Saturday, December 18, 2010

When Threats Backfire: A Critique of the NYU Child Study Center’s 2007 “Ransom Note” Campaign – Debora Case


The New York University Child Study Center is a nationwide resource for parents, educators, physicians, and

mental health professionals. Their focus is “to improve the treatment of child psychiatric disorders through

scientific practice, research, and education, and to eliminate the stigma of being or having a child with a

psychiatric disorder.” (1) In December 2007, the Center introduced a public health campaign in New York City

to raise awareness of mental illness in children. The campaign was produced pro bono by BBDO and included a

series of billboards and advertisements represented as ransom notes containing threats from the perspective of

depression, obsessive-compulsive disorder, attention-deficit hyperactivity disorder, autism, Asperger’s

syndrome, and bulimia. Underneath the notes are short messages with the organization’s website and

telephone number listed for more information. These ads were posted across billboards, kiosks, magazines,

newspapers, and the Internet. (2-3)

Many professional organizations and advocacy groups, such as the Autism Self Advocacy Network, responded

negatively with immediate complaints. Dr. Harold Koplewicz, the center’s founder stated, “Everyone who

participated felt the ads were informative… I am disappointed. I thought the people we’d be arguing with are the

people who believe psychiatric illness doesn’t exist.” In response to their concerns, a petition was successfully

organized and the campaign was halted two weeks after its introduction. (4)

Although this campaign is no longer current, it provides an excellent opportunity to discuss fear, threats, and public health

intervention efficacy. Why did these advertisements invoke such a response? What could the designers have done

differently? We will discuss three main concerns associated with this campaign:

1) The intended message, recommended response, and target population are unclear, potentially encouraging denial and defensive avoidance of the threat.

2) The presented message enforces stereotypes and further stigmatizes those who suffer from these disorders and illnesses.

3) There is a lack of a suggested alternative behavior or response, a critical component to fear appeal based social science models and theories.

For the purpose of this critique, we will focus primarily on the notes written for autism and depression, as each of the six diagnoses are accompanied by many different theories on causes, effective treatments, and prevention or intervention strategies.

The two notes state:

We have your son. We will make sure he will no longer be able to care for himself or interact socially as long as he lives. This is only the beginning. ~ Autism

We have taken your son. We have imprisoned him in a maze of darkness with no hope of ever getting out. Do nothing and see what happens. ~ Depression (2)

Concern #1: What is the message?

In a public health intervention campaign your message, including desired response, is your core. Who are you trying to reach and what do you want them to hear? What information are you sharing and what do you want them to do with it? The following is an excerpt from the NYU Child Study Center’s press release regarding their intended message.

“Twelve million American children and adolescents face daily battles with

psychiatric disorders, yet childhood mental illness remains stigmatized, under-diagnosed and under-treated,” says Dr. Harold S. Koplewicz, founder and director of the NYU Child Study Center, which is dedicated to preventing, identifying and treating childhood psychiatric and learning disorders.

“Left untreated, these illnesses can hold children hostage. That’s why we’ve chosen to deliver our message in the form of a ransom note,’ says John Osborn, President and CEO of BBDO New York. “We hope the campaign will act as a wake-up call to families, educators and healthcare professionals, and spark dialogue so children can get the help they need. (2)

These quotes from Dr. Koplewicz and Mr. Osborn suggest the message is to promote discussion. Dr. Koplewicz is concerned with stigma and treatment, and the hope is that the discussions will result in children getting the help that they need. This is a serious public health concern and these are positive goals. However, this is not what the advertisements say.

The advertisements say, “Do-or-die!” It is a threat: If you do nothing, your child is doomed every time. Ransom notes are connected with terror, crime, ultimatums, and helplessness. Victims are presented with a strict time frame and demanded they give up something of great value or suffer grave consequences. This message doesn’t demand any alternative, positive or negative. At best, it offers a small message in the corner to call the center and alludes onto to do “something”. This places the burden onto the parent, taking any responsibility to reach out to them away from the center.

If this is the message being sent, who is it intended for? Mr. Osborn suggests they are trying to reach “families, educators and healthcare professionals.” (2) Since there is no mention of symptoms to look for in the autism note, it could be assumed that some previous knowledge is expected. By stating, “We have your son” and “We have taken your son”, the message is most likely intended for a parent. However, it is unclear what type of parent they are addressing.

One option is parents of children without a diagnosis. As stated above, Dr. Koplewicz is concerned with under-diagnosis and under-treatment of these illnesses, thus they may wish to encourage these parents to bring their children in for an evaluation. However, there is no mention of signs or symptoms to look for. This lack of information leaves too much room for a parent’s own assumptions. Only telling parents that autism or depression is chronic and will continue to get worse may discourage them from seeking help. These parents could easily avoid the threat entirely A common response to fear is defensive avoidance. This refers to denial or a minimization of the threat. ( 5) If having a child with such an illness is so horrific and traumatic, why would one seek out the diagnosis and all the suggested pain associated with it? “Of course my child is different from that child.”

The second potential target population is parents of children who have already been diagnosed. The center may wish to remind them that these illness or disorders are all consuming and chronic, or to suggest some of them aren’t doing enough to prevent things from getting worse. This may invoke anger, as their parenting choices are being questioned or attacked. They could interpret this as insulting or a threat to their freedom of choice in their child’s treatment. This may induce reactance. Reactance occurs when someone feels their perceived freedoms are reduced or taken away completely. The result is often an active choice to reclaim ones freedom, usually the opposite of what is being suggested. (6) In this case, if they feel they are being told to pay attention or take more action, they may choose not to listen and do nothing. In addition, denial that may be experienced with the first group of parents could also apply here. “Why does this have anything to do with me?”

Concern #2: Why is the message stigmatizing?

Mental illness is well known for its constant struggle with social stigma. As Dr. Koplewicz states, “childhood mental illness remains stigmatized.” The same is true for adults and adolescents. Neurological disorders and psychiatric illnesses are still seen as frightening, mysterious, and misunderstood. Advocates in mental health, such as the National Alliance on Mental Illness’s Stigma Busters, dedicate efforts to fighting inaccurate and hurtful representations of mental illness. They constantly observe and review movies, television, and the press for stigmatizing agents and then bring these to the attention of the public to correct misconceptions. (7) A common theme is that mental illness is terrifying, incurable, and threatening, that those with a diagnosis may as well no longer be members of society. These notes offer gross, negative generalizations regarding each diagnosis and connect mental illness to all of these frightening thoughts. Mental health is anything but black and white and none of these illnesses or symptoms associated with them should be presented as evil, especially to the general public.

The word “autism” can represent either autistic spectrum disorder (ADS) or the more severe form otherwise known as classical ADS. ADS is a wide range of complex neurodevelopmental disorders, including many forms of disability. (8) It is assumed that this ad is referring to classical ADS, but it is worth noting that as a spectrum disorder, many individuals will respond to treatments, or lack thereof, very differently. The autism note shoves them all into one category of someone who cannot “care for himself or interact socially.” This misrepresentation may cause anyone with previous knowledge of the spectrum to disregard the message as it loses credibility. The same goes for depression, as there are many different symptoms, degrees of severity, and causes of the illness. There are multiple diagnoses under the umbrella term in the DSM-IV. (9)

As ransom notes are associated with threats of abuse and murder, they will likely make one think of death. For autism, the note assumes that the life of someone who cannot care for himself or interact socially must be comparable to not living at all. For depression, the threat “Do nothing and see what happens.” could be interpreted as alluding to suicide. Not everyone who is living with these symptoms wants to die. These are both hurtful assumptions for anyone living with either diagnosis.

Concern #3: We feel threatened, what should we do?

The fact that there is no clear suggestion for alternative action is a key component to the ineffectiveness of this campaign. Fear appeal has been used through the history of public health intervention and a number of researchers have created social science theories to review how it works, such as the parallel process model. A more recent model, the extended parallel process model explains why there are instances when it doesn’t work. We will review this model to discuss why the lack of an effective alternative was detrimental to the campaign. (5)

There are three key variables used across the board of fear appeal theories: fear, perceived threat, and perceived efficacy. Fear refers to the high level of emotional arousal that is felt in response to perceiving an event, most often a dangerous or harmful one. The feeling of fear is followed by perceived threat. A threat is an external stimulus, while the perceived threat is how the individual interprets this stimulus. Perceived threat consists of perceived susceptibility – how at risk someone may feel – and perceived severity – how harmful he or she feels the threat is. The third variable, perceived efficacy has to do with an individual’s outlook on the response. Perceived efficacy consists of perceived self-efficacy - his or her belief on how well they would be able to perform the response or adapt to the new behavior – and perceived response efficacy - how well they believe the behavior or response will work to avoid the threat. (5 & 10)

The next step is outcome. In fear appeal theories there are two categories of outcomes commonly referred to: acceptance and rejection. Message acceptance is defined as an attitude, intention, or change in behavior. The other outcome is message rejection, as mentioned when discussing the first concern. Message rejection can include defensive avoidance, such as denial or minimizing the threat or reactance, when one feels their freedom is in jeopardy and they chose to reclaim the freedom. This is often executed by doing the opposite of what is demanded or strongly suggested of them. (6)

The parallel response model, also referred to as the parallel process model was developed by Howard Leventhal in the early 1970’s. Leventhal’s model suggests that there are two independent processes involved in fear appeals: danger control and fear control. Danger control processes are efforts an individual exerts to control the threat itself, while fear control processes are efforts to control an individual’s own fears about the threat. (11) This model is not well supported by specific evidence, due to the fact that it is difficult to test. However, it is the basis of the extended parallel process model (EPPM). (5)

EPPM is the theory best used to evaluate this particular campaign. It was introduced by Kim Witte and Mike Allen in 2000. This model differs from others because it explains both successes and failures of fear appeals. It suggests that the perceived threat contributes to the individual’s emotional response, but that the perceived efficacy is what contributes to the nature of their response. (5)

To review this model, we will refer to a subject named Joe and follow him through the model after he is exposed to one of the ransom notes. Joe is a father and has some previous knowledge of mental illness. According to the EPPM, there are two appraisals of the message. First, Joe will evaluate the threat from the message. (The child is held hostage.) The more he believes he may be susceptible to the threat, the more likely he is to move onto the second appraisal, evaluating the efficacy of the recommended response. If he doesn’t believe he is susceptible and sees the threat as insignificant, he is likely to ignore it. (5)
As a father, Joe chooses to evaluate the efficacy. He will likely become scared of the threat as ransom notes are terrifying to a parent. (Could this be my child?) This fear will motivate him to take some course of action to reduce the feeling of fear. This is where perceived efficacy comes into play. It is this stage that determines if an individual will follow with Leventhal’s suggested danger control or fear control. If Joe feels he can perform the recommended response, he will likely choose to control the danger. If Joe doubts his ability to follow through on the recommended response or doubts the effectiveness of the response, then he his more likely to control his fear through message rejection: denial, defensive avoidance, or reactance. (11)

As you can see, this theory suggests that efficacy of a fear appeal relies heavily on the suggested response. As there are no clear responses recommended, Joe could easily respond with fear control and message rejection. This is why the lack of a clear alternative action or behavior is the issue in this campaign.

Now What? How to prevent a backfire

There is no debating whether child mental illness awareness is a public health concern. Below are suggestions on how to address the concerns discussed above and examples of alternative campaign options.

Suggestion #1: Review social science models and theories to identify target populations and details of the issue.

There are unlimited options on ways to approach a public health intervention and campaign. Social and behavioral science models are very useful to help shift through human behavior and predict outcomes. They are used to investigate and understand why people may engage in certain behaviors and why they may or may not adopt an alternative. It has been common to use theories such as fear appeal, the health belief model, or the transtheoretical model to improve public health and design a number of different types of interventions. (12-13)

Fear appeal was the basis of this campaign, but as we reviewed above, this was not effective because there was no alternative mentioned, no option for the viewer to decide how to confront the threat and deal with the danger. What is missing from these campaign notes is hope. For a family that can feel trapped suggesting that they are is counterproductive. Reminding them that they can escape the feeling and improve their situation is your best alternative. If any of these messages were accompanied by a response from the child or parent to the illness stating that they are taking control and not letting the illness take over their lives, this would have been much more effective. The alternative action that this suggests is to take back the feeling of control that he or she feels they have lost. Freedom and control are basic human core values and it is helpful in public health campaigns to focus on them.

Suggestion #2: Be clear on the issue, target population, and desired effect, in both design and implementation.

Understanding the population, your goals, and your barriers is challenging, but well worth the effort when designing your intervention. Why are you doing this campaign? Who are you trying to reach and what do you want them to hear? What do you want them to do with it? How do you do it? As you start to research your target population EPPM or any additional social science theories can be used to assess the situation and help you decide how best to approach an intervention.

What if the biggest issue in this situation is lack of service utilization? If this is our concern, we will need to evaluate a number of factors. Why are services not being utilized? Is this because of a concern that people aren’t seeking help or that the help isn’t there? If the former is true, then your target would be parents of children who likely have an illness or disability and have chosen, for one reason or another, not to seek treatment. If this is the case, then it would help to evaluate why. Are there barriers preventing them from seeking treatment? Do they know where to look? A possible intervention strategy includes education for parents, possibly from the schools, on what signs and symptoms to look for, while always adding in a feasible next step should they notice anything. In addition, if there are any other barriers observed, it is best to include suggestions or options on how to work around these as well. (10)

What if they know where to look, but the lack of utilization is because of a lack of services available to the community? If this is the case, your assessment should involve a review of where effective services are and why there aren’t more of them. Is it simply that more personnel are needed to meet the demand? Are these government or private services? Are you concerned about the school system or private physicians? If this is the case and awareness to the general public is your goal, a suggestion would be to focus on the positives of treatments. Instead of showing how terrible the disease is and end the note with doom, suggest a positive outcome that can demonstrate the magnitude of recovery possible.

Suggestion #3: Be conscious of possible perceived messages, whether intended or unintended.

Unfortunately, we will never be able to predict exactly how someone will perceive a message we are sending. However, it is possible to creatively review possibilities by trying to think like the population we are serving. In what sort of light is this message placing the child? What about the parents or the illness? Are these messages accusing or blaming anyone of anything negative? Subliminal associations are always possible too, so it’s important to really examine our finished product with objective lenses. In this case, because the center is concerned with fighting stigma, it may have helped to review things that they find stigmatizing. Perhaps focus groups of parents, children, and healthcare providers would help to gage the response to the intervention in addition to just the design process.

In this case, it would be best to avoid a negative association with the illnesses and focus more on the positive aspects of recovery. For many illnesses, early intervention is important. An intervention could be designed to fight the stigma of seeking services by sharing information on how receiving a diagnosis will help, not hurt the child. Again, the perceived effectiveness of the suggested action is the ticket. (10)


In conclusion, this campaign failed because it did not properly take into account all behavioral aspects of fear appeal as referenced in the EPPM. A meta-analysis of fear appeal models from the past 50 years suggests that it should be used cautiously. They can, and in this case did, backfire if the audience doesn’t feel they have any option to avoid the threat. Strong fear appeals work best when accompanied by strong efficacy messages. “Fear appears to be a great motivator as long as individuals believe they are able to protect themselves.” (10)


(1) The New York University Child Study Center. New York, NY.

(2) The New York University Child Study Center. New York, NY. Press release: Millions of Children Held Hostage by Psychiatric Disorders: Provocative New PSA Campaign Highlighting Autism, Asperger’s ADHD, OCD, Depression and Bulimia, Debuts in December in NYC, December 1, 2007.

(3) Kaufman, J. Campaign on Childhood Mental Illness Succeeds at Being Provocative. The New York Times Online, December 14, 2007.

(3) Kaufman, J. Ransom-Note Ads About Children’s Health Are Canceled. The New York Times Online, December 20, 2007.

(4) Nabi RL, Roskos-Ewoldsen D, Carpentier FD. Subjective knowledge and fear appeal effectiveness: implications for message design. Health Communication, 23: 191–201, 2008.

(5) Witte K. Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs; 59: 329-349, 1992.

(6) Brehm, JW. A Theory of Psychological Reactance. New York, NY: Academic Press, 1966.

(7) The National Alliance on Mental Illness. Fight Stigma. Arlington, VA.

(8) National Institute of Neurological Disorders and Stroke. Autism Fact Sheet. Bethesda, MD.

(9) American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders (4th Ed.). Arlington, VA: American Psychiatric Publishing, Inc., 2000.

(10) Witte K, Allen M. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Education Behavior; 27, 5: 591-615, 2000.

(11) Leventhal H. Fear Appeals and Persuasion: The differentiation of a motivational construct. American Journal of Public Health; 61: 1208-1224.

(12) Smedley BD, Syme SL (Eds.). Promoting Health: Intervention strategies from social and behavioral research. Washington, DC: National Academy Press. 2000

(13) Crosby RA. Kegler MC, DiClemente RJ. Understanding and applying theory in health promotion practice and research (Chapter 1). In: DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: John Wiley & Sons, Inc., 2002, pp. 1-15.

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