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PROJECT 99: DESK BASED RESEARCH A SUMMARY OF PUBLISHED LITERATURE AND PRACTICE EXAMPLES, AND PRESENTS A PROTOTYPE MAP OF DIGITAL ASSETS FOR YOUNG PEOPLE’S MENTAL HEALTH.

SNOOK


OUR APPROACH TO SHARING THE PROJECT 99 REPORT MATERIALS: Open Access, Some Rights Reserved The outputs of the Project 99 exploration of internet-based approaches to support youth mental health have emerged through a coproduction approach, involving Greater Glasgow and Clyde NHS (GGCNHS) as commissioning body, a three agency consortium (consisting of Mental Health Foundation, Snook and Young Scot) and young people, all supported by a multi-agency steering group. In turn, this project is an agreed action within the Board’s Strategic Framework for Child and Youth Mental Health Improvement, ratified by the Child and Maternal Health Strategy Group in June 2012.

embedded in the report documentation, which is a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, its main conditions being:

Note that the material presented in the Project 99 reports is the result of combined work from the commissioned partners and the participating young people and does not represent the views of GGCNHS.

· The work is not resold or used for any commercial purposes

GGCNHS is keen to make this work available to any interested party, while retaining the copyright. We have therefore applied an open access policy to this work which allows anyone to access the report material online without charge. Anyone can download, save or distribute this work in any format, including translation, without permission. This is subject to the terms of the licence

· GGCNHS and the three commissioned partners – Mental Health Foundation, Snook and Young Scot are credited · This summary and the address www. wegot99.com are displayed · Creation and distribution of derivative works is permissible, but only under the same or a compatible licence

· A copy of the work or link to its use online is sent to GGCNHS via the contact form on wegot99.com

You are welcome to ask for permission to use this work for purposes other than those covered by the creative commons license. GGCNHS gratefully acknowledges the work of Creative Commons in inspiring our approach to copyright for this report. To find out more go to www. creativecommons.org Potential for Future Development and Collaboration GGCNHS and its local community planning partners will now be actively considering all the material and recommendations contained in this work with a view to formulating a response and a forward development programme, as part of the wider body of work to improve child and youth mental health in Greater Glasgow and Clyde. In recognising the emerging nature of this agenda, the Health Board would welcome dialogue with partners and potential partners who may be interested in collaborating in aspects of this work, and in discussion with agencies who may already be engaged in similar work, with a view to sharing good practice. For further discussions please contact us via the wegot99.com contact form.

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CHAPTER 5: SUMMARY KEY FINDINGS There are challenges in presenting evidence in the digital field, when the pace of developments outstrips conventional methodologies for building an evidence base.

There is good evidence that digital participation through social networking services, gaming and peer communities has benefits for young people’s mental health.

Internet use is to all intents and purposes ubiquitous amongst young people in Scotland. Young people frequently access the internet using personal devices and mobile technology, and prioritise access to the internet in making choices on what to spend money on.

Participation in social networking services has been associated with positive identity development, engagement and participation in campaigning and political activities in communities and online, the development of creative skills, and the development of social capital.

Media literacy is a key determinant of young people being able to use digital technology to improve their mental health and wellbeing. This encompasses technical, social and academic aspects.

Finally, young people need to develop the critical skills to evaluate content and sources in deciding what to believe in terms of that they do online. Evidence suggests that the necessary skills for young people are not always available in schools.

Young people need the skills and access to use the devices, software and applications (apps) available in a useful and responsible way. They need to be aware of appropriate social use of the web in terms of managing unwanted attention, and conducting online relationships with respect.

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KEY FINDINGS Creativity has long been associated with good mental health, and indeed with assisting people to make sense of and communicate their feelings in relation to distress and mental ill health. Young people have been at the leading edge of using digital media to express themselves and develop their identities using creativity. Collation and curation of media, and the production

of video, graphic and written content both individually and collaboratively has been associated with both positive mental health and peer support in recovery. There is work to be done to ensure young people understand copyright and intellectual property law in this regard, and are able to negotiate challenging content, including around suicide, eating disorders and sexual content.

There is a body of encouraging practice in terms of clinical use of technology for young people’s mental health. Online counselling and peer support shows some promise, and eCBT has been used successfully with young people, although evidence suggests that guided selfhelp with offline and online content helps young people to complete programmes. Young people specific mood

trackers have been developed and services have also begun to use online modalities to introduce services. For example SPARX in New Zealand uses online gaming and avatars (game characters representing the player) to guide young people through CBT activities.

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KEY FINDINGS Evidence suggests that young people who are most at risk in the offline world are at most risk in the online world, a general theme in terms of assessing risk in digital environments. Young people with mental health problems or poor mental health are therefore even more likely than the general youth population to need guidance and support in making best use of the digital world, and managing the risks and opportunities present. Collin (2011) makes three central recommendations to policy and practice in relation to social networking use:

1. The concept of cyber-

citizenship should be mainstreamed and not confined to young people. Most policy frameworks emphasise young people and therefore talk in terms of what they should become, rather than what they already are. Collin proposed that cyber-citizenship policies and practice should include the community as a whole, as opposed to being constructed as a set of policies to protect young people from the digital environment; which they may be more adept at negotiating safely than many adults. This, Collin proposes, could have a positive effect in terms of young people working alongside adults in policy and practice to close the intergenerational gap that could widen as technology developments increase in pace still further.

2. The move the paradigm

of cyber-citizenship from one solely concentrated on risk management and protection, to one that includes the nurturing and recognition of the positive aspects of participation, such as creativity, sharing self-generated content and engagement with civil society. This, the reviewers conclude may mean that people in authority might have commonly held notions about childhood, gender, youth etc challenged. It would also necessitate the review of the way legal and ethical information on digital citizenship was presented.

3. Finally, Collin

recommends that in considering cybercitizenship, policy makers and practitioners should take a holistic view of the way people’s digital lives interrelate with their work, home, school and leisure time, as opposed to emphasising an artificial distinction between online and offline worlds.

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FINDINGS THROUGH DESK RESEARCH: INTRODUCTION Introduction This rapid review is intended to frame the context for the project field work, and provide a selection of key points from the literature, and from practice in Scotland, the UK and beyond. We begin with a brief analysis of quantative data gathered through a survey by Young Scot. We continue with a summary of available literature and practice. There have been several recent comprehensive literature reviews in this area,

including on technology, mental health and young people generally (Powell et al 2010), the benefits of social networking to wellbeing (Collin et all 2011), vulnerability (Singh et al 2011, 2013), and the mental health impact of gaming (Johnson et al 2013). We draw on these to summarise key learning here, but urge readers wanting a more detailed analysis of the literature to consult these reviews.

We have also created a prototype mapping framework which presents a wider range of example practice examples in the field by audience sector and by activity (presented as a separate document in the Appendices.) This was developed from the research output, and was populated with a selection of examples of digital initiatives from the UK and beyond at a mapping session involving the partners. The prototype map is presented as an outline for discussion with

the project team, for further development. Examples have been placed in the map using the considered judgement of project team members, in keeping with the illustrative approach commissioned here. We have not conducted a detailed assessment of the content presented online by the example initiatives, so cannot quality assure them for use by professionals in their work with young people.

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5.1 SUMMARY OF QUANTATIVE DATA: INTERNET USE IN YOUNG PEOPLE IN 2012, 51% OF 16 TO 24 OF SMARTPHONE USERS AGREED WITH THE STATEMENT: “MY PHONE IS MORE IMPORTANT TO ME FOR ACCESSING THE INTERNET THAN ANY OTHER DEVICE.” In 2011 the level was at 33% net agreement compared to 42% net agreement in 2012. (ofcom uk-4.03)

The extent and manner of internet use by young people Mobile internet usage has grown quickly over the last three years, with young people leading the way as early adopters in both hardware (mobile and tablet handsets) and in internet and app usage. The rise of mobile internet access in young people has continued to grow into 2013 with visits to www. youngscot.org from mobile devices in July 2011 at 7% of overall visits, in July 2012 it was 24% and in July 2013 this figure was over 42%. For health-related topics this figure is even higher with mobile visits for health information website www. getthelowdown.co.uk at 54.5% of overall visits in July 2013. According to a Young Scot survey in June 2013, 95.7% of respondents owned a mobile phone. 37% of these young people said the spent between 1-2 hours on their mobile devices each day and 42% of respondents said they spent over 2 hours on their mobile devices.. Of the time spent on a mobile device the estimated percentage

of that time spent on “social” apps such as Facebook or Twitter was 38%, using the internet: 35%, playing games: 18%, and “using other apps”: 14%. Social Networking apps were heavily used on mobile devices with over 80% of respondents using Facebook, 53% using Twitter and over 89% using YouTube.

ALL OF THE MOST POPULAR APPS WERE FREE WITH 84% OF YOUNG PEOPLE SAYING THAT THEY “RARELY” OR “NEVER” BUY APPS.

Scotland is still behind the UK average for Broadband take-up, although gaining ground. 68% of homes in Scotland now have broadband, up from 61% a year earlier: “Broadband take-up in Scotland has risen faster than any other UK nation over the last year, jumping 7 percentage points over 2011.” The Communication Market Report: Scotland (2012) Glasgow is 17% down on the national average for Broadband. Young people have a higher penetration rate of 3G (mobile broadband) people than the national average of 77%. See fig 1 overleaf for an infographic summary of research.

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YOUNG SCOT SURVEY: MOBILE, INTERNET AND APPS

April-June ‘13

634 responses

OFCOM OMNIBUS RESEARCH

MOBILE PHONES USE

38%

35%

18%

14%

Social Apps

Internet Browsing

Video Games

Other Apps

11-26 YO

RESULTS

MOBILE PHONES USE

MONEY

95.7%

84%

Own mobile phones

42%

Use their mobile 2 hrs/per day

rarely or never buy phone apps

37%

Use their mobile 1-2 hrs/per day Fig 1. The extent and manner of internet use by young people

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OFCOM OMNIBUS RESEARCH

March ‘12 & ‘13

51% Connect to the internet with their phones.

THE COMMUNICATIONS MARKET REPORT: SCOTLAND

2012

68% Homes in Scotland have broad band.

THE CARNEGIE UK TRUST: “ACROSS THE DIVIDE TACKLING DIGITAL EXCLUSION IN GLASGOW

GLASGOW

2013

51% Homes in Glasgow have broad band.

THE WORLD CELLULAR INFORMATION (WCIS)

YOUNG PEOPLE 3G PENETRATION IN THE UK

>

NATIONAL 3G PENETRATION RATE OF 77%

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5.2 SUMMARY OF LITERATURE: THE POTENTIAL OF SOCIAL MEDIA The potential for social networking services to improve and protect young people’s mental health Public and media discourse on internet and technology use by young people often concentrates on the risks posed by factors such as cyber bullying, exploitation, overuse and withdrawal from faceto-face interaction. A set of common negative perceptions about the effect of social media, gaming and other online interactions have arisen, when though risks to need to measured, there is a lot of evidence to suggest positive benefits to mental health from a range of online practices. These benefits are indicated across a spectrum of young people, from those with mental health problems or long term conditions, to those in distress or at risk of poor mental health due to exclusion or isolation, to a general population of young people. The Australian Cooperative Research Centre for Young People, Technology and Wellbeing1 (YAW-CRC) was founded in 2010 to bring together academic, voluntary sector and commercial partners to collaborate on research and innovation in young people, digital and mental health research. The organisation

has invested substantially in high quality literature reviews, and syntheses of practice, as well as adding substantially to the evidence base through developing, piloting, and evaluating methods of engaging young people and other stakeholders in the field.

The Collin review, key findings of which are summarised below, concentrates principally on the positive aspects for mental health and wellbeing of social networking services, placing these in the context of widely reported risks, and calling for a review in our approach to cybercitizenship as being the best route to addressing both risk and leveraging opportunity. They summarise their top level findings thus:

In 2011, YAW-CRC published a major literature review on the benefit of social networking services for young people (Collin et al, 2011). They use the broad Boyd and Ellison (2008) definition of a social network services as:

“… THERE ARE A NUMBER OF SIGNIFICANT BENEFITS ASSOCIATED WITH THE USE OF SOCIAL NETWORKING SERVICES (SNS) INCLUDING: DELIVERING EDUCATIONAL OUTCOMES; FACILITATING SUPPORTIVE RELATIONSHIPS; IDENTITY FORMATION; AND, PROMOTING A SENSE OF BELONGING AND SELF ESTEEM ...”

“web-based services that allow individuals to (1) construct a public or semi-public profile within a bounded system, (2) articulate a list of other users with whom they share a connection, and (3) view and traverse their list of connections and those made by others within the system. The nature and nomenclature of these connections may vary from site to site.” Boyd and Ellison (2007)

Collin et al. (2011)

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5.2 SUMMARY OF LITERATURE: THE POTENTIAL OF SOCIAL MEDIA Further to this, they suggest that: “the strong sense of community and belonging fostered by SNS has the potential to promote resilience, which helps young people to successfully adapt to change and stressful events.”

Further key recommendations of the Collin review can be found summarised in the table overleaf.

However, they emphasise that for these positive aspects to be fully realised, they rely on a level of awareness of good ‘cyber-citizenship’ amongst young people:

“IMPORTANTLY, THE BENEFITS OF SNS USE ARE DEPENDENT ON GOOD INTERNET AND MEDIA LITERACY: HAVING THE SKILLS TO ANALYSE AND CREATE MEDIA CONTENT. MAXIMISING THE BENEFITS OF SNS AND PROMOTING INTERNET AND MEDIA LITERACY MAY HELP PROTECT YOUNG PEOPLE FROM MANY OF THE RISKS OF ONLINE INTERACTION, SUCH AS CYBER-BULLYING.” Collin et al. (2011) 95


THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 1. MEDIA LITERACY Underpinning their comprehensive examination of evidence to support the positive value of social networking services across the spectrum of mental health promoting activities described above, Collin points to the need to ensure that the opportunities provided by interpersonal communication online are balanced by ensuring that renewed media literacy work with young people enables them to take the opportunities afforded, and to avoid the risks. The review describes a number of components to online media literacy. These include: >>>

Critical content literacy The ability to use search engines, appreciate how they order information and to consider sources and appraise the credibility of information.

Communicative and social networking literacy An appreciation of the range of online communication methods, the appropriate and safe use of these, the norms for online communication and how to manage privacy and unwanted communication.

Creative content and visual literacy An understanding of how to create content using media, and an appreciation of how to use this appropriately, and within copyright where applicable.

Mobile media literacy An understanding and awareness of the etiquette of mobile device use, and the norms and conventions of online communication on mobile devices.

The review highlights evidence that supports the assertion that ‘learning by doing’ with social media helps young people to develop media literacy, creative content and visual literacy and technical literacy in terms of creating, sharing and using online content that isn’t always part of the school curriculum. Similarly, there is a need to ensure that young people are guided in terms of copyright, privacy, and critical appraisal of information.

Technical literacy The knowledge and skills to use a device, software, or app.

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THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 2. FORMAL & INFORMAL LEARNING The review points to the value of online learning environments and the potential for personal devices and ICT in schools to improve learning outcomes. To some extent this is already recognised in Scotland and the UK. The review points to a dearth of evidence in terms of the effect of social media in formal education (as 2008), in part because of the restriction of social media in some schools and states in Australia (Notley 2009). That said, the review points to positive examples of social media use in bringing together students from diverse geographical areas, or from different cultural backgrounds. Additionally there is some evidence suggesting that social network service use

between teachers and students can improve rapport, motivation and engagement with education (Mazer et al 2007). There is evidence to indicate that use of social networking services can assist young people in learning and skills development outside formal environments. This includes development of transferable skills relevant to the modern workplace (Notley 2009); collaborative skills and sharing content in communities of interest; and in understanding of citizenship. (Ito et al, 2006; Jenkins 2007). Because participation in social networking services can be highly personalised and controlled, the sense of personal agency they can create can make them important tools

for learning for those who struggle in traditional learning environments (Green, 2007) or have specific interests or needs, such as young parents (Notley 2009).

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THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 3. CREATIVITY, IDENTITY & EXPRESSION Social networking services and social media have rapidly created multiple avenues for media consumers/users to create and share their own content. This includes original content such as artwork, writing video and images; and ‘remixed’ content, such as playlists, animated pictures (GIFs). Young people have become particularly competent in producing and disseminating their own ‘small media’ as part of everyday life (Collin et al, 2011). The positive benefits to young people in terms of their development of a sense of community and identity are wide. These include development of literacy; a sense of aspiration and self-worth, including getting feedback and validation to develop skills; encouraging

experimentation and exploration with identity, and reinforcement and validation of aspects of cultural or personal identity. Finally, collaborative creative activities have been shown to foster connection with others and a sense of community, whether or not these communities are long term or ephemeral (Richardson, Third and MacColl, 2009) Ito and Okabe (2005), in a report entitled ‘Personal, Portable and Pedestrian’ on the use of mobile devices in Japansese culture reported the role that sharing and curating multimedia content with a small group of people in a collaborative space helped to build a sense of collective belonging. This is eerily similar to the way in which social media channels such as Twitter,

Tumblr and wiki/fan pages work now. Linked to the sense of community identity created by young people online, social network services are also becoming key to young people’s expressions of their personal identity. This is enabled by the high degree of personalisation possible within the framework of the services. A sense of belonging and acceptance, for example of sexual orientation, gender diversity or disability can arise from collective identification with geographically and culturally diverse individuals with a peer connection (Harris 2004, Hiller and Harrison 2007, Munt, Basset and O’Riordan 2002). The connection to online communities can endure

even after an initial impetus is gone (Richardson and Third, 2009), a phenomenon often observed in mental health forums, and which can be utilised in terms of recruiting moderators trusted by members, a practice developed as a volunteering opportunity by YouthNet for TheSite. Young people are using social networking services to experiment and seek legitimacy for political, sexual, ethnic and cultural identities (Coleman and Rowe, 2005; Montgomery et al 2004, Hillier and Harrison 2007) This has been well demonstrated in groups of young people exposed to risk of poor mental health, including new migrants, BME groups and young people with long-term

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THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 3. CREATIVITY, IDENTITY & EXPRESSION Rare conditions groups such as Brittle Bone UK and Action for ME have also used online collaboration to connect distant young people with a peer connection. The phenomenon is also apparent in any examination of the way young people with mental health problems use social media to express their feelings and seek validation and peer connections. Civic involvement and connection to decision making in communities is associated with good mental health. Social networking services provide a range of new spaces and environments for civil and political activity (Montgomery 2007, Vromen 2007). Organisations and services are increasingly looking to use social

networking and social networking practice to engage young people in government and community decision making (Collin, 2010). In Scotland, organisations like Young Scot, NUS Scotland and the Scottish Youth Parliament have sought to develop young people’s interest and capacity to engage with civic activities using online communication, and it will be interesting to note the effect that extending the franchise for the independence referendum to 16 year olds may have on the use of social media in the debate.

4. STRENGTHENING SOCIAL RELATIONSHIPS Strong interpersonal relationships are critical for the development of good mental health, and the resilience young people need to face challenge. Social networking services have been shown to play an important role in developing and strengthening relationships of all kinds, both in terms of strengthening existing relationships and creating new ones. In terms of strengthening existing relationships, internet use in general has been found to strengthen young people’s interpersonal relationships. Concerns such as lack of places for young people to meet in communities, and lack of time and space outwith school and structured activities can be addressed

by social networking and social media, which challenge these boundaries. Equally, social media use has been shown to address concerns and maintain social networks when complexity (such as illness) or mobility (such as moving town or transitioning to college/university from school) interfere with face to face social networks. Facebook was founded to enable members of college classes to keep in touch, and research has suggested that students with lower selfesteem and satisfaction with university life have benefitted most from active use of Facebook (Ellison, Steinfield and Lampe 2007) Social networking services have also become a key part of young people’s exploration

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THE BENEFITS OF SOCIAL NETWORKING SERVICES: A LITERATURE REVIEW (COLLIN ET AL. 2012) 4. STRENGTHENING SOCIAL RELATIONSHIPS relationships, particularly with the proliferation of own device internet use via mobile phones. (Livingstone 2008) Recent news stories have highlighted the potential for abuse, exploitation and breaches of trust to lead to tragic consequences in this regard. Equally, it seems clear that most young people have adapted to use of social networking services more rapidly than people of earlier generations, who are often responsible for educating and supporting young people to have these conversations. Traditionally, research has focused on social networking services in the maintenance of existing relationships. There has been often been a suggestion that relationships which occur solely online are

‘weaker’ (Donath and Boyd, 2004). There is evidence to suggest though that for some of the most marginalised or socially/ literally isolated young people, online connections with peers can be a key source of social contact. Third and Richardson (2010) point to a study of young people with long term conditions using an online community, who described the friends they made there as ‘true friends’ that were ‘amongst the most dependable and enduring’. Facebook has been associated with helping young people with less developed social skills to develop friendships that then translated offline (Valkenburg et al, 2005). Finally, connection made with others in online environments can enable and encourage

marginalised groups of young people to develop the confidence to utilise assets in their communities to address concerns.(Munt, Basset and O’Riordan, 2002) Differentiation of social networking use with new versus existing relationships is based on an ‘assumed distinction’ between the two. Increasingly, evidence points to young people viewing online conditions.

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5.2 SUMMARY OF LITERATURE: GAMING AND WELLBEING Gaming and Wellbeing The Young and Well CRC Gaming Research Group published a comprehensive review on the state of play in research linking videogames to flourishing mental health, responding to concerns about the potential negative effects of gaming. They summarise their findings:

They continue to discuss gaming in a nuanced fahsion: “Emerging research suggests that how young people play as well as whom they play with may be more important in terms of wellbeing than what they play. Further research is needed to explore key questions including the moderating influence of personal characteristics on the relationship between videogames and wellbeing and extending existing research by replicating findings across game types, demographic samples and play environments.”

“EXISTING RESEARCH SUGGESTS THAT VIDEOGAMES CONTRIBUTE TO YOUNG PEOPLE’S EMOTIONAL, SOCIAL AND PYSCHOLOGICAL WELLBEING ... VIDEOGAMES HAVE BEEN SHOWN TO POSITIVELY Johnson et al, 2013 INFLUENCE YOUNG PEOPLES The review discuses evidence to support a positive role for gaming in EMOTIONAL STATE, SELF-ESTEEM, emotional intelligence and control, building of healthy relationships and OPTIMISM, VITALITY, RESILIENCE, social capital, including between those from marginalised groups, ENGAGEMENT, RELATIONSHIPS, SENSE and improvements in self-esteem. Furthermore, evidence suggests that OF COMPETENCE ... AND SOCIAL even playing violent games can can have creative, social and emotional CONNECTIONS AND FUNCTIONING.” benefits. The degree of violence

suggest that further research might concentrate on the ways in which character selection, game choices and styles of play may influence wellbeing. Frequency of play did not significantly relate to neither body mass index nor school performance. The review also points to evidence that gaming can be a successful play therapy tool, being helped to change their views of themselves and others through the use of metaphors in games, such as collecting attributes or conquering tasks.

Johnson et al. (2013) is not a key factor in determining

enjoyment, through the review does

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5.2 SUMMARY OF LITERATURE: GAMING AND WELLBEING In New Zealand, the benefits of using fantasy games was harnessed in the development of SPARX, a game based method of delivering computerised CBT. In a controlled trial of SPARX, Merry et al (2012) found that the programme was effective and that SPARX is a potential alternative to usual care for adolescents presenting with depressive symptoms in primary care settings, and could be used to address some of the unmet demand for treatment.

“SPARX IS AN INTERACTIVE FANTASY GAME DESIGNED TO DELIVER [CBT] FOR THE TREATMENT OF CLINICALLY SIGNIFICANT DEPRESSION. IT UTILISES BOTH FIRST PERSON INSTRUCTION AND A THREE DIMENSIONAL INTERACTIVE GAME IN WHICH THE YOUNG PERSON CHOOSES AN AVATAR AND UNDERTAKES A SERIES OF CHALLENGES TO RESTORE THE BALANCE IN A FANTASY WORLD DOMINATED BY GNATS (GLOOMY NEGATIVE AUTOMATIC THOUGHTS).” Merry et al. (2012)

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5.2 SUMMARY OF LITERATURE: TECHNOLOGY IN MENTAL HEALTH SERVICES The use of technology to support young people in distress, or in mental health services Powell et al (2010) were commissioned by Comic Relief to undertake a scoping literature review and stakeholder consultation exercise about young people’s use of digital technology in relation to their mental health, to underpin Comic Relief’s emerging interest in the field. The review concentrated on three areas:

1. The use of digital technology by young people.

2. The use of digital technology to support young people with a range of mental health problems, and those at risk from suicide or self-harm.

The review points to several caveats in considering the evidence: There is wealth of evidence in relation to ICT use in mental health in an adult population, but fewer papers specifically discussing young people.

The ehealth literature includes reports of a large number of small pilot studies, often ‘initiated by enthusiasts’, and therefore the reviewers warn that these data may not generalise in different contexts, particularly as there is a tendency to write up successful findings and not report unsuccessful activities.

The pace of development of new technologies is such that robust studies in the literature are outdated almost as soon as published. A similar caveat must be applied in this report, as reviews published even in the last year or two would have reviewed literature older than that. Powell et al (2010) used the scoping review to highlight examples of good practice from the evidence, and highlight gaps in domains in a young person’s experience of mental ill health. These are summarised in the table overleaf.

3. The evidence of harm relating to the use of technologies.

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) TREATMENT • Computerised CBT (cCBT) is the ehealth intervention with the most established evidence base for efficacy, with evidence that it is an effective and acceptable tool for treating mild and moderate depression and eating disorders such as bulimia, as well as a tool for self-management.

• The review found limited information specifically relating to cCBT in young people, although studies with interventions such as MoodGYM found moderate benefits for young people with depression. Another study found that completion rates (a key factor in successful outcomes) amongst young people were lower; leading to the recommendation that cCBT may be best delivered to young people with support. Young people showed improvement in both attitudes and behaviours associated with eating disorders following cCBT sessions, providing positive feedback and indication that they might seek further support. That said, positive results may be short term.

• The potential for online delivery of counselling and psychotherapy is now being realised, with implementation at scale through initiatives such as Kooth.com (for young people) and Big White Wall (for general population). The review points to a few studies of online counselling, which show promise. One study with a student population reported a positive effect from disinhibition, the therapeutic benefit of writing, and satisfaction with the service.

a viable service option, especially with those who are typically isolated, or find coming forward a challenge due to stigma.

Other studies highlight the need for caution, with concern about the lack of verbal and non-verbal processes in sessions leading to a concentration on rapport in online sessions as opposed to the accomplishment of tasks. Nevertheless, online counselling appears to be

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) ADJUNCT TO TREATMENT • There is some evidence to support guided self-help (such as bibliotherapy) with therapist initiated telephone or email contact. Telephone contact had the better reported increase in positive outcome compared to email, but the study was from 2006, and this may have shifted with the rapid advancement of social media. Email contact as an adjunct to therapy has shown promise in both a counselling setting, and in work with people with more complex mental health problems. Email as an adjunct might be particularly useful for clients who express a preference to communicate in this way, to those with particularly high anxiety of social situations, and those who are isolated.

• SMS text messaging has shown some promise in supporting individuals during the therapy process, in terms of exploring issues, addressing suicidality, and ‘checking in’ between appointments. SMS technology is much more widely accessible than smartphones. Examples of SMS support is used by Samaritans, TESS Self-harm support and by the WISH Project in Harrow, North London. WISH uses a two question text based tool to assess risk of suicide in its young female clients, and adjusts frequency and urgency of support based on answers.

• Data on the use of therapeutic role play in avatar based computer generated worlds are emerging, with work in counselling, in ADHD support, and in cCBT (Merry et al 2012)

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) PEER SUPPORT • The evidence for peer support in mental health, including for young people has developed over the last few years. Powell et al (2010) call for further research on the efficacy of online peer support and in particular for internet support groups (ISGs), given the number of informal peer support networks that exist and which young people use.

• There is evidence on the acceptability and desirability of these support groups and forums for their users, but less in terms of outcomes. There is also some evidence that virtual communities do not harm the health and social outcomes of their members.

• Online peer support is growing, including in the postdiagnosis phase, and in terms of buddying or mentoring as an adjunct to self-management training. There are advantages, in terms of the willingness of individuals to disclose and discus issues of a sensitive nature, but also disadvantages, such as creating an illusion of privacy, and a limitation on the ability to probe for elaboration and escalate support in crisis.

• The review discusses anecdotal evidence from the development of the ReachOut online community forums, which provides an online forum for young people that is peer moderated by trained volunteers aged 16-25. Users saw the forum as positive, unique and helpful, but little was reported about the impact on stigma or the translation of online discussions into uptake of services offline.

•There is some evidence that online peer support spaces where there is an option to call on the expertise of a clinician or other expert are more accepted.

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) HELP SEEKING • The review reports the reluctance of young people who experience mental health problems to seek support, with only 20% of young people approaching services for assistance. There is a general assumption that technology may assist those who do not seek help to reach out, to services, and to find and utilise self-help/selfmanagement.

•Text messaging has been associated with improved help seeking behaviour, for instance in mass texting of students with details of sources of help and advice.

MONITORING • There is some evidence to suggest that participation in online discussions with peers and use of information sites enables people to build courage to seek treatment and persist with it.

Predictors on online help seeking for suicidal ideation included use of telephone helplines, and not going to offline mental health services.

There is good evidence to support the use of mood trackers and similar means of monitoring symptoms. This could be via text message or using web based tools or applications.

• Online screening tools offered to large populations have been used to ‘find’ students at risk from suicide. Where respondents were given the opportunity to have online dialogue with a counsellor following an assessment, they were three times more likely to attend in person for detailed assessment and treatment than those who did not have that contact. Results showed that internet skills, hours online, demographic and depressive symptoms were not significantly related to online help seeking.

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SUMMARY OF REVIEW EVIDENCE ON USE OF DIGITAL TECHNOLOGY TO SUPPORT YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS (data drawn from Powell et al 2010) EDUCATION • Online information sources are well regarded by young people, particularly when digital products are designed with young people. Research to co-design selfhelp/education sites on student mental health has demonstrated the importance of working with target audiences to define and develop resources.

• One major survey (2009) compared young people’s preferences for a website with self-help books, face to face counselling or mental health services. 71% of people rated books and websites as being helpful, which was more than for mental health service and less than for counselling. Predictors of finding websites useful included older age (1825), belief in help-seeking, less social distance from the vignette presented. Most young people appeared open to the idea of accessing mental health information online, especially for problems considered to be ‘behavioural’. These young people seemed more interested in help seeking generally, and more willing to associate with peers who have mental health problems.

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5.2 SUMMARY OF LITERATURE: PERSPECTIVES ON RISK & VULNERABILITY Perspectives on risk and vulnerability Research indicates that online risks are ‘not radically different in nature or scope than the risks minors have long faced offline, and minors who are most at risk in the offline world continue to be most at risk in the online world’ (Palfrey et al, 2008) Young people using technology do face risks, including from grooming and exploitation, from cyberbullying, sexting, blackmail and the consequences of sharing personal data or betrayal of trust. Most of these have a mental health impact, and indeed have been associated with episodes of suicide and selfharm widely reported in the media. Data from EU Kids Online (Staksrud et al, 2013) suggest for instance that children who use social networking are more likely to encounter online risk, and that those with greater digital competence encounter more risks, not fewer risks; because they undertake a wider range of online activities. Staksrud also reported that digital competence did not reduce the likelihood that children would be upset by online risks. They did however find that children who had public profiles experienced

more risks than those who followed guidelines about maintaining privacy settings. Most reviews suggest that the route to mitigating the risks that young people encounter lies in changing our approach to cybersafety, to focus on the way young people actually understand risk and internet use, as opposed to the way adults often perceive that they do: that even playing violent games can have creative, social and emotional benefits.)

“POLICY CURRENTLY FOCUSES PRIMARILY ON REGULATING THE NEGATIVE EFFECTS OF SNS AND SOCIAL MEDIA, FREQUENTLY FRAMING DIGITAL CITIZENSHIP WITHIN AN ONLINE RISK-MANAGEMENT PARADIGM ... RECONCEPTUALISING THESE CHALLENGES IN TERMS OF EXPANDING YOUNG PEOPLE’S DIGITAL CITIZENSHIP OPENS UP THE POTENTIAL TO MAXIMISE THE WIDE RANGE OF SUBSTANSIVE BENEFITS ASSOCIATED WITH ONLINE COMMUNICATIVE PRACTICES.” Collin et al. (2011)

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5.2 SUMMARY OF LITERATURE: PERSPECTIVES ON RISK & VULNERABILITY Singh et al (2011) call for a reframing of the term vulnerable young people, in terms not just of an individual’s risk taking behaviour or circumstances, but also of the context in which their lives are led. Vulnerability, they argue, is often a function of systemic inequalities woven throughout the system. They suggest that vulnerability could be viewed as:

“…a circumstance young people may experience or are exposed to, as opposed to a concept that they in themselves are. By suggesting they are vulnerable in and of themselves, young people’s individual identities and uniqueness are diminished, and they are homogenised into a definition which does not recognise their individuality as anything other than vulnerable.” (Singh et al, 2011)

Within this framework, there is a recognition that young people facing vulnerability are at risk from poor mental health, and also that these young people might seek to use technology to emphasise their identity, and reduce their risk of vulnerability by using social networking and other services to reduce isolation and structural barriers, and online services to access peer support and treatment. The evidence base on the use of the internet by young people experiencing vulnerability is still sparse, and there is a need for further research which recognises the complexity in young people’s lives, including the way in which they use technology.

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5.3 SUMMARY OF PRACTICE: EXEMPLAR PRACTICE EXAMPLES Exemplar Practice Examples In the past year several useful guides for practitioners have been published. The following is intended to serve as a brief guide for readers who wish to explore the subject in greater detail.

Innovation Labs http://www/innovationlabs.org.uk Innovation Labs is a joint programme between Comic Relief, Paul Hamlyn Foundation, Nominet Trust, Mental Health Foundation and Right Here. The programme worked with young people, service designers, developers and funders to codesign a suite of digital tools that young people would use to assist them with their mental health. Two participative design events were led in 2011, where a design process encouraged the generation of ideas, and then wireframe prototyping of projects. The top projects were then developed as briefs which organisations were invited to bid to develop.

to every project, and the programme board includes and supports young people to participate in the management of the work. The programme is being evaluated as it progresses, and the funders have also enabled the sharing of good practice with all interested parties, via the Innovation Labs website and regular e-bulletins.

Using technologies safely and effectively to promote young people’s wellbeing: A Better Practice Guide for Services (Young and Well CRC) http://reports.youngandwellcrc. org.au/a-better-practice-guide-forservices/ Published in March 2013, this guide provides a range of examples to assist health, social care and third sector services to use digital technology to support young people with their mental health. The guide summarises evidence, highlights good practice, and suggests top tips for implementation. It covers both both the principles of using technology such as email or forums, and the practical application of specific platforms such as Facebook, or Twitter.

Seven projects have each been awarded ÂŁ50k to develop the projects into sustainable digital tools using a rapid start-up digital innovation model for launch by June 2014. The projects are being delivered by a range of partnerships including statutory organisations, digital agencies, national and local

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5.3 SUMMARY OF PRACTICE: EXEMPLAR PRACTICE EXAMPLES

Participatory Design of evidencebased online youth mental health promotion, prevention, early intervention and treatment (Young and Well CRC) http://www.yawcrc.org.au/knowledgehub/publications Young and Well CRC have produced this guide for applying participatory design principles to the development of digital tools for young people in relation to mental health and well-being. The guide explores the evidence for co-design/ service design approaches and discusses in an accessible format how these methods can be used in practice by youth agencies.

Social Media in Mental Health Practice: Online Network tools for Recovery and Living Well. http://www.leedsandyorkpft.nhs.uk/ professionals/digitalhealthinnovation Social Media in Mental Health Practice is a social media guide for health and social care practitioners working in mental health services. The free ebook gives a broad

overview of key social media that can be used to help people as part of their recovery, using examples from across the UK and beyond.

The role of online and online peer support for young people who self-harm – Good practice guide. (YouthNet) http://www.youthnet.org/2012/12/ the-role-of-online-and-online-peersupport-for-young-people-who-selfharm/ Youthnet, 42nd Street and Depaul UK were partners in an EU funded project about online support for young people who self-harm. Youthnet collated a good practice guide based on work with partners in the UK, Denmark, Slovenia and Italy. It presents a framework for delivering online peer support to young people who self-harm, linking this back to evidence on stigma, self-stigma and the challenges of working with young people who are self-harming or at risk of self-harm.

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REFERENCES References Bacon, K and Turberville, V (2013) Finding the Digital Edge. Digital Engagement UK. London http:// www.onlineyouthoutreach.co.uk/ downloads/Finding_the_Digital_ Edge.pdf (accessed July 2013) Betton, V and Tomlinson, V (2013) Social Media in Mental Health Practice: Online Network tools for Recovery and Living Well. Leeds and York Partnership NHS Foundation Trust. Leeds. http:// www.leedsandyorkpft.nhs.uk/ professionals/digitalhealthinnovation (accessed July 2013) Boon, V (2013) Innovation Labs Process Evaluation: Dec 2010 – Feb 2012. Innovation Labs. London. http://www.innovationlabs.org. uk/wp-content/uploads/2013/07/ Innovation-Labs-Process-201012-Evaluation-External-Report.pdf (accessed July 2013) Boyd D and Ellison M (2008) Social Network Sites: Definition, History & Scholarship. Journal of ComputerMediated Communication 13:210230. http://onlinelibrary.wiley.com/ doi/10.1111/j.1083-6101.2007.00393.x/ abstract (accessed July 2013)

Burns, JM, Davenport, TA, Christensen, H, Luscombe, GM, Mendoza, JA, Bresnan, A, Blanchard, ME & Hickie, IB, 2013, Game On: Exploring the Impact of Technologies on Young Men’s Mental Health and Wellbeing. Findings from the first Young and Well National Survey. Young and Well Cooperative Research Centre, Melbourne. http://www.yawcrc.org. au/knowledge-hub/publications (accessed July 2013) Campbell, AJ and Robards, F (2013) Using technologies safely and effectively to promote young people’s wellbeing: A Better Practice Guide for Services. NSW Centre for the Advancement of Adolescent Health. Westmead and the Young and Well CRC, Abbotsford, Australia. http://reports. youngandwellcrc.org.au/a-betterpractice-guide-for-services/ (accessed July 2013) Collin, P , Rahilly K, Richarson I, Third A(2011) The Benefits of Social Networking Services: A Literature Review. Young and Well CRC, Melbourne http://www.yawcrc.org.au/ knowledge-hub/publications

(accessed July 2013) Foster, C (2013) Essential Skills for Giving Online Peer Support at YouthNet. Blog. Youthnet. London http://www.youthnet.org/2012/06/ essential-skills-for-giving-onlinepeer-support-at-youthnet/ (accessed July 2013) Hagen, P et al (2012) Participatory Design of evidence-based online youth mental health promotion, intervention and treatment. Young and Well CRC, Melbourne http:// www.yawcrc.org.au/knowledge-hub/ publications (accessed July 2013) Hagen, P, Collin, P, Metcalf, A, Nicholas, M, Rahilly, K, & Swainston, N 2012, Participatory Design of evidence-based online youth mental health promotion, prevention, early intervention and treatment, Young and Well Cooperative Research Centre, Melbourne.ICO (2013) http:// www.yawcrc.org.au/knowledge-hub/ publications (accessed July 2013) Innovations Labs (2013) Labs Innovation Process Evaluation 201012: What We Learnt (blog) http:// www.innovationlabs.org.

uk/2013/07/24/innovation-processlearning/ (accessed July 2013) Johnson, D, Jones, C, Scholes, L & Carras, M 2013. Videogames and Wellbeing, Young and Well Cooperative Research Centre, Melbourne. http://www.yawcrc.org. au/knowledge-hub/publications (accessed July 2013) Livingstone, Sonia and Helsper, Ellen (2013). Children, internet and risk in comparative perspective. Journal of children and media, 7 (1). pp. 1-8. ISSN 1748-2801 http:// eprints.lse.ac.uk/48952/ (accessed July 2013) Livingstone, Sonia, Palmer, Tink and other, contributers (2012). Identifying vulnerable children online and what strategies can help them. UK Safer Internet Centre, London, UK. http://eprints.lse. ac.uk/44222/ (accessed July 2013) Livingstone, Sonia, Ólafsson, Kjartan and Staksrud, Elisabeth (2013)Risky social networking practices among ‘under-age’ users: lessons for evidence-based policy. Journal for computer-mediated communication,

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REFERENCES 18 (3). pp. 303-320. ISSN 10836101http://onlinelibrary.wiley.com/ doi/10.1111/jcc4.12012/pdf (accessed July 2013) Livingstone, Sonia, Kirwil, Lucyna, Ponte, Cristina and Staksrud, Elisabeth (2013) In their own words: what bothers children online? with the EU Kids Online Network. EU Kids Online, London School of Economics & Political Science, London, UK. http://eprints.lse.ac.uk/48357/ (accessed July 2013) Livingstone, Sonia, Haddon, Leslie, Görzig, Anke and Ólafsson, Kjartan (2011). Risks and safety on the internet: the perspective of European children: full findings and policy implications from the EU Kids Online survey of 9-16 year olds and their parents in 25 countries. EU Kids Online, Deliverable D4. EU Kids Online Network, London, UK. http:// eprints.lse.ac.uk/33731/ (accessed July 2013) McGrath, H 2009, Young People and Technology: A review of the current literature, 2nd ed., prepared for The Alannah and Madeline Foundation. Merry J et al (2012) The effectiveness of SPARX, a

computerised self-help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ 2012; 344 :e2598 doi: 10.1136/bmj. e2598 http://www.sparx.org.nz/cdn/ Merry%20et%20al%20(2012)%20 BMJ.pdf (accessed July 2013) Ólafsson, Kjartan, Livingstone, Sonia and Haddon, Leslie (2013). Children’s use of online technologies in Europe : a review of the European evidence base. EU Kids Online, EU Kids Online Network, London, UK http://www. lse.ac.uk/media@lse/research/ EUKidsOnline/Home.aspx (accessed July 2013)

harvard. edu/pubrelease/isttf/ (accessed July 2013) Powell J, Martin S, Sutcliffe P, Todkill D, Gilbert E, Moli P, Sturt J (2010) Young People and Mental Health: The Role of Information and Communication Technology. University of Warwick/ Comic Relief. London. (unpublished but available on request) Princes Trust (2013) Digital Literacy Survey 2013. Princes Trust. London http://www.princestrust.org.uk/about_the_trust/what_ we_do/research/digital_literacy_ research_2013.aspx (accessed July 2013)

Office of the Information Commissioner (2013) Social networking and online forums – when does the DPA apply? London. http://www.ico.org.uk/ for_organisations/data_protection/ topic_guides/online (accessed July 2013

Singh J, Hartup M, Blanchard M, Burns J (2013) Cybersafety and Young People: Negotiating Responsible Digital Citizenship. Young and Well CRC, Melbourne http://www.yawcrc.org.au/knowledgehub/publications (accessed July 2013)

Palfrey J, Sacco D, Boyd D, DeBonis L (2008). Enhancing Child Safety and Online Technologies: Final Report of the Internet Safety Technical Taskforce, Harvard University, Berkman http://cyber.law.

Singh J, Hartup M, Blanchard M, Burns J (2011) Young People and Vulnerability: Reframing Issues and Addressing Challenges. Young and Well CRC, Melbourne. http:// www.yawcrc.org.au/knowledge-hub/

publications (accessed July 2013) Staksrud, Elisabeth, Ólafsson, Kjartan and Livingstone, Sonia (2013) Does the use of social networking sites increase children’s risk of harm? Computers in human behavior, 29 (1). pp. 40-50. ISSN 0747-5632 http://eprints.lse. ac.uk/45016/ (accessed July 2013) The Corner (2012) Pose, Sext, What Happens Next (Leaflet) The Corner. Dundee http://www.thecorner. co.uk/3_Sexting.html Third, A., Richardson, I., Collin, P., Rahilly, K. & Bolzan, N. (2011) Intergenerational Attitudes Towards Social Networking and Cybersafety: A living lab. Cooperative Research Centre for Young People, Technology and Wellbeing. Melbourne. http:// www.yawcrc.org.au/knowledge-hub/ publications (accessed July 2013) Third, A, Spry, D & Locke, K 2013, Enhancing parents’ knowledge and practice of online safety: A research report on an intergenerational ‘Living Lab’ experiment, Young and Well Cooperative Research Centre, Melbourne. http://www.yawcrc.org. au/knowledge-hub/publications (accessed July 2013)

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REFERENCES A Thin Line (MTV) http://www. athinline.org/ (accessed July 2013) Think U Know http://www. thinkuknow.co.uk/11_16/ (accessed July 2013)

Young Scot (2013) “Mobile, Internet & Apps Survey”. 634 responses from young people aged 11-26.

Youthnet (2012) The role of online and online peer support for young people who self-harm – Good practice guide. London. http://www. youthnet.org/2012/12/the-role-ofonline-and-online-peer-supportfor-young-people-who-self-harm/ (accessed July 2013) Ofcom Communications Market Report (2012) http://stakeholders. ofcom.org.uk/market-data-research/ market-data/communicationsmarket-reports/cmr12/internet-web/ uk-4.03 Ofcom Communications Market Report Scotland (2012) http:// stakeholders.ofcom.org.uk/ market-data-research/market-data/ communications-market-reports/ cmr12/scotland/ The Carnegie UK Trust. “Across the Divide: Tackling Digital Exclusion in Glasgow” (2013)

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ILLUSTRATIVE MAP OF DIGITAL ASSETS FOR YOUNG PEOPLE’S MENTAL HEALTH. (See appendices for full mapping document.) ABOUT THIS DOCUMENT: The project team collected around fifty examples of services, campaigns and digital assets that were targeted at young people, both in development and in operation. The mapping exercise was not exhaustive. Based on the examples we have identified, we have proposed three ‘activity types’ to base a map of assets in the six key audience areas. What is clear is that many services fit more than one activity type.

In terms of the public service context, the value of online information sources is already well recognised. We present examples which show both mental health specific information and wider youth information which includes mental health, with an idea of enabling discussion about how best to present information and encourage interaction and social sharing by young people of accurate content.

In terms of online services, we have presented examples from NHS, third sector and social enterprise/business sectors, which use digital technology to deliver mental health services, increase young people’s engagement with services, and enable young people to self-manage their mental health problems. Assets in this category are likely to be of particular interest to NHS stakeholders.

Finally, we have sought to connect the audience categories to the ways in which young people use the internet to develop and maintain social capital, explore identity and reflect. These assets will be of interest both in terms of their touch points with those using NHS services, and in terms of understanding how young people are using digital in the way young people of previous generations may have kept paper diaries and passed notes in class.

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