Cognitive Behavioral Therapy for Children

It was really inspiring to hear from the Edison Learning team about their program. They developed an entire online learning system from the ground up, and they are still planning and implementing new ideas. With my own project for the class, I'm inspired to move beyond the summaries and readings, and take the next step into developing a solution.

To help clinically depressed children, I could focus on prevention by promoting activities like healthy eating and lots of outdoor exercise. Or I could develop a system for treating existing depression, based on established therapy techniques. In order to focus my project specifically on the marginalized population (children with depression), I'd like to tackle treatment options first, and see what I can find.

I wanted to take a look at cognitive behavioral therapy, or CBT, which is one of the most widely used treatment methods for clinical depression. In fact, CBT has been used successfully with children, and it is often recommended for various mental health disorders in young kids and adolescents. Although there is no specific protocol for CBT (it refers to a wide umbrella of treatments), it tends to rely on several key principles:

• Systematic and goal-oriented
• Time-limited treatments
• Focus on here and now
• Focus on alleviating symptoms

If you think about it, many of these characteristics make CBT a natural choice for mobile or web-based interfaces. Its goal-oriented nature can be channeled into games or directed puzzles, much as Edison's goal-oriented modules direct students toward understanding of a particular concept. Time limits are easily placed on computer-based activities, and many computer programs have a here-and-now focus. Plus, with an emphasis on alleviating symptoms, progress can be concrete and measurable.

In terms of the ABCD approach we learned in class, I found an interesting set of specific behavioral goals from the American Institute for Cognitive Therapy. After completing therapy, children should be able to:

• Recognize and modify irrational and self-deprecating thoughts.
• Adopt more appropriate and/or positive responses to their own and others’ thoughts and feelings.
• Improve listening, social, and problem-solving skills.
• Plan positive/pleasant individual and social activities.

Here are a few techniques used in CBT that could be easily translated to the web:

- Keeping a diary of events and feelings: The web is already a useful tool for journaling and recording thoughts, and it would be an interesting challenge to develop an online journaling system specifically for managing childhood depression.

- Questioning assumptions and beliefs: People learn many cognitive skills from the Internet, including critical thinking and questioning what they see. I could imagine a game based on rejecting beliefs that don't make sense, and accepting ones that do.

- Gradually facing avoided activities: People often use their mobile devices to set reminders for themselves or plan activities. Perhaps an application could be designed to systematically propose new activities (such as exercise or social interaction), gradually encouraging the child to try them for a reward.

- Relaxation, mindfulness, distraction: Stress management is a big part of both prevention and treatment for depression. There are hundreds of stress management programs online, and along with soothing video and audio collections designed to enhance relaxation. I wonder if I could design a web-based relaxation system especially for children.

As it turns out, there are already a few computer-based therapy programs, collectively referred to as Computerized Cognitive Behavioral Therapy (CCBT). These programs have the advantage of being less intimidating than talking to a therapist, less expensive than paying for sessions, and more accessible for people who would have trouble getting to a doctor's office. Children often fit these criteria very well, having little to no disposable income and not much personal freedom without their parents. The National Institute for Health and Clinical Excellence (NICE) has described a set of guidelines for using CCBT, and preliminary studies have suggested that it can be a successful supplement to existing treatment programs.

Computerized therapy initiatives have been developed for a number of mental disorders. Specifically for depression, NICE recommends a program known as "Beating the Blues," which consists of 8 sessions of self-help treatments. The program is described as follows:

"They work through cognitive modules which focus on the identification and challenge of automatic thoughts, thinking errors, distractions, core beliefs and attributional styles. Interwoven with these cognitive elements are problem directed behavioural components where patients can work on any two of activity scheduling, problem solving, graded exposure, task breakdown or sleep management according to their specific problems. The final module looks at action planning and relapse prevention."

Although I can't access Beating the Blues without making a payment and performing a screening over the phone, I might send an email to request access for my project, because I'm curious as to how the program works. There's also a free program called Mood Gym, which I'd like to check out as well.

To develop my next artifact, I'd like to take advantage of the principles of cognitive behavioral therapy to reach out to children, especially those who want help but aren't seeing a therapist yet. I'd like for my web-based system to emphasize education: teaching kids the skills they need to manage depression. Hopefully I can pull inspiration from Edison Learning and other online educational programs to make an effective treatment tool.

Digital Artifact Debrief

Class Presentations

Last week, we presented our first digital artifacts for marginalized and underprivileged populations. I was impressed to see such a wide variety of topics, and so many ways to discuss them: videos, Powerpoints, websites, posters...I enjoyed seeing the circumstances and populations people are passionate about. The presentations came from all over the place, from rural America to the far reaches of Africa and India. Seeing so many situations in which getting a good education can be difficult or impossible, I realized that our own niche in the system is the exception, not the norm. Only a few people have the chance to grow up in upper-middle-class America and attend fancy universities. It's nice to see that despite our mostly privileged backgrounds (and certainly privileged in terms of education), we still have the desire to reach out to those who don't share these opportunities. I'm curious to see how all this information will be translated into a second digital artifact.

I chose to explore childhood depression in schools, and I used a mind map as a presentation tool. It seemed to go pretty well, and I think people got most of the points I wanted to express. To find out everything I could about childhood depression, I looked through lots of different resources and articles. I was surprised at how little we still know about depression in general, and especially how it affects children. Given the devastating effect it can have on a child's education, it's certainly an area that could use more research.

Drawings / Process

I want to share a little bit about how I put together my artifact. I had a good time constructing the diagram and the website, since I enjoy visual thinking, and my past few blog entries have been focused on how people lay out information. I started with some drawings, and built them into a map and webpage framework:

Lots of icons to go into the map:



What the full map looks like:



Website screenshots:





A lot of little details go into the actual implementation, like the Flash plugin for the images and little Javascript goodies for the mouseover effects. These are always some of my favorite parts, because they offer a tricky set of little challenges, but they really give that something extra to a webpage.

Ideas for Digital Artifact #2

So now what? Now that I've gotten a decent overview of childhood depression, naturally I want to keep finding more resources, but ultimately turn this information into something that can help people. There are lots of organizations out there designed to spread awareness about mental health, but I wonder if there's something more active I can do? In the spirit of the presentations I heard last week, I'm optimistic that technology can be used to make a real difference to people who are suffering.

I had a few ideas of what I could do about the problem of depression in schools. It seems impractical to tackle the whole thing at once, so perhaps I could focus on a few elements that seem manageable. For example, I found that depression is often ameliorated by healthy food and exercise, especially for children who are prone to obesity. I'd like to develop a game that would encourage kids to play outside and eat healthy food. My current idea is based on what my siblings and I used to play when we were little: set up outdoor "restaurants" with snacks, and ride our bicycles between each one. If I could place this kind of game in some sort of framework where lots of kids could use it (such as a website or application), it might help kids go outside and eat healthy snacks...two for one.

Still shuffling through some ideas, but I hope that in the next few weeks I come up with something exciting and concrete.

To the drawing board

As a thought experiment, I imagined I was in charge of designing a new, better information management system. How would I organize things? What would I include? What would I change? The way we handle information is crucial for how we learn, and perhaps a better system would help people retain information and learn new things more quickly.

My design specs:

After checking out some organizational tools, I considered their key elements that could inform my own design. If I were to construct a visual information system, it would have to include these features:

Large volume of information: It's important to include the flexibility of systems like Jira and EndNote, which can handle as much information as you care to throw at them. This is the Achilles' heel of MindMeister and Comapping. I would love to see a visual information system that could somehow include tons of bookmarks and links without becoming chaotic.

Icons / graphics: The plain interface of EndNote makes me yawn...I love the punchy visuals and colorful graphics, like the ones at 37signals (see image further above).

Visual layout / structure: Long lists and endless spreadsheets tend to make information blur together, and as the paper about visual mapping (Kim, first post) demonstrates, people learn more when they can organize in a more visual way.

Collapse / expand: I was pleased to see that the mind maps allow you to expand and collapse their information. This feature is useful in Jira as well. To keep from being overwhelmed by information, it would be nice to allow users to selectively view chunks of data at a time.

My sketches:

If I were to make the ideal visual organizing system, what would it look like? Here are some different ideas I was thinking about...

I'm not planning to make a fully-functional information system, but it's useful to think about what design principles make such tools easy to use. And actually, it would be nice to incorporate some of these elements into my presentation on Wednesday, to make the information more memorable for my audience.

Evaluating some new tools

I was pleased that we went over concept mapping in class, getting some practice with mind maps and checking out some new websites (comapping.com, mindmeister.com). I thought I'd look a bit deeper at these sources, along with some other information management websites that are starting to become popular in schools and workplaces. A few impressions:

37signals: Love the visual nature of this website, home of small-business solutions Backpack, Highrise, and other "make work easier" systems. 37signals has specific tools and interfaces for different types of data: people / important contacts have a system, tasks / projects have a system, and so on. I liked seeing all the different methods of handling information. Like 37signals, my ideal system would incorporate many different tools to allow for robust, versatile data management.

Jira: I used this task management system during my summer internship at Linden Lab. They've taken advantage of Jira to make an enormous task system, well-organized and indexable by identification number, title, category, or asignee. Jira can accommodate a massive amount of information (there must be thousands of tasks in Linden's development category alone). Scalability is very important, and I admire that Jira can be used by a single person wanting to store their daily to-do list, or by a large company like Linden trying to manage the entire realm of Second Life.

Comapping: I watched the introductory video and cruised through some sample maps from Comapping. Favorite feature: Comapping allows lots of file types, including pictures, links, and text. This would be very useful for an integrative system, rather than limiting someone to purely text. Main concern: the maps have a tendency to become unwieldy and confusing as they expand, which harms their scalability.

Google Wave: New collaborative conversation tool from Google. I watched a chunk of their long introductory presentation, which described the features of the new system, and ways it can encourage collaborative work. I like the simple interface and real-time updates, and I think the ability to allow multiple contributors could add a new, interesting dimension to the system I'm imagining.
MindMeister: We used this website in class to construct big idea webs. I love the concept of organizing ideas visually in space, instead of just a boring drop-down list. Like Comapping, however, MindMeister tends to generate large, confusing maps, and it's difficult to jump cleanly from one place to the other. I also found it limiting that these maps (as far as I can tell) only include text inputs.

Wikis / Blogs / Google Docs: I considered a handful of other websites that were designed for one purpose (like word processing or journaling) and can be appropriated for other purposes of information management: for example, someone might use Google Docs to store a list of important links, or start a blog with lists of key resources for a paper. These flexible websites allow for a wide variety of different uses, but it would be nice if I could develop something with more affordances for specific information needs, like bookmarks, sources, contacts, etc. I'm picturing the specific tools of 37signals with the versatility of Google Docs and the scalability of Jira (sound impossible yet?).

EndNote: I've been using this program to store resources for my honors thesis. Its design is barebones and simple: big spreadsheet-style assortment of items, organized by title, author, year of publication, etc. The program conveniently formats your sources for you, according to the formatting convention you choose. Perfect example of a program designed to handle one type of information. Now if only I could expand it to include other types of information (links, videos...) and present the information in a more appealing way.

Thoughts on Health Education

I've been browsing through articles and research papers in my search for a project topic. I'm starting to gravitate towards studies about psychological health, especially in children. When it comes to education, "underprivileged" refers to more than just socioeconomic disadvantage; learning disabilities, preexisting health conditions, psychological distress, and a host of other factors can impact a student's ability to learn. All else being equal, a student who struggles with a psychological disorder will have a more difficult time in the classroom than his healthy classmate. I'm curious whether web technology can be used to alleviate some of these differences, making education more accessible to the marginalized and underprivileged.

I was intrigued to see the article about web-based avian flu education. As it turns out, applying web technology to health initiatives (especially for children) is more complicated than I realized. How do you set up a post-test that accurately measures understanding? How do you measure attitude change? What about behavior change? If a study changes someone's knowledge and attitude, but doesn't change their behavior, was it successful? It was discouraging to see that no behavior changes were noticed after the avian flu study, but I wonder if we can still take advantage of the web's unique capabilities to make strides in children's health.

One of the valuable aspects of web technology is the sense of control people derive from using web applications. People use the web to organize their mail, communicate with friends, manage their tasks, and keep their lives in order. Web technology can instill a sense of self-agency, and if this feeling could be harnessed, it could have a noticeable impact on health. I've started some cursory readings about depression and stress, both obstacles that can take a toll on education, and it seems that self-efficacy has a profound effect on the degree to which people experience stress. In fact, a feeling of control can have a positive effect on a variety of chronic illnesses. So it seems that an important aspect in health is the ability to control what happens to your body, or at least to perceive that they can.

So web technology has perhaps a unique ability to shape health education. Adjusting a sense of control, and consequently adjusting stress and attitudes, can be particularly relevant with psychological conditions that impact learning, like ADHD, depression, mental illness, and certain learning disabilities. My next step is to keep investigating: one of my favorite parts about reading relevant research papers is that they almost always offer a whole new set of sources to check out. In the References section of the avian flu paper, I circled 19 sources to check out, some about health, some about web tech, some about the role of humor in education.

Which reminds me: I'm intrigued by the science of laughter and humor, and its possible role in health and learning. I think laughter is perhaps underutilized in education, and since I've always had an interest in cartoons and humor, it seems like an avenue I could explore further. So as these disparate factors are coming into focus -- child psychology, web technology, humor, and visual learning from last week -- I'm hoping a fruitful project will begin to come together.