ATTUNE : Understanding mechanisms and mental health impacts of Adverse Childhood Experiences to co-design preventive arts and digital interventions.

This research investigates how adverse childhood experiences (ACEs) unfold to affect adolescents' mental health and co-produces novel prevention approaches. ACEs refer to harsh, unsafe, abusive and/or distressing events or living conditions during childhood. Three in four adolescents exposed to multiple ACEs develop significant distress and mental health disorders as young adults, including anxiety, depression, and post-traumatic stress disorder. We do not fully understand what makes an adolescent vulnerable to, or protected from, mental health problems following ACEs nor how to best to protect and support affected young people, many of whom struggle to find and engage with care services. This research aims to address these gaps in knowledge and support by placing young people's lived experience at the centre of our learning and action planning. Young people will be key actors in the design, delivery, governance, evaluation, dissemination and impact of six work packages (WPs). All WPs involve diverse young people (age, gender, ethnicity, LGBTQ, neurodiversity/autism) from different locations (rural, urban, coastal) because place affects local assets, opportunities, and access to care services. Young people will produce a film to ensure good communication and learning from all parts of the research and to evaluate the research. Ethical issues and safeguarding are addressed throughout.

WP1 explores the lived experience of young people exposed to ACEs, how they define and explain their mental health, and how and why ACEs impact people differently. We highlight the needs of young people who are under-represented in ACE research, and of diverse identities and places. We will engage young people via creative arts and writing, performance, film, music and state-of-the-art games technology, and examine if these help young people express and share their experiences. WP1 will identify care approaches for ACE-related mental health problems that are considered useful and acceptable. WP2 will extend our understanding via analysis of existing large data sets collected from over 30,000 individuals to learn which personal or context factors best explain mental health outcomes following ACEs. WP3 turns WP1 and 2 learning and outputs into action. We will work intensively with young people and key stakeholders to co-produce public mental health resources for secondary schools, the third sector and social services to help them understand and better support adolescent mental health following ACEs. WP4 involves young people in co-design of a digital version of a promising therapy (Narrative Exposure Therapy, NET). Many young people actively avoid talking about their most adverse experiences even though this can help their mental health. We want to test if a co-designed version of NET that makes use of serious games or mixed reality technology, directly informed by WP1&2, helps young people engage and benefit from NET. Merging NET with technology is novel and requires multiple stages of prototype refinement. Young people will shape implementation and testing in rural, coastal and urban settings. WP4 examines if the new approach is feasible, acceptable and helpful to young people of diverse identities and to clinicians; we will understand how it works and what improvements are needed before proceeding to larger studies of effectiveness. WP5 will deliver preliminary cost-effectiveness information on distinct approaches. WP6 runs across the project to share learning with young people, clinicians, communities, policy and decision-makers, who will produce guidance on care for young people following ACEs. Our team includes diverse arts, digital and health experts, researchers and clinicians, carers, voluntary and community groups, local government, commissioners and providers. The research will bring a spotlight to ACEs and young people's mental health, and advance understanding of risk, resilience, and recovery for affected young people.

Research Questions: What are the psychological and geo-socio-economic contextual mechanisms by which ACEs unfold to affect or safeguard the mental health and lives of young people (aged 10-24)? Are co-designed, youth-informed public mental health and serious games interventions acceptable, feasible, potentially cost effective, and beneficial for ACE exposed young people? Research Plan: Via participatory creative arts methods we will generate lived experience data and combine this with secondary analysis of large cohorts to address knowledge gaps about mental health risk and resiliency pathways. Using this information, a) we will undertake an experience based co-design process to produce public mental health resources relevant to schools, the third sector and social services; b) We will test if ACE-exposed adolescents engage with and benefit from a co-designed serious game version of Narrative Exposure Therapy (NET). We will test feasibility, acceptability, levels of personalization and guidance, potential cost-effectiveness, and scalability by place. There are four cross-cutting themes: ethics, PPI, interdisciplinary learning, and neurodivergence, throughout. Expected outputs: 1) Data showing how ACEs impact the developing mind, gaps in care, and youth perspectives on ACEs and appropriate care. 2) New knowledge about mechanisms of risk and resiliency. 3) Youth led evaluative films and arts outputs enhancing interdisciplinary learning and reporting research findings about interventions and mechanisms/logic models. 4) Interdisciplinary learning on ethical issues in arts/digital/mental health research, PPI, and neurodiversity. 5) Co-produced public mental health resources and serious game-based psychoeducational and therapeutic interventions, with data on acceptability, feasibility, potential cost-effectiveness, and mechanisms. Impacts: Transform practice, care pathways and systems. Provide trauma-informed resources. Learning for future research, policy and practice.