JMIR Publications

ABSTRACT

Background:

Young people exposed to adverse childhood experiences (ACEs) are at risk of poor mental and physical health across the life course, yet many struggle to access timely help. Serious games offer an engaging, scalable, and stigma-reducing support, but few are co-designed with young people who have lived experience of ACEs, and methodological accounts of how participatory design is operationalised alongside software delivery are scarce.

Objective:

We aimed to (1) develop and apply a novel methodological framework integrating experience-based co-design (EBCD) with agile game development to co-design a serious game with young people affected by ACEs, (2) describe the co-designed game prototype and the design decisions shaped by youth participation, and (3) examine the ethical and safeguarding considerations arising from co-designing digital mental health interventions with trauma-exposed young people.

Methods:

We conducted a participatory co-design study comprising 12 workshops across 8 iterative co-design sprints, involving 18 diverse young people (aged 12–24) with lived experience of ACEs, 5 professional stakeholders, and a multidisciplinary game development team. Young people were recruited across England through partner youth organisations and regional Young People’s Advisory Groups. Co-design ran from June 2022 to April 2024 in hybrid and online formats. Baseline characteristics include demographics and mental health and wellbeing measures. EBCD activities were mapped onto agile practices (sprint planning, sprint reviews, and retrospectives), all feedback was logged in a “You Said, We Did” form. Analyses were descriptive and reporting followed the GRIPP2 (Guidance for Reporting Involvement of Patients and the Public) long-form checklist.

Results:

The resulting prototype, ACE of Hearts, comprised a central “Cosy Den” hub and four mini-games addressing bereavement and caregiving, trauma and disability, gender dysphoria, and poverty. Youth feedback directly shaped 47 documented feedback and design decisions. Co-design participants (n=14 out of 18 participants) were diverse in gender (8/14, 57% men or boys; 3/14, 21% women or girls; 1/14, 7% non-binary; 2/14, 14% another identity; 3/14, 21% transgender), ethnicity (5/14, 36% from minoritised ethnic backgrounds), sexuality (6/14, 43% bisexual or pansexual), and neurodivergence (7/14, 50% autistic), with elevated levels of depression (mean PHQ-9: 8.8, SD 4.5) and anxiety (mean GAD-7: 8.4, SD 3.9). Mean posttraumatic stress symptom severity (CRIES-8; n=13) was 22.5 (SD 7.7). Design innovations included metaphoric storytelling, integration of Narrative Exposure Therapy principles into gameplay, and an embedded ethics framework addressing representation, agency, and emotional safety.

Conclusions:

Integrating EBCD with agile development is a feasible and transparent method for co-producing trauma-informed serious games with young people who have lived experience of ACEs. The novel contribution is methodological, an integrated EBCD-Agile framework that must balance youth voice, clinical safety and technical feasibility. The approach is transferable to other participatory digital-health projects involving vulnerable populations. Future work would evaluate acceptability, feasibility and clinical outcomes.