Evidence-based app teaches young people skills to improve wellbeing

Maia is a 13-year-old ākonga (student) who has been experiencing worries about her studies and how to “fit in” since moving to high school. She has also begun to cut herself when she feels lower in mood. Her mother brings her into your clinic to get some help.

Josh is a 16-year-old apprentice mechanic who has been experiencing anger outbursts over the past few months. Home life has been stressful since his parents split up, and his girlfriend recently said she wants to go out with someone else. He attends your clinic with a black eye following an altercation with a classmate.

Kupe is an 18-year-old tangata taiohi (young man) who is referred to the university counselling service by his tutor after he begins to experience panic attacks around the time of exams. On review, he reveals that he has been comfort eating and binge drinking to manage his feelings.

All three young people have difficulties with emotional self-regulation that are leading to problems with behaviour, anxiety and/or low mood. Self-regulation is defined as the ability to control one’s behaviour, emotions and thoughts in the pursuit of long-term goals.¹

Skills for emotional self-regulation (also known as “coping skills”) are essential for wellbeing and are usually learnt during childhood and early adulthood through modelling and experience. Such coping skills may broadly be categorised as functional or healthy in nature when they relieve stress and help to manage situations, and dysfunctional or unhealthy when they lead to personal or external harm.

During adolescence, young people experience numerous developmental and environmental challenges. Given their increased cognitive abilities (especially development of abstract thinking), they may begin to utilise more sophisticated skills for emotional self-regulation. They are also at risk of learning unhealthy ways to manage stress that continue to be used throughout adulthood (eg, using substances, self-harm and acting out).

While there are many ways to help young people learn skills for emotional self-regulation, we know from clinical experience and research that there are no universally preferred strategies and that, in essence, different things work for different people.

Traditionally, many self-regulation strategies were embedded within face-to-face talking therapies (psychotherapies). For instance, problem solving and goal setting were part of cognitive therapies; deep breathing and progressive muscle relaxation were part of behaviour therapies; and sensory focus exercises were part of mindfulness-based therapies.

As our understanding of the overlap between different mental health problems has improved, we have learnt that the acquisition of self-regulation skills can have transdiagnostic benefits.² Such skills can be learnt either in an individual or combined manner.

Yes. Given their increasing health literacy and their preference for trying self-help over external mental health support in the first instance, young people are more actively learning ways to manage their wellbeing these days.

Further, given their status as “digital natives”, high rates of smartphone access (including among rangatahi Māori³) and difficulties accessing stretched face-to-face services, many young people are open to learning self-regulation skills via technology.⁴

Whitu – 7 Ways in 7 Days is a wellbeing app that was co-designed and developed by young people, Māori, Pacific and digital mental health researchers at the University of Auckland. As its name suggests, it includes seven modules based on principles of positive psychology, cognitive behavioural therapy and psychoeducation that can be completed within a week (see panel). The app opens with a karanga (Māori welcome song) and has consciously been designed to be culturally appealing to Māori and Pacific young people.⁵

Users are encouraged to trial a range of strategies, discover new ones, and keep using the ones that work best for them. Badge rewards and daily notifications encourage app completion and reuse. Data entered by users are stored in an unencrypted database on their device and can be safely removed at any time by deleting the app.

Whitu is free to use and can be downloaded from the App Store (tinyurl.com/Whitu-Apple) and Google Play (tinyurl.com/Whitu-Google).

To date, three clinical trials have been conducted with positive results. In 2020, an open trial of Whitu demonstrated improvements in wellbeing, anxiety and depression among young people aged 16 and over, as well as the feasibility of a larger trial.⁶

In 2021, a subsequent randomised controlled trial with the same age group demonstrated similarly impressive benefits in emotional wellbeing (p=0.005), mental wellbeing (p=0.027), self-compassion (p<0.001), sleep (p=0.018), stress (p=0.002) and depression (p=0.030), with effects sustained at three-month follow-up. Levels of anxiety also reduced to a non-significant degree at four weeks, and to a significant degree (p=0.042) at three months. The app was culturally acceptable to Māori users.⁷

A more recent RCT with university students also found improvements in wellbeing (p=0.005), mental wellbeing (p=0.027), self-compassion (p=0.001), stress (p=0.002), sleep (p=0.018) and depression (p=0.030; results being prepared for publication).

There have not been any reported adverse effects from using Whitu during these three clinical trials.

No. While there are over 20,000 health apps currently available worldwide, the majority are not evidence based, nor are they culturally relevant for young people in Aotearoa. For more information about those that do meet these criteria, check out the Healthify He Puna Waiora website (healthify.nz/apps; previously Health Navigator).

Whitu may be a useful first-line intervention for young people who either present with self-regulation problems or who are incidentally identified as such. It can be a useful option to “put on the table”, along with speaking to a health improvement practitioner (HIP), primary service psychologist or specialist mental health clinician.

Medication is usually reserved as a second-line intervention or when symptoms are severe and significantly affecting social or occupational functioning.

Just because we are digital immigrants does not mean we cannot learn about new technology

It is best to have read a little about, and ideally tried using, the app. It can be helpful to think about the type and amount of information you would usually provide someone regarding a new medication. Young people need to know what the app does, how long it takes to complete, what it might do to help them and if there are any known adverse effects.

Although many mental health and wellbeing apps are designed as self-help tools, it may also be useful to offer young people some active support (eg, parent supervision) or passive support (eg, a follow-up appointment to see how they fared) to increase app engagement and/or completion.

While it can be easier to avoid discussing health apps due to lack of clinician confidence about technology, remember it’s fine – just because we are digital immigrants does not mean we cannot learn about new technology. We just need to invest a little time to get to know what’s available and how it works. Even spending 15 minutes checking out an app can increase your confidence about prescribing one to your next patient. Healthify provides additional guidance on how to choose a suitable app (tinyurl.com/choosing-apps).

Whitu has recently been adapted for use in high schools, and the new bilingual (English and te reo Māori) version is due to be clinically trialled this year. If the trial results are positive, Whitu for Schools may be a useful, cost-effective and easily disseminable means of teaching high-school students self-regulation-related wellbeing skills before they develop mental health problems. It may also hopefully help to prevent their onset. Watch this space!

Hiran Thabrew is a paediatrician and child psychiatrist at Starship Children’s Hospital, and director of Te Ara Hāro, Centre for Infant, Child and Adolescent Mental Health, University of Auckland