Moving from ACE clinical screening to evaluations and e interventions: the potential of the JoyPop app (Dr. Christine Wekerle)

1. Moving from ACE Clinical
Screening to Evaluations and
E-Interventions? The potential
of the JoyPopTM app
ISPCAN International Congress Keynote,
Milan 2021
Dr. Christine Wekerle, McMaster University:
wekerc@mcmaster.ca
https://linktr.ee/JoyPopApp

2. 2
What are ACEs?
● Over 30% of a child welfare-
involved youth sample (US National
Survey of Child & Adolescent Well-
Being, NSCAW) experienced three
or more ACEs (Garcia et al., 2017)
● With youth aged 11+, over 18m
○ 50% maintained resilience>
safe relationships
○ 17% dropped >CPA, deviant
peers (Yoon et al., 2021)

3. 3
More ACEs, More Problems
● Dose-response relationship
between ACEs and negative
health and mental health
outcomes (e.g., depression,
substance abuse, sexually
transmitted infections, etc.)
(Centers for Disease
Control and Prevention
[CDC], 2016)

4. ACEs & treatment options
● Maltreated persons have earlier onset, >severity,
>comorbidity psychiatric conditions with a 2 to 17-fold
increase in psychiatric medication prescriptions
● Trauma-focused CBT is flexible components-based model
- emotion regulation (avoidance - trauma narrative;
relaxation skills, cognitive coping) etc
○ E.g., reduces internalizing symptoms, anxiety
symptoms, PTSD symptoms, etc.
4
(Deblinger et al., 2011; Kirlic et al., 2020; Lenz & Hollenbaugh, 2015; Teicher & Samson, 2013; Anda et al., 2007)

5. ● Since COVID-19, the number of
youth reporting excellent or very
good mental health has dropped by
20% (Statistics Canada, 2020)
● E.g., Guo et al. (2020): Pre-pandemic
maltreatment experiences/ACEs
predicting PTSS and anxiety in youth
5
40
%
Pre-COVID
July 2020
60%
What is the current state of mental health?
Resource: World Health Organization Guidelines
on mental health promotive and preventive
interventions for adolescents (2020)

6. 6
International Classification of Functioning (Distal)
Kim, K., Moss, C., Park, J., & Wekerle, C. (2021). Child maltreatment and the child welfare system as environmental factors in the International
Classification of Functioning. Frontiers in Rehabilitation Sciences. Manuscript submitted for publication.

7. 7
International Classification of Functioning (Proximal)
Kim, K., Moss, C., Park, J., & Wekerle, C. (2021). Child maltreatment and the child welfare system as environmental factors in the International
Classification of Functioning. Frontiers in Rehabilitation Sciences. Manuscript submitted for publication.
mHealth
JoyPop app

8. State of mHealth apps for youth
● None taking a resilience approach
● Few target mental health - limited evaluation (15 apps, 2017
review), few significant outcomes (4 apps, 2019 review)
● Key features from review article (Jeminiwa et al., 2019)
○ (1) Technical Quality (4) Autonomy*
○ (2)Engagement (5) Safety, Privacy, Trust*
○ (3) Support System*
○ *consistent with a trauma-informed care approach
*(Bargeman, Smith, & Wekerle, 2020)
8

9. ● iOS mobile app for mental
wellness and resilience
● Based on positive psychology,
emotions theory, and
information processing theory
● Designed with a trauma-
informed care approach
9
What is JoyPopTM?
https://www.youtube.com/watch?v=pxJYUkho4pE

10. What is resilience?
● Resilience is the ability to overcome adversity as
well as develop and adapt inner resourcefulness
with external resources to achieve positive
outcomes (e.g., Wekerle, Waechter, & Chung,
2012)
10

11. What is emotion regulation?
● Emotion regulation is the ability to manage
emotional expressions, experiences, and
responses (Hofstee et al., 2020)
11
Child maltreatment Alcohol misuse
Post-traumatic
stress symptoms
Coping motives
(e.g., to forget about worries)
Maltreatment
and Adolescent
Pathways
(MAP) Study
(Park et al.,
2019)

12. 12
Sense-making
Processing the meaning of events or experiences
● Journalling
● Understanding emotions
Relating
Social connectedness
● Safe social circle
● Availability of helplines
Visioning
Developing daily resilience routine
● Creative expressions
● Art
Intervening
Taking action with specific targets in mind
● Strategic gaming/Tetris
● Deep breathing
● Sleep hygiene
https://www.openaccessgovernment.org/youth-resilience-2/80464/
What do youth do for resilience?

13. JoyPopTM features include…
Helplines
13
Deep Breathing Mood Rating Journalling
Circle of Trust SquareMoves Art SleepEase

14. Breathing & Science
14
● Sympathetic/SNS-fight/flight/faint/freeze
● Maltx/ACEs - Reactive Sympathetic
response to threat or stress situation →
poor decision-making in emotional
situations, low levels of positive approach
behaviours (McLaughlin et al., 2014)
● Deep or diaphragmatic breathing -
Parasympathetic/PSN
● Mechanism: activation of vagus nerve

15. Vagus Nerve
15
https://www.youtube.com/watch?v=5gDfmBAh3ww

16. Tetris — Working Memory Task
16
● Playing tetris can help disrupt harmful mental imagery
by competing for cognitive resources, among young
adults (Lau-Zhu et al., 2017)
● Increased frontal brain activity while playing Tetris
(Haier et al., 2009)

17. Tetris — Working Memory Task
17
vs
Attention-
Placebo
Control
Participants who used Tetris reported:
● Fewer intrusive memories at 1 week
● Faster decline of intrusion incidence
High visuospatial demands task
engagement can disrupt consolidation of
sensory elements of trauma memory and
impair memory reconsolidation
Tetris or an attention-
placebo control were delivered
to 71 participants for 20
minutes within 6 hours of a
motor vehicle accident (Iyadurai
et al., 2018)

18. JoyPopTM scroll-through video (4min)
18
https://www.youtube.com/watch?v=3LzYTdjZPnU

19. What does the
research show?
19
See: www.youthresilience.net for on-going updating

20. 20
@CopingLab
@AislinMushquash
MacIsaac A, Mushquash AR, Mohammed S, Grassia E, Smith S, Wekerle C
Adverse Childhood Experiences and Building Resilience With the JoyPop App:
Evaluation Study
JMIR Mhealth Uhealth 2021;9(1):e25087
doi: 10.2196/25087
PMID: 33393908
PMCID: 7813633
Impact of JoyPopTM
Important time to promote resilience
And evaluate impact on related outcomes and mental health
University transition
A time of excitement and opportunity, but also uncertainty and stress

21. 156 first-year students
(mean age 19.02 yrs; 30% male)
Used app 20.43 of 28 days
on average
21
@CopingLab
@AislinMushquash
MacIsaac A, Mushquash AR, Mohammed S, Grassia E, Smith S, Wekerle C
Adverse Childhood Experiences and Building Resilience With the JoyPop App:
Evaluation Study
JMIR Mhealth Uhealth 2021;9(1):e25087
doi: 10.2196/25087
PMID: 33393908
PMCID: 7813633

22. Depression
symptoms reduced
with each day of usage by 0.08
points on a 9 point scale
22
Emotion regulation
improved
with each day of usage by 0.25
points on an 18 point scale
@CopingLab
@AislinMushquash
MacIsaac A, Mushquash AR, Mohammed S, Grassia E, Smith S, Wekerle C
Adverse Childhood Experiences and Building Resilience With the JoyPop App:
Evaluation Study
JMIR Mhealth Uhealth 2021;9(1):e25087
doi: 10.2196/25087
PMID: 33393908
PMCID: 7813633

23. 23
No ACEs
19.9%
N/A
2.6%
One ACE
16%
Two
ACEs
21.2%
Three ACEs
12.2%
Four or
more ACEs
28.2%
77% of participants
reported experiencing at
least one ACE
@CopingLab
@AislinMushquash
Adverse Childhood Experiences (ACEs)
MacIsaac A, Mushquash AR, Mohammed S, Grassia E, Smith S, Wekerle C
Adverse Childhood Experiences and Building Resilience With the JoyPop App:
Evaluation Study
JMIR Mhealth Uhealth 2021;9(1):e25087
doi: 10.2196/25087
PMID: 33393908
PMCID: 7813633

24. 24
An interaction
between ACEs and
days of app use
existed for emotion regulation,
such that participants with
more adversity evidenced a
faster rate of change in
emotion regulation
@CopingLab
@AislinMushquash
MacIsaac A, Mushquash AR, Mohammed S, Grassia E, Smith S, Wekerle C
Adverse Childhood Experiences and Building Resilience With the JoyPop App:
Evaluation Study
JMIR Mhealth Uhealth 2021;9(1):e25087
doi: 10.2196/25087
PMID: 33393908
PMCID: 7813633

25. 25
@CopingLab
@AislinMushquash
Rate My Mood, Journal, and
SquareMoves
Most used features
Rate My Mood, Journaling,
and Breathing Exercises
Most helpful features
30 participants
(80% female)
completed semi-structured
interviews about their
experiences with and their
perspectives on the utility of
the JoyPop app
Users’ Perspectives
Mushquash, A. R., Pearson, E. S., Waddington, K., MacIsaac, A., Mohammed, S.,
Grassia, E., Smith, S., & Wekerle, C. (accepted). User perspectives on the
resilience-building JoyPop app: Qualitative study. JMIR mHealth and uHealth.
http://dx.doi.org/10.2196/28677

26. 26
@CopingLab
@AislinMushquash
self-monitoring, prompts,
creating routine
Facilitators
student lifestyle, lack of
variety, editing
Barriers
increased awareness,
checking in with oneself,
helpful distraction, emotional
control
Outcomes
additional features, feature
enhancements, personalization
Recommendations
Themes related to app use
Mushquash, A. R., Pearson, E. S., Waddington, K., MacIsaac, A., Mohammed, S.,
Grassia, E., Smith, S., & Wekerle, C. (accepted). User perspectives on the
resilience-building JoyPop app: Qualitative study. JMIR mHealth and uHealth.
http://dx.doi.org/10.2196/28677

27. 27
“It definitely helped me figure [my feelings] out
... actually helped me to relate my mood ... Often I
would feel better afterwards because I’d be like,
‘Ok. I know how to deal with this now’ ... rather than
just sitting there and stewing not knowing what to
do.”
“It helps give students like, the opportunity to have
a way to express themselves... the journal
[feature] for example. But also, like keeping track of
how they’re feeling and keeping themselves in
check by having like, that visual… showing them
where they’re at with their emotions.”
Quotes
@CopingLab
@AislinMushquash
“I was really impressed with the fact that
it brought my attention more to how
I was feeling. So, instead of just
acknowledging that I was stressed and
then managing with that, it really
brought attention to why I was feeling
that and just acknowledging that, which I
thought was really cool.”
“It kinda like, distracted me from
everything that was going on in my
head, and like, gave me something
else to focus that attention on.”
Mushquash, A. R., Pearson, E. S., Waddington, K., MacIsaac, A., Mohammed, S., Grassia, E., Smith, S., & Wekerle, C.
(accepted). User perspectives on the resilience-building JoyPop app: Qualitative study. JMIR mHealth and uHealth.
http://dx.doi.org/10.2196/28677

28. Next steps for the app research
● Build evidence-based re: JoyPop in different
locales
● Larger scale research with…
○ Collegiates
○ Youth waiting for mental health services, adjunct
to evidence-based programming
○ Support tool to specific trauma groups (e.g., child
welfare, Indigenous youth living on reserves, etc.)
28

29. Thank you!
Any questions?
@joypop_app @CopingLab @AislinMushquash @DrWekerle
@joypop.app
@joypop_app
www.facebook.com/JoyPopApp
www.youtube.com/playlist?list=PLjGdby9qio-GfCO2-
L8sd_JN7jZdfwfkU
https://linktr.ee/JoyPopApp
www.youthresilience.net
29

30. Andrea’s favourite feature on JoyPopTM
30
https://www.youtube.com/watch?v=R2QHd1W-iac&t=1s

31. 31
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