Lessons from end-users: how young people select mobile mental health applications

This blog post discusses findings from a peer-reviewed article titled: “What criteria are young people using to select mobile mental health applications? A nominal group study” published in Digital Health (2022, paper here).

Mental health apps: more accessible mental health support

According to the World Health Organization, as many as one in seven children and teenagers aged 10-19 experience mental health disorders (1). Despite the prevalence of mental health issues in this group, access to professional diagnosis and treatment remains low. As a result, children and teenagers are turning to smartphone applications to support their mental wellbeing. When young people search for apps to support their mental health in general or to address a specific problem, such as anxiety, they are faced with an overwhelming number of options.

How to pick a mental health app?

The smartphone applications available on platforms such as Google Play or App Store are evaluated based on general user experience or satisfaction, usually on a 1 to 5-star rating scale. This system results in apps being suggested based on popularity, rather than the content of the app or its effectiveness in addressing mental health concerns. While some mental health interventions delivered by apps are developed based on evidence, most of the apps on the market are not supported by science. Additionally, there is no regulatory oversight to prevent apps from promoting potentially harmful interventions, making false claims, or mishandling user data (2,3). Based on a search from 2016, only 2.6% of apps make effectiveness claims that are supported in any way (4). The high number of available apps combined with only popularity-based rankings make it difficult to choose apps that are safe and effective.

Young people’s criteria for selecting mental health apps

Since selecting mental health support apps is challenging, the Neuroscience Engagement and Smart Tech (NEST) lab at Neuroethics Canada, in collaboration with Foundry BC, set out to develop a tool that would make it easier to select an app that is best suited to user’s circumstances. A tool that is helpful to young people has to align with their needs and priorities. Thus, we conducted a series of nominal group meetings to identify the criteria that are important to young people when they select mental health apps. The infographic below summarizes the criteria that emerged in discussions with 47 young people aged 15-25 in four towns in British Columbia, Canada. These criteria will inform the development of an app-selection tool that will combine end-user priorities with expert input.

The future of mental health support

As mental health apps continue to increase in popularity, so does the diversity and complexity of the features they offer. For example, some mobile applications offer access to healthcare professionals via video or chat but may also use AI chat bots to provide help or counselling. As we uncovered in the nominal groups, young people want the apps to provide links to community services that are available in their area and allow users to share the information that the apps collect with their health care team. As such, it is critically important to identify the priorities of end-users to guide the ethical usage of this innovative form of mental health support.

References

1. Adolescent mental health [Internet]. [cited 2022 Dec 16]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health
2. Anthes E. Mental health: There’s an app for that. Nature News. 2016 Apr 7;532(7597):20.
3. Robillard JM, Feng TL, Sporn AB, Lai JA, Lo C, Ta M, et al. Availability, readability, and content of privacy policies and terms of agreements of mental health apps. Internet Interventions. 2019 Sep 1;17:100243.
4. Larsen ME, Nicholas J, Christensen H. Quantifying App Store Dynamics: Longitudinal Tracking of Mental Health Apps. JMIR mHealth and uHealth. 2016 Aug 9;4(3):e6020.

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Would you join a clinical trial advertised on Facebook? The ethics of dementia research content on social media

Some areas of dementia research are relevant to healthy older adults, and social media can help spread the word. What should researchers and the public know about dementia research content on social media to support future brain health?

Dementia risk reduction is highly relevant for healthy adults. Addressing certain lifestyle factors may reduce future cases of dementia (1). Examples include education, performing physical activity, quitting smoking, preventing head injury, and stabilizing blood pressure.

Online exposure to this topic may encourage lifestyle changes but also promote much-needed dementia research participation for risk reduction. Some dementia researchers are turning to social media as a low-cost way to increase community awareness and research participation (2–5).

Appropriateness of social media in brain health research

Health-related content on social media is not without risk. Ethical concerns accompany the use of social media in research (6,7). Common concerns include privacy, confidentiality, informed consent, the spread of misinformation, and the protection of vulnerable groups. 

Understanding how dementia research is typically presented online can inform social media use to improve public involvement. Currently, however, there is no thorough overview of the type of dementia research content users may encounter on social media. 

To inform future ethical guidance of online brain health engagement, we investigated current uses of social media for dementia research. 

Image by Jason A. Howie under the cc-by-2.0 license on Wikimedia Commons. Creator assumes no responsibility or liability for the content of this site. Original image.

Dementia research on Facebook vs. Twitter

We reviewed a sample of public dementia research posts on Facebook and Twitter (8). Our analysis included understanding the types of users posting about dementia research and the topics discussed. 

Facebook users were mainly advocacy and health organizations rather than individuals. In contrast, Twitter users largely had academic or research backgrounds. This difference in user groups may explain the greater amount of academic content on Twitter, such as peer-reviewed research articles. Most research articles were open access and available to the public but may not be accessible for a wide range of literacy levels.

For both platforms, prevention and risk reduction were main areas of focus in dementia research. Posts with these topics appeared the most frequently and received a lot of attention in the form of likes, shares, and comments.

Other popular topics included dementia treatment and research related to the detection of dementia. Treatment posts primarily discussed the approval of aducanumab¹ by the Food and Drug Administration (FDA), leading to much online debate. This may explain why, at the time, non-academic users had more interactions on dementia treatment tweets. The purpose behind most posts was to share dementia research information and knowledge.

On risk, responsibility, and stigma

The posts in our social media data emphasized individual prevention efforts, such as diet and exercise. However, topics also included social and environmental barriers that interfere with dementia risk reduction, care, treatment delivery, and other research areas. 

As stated in one Facebook post, “[the] social determinants of health can significantly impact brain health disparities & the ability to access care.”

Barriers are unequally distributed across communities that vary by race, ethnicity, sex and gender, socioeconomic background, disability, and other aspects of identity.

Dementia researchers on social media should avoid using language that elicits stigma or equates brain health with personal responsibility (9). Society-wide initiatives that overcome barriers can potentially impact future population health on a broader scale positively and more effectively.

Image from Pixabay.

Practical social media guidance is needed for dementia research

A better understanding of the dementia research space on social media can inform future ethical guidelines. Dementia research engagement should incorporate the community’s values and perspectives on using social media for risk reduction.

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¹ The FDA approved aducanumab as a treatment for Alzheimer’s disease in June 2021. The decision was met with much controversy and ethical discussion. More information can be found here.

Access the full research paper here.

This work is supported by the Alzheimer’s Association Research Grant program (JMR), the Canadian Consortium on Neurodegeneration in Aging, AGE-WELL NCE Inc., a member of the Networks of Centres of Excellence program, and the University of British Columbia Four Year Doctoral Fellowship (VH).

References

1. Livingston G, Huntley J, Sommerlad A, Ames D, Ballard C, Banerjee S, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet. 2020 Aug 8;396(10248):413–46.
2. Corey KL, McCurry MK, Sethares KA, Bourbonniere M, Hirschman KB, Meghani SH. Utilizing Internet-based recruitment and data collection to access different age groups of former family caregivers. Appl Nurs Res. 2018 Dec 1;44:82–7.
3. Isaacson RS, Seifan A, Haddox CL, Mureb M, Rahman A, Scheyer O, et al. Using social media to disseminate education about Alzheimer’s prevention & treatment: a pilot study on Alzheimer’s universe (www.AlzU.org). J Commun Healthc. 2018;11(2):106–13.
4. Friedman DB, Gibson A, Torres W, Irizarry J, Rodriguez J, Tang W, et al. Increasing Community Awareness About Alzheimer’s Disease in Puerto Rico Through Coffee Shop Education and Social Media. J Community Health. 2016 Oct;41(5):1006–12.
5. Stout SH, Babulal GM, Johnson AM, Williams MM, Roe CM. Recruitment of African American and Non-Hispanic White Older Adults for Alzheimer Disease Research Via Traditional and Social Media: a Case Study. J Cross-Cult Gerontol. 2020 Sep 1;35(3):329–39.
6. Bender JL, Cyr AB, Arbuckle L, Ferris LE. Ethics and Privacy Implications of Using the Internet and Social Media to Recruit Participants for Health Research: A Privacy-by-Design Framework for Online Recruitment. J Med Internet Res. 2017;19(4):e104.
7. Gelinas L, Pierce R, Winkler S, Cohen IG, Lynch HF, Bierer BE. Using Social Media as a Research Recruitment Tool: Ethical Issues and Recommendations. Am J Bioeth. 2017 Mar 4;17(3):3–14.
8. Hrincu V, An Z, Joseph K, Jiang YF, Robillard JM. Dementia Research on Facebook and Twitter: Current Practice and Challenges. J Alzheimers Dis. 2022 Jan 1; 1–13.
9. Lawless M, Augoustinos M, LeCouteur A. “Your Brain Matters”: Issues of Risk and Responsibility in Online Dementia Prevention Information. Qual Health Res. 2018 Aug 1;28(10):1539–51.

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Viorica Hrincu, MSc is doing her PhD in Experimental Medicine at the University of British Columbia in the Neuroscience Engagement and Smart Tech (NEST) lab.

Neuroethics Canada goes green: A year-in-review of medical cannabis research

In collaboration with Canadian Childhood Cannabinoid Clinical Trials, Neuroethics Canada conducted a series of research projects to investigate ethical, legal and social issues surrounding medical cannabis. We studied news media representations of medical cannabis, conducted interviews with clinicians, and held virtual workshops to garner a greater understanding of the perspectives of key stakeholders, and to make recommendations for future medical cannabis research, regulation and use.

Ethical issues at the forefront of news reporting on medical cannabis: Capturing the focus of multiple formats of news media coverage on medical cannabis is essential to understanding how public opinions and public policy are shaped. We studied traditional and alternative news media messaging surrounding medical cannabis and health. Analysis revealed that key ethical, legal and social (ELS) issues were the main focus of both traditional and alternative news articles. Alternative news articles covered ELS issues more in fewer articles, and reported on fewer themes per article. Overall, access was found to be the dominate ELS issue. Multiple factors impacting patient access, such as institutional regulations and supply of products, were reported on in both traditional and alternative sources (Figure 1). In traditional news coverage, institutional gatekeeping of patient access declined significantly post-legalization of adult possession and use of medical cannabis; by comparison, there was no change in alternative news pre- and post-legalization with regard to gatekeeping, although coverage of the access factor of product supply increased post-legalization (Cannabis Act, 17 October 2018). There was limited coverage of issues specific to exceptional populations, including children with neurological and medical disorders and Indigenous peoples. See Gunning and Illes, Coverage of medical cannabis by Canadian news media: Ethics, access and policy, International Journal of Drug Policy, 97, 103361 (2021); and response to publication, International Journal of Drug Policy, under review.

Figure 1: Major access factors by percentage of coverage of the ELS subtheme of access. Minor access factors accounting for less than 5% of total coded references are not shown.

Harm reduction approach for medical cannabis in the care of youth and children: The use of cannabis for medical purposes by youth and children is expanding. However, supporting evidence and federal and local regulations are lacking. Understanding clinician perspectives of this landscape is key for addressing access barriers, and for supporting safe, appropriate use. We interviewed Canadian clinicians practicing in areas related to paediatric medicine including neurology, oncology and palliative care. Clinicians discussed barriers to patient access, chiefly obstacles in the authorization process such as considerations around supply, quality and cost of products. The need for facilitating open, honest clinical communication between patients, caregivers and clinicians was described as essential for ensuring informed consent. As with all other treatment decisions, clinicians described considerations that could mitigate risks, such as life-limiting prognosis and number of tried and failed conventional therapeutic options. Further, they expressed that more methodologically-sound research is essential for expanding medical applications of cannabis. Overall, the discourse aligned with the principles of harm reduction: pragmatism, humanism, harms, and prioritization of immediate goals (Figure 2). Gunning et al., Canadian Medical Association Journal, under review.

Figure 2: Harm reduction approaches employed by clinicians to ensure ethical, safe use of medical cannabis for children and youth.

Building trust in the tense world of medical cannabis: We convened a two-day virtual workshop to discuss ethics and medical cannabis for children and youth in healthcare. Three main topics were covered in each session: (1) the current scientific and regulatory landscape of medical cannabis; (2) surrogate decision-making and assent; and (3) social and political culture of medical cannabis. In attendance were members of the public, ethicists, clinicians, researchers, policy makers, patient representatives, and industry representatives. Despite having a medical cannabis access program in Canada for two decades, participants expressed disappointment that there is still a large amount of uncertainty around medical cannabis due to a lack of data and poor data translation. Also highlighted by participants was the importance of clinicians building trust with patients by demonstrating their trustworthiness in clinical consultation. Respecting patient informed choice, assent and dissent, and understanding and addressing the root cause of clinician hesitancy to authorize were described as ways clinicians can facilitate trust with patients and their caregivers. Participants discussed historical and ongoing stigmatization of medical cannabis and medical cannabis users, particularly of people who are already marginalized within the healthcare system. There were calls for more strength-based research with Indigenous youths’ and communities’ to understand their perspectives on medical cannabis and health. Gunning et al., in preparation.

Our work, including media analyses, interviews, and workshops, highlighted three key areas that will be critical to addressing ongoing issues in the study, regulation, authorization and use of medical cannabis: (1) continued examination of ethics issues surrounding medical cannabis; (2) acquisition of evidence using innovative, adaptive study designs and diverse knowledge systems; and (3) public consultation and engagement with key stakeholders.

Acknowledgments to Dr. Judy Illes, research members Ari Rotenberg and Alissa Wong, project collaborators at Canadian Childhood Cannabinoid Clinical Trials, and members of Neuroethics Canada for their leadership, contributions and continued support.

Can social robots improve children’s mental health? What we know and what we still need to learn

This blog post discusses some of the key findings from the article “Socially Assistive Robots as Mental Health Interventions for Children: A Scoping Review” published in the International Journal of Social Robotics (2020, paper here).

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What is a social robot?

Social robots are small robotic devices that are capable of social interactions, such as cooperation, instruction and play. The robots can be shaped like animals (e.g., Aibo – the robotic dog (Fig. 1(a)) or characters (e.g. humanoid robot Nao (Fig. 1(b)). Among other functions, social robots can play a therapeutic role (1), serve as companions (2) and aid in education (3,4). One of the application areas of social robotics is therapy for children with autism spectrum disorder. In this domain, robotic companions have the potential to improve a variety of behavioural outcomes, including social and language skills (5). Social robots are also used with older populations. For example, robots like Paro (Fig. 1(c)) are being used in elder care settings. This baby harp seal lookalike helps reduce loneliness and agitation among residents (6).

Fig. 1 Commonly used social robots Aibo (a)(7), Nao (b)(8), Paro (c)(9).

A new mental health intervention for children

Since social robots seem to have a positive impact on mental health in different populations, there is a growing interest in using them as a tool to promote and improve mental health among children. As a result, a number of studies are being conducted to test social robots in this relatively new domain. In the Neuroscience Engagement and Smart Tech (NEST) Lab, we collected and analyzed the existing research studies which investigate the use of social robots to improve children’s mental health (10), to get a fuller view on what interventions are being tested and how.  

What we know: Feasibility and short-term effects

Using social robots to benefit children’s mental health is a new and rapidly developing field. Hence, the majority of currently available studies are intended as means of exploring what is possible and what could be effective in the future. The studies usually include a single session with the robot, which shows only short-term outcomes of the interaction. While the evidence does not allow for drawing strong and long-term conclusions, the studies in our sample demonstrate that various robotic interventions are feasible. We know that social robots can be introduced and deployed in therapy, clinical and other settings. But perhaps the most crucial aspect of determining whether robotic companions could be successful, is the fact that children participating in the studies usually showed a positive response to the robots and were engaged in the interaction, e.g., distraction during vaccination (11). This positive reception makes the developments in the use of social robots promising.

What we still need to learn: Effectiveness and social impact

To be able to draw conclusions about the effectiveness of robotic interventions we need more evidence. Future research in this field needs to systematically address well-focused questions around specific outcomes (e.g., stress reduction). Additionally, potential social impacts of the robots should be more carefully considered. Robots are intended to be introduced into different environments as social entities. For example, a robot present at a hospital to distract children during medical procedures will likely affect others around the child such as parents and nurses. Moving forward, we need to learn more not only about specific social robot interventions that can be helpful, but also about how introducing social robots into new environments will affect social dynamics.

What about ethics?

Conducting child-robot interaction research comes with unique ethical concerns. In our scoping review of the literature, we found that the majority of studies in the sample provide only generalized statements about the assent process used (10). Transparency about how the robot is introduced and described  to young participants is crucial, as children of different ages may have different beliefs about the animacy of robots. Other notable ethical considerations include attachment and deception. For example, children could experience distress when the robot is taken away or mistreated (12). The key to proactively addressing these ethical issues could be using participatory approaches throughout the research process. Working together with children and parents will help minimize the risk and maximize the benefit of future social robot mental health interventions.

Acknowledgements to the leaders of this work Dr. Julie Robillard and Dr. Tony Prescott.

References:

1. Howard AM. Robots learn to play: robots emerging role in pediatric therapy. FLAIRS Conference. 2013 May; Available from: https://smartech.gatech.edu/handle/1853/49760.
2. Abdi J, Al-Hindawi A, Ng T, Vizcaychipi MP. Scoping review on the use of socially assistive robot technology in elderly care. BMJ Open. 2018 Feb 1;8(2):e018815.
3. Looije R, Neerincx MA, Peters JK, Henkemans OAB. Integrating Robot Support Functions into Varied Activities at Returning Hospital Visits. Int J of Soc Robotics. 2016 Aug 1;8(4):483–97.
4. Ros R, Oleari E, Pozzi C, Sacchitelli F, Baranzini D, Bagherzadhalimi A, et al. A Motivational Approach to Support Healthy Habits in Long-term Child–Robot Interaction. Int J of Soc Robotics. 2016 Nov 1;8(5):599–617.
5. Pennisi P, Tonacci A, Tartarisco G, Billeci L, Ruta L, Gangemi S, et al. Autism and social robotics: A systematic review. Autism Research. 2016;9(2):165–83.
6. Pu L, Moyle W, Jones C, Todorovic M. The Effectiveness of Social Robots for Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. Gerontologist. 2019;59(1):e37–51.
7. Entertainment Robot “aibo” Announced. Sony Group Portal – Sony Global Headquarters. [cited 2021 Jun 29]. Available from: http://www.sony.com/en/SonyInfo/News/Press/201711/17-105E/index.html
8. Nao – ROBOTS: Your Guide to the World of Robotics. [cited 2021 Jun 29]. Available from: https://robots.ieee.org/robots/nao//
9. Purchasing PARO seal. [cited 2021 Jun 29]. Available from: https://www.paroseal.co.uk/purchase
10. Kabacińska K, Prescott TJ, Robillard JM. Socially Assistive Robots as Mental Health Interventions for Children: A Scoping Review. Int J of Soc Robotics .2020 Jul 27;10.1007/s12369-020-00679-0.
11. Beran TN, Ramirez-Serrano A, Vanderkooi OG, Kuhn S. Reducing children’s pain and distress towards flu vaccinations: A novel and effective application of humanoid robotics. Vaccine. 2013 Jun 7;31(25):2772–7.
12. Kahn Jr. PH, Kanda T, Ishiguro H, Freier NG, Severson RL, Gill BT, et al. “Robovie, you’ll have to go into the closet now”: Children’s social and moral relationships with a humanoid robot. Developmental Psychology. 2012;48(2):303–14.

Dementia Technology Policies: Benefits Are Clear – But What About the Harms?

This blog post discusses some of the key findings from the article “Prioritizing Benefits: A Content Analysis of the Ethics in Dementia Technology Policies” published in the Journal of Alzheimer’s Disease (2019, paper here).

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A new era of dementia care

From tracking devices to social robots, technology is rapidly transforming the scope of dementia care. Persons living with dementia and their caregivers can now choose from a wide range of innovative technologies to assist with everyday activities, symptom management, and more. With potential benefits such as increased autonomy and enhanced safety for persons living with dementia (1), new technologies are continuously being developed and entering the market.

Despite the excitement of innovation, the promising benefits of dementia technology must not be the only ethical implication to consider. Although monitoring technologies such as video surveillance can keep older adults safe, this may be at the cost of compromising privacy and independence. While companion robots may show potential in enhancing well-being and connection in older adults (2), this often comes with an expensive price tag. These diverse ethical implications are important for older adults to consider so they adopt technology that best aligns with their needs and values.

The question is, how are these ethical implications communicated to the dementia community through public policies?

The guidance of public policies

Alzheimer associations around the world create public-facing policies to guide the adoption and use of technology in dementia care. Given the wide array of ethical implications in need of consideration, policies play a critical role in raising the ethical issues of care technology to the dementia community. However, we found that the quality and ethical content of these policies can greatly vary, particularly around what ethical implications are being most and least discussed with the public (3).

What we found: Policies prioritize benefits

In the Neuroscience, Engagement, and Smart Tech (NEST) Lab, we analyzed the ethical content of 23 international policies using the four principles of biomedical ethics (4): beneficence, non-maleficence, autonomy, and justice (Fig. 1).

Fig. 1. The four principles of biomedical ethics adapted from Beauchamp and Childress (4).

What we found was that nearly all policies (96%) discussed the benefits of using technology such as increased independence, improved social contact, and enhanced quality of life for the person affected by dementia (3). However, this near-perfect score was not matched by the other ethical principles that raise the potential risks and harms associated with using dementia care technology (Fig. 2)

Fig. 2. Prevalence of policy documents based on the four principles of biomedical ethics.

Themes of justice, for example, were discussed in 74% of the policies, followed by themes of non-maleficence at 52% and autonomy at only 43% (Fig. 2). This lack of comprehensive discussion surrounding the risks and potential harms of dementia care technology is critical for users. Understanding ethical considerations such as cost, privacy, and consent are imperative for people affected by dementia to make well-informed decisions about their care.

Reshaping dementia technology policies

As dementia care technology continues to rapidly develop, so should policies that shape their adoption and use. To maximize the current and future benefits of dementia technologies, policies need to be reworked so that they are in the best interest of the dementia community. Important to this is the inclusion of not just benefits, but the potential risks and harms associated with dementia care technology. Persons with dementia, caregivers, and family members need to be actively engaged in the policy-making process to ensure patient-centred guidance in public policies.

A guide to adopting new technology in dementia care

Based on our findings, we disseminated a public resource to guide the adoption of new technologies in dementia care. Here are 10 questions for older adults to consider when adopting a new technology:

Acknowledgements to Dr. Julie Robillard for her leadership in this project and research members Tanya Feng and Mallorie Tam for their substantial contributions. This work was supported by the Canadian Consortium on Neurodegeneration in Aging and AGE-WELL NCE.

References

1. Meiland F, Innes A, Mountain G, Robinson L, van der Roest H, García-Casal JA, et al. Technologies to Support Community-Dwelling Persons With Dementia: A Position Paper on Issues Regarding Development, Usability, Effectiveness and Cost-Effectiveness, Deployment, and Ethics. JMIR Rehabil Assist Technol. 2017 Jan 16;4(1):e1.
2. Pike J, Picking R, Cunningham S. Robot companion cats for people at home with dementia: A qualitative case study on companotics. Dementia. 2021 May 1;20(4):1300–18.
3. Robillard JM, Wu JM, Feng TL, Tam MT. Prioritizing Benefits: A Content Analysis of the Ethics in Dementia Technology Policies. J Alzheimers Dis. 2019;69(4):897–904.
4. Beauchamp T, Childress J. Principles of Biomedical Ethics: Marking Its Fortieth Anniversary. Am J Bioeth. 2019 Nov;19(11):9–12.

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Julia Wu, BSc is a Research Assistant in the Neuroscience, Engagement and Smart Tech (NEST) Lab at the University of British Columbia and BC Children’s and Women’s Hospital. Her research interests include mental health and innovative approaches to improving patient experience and person-centred care in health care systems.

Experimental Neuroethics

Photo credit: Timothy Epp, Shutterstock

Four years ago, Neil Levy gave the concluding lecture at the first Brain Matters conference in Halifax. He alerted the audience of neuroethicists to the fact that the field of philosophy was undergoing a revolution – rather than muse from their armchairs in the ivory tower, a group of renegade philosophers were carrying out real experiments, asking people what their intuitions were about central issues in philosophy. Dubbed experimental philosophy, the new initiative was met with more than passing resistance from traditional philosophers. The apostate experimental philosophers responded by developing a logo of a burning armchair.

The landmark experiment was carried out by Josh Knobe, and its findings subsequently became known as the Knobe effect (you can watch a great recreation of the phenomenon in this YouTube video). Essentially, what Josh did was repurpose an old method from social psychology called the contrastive vignette technique (CVT) [1]. At its simplest, the CVT involves designing a pair of vignettes that carefully describe a particular situation (in the case of experimental philosophy, one that is often morally charged) but crucially differ in one detail, hence the term contrastive. Respondents see one and only one version of the vignette, and are then asked questions about what they have just read, with responses commonly recorded as a numerical rating on a Likert scale. By comparing the averaged responses between separate groups of people who have read the vignettes, the experimenter can systematically investigate the effects of small changes (of which the respondents are entirely unaware) upon attitudes towards nearly any topic. The experimental philosophers tend to use the technique to explore the meaning of concepts. Neil Levy pointed out that this same approach could, in principle, be applied to the full range of issues in neuroethics.

Neil’s presentation struck me like a thunderbolt. I had come to the field of neuroethics with a background in cellular and molecular biology, and had spent much of my career as a card-carrying reductionist: as a graduate student in the 1980’s, I championing the then-novel technique of recording from single neurons in freely moving animals, and as a postdoc I moved on to the better controlled (if less naturalistic) technique of patch clamp analysis of identified neurons in slices of brains. My subsequent rise through the ranks of academia was one in which I applied quantitative rigor to every question that I asked, and in the circles in which I traveled, this was lauded as the ultimate way to provide reproducible (and by inference, meaningful) results. I saw at once that the CVT opened the door towards doing something similar in the field of neuroethics.

My research group at the National Core for Neuroethics has embraced the use of contrastive vignettes wholeheartedly, and with a nod to the experimental philosophy camp, we call the approach Experimental Neuroethics. The team is applying the technique to a range of issues in contemporary neuroethics, probably best exemplified by our recent publications exploring public attitudes towards cognitive enhancement [2] as well as the acceptability of overt and covert nudges [3].

If the vignettes appear simple, I can assure you that properly crafting them is hard work. We begin with a carefully considered hypothesis and regularly find that the hypothesis morphs substantially (usually into something much more insightful) as the process unfolds. We then compose two or more contrastive vignettes, working hard to have the vignettes as minimally contrastive as possible (one word differences between vignettes is the ultimate goal, but this is often not feasible). Finally, we develop questions; we like to have the wording of the questions always be identical irrespective of the contrastive nature of the vignette.

Then the real fun begins. After a day or two, we assemble as a team and attack our previous work. Inevitably, we find it wanting in some respect. Sometimes, embarrassingly so. We find it best to begin by asking whether the vignette and the questions directly address the hypothesis. Sometimes that means that the hypothesis changes. Nearly always, that means that the vignette changes. This process is repeated again and again, over days and weeks and sometimes months (yes, and even sometimes years!) until we have a set of vignettes that get to the heart of the matter.

At some point late in the process we carry out cognitive pre-testing. This involves sharing the vignette and the questions with someone who has no particular expert knowledge (friends of friends are likely culprits), and debriefing them about what they read. We are sometimes amazed to find that what we intended for people to glean from a vignette is at odds with their reading of the vignette. That sends us back to the drawing board.

We also run some metrics to determine whether the words we have used are understandable by a general audience. We use online readability tests such as this one to establish the educational level required for understanding the vignette; our goal is that no more than a high school education is required. Finally, we launch the survey, recruiting respondents from amongst the thousands of people who have signed up on Amazon’s Mechanical Turk – they’re more representative of the real population and aren’t as blatantly WEIRD as typical undergraduate samples. And then we hold our breath.

Once the data is analyzed, we get mired once again in deep discussion. For it is not just the quantitative aspect of Experimental Neuroethics that it satisfying (to me), but also that the data gives us an entirely new benchmark for engaging in the process of wide reflective equilibrium. Throughout this process we remain aware that an ought can not derive from is, but having the data at hand, our version of ought is very much informed by the is. Ultimately, our data emerge in concert with our normative insights, and then one more advantage of Experimental Neuroethics is realized: it is easy for others to replicate our experiments, or even to improve them by taking our vignettes and modifying them to further test their own. This iterative process of replication, critique, and systematic modification has proven to be a robust strategy for advancing insights into the nature of biological and physical phenomena. Only time will tell whether Experimental Neuroethics catches fire in our discipline as it has in the field of philosophy (where it remains controversial). If it does, we can trace it back to Neil’s presentation in Halifax….

[Cross posted at the Neuroethics Blog]

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[1] Burstin K, Doughtie E, Raphaeli A. Contrastive Vignette Technique: An indirect Methodology Designed to Address Reactive Social Attitude Measurement1. Journal of Applied Social Psychology. 1980;10(2):147–65.

[2] Fitz NS, Nadler R, Manogaran P, Chong EWJ, Reiner PB. Public attitudes toward cognitive enhancement. Neuroethics. 2013 doi: 10.1007/s12152-013-9190-z.

[3] Felsen G, Castelo N, Reiner PB. Decisional enhancement and autonomy: public attitudes towards overt and covert nudges. Judgment and Decision Making. 2013;8(3):202–13.

Racing to restoring cognitive function

Wisdom may come with age, but so too does an inexorable decline in cognitive abilities. Whether it is speed of processing, working or long-term memory, it all starts to go downhill as people move into their 30s, and continues as they enter their 40s and beyond (click on the figure for the details). What to do? Some people do crossword puzzles.Mostly they just worry. A few sign up for one of the many brain fitness software suites out there, but do they really work? The answer has mostly been maybe. Until now.

Before getting to the breakthrough, let’s briefly see what the state of affairs were last week. Many studies have shown improvements with brain training, but the gain is mainly in the game; overall, cognitive function is usually not affected. Getting better at a game is all well and good, but that is not what people are after.

One study was a clear exception. In 2008, Jaeggi et al. published a paper in PNAS which showed that one particular game – the N-back task – improved not just task performance but also fluid intelligence. This was met with a great deal of excitement, and you can find many N-back tasks on the internet. But the N-back is hard. It’s also pretty boring. I suppose that is why I have struggled with maintaining a regular practice of N-back training. While no one has disputed Jaeggi et al’s findings, the field was rocked on its heels in 2010 when Adrian Owen and his colleagues at Cambridge published a paper in Nature in which they tested 11,430 people (!!) in Britain. What they reported was that “in every one of the cognitive tasks that were trained, no evidence was found for transfer effects to untrained tasks, even when those tasks were cognitively closely related.” [Notably, the N-back task was not included in the study.]  At the time I wrote that more than anything, Owen’s results were likely to spur further investigation.

And so they have.  In a very thoughtfully designed set of experiments published this past week in Nature, Adam Gazzaley’s group at UCSF report that they have developed a new game called Neuroracer that not only improves the ability of older adults to multitask, but it also improves cognitive control, working memory, and attention; all of these are cognitive domains that are known to degrade in normal aging.  The experiments are exceedingly carefully carried out – there is both an active control group who had a slightly different task and a no-contact control group; neither showed any benefit. [It is not clear whether the game would have a similar effect in younger adults, but you can be sure that those data, and more, are in the pipeline.] What is remarkable is the degree to which the Neuroracer was able to restore cognitive function.

I have not played the Neuroracer game myself, but I know from discussions with Adam that his objective was to solve not just the efficacy side of the equation, but also to make the game interesting. Although it was not discussed in the article, if Neuroracer satisfies this criterion as well, it represents a doubly important advance in the field.

Adam visited us in November 2011 and I had a chance to sit down to talk with him about the degradation of attention that accompanies multitasking in the modern world. The video can be found below.

When is it rational to be nudged?

Image Credit: http://tinyurl.com/kwyqxl4

Five years ago, Richard Thaler and Cass Sunstein published a thoughtful little book called Nudge in which they outlined a broad program for improving the outcomes of human decisions. Drawing on the maturity of the field of behavioural economics, Thaler and Sunstein outlined the myriad ways in which small changes in the environment can affect the choices we make. In the intervening years, interest on the part of governments in developing such programs has grown ever stronger. In Great Britain, the Conservative government of David Cameron established the Behavioural Insights Team in 2010, with Richard Thaler as advisor. Cass Sunstein was appointed Administrator of the White House Office of Information and Regulatory Affairs under Barack Obama, where, among other tasks, he developed government-wide regulations that nudge people in numerous ways, although exactly what was done has always been a bit under the radar. Now comes news that the US government is developing its own Behavioral Insights Team, and there is a call  for people with appropriate skills to join.

Nudging is not without its critics. Those with libertarian sensibilities are predictably outraged, even if Thaler and Sunstein described the program as an exercise in libertarian paternalism.The primary concern is that nudging infringes upon autonomy, which brings it directly into the sight lines of neuroethics. The key issues were recently summarized in a short article in The New Scientist by Evan Selinger.

Fair minded individuals may debate the degree to which the infringement upon autonomy engendered by nudges is problematic, but Gidon Felsen, Noah Castelo and I decided to take a different tack.  First of all, we reframed the issue, calling it Decisional Enhancement rather than nudging (that our reframe is, in and of itself, a bit of a nudge did not escape our notice). More importantly, we have begun to explore the question of how the public view the infringement of autonomy that decisional enhancement programs provide. Essentially, we wanted to explore the degree to which people are willing to trade autonomy for better outcomes. The results of our adventures in experimental neuroethics can be viewed in our recently published paper in Judgement and Decision Making.  One key insight is this: when people need help achieving their objectives in life, they are not loathe to give up a bit of autonomy. It does not appear to be the case that people are enthusiastic about giving up autonomy just because their objectives are aligned with the decisional enhancement program. Rather, it is when their objectives align with the program and they recognize that they are struggling with achieving that objective that the endorsement is most evident.  To put it into terms developed by Harry Frankfurt, it seems that autonomy violations are most acceptable when people recognize that their decisions are more likely to follow their lusty first-order desires – to overeat, to spend money foolishly, etc. – than their sober life objectives, what Frankfurt called second-order desires.  Viewed in this light, perhaps it is entirely rational to give up a bit of autonomy to live as we wish.

Neuroscience in the public sphere

Here at Neuroethics at the Core, we have been trumpeting the rise of neuroessentialist thinking in the eyes of the public for some time (here and here and here), and it represents one of the two pillars of my research program in neuroethics. In today’s issue of Neuron, there is a great paper by O’Connor et al. entitled “Neuroscience in the Public Sphere“. The  abstract sums it up rather well:

The media are increasingly fascinated by neuroscience. Here, we consider how neuroscientific discoveries are thematically represented in the popular press and the implications this has for society. In communicating research, neuroscientists should be sensitive to the social consequences neuroscientific information may have once it enters the public sphere.

There are a few points that I would like to highlight. First, as my graduate student Roland Nadler relayed in an email to me last night after we both had a first glance at the paper:

…this is a fantastic article from start to finish. Worth really savoring as an example of how to do the normative stuff well, and its lessons are important for us to avoid producing stuff that could be tarred as neurotrash. Particularly neat that they get the definition of neuroessentialism right. Their discussion of it near the end is trenchant. It makes it clear that some philosophical work needs to be done to save neuroessentialism from the pitfalls of essentialism tout court – as they rightly point out, the latter is some bad juju.

On the topic of neuroessentialism, I particularly liked their final paragraph:

Neuroscience does not take place in a vacuum, and it is important to maintain sensitivity to the social implications, whether positive or negative, it may have as it manifests in real-world social contexts. It appears that the brain has been instantiated as a benchmark in public dialogue, and reference to brain research is now a powerful rhetorical tool. The key questions to be addressed in the coming years revolve around how this tool is employed and the effects this may have on society’s conceptual, behavioral, and institutional repertoires.

Not only do O’Connor et al. provide thoughtful normative comments, they also carried out empirical work, employing content analysis to study the themes that arise most frequently in the popular press. At the top of the list is enhancement of the brain, which represented 28.3% of the articles retrieved from the LexisNexis database. As this just so happens to be the other pillar of my research program, how could I not like this paper?

Excellent stuff.

Nudge symposium proceedings

The current issue of the European Journal of Risk Regulation has the proceedings of a symposium on nudging, and it contains a set of insightful papers. The introduction by the editor says it best.

The EJRR starts the new year by hosting a pioneering symposium devoted to one of the latest policy innovations that is currently experimented in the United Kingdom and the United States: the ubiquitous, yet controversial, Nudge. This idea originates from the homonymous, 2008 best-selling book published by the economist Richard Thaler and the legal scholar Cass Sunstein. By building upon the findings of behavioural research, they refute the classic economic assumption that “each of us thinks and chooses unfailingly well”1 and they advocate the need for public authorities to nudge people to make decisions that serve their own long-term interests without however removing their right to choose.

At a time in which governments are taking considerable interest in the use of nudging, we have asked some of the leading authors who have already contributed to the literature surrounding the regulatory innovations, generally referred as New Governance, to share their ideas on this appealing regulatory approach.

In his opening essay, Nudging Healthy Lifestyles, Adam Burgess provides a critical assessment of the introduction of behavioural, nudging approaches to correct lifestyle behaviours in the UK. His thought-provoking analysis triggered a lively debate that has been framed along the subsequent essays signed by On Amir and Orly Lobel, Evan Selinger and Kyle Powys White, Alberto Alemanno and Luc Bovens.

The article by Alberto Alemanno, Managing Editor of the European Journal of Risk Regulation is a fulsome account of the propriety of nudging in the case of tobacco control (recently highlighted by Roland on these pages); that nudging in this instance overcomes many of the objections that are raised in the other contributions to the symposium.

I also liked Selinger & White’s analysis of nudging in the context of Brad Allenby and Dan Sarewitz’s insight on the three levels by which we should view technological fixes (as articulated in their excellent book The Techno-Human Condition, which I have written about before). In particular, they point out the naiveté of only considering shop-floor arguments, a topic we will return to again.

Hat tip to Marleen Eijkholt for alerting me to this symposium.

Image credit: Transcapitalist