technology transcends, really, geographical boundaries. And although we may have cultural and political differences across the world, I think when it comes to children’s mental health, we all unite in our anxieties about the risks of digital media but also are sometimes counting our blessings that we are now able to use technology to communicate with our children but also to educate them.
Jo Carlowe: Thank you. Why this particular focus on technology and children’s mental health? What makes this an important enough area to warrant its own special issue?
Dr. Hiran Thabrew: Well, children and young people these days are growing up as so-called digital natives, and they’re spending a significant portion of their time using personal devices for study, entertainment, and socializing. And as such, we’re seeing an increasing impact of this technology use on their well-being and mental health. And there’s been a lot of discussion amongst clinicians, press, and even the public about whether technology is beneficial or harmful to children and young people’s mental health.
So in this special issue, we’re trying to actually look at the evidence that underlies that answer, essentially. And we also have suggestions for how we can increase the benefits and reduce the harms associated with the technology that Lina was just mentioning.
Jo Carlowe: The pandemic put the spotlight on technology. How has it changed our understanding about the influence of technology on children and young people’s mental health?
Professor Lina Gega: It’s true that the pandemic was like an unplanned natural experiment of using technology really quickly and massively to educate children, give them health care, social care, engage them in recreation and social interactions. And actually, three of the papers in this special issue feature examples of the impact of the pandemic on children and adolescent mental health. My take on it is that for specific groups of young people, the mental health effects of the pandemic have been negative, for example, children living in adverse family circumstances where technology is not available, or is not a safe space, or is not sufficient to meet their needs.
We also know from one of the papers in the special issue that teenagers with poorer social support had more problematic internet use and, as a result, sleep problems. But then there was another group of young people for whom the pandemic had positive effects on mental health. And technology was instrumental for this because it enabled children and young people to carry out activities and stay connected with friends.
Jo Carlowe: And as you’ve both already mentioned, the CAMH special issue offers insights and evidence about technology’s ability to act as a force of good and also as a source of harm for young people’s mental health. Can you talk us through some of the harms and also some of the benefits?
Dr. Hiran Thabrew: Sure. So, I’ll start with the benefits first. There’s numerous obvious benefits of technology. Most people use it for entertainment and for relaxation, but also, in terms of health, it’s quite useful as a source of education, both about how to preserve one’s well-being and also how to identify mental health issues when they arise and/or what kind of treatments might be available. So this is what we call health literacy.
Technology is also very useful for connection and support. In fact, one of the studies by Rebecca Anthony and colleagues in our special edition showed that this is most likely to be helpful when it’s obtained from real world known friends rather than online strangers. Technology can also be useful for identifying mental health issues in a timely manner through electronic screening, for instance, and also providing treatment at a timely and cost-effective manner.
And this could be to children and young people directly through online therapies, or e-therapies, as they’re called, but also to parents. In this special edition, we’ve got a couple of studies by Palmer and Green that showed that parent-directed online therapies were actually helpful for preventing and reducing childhood anxiety, for instance. Having said all that, there are a number of harms of technology that we’ve identified and that we’re aware of which impact children’s mental health.
First and most important is distraction from the real world relationships, and this just includes people spending so much more time on their devices that they’re spending less time engaging directly with each other. And there’s even a concept called phubbing, which is phone snubbing, where people might snub each other by being more on their cell phone, sometimes even parents that’s phubbing their children.
Doomscrolling is something we’re much more aware of since COVID. I think just constantly being exposed to what’s happening in the world can be interesting, but when there’s difficult things going on, it can also lead us to become more anxious and affected by this news. Contagion is another possible side effect of technology use. We know, certainly, for people of all ages and particularly for young people, there’s increased chance of developing issues such as self-harm, say, when you know other people who were experiencing the same issue.
In the past, contagion used to be geographically limited, but these days it seems to be global and more mediated through technological connection between individuals. There’s also falsification of self-image and increased pressure to be perfect, something which is particularly relevant to the onset of eating disorders. Cyberbullying, doing online gaslighting is an increasing problem as well, and numerous social media companies are trying their best to address this while also allowing their platforms to be used in a more open and transparent manner by everybody.
And then there are some newer concepts such as digital self-harm, where people post negative things about themselves online– this is something quite recent– just in order to gauge how other people might respond. I don’t think that many clinicians would be aware of digital self-harm. Please do read the article in the special edition. And then last but not least, gaming and online addiction, which I think people are more familiar with.
Jo Carlowe: In the editorial, you say minimization of technology-related harm is as important as maximization of technology-related gains. Can you elaborate on this and give some examples, perhaps, or suggestions of how to combat harms or promote gains?
Professor Lina Gega: It’s a good point because as researchers, as clinicians, we need to define the problems we’re trying to solve or the questions we are trying to answer. For example, one issue that was raised is that my child spends too long gaming or on social media. But I think the issue or the question here is whether they feel lonely, or angry, or depressed, or anxious, or whether they’re falling behind at school. And then gaming or social media is just one factor that may feed into their vulnerable, emotional state or is a distraction or avoidance, but it may also be a bridge that connects them with people and things that are important to them, or a means by which they can access therapy.
So in this instance, minimizing technology-related harms would be for the child to change the nature of their interaction with technology, so from passive, watching other people’s videos or social media posts, to active, which is through reconnecting with family members, or learning a skill, or doing something creative, like building their own website.
Jo Carlowe: We’ve talked about harms and gains, but in your editorial, you say we need to move beyond dichotomous narratives about technology being good or bad. How might we achieve a more nuanced stance?
Dr. Hiran Thabrew: I think that’s probably the crux of the editorial. And it’s very tempting to get caught up in a polar argument about whether technology is good or bad. And really, it’s merely a vehicle for helpful and unhelpful content and behaviours. It’s also merely the latest in a series of changes which we as humans have had to adapt. Once upon a time, I’m pretty sure that people thought that people spending all their time reading books would be terrible for them because they wouldn’t get the– they’re getting enough physical exercise and fresh air.
And then when television came along, it was thought to be terrible because people were no longer spending time reading books. And now that the internet and smartphones are here, we’re all saying the same thing about those devices. The fact is, things always change, and we have to adapt to them. And as technology is here to stay, and in fact, likely to play a much larger part in our lives and the lives of future generations going forward, we need to understand and harness its uses and also try to mitigate its dangers.
One of the key challenges in doing this is the rapid pace at which technology is changing, compared with the pace at which research is undertaken. So, we probably also need to work out how to conduct sound research in a much more efficient manner to keep up with new technology.
Professor Lina Gega: I completely agree with Hiran. And this reminded me of a point that a colleague made, who came from not from a mental health background but from a technology background. And he sort of said that he was surprised of how we treat technology as a single entity because he said it’s like talking about electricity. It’s everywhere, and it would be strange to talk about it as a single thing. So a more nuanced stance would be to consider technology in context.
Like, if we look at the motivating elements of digital games, for example, like unlocking rewards and getting a digital bonus, this motivating element would be brilliant for a teenager with depression that needs positive reinforcement to progress through a gamified therapy program, for example. But this digital reward can become a gambling problem for teenagers who are prone to addiction. And other young people diagnosed with depression, interestingly, one of the papers in the special issue highlighted that they find it more problematic and more difficult to regulate their digital engagement, but this is when it comes to entertainment games rather than our therapeutic games. So I think it all comes back to who is using what, to be able to assess harms and gains.
Jo Carlowe: From the body of research covered in the special issues, I’m wondering what understandings emerge in terms of gender diversity and social economic status as it relates to the use of technology and mental health in children and young people. Just in that last comment, you were sort of pointing out that it really depends on individuals often.
Professor Lina Gega: That’s right, and it is individuals not only in terms of the clinical need and the particular problem that they’re experiencing or symptoms they have. And it was interesting, actually, gender came out of several papers as an important factor in this. And girls and women are often disadvantaged. One of the studies from Slovakia found that problematic technology use was more likely to be linked to cyber bullying for girls, but not for boys.
And another study from Wales, UK found that virtual-only friendship groups have a negative impact on girls’ mental health but not boys’. In a third study— and it’s really interesting because the study was from Turkey and reported that the mother’s education but not the father’s was associated with cyberbullying in their children. And interestingly, the authors explained this by saying that better educated mothers may have more high-powered jobs or they spend more time outdoors and less time with their children.
But the finding and its interpretation is biased. It highlights, though, that gender expectations, pressures, disadvantaged girls and women, even in the digital world, other sort of factors like in terms of diversity, socioeconomic status– and there are usually assumptions that digital interventions have the risk of excluding young people from, for example, low income families or from minorities.
But one really good quality systematic review in this issue found that digitally-enabled interventions are promising for meeting the mental health needs of marginalized children and young people. And they looked at Aboriginal and Indigenous youth in New Zealand and Australia, homeless young people in the US, adolescent girls living in the slums of India and less economically developed areas in Indonesia. So from across the world, there is really this glimmer of hope that digital media may provide mental health care for those who perhaps wouldn’t have access to it otherwise.
Jo Carlowe: In your editorial, you conclude by saying collective responsibility can make a difference in the way technology is used to protect and improve mental health. Who are the stakeholders here? With whom does this responsibility lie?
Professor Lina Gega: My mind, there are three groups of stakeholders– of course, the technology providers, the people who design all the digital media, the social media platforms, like gaming companies. And there is the end users, so the children, the young people, and their families. And finally, the third group is all the different agencies within the wider society, regulators, law makers, academics, who disseminate evidence, public services like schools and health care.
And of course, there is a personal responsibility we’re all having as parents and as clinicians. And also, empowering young people to take responsibility is a good thing, but children and families have different resources. They live under different circumstances. So, this is where the collective responsibility comes in to support and protect those whose circumstances put them at a disadvantage or make them vulnerable at some point in their lives.
So this is where the companies and the regulators really need to be responsible to protect– for example, I mentioned teenagers, and gambling and addiction linked to loot boxes in games. But also, schools and community organizations need to prevent exploitation or cyberbullying by educating young people on digital safety and digital citizenship.
Jo Carlowe: And you mentioned CAMH professionals there as well. What advice or thoughts do you have for CAMH professionals listening to our conversation?
Dr. Hiran Thabrew: So, I think there’s a number of messages for CAMH professionals. I work clinically and most of my colleagues, I would say, did not grow up as digital natives and were not familiar with technology in the way that young people are. Basing this advice on that audience, I think that CAMH professionals need to firstly think about asking about technology when conducting assessments with children and young people, not just about the time spent on devices but also what kind of apps they use and how it thinks they affect them because there might be positive effects from the use of those apps, for instance, being able to gain social connection, which will be protective for them.
There might also be harms in terms of some of what they’re exposed to which makes them feel less good than they should be or makes them get ideas for what else they could be doing when they’re not feeling great. The second thing I’d suggest is to familiarize themselves with available and evidence-based digital interventions. It’s useful to try things out yourself before recommending them because otherwise, it’s hard to understand what these treatments or therapies are.
It can be useful to show young people what these therapies look like before recommending, so actually show them your smartphone, get them to download something on their phone, and just walk them through it on the opening screen. And you can also support them to use and complete e-therapies. One of the key issues with e-therapies in the real world compared to research settings is that people often start them but don’t complete them.
If therapists can support the completion of those e-therapies, they’re much more likely to be successful. And at the end, if and when they do complete them, ask for feedback and feel free to pass that back to the people who develop those e-therapies as well because I’m one of those people, and we always want to know how we can improve what we’re doing.
I’d also suggest to you– I mean, you can use technology in many ways to support engagement with face-to-face therapy. So thanks to the pandemic, I think we’re much more open now in clinical services to using things like text, and email, and Zoom to check in, to make appointments, to undertake sessions with young people and families. And that’s a great thing, I think, to continue going forward. But mostly, for clinicians, if they don’t feel tech savvy enough to do some or all of these things, it would be useful to ask colleagues for help or try and invest in some locally available training.
Jo Carlowe: Lina, a question for you, really, the same question but focusing on academics, there is debate around whether academics should collaborate with digital companies to improve young people’s mental health. What are your views on this?
Professor Lina Gega: That’s an important question, Jo, and four of the papers in the special issue actually discuss it. And there are two themes that emerge. One is design decisions, and the second is data ownership. So really, how can we enable collaboration between academics and digital companies but keep transparency and integrity? So, the first theme, in terms of design decisions, my view is that we should encourage academic collaboration with digital companies because the industry needs to become more evidence-based and attuned to ethical issues.
But also, academics need to become more industry-savvy so we can influence design decisions from the perspective of the public good. Case in point from my own experience, one of our software engineers at the university said that after working with me on a game for children with phobias, he now spontaneously thinks how would this affect children who are emotionally vulnerable when he works on other games unrelated to mental health.
And this is something that hadn’t crossed his mind before. So developing a bit of insight in mental health just has a generalized effect in his other practice. And then the second issue, that is data ownership. And that’s sort of– I mean, I know companies may have ulterior motives, and they only share things that serve their interests. And researchers may have their own interests in advancing their career.
So there are complexities. There’s also things that have to do with data confidentiality, commercial sensitivity. But aside all that, I think data sharing arrangements between companies and academics should be encouraged. And we just have a lot of things that they can mitigate, all the risks and all the barriers, because data sharing has been happening for decades with pharmaceutical companies, and we do have best practice guidelines.
So I think by enabling access, we can answer very important questions because the industry has massive databases. And then this access should be open, so then researchers and academics from different perspectives could look at the data, and they can produce a more balanced perspective, and findings, and interpretation of the effect of digital technologies on children’s mental health.
Jo Carlowe: Thank you. Is there anything else that feels important to highlight, that we’ve not covered, as it relates to technology and young people’s mental health?
Professor Lina Gega: There is something that I was thinking. I think it’s sort of evident from the papers that will be featured in the special issue– is that we do need to involve more children and teenagers as research advisors, our sort of patient and public engagement activities. Now, this is happening in the UK to some extent, but it is not always representative of the different social groups that we serve as researchers or care professionals.
Children and young people are far more savvy and insightful when it comes to technology and mental health compared to a middle aged professor. So we need to give a voice to more of them, and to be inclusive of different walks of life, and also to make the outputs of our research more accessible to young audiences. And digital technologies and creative media are a great way to do this.
Dr. Hiran Thabrew: I completely agree. I think we’re certainly recognizing the importance of co-design of anything we create with young people and the intended audience. But also, we know that there’s no such thing as a homogeneous group of young people, based on previous studies which have identified user segmentation, that different groups of young people have different needs. This might be in terms of their age, but it also might be in terms of their cultural or socioeconomic background.
So it’s very important, when you’re trying to design interventions or therapies to help particular groups of people, that you design them in a way with the key intended audience and in a way that reduces rather than increases inequity.
Jo Carlowe: Is there anything else in the pipeline for either of you that you’d like to share with us?
Professor Lina Gega: There’s just one interesting project that I’d like to mention. I’m involved with it, but it’s led by my colleague, Professor Paul Tiffin at the University of York, and he is an adolescent psychiatrist. So, it ties in with what Hiran mentioned earlier about the challenge of doing research in an efficient way. And this project is about using machine learning as a way of showing whether an intervention or a policy that aims to improve mental health in young people, whether it works, without doing a long randomized controlled trial that takes years to complete.
So Paul is using algorithms that analyse existing large data set, that can predict how different groups of young people may respond to these interventions or initiatives that aim to improve mental health.
Dr. Hiran Thabrew: And here in New Zealand, we’re doing a number of things with digital technology in the mental health space. Both myself and colleagues are studying how we can use particularly app-based technology, chatbots, and other forms of tech to help young people learn skills to manage and preserve their well-being, both in high school and other settings, but also in the hope that it will prevent the onset of mental health issues.
We’re also trialling apps for helping young people experiencing low mood, self-harm, and suicidal ideation to receive time and support from family and friends. And these are people they know, but just make it easier to get that support. And that app has been nationally released. But also, I think we’re starting to kind of explore ways in which we can improve mental health clinician comfort and awareness of digital interventions, so that the children, and young people, and families can be offered these therapies as part of standard care.
Jo Carlowe: Finally, a question to you both, what are your take home messages for our listeners?
Professor Lina Gega: We usually ask our children, how did you do at school today, or how are you feeling? And for children and young people, the digital world is an extension of their physical and internal world. So, I think our conversations with them and the questions we ask clinicians or as parents on a day-to-day basis should always include their digital world.
Dr. Hiran Thabrew: Yeah, and I hope that the papers in this special edition will stimulate clinicians to discuss with their colleagues how technology may be an important factor leading children and young people to present at services but also a useful element of treatment planning, both in terms of limiting related harms but also optimizing the potential benefits of digital information and therapies.
Jo Carlowe: Fantastic. Thank you both so much for talking us through this CAMH special issue. For more details on Professor Lina Gega and Dr. Hiran Thabrew, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review, and do share with friends and colleagues.